Atlas Phẫu Thuật Vi Phẫu Mạch Máu (Atlas of Microvascular Surgery)

SERRATUS ANTERIOR MUSCLE FLAP
479
Identifying the Neurovascular Bundle
(Fig. 9–24)
The anterior border of the latissimus dorsi (7) and the
anterior part of the serratus anterior (6) are exposed.
Retracting the proximal portion of the latissimus dorsi
dorsally, the main trunk of the thoracodorsal neurovas-
cular bundle (3) is identi ed between the serratus ante-
rior (6) and latissimus dorsi (7). Careful dissection of
the vessels leads to nding one or two branches (5) to
the serratus anterior that arise from the thoracodorsal
vessel 3 to 6 cm cephalad to the entrance of the latis-
simus dorsi. The long thoracic nerve (8) can be found on
the surface of the muscle joining the vascular bundle at
the level of the sixth rib.
Figure 9–24
Identifying the
neurovascular bundle.
1. Axillary a. and v.
2. Subscapular a. and v.
3. Thoracodorsal a. and v.
4. Thoracodorsal n.
5. Branch to serratus anterior
6. Serratus anterior m.
7. Latissimus dorsi m.
8. Long thoracic n.
9. Pectoralis major m.

480
III.9 TRUNK: THORAX
Mobilizing the Muscle (Fig. 9–25)
The fth to eighth digitations of the serratus anterior
(6) are m obilized from the chest wall by carefully divid-
ing attachments on the ribs with a cautery. The upper
and lower portion with their innervation should be pre-
served to prevent a winging scapula and limitation of
arm m ovement.
Figure 9–25
Mobilizing the muscle.
3. Thoracodorsal a. and v.
5. Branch to serratus anterior
6. Serratus anterior m.
8. Long thoracic n.

SERRATUS ANTERIOR MUSCLE FLAP
481
Dissection of the Vascular Pedicle
(Fig. 9–26)
The branch to the latissimus dorsi (7) is ligated, pre-
serving the thoracodorsal nerve. Then the latissim us
dorsi (7) is retracted posteriorly. Dissection between
the muscle and subscapularis exposes its insertion as
far as possible.
Figure 9–26
Dissection of the vascular
pedicle.
3. Thoracododrsal a. and v.
5. Branch to serratus anterior
6. Serratus anterior m.
7. Latissimus dorsi m.
8. Long thoracic n.

482
III.9 TRUNK: THORAX
Detaching the Insertion and
Completion of Harvesting (Fig. 9–27)
After dividing the muscle from its scapular attachment
by cautery, the serratus anterior m uscle ap (5) is
raised.
Figure 9–27
Detaching the insertion and
completion of harvesting.
5. Branch to serratus anterior
6. Serratus anterior m.
8. Long thoracic n.

SERRATUS ANTERIOR MYOCUTANEOUS FLAP
483
SERRATUS ANTERIOR
MYOCUTANEOUS FLAP
Flap Design (Fig. 9–28)
The skin territory comprises the area, posteriorly, to the
lateral border of the latissimus dorsi m uscle and, ante-
riorly, to the anterior line of the axilla. The skin paddle
usually lies over the fourth to seventh ribs.
Figure 9–28
Flap design.
1. Thoracodorsal a. and v.
2. Long thoracic n.
3. Serratus anterior m.

484
III.9 TRUNK: THORAX
Dissection of the Vascular Pedicle and
Flap Elevation (Fig. 9–29)
Dissection starts with a posterior incision. While dis-
secting the thoracodorsal vessels (1), attention should
be paid to preserve the m uscular and cutaneous
branches from the vessels to the serratus anterior and
its overlying skin. Keeping the skin paddle intact with
the fourth to seventh digitations of the m uscle (3), the
serratus anterior myocutaneous ap is elevated, follow-
ing similar procedures described for the muscle ap.
Figure 9–29
Dissection of the vascular pedicle
and ap elevation.
1. Thoracodorsal a. and v.
2. Long thoracic n.
3. Serratus anterior m.

COMPOSITE SERRATUS–LATISSIMUS MUSCLE FLAP
485
COMPOSITE SERRATUS–LATISSIMUS
MUSCLE FLAP
Incision (Fig. 9–30)
The latissimus dorsi and serratus anterior m uscles can
be isolated on a common vascular pedicle of the thora-
codorsal artery and can be transferred together. The
incision is demonstrated in the illustration.
Figure 9–30
Incision.
1. Thoracodorsal a., v., and n.
2. Branch to the serratus m.
3. Long thoracic n.
4. Serratus anterior m.
5. Latissimus dorsi m.

486
III.9 TRUNK: THORAX
Muscle Flap Elevation (Fig. 9–31)
After identi cation of the thoracodorsal artery (1) and
its branches (2) to these two m uscles, the latissimus
dorsi ap (5) is raised and re ected cranially. The serra-
tus anterior (4) is then detached from the ribs and
scapula. (See the techniques detailed in the sections on
both of these muscles.)
Figure 9–31
Muscle ap elevation.
1. Thoracodorsal a., v., and n.
2. Branch to the serratus m.
3. Long thoracic n.
4. Serratus anterior m.
5. Latissimus dorsi m.

SERRATUS ANTERIOR COSTO-OSTEOMUSCULAR FLAP
487
SERRATUS ANTERIOR COSTO-
OSTEOMUSCULAR FLAP
Flap Design and the Proposed Rib
(Fig. 9–32)
Any of the fth to eighth ribs is available for combina-
tion with the serratus anterior m uscle ap, but the
sixth rib is usually selected.
Figure 9–32
Flap design and the proposed rib.
1. Thoracodorsal a. and v.
2. Long thoracic n.
3. Serratus anterior m.
4. Intercostal m.
5. Sixth rib

488
III.9 TRUNK: THORAX
Dissection of the Vascular Pedicle,
Osteotomy, and Flap Elevation
(Fig. 9–33)
After dissection of the thoracodorsal vessels (1) and
branches to the serratus anterior (3), the digitations of
the m uscle are separated from all other ribs except the
sixth. All connections between the muscle and the sixth
rib (5) are preserved. Both ends of the rib are tran-
sected according to length requirem ents. The blood
supply to the bone can be maintained through the peri-
osteal circulation.
Figure 9–33
Dissection of the vascular
pedicle, osteotomy, and ap elevation.
1. Thoracodorsal a. and v.
2. Long thoracic n.
3. Serratus anterior m.
4. Intercostal m.
5. Sixth rib

