The lower transverse incision is performed at this time as well as the releasing of the umbilicus from the flap. The contralateral portion of the flap is raised from the lateral to medial taking the opportunity to map out the perforators as they are encountered and then mapping them on the actual flap. Then the ipsilateral flap is then raised from lateral to medial along to the edge of the rectus sheath, keeping in mind the established location of the rectus perforators. The lateral and medial width of the rectus muscle is defined by touching the rectus sheath with a cautery to look for the vertical twitch. The first incision of the rectus sheath is on the lateral border of the rectus muscle at the superior edge of the flap. The incision is extended inferiorly to just past the arcuate line. Approximately one sonometer margin of anterior rectus sheath is retained laterally in earlier methods. We would keep a strip of lateral muscle to protect the segmental nerves and length of the muscle. However, at this point we retain as much of the muscle as possible. The inferior epigastric artery and vein are located on the inferior aspect of the rectus muscle. The vessels meet the edge of the muscle and this can be a variable anatomical point.

transverse incision

perforator mapping

rectus muscle

inferior epigastric artery

muscle retention