Use of a combined SIEA and SCIP based double pedicled abdominal flap for breast reconstruction

Superficial Inferior Epigastric Artery Flap: Vascular Pattern and Territory Across the Midline

BACKGROUND

 Superficial inferior epigastric artery (SIEA) flap offers a significant advantage of lower donor site morbidity over other abdominal-based flaps for breast reconstruction. However, the inconsistent anatomy and territory across the midline remains a major issue. This study aimed to investigate the SIEA and determine its pattern and territory across the midline.

METHODS

 Twenty cadavers were studied. Ipsilateral dye was injected to the dominant SIEA. Dissection was performed to evaluate the SIEA origin, artery and vein pattern, vessel diameter, and dye diffusion territory.

RESULTS

 Overall, three SIEA patterns were identified: bilateral presence (45%), ipsilateral presence (30%), and bilateral absence (25%). The territory depended on the vessel course and dominant SIEA diameter, not on its common origin from the femoral artery, at the pubic tubercle level. Regarding the midline territory (pubic tubercle level to umbilicus), SIEA (type 1a) with a diameter of ≥1.4 mm on either side supplied at least half the distance, whereas SIEA with a diameter of <1 mm was limited to the suprapubic area.

CONCLUSION

 Designing a SIEA flap island across the midline is feasible when contralateral SIEA is present to augment the contralateral territory (e.g., type 1a SIEA) or in SIEA with a common/superficial external pudendal artery origin. Preoperative imaging studies are important for confirming the SIEA system. When the diameter at the origin of the SIEA flap is larger than 1.4 mm, the blood supply to the ipsilateral and contralateral sides is sufficient to enable safe flap elevation.

Comparing seroma formation rate after harvest of the deep inferior epigastric artery perforator flap and the superficial abdominal perforator flaps in autologous breast reconstruction: A propensity-matched analysis

BACKGROUND

Donor site seroma formation and prolonged drainage duration are commonly seen after harvest of perforator-based abdominal flaps. The lymphatic network including the lymphatic vessels and the lymph nodes can be traumatized during harvest of a perforator-based abdominal flap, eventually causing seroma formation. The aim of this study was to compare postoperative seroma occurrence rates between the deep system group including the deep inferior epigastric artery perforator (DIEP) flap and the superficial system group comprised of the superficial inferior epigastric artery (SIEA) flap, the superficial circumflex iliac artery perforator (SCIP) flap, and the SIEA-SCIP combined flap.

PATIENTS AND METHODS

A retrospective analysis of all patients who underwent unilateral breast reconstruction using perforator-based abdominal flaps from June 2020 to May 2021 was performed. The patients were divided into the deep system group and the superficial system group. Propensity score matching was used to compare in the two groups the mean duration of drainage in the donor site and the occurrence of postoperative aspiration. Covariates included sex, age, body mass index, history of smoking, past history of diabetes mellitus. One hundred and fifteen patients (the deep system group, n = 100 and the superficial system group, n = 15) met inclusion criteria for a 1:1 match performed on 14 deep system group patients using propensity scores, with 14 superficial system group patients having similar characteristics.

RESULTS

The mean duration of drainage in the donor site was shorter in the deep system group (6.6 ± 1.9 days) than in the superficial system group (9.3 ± 2.3 days, p < .01). The occurrence rate of postoperative aspiration was lower in the deep system group (0%) than in the superficial system group (50%, p < .01).

CONCLUSIONS

Although superficial abdominal perforator flaps are considered to be less invasive than the DIEP flap, they are associated with prolonged donor site drainage and more frequent occurrence rate of postoperative aspiration.

Deep Fat Saving Elevation of the Superficial Circumflex Iliac Artery Perforator Flap

Background and Objectives: Prolonged drain stay and lymphorrhea are often problems at the donor site of the superficial circumflex iliac artery perforator (SCIP) flap. This study aimed to introduce a novel technique of the SCIP flap elevation: Deep Fat Saving (DFS) technique. Materials and Methods: Thirty-two patients who underwent the SCIP flap transfer were divided based on the flap-elevated layer: above the deep fascia or the Camper fascia saving the deep fat. The duration of drain stay and the rates of flap survival and donor-site complications were compared between the groups. The inverse probability weighting (IPW) method was conducted to balance confounders. Results: By IPW, two balanced pseudo-populations were created: DFS = 33.9 and Conventional = 31.3. There were no significant differences in the rate of flap survival (DFS: 100% verses Conventional: 95.8%, p = 0.32) and donor site complications (DFS: 2.4% versus Conventional: 1.3%, p = 0.68, respectively). The duration of drain stay was shorter in the DFS group (weighted median: 6 versus 8 days; weighted difference: -1.6 days (95% confidence interval: -2.8 to -0.4), p = 0.01). Conclusions: An SCIP flap can be reliably harvested using the Deep Fat Saving technique.

Novel Classification of the Branching Patterns of the Superficial Branch and the Deep Branch of the Superficial Circumflex Iliac Artery and the Superficial Inferior Epigastric Artery on Computed Tomographic Angiography

BACKGROUND

 Recent advances in the superficial circumflex iliac artery (SCIA) perforator flap transfer emphasized the necessity to comprehensively understand the lower abdominal vasculature. This study aimed to clarify the relationship among the superficial inferior epigastric artery (SIEA), the superficial branch (SCIAs), and the deep branch (SCIAd) of the SCIA.

METHODS

 Computed tomographic angiography was retrospectively reviewed in 312 hemiabdomens in 161 female patients who underwent abdominal flap breast reconstruction. We assessed the presence, caliber, and branching patterns of the SCIA branches and the SIEA.

RESULTS

 The SIEA-SCIA common trunk was present in 40.1% of the hemiabdomen and was identified in either side of the abdomen in 63.6% of patients. At least one superficial vessel larger than 1.5 mm was found in 61.5% of hemiabdomens. Seven branching patterns of the SCIA-SIEA system were noted: (1) the SCIA and the SIEA originated together (17.0%); (2) the SIEA and the SCIAs shared an origin (22.8%), (3) the SCIA and the SIEA branched separately (17.0%), (4) each artery originated separately (8.0%); (5) the SCIAs and the SCIAd emerged together with the SIEA absent (17.3%); (6) the SCIAs and the SCIAd originated separately with the SIEA absent (13.1%); (7) the SIEA and SCIAd originated separately with the SCIAs absent (3.5%).

CONCLUSION

 SCIA-SIEA branching patterns were classified into seven distinctive patterns. This novel classification may help surgeons to choose the optimal pedicle when using the hemi-abdomen region as the donor site.