REVASCULARIZED COSTAL BONE GRAFT AND INTERCOSTAL FLAP
489
REVASCULARIZED COSTAL BONE GRAFT
AND INTERCOSTAL FLAP
Arterial Anatomy (Fig. 9–34)
The posterior intercostal artery (2) arises directly from
the aorta (1) and soon gives off the dorsal branch to the
paraspinal m uscle and spinal cord. It then goes upward
in the costal groove of the rib above, continuing anteri-
orly. The nutrient artery (6) of the rib arises from the
posterior intercostal artery and enters the nutrient
foramen just distal to the tubercle. The diam eter of the
posterior intercostal artery (2) is ~2.0 mm up to the nu-
trient artery and ~1.5 mm beyond the nutrient artery.
For the lower three intercostal spaces, the lateral
cutaneous perforator (3) arises from the posterior in-
tercostal artery (2) in the distal part of the costal
groove, accom panied by a vein and nerve branch. It
reaches the subcutaneous level a short distance in front
of the anterior edge of the latissimus dorsi m uscle. At or
before this point, it divides into two branches—a small
posterior branch and a large anterior branch.
The anterior intercostal artery (4) arises from the in-
ternal mammary artery (5), ultimately communicating
with the posterior intercostal artery (2) at the anteromid-
dle third of the rib. The diameter of this artery is ~1.0 mm.
The internal mamm ary artery (5) descends along
the internal surface of the anterior part of the rib cage,
~1 to 2 cm lateral to the margin of the sternum. Below
the third costal cartilage, it is separated from the pari-
etal pleura by the transverse thoracic muscle. The di-
ameter is ~2.0 to 3.0 m m.
The anterior perforator to supply the skin and pec-
toralis m uscle is directly derived from the internal
m ammary artery. Its diam eter is ~0.5 to 1.0 mm.
Figure 9–34
Arterial anatomy for revascularized costal bone graft and intercostal ap.
1. Aorta
2. Posterior intercostal a.
3. Lateral cutaneous perforator
4. Anterior intercostal a.
5. Internal mammary a.
6. Nutrient a.

490
III.9 TRUNK: THORAX
VASCULARIZED RIB GRAFT (BASED ON
THE POSTERIOR INTERCOSTAL ARTERY)
Incision and Proposed Rib (Fig. 9–35)
The seventh to tenth ribs can be utilized as donors.
More com m only, however, the eighth or ninth rib
would be selected.
An incision is placed directly over the selected rib
(the eighth rib), beginning posteriorly 5.0 cm from the
midline and extending as far as is necessary.
Figure 9–35
Incision and proposed rib.
1. Latissimus dorsi m.
2. Serratus anterior m.
3. Angle of the eighth rib
4. Intercostal m.
5. Posterior intercostal a.
6. Pleura

VASCULARIZED RIB GRAFT (BASED ON THE POSTERIOR INTERCOSTAL ARTERY)
491
Exposure of the Serratus Anterior
Muscle (Fig. 9–36)
The skin and deep fascia are incised, the lateral edge
of the latissimus dorsi (1) is identi ed, and the seventh
to ninth digitations of the serratus anterior (2) are
exposed.
Figure 9–36
Exposure of the serratus anterior muscle.
1. Latissimus dorsi m.
2. Serratus anterior m.

492
III.9 TRUNK: THORAX
Exposure of the Ribs and Their
Intercostal Spaces (Fig. 9–37)
The latissimus dorsi (1) and serratus anterior (2) mus-
cles are separated or detached from the ribs to expose
the ribs and their intercostal spaces (4). The latissimus
dorsi m uscle may be divided for further exposure.
Figure 9–37
Exposure of the ribs and their intercostal spaces.
1. Latissimus dorsi m.
2. Serratus anterior m.
4. Intercostal m.

VASCULARIZED RIB GRAFT (BASED ON THE POSTERIOR INTERCOSTAL ARTERY)
493
Identi cation and Dissection of the
Intercostal Neurovascular Bundle
(Fig. 9–38)
The erector spinae is separated and retracted to expose
the angle of the rib (3) at which the neurovascular bun-
dle (5) leaves the subcostal groove to pass obliquely
downward; the bundle can then be identi ed and iso-
lated. The collateral branch can either be preserved or
ligated.
The intercostal m uscles (4) are divided layer by
layer along the upper borders of the selected rib and the
ninth rib below, avoiding incision damage to the pleura
and to the intercostal neurovascular bundle. Simultane-
ously, the serratus posterior inferior m uscle (7) can be
divided in the course of dissection. Then the pleura (6)
is carefully dissected from the eighth rib.
Figure 9–38
Identi cation and dissection of the
intercostal neurovascular bundle.
3. Angle of the eighth rib
4. Intercostal m.
5. Posterior intercostal a.
6. Pleura
7. Serratus anterior m.

494
III.9 TRUNK: THORAX
Osteotomy and Bony Graft Isolation
(Fig. 9–39)
According to the length and curvature required, the rib
is divided at both ends, and the neurovascular bundle
(5) on the distal end is ligated. The rib is thus isolated
on the posterior intercostal neurovascular bundle. Fur-
ther dissection to obtain a greater pedicle length can
proceed over the tubercle of the rib, and the nutrient
artery can be ligated.
Figure 9–39
Osteotomy and bony graft isolation.
4. Intercostal m.
5. Posterior intercostal a.
6. Pleura

LATERAL INTERCOSTAL SKIN FLAP
495
LATERAL INTERCOSTAL SKIN FLAP
Flap Design (Fig. 9–40)
The neurovascular pedicle selected is usually at T10 or
T11. The ap is marked according to the following pa-
rameters. Its axis corresponds to the lateral cutaneous
perforator of the posterior intercostal vessels of T10, for
example. The posterior border of the ap should be at
least 5.0 cm behind the posterior axillary line. Flap size
ranges from 10
14 cm to 17
24 cm.
Figure 9–40
Flap design.
1. Latissimus dorsi m.
2. Lateral cutaneous perforator and n.
3. 10th rib
4. External oblique m.
5. Posteroinferior serratus m.
6. Anterior serratus m.
7. Intercostal m.
8. Pleura
9. Posterior intercostal a., v., and n.
Posterior Elevation and Perforating
Bundle Identi cation (Fig. 9–41)
The posterior border of the ap is elevated with deep
fascia to expose the lateral border of the latissim us
dorsi (1). Careful dissection should be undertaken ante-
riorly to identify the lateral cutaneous perforating bun-
dles (2) of the 10th and 11th intercostal spaces that are
just anterior to the edge of the latissim us dorsi (1). The
posterior branches of the bundles appear under the fas-
cia of the ap at these points.
Figure 9–41
Posterior elevation and perforating
bundle identi cation.
1. Latissimus dorsi m.
2. Lateral cutaneous perforator and n.

