Superficial Inferior Epigastric Artery Abdominoplasty Flap Breast Reconstruction Revisited

In 1863, Dr John Wood published the use of the pedicled superficial inferior epigastric artery (SIEA) flap for reconstruction of a forearm burn scar contracture. The first successful cutaneous free flap reported by Taylor and Daniel in 1973 was an SIEA free flap. Many thought mistakenly this first "groin flap" was based on the superficial circumflex iliac artery (SCIA). Although Taylor and Daniel planned on using the SCIA, it was quite small and the SIEA was much larger and more suitable for anastomosis to the recipient artery. The first SIEA flap for breast reconstruction was at Charity Hospital in New Orleans in 1989. We present our experience with 408 SIEA flaps for breast reconstruction. Our methods and techniques have continually evolved over the years. The SIEA breast reconstruction is the only technique using abdominoplasty territory that does not involve opening the anterior rectus sheath or the oblique fascia and muscles, resulting in the least donor-site morbidity of all abdominal based breast flaps. Our SIEA flap survival rate has been 97% over the past 35 years. The superficial inferior epigastric system is the key to understanding the blood supply of the lower abdomen.

A retrospective review of 408 SIEA breast reconstructions performed since 1989 was conducted. Patients were selected based on preoperative Doppler assessment of the SIEA, with 1.2-1.5 mm considered adequate. A subset underwent surgical delay to enhance arterial caliber. Outcomes assessed included flap survival, complications, and failure rates.

Flap survival was 97%. The SIEA flap can be used in 40% of patients based on our experience. Delayed SIEA flaps had no failures and reduced fat necrosis (0% vs 15%). Complications included partial ischemic necrosis (4%) and donor-site seromas or hematomas. A dual-plane approach with SIEA and DIEP flaps was used when increased volume of flap perfusion was needed.

The SIEA flap offers minimal donor-site morbidity but is limited by absent or inadequate artery diameter in approximately 60% of patients. The delay phenomenon increases flap vascularity and territory. Our findings support its integration into reconstructive practice, alone or combined with DIEP flaps, to optimize outcomes.