Perfusion classification in a IR injury DIEP flap model Figure 7.1 (A) Design of the flap on the lower abdomen. (B) TRAM flap is dissected based on the deep inferior epigastric vessels. The abdominal fascia is closed with a running suture, and an elastic sheet is placed before the inset of the flap in order to prevent the direct ingrowth of the flap from the undersurface. (C) Flap sutured in place. (D) Partial flap loss located on the contralateral and lower border of the flap. The operation is performed using microsurgical instruments and magnification with the use of an operating microscope. Skin is incised down to the fascia circumferentially. The superficial epigastric artery is coagulated with bipolar tweezers bilaterally. The right skin island is elevated up to the linea alba, and the perforators of the deep epigastric system are transected on the right side. The left skin island is elevated toward the lateral edge of the rectus abdominus muscle. The abdominal fascia is then incised at both sides of the rectus muscle. After the transection of the muscle at the cranial edge of the skin island marking, the superior epigastric artery is coagulated. The rectus muscle and flap are elevated toward a pedicle tram flap based on the deep inferior epigastric artery (Figure 7.1B). At the caudal margin, the skin flap is dissected over 3 mm so that the microvascular clamp (Acland, S&T®, Switzerland) can be placed over the rectus muscle and the vascular pedicle. The fascia is closed with the pedicled flap on top with interrupted Polysorb 6‐0 sutures (Tyco®, USA). The vascular pedicle is not dissected from the rectus muscle to ensure that no surgical trauma is caused and that during the closure of the fascia, 103
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