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Since plastic surgery evolved as a specialty in the early part of this century, the integument of the anterior abdominal wall has been one of the premier sources of tissue for local and distant flap transfer. It enjoys a robust blood supply, scars are easily concealed, the anatomy is familiar to most surgeons, and there is an abundance of skin and subcutaneous tissue, especially in the parous woman. Perhaps the most coveted expanse of skin and fat is that area below the umbilicus because in most cases the donor defect can be closed by an abdominoplasty procedure, leaving only a suprapubic transverse scar.It is not surprising therefore that for decades attention has focused on the lower abdomen as a potential donor site for reconstruction of the breast following mastectomy. Initially flap transfers were performed as multistaged, tube pedicle procedures, but the pendulum of surgical preference has since swung towards one-stage operations. The first of these was a brief encounter by microsurgeons in which the lower abdominal integument was transferred to the breast as a free flap, designed to be based on the deep inferior epigastric (DIE) vesse1s.l Soon after, proponents of the pedicled musculocutaneous flap advocated a "burrowing" approach from above and Hartrampf, Scheflan, and Black2 introduced the lower transverse rectus abdominis musculocutaneous (TRAM) flap. More recently, the lower abdomen has been reappraised by microsurgeons. Hester et aL3 have transferred this skin paddle based on the superficial inferior epigastric (SIE) system, and Shaw4 has produced a large series of free flap reconstructions of the breast, returning once again to the DIE vessels to nourish the tissue.Unfortunately, none of these operations has proved to be a panacea for all occasions. Free flap operations provide tissue with a good blood supply, but then the surgeon is confronted with anastomotic problems: the SIE vessels are small and the pedicle is short. The DIE vessels are longer and Downloaded by: National University of Singapore. Copyrighted material.

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