Autologous breast reconstruction has continued to evolve, with significant decreases in the abdominal-wall morbidity associated with these newer reconstructions. Recently, the superficial inferior epigastric artery (SIEA) flap has replaced the perforator flaps in the majority of the authors' autologous tissue breast reconstruction cases. They reported their series of 75 SIEA flaps for breast reconstruction with a discussion about the difficulties and limitations of using this specific flap.
A retrospective review of all 75 SIEA breast reconstructions between July 2004 and June 2005 was completed. The rates of failure, return to the operating room, abdominal-wall complications, and flap fat or skin necrosis were recorded.
Two complete flap failures were recorded (2.7%). Five patients required emergent returns to the operating room for bleeding or vessel thrombosis (6.7%). Fat necrosis requiring repeat operations for symmetry occurred in 4 patients (5.3%), and palpable fat necrosis of greater than 2 cm in diameter occurred in 12 flaps (16%). No abdominal-wall hernias occurred. Delayed skin healing on the abdominal wall occurred in 10 patients (13.3%).
The SIEA is the ultimate autologous tissue flap from the abdomen. There is complete preservation of the fascia/muscle of the abdomin while presenting a relatively quick and reliable harvesting, its main advantage. Still, significant limitations of this flap must be weighed against its advantages. The most significant disadvantage experienced in 25% of cases in this series was that there was no definable artery, or the artery was < 1 mm in diameter. Second, due to the small size of the SIEA, size mismatch between the internal mammary artery (IMA) and SIEA is significant. Size discrepancy is reduced by anastomosing to an IMA perforator. Third, perfusion characteristics of the SIEA allow the safe transfer of only a hemi-abdomen. Breast size needs to be estimated accurately in order to ascertain preoperatively that the hemi-abdomen will provide enough tissue to reconstruct the mastectomy defect. Finally, the short SIEA pedicle requires careful positioning of the flap in the mastectomy defect. This short pedicle length is most significant with obese patients. Thicker abdominal flaps require a great deal of pedicle length to reach from the subcutaneous position on the pedicle to the intra-thoracic position of the internal mammary vessels. Here again, the use of IMA perforators improves the situation. If these difficulties are carefully considered pre- and intraoperatively, the SIEA flap can be the best choice for autologous tissue breast reconstruction.