Exposure of the Intercostal Space
(Fig. 9–42)
After a comparison of the 10th and 11th bundles, the
larger is chosen. If the axis of the ap is to be changed,
ap design is readjusted; the remaining bundles are lig-
ated. Using the 10th bundle as an example: to trace the
m ain bundle, the slip of the origin of the external
oblique (4) below it is detached, and the latissim us
dorsi (1) and serratus posteroinferior muscles (5) are
incised and retracted to expose the 10th interspace.
496
III.9 TRUNK: THORAX
Figure 9–42
Exposure of the intercostal space.
1. Latissimus dorsi m.
2. Lateral cutaneous perforator and n.
3. 10th rib
4. External oblique m.
5. Posteroinferior serratus m.
6. Anterior serratus m.
7. Intercostal m.

LATERAL INTERCOSTAL SKIN FLAP
497
Exposure of the Intercostal
Neurovascular Bundle (Fig. 9–43)
The external and internal intercostal m uscles (7) are
then cut from the lower border of the rib, identifying
the junction of the lateral cutaneous perforator (2) with
the posterior intercostal bundle (9).
The periosteum of the lower border of the rib is in-
cised and re ected downward, and the periosteum on
the roof of the subcostal groove is released sub-
periosteally using an elevator. The intercostal bundle
(9) is then delivered by pulling the incised edge of the
periosteum downward.
Figure 9–43
Exposure of the intercostal neurovascular
bundle.
2. Lateral cutaneous perforator and n.
7. Intercostal m.
8. Pleura
9. Posterior intercostal a., v., and n.

Dissection of the Vascular Pedicle and
Flap Elevation (Fig. 9–44)
The continuation of the posterior intercostal vessels (9)
(after giving off the lateral cutaneous branch) is ligated.
A desired length of pedicle can be dissected posteriorly;
it is usually 8 to 15 cm in length. The lateral cutaneous
nerve can be stripped from the main nerve. Remaining
ap borders are incised down to and including the deep
fascia, and the ap is quickly elevated.
498
III.9 TRUNK: THORAX
Figure 9–44
Dissection of the vascular pedicle
and ap elevation.
2. Lateral cutaneous a., v., and n.
3. 10th rib
4. External oblique m.
7. Intercostal m.
8. Pleura
9. Posterior intercostal a., v., and n.

Advice about Possible Anatomic
Variations (Fig. 9–45)
The surgeon is advised that caution is necessary in
identifying the anterior branch of the lateral cutaneous
perforator (2) before ligating the continuation of the
posterior intercostal bundle (9). This is because of
anatom ic variations at the incipient division of the lat-
eral cutaneous branch deep in the intercostal space.
LATERAL INTERCOSTAL SKIN FLAP
499
Figure 9–45
Advice about possible anatomic
variations.
2. Lateral cutaneous a., v., and n.
8. Pleura
9. Posterior intercostal a., v., and n.

POSTERIOR COSTAL
OSTEOCUTANEOUS FLAP
Flap Design (Fig. 9–46)
The skin ap is marked using the following parameters.
The ap axis is the lateral cutaneous branch that
em erges on the midaxillary line and is parallel to the
selected rib. Assuming choice of the ninth rib, the pos-
terior edge of the ap is located ~10 cm away from the
midline of the back. Maximal ap size is ~20
12 cm.
500
III.9 TRUNK: THORAX
Figure 9–46
Flap design.
1. Angle of the ninth rib
2. Posterior intercostal a., v., and n.
3. Intercostal m.
4. Latissimus dorsi m.
5. Pleura
6. Serratus anterior m.

Identi cation of the Intercostal
Neurovascular Bundle (Fig. 9–47)
The posterior intercostal neurovascular bundle (2) is
identi ed near the angle of the rib (1).
While deepening the incision, a subcutaneous vein
is preserved for subsequent anastomosis. Skin should
be xed to the underlying intercostal m uscle (3) to
avoid shearing.
POSTERIOR COSTAL OSTEOCUTANEOUS FLAP
501
Figure 9–47
Identi cation of the intercostal neurovascular
bundle.
1. Angle of the ninth rib
2. Posterior intercostal a., v., and n.
3. Intercostal m.
4. Latissimus dorsi m.
5. Pleura
6. Serratus anterior m.

Osteotomy and Flap Elevation
(Fig. 9–48)
The costal osteocutaneous ap can be raised following
principles similar to those of a free rib technique.
502
III.9 TRUNK: THORAX
Figure 9–48
Osteotomy and ap elevation.
1. Angle of the ninth rib
2. Posterior intercostal a., v., and n.
3. Intercostal m.
4. Latissimus dorsi m.
5. Pleura
6. Serratus anterior m.

VASCULARIZED RIB GRAFT (BASED ON
THE ANTERIOR INTERCOSTAL ARTERY)
Incision and Proposed Rib Graft
(Fig. 9–49)
The fth and sixth ribs are choice donor sites for this
procedure because the transverse thoracic muscle sep-
arates the internal m am m ary vessels and their
branches from the parietal pleura. An incision is placed
directly over the selected rib. Using the fth rib as an
example, the incision would run from the anterior mid-
line and as far laterally as necessary.
VASCULARIZED RIB GRAFT (BASED ON THE ANTERIOR INTERCOSTAL ARTERY)
503
Figure 9–49
Incision and proposed
rib graft.
1. Fifth rib
2. Pectoralis major m.
3. Pectoralis minor m.
4. Intercostal m.
5. Serratus anterior m.
6. Sternum
7. Internal mammary a. and v.
8. Anterior intercostal a., v., and n.
9. Transverse thoracic m.
10. Pleura

Exposure of Intercostal Spaces
(Fig. 9–50)
The fth rib (1) and two interspaces (4) above and be-
low it are exposed after splitting the pectoralis major
(2), detaching the origin of the pectoralis minor (3), and
ligating the direct cutaneous perforating branches of
the internal mammary vessels in the fourth and fth in-
terspaces.
504
III.9 TRUNK: THORAX
Figure 9–50
Exposure of intercostal
spaces.
1. Fifth rib
2. Pectoralis major m.
3. Pectoralis minor m.
4. Intercostal m.
5. Serratus anterior m.
6. Sternum
Cartilage Resection and Identi cation
of Vascular Bundle (Fig. 9–51)
A segm ent of the costal cartilage is isolated and re-
moved subpericondrially. Dissection proceeds, identi-
fying and isolating the underlying internal mammary
vessels (7) and the anterior intercostal vessels (8). At-
tention should be paid to preservation of the pleura.
Figure 9–51
Cartilage resection and
identi cation of vascular bundle.
4. Intercostal m.
7. Internal mammary a. and v.
8. Anterior intercostal a., v., and n.
9. Transverse thoracic m.

