SIEA Flap for Breast Reconstruction: Refinements in Flap Selection Criteria

The deep inferior epigastric perforator (DIEP) flap has firmly established itself as a reliable flap for breast reconstruction. A further refinement in the transfer of lower abdominal tissue for breast reconstruction is the superficial inferior epigastric artery (SIEA) flap. Although this flap virtually eliminates donor-site morbidity because the rectus abdominis muscle and fascia are kept intact, it has yet to establish itself as a reliable flap for breast reconstruction. A retrospective study was conducted to assess the reliability and examine the outcomes of the use of SIEA flaps for breast reconstruction.

A total of 93 SIEA flaps for breast reconstruction were performed over a 3-year period. During the same time period, a total of 82 DIEP flaps were also performed by the senior author. The average patient was 49 years old and the average body mass index (BMI) was 28 kg/m². The average SIEA diameter was 1.7 mm. The internal mammary vessels were used as recipients in all cases with an average diameter of 2.2 mm. Of the first 70 SIEA flaps, 5 were lost because of arterial thrombosis. It was observed that all failed flaps had an SIEA diameter of less than 1.5 mm. No DIEP flaps performed during that time were lost. In February 2004, the senior author implemented an intraoperative algorithm for flap selection that allowed the use of the SIEA flap only in cases where the SIEA diameter was = 1.5 mm. In the remaining cases, a DIEP flap was used for breast reconstruction.

Since February 2004, 23 SIEA flaps were performed without any flap losses. Furthermore, no risk factors, including age, BMI, or abdominal scars, demonstrated significant association with any breast or abdominal complication. A trend, however, was observed with more overall complications with a flap weight greater than 1000 gm (p = 0.0812) and with delayed vs. immediate reconstructions (p = 0.0696). This study indicated that when attempted in cases of sufficient arterial diameter, the SIEA flap is an attractive and reliable option for breast reconstruction. Taylor and Daniel's classic anatomic study indicated that the SIEA is “absent” in 35% of cases but this study indicated that it is more consistently present. In addition, complication rates were comparable or less than those previously reported with the use of DIEP flaps for breast reconstruction.