Diep an

Tissue:Skin & fat from the lower abdominal wall. The reliable area crosses the midline. Zones 1, 2 và 3 are generally well perfused. Innervation: Intercostal T11 and T12 dermatome via intercostal nerves. Not usually harvested as a sensory flap. There are some who encourage this, but the benefit and outcome are unclear. Blood supply: The deep inferior epigastric artery & venae via perforators through the rectus muscle. The perforators range in form size from from 0.3 milimet khổng lồ 1 mm. Flaps can be harvested reliably on a single large perforator system. Artery: Large caliber artery from 2 to 4 millimeters. Vein(s): The venae are typically paired, & often join to lớn a comtháng vessel at their draining point on the external iliac. One vein is usually larger & comparable in caliber khổng lồ the artery. Pedicle length: From the perforator point to lớn the origin on the external iliacs. Very long with significant freedom to position.
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The DIEPhường. flap can be used for a variety of reconstructive procedures when a large segment of soft tissue, including fat & skin is necessary. It has become more popular for breast reconstruction, but requires significant microsurgical experience khổng lồ harvest.

Anatomy

The deep inferior epigastric artery arises from the external iliac artery & runs from lateral to medial under the rectus muscle. It can enter the substance of the muscle or run deep to it, while sending branches into the muscle và through the muscle. Perforators often travel through the tendinous inscriptions of the rectus muscle, making their dissection somewhat more difficult. In most patients the DIEP. và its venae can supply adequate circulation for zones 1-3, making the territory of perfusion larger than that of the SIEA flap.

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Anatomy of the abdominal skin harvested with the DIEPhường. flap. On the right side of the abdomen, a large DIEPhường perforator through the rectus muscle is illustrated. On the contralateral side, the superficial inferior epigastric artery (SIEA) and the superficial inferior epigastric vein (SIEV) are demonstrated. Both the DIEP and SIEA system provide circulation khổng lồ the lower abdominal skin. However, the SIEA is usually small and has a shorter vascular leash. Most surgeons prefer the DIEP flap is available.


The perforating branches pierce the rectus fascia to lớn supply the abdominal fat và skin. The DIEA & the accompanying veins are pictured in the illustration entering the muscle below the junction of the middle & lower third of the muscle. The DIEA can run laterally, medially or centrally under the muscle, as it ascends superiorly. There often is symmetry with the contralateral vessels, however this is not consistent.


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Cross Section of the abdominal wall demonstrating DIEA perforators. In this case a central DIEA system is shown with a perforating system piercing the rectus muscles và supplying the overlying skin and fat.


Flap Design

The abdominal skin island is designed with the lower aspect of the incision transversely placed above the pubic bone, in line with the typical transverse Cesarean section incision. It extends laterally with a gentle curve superior to lớn the inguinal ligament finishing adjacent to lớn the anterior superior iliac spines. The upper incision is placed above sầu the umbilicus và gently curves laterally to meet the lower transverse incision marking. With the patient in the supine position và the knees slightly flexed.

After flap harvesting, the abdominal skin và fat above the flap is elevated lớn the costal margin (green arrows). The tissue plane is just superior to lớn the rectus sheath, centrally it is firmly attached to lớn the rectus sheath while laterally this plane is quite Smartphone. By beginning the elevation laterally and then focusing medially, the elevation is simpler.


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The green arrows show the extent of undermining after flap harvest to lớn cthua the abdomen. A preoperative pinch test with the knees flexed can help assess the extent of the flap markings so closure is not too tight.


Operative Procedure

The patient is prepped and draped supine with the arms stretched out on an arm board. The abdominal tissue can be pinched to lớn determine the tightness of postoperative sầu closure và markings can be adjusted accordingly. This is best done with the knees and hips slightly flexed. Perforators can optionally be assessed with the pencil Doppler. If bilateral flaps are to be harvested, the Doppler signals can be marked on the contralateral side as well. This is a good practice even in unilateral flaps lớn find the largest và loudest perforators.

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The flap is marked & the loudest Doppler signals are marked with an "x". The loudest perforator is marked with largest kích thước "x". This is the perforator that is dissected miễn phí in the illustrations below.


The flap is usually elevated from lateral lớn medial và the tìm kiếm for perforators is begun when the territory of the rectus sheath over the lateral rectus muscle is reached. This dissection can be performed with the electrocautery on a low setting, or with bipolar forceps & scissors. If bilateral flaps are being prepared, the midline incision can be made & the flap traced from medial lớn lateral as well, in order to help surround the perforators. lưu ý that the attachment of the flap to the rectus fascia in the midline is much more adherent & the plane is more difficult khổng lồ dissect at this màn chơi.


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The major perforator lớn the skin is identified. In this case there is one major perforator & it is used for the flap harvest.


As larger perforators are identified, smaller ones may be ligated. Usually the single flap can be supported on one major perforator. Occasionally, if the perforators are small, a second perforator may be used as well, as long is it is in a similar longitudinal plane with its counterpart. Two different longitudinal planes would result in excess muscle transection. The whole point of the DIEPhường flap is khổng lồ preserve abdominal muscles.

The umbilicus is separated from the flap with a periumbilical incision (marked in xanh above), leaving the stalk attached lớn the abdominal wall. When the abdomen is re draped, the umbilicus is brought through an new incision.


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The facia is incised longitudinally and the perforator is traced through the rectus muscle. Very small branches to the muscle are ligated or coagulated with the bipolar electrocautery.


When a large dominant perforator is isolated, the rectus fascia is incised longitudinally, around the perforator. Great care is required so as to lớn not injure the vessels, especially the vein, which can be quite delicate. The fascia is opened for 10 lớn 12 centimeters và the perforator is traced through the muscle, using gentle retraction of the muscle & the bipolar electrocautery. Small branches of the perforator are coagulated or clipped as they sprout into lớn the muscle và the perforator is traced to lớn the DIEA and the venae commitans.


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The perforator is approached from medial and lateral và isolated lớn the DIEA & veins. It is "surrounded".


The DIEA vessels are then traced baông chồng to lớn near their origin while retracting the muscle away from the deep abdominal contents. When the entire flap is isolated on the perforator and DIEA/DIEV, và the recipient area is ready, the DIEA and the venae can be ligated và divided. The rectus sheath is closed with a running large caliber non-braided suture.


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The flap is isolated on the DIEPhường vessels. In this case the contralateral superficial vein was also harvested.


The abdominal wall is undermined lớn the costal margin và the abdominal incision is closed in layers over suction drains with the hips flexed và knees bent in a semi-Fowler position. The umbilicus is brought through the abdominal wall and sutured inkhổng lồ position. The patient is allowed lớn mobilize when clinically indicated for the recipient area. The patient ambulates with the hips flexed until the tension of the closure slowly resolves.