Orienting the superficial inferior epigastric artery (SIEA) pedicle in a stacked SIEA-deep inferior epigastric perforator free flap configuration for unilateral tertiary breast reconstruction

• Published in: Archives of plastic surgery Vol. 47; no. 5; pp. 473 - 482
• Main Authors: Yu, Ya-han, Ghorra, Dina, Bojanic, Christine, Aria, Oti N., MacLennan, Louise, Malata, Charles M.
• Format: Journal Article
• Language: English
• Published: 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA Thieme Medical Publishers, Inc 01.09.2020; Korean Society of Plastic and Reconstructive Surgeons; 대한성형외과학회
• Subjects: bipedicled free flap; Case Report; keywords; microsurgical free flap; siea-diep flap; tertiary breast reconstruction; 성형외과학; Tertiary breast reconstruction; SIEA-DIEP flap; Keywords; Microsurgical free flap; Bipedicled free flap
• ISSN: 2234-6163; 2234-6171
• DOI: 10.5999/aps.2019.01319

Superficial inferior epigastric artery (SIEA) flaps represent a useful option in autologous breast reconstruction. However, the short-fixed pedicle can limit flap inset options. We present a challenging flap inset successfully addressed by de-epithelialization, turnover, and counterintuitive rotation. A 47-year-old woman underwent left tertiary breast reconstruction with stacked free flaps using right deep inferior epigastric perforator and left SIEA vessels. Antegrade and retrograde anastomoses to the internal mammary (IM) vessels were preferred; additionally, the thoracodorsal vessels were unavailable due to previous latissimus dorsi breast reconstruction. Optimal shaping required repositioning of the lateral ends of the flaps superiorly, which would position the ipsilateral SIEA hemi-flap pedicle lateral to and out of reach of the IM vessels. This problem was overcome by turning the SIEA flap on its long axis, allowing the pedicle to sit medially with the lateral end of the flap positioned superiorly. The de-epithelialized SIEA flap dermis was in direct contact with the chest wall, enabling its fixation. This method of flap inset provides a valuable solution for medializing the SIEA pedicle while maintaining an aesthetically satisfactory orientation. This technique could be used in ipsilateral SIEA flap breast reconstructions that do not require a skin paddle, as with stacked flaps or following nipple-sparing mastectomy.