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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3600_Библиотеки_им_академика_М_И_Перельмана
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20 Inferior andSuperior Epigastric Artery Flaps: TheRectus Abdominis Muscle Flap
207
Fig. 20.2 Skin marking for a vertical rectus abdominis myocutaneous
ap
rated in the ap. Palpate and mark 7–10cm laterally to mark
the linea semilunaris which is the lateral border of the rectus
muscle. Draw the costal margin to mark the superior limit of
the muscle, and draw a horizontal line across from ASIS to
ASIS to mark the arcuate line. Check the degree of skin laxity in the abdomen for direct closure and draw the skin paddle over the rectus muscle. The size of the skin paddle can be
templated on the defect. Ensure the base of the skin paddle is
located over the periumbilical perforators (Fig.20.2).
Step 2: Identifying the Perforators Incise the midline skin
and subcutaneous fat down to the anterior rectus sheath fascial layer. Blunt dissect at the periumbilical region to carefully visualise perforators coming through the rectus fascia
into the skin and fat of the ap.
Step 3: Raising the Anterior Sheath Incise the lateral skin
and subcutaneous edge of the ap down to the semilunaris
(Fig.20.3). The portion of rectus sheath containing the perforators is islanded from the rest of the rectus sheath by
extending the sheath incision vertically on the medial and
lateral edge of the sheath. A fascial incision inferior and
superior to the perforators to join the lateral and medial incisions completes the island of the rectus fascia. The rectus
sheath should ideally not be cut below the arcuate line as this
risks a hernia due to a lack of posterior rectus sheath below
this point. Vertically incise the rectus sheath in the middle of
the muscle superior to the perforators, and divide the muscle
horizontally (Fig.20.4). Identify and clip the superior epigastric vessels within the rectus muscle.
Step 4: Mobilising the Rectus Muscle The ap is freed
from the remaining rectus sheath. There are adhesions at the
tendinous intersections of the rectus muscle, but the muscle
Fig. 20.3 Incision to the anterior rectus sheath
Fig. 20.4 Raising the cranial end of the rectus abdominis muscle prior
to dividing it
belly is otherwise easily mobilised off the sheath. Start by
completing the dissection of the muscle off of the sheath
anteriorly, then around the medial edge and onto the posterior sheath towards the lateral edge. The pedicle will be visible on the posterior surface of the muscle. Medially is an
avascular plane, laterally there are anastomoses between the
pedicle and the lower intercostal vessels and the segmental
nerve innervation will also need dividing.
Step 5: Mobilising the Pedicle Once the rectus muscle is
free from the sheath, the deep interior epigastric artery pedicle and venae comitantes should be mobilised into the pelvis
(Fig.20.5). The pivot point for the pedicled ap is the origin
at deep inferior epigastric artery from the external iliac artery
at the inguinal ligament. For pedicled perineal reconstruction, the ap is to be rotated medially and passed down
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M. Wordsworth et al.
Fig. 20.5 Mobilising the pedicle into the pelvis
Fig. 20.6 An inset ap
through the pelvis to ll the defect. The transversalis defect
needs to be sufcient to prevent constriction of the pedicle. If
the ap is being used as a free ap, then the pedicle is divided
close to the origin which provides 5–10cm of pedicle length
and usually a 2–3mm diameter artery.
Fig. 20.7 Donor site closed
Fig. 20.8 Onlay mesh closure of the anterior sheath
sheath should be closed directly. An onlay mesh may be indicated to strengthen the anterior rectus sheath repair (Fig.20.7).
The donor site skin can be closed directly (Fig.20.8).
