Breast Reconstruction with Superficial Inferior Epigastric Artery Flaps: A Prospective Comparison with TRAM and DIEP Flaps

Abstract

Breast reconstruction using the lower abdominal free superficial inferior epigastric artery (SIEA) flap has the potential to virtually eliminate abdominal donor-site morbidity because the rectus abdominis fascia and muscle are not incised or excised. However, despite its advantages, the free SIEA flap for breast reconstruction is rarely used. A prospective study was conducted of the reliability and outcomes of the use of SIEA flaps for breast reconstruction compared with transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps. Breast reconstruction with an SIEA flap was attempted in 47 consecutive free autologous tissue breast reconstructions between August of 2001 and November of 2002. The average patient age was 49 years, and the average body mass index was 27 kg/m. The SIEA flap was used in 14 (30 percent) of these breast reconstructions in 12 patients. An SIEA flap was not used in the remaining 33 cases because the SIEA was absent or was deemed too small. The mean superficial inferior epigastric vessel pedicle length was approximately 7 cm. The internal mammary vessels were used as recipients in all SIEA flap cases so that the flap could be positioned sufficiently medially on the chest wall. The average hospital stay was significantly shorter for patients who underwent unilateral breast reconstruction with SIEA flaps than it was for those who underwent reconstruction with TRAM or DIEP flaps. Of the 47 free flaps, one SIEA flap was lost because of arterial thrombosis. Medium-size and large breasts were reconstructed with hemi-lower abdominal SIEA flaps, with aesthetic results similar to those obtained with TRAM and DIEP flaps. The free SIEA flap is an attractive option for autologous tissue breast reconstruction. Harvest of this flap does not injure the anterior rectus fascia or underlying rectus abdominis muscle. This can potentially eliminate abdominal donor-site complications such as bulge and hernia formation, and decrease weakness, discomfort, and hospital stay compared with TRAM and DIEP flaps. The disadvantages of an SIEA flap are a smaller pedicle diameter and shorter pedicle length than TRAM and DIEP flaps and the absence or inadequacy of an arterial pedicle in most patients. Nevertheless, in selected patients, the SIEA flap offers advantages over the TRAM and DIEP flaps for breast reconstruction.

A comparison of the superficial inferior epigastric artery flap and deep inferior epigastric perforator flap in post-mastectomy reconstruction: A cost-effectiveness analysis

“…Two SIEA articles that were found after the initial search were also included (19,30). In summary, a total of 30 studies were used for the present analysis (five SIEA [ Table 1] [6,19,[28][29][30]) and 27 DIEP [ Table 2] [6,9,13,28,.…”

“…As mentioned in the introduction, the SIEA and superficial inferior epigastric vein are not present as single dominant flap vessels in 35% of dissections (14). Even when preoperative colour Doppler ultrasounds are used to localize, measure and identify the SIEA flap vascular supply, the SIEA is often deemed to be unsuitable based on the intraoperative assessment (23,24). Two approaches to deal with this uncertainty were considered.…”

“…Therefore, there is a need to question why the SIEA flap, which leaves the rectus muscle and anterior rectus fascia intact, has not been widely accepted (6,10,11). Taylor and Daniel (10) described the SIEA flap anatomy in 1975, but it was only in the 1990s that case series first reported its use for breast reconstruction (11).…”

“…Recent articles comparing the SIEA and DIEP flaps have been published (6,19), but none employs a full economic analysis. In an economic analysis comparing any two surgical techniques, there are nine possible outcomes based on incremental cost and effectiveness of a given procedure over another ( Figure 1) (20).…”

“…Some procedures such as tissue expanders and implants (1)(2)(3), and the transverse rectus abdominis myocutaneous (TRAM) flap (4)(5)(6), have been used for many years, whereas others such as the deep inferior epigastric perforator (DIEP) flap (6)(7)(8), muscle-sparing TRAM flaps (9) and the superficial inferior epigastric artery (SIEA) flap are relatively new. In the quest for the best abdominal autogenous tissue reconstruction technique, there has been a recent trend to minimize the harvesting of the rectus abdominis muscle and its fascia.…”