Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 7:
Bilateral Inferior Epigastric Flap (BIEF)
  The minimal donor site deformity and the ability to provide a large segment of tissue are probably the greatest assets of the BIEF. As in any reconstruction, replacing like with like remains the final goal. With the BIEF, the defect is replaced with durable soft skin that will not undergo much, if any, shrinkage or texture change. Further, skin flaps are ischemictolerant when compared with muscle flaps, a consideration sometimes forgotten except in the rocky postoperative period. Also, it is an anterior flap, which makes harvest easier for anterior recipient defects because the position of the patient is usually determined by the location of the recipient area.

As will be illustrated in the following section, the vascular anatomy of the anterior abdominal skin is complex and varies with respect to both vessel dominance and arrangement. 5,6 Because of this, time must be taken to expose the feeding vessels enabling use of one or more systems as the situation dictates. This leads to the principal drawback in that multiple microvascular anastomoses may be necessary and sufficient recipient vessels may indeed be difficult to find. Further, the size of the vessels is often small and the pedicle lengths short.

In addition, the flap is difficult to develop in obese individuals or in those with previous abdominal operations or infections. With the advent of liposuction, post-transplant removal of fat and contouring is now possible and rewarding. Also, skin flaps, although providing good cover, seldom bring in the same degree of vascularity as muscle and are therefore not as tolerant of infection.


Technical Considerations

The vascular supply of the BIEF is by two main arteries: the superficial inferior epigastric and deep inferior epigastric plus contributions laterally from perforators from the deep circumflex iliac vessels. The deep inferior epigastric supplies the upper third of the territory through myocutaneous perforators that reliably come through the rectus muscle clustering around the paraumbilical location. Lateral to the rectus sheath, one or two large myocutaneous perforators from the deep circumflex iliac pierce the internal and external oblique muscles and fascia to reach the subcutaneous tissue and skin. The superficial inferior epigastric vessels rise from below the inguinal ligament and enter a subcutaneous plane as pure cutaneous vessels to supply the skin from the midline to the flank. The skin territory has multiple venous outputs including the deep circumflex iliac, the deep inferior

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