20.6 Core Surgical Techniques inFlap
Dissection
Step 6: Insetting the Flap and Closing the Donor Site For
the pedicled reconstruction, the ap is passed down into the
inis has not been lateralised by a diastasis; the degree of diastasis can be assessed preoperatively on CT.
pelvis under direct vision and brought through the perineal
Step 1 When marking the midline, check the rectus abdom-
defect. The inferior insertion of the rectus muscle can be partially or completely divided if it is limiting the pedicle’s
Step 2 Incise the skin with a blade and the subcutaneous
tissue with a monopolar diathermy.
reach. The skin island can be temporarily stapled in position
to adjust the size of the skin island if required and to check
that there is no tension on the pedicle. The ap can then be
inset in layers (Fig.20.6). Where possible the anterior rectus
Step 3 Dividing the superior rectus muscle can be done
quickly and cleanly with a linear stapler. When mobilising
the rectus muscle off the sheath, keep gentle traction on the
20 Inferior andSuperior Epigastric Artery Flaps: TheRectus Abdominis Muscle Flap
209
Fig. 20.9 Suturing the skin island to the muscle to prevent shearing
edge of the sheath with Allis clamps. When incising the
sheath, leave a cuff of rectus sheath adjacent to the linea alba
and linea semilunaris to facilitate direct closure (or mesh
attachment if needed).
When mobilising the muscle to prevent shear forces on
the perforators, a tacking suture can be placed from skin
island edge through the muscle edge to the cut fascial edge
(Fig.20.9).
Step 4 The lateral edge of the rectus abdominis muscle is
best delineated from a posterior approach. Branches can be
clipped, and smaller branches can be cauterised with
bipolar.
Step 5 The pedicle can kink on the transversalis fascia when
rotated down into the pelvis so it should be fully mobilised.
Partial division of the medial attachments of the rectus
abdominis pelvic insertion allows for increased reach, whilst
leaving the lateral musculotendinous bres intact protects
the pedicle from excessive traction.
Step 6 A layered and meticulous closure is critical to a good
outcome. The rectus abdominis muscle can be inset as a sling
to obliterate the dead space; the Scarpa’s fascia can be
Fig. 20.10 An example of ap planning for a combined pedicled
VRAM and ALT aps to reconstruct the planned excision of a Merkel
cell carcinoma and lymph node
sutured to the levator ani muscle layer. It is easier to deepithelialise any areas of the skin if required prior to delivering the ap into the perineum.
20.7 Clinical Scenario
The patient pictured has a Merkel cell carcinoma of the
right gluteal skin region with a metastatic lymph node in
the right groin. The lesion and node are excised en bloc
with appropriate margins leaving a large soft tissue defect
(Fig.20.10).
A pedicled anterolateral thigh ap was used to reconstruct
the lower half (Fig.20.11). The rectus abdominis ap donor
site was closed directly, and the anterolateral thigh ap donor
site was grafted with a split thickness skin graft (Fig.20.12).
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M. Wordsworth et al.
Fig. 20.11 Intraoperative reconstruction using a pedicled rectus
abdominis ap passing under a tunnel of lower abdominal skin to
reconstruct the superior half of the defect
Fig. 20.12 Postoperative appearance of the inset aps
20 Inferior andSuperior Epigastric Artery Flaps: TheRectus Abdominis Muscle Flap
20.8 Pearls andPitfalls 20.9 Selected Readings
• McMenamin DM, etal. Rectus abdominis myocutaneous
Pearls
• The male pelvis is longer than the female and will
therefore require a longer length of the VRAM ap
to reconstruct a perineal defect.
• The arcuate line is not visible directly so mark the
skin and respect the boundary to reduce the risk of
postoperative hernia.
• The easiest way to nd the pedicle is approaching
the vessels from medial to lateral on the posterior
surface of the rectus muscle and following it
caudally.
• A strip of muscle lateral to the pedicle can be left as
it will remain innervated and vascularised by the
lateral supply of the intercostal neuromuscular bundle. The dissection is more challenging and
time-consuming.
• If there is difculty closing the donor site, consider
a component separation to achieve tension-free
closure.
Pitfalls
• If the superior epigastric artery is not identied and
clipped during the division of the superior portion
of the rectus muscle, it may retract into the proximal muscle and bleed.
• If the skin paddle is not carefully handled, it can
shear on the anterior rectus sheath damaging the
perforators.
• The inferior insertion of the rectus prevents traction
injury to the pedicle as the ap is moved into the
pelvis. If the muscle is released inferiorly, take care
not to stretch the pedicle.
• If the anterior rectus sheath is incised below the
arcuate line, a postoperative hernia is more likely so
a mesh reinforcement is necessary.
