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19 Inferior Epigastric Artery Flap: Deep Inferior Epigastric Artery Perforator Flap
Fig. 19.17 Clinical
illustration demonstrating
drain placement, fascial
closure, umbilicus retrieval
and abdominal wall closure
197
(b) Rectus sheath catheters or TAP blocks can be used to
reduce systemic postoperative analgesic requirements [12].
19.6 Core Surgical Techniques inFlap
Dissection
19.6.1 Perforator Dissection
When in close proximity to the anticipated perforators, transition to bipolar cautery. Meticulous dissection and haemostasis
are essential at this stage as even a small amount of bleeding
can cause tissue staining which renders the dissection much
more difcult. With guidance from preoperative imaging, the
dominant perforator is approached; however care should be
taken to identify and preserve adjacent perforators which may
be required in the event of smaller than anticipated dominant
perforators. A suprafascial dissection is performed circumferentially around the dominant perforator and adjacent perforators in the event of a small dominant perforator, before the
fascia is incised. This creates a zone of safety around the perforator and prevents future injury during the nal stages of ap
raise. A small vascular clamp can be applied to the back-up
perforator(s) to assess adequate perfusion and aid decisionmaking regarding the required number of perforators.
Bipolar cautery at low current of the planned fascial
incision can reduce the risk of blood staining. Care must
be taken when incising the fascia as the perforator can
travel obliquely under the fascia before commencing its
intramuscular course. When the fascia is rmly adherent to
the perforator, it is safest to leave a small cuff of fascia
around the vessel. The perforator must be circumferentially dissected in the subfascial plane as was performed
suprafascially, and then intramuscular dissection can
begin. The fascia is now incised parallel to the rectus
abdominis bres. The muscle bres overlying the pedicle
are gradually divided allowing adequate exposure of the
entire pedicle length. Care is taken to identify and ligate or
coagulate all side branches throughout the intramuscular
course, a distance of 1–2mm from the main pedicle to prevent unintended vessel injury, thereby isolating the pedicle
from the surrounding rectus muscle. The vessel runs in a
loose areolar plane allowing blunt dissection and resistance is indicative of a side branch requiring ligation. The
pedicle dissection proceeds until adequate length or ideal
calibre vessel for anastomosis has been reached. Typically
one artery and two venae comitantes are included in the
pedicle. Ligation of the smaller vein at the end of the dissected pedicle diverts ow through the large vein prior to
transfer and avoids confusion once the veins have collapsed post transfer.
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A. O’Neill et al.
19.6.2 Nerve Preservation
Nerves enter the rectus with the lateral row perforators of the
DIEA placing them at risk particularly when multiple lateral
row perforators are harvested. When perforator dissection
necessitates motor nerve division, we advocate a perineurial
repair under loupe magnication with 9/0 nylon sutures once
the ap has been harvested. Division of type II nerves results
in larger segments of muscle denervation and potential for
abdominal wall complications. Underlay mesh should be
considered in this situation.
19.6.3 Bipedicled andStacked DIEP
Bipedicled and stacked DIEP aps are useful in women with
a paucity of abdominal tissue, those requiring large volume
reconstructions and those with midline abdominal scars.
Bipedicled/stacked aps involve raising the entire abdominal
pannus on two pedicles for a unilateral reconstruction.
Murray etal. described a classication system for the use of
the bipedicled ap, the pedicle options and the four types of
intraap anastomotic congurations [13]. The internal mammary artery/vein (IMA/V) antegrade or large intercostal perforator remains the primary recipient; however in type 4
anastomosis, where pedicles are independently anastomosed,
the IMA/V retrograde is also used. Shaping the entire
abdominal ap has been described in four different congurations involving folding, dividing and coning the tissue to
achieve best aesthetic outcomes [14].
19.7 Breast Neurotisation
Post-mastectomy breast numbness has a signicant impact
on postoperative quality of life with patients now seeking not
only reconstruction of the breast mound but also restoration
of cutaneous sensation. The value of nerve coaptation has
been debated in the literature with some arguing collateral
ingrowth from surrounding nerve bres is sufcient for protective sensation; however a recent study of bilateral autolo-
gous breast reconstruction with unilateral sensory nerve
coaptation demonstrates improved sensory recovery in the
neurotised breast compared to the contralateral nonneurotised breast [15, 16].