Division of the Intercostal Muscles
(Fig. 9–52)
After the vascular pedicle (8) is safely dissected, the in-
tercostal muscles (4) of the fourth and fth interspaces
are incised below the fourth and above the sixth ribs,
leaving as wide a muscle cuff as possible for the fth
rib, both superiorly and inferiorly.
Osteotomy and Elevation of the Rib
Graft (Fig. 9–53)
The fth rib (1) is divided laterally as far as required,
and the vascularized rib is elevated from the pleura
(10). The internal mammary vessels (7) inferior to the
origin of the fth anterior intercostal vessels are lig-
ated. Then the vascularized rib is based on the vessels
superiorly. Pedicle length is ~6.0 cm .
VASCULARIZED RIB GRAFT (BASED ON THE ANTERIOR INTERCOSTAL ARTERY)
505
Figure 9–52
Division of the intercostal muscles.
4. Intercostal m.
7. Internal mammary a. and v.
8. Anterior intercostal a., v., and n.
9. Transverse thoracic m.
10. Pleura
Figure 9–53
Osteotomy and elevation of the
rib graft.
1. Fifth rib
4. Intercostal m.
7. Internal mammary a. and v.
8. Anterior intercostal a., v., and n.
9. Transverse thoracic m.
10. Pleura

ANTERIOR COSTAL
OSTEOCUTANEOUS FLAP
Flap Design and Proposed Rib
(Fig. 9–54)
The axis of the ap is the intercostal space of the pro-
posed rib (as an example, the fth intercostal space).
Flap size is up to ~10
30 cm, corresponding to the rib
length required.
506
III.9 TRUNK: THORAX
Figure 9–54
Flap design and proposed rib.
1. Internal mammary a.
2. Anterior intercostal a.
3. Direct cutaneous perforator
4. Pectoralis major m.
5. Sternum
6. Transverse thoracic m.
7. Fifth rib
8. Pleura
9. Intercostal m.

Identi cation of the Vascular Bundle
(Fig. 9–55)
In the medial incision of the ap, the direct cutaneous
perforator (3) from the internal m ammary vessels (1)
should be carefully identi ed and preserved before dis-
secting the costal cartilage.
The skin should be kept intact and connected with
the pectoralis (4) and intercostal muscles above and be-
low the fth rib during ap dissection. It is useful to an-
chor the skin to the underlying m uscle to prevent
shearing.
ANTERIOR COSTAL OSTEOCUTANEOUS FLAP
507
Figure 9–55
Identi cation of the vascular bundle.
1. Internal mammary a.
2. Anterior intercostal a.
3. Direct cutaneous perforator
4. Pectoralis major m.
5. Sternum
6. Transverse thoracic m.
9. Intercostal m.

Osteotomy and Flap Elevation
(Fig. 9–56)
Following the technique of vascularized rib graft (7)
based on the anterior intercostal artery (2), the anterior
costal osteocutaneous ap is isolated on the internal
mammary vessels (1).
508
III.9 TRUNK: THORAX
Figure 9–56
Osteotomy and ap elevation.
1. Internal mammary
2. Anterior intercostal a.
3. Direct cutaneous perforator
4. Pectoralis major m.
6. Transverse thoracic m.
7. Fifth rib
8. Pleura
9. Intercostal m.

LATERAL THORACIC FLAP
(AXILLARY FLAP)
Arterial Anatomy (Fig. 9–57)
The anatomy for this area may be quite variable. There are
perhaps three axial arteries to nourish this skin region.
The cutaneous branch from the subscapular or tho-
racodorsal arteries (4) arises generally within 2 to 5 cm
beyond the origin of the subscapular artery and then
runs along the free anterior border of the latissim us
dorsi (6). The cutaneous branch (4), which has a diam e-
ter of ~1.0 mm in 70% of cases, can usually supply a skin
area of 10
20 cm on the posterior portion of the lat-
eral thoracic wall.
The cutaneous branch from the lateral thoracic ar-
tery (3) usually serves as the terminal branch after giv-
ing off branches to the pectoralis m uscles, and then
runs along the lateral border of the pectoralis major (5).
In females, this terminal branch thickens as it goes to
the breast. The cutaneous branch, present in 30% of
cases, with a diameter of 1.5 mm, supplies a skin area of
8
15 cm in the anterior portion of this region.
The accessory lateral thoracic artery originates
directly from the axillary or brachial artery (1) on its
anterior aspect and goes from the center of the axillary
fossa inferiorly along the middle axillary line; it then
turns toward the nipple. The artery is present in 70% of
cases and has a diameter of 1.4 mm; it supplies a skin
area of 7 12 cm in the midportion of this region. It can
also nourish the inner aspect of the upper arm.
Som e authors believe that the accessory lateral
thoracic artery is a variation of the cutaneous branch of
the lateral thoracic artery, with a different takeoff (ori-
gin). They use a com mon term, super cial lateral tho-
racic artery, for both vessels.
Venous Drainage
Usually, one or two venae comitantes accompany these
arteries.
Innervation
The sensibility of this region is supplied segmentally by
the intercostal nerves.
LATERAL THORACIC FLAP (AXILLARY FLAP)
509
Figure 9–57
Arterial anatomy for the lateral
thoracic ap.
1. Axillary a.
2. Accessory lateral thoracic a.
3. Lateral thoracic a. and its cutaneoous
branch
4. Thoracodorsal a. and its cutaneous branch
5. Pectoralis major m.
6. Latissimus dorsi m.

