SUMMARY. The authors present their experience of the extended deep inferior epigastric flap (EDIEF) for the coverage of over 30 cases of extensive compound defects of the groin, lower abdomen, perineum and trochanteric areas, and the thigh, as well as distant areas such as the hand where this flap can be used both as a distant or as a free flap. The EDIEF, though described since 1983 by Taylor et al., has not been given enough trials for extensive clinical application. The indications for its use, its limitations, and the technical difficulties and hazards during use, as well as its application in different ages and sex, are demonstrated and discussed. The EDIEF seems to be one of the most robust and the most consistently vascularised flaps. Its length and width, the arc of rotation, the presence of both muscular and fascial portions, the ability to include other musculocutaneous and random territories of the epigastric system, its rich vascularity, plus the size of the flap and of the deep inferior epigastric artery make it one of the most versatile and reliable flaps for the coverage of large defects.

The epigastric vascular arcade supplies a wide area of the anterior abdominal wall and exhibits a strategic location providing a highly versatile multicomponent flap that can bridge defects from chest to knees (Brown et al., 1975). The vascular tree of this part of the body is a link between the subclavian vessels (via internal mammary and superior epigastric vessels), external iliac vessels (via inferior epigastric vessels) and intercostals (via costomarginal. vessels) (Boyd et al., 1984).
These excellent communications between such sizable vessels ensure a highly vascular territory and hence construction of a safe transfer of various tissue (Corlett and Taylor, 1980). One of the best uses of this vascular arcade is the extended inferior epigastric flap (ElEF) (Boyd et al., 1984) which is a multicomponent transfer formed of axial component (inferior epigastric vessels), muscular component (rectus abdominis muscle), fasciocutaneous component (of vessel dispositions and locations), and a bony component (9th or 10th rib). The resulting flap is long (nearly 1/4 of body height), narrow based (trunk of inferior epigastric vessels), and reaches as far as chest, breast, anterior trunk, perineum, posterior trunk, flank, groin and thigh down to ipsilateral knee (Mixter et aL, 1989).

Thirty cases of various defects were treated by using the E1EF during the period 1989-1992 in the Kasr-El-Aini and AI-Salam Hospitals, Egypt. Twelve cases were groin defects, ten of which were contracted scars treated by release and/or excision, one case was epithelioma of the vulva and groin fold treated by radical vulvectomy, and the last was a histiocytoma of the groin excised with a safety margin. All defects were covered using the E1EF and donor site closed primarily.
Five cases of bed sores affecting the trochanteric, iliac crest, and sacral regions were treated by bursectomy, debridement and covered E1EF. One of these was an axial flap based on skeletonized inferior epigastric vessels to enable 120' rotation of the flap to cover a trochanteric ulcer. Four cases of infected traumatic wounds of the femoral triangle were cleaned and covered by E1EF to save the limbs from risk of secondary haemorrhage. One case of haemangioendothelioma of the lateral aspect of the thigh, which was excised leaving a large defect, was successfully closed using the ElEE Three cases of lacerated wounds around the elbow, with various extents of soft tissue loss and exposure of nerves and vessels and parts of bones, were treated by debridement and primary neurovascular repair and covered by the fasciocutanteous element of the flap only, which was detached 3 weeks later.
Two cases of degloved injury of the forearm were also treated by the same technique. Two flaps were used simultaneously to cover both hands and distal forearms of a post-burn contracted scar (PBCS) in a 5-year-old child.One case of above-knee amputation, with exposure of distal end femur, was covered by the E1EF.

In this work 30 flaps were performed to demonstrate the clinical applications and versatility of the E1EF. The flap was successfully used to cover defects of different aetiology and location. One case however developed severe venous congestion and gangrene, while another suffered loss of the distal 5 cm of the fasciocutaneous component (see Table).

