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is on the superficial inferior epigastric system, providing that it is large enough. If it is small, one may be faced with anywhere from four to six anastomoses to perfuse the flap.
Operative Sequence
PLATE VII-1. BIEF Superficial System
 A. The territory of the BIEF is outlined over the lower abdominal key anatomic landmarks. It is the same area as that discarded in a paniculectomy. In thin individuals, however, the territory is proportionately smaller. The superficial epigastric artery and vein and the
deep inferior epigastric system are shown here, relatively larger than in actuality. Veins of the superficial epigastric system can often be visualized through the skin surface, particularly in thin individuals. The deep inferior epigastric system arises from the medial side of the external iliac vessels 1 to 2 cm above the level of the inguinal ligaments.
 B. An incision has been made along the right lower margin of the flap to expose the superficial inferior epigastric vessels draining into the saphenous bulb on the venous side and deeper into the medial side of the femoral artery. Occasionally, this artery is joined by the superficial circumflex iliac vessel as a common origin. Two to three veins
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may be encountered, one of which parallels and accompanies the inferior epigastric artery, which may be quite small. A Doppler probe helps to confirm the presence of the artery. The vessels are traced to their origin, increasing in size as branches encountered.
 C. The upper margin of the flap at the level of the umbilicus has been incised. If the inferior system is large, this dissection can proceed rapidly from above down at the level of the deep fascia to the lower border of the flap and the isolated inferior pedicles. If the superficial inferior epigastric system is small, the deep dissection must be isolated.
This is outlined in Plate 7-2.
 D. The bridge of tissue through the two inferior pedicles has been cut paralleling the pubic hairline.
 E. The mobilized flap is left on its isolated pedicle until the recipient reception area is completed. Two safety stitches should be placed next to each inferior pedicle to prevent traction disruption of the delicate vascular structures during this waiting period.
 F. The isolated BIEF illustrates its long, relatively wide conFIGuration and double inferior vascular input.
PLATE VII-2. BIEF Deep System
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