510
III.9 TRUNK: THORAX
The color and texture of this ap are good matches for
the head, neck, and hand. The donor scar is easy to con-
ceal, and the donor defect can be closed directly. Axil-
lary hair is available if it is required in the transfer. A
vascular pedicle can be created to a length of 10 cm . Ex-
ternal diam eters of the selected artery and vein are
usually ~1.2 and 1.5 mm, respectively. The size of the
ap can be ~10
20 cm.
One of the m ain disadvantages is the variable
anatomy of the three axial arteries, requiring more ex-
tensive dissection. The dominant vessels should be de-
termined and selected intraoperatively. For this reason,
this ap is not widely used. It cannot be a sensory skin
ap because its innervation is segmentally provided.
This ap is not recommended for routine use.
COMMENT AND INSIGHTS
Harvesting Technique
Flap Design and First Incision (Fig. 9–58)
The territory of the ap comprises the upper border,
pulsating path of the axillary artery; the posterior bor-
der, the lateral border of the latissimus dorsi; the ante-
rior border, the lateral border of the pectoralis major;
and the lower border, above the eighth rib. The ap lo-
cation m ay be changed slightly back and forth, accord-
ing to the arterial axis, with a suf cient diam eter
discovered during dissection.
The rst incision is along the course of the axillary
artery (the upper border of the ap).
Figure 9–58
Flap design and rst incision.
1. Axillary a. and v. and brachial plexus
2. Accessory lateral thoracic a. and v.
3. Lateral thoracic a. and v. and their cutaneous
branches
4. Thoracodorsal a. and v. and their cutaneous
branches
5. Pectoralis major m.
6. Latissimus dorsi m.
7. Serratus anterior m.

Dissection Using the Accessory Lateral
Thoracic Artery (Fig. 9–59)
The accessory lateral thoracic artery (2) is rst dis-
sected because it courses through the most super cial
layer. If its diameter is adequate, the vascular pedicle
can be dissected to the axillary or brachial artery (1).
LATERAL THORACIC FLAP (AXILLARY FLAP)
511
Figure 9–59
Dissection using the accessory lateral
thoracic artery.
1. Axillary a. and v. and brachial plexus
2. Accessory lateral thoracic a. and v.
5. Pectoralis major m.
6. Latissimus dorsi m.

Dissection Using the Lateral
Thoracic Artery (Fig. 9–60)
If the accessory lateral thoracic artery is absent or too
small, the dissection is carried onto the anterior wall of
the axillary fossa, along the lateral edge of the pec-
toralis major (5), to explore for the cutaneous branch of
the lateral thoracic artery (3). If the cutaneous branch is
large enough, the lateral thoracic artery is dissected,
and the skin ap is designed a little forward.
512
III.9 TRUNK: THORAX
Figure 9–60
Dissection using the lateral thoracic artery.
1. Axillary a. and v. and brachial plexus
3. Lateral thoracic a. and v. and their cutaneous branches
5. Pectoralis major m.
6. Latissimus dorsi m.

Dissection Using the Thoracodorsal
Artery (Fig. 9–61)
If both the above arteries are absent or too small, the
dissection is turned to the posterior wall of the axillary
fossa, along the anterolateral edge of the latissim us
dorsi (6), to explore for the cutaneous branch of the
thoracodorsal artery (4). If this branch is suf cient, the
thoracodorsal artery (4) is dissected out and the ap is
designed somewhat back.
LATERAL THORACIC FLAP (AXILLARY FLAP)
513
Figure 9–61
Dissection using the thoracodorsal artery.
1. Axillary a. and v. and brachial plexus
4. Thoracodorsal a. and v. and their cutaneous branches
5. Pectoralis major m.
6. Latissimus dorsi m.

Flap Elevation (Fig. 9–62)
The lateral thoracic ap is elevated, based on the pedi-
cle of the accessory lateral thoracic artery (2), as an
example.
514
III.9 TRUNK: THORAX
Figure 9–62
Flap elevation.
1. Axillary a. and v. and brachial plexus
2. Accessory lateral thoracic a. and v.
5. Pectoralis major m.
6. Latissimus dorsi m.
7. Serratus anterior m.