It was always been the dream of the plastic surgeon to find an ideal flap that is highly versatile, safe, with a wide arc of rotation, able to reach a distant destination, with rich blood supply, easy design, rapid raising and not bulky. The EIEF seems to top the list of flaps achieving the above criteria (Boyd et al., 1984).
The anatomical study done by Taylor et al. (1984) showed that the EIEF is nourished by the deep epigastric system that forms the abdominal portion of a vascular railroad which links the subclavian and iliac vessels and provides reliable perforators that permit the raising of several flaps.
In our work we found that a skin flap of large dimensions can be raised in one stage. The largest was 36 cm. This was extended to the scapular line, although we lost the distal 5 cm of this flap, i.e. nearly up to the post-axillary line. We also succeeded in raising two other flaps safely to the post-axillary line without any ill effects. The longest flap done by Taylor et al. (1983) reached only as far as the midaxillary line.
The disc in the anterior rectus sheath, necessary to capture the cutaneous perforators, was narrowed by carefully approaching the vessels from both medial and lateral directions. In this way the skin island mobility is increased and hence its arc of rotation. The narrowing of the disc until it carries two perforators is optimum for flap survival, although Taylor et al. (1984) harvested only one perforator and luckily enough the flap survived.
This flap is advantageous in that it has a wide arc of rotation which reaches almost to the ipsilateral knee and contralateral mid-thigh (Gottlieb et al., 1986). In our work we were able to cover a defect following soft tissue sarcoma immediately above the knee on the same side (as done by Gottlieb et al., 1986), to cover a defect over the medial condyle femur following liposarcoma excision.
Lewis et al. (1980) described the use of a nondelayed thoraco-epigastric flap for a defect of the upper extremity.
In our work we used the fasciocutaneous element of the EIEF alone to cover the forearm and hand of a child with a defect following excision and release of a PBCS, with preservation of most of the integrity of the anterior abdominal wall. The fasciocutaneous element of the flap proved to be supple, soft, not bulky and is equal to the Chinese flap in many aspects and even superior in having less donor site morbidity.
The versatility of the flap was demonstrated by Taylor et al. (1984) in 18 patients, when they used it as a free flap in 15 cases and as a pedicle in three.
In our work we demonstrated the versatility of the flap as a pedicled flap to cover large defects in the groin, trochanters, forearm and hands, and to reconstruct the vulva and perineum.
Out of 30 cases we had two complications, one with venous congestion and gangrene, most probably due to too much bending of the flap, the other with distal 5 cm flap necrosis due to too much extension of the flap to the scapular line.
The donor defect was successfully closed primarily in all cases without the need to mesh, and no hernia developed in any of our cases, which were followed up for between some months to two years post-operatively. They all have an accepted scar. In one case we used the two sides to provide two flaps simultaneously to cover post-burn defects in both upper limbs and we closed the donor defects primarily by utilizing the ample tissue reserve provided by the anterior abdominal wall and saving the patient much suffering by avoiding a multistaged procedure such as the classical jump flap or some other technique.
With our experience in 30 cases we are convinced that this procedure is safe, speedy and reliable, and that it fulfils almost all the criteria sought by every reconstructive surgeon.

Fig. (1-A) Fig. (I-B) Fig. (2-A) Fig. (2-B) Fig. (3-A) Fig. (3-B)

Fig. 4

RESUME. Les auteurs présentent les résultats de leur expérience de l'emploi du lambeau épigastrique intérieur profond étendu pour la couverture de 30 cas de défauts composés étendus dans la région de l'aine, l'abdomen inférieur, le périnée, les trochanters et la cuisse, comme aussi dans les régions distantes comme la main, où ce type de lambeau peut être utilisé soit comme lambeau à distance soit comme lambeau libre. Le lambeau épigastrique inférieur profond étendu a été décrit pour la première fois par Taylor et coll. (1983) mais il a eu une application clinique très limitée à cause de l'insuffisance des épreuves pratiques. Ici les auteurs donnent des indications pour ce qui concerne son emploi, ses limitations, les difficultés et les dangers techniques pendant l'emploi, et l'application chez les patients masculins et féminins d'àge divers. Ce type de lambeau parait être un des lambeaux les plus résistants et les plus régulièrement vascularisés. Sa Ion ueur et sa largeur, l'arc de rotation, la présence de portions non seulement musculaires mais aussi fasciales, la capacité d'embrasser 9 d'autres territoires musculocutanés et variés du systyme épigastrique, sa riche vascularité, les dimensions du lambeau et de l'artère épigastrique inférieure profonde - tous ces facteurs se combinent pour faire de ce lambeau une des méthodes les plus universelles et fiables pour la couverture des gros défauts cutanés.

BIBLIOGRAPHY

1. Boyd J.B., Taylor GI Corlett R.J.: The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast. Reconstr. Surg., 73: 1, 1984.
2. Brown R.G., Vasconez L.O., Jurkiewiez M.L: Transverse abdominal flaps and the deep epigastric arcade. Plast. Reconstr. Surg., 55: 416, 1975.
3. Corlett R.J., Taylor GI: The angiotomes of the body and their relation to local and distant tissue transfer. Paper presented at the British Association of Plastic Surgeons Summer MeetiDg, July 1980.
4. Gottlieb M.E. et al.: Clinical applications of the extended deep inferior epigastric flap. Plast. Reconstr. Surg., 78: 782, 1986.
5. Lewis V.L. Cook J.Q.: The nondelayed thoracoepigastric flap: coverage of an extensive electric burn defect of the upper extremity. Plast. Reconstr. Surg., 65: 492, 1980.
6. Mixter R.C., Wood W.A., Dibbell D.G.: Retroperitoneal transposition of rectus abdominis myocutaneous flaps to the perineum and back. Plast. Reconstr. Surg., 65: 437, 1990.
7. Taylor G.I. et al.: The extended deep inferior epigastric flap: a clinical technique. Plast. Reconstr. Surg., 72: 751, 1983.
8. Taylor G.I. et al.: The versatile deep inferior epigastric (inferior rectus abdominis) flap. Brit. Plast. Surg., 37: 330, 1984.