19.8 Clinical Scenario
Case 1: Immediate Unilateral Breast Reconstruction
A 56-year-old female underwent unilateral skin sparring,
nipple sacricing mastectomy and sentinel lymph node
biopsy for a grade 2 invasive ductal carcinoma of the left
breast. Mastectomy weight was 914g. She underwent immediate reconstruction with stacked DIEP aps with a total ap
weight of 1029g (Fig.19.18a, b).
Case 2: Bilateral Delayed Reconstruction
A 58-year-old lady underwent bilateral breast reconstruction with DIEP free aps 4years post bilateral mastectomy
and left sentinel lymph node biopsy (SLNB) for left breast
grade III IDC and high-grade DCIS; concurrent SLNB was
negative for malignancy. Mastectomy weights were right
700 g and left 990 g and DIEP reconstructions weighed
676g and 862 g. Post-op day 1 the ap was noted to be
venously congested, and she underwent return to theatre for
a cephalic turn-up and anastomosis to the SIEV with a successful outcome (Fig. 19.19). (See Video 19.1—demonstrating another case of a delayed DIEP with cephalic
turndown.)
Case 3: Bilateral Immediate Reconstruction with
Mastectomy Skin Reduction for Ptosis Correction
A 44-year-old lady underwent a bilateral nipple-sacricing
mastectomy for strong family history and BRCA1 genetic
mutation with immediate breast reconstruction with DIEP
free ap. Mastectomy weights were right 531 g and left
676g, and her respective ap reconstructions weighed 484g
and 525g. She was noted to have grade III ptosis and was
subsequently planned for bilateral skin reduction with an
inverted T technique to be performed simultaneously
(Fig.19.20a, b).
19 Inferior Epigastric Artery Flap: Deep Inferior Epigastric Artery Perforator Flap
a
199
b
Fig. 19.18 (a) A 56-year-old lady underwent a unilateral immediate breast reconstruction with stacked DIEP ap. Preoperative photographs. (b)
Post reconstruction
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a cb
A. O’Neill et al.
Fig. 19.19 (a) Case 2: Preoperative markings of a 58-year-old lady
undergoing delayed breast reconstruction 4 years following bilateral
mastectomy. Note the template of the new breast footprint, with care
taken to prevent symmastia of the reconstructed breasts. (b) On table
a b
appearances immediately following bilateral delayed breast reconstruction with DIEP free aps. (c) 12 months following bilateral delayed
breast reconstruction with DIEP aps, very faint scars from the cephalic
turn-up procedure can be seen
Fig. 19.20 (a) Case 3: Preoperative markings for a 44-year-old woman undergoing bilateral breast reconstruction, requiring simultaneous reduc-
tion of the skin envelope. (b) Day 2 post-bilateral breast reconstruction with wise pattern skin reduction
19 Inferior Epigastric Artery Flap: Deep Inferior Epigastric Artery Perforator Flap
19.9 Pearls andPitfalls
Nerve preservation
Motor nerve preservation is essential for preserving
function of the rectus abdominis muscle but should not
Patient selection is key to success.
Patient understanding of expected volume, abdominal
scarring that is typically higher than a cosmetic abdominoplasty and the transfer of abdominal wall features
such as striae, moles, etc. is key to patient satisfaction.
Numerous studies demonstrate increased complications in both active and ex-smokers, and patients
should be counselled to cease smoking 6weeks either
side of surgery [17]. Although signicant interunit
variability exists, extrapolated evidence suggests a
BMI over 30 is associated with increased morbidity,
predominantly donor site morbidity. Reconstruction is
generally afforded to women with a BMI up to 32;
however, immediate cases can be considered judiciously up to a BMI of 35 [18].
Dual consultant team has been shown to reduce surgical time and also provides an ideal opportunity for
training and mentorship of junior surgeons [19, 20]. In
delayed breast reconstruction, one team can prepare
the breast pocket and recipient vessels, while the second team raises the DIEP ap from the contralateral
abdominal wall. In bilateral breast reconstruction,
while one team is performing the microvascular anastomoses, the second team can proceed with the second
DIEP ap raise.
Adjustment of ap markings
The inferior and superior ap incisions can be moved
superiorly to increase tissue capture and ensure
tension- free closure of the abdominal wound.