• If the pedicle is not fully mobilised, it can be compressed by the transversalis fascia when the ap is
pedicled into the perineum.
aps for perineal reconstruction: Modications to the
technique based on a large single-centre experience. Ann
R Coll Surg Engl. 2011;93(5):375–81.
• A British case series with useful pearls and technical
discussion.
• Rai R, etal. Tendinous inscriptions of the rectus abdominis: a comprehensive review. Cureus. 2018;10(8)e3100.
• Detail on tendinous inscription and discusses the muscu-
lar anatomy and segmental innervation of the rectus
abdominis.
• Lejour M, Dome M.Abdominal wall function after rectus
abdominis transfer. Plast Reconstr Surg.
1991;87(6):1054–68.
• Discussion and data on donor site morbidity.
• Campbell CA, Butler CE. Use of adjuvant techniques
improves surgical outcomes of complex vertical rectus
abdominis myocutaneous ap reconstructions of pelvic
cancer defects. Plast Reconstr Surg. 2011;128(2):447–58.
• Six technical modication to reduce wound healing
complications.
• Cordeiro PG, Santamaria E.A classication system and
algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg. 2000;105(70):2331–46.
• An algorithm for mid facial reconstruction using the rec-
tus muscle free ap.
References
1. Pennington DG, Lai MF, Pelly AD.The rectus abdominis myocutaneous free ap. Br J Plast Surg. 1980;33(2):277–82.
2. Taylor GI, etal. The extended deep inferior epigastric ap. Plast
Reconstr Surg. 1983;72(6):751–65.
3. Butler CE, Gündeslioglu AÖ, Rodriguez-Bigas MA.Outcomes of
immediate vertical rectus abdominis myocutaneous ap reconstruction for irradiated abdominoperineal resection defects. J Am Coll
Surg. 2008;206(4):694–703.
4. 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.
5. Villa M, etal. Extended vertical rectus abdominis myocutaneous ap
for pelvic reconstruction: three-dimensional and four- dimensional
computed tomography angiographic perfusion study and clinical
outcome analysis. Plast Reconstr Surg. 2011;127(1):200–9.
211
Superficial Inferior Epigastric Artery
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and Superficial Circumflex Iliac Artery
Perforator Combined Flaps
HidehikoYoshimatsu, YumaFuse, RyoKarakawa,
andAkitatsuHayashi
21
21.1 Introduction
The supercial inferior epigastric artery (SIEA) ap has
been widely used in autologous breast reconstruction for
small to medium breasts. Dissection of the pedicle does
not entail intramuscular dissection, thus resulting in low
donor site morbidity. The SIEA ap is also indicated for
coverage of a small- to medium-sized defect, especially
when the supercial circumex iliac artery (SCIA) perforator (SCIP) ap cannot be used due to scars from previous
surgeries.
A unique application of the SIEA ap is combining the
ap with the SCIP ap to cover a large defect. For coverage
of large defects, using multi-lobed aps, KISS ap, and
multi-lobed latissimus dorsi musculocutaneous ap have
been reported by Zhang etal. A combined bilobed ap consisting of the SCIP ap and the SIEA ap allowed a ap
coverage strategy that can be applied in a prone position
with minimal donor site morbidity (with no muscular sacrice and little or no muscular dissection). Using this strategy of combined aps, a large ap up to 20 x 20cm can be
obtained with primary closure of the donor site. The bilobed
design allows coverage of three-dimensional convex
defects, especially useful for coverage of the knee, the
elbow, and the scalp, while maintaining minimal donor site
morbidity.
21.2 Anatomy (Fig.21.1)
The SIEA takes off from the femoral artery 1–3cm below
the inguinal ligament, sharing a common branch with the
SCIA in 33–48% of cases (Fig.21.2). After penetrating the
Scarpa’s fascia just superior to the inguinal ligament, the
SIEA ascend lateral to the linea semilunaris. The branches
from the SIEA do not cross the midline in most cases, thus
limiting its angiosome. Unlike the deep inferior epigastric
artery (DIEA), which runs beneath the rectus abdominis
muscle giving off perforators to the adipose layer and the
skin paddle, the SIEA runs toward the supercial layer of the
adipose tissue as it travels in the superior direction. This
peculiar characteristic allows a fairly thin axial-pattern ap.
