Why there are two rows of deep inferior epigastric artery perforators despite variability in the number of deep inferior epigastric artery trunks: An anatomical and embryological argument

Abstract

The deep inferior epigastric artery (DIEA) distributes musculocutaneous perforators in a uniform pattern that comprises "medial row" versus "lateral row" perforators, with these two rows having anatomical and functional differences. This pattern of two perforator rows is distributed from the DIEA regardless of the number of major DIEA trunks, with there variably being one to four major trunks. As such, a single DIEA trunk will still distribute two perforator rows, as will four major DIEA trunks. What remains to be answered is how such an anatomical fact may come to be? The answer probably lies in the anatomy and embryology of the rectus abdominis muscle itself. With two muscle heads to each hemiabdominal rectus abdominis muscle present from early in its development, it is highly likely that each head of rectus abdominis muscle draws its own blood supply from its source DIEA pedicle, one "perforator row" for each head, regardless of DIEA branching pattern from which these rows are drawn, thus providing an embryological and anatomical basis for the observation of two uniform perforator rows.

Development of the Rectus Abdominis and Its Sheath in the Human Fetus

“…In three of four of the present specimens at 9 weeks, in which the rectus abdominis grew rapidly at the level below the umbilicus, the inferior epigastric artery divided into two major branches at the level above the umbilicus. Although the present specimens were very limited in number, this variation appears not to be so different from that known in adults 13. The two-row arrangement of the perforators seems to depend on a fact that there are two major arterial branches running longitudinally in fetuses.…”

“…If so, that band may have a different role in humans compared to mice and rats. Rozen, et al13 introduced a theory of rectus abdominis muscle development: 1) the ventral longitudinal column containing myogenic cells or the primitive rectus abdominis divides into the "two heads of origin" comprising an attachment at the pubic symphysis medially and that from the upper border of the pubic crest laterally; 2) the two muscle slips develop cranially to reach the costal cartilage. However, according to the present results, rather than the inferior part near the pubic bone anlage, the muscle is most likely to start development above the umbilicus, especially in front of the liver at 7 weeks.…”

“…Finally we discussed the medial and lateral perforator rows of the inferior epigastric artery that is of great interest to surgeons 13. Rozen, et al13 considered that, because there are two muscle heads very early on in its development, each head draws its own blood supply to provide "a perforator row" for each head.…”

“…Rozen, et al13 considered that, because there are two muscle heads very early on in its development, each head draws its own blood supply to provide "a perforator row" for each head. However, we have provided evidence against this possibility (see the first paragraph of the Discussion).…”

Regarding the vascular anatomy of muscles with a special focus on the gracilis muscle

“…The recent years, studies in clinical anatomy have produced valuable information on specific vascularization of the anatomical structures used in these flaps (Saadeh et al, 1998;Fróes et al, 1999;Traxler et al, 1999;Tao et al, 2000;Halim and Wan, 2004;Macchi et al, 2008Macchi et al, , 2009Rozen et al, 2008Rozen et al, , 2009Rozen et al, , 2010Rozen et al, , 2011Ger, 2009;Ma et al, 2009;Papadimas et al, 2009;Beer and Manestar, 2010;Piquilloud et al, 2011;Janus et al, 2012).…”