Perforator selection
Preoperative CT angiogram provides an excellent
guide to perforator selection. If the perforator is small,
then a second perforator should be included in the ap.
If there is uncertainty about the perfused skin territory,
adjacent perforators can be preserved and vascular
clamps applied to assess the ap perfusion. If deemed
adequate, then the perforators can be ligated with haemoclips. Similarly, in unilateral DIEPs the contralateral DIEA perforators can be dissected suprafascially
and microvascular clamps applied on the dominant
perforators as a contingency plan.
Venous lifeboat
Time should be taken to preserve a 3–5cm length of
the supercial epigastric vein which can provide a secondary venous outow in the event of venous congestion. The SIEV can be dissected into the ap in the
event it is required.
compromise ap perfusion. If a second perforator is
required at the cost of a nerve, then the perforator takes
precedence, and mesh should be considered to aug-
ment the rectus abdominis.
Flap preparation on the abdomen
Mark and excise zone IV plus any obvious ap excess
so that the ap is marginally bigger than anticipated.
Judicious de-epithelialisation can occur prior to trans-
fer. Delayed reconstructions can be more difcult in
predicting the extent of de-epithelialisation and are
often easiest if done during ap inset.
Abdominal closure
Elevation of the superior abdominal skin early in the
operation facilitates abdominal wall closure during the
ap inset.
Identify abdominal scars
Pfannenstiel incisions don’t preclude the use of the
DIEP ap, consideration should be made regarding
incorporating the scar in the inferior incision versus
placing the ap incision a safe distance from the scar,
and the surgeon should be aware of the increased scar-
ring in this region.
Flap inset—immediate versus delayed breast recon-
struction—ap orientations (Fig.19.21).
Delayed breast reconstruction requires recreation of
the breast footprint and reestablishment of the infra-
mammary fold (IMF). In cases of unilateral delayed
reconstruction, the contralateral breast can be used to
guide IMF placement, typically 2 to 3cm higher than
the contralateral side unless there is signicant skin
brosis and contraction at the mastectomy site, in
which case the IMF should be positioned higher. The
scar is excised, and the skin between the scar and IMF
is de-epithelialised which aids creation of lower pole
projection. The breast pocket above the scar is raised
according to the preoperative footprint markings supe-
riorly, medially and laterally. The ap then needs to be
fashioned into a three-dimensional asymmetric conus
to replicate the native breast. Although not essential,
we routinely utilise the contralateral abdomen which is
rotated 180 degrees as originally recommended by
Blondeel which places the bulk of the ap in the infe-
rior pole of the breast. Once the anastomoses are per-
formed, shaping of the breast begins. Techniques such
as removing a wedge of tissue from the periumbilical
region to create greater inferior fullness and suture
techniques are described for creating the breast conus.
201
202
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A. O’Neill et al.
Fig. 19.21 Preoperative marking and postoperative skin paddle differences between immediate and delayed unilateral breast reconstructions
We recommend making the reconstructed breast 10%
larger than the native breast to account for resolution
of swelling postoperatively and to create an appropriate scaffold that can be liposculpted during a future
procedure.
In immediate reconstructions, the ap weight is guided
by the mastectomy weight. In particularly ptotic
breasts or where the patient requests a breast reduction
at the time of reconstruction, the excess skin envelope
can be addressed with a keyhole or wise pattern skin
reduction. It is essential to mark the breast footprint
preoperatively and reconstruct any borders that are
violated during the mastectomy, the most common
being the IMF and the lateral border. Sutures are again
used to fashion the breast conus, with the skin gently
draped over the ap and the nal result assessed.
19.10 Selected Readings
203
reading for all surgeons reconstructing the breast as it
simplies a complex reconstructive problem into three key
anatomic features, thereby providing an algorithm of
sorts to produce consistent and aesthetically pleasing
reconstructive results.
• Blondeel PN, etal. Shaping the breast in aesthetic and
reconstructive breast surgery: an easy three-step princi-
ple. Part II--Breast reconstruction after total mastectomy.
Plast Reconstr Surg. 2009;123(3):794–805 [23].