Although a high absence rate (35%) of the SIEA was reported
in historical works, a recent study using modern imaging
H. Yoshimatsu (*) · Y. Fuse · R. Karakawa
Department of Plastic and Reconstructive Surgery, Cancer Institute
Hospital of the Japanese Foundation for Cancer Research,
Tokyo, Japan
A. Hayashi
Lymphedema Center, Kameda General Hospital,
Chiba, Japan
© 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_21
Fig. 21.1 Reconctructed image of CT anigography of the
groin arteries
213
214
Fig. 21.2 Anatomical
variations of the SIEA
and the SCIA
SIEA
Superficial branch
of SCIA
SCIA
Deep branch
of SCIA
techniques identied the SIEA in 94% of cases. The average
diameter of the SIEA is 1.4mm (0.6–2.0mm). The supercial inferior epigastric vein (SIEV) and the supercial circumex iliac vein (SCIV) consist of the main venous
drainage system in the lower abdomen and the groin area.
The venae comitantes of the SIEA and the SCIA work as
additional drainage. The SIEV runs with the SIEA in some
cases, but in many cases, the SIEV runs parallel to and 4cm
medial to the SIEA at the inguinal ligament level.
After branching off from the femoral artery, the supercial circumex iliac artery (SCIA) bifurcates into the supercial branch and the deep branch. While the supercial
branch gives off perforators to the skin, the deep branch runs
beneath the deep fascia, giving off branches to the sartorius
muscle and the iliac bone. The transverse branch of the deep
branch, which runs in the lateral direction, is given off from
the deep branch of the SCIA approximately 2.5cm caudal to
the ASIS.The transverse branch can be used as a guideline to
identify the deep branch.
SIEA
H. Yoshimatsu et al.
Superficial branch
of SCIA
Deep branch
of SCIA
SCIA
52-67%33-48%
21.3 Preoperative Investigation
Preoperative CT angiography is highly recommended to
identify the SIEA and the SIEV.If CT angiography cannot
be used, Doppler ultrasonography or handheld Doppler
should be used to mark the course of the SIEA and the
SIEV.When planning a SCIP-SIEA combined ap, the use
of CT angiography or Doppler ultrasonography is highly
recommended to evaluate whether the SCIA and the SIEA
share a common trunk. For elevation of the SCIP ap,
handheld Doppler should sufce. The course of the supercial branch of the SCIA can be detected with handheld
Doppler.
Fig. 21.3 A vertically designed SIEA ap
21.4 Flap Design andMarkings
For use in autologous breast reconstruction, the SIEA ap is
designed similar to the DIEP ap, in an abdominoplasty-like
fashion. The perfusion of the ap should be evaluated with
intraoperative indocyanine (ICG) angiography after the elevation, and malperfused regions should be discarded.
For use in other purposes, a vertically designed SIEA ap,
which allows direct closure of the donor site, should be designed
with the SIEA and the SIEV situated in the middle of the skin
21 Supercial Inferior Epigastric Artery and Supercial Circumex Iliac Artery Perforator Combined Flaps
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Fig. 21.5 An incision (blue arrow) is placed over the inferior markings
of the SIEA and the SIEV
215
Fig. 21.4 A SIEA-SCIP combined bilobed ap for coverage of larger
defects
paddle (Fig. 21.3). The width of the ap is determined by the
laxity of the abdominal tissue, usually between 9 and 12cm.
The length of the ap can exceed the umbilicus, reaching 20cm,
but the perfusion should be conrmed intraoperatively using the
ICG angiography. When a certain pedicle length is required, the
skin paddle should be designed superiorly. The pedicle length
should be expected to be around 5cm in these cases.
To cover a large defect with minimal donor site morbidity,
the SIEA ap can be combined with the SCIP ap (Fig.21.4).
For this bilobed ap, the preoperative examination should be
performed with CT angiography or color Doppler ultrasonography to evaluate whether the SIEA and the SCIA share a
common trunk. The width of each ap is determined by the
laxity of the tissue, but in many cases, a 10cm width can be
achieved in both aps, resulting in a combined width of 20cm.
