Criteria for the Use of the SIEA Flap for Breast Reconstruction.

Abstract

Sir: We read with interest the article entitled “SIEA versus DIEP Arterial Complications: A Cohort Study” (Plast Reconstr Surg. 2015;135:802e–807e) by Coroneos et al. We agree with the authors that the anatomy of the superficial inferior epigastric artery (SIEA) is highly variable; however, we feel that their decision to therefore no longer perform SIEA flaps is premature.1 We would like to point out two potential problems with the authors’ practice in regard to SIEA flaps. First, the internal mammary artery was used as the recipient in most cases. In our experience, the size discrepancy between the internal mammary artery and SIEA is often problematic. We suspect that the higher rate of arterial failure reported by the authors is the result of this size discrepancy. In our practice, we prefer using the thoracodorsal artery rather than the internal mammary artery in patients with a small SIEA. In most cases, the size of the thoracodorsal artery or its serratus anterior branch better matches that of the SIEA. Second, it seems that an imaging modality was not used preoperatively, despite the well-established utility of preoperative computed tomographic angiography before harvesting deep inferior epigastric perforator (DIEP) flaps. Computed tomographic angiography also provides valuable information on the SIEA.2,3 In previous reports, a SIEA diameter greater than or equal to 1.5 mm was the criterion for using a SIEA flap.4,5 In our practice, we assign similar importance to the presence or absence of dominant deep inferior epigastric artery (DIEA) perforators because of the strong interplay between the angiosomes of the DIEA and the SIEA.2 In the absence of a dominant DIEA perforator, the reliability of the SIEA, even one of smaller diameter, will increase. If a dominant DIEA perforator is present, whether the SIEA—despite a sufficiently large diameter—can be used should be carefully determined. Intraoperative findings will strongly influence the decision regarding the utility of the SIEA flap. We always preserve large DIEA perforators along with the SIEA and the superficial inferior epigastric vein during elevation of the SIEA flap. After completing pedicle dissection, we temporarily clamp the DIEA perforators and then examine the oxygenation of the flap using the ViOptix tissue oximeter (ViOptix, Fremont