Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 7:
Bilateral Inferior Epigastric Flap (BIEF)
  epigastric, and the superficial inferior epigastric. The venous outflow is primarily through the superficial inferior epigastric veins and the venous comitantes with the superficial inferior epigastric arterial pedicles. The superficial inferior epigastric veins are usually large and can often be seen through the skin surface, particularly in thin individuals. They may be two or three in number and join to empty into the saphenous bulb as a single vein. On occasion, there may be multiple connections into the saphenous bulb or directly into the femoral vein. This venous pattern can be used to guide the plan of dissection. The Doppler probe also helps to document the arterial pattern that usually accompanies one of the visible venous patterns.7

In developing the BIEF, one must be ready to use one or all of the vascular pedicles depending on the size of each unit. As with groin flap, the only anatomic point that one can be sure of is that each dissection is different. 8-10 The magnitude of the Doppler signal can be used as an appraisal of the potential size of the vessel. One cannot be certain, however, that the signal is not coming from the deep inferior epigastric or femoral system. By developing all three systems during the elevation of the flap, one has the option of using the deep system or superficial systems to perfuse the transplant at completion of its dissection. If the superficial inferior epigastric arterial system is large, that is, in the realm of 1 mm or more, it will certainly sustain the entire flap. If this system is extremely small, there will be a need to augment the arterial input. As pointed out before, the superficial venous system draining into the saphenous bulb is adequate to drain the

  entire flap.

The skin territory is the same as that of the TRAM flap or the tissue discarded in a paniculectomy. The width of the flap can be estimated by pinching the lower abdominal skin remembering that one can always pinch more than one can close. Surface markings include the midline, anterior superior iliac spine, pubic, femoral vessels, and superficial inferior epigastric veins. In flap planning, even when a template is used, consideration must be given to closure with matching length. A recipient angiogram may play a key role in ensuring adequate numbers of recipient arteries.

The superficial inferior epigastric vein can be easily identified with the Doppler probe in thin people in whom the venous architecture is evident. Use of the Doppler probe along the various venous branches usually reveals that the central or medial branch has an arterial signal with the vein. One must be careful to point the Doppler handle medially or laterally so that the signal of the deep inferior epigastric femoral artery is not mistakenly picked up. Once the vessel is found, it can be confirmed by studying it almost

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