AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

The SIEA Flap Revisited: New and Improved Techniques
Institution where the work was prepared: The Methodist Hospital, Houston, TX, USA
Aldona J. Spiegel, MD; Farah Naz Khan, MD; The Methodist Hospital
Background:
Although the superficial inferior epigastric artery (SIEA) flap was first described for breast reconstruction by Grotting in 1991, few authors have subsequently
reported its dissection or use. The purpose of our study is to provide a detailed explanation of the evolution of our dissection and harvesting techniques.
Patients and Methods:
All 83 patients who underwent 100 SIEA flaps for breast reconstruction are included in this study. The pre-operative and intra-operative records for these
patients were reviewed with respect to flap design, the external diameter of the SIE and internal mammary vessels, the use of contralateral versus ipsilateral
vessels, and the percentage of flap used (for a unilateral reconstruction).
Results:
To increase flap reliability, we changed our algorithm midway through our series so that the SIEA flap was only harvested if the external diameter of the SIEA
at the lower abdominal incision was larger than or equal to 1.5 mm. The average SIEA external diameter in nonthrombotic vessels was 1.8 mm. The average
IMA diameter in the third intercostal space was 2.14 mm. Of the 52 unilateral reconstructions performed, 18 were done using ipsilateral vessels and 34 were
done with contralateral vessels. In 40 of those unilateral reconstructions, the average percentage of total flap used after excision of zone IV and any other
ischemic tissue was 66.5%.
Discussion:
We have found that because of the anatomic variability inherent to the SIEA flap, several important points need to be addressed: (1) To help ensure flap reliability,
we believe it is necessary for the SIEA to have an external diameter larger than or equal to 1.5 mm at the level of the lower abdominal incision. This
allows for minimal size mismatch with the IMA in the third intercostal space. (2) It is possible to safely harvest tissue across the midline as long as zone IV and
any ischemic looking tissue is excised prior to flap inset. (3) We prefer to use the ipsilateral flap, when possible, because it allows for better inset and shaping.
(4) To reduce the rate of donor-site seroma formation, it is best to skeletonize the SIE vessels down to their origin and to leave the lymphatics intact. (5) We
recommend use of the venae comitantes for the anastomosis with the IMV because sufficient length is available. The SIEV can be kept as a lifeboat in cases
of venous congestion where it can be used for a second anastomosis.
A Head to Head Comparison of the SIEA Flap and the Muscle Sparing Free TRAM: Is the Rate of Flap Loss
Worth the Gain in Abdominal Wall Function?
Institution where the work was prepared: University of Pennsylvania, Philadelphia, PA, USA
Jesse Creed Selber, MD, MPH1; Stephen J. Vega, MD2; Seema Sonnad1; Joseph Serletti3; (1)University of Pennsylvania, (2)Strong-Memorial Hospital, The University of
Rochester Medical Center, (3)Division of Plastic Surgery
As evidence increasingly indicates a relatively small functional difference in abdominal wall donor site morbidity between the muscle sparing free TRAM and
the DIEP flap, microsurgeons continue to search for the “perfect flap” with respect to both reliability and donor site morbidity. The SIEA flap is a candidate
for such a monicher. In this study the authors compare the SIEA to the muscle sparing free TRAM across a spectrum of clinical outcomes to determine whether
gains in abdominal wall function are off-set by a higher complication rate.
Methods:
Forty-six consecutive SIEA flaps in 39 patients are compared to 569 consecutive free TRAMs in 500 patients. A database was compiled prospectively. Chi square
and Fisher's Exact tests were used to determine significant differences in preoperative risk factors as well as complications in the two groups.
Results:
There was no significant difference in age, past medical history, history of smoking , BMI, immediate versus delayed, length of follow-up or recipient vessels
between the two groups. Outcomes included rate of intraoperative and post operative arterial and venous thrombosis, reoperation, abdominal hernia, seroma,
hematoma, fat necrosis, delayed wound healing, infection, partial flap loss, and total flap loss. In the SIEA group, there was 1 instance total flap loss (2.2%)
and no clinically relevant abdominal morbidity. In the free TRAM group, there were two total flap losses (.2%), and a hernia rate of 1.9%. There was a higher
incidence of intraoperative and post-operative vessel thrombosis requiring anastomotic revision in the SIEA group (13%) compared to the free TRAM group
(5.6%).
Conclusion:
The SIEA flap has the clear advantage of leaving the abdominal wall completely unviolated. It has the clear disadvantagge of a substantially higher rate of
thrombotic complications, although the flap success rate remains high. Because of these thrombotic complications, the SIEA flap should be limited to nonsmokers,
moderate obesity, patients unlikely to require postoperative radiation, and breast reconstruction volumes requiring only half of the typical skin island.
In addition, the SIEA flap should be performed by those experienced in the management of intraoperative and postoperative thrombosis. For all other clinical
situations, the free TRAM flap remains the flap of choice for dependable results and limited donor site morbidity.
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