ARTERIAL VASCULAR ANATOMY OF THE UMBILICUS

The rare occurrence of umbilical necrosis after performance of a trans verse rectus abdominis muscle (TRAM) flap prompted this investigation into the specific arterial anatomy of the umbilicus using multiple ana tomic techniques. Sixteen fresh cadavers were studied by using dissect ion of blue latex-injected specimens, radiography of barium latex-inje cted specimens, and selective ink injection of individual perforators. It was discovered that the umbilicus receives arterial inflow by mean s of three distinct deep sources in addition to the subdermal plexus. These deep sources are (1) the right and left deep inferior epigastric arteries that each give off several small branches, and a large ascen ding branch, which courses between the muscle and the posterior rectus sheath passing directly to the umbilicus; (2) the ligamentum teres he paticum; and (3) the median umbilical ligament. The clinical implicati ons of this study are that the umbilicus should have robust arterial i nflow if only one rectus muscle is removed, such as during a unilatera l TRAM flap, because the contralateral side should still provide large direct vessels from the deep inferior epigastric arteries to the umbi licus. During bilateral TRAM elevation, all of the large arterial sour ces are removed from the umbilical inflow and circulation must depend on small vessels from the ligamentum teres and median umbilical ligame nt. Care should be taken in this latter clinical situation to presence these sources of blood flow during umbilical flap creation.