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Manktelow RT, McKee NH. Free muscle transplantation
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Palm er JH, Batchelor AG. The functional pectoralis
m ajor musculocutaneous island ap in head and neck
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of pectoralis m ajor m usculocutaneous free ap. Br J
Plast Surg 1986;39:57
Research Laboratory for Replantation of Severed Limbs,
Shanghai Sixth People’s Hospital. Free m uscle trans-
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m oses: report of a case. Chin Med J (Engl) 1976;2:47
Sharzer LA, Kalism an M, Silver CE, Strauch B. The
parasternal paddle: a m odi cation of the pectoralis
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67:753
Stepanov VS, Tatyanchenko VK. Surgical anatomy of
the m usculus pectoralis m ajor. Arkhiv Anatom ii Gis-
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Tobin GR. Pectoralis m ajor segm ental anatomy and
segmentally split pectoralis major aps. Plast Reconstr
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Wei WI, Lam KH, Wong J. The true pectoralis m ajor
myocutaneous island ap: an anatom ical study. Br J
Plast Surg 1984;37:568
Pectoralis Minor Muscle Flap
Harrison DH. The pectoralis m inor vascularized muscle
graft for the treatment of unilateral facial palsy. Plast
Reconstr Surg 1985;75:206
Manstein CH, Manstein G, Somers RG, Barwick WJ. Use
of pectoralis minor muscle in imm ediate reconstruc-
tion of the breast. Plast Reconstr Surg 1985;76:566
Terzis JK. Pectoralis minor: a unique muscle for correc-
tion of facial palsy. Plast Reconstr Surg 1989;83:767
Serratus Anterior Flap
Agarwal R, Agarwal S, Chandra R. The lateral pectoral
ap. J Hand Surg [Br] 1999;24:542
Arnold PG, Pairolero PC, Waldorf JC. The serratus ante-
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Bartlett SP, May JW Jr, Yarem chuk MJ. The latissimus
dorsi m uscle: a fresh cadaver study of the prim ary
neurovascular pedicle. Plast Reconstr Surg 1981;67:631
Buehler MJ, Pacelli L, Wilson KM. Serratus fascia “sand-
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15:315
Chang DW, Miller MJ. A subperiosteal approach to har-
vesting the free serratus anterior and rib myo-osseous
composite ap. Plast Reconstr Surg 2001;108:1300
Cuadros CL, Driscoll CL, Rothkopf DM. The anatomy of
the lower serratus anterior m uscle: a fresh cadaver
study. Plast Reconstr Surg 1995;95:93
de Fontaine S, Decker G, Goldschm idt D. Anom alous
blood supply to the serratus anterior muscle ap. Br J
Plast Surg 1994;47:505
Derby LD, Bartlett SP, Low DW. Serratus anterior free-
tissue transfer: harvest-related m orbidity in 34 con-
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Fotopoulos P, Holmer P, Leicht P, Elberg JJ. Dorsal hand
coverage with free serratus fascia ap. J Reconstr Mi-
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Gordon L, Rosen J, Alpert BS, Buncke HJ. Free microvas-
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Grotting JC. Microneurovascular free transfer of the
serratus anterior m uscle. In: Strauch B, Vasconez LO,
Hall-Findlay E, eds. Grabb’s Encyclopedia of Flaps. Vol
1. Boston: Little, Brown; 1990:608–612
Guelinckx PJ, Sinsel NK. The “Eve” procedure: the
transfer of vascularized seventh rib, fascia, cartilage,
and serratus m uscle to reconstruct dif cult defects.
Plast Reconstr Surg 1996;97:527
Harii K, Yamada A, Ishihara K, et al. A free transfer of
both latissimus dorsi and serratus anterior aps with
thoracodorsal vessel anastomoses. Plast Reconstr Surg
1982;70:620
Igawa HH, Minakawa HM, Sugihara T, Homma K. Cheek
reconstruction with an expanded prefabricated m us-
culocutaneous free ap: case report. Br J Plast Surg
1995;48:569
Kim Y, Chung Y, Kwon T, et al. Reconstruction of soft-
tissue defects using serratus anterior adipofascial free
ap. Plast Reconstr Surg 1999;103:925
Kurokawa M, Muneuchi G, Hamagami H, Fujita H. Re-
construction of four m etatarsal bone and soft-tissue
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cutaneous free ap. Plast Reconstr Surg 1998;101:1616
Lin C-H, Wei F-C, Levin LS, et al. Free com posite ser-
ratus anterior and rib aps for tibial com posite bone
and soft-tissue defect. Plast Reconstr Surg 1997;
99:1656
Lipa JE, Chang DW. Lateral thoracic artery as a vascular
variant in the supply to the free serratus anterior ap.
J Reconstr Microsurg 2001;17:413
Moscona RA, Ullmann Y, Hirshowitz B. Free composite
serratus anterior muscle–rib ap for reconstruction of
severely dam aged foot. Ann Plast Surg 1988;20:167
Richards MA, Poole MD, Godfrey AM. The serratus an-
terior/rib composite ap in mandibular reconstruction.
Br J Plast Surg 1985;38:466
Schwabegger AH, Hussl H, Rainer C, et al. Clinical ex-
perience and indications of the free serratus fascia
ap: a report of 21 cases. Plast Reconstr Surg 1998;
102:1939
Takayanagi S, Ohtsuka M, Tsukie T. Use of the latis-
sim us dorsi and the serratus anterior m uscles as a
combined ap. Ann Plast Surg 1988;20:333
Takayanagi S, Tsukie T. Free serratus anterior m uscle
and myocutaneous aps. Ann Plast Surg 1982;8:277
Tanaka Y, Miki K, Tajima S, et al. Reconstruction of an
extensive scalp defect using the split latissimus dorsi
ap in com bination with the serratus anterior m us-
culo-osseous ap. Br J Plast Surg 1998;51:250
Revascularized Costal Bone Graft and
Intercostal Flap
Ariyan S, Finseth FJ. The anterior chest approach for ob-
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Badran HA, El-Helaly MS, Safe I. The lateral intercostal
neurovascular free ap. Plast Reconstr Surg 1984;73:17
Buncke HJ, Furnas DW, Gordon L, Achauer BM. Free os-
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the intercostal ap for torso reconstruction. Plast Re-
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Harashina T, Nakajim a H, Im ai T. Reconstruction of
mandibular defects with revascularized free rib grafts.
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Little, Brown; 1990:1374–1378
516
III.9 TRUNK: THORAX

Little JW III, Fontana DJ, McCulloch DT. The upper-
quadrant ap. Plast Reconstr Surg 1981;68:175
Sera n D, Riefkohl R, Thomas I, Georgiade NG. Vascu-
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Reconstr Surg 1980;66:718
Sera n D, Vilarreal-Rios A, Georgiade NG. A rib-con-
taining free ap to reconstruct mandibular defects. Br
J Plast Surg 1977;30:263
Lateral Thoracic Flap
Baudet J, Garbe JF, Guimberteau JC, Lemaire JM. Axil-
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Composite Tissue Transplantation. St. Louis: CV Mosby;
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Baudet J, Guim berteau JC, Nascim ento E. Successful
clinical transfer of two free thoraco-dorsal axillary
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Cabanie H, Garbe JF, Guim berteau JC. Les bases
anatom iques du lam beau axillaire thoracodorsal en
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Corm ack GC, Lamberty BGH. The anatomical vascular
basis of the axillary fasciocutaneous pedicled ap. Br J
Plast Surg 1983;36:425
Harii K, Torii S, Sekiguchi J. The free lateral thoracic
ap. Plast Reconstr Surg 1978;62:212
Hu BC, Jian JB, Wang LB, et al. Surgical anatomy of the
free lateral thoracic ap: providing a new arterial ap
(Chinese). Chin J Surg 1981;19:479
Rowsell AR, Davies DM, Eisenberg D, Taylor GI. The
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BIBLIOGRAPHY
517