• Part two of the four-part series builds on the anatomic
features discussed in part one and provides an approach
to analysing the post-mastectomy breast. It explores dif-
ferences in unilateral and bilateral breast reconstruction
as well as primary versus delayed reconstruction provid-
ing key steps to addressing the breast footprint, conus and
skin envelope. This is a must-read paper for any surgeon
embarking on a career in breast reconstruction.
• Hembd AS, etal. Intraoperative assessment of DIEP ap
breast reconstruction using indocyanine green angiogra-
phy: reduction of fat necrosis, resection volumes, and
postoperative surveillance. Plast Reconstr Surg.
2020;146(1):1e–10e.
• Koshima I, Soeda S.Inferior epigastric artery skin aps
without rectus abdominis muscle. Br J Plast Surg.
1989;42(6):645–8.
• The original paper demonstrating a large fasciocutane-
ous ap based on a single rectus abdominis muscle perforator was possible, thereby addressing the donor site
morbidity associated with rectus abdominis sacrice and
the bulk issues that were sometimes undesired with the
TRAM ap.
• Dancey A, Blondeel PN.Technical tips for safe perforator
vessel dissection applicable to all perforator aps. Clin
Plast Surg. 2010;37(4):593–606, xi–vi [21].
• A comprehensive stepwise approach to DIEA perforator
dissection accompanied by detailed intraoperative photography and numerous technical tips learned throughout
the senior authors’ extensive career.
• Rozen WM, etal. The perforator angiosome: a new concept in the design of deep inferior epigastric artery perforator aps for breast reconstruction. Microsurgery.
2010;30(1):1–7.
• This paper identies fundamental differences in the
medial and lateral row perforators of the DIEA and proposes a new model of abdominal wall perfusion based on
a single perforator.
• Blondeel PN, etal. Shaping the breast in aesthetic and
reconstructive breast surgery: an easy three-step principle. Plast Reconstr Surg. 2009;123(2):455–62 [22].
• The rst of a four-part series addressing the aesthetics of
breast reconstruction. While not directly related to microvascular breast reconstruction, this paper is essential
Acknowledgements We thank Julia Ruston for her illustrations in this
chapter for the text and also the video.
References
1. Koshima I, Soeda S. Inferior epigastric artery skin aps without
rectus abdominis muscle. Br J Plast Surg. 1989;42(6):645–8.
2. Allen RJ, Treece P. Deep inferior epigastric perforator ap for
breast reconstruction. Ann Plast Surg. 1994;32(1):32–8.
3. Moon HK, Taylor GI.The vascular anatomy of rectus abdominis
musculocutaneous aps based on the deep superior epigastric system. Plast Reconstr Surg. 1988;82(5):815–32.
4. Blondeel PN, etal. Doppler owmetry in the planning of perforator
aps. Br J Plast Surg. 1998;51(3):202–9.
5. Bailey SH, etal. The single dominant medial row perforator DIEP
ap in breast reconstruction: three-dimensional perforasome and
clinical results. Plast Reconstr Surg. 2010;126(3):739–51.
6. Schaverien M, etal. Arterial and venous anatomies of the deep inferior epigastric perforator and supercial inferior epigastric artery
aps. Plast Reconstr Surg. 2008;121(6):1909–19.
7. Rozen WM, etal. The perforator angiosome: a new concept in the
design of deep inferior epigastric artery perforator aps for breast
reconstruction. Microsurgery. 2010;30(1):1–7.
8. Rozen WM, et al. Avoiding denervation of rectus abdominis in
DIEP ap harvest: the importance of medial row perforators. Plast
Reconstr Surg. 2008;122(3):710–6.
9. Masia J, etal. Multidetector-row computed tomography in the planning of abdominal perforator aps. J Plast Reconstr Aesthet Surg.
2006;59(6):594–9.
10. Hembd AS, et al. Intraoperative assessment of DIEP ap breast
reconstruction using indocyanine green angiography: reduction
of fat necrosis, resection volumes, and postoperative surveillance.
Plast Reconstr Surg. 2020;146(1):1e–10e.
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11. Momeni A, Sheckter C.Intraoperative laser-assisted indocyanine
green imaging can reduce the rate of fat necrosis in microsurgical
breast reconstruction. Plast Reconstr Surg. 2020;145(3):507e–13e.
