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Orchiopexy of high intra-abdominal testes with division of the internal spermatic artery and vein is associated with subsequent testicular atrophy in a significant percentage of cases. We herein describe 2 patients in whom arterial supply and venous drainage to the testis were maintained using microvascular anastomosis. The internal spermatic artery and vein were anastomosed to the deep inferior epigastric artery and vein. Patency of the vascular anastomosis was verified by subsequent radionuclide examinations and selective arteriography in 1 patient.

The rapid development of postmastectomy breast reconstruction has shown that the rectus abdominis muscle is a useful carrier for abdominal wall skin. Detailed analysis of the vascular anatomy of the abdominal wall has extended the uses of the transverse rectus abdominis musculocutaneous flap to major chest-wall reconstruction, both as a transposition flap and as a free-tissue transfer. Although the most direct pathway to the paraumbilical perforators that supply the large skin island of the flap is from the deep inferior epigastric artery, numerous collateral pathways exist from above that recruit blood from the intercostal vessels and the internal mammary artery even if it has been ligated or used for myocardial revascularization. Awareness of these collateral pathways and care to preserve them whenever possible, combined with the willingness to supplement blood flow with a microvascular anastomosis of the deep inferior epigastric vessels, allows the surgeon to use the rectus abdominis flap and its variations in almost any major chest-wall reconstruction (Fig. 11).

The rectus abdominis musculocutaneous flap has many advantages, but its disadvantages are also well-known. These are the possibility of abdominal herniation and, in certain situations, its bulk. To overcome these problems, an inferior epigastric artery skin flap without rectus abdominis muscle, pedicled on the muscle perforators and the proximal inferior deep epigastric artery, have been used in two patients. A large flap without muscle can survive on a single muscle perforator.

The vascular territories of the superior and the deep inferior epigastric arteries were investigated by dye injection, dissection, and barium radiographic studies. By these means it was established that the deep inferior epigastric artery was more significant than the superior epigastric artery in supplying the skin of the anterior abdominal wall. Segmental branches of the deep epigastric system pass upward and outward into the neurovascular plane of the lateral abdominal wall, where they anastomose with the terminal branches of the lower six intercostal arteries and the ascending branch of the deep circumflex iliac artery. The anastomoses consist of multiple narrow "choke" vessels. Similar connections are seen between the superior and the deep inferior epigastric arteries within the rectus abdominis muscle well above the level of the umbilicus. Many perforating arteries emerge through the anterior rectus sheath, but the highest concentration of major perforators is in the paraumbilical area. These vessels are terminal branches of the deep inferior epigastric artery. They feed into a subcutaneous vascular network that radiates from the umbilicus like the spokes of a wheel. Once again, choke connections exist with adjacent territories: inferiorly with the superficial inferior epigastric artery, inferolaterally with the superficial circumflex iliac artery, and superiorly with the superficial superior epigastric artery. The dominant connections, however, are superolaterally with the lateral cutaneous branches of the intercostal arteries. For breast reconstruction, it would appear that prior ligation of the deep inferior epigastric artery would be of advantage when elevating the lower abdominal skin on a superiorly based rectus abdominis musculocutaneous flap. The vascularity of this flap would be further increased by positioning some part of the skin paddle over the dense pack of large paraumbilical perforators. Based on these anatomic studies, the relative merits of the superior and deep inferior epigastric arteries with respect to local and distant tissue transfer using various elements of the abdominal wall are discussed in detail.

The intraoperative evaluation of flap perfusion is essential to the success of tissue transfer.1,2 Despite flap survival, hypoperfusion at the tip or along the wound edges predisposes patients for delayed wound healing, tissue necrosis and sometimes requires a second flap.3,4 As this represents a major complication, considerable efforts have been undertaken to improve intraoperative assessment of peripheral flap perfusion, which often remains a highly subjective evaluation based on the surgeon's individual experience taking into account parameters such as capillary refill, turgor, flap temperature, and bleeding from the wound edges to variable degrees.2 Objective methods like thermography, laser-assisted Doppler flow measurement, or tissue oxygenation have been proposed but have not become widely accepted in the clinical setting for numerous reasons.2 In recent years, indocyanine-green fluorescence angiography (ICG-FA) has evolved considerably making it cost-effective and simple to use in the clinical setting.2,5–7 In autologous breast reconstruction with microvascular-free flaps, ICG-FA has helped to reduce postoperative fat necrosis by allowing visualizing the extent of critically perfused areas intraoperatively which need to be resected.8–10 Only few reports utilizing ICG-FA in pedicled flaps exist.11–13 In a pedicled flap, both the amount of tissue available for transfer and inset of the flap are limited. Contrary to a microvascular deep inferior epigastric artery perforator flap, the potential for intraoperative tissue resection at the margins is significantly limited as it reduces flap reach without any means of lengthening the vascular pedicle. Adequate perfusion of the tip of the flap is crucial as it often covers the most critical aspect of the defect. Similar to microvascular perforator flaps, ICG-FA may be useful in pedicled perforator flaps to assess perfusion. The aim of the study is to retrospectively evaluate our experience with ICG-FA to determine safe flap dimensions of pedicled flaps based on a single perforator intraoperatively.