10
Abdominal Wall and Cavity
RECTUS ABDOMINIS FLAP
Anatomy (Fig. 10–1)
The origins of the rectus abdominis muscle (8) are the
symphysis pubis and pubic crest. Insertions are at the
fth, sixth, and seventh costal cartilages, interdigitating
with the pectoralis m ajor muscle. The rectus abdominis
form s an important part of the anterior abdominal wall
and exes the vertebral column. It is a long strap mus-
cle, thickly enclosed by the rectus sheath (6), except for
the posterior part below the arcuate line (7) that is
usually located m idway between the um bilicus and
symphysis pubis. The muscle has three tendinous inter-
sections: one at the xiphoid, one at the um bilicus, and
one in between. Average m uscle length, width, and
thickness are 30, 6, and 0.6 cm, respectively.
Blood Supply
The deep superior epigastric artery (3) comes from the in-
ternal mammary artery (4) at the level of the sixth inter-
costal space. It then runs down through the space between
the costal and xiphoid origins of the diaphragm, before the
lower bers of the transversus thoracis and the upper
bers of the transversus abdominis. It pierces the sheath of
the rectus abdominis lying behind the muscle, then enters
it and supplies the muscle and its overlying skin.
The average length of the superior epigastric artery
from its origin—the point of bifurcation with the mus-
culophrenic artery (5)—to its entrance to the rectus is
~4.6 cm (range, 3.1 to 6.1 cm). The diameter at its origin
is 2.1 mm (range, 1.2 to 3.8 mm), and the diameter at its
entrance to the rectus is 1.9 m m (range, 1.2 to 2.6 mm).
The vessel generally has two venae comitantes, the
diameter of which is 2.8 mm at the origin (range, 1.8 to
3.9 mm), and 1.3 mm at the muscular entrance (range,
1.1 to 2.6 mm).
The deep inferior epigastric artery (DIEA) (2) arises
from the external iliac artery (1) immediately above the
inguinal ligament. It then ascends obliquely and medi-
ally, penetrating the transversalis fascia, traveling in
front of the arcuate line (7), and continuing upward be-
tween the rectus abdominis and the posterior wall of its
sheath (6). Its entrance to the muscle is ambiguous and
not constant. Generally, it divides into the lateral and
m edial branches.
Usually, the lateral one is larger in diameter (in 88%
of cases) and runs lateral to the midline of the muscle.
It can be traced in continuity with the superior epigas-
tric artery (in 38% of cases). In addition to the perfora-
tors, the lateral branch gives off two or three twigs to
communicate with the superior epigastric artery.
The medial branch runs m edial to the midline of
the m uscle and becom es tapering at the level of the
umbilicus. It has no direct continuity with the superior
epigastric artery.
The average arterial length from its origin to its en-
trance to the rectus is 10.9 cm (range, 7.1 to 14.7 cm).
Diameters of the artery at the origin and entrance are,
respectively, 2.7 mm (range, 1.6 to 3.5 mm) and 2.0 mm
(range, 1.5 to 2.6 m m). The artery has two venae comi-
tantes, the diameter of which is 3.0 mm (range, 1.7 to
3.8 mm) at the origin and 2.2 mm (range, 0.8 to 3.1 mm)
at the entrance.
Both superior and inferior epigastric vessels give
off multiple myocutaneous perforators to penetrate the
m uscle and its anterior sheath, joining the vascular net-
work as the subcutaneous layer to nourish the skin of
the anterior wall of the abdomen. For details, refer to
the section which follows, Cutaneous Perforators and
Blood Supply of Abdominal Skin.

RECTUS ABDOMINIS FLAP
519
Figure 10–1
Anatomic diagram of the
rectus abdominis muscle and its arterial
supply.
1. External iliac a.
2. Deep inferior epigastric artery (DIEA)
3. Superior epigastric a.
4. Internal mammary a.
5. Musculophrenic a.
6. Posterior sheath of rectus
7. Arcuate line
8. Rectus abdominis m.
9. Lateral branch of DIEA
10. Medial branch of DIEA

CUTANEOUS PERFORATORS AND BLOOD SUPPLY
OF ABDOM INAL SKIN (FIG. 10 – 2 )
In its course behind or in the rectus abdominis muscle,
the superior and inferior epigastric vessels send off
many myocutaneous perforators, which penetrate the
rectus and its anterior sheath to join the network in
the subcutaneous layer, where they communicate with
the super cial inferior epigastric vessels (2) inferiorly,
with the super cial circum ex iliac vessels (4) infero-
laterally, with the lateral cutaneous branches of the in-
tercostal vessels (5) superolaterally, as well as with the
super cial superior epigastric vessels (3) superiorly.
According to recent anatomic investigations, among
these perforators there are about six major perforators
with a diameter greater than 0.5 mm, which are highly
concentrated in the paraumbilical area. The one at or a
little below the level of the umbilicus that arises from
the lateral branch of the deep inferior epigastric vessel is
usually the largest and mainly applicable for the pedicle
of the deep inferior epigastric perforator (DIEP) ap.
The vascular networks in the subcutaneous layer on
both sides of the abdominal wall also connect with each
other across the midline. However, according to some re-
cent reports, venous drainage by only the venae comi-
tantes of the DIEA may not be suf cient, especially in zone
IV (the farthest portion of the opposite side) of DIEP aps.
Venous congestion may occur in ~8% of cases, and some of
them may result in fat necrosis or partial necrosis. For this
reason, it is better to reserve the super cial inferior epi-
gastric vein for the DIEP ap to avoid venous congestion.
Innervation (Fig. 10–2)
The rectus abdominis m uscle is segmentally supplied
by nerves that are the continuation of the seventh to
11th intercostal nerves and the subcostal nerve (the
12th thoracic ventral ram us). After leaving the inter-
costal or subcostal spaces, they pass between the trans-
versus and internal oblique abdom inis and pierce the
sheath of the rectus to supply it. Some sensory bers, as
the term inals of nerves, penetrate the rectus m uscle
and its anterior sheath to supply the skin on the medial
portion of the abdominal wall. The lateral part of the
abdom inal wall is supplied by the lateral cutaneous
branches of the intercostal nerves.
The skin area at the um bilicus is supplied by the
10th intercostal nerve.
520
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Figure 10–2
Anatomic diagram of the cutaneous
perforators of the deep inferior epigastric vessels and
the cutaneous nerve supply.
1. Cutaneous perforator
2. Super cial inferior epigastric a.
3. Super cial superior epigastric a.
4. Super cial circum ex iliac a.
5. Lateral cutaneous branches of intercostal a.
6. Lateral cutaneous branches of intercostal n.
7. Anterior cutaneous branches of intercostal n.
8. Super cial external pudendal a.