12. Zhong T, et al. Transversus abdominis plane (TAP) catheters
inserted under direct vision in the donor site following free DIEP
and MS-TRAM breast reconstruction: a prospective cohort study
of 45 patients. J Plast Reconstr Aesthet Surg. 2013;66(3):329–36.
13. Murray A, etal. Stacked abdominal ap for unilateral breast reconstruction. J Reconstr Microsurg. 2015;31(3):179–86.
14. Patel NG, et al. Stacked and bipedicled abdominal free aps for
breast reconstruction: considerations for shaping. Gland Surg.
2016;5(2):115–21.
15. Slezak S, McGibbon B, Dellon AL. The sensational transverse
rectus abdominis musculocutaneous (TRAM) ap: return of
sensibility after TRAM breast reconstruction. Ann Plast Surg.
1992;28(3):210–7.
16. Bijkerk E, et al. Breast sensibility in bilateral autologous breast
reconstruction with unilateral sensory nerve coaptation. Breast
Cancer Res Treat. 2020;181(3):599–610.
17. Klasson S, et al. Smoking increases donor site complications
in breast reconstruction with DIEP ap. J Plast Surg Hand Surg.
2016;50(6):331–5.
18. Lee KT, Mun GH.Effects of obesity on postoperative complications after breast reconstruction using free muscle-sparing transverse rectus abdominis myocutaneous, deep inferior epigastric
perforator, and supercial inferior epigastric artery ap: a systematic review and meta-analysis. Ann Plast Surg. 2016;76(5):576–84.
19. Butler DP, Woollard A, Grobbelaar AO. Dual-consultant led elective microsurgery: the implications on service provision and training. J Plast Reconstr Aesthet Surg. 2013;66(10):1435–6.
20. Canizares O, et al. Optimizing efciency in deep inferior epigastric perforator ap breast reconstruction. Ann Plast Surg.
2015;75(2):186–92.
21. Dancey A, Blondeel PN. Technical tips for safe perforator vessel dissection applicable to all perforator aps. Clin Plast Surg.
2010;37(4):593–606, xi–vi.
22. Blondeel PN, etal. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Plast Reconstr
Surg. 2009;123(2):455–62.
23. Blondeel PN, et al. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Part II-Breast reconstruction after total mastectomy. Plast Reconstr Surg.
2009;123(3):794–805.
Inferior andSuperior Epigastric Artery
Flaps: TheRectus Abdominis Muscle
Flap
MatthewWordsworth, DariushNikkhah, AlexWoollard,
andNorbertKang
20
20.1 Introduction
The deep inferior epigastric artery is a workhorse of reconstructive plastic surgery. It can be raised as a muscle ap or
as a myofasciocutaneous ap with a wide range of skin paddles; the inferior epigastric artery supplies the largest skin
area on the body. It is most commonly used as a fasciocutaneous ap in breast reconstruction (the DIEP ap) or as a
transverse rectus abdominis myofasciocutaneous ap (the
TRAM ap). As an inferiorly based pedicled ap, the tissue
pivots at the level of the pubis, and the ap is used for perineal, groin and lower trunk reconstruction, usually with a
vertically orientated skin paddle (the VRAM ap). The rectus abdominis muscle can also be raised on the superior epigastric artery, as a pedicled ap to reconstruct chest wall and
midline sternal defects.
In the 1970s a number of surgeons had published on using
a superiorly based pedicled rectus muscle ap for breast and
chest wall reconstruction, but the rst use of the inferior epigastric artery free rectus muscle ap was by published by
Pennington etal. [1]. The work of Taylor etal. [2] demonstrated the dense anastomotic network between the supercial and deep inferior epigastric vessels and reliability of the
skin perforators. The rectus abdominis ap has been
described in both limb and head and neck reconstruction, but
it is most commonly used when the abdomen has been
opened as part of the resection surgery. Pedicled VRAMs in
M. Wordsworth (*)
Royal Centre for Defence Medicine, Birmingham, UK
e-mail: matt.wordsworth1@nhs.net
D. Nikkhah · A. Woollard · N. Kang
Royal Free Hospital, London, UK
e-mail: d.nikkhah@nhs.net
perineal reconstruction have been shown to reduce wound
healing complications in irradiated abdominoperineal resection defects [3].
