Invited Discussion

These authors reported a case in which an SIEA flap was used to reconstruct a partial mastectomy defect, and summarized that the SIEA vessels are well matched with the internal mammary vessels; that no abdominal hernia or bulge occurs; and that there is a very low and inconspicuous scar. I agree with the authors' opinion that this flap would be best for the breast reconstruction reported, but I have some additional points to make on the actual operative procedure.

Regarding the anatomy of the SIEA, the authors classified these flaps in three types based on the course of the proximal division of the SIEA. In my experience, a considerable number of cases will demonstrate no or a very small SIEA. The authors also reported that, based on 100 cadaver dissections, the SIEA exists in 72 percent of cases, and bilateral SIEA is present in 58 percent of cases; this would mean that there is a bilateral absence in 28 percent of cases, and an ipsilateral absence in 42 percent. It is my opinion that the SIEA cannot be used in nearly half of the cases presenting. Therefore, it is very important that other flaps should be prepared preoperatively in such cases. Although the authors recommend the DIEP flap in such cases, I personally believe that the SIEA flap can be used with a change of pedicle vessel, because a hypoplastic SIEA system is complemented by an ascending branch of the SCIA system. Based on our cadaveric and clinical experiences, the SCIA sometimes has a dominant ascending branch on the lateral abdominal wall, which is independent from the terminal branch on the anterior iliac spine. This ascending branch is usually sufficiently large and long in those cases in which the SIEA is missing or hypoplastic.

The authors used the flap as a dermal fat flap with a small skin island flap. We always use a free vascularized adiposal flap, rather than a dermal fat flap, for augmentation of the breast and malar regions. In the reported case, with no need to include a skin portion in the flap, I recommend a minimally invasive adiposal flap without dermis.[1] [2]

REFERENCES

• 1 Koshima I, Inagawa K, Urushibara K, Moriguchi T. One-stage facial contour augmentation with intraoral transfer of a paraumbilical perforator adiposal flap.  Plast Reconstr Surg. 2001;  108 988-994
• 2 Koshima I, Inagawa K, Yamamoto M, Moriguchi T. New microsurgical breast reconstruction using free paraumbiical perforator adiposal flaps.  Plast Reconstr Surg. 2000;  106 61-65