RECTUS ABDOMINIS FLAP
521
Use of the rectus abdominis m uscle and musculocuta-
neous ap, based on the deep inferior epigastric vessels,
was a popular and acceptable procedure. The vascular
pedicle is quite constant, reliable, and anatom ically
long, with large-sized vessels. Elevation of the ap and
microvascular repair at a distant site are easily and rap-
idly accomplished.
Because the arterial system of the rectus abdominis
has extensive circulatory connections with som e of the
circum ferential arteries in the subcutaneous layer of
the abdom en (e.g., intercostal arteries), the size and
shape of the ap can be varied to suit any number of re-
cipient site requirements. Abundant tissue is available.
Subcutaneous tissue tends to be thicker, especially in
obese patients; however, on the lateral thorax in a tho-
racoumbilical ap, it tends to be of moderate thickness.
The entire rectus abdom inis muscle can survive on
either superior or inferior pedicles. Nevertheless, the
DIEA has certain advantages over the superior epigas-
tric artery: it is a larger vessel with a longer pedicle; the
cutaneous vascular territory is greater; and it gives rise
to the paraum bilical perforators, rather than m erely
connecting with them via a system of reduced caliber
vessels within the rectus muscle. Taking these facts into
account, the free transfer of the rectus abdom inis is
generally based on the inferior epigastric vessels. A ap
based on the superior vessels can be used for more local
transfer, for example, in breast reconstruction.
The rectus muscle ap is generally used for wound
coverage rather than for functional reconstruction. The
myocutaneous ap is not sensate because of m ultiseg-
mental innervation.
Taking the rectus m uscle and its anterior sheath
can result in some weakness of the abdominal wall and
m ay possibly cause abdom inal herniation or bulging.
For this reason, the resultant defect should be very
carefully repaired, especially below the arcuate line. If
both m uscles are taken, then it is imperative that the
sheath be closed with a patch, usually of non-autolo-
gous material.
The DIEP ap was developed because of a m ajor
concern about the functional and structural weakness
of the abdom inal wall from loss of the rectus m uscle.
This procedure leaves the m uscle and takes the skin
and subcutanaeous fat connecting w ith the vascular
pedicle via the perforator. The DIEP flap has been
widely applied for breast reconstruction or coverage
for skin defects. Donor-site m orbidity, such as abdom i-
nal herniation, bulging, and weakness is reduced, post-
operative pain is less, recovery is m ore rapid, and the
hospital stay is shorter. The m ajor disadvantage of the
DIEP ap is that the procedure becom es considerably
m ore com plex in dissection of the perforators from
their m uscular branches, w hich takes significantly
m ore tim e.
The m odi ed transverse rectus abdom inis myocu-
taneous (TRAM) ap m ay produce som e improvem ent
in the structural and functional loss of the rectus abdo-
m inis m uscle, when the lateral third of the m uscle is
left intact, whereas the m odi ed DIEP ap m ay sim -
plify dissection of the perforator by taking a 2 cm 2 cm
m uscle segm ent with it. The surgeon m ay choose the
procedure according to personal experience and clinical
indications.
COMMENT AND INSIGHTS

RECTUS ABDOMINIS MUSCLE FLAP
(BASED ON THE DEEP INFERIOR
EPIGASTRIC ARTERY)
Incision (Fig. 10–3)
A paramedian incision is made; the inferior portion of
the incision below the level midway between the um-
bilicus and symphysis pubis runs laterally down to the
midpoint of the inguinal ligament.
Exposure of the Muscle (Fig. 10–4)
The skin, fascia, and anterior sheath (2) are incised, and
the anterior surface of the rectus abdom inis (1) is
exposed.
522
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Figure 10–3
Incision.
1. Rectus abdominis m.
2. Sheath of rectus
3. DIEA
4. Arcuate line
Figure 10–4
Exposure of the muscle.
1. Rectus abdominis m.
2. Sheath of rectus

Identi cation of the Vascular Pedicle
(Fig. 10–5)
The deep inferior epigastric vascular bundle (3) is
identi ed at the lateral border of the lower part of the
m uscle above the pubic tubercle. The origin on the
symphysis pubis and pubic crest is detached.
RECTUS ABDOMINIS MUSCLE FLAP (BASED ON THE DEEP INFERIOR EPIGASTRIC ARTERY)
523
Figure 10–5
Identi cation of the vascular pedicle.
1. Rectus abdominis m.
2. Sheath of rectus
3. DIEA
4. Arcuate line

Completion of Harvesting (Fig. 10–6)
The rectus abdominis musclce (1) is separated from the
posterior sheath. It can be divided at any tendinous in-
tersection, even on its insertion, if necessary. After fur-
ther dissection, the length of the vascular pedicle (3)
can reach ~10 cm. The anterior sheath should be metic-
ulously sutured after transfer of the muscle ap.
524
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Figure 10–6
Completion of harvesting.
1. Rectus abdominis m.
3. DIEA
2. Sheath of rectus
4. Arcuate line
Patterns of the Myocutaneous Flap
(Fig. 10–7)
The base of the skin area of this ap is the rectus abdo-
minis muscle, and the center of the base is the paraum-
bilical area within 3 to 5 cm of the umbilicus. Owing to
the abundant interconnected circulation previously
described, the skin ap can be extended over the muscle
area, even across the midline, to at least the lateral border
RECTUS ABDOMINIS MYOCUTANEOUS
FLAP (BASED ON THE INFERIOR
EPIGASTRIC ARTERY)

C. Middle TRAM ap. The umbilicus is left in situ.
D. Thoracoumbilical ap (extended deep inferior epigas-
tric ap). The procedure will be described in detail later.
E. Thoracoum bilical and vertical com bined myo-
cutaneous ap.
Figure 10–7
Patterns of the
myocutaneous ap (see the text for
details).
of the opposite rectus muscle. The ap can be designed
transversely, obliquely, or vertically, on either the upper
or lower abdomen.
A. Vertical rectus abdom inis myocutaneous ap. The
procedure is fairly similar to the muscle ap.
B. Lower TRAM ap. The procedure will be described in
detail later.
RECTUS ABDOMINIS MYOCUTANEOUS FLAP (BASED ON THE INFERIOR EPIGASTRIC ARTERY)
525

LOWER TRANSVERSE RECTUS
ABDOMINIS MYOCUTANEOUS
(TRAM) FLAP
For drawing the design of the lower TRAM ap, refer to
type B of the rectus abdom inis myocutaneous aps
(Fig. 10–7).
The skin territory of the ap is de ned below the
um bilicus, above the inguinal ligam ent, and not ex-
tending to the anterosuperior iliac spine. Its maximum
area may be 30
20 cm.
Elevation of Lateral Flap Edges
(Fig. 10–8)
The skin ap is incised to the deep areolar fascia or sheath
of the rectus (2). Both lateral edges of the ap are raised,
preserving the fascial layer on the undersurface of subcu-
taneous fat. Dissection proceeds medially to both borders
of the carrier rectus muscle (1). The anterior sheath (2)
beneath the skin ap is incorporated into the ap, and
several tacking stitches are applied at the edges to pre-
vent shearing of the musculocutaneous perforators.
526
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Figure 10–8
Elevation of lateral ap edges.
1. Rectus abdominis m.
2. Sheath of rectus
3. DIEA
4. External oblique m.
5. Synthetic or alloplastic mesh

Identi cation of DIEA (Fig. 10–9)
The rectus m uscle (1) inferior to the skin ap is ex-
posed, and the deep inferior epigastric vessels (3) are
identi ed and dissected at the lateral border of the rec-
tus above the pubic tubercle. The muscle is divided over
the superior edge of the skin ap.
LOWER TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP
527
Figure 10–9
Identi cation of DIEA.
1. Rectus abdominis m.
2. Sheath of rectus
3. DIEA