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.