21.5 Flap Raise/Elevation: AStep-by-Step
Guide
21.5.1 Vertical SIEA Flap (Figs.21.5, 21.6, 21.7,
and21.8)
Fig. 21.6 The SIEA and the SIEV are looked for in the adipose tissue.
The SIEA (white arrow) and the SIEV (blue arrow) are found and
dissected
216
H. Yoshimatsu et al.
21.5.2 SCIP-SIEA Combined Flap (Figs.21.9,
21.10, 21.11, and21.12)
Fig. 21.7 An incision is made around the ap design. The ap can be
elevated from the cephalad to the caudal at a dissection plane immediately above the deep fascia
Fig. 21.9 An incision (blue arrow) is placed to identify both the SIEA
and the SCIA
Fig. 21.8 The donor site is closed primarily in a multilayer fashion
over a drain
Fig. 21.10 After identication of the SIEA, the SCIA (yellow arrow),
the SIEV (blue arrow), and the SCIV (yellow arrow), the ap is elevated
above the deep fascia
21 Supercial Inferior Epigastric Artery and Supercial Circumex Iliac Artery Perforator Combined Flaps
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with preoperative CT angiography or Doppler ultrasonography. If the identied SIEA is not pulsating or its
diameter is smaller than 1.0mm at its takeoff from the
femoral artery, conversion to other aps (e.g., DIEP ap
or SCIP ap) should be considered.
3. The SIEA runs supercially as it takes its cephalad
course; the ap can be elevated safely including the SIEA
and the SIEV if the dissection plane is set at the layer
where the SIEA and the SIEV were found. The authors
use a monopolar cautery device set at 30/30 for this
procedure.
4. The patient should be informed of the displacement of the
umbilicus.
217
Fig. 21.11 A longer pedicle can be obtained by placing the caudal
edge of the skin paddle superiorly (red dotted line)
Fig. 21.12 The donor site is directly closed in a multilayer fashion
over a drain
21.6 Core Surgical Techniques inFlap
Dissection
21.6.2 SCIP-SIEA Combined Flap
1. The side where the SIEA and the SCIA share a common
trunk should be selected as the donor site when possible.
If they do not share a common trunk, two arterial anastomoses will be necessary. As for the SCIA, either the
supercial branch or the deep branch of the SCIA can be
used as the pedicle.
2. If the diameter of the SIEA is smaller than 0.5mm, a deep
inferior epigastric artery perforator (DIEP) found within
the ap design can be used. For minimal donor site morbidity, the DIEP dissection can be limited to its takeoff
point from the DIEA. If the SCIA and the SIEA share
origins, a single arterial anastomosis is made. If they do
not, both arteries are anastomosed. The anastomosis of
both the SIEV and SCIV is recommended, which will
sometimes require intra-ap anastomosis.
3. The same pedicle elongation method can be applied in
vertically designed SIEA aps.
4. The patient should be informed of the displacement of the
umbilicus.
21.6.1 Vertical SIEA Flap
21.7 Clinical Scenario
1. Preoperative identication of the SIEA is critical for success. Precise markings of the pedicle are possible when
Doppler ultrasonography is used.
2. Identication and dissection of the SIEA is the crux of the
elevation. Meticulous care should be taken at this step
since the SIEA can be located at a supercial layer,
usually just beneath the Camper’s fascia. The authors prefer using a monopolar cautery device set at 15/15 for this
purpose. Meticulous hemostasis maintains a clear surgical eld and thus is the key to the successful identication
of the vessels. The depth of the SIEA should be conrmed
The SIEA ap is indicated for coverage of small- to mediumsized defect, when the SCIP ap cannot be used due to previous surgical history, etc. The ap can be converted from the
SCIP ap to the SIEA ap if the SIEA is larger than the
SCIA.
The SCIP-SIEA combined ap is indicated for coverage
of large defects (up to 20 × 20 cm). The bilobed design
allows coverage of three-dimensional convex defects, especially useful for coverage of the knee, the elbow, and the
scalp.
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