|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
A. The deep epigastric vessels arise from the medial side of the external iliac vessels 1 to 2 cm above the inguinal ligament and skirt the internal inguinal ring to reach the mid-deep surface of the rectus muscle below the arcuate line. The vessels arborize over the deep surface of the muscle, anastomosing with the intercostal neurovascular bundles that enter the lateral edge of the muscles to innervate it in a segmental fashion. Several large perforators penetrate the muscle and anterior rectus sheath to nourish the overlying BIEF territory. The largest of these perforators is usually located at the junction of the upper and middle thirds of the mid-rectus sheath between the umbilicus and the pubis. One large perforator is sufficient to sustain the entire flap, if venous outflow is provided through the contralateral superficial inferior epigastric system. The large venae comitantes that accompanied the deep system usually converge to a single vessel as they join the external iliac vein, providing additional venous outflow.
B. Preliminary exposure of the superficial epigastric vessels in the groin area has found the vessels to be small in caliber. The dissection then shifts to the upper and lateral edges of the BIEF, which are mobilized at the fascial level from a lateral and superior direction to a medial and inferior direction. This mobilization commences on the
| contralateral side to the superficial epigastric exposure and can be completed rapidly to
the lateral edge of the rectus sheath. Once over the upper umbilical area of the rectus sheath, the dissection proceeds slowly, identifying and preserving the major perforators. The largest perforators are selected and preserved.
C. The vascular sheath around the principal perforator is opened longitudinally and the muscle belly carefully split, preserving a cuff of muscle around the perforator that is traced through the muscles to the deep inferior epigastric vessel. The sheath is opened inferiorly and the lateral border of the muscle mobilized to expose the deep inferior epigastric vessels. The muscle at the level of the principal perforator is cut laterally, permitting the deep inferior epigastric AV pedicle to be transposed to the superficial surface of the muscle.
D. The deep inferior epigastric vascular pedicle is mobilized up to the level of the principal perforators and brought onto the outer surface of the muscle through a lateral muscle cut, permitting the entire BIEF island to be mobilized inferiorly to the contralateral superficial inferior epigastric pedicle. The lateral incision in the muscle is repaired as well as the anterior rectus sheath, restoring abdominal wall integrity and preserving the innervated rectus muscle.
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