20.2 Anatomy
The rectus abdominis muscle can be easily palpated and
visualised in slim patients. The medial border is the midline,
the linea alba, and the lateral border is the linea semilunaris.
The rectus abdominis muscle is 7–10cm wide and is a long
muscle stretching from its origin at the cartilaginous union of
the lower ribs and xiphisternum to the insertion at the symphysis and crest of the pubis bone. The muscle is segmented
by three (rarely four) tendinous insertions running horizontally creating the colloquially named ‘six-pack’ appearance.
Anterior to the rectus muscle throughout its length is the
anterior rectus sheath consisting of the aponeurosis of the
external oblique muscle and the anterior aponeurosis of the
internal oblique muscle. The posterior rectus sheath consists
of the posterior aponeurosis of the internal oblique and the
aponeurosis of the transversus abdominis muscle until that
sheath ends at the horizontal level of the anterior superior
iliac spine: the arcuate line. Caudal to the arcuate line, the
rectus muscle therefore only lies on the transversalis fascia
and parietal peritoneum (Fig. 20.1). The rectus abdominis
muscle is innervated segmentally by terminal branches of the
intercostal nerves from the sixth to twelfth ribs; these nerves
enter the muscle posteriorly on the lateral third of the
muscle.
The rectus abdominis ap has a Mathes and Nahai type III
arterial supply with two dominant and minor pedicles. The
dominant pedicles are the superior and inferior epigastric
arteries. The internal mammary artery and vein become the
superior epigastric vessels and insert into the superior third
of the rectus muscle posteriorly and medially. The superior
epigastric vessels anastomose in the middle third of the muscle with the inferior epigastric artery and vein, a branch of
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_20
205
206
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Fig. 20.1 Rectus sheath
anatomy
M. Wordsworth et al.
Above the
arcuate line
Peritoneum
Transversalis fascia
Below the
arcuate line
Peritoneum
Transversalis fascia
the external iliac artery and vein. The inferior epigastric
artery pierces the transversalis fascia and enters the muscle
at the inferior aspect of the middle third, posteriorly and in
the lateral aspect of the muscle. The minor pedicles are six
small intercostal arteries and one subcostal artery that enter
the deep aspect of the muscle and anastomose with the epigastric arteries. Anatomical variability exists with the number
of anastomoses between the superior and inferior epigastrics
and where the deep inferior epigastric vessels enter the muscle (usually 3cm caudally to the arcuate line)—see Moon
and Taylor [4] for more detail. The inferior epigastric artery
is typically 2–4mm diameter and 5–10 cm pedicle length
can be harvested. Venous drainage is from two venae comitantes with one vein usually similar in size to the artery.
External oblique
muscle
Linea alba
Linea alba
Internal oblique m.
Transversus abdominus m
External oblique
muscle
Internal oblique m.
Transversus abdominus m
20.4 Flap Design andMarkings
The design of the rectus abdominis ap depends on which
components are required. The ap can be raised as a muscleonly ap but it is more commonly used with a skin paddle.
The skin paddle can be orientated vertically, horizontally or
obliquely. The para-umbilical perforators are the most crucial
for skin perfusion, and therefore the fasciocutaneous portion
of the ap should not be dissected from the central portion of
the rectus muscle belly. An extended VRAM that incorporates
a vertical skin paddle with an oblique extension to the costal
margin has been described by Villa etal. [5]. The size of the
skin paddle is determined by the requirements of the defect
and what can be closed directly in the donor site.
20.3 Preoperative Investigation
Skin perforators in the rectus abdominis ap can be simply
identied using handheld Doppler. CT angiography is not
mandated but is recommended in instances where previous
surgery may have affected the normal vascular anatomy of
the inferior and superior epigastric arteries. Preoperative CT
20.5 Flap Raise/Elevation
In this description a pedicled myocutaneous ap is used with
a vertical skin paddle over the middle and upper portion of
the rectus for a perineal reconstruction after an open abdominoperineal resection, for example, for the excision of a low
rectal carcinoma.
angiography reduces the duration of surgery in DIEP breast
reconstruction, and this may be applicable when mobilising
the inferior epigastric artery in the setting of a rectus abdominis ap.
Step 1: Skin Marking Choose the side, contralateral to any
planned or current stoma or signicant scars. Mark the midline, and curve around the umbilicus so that it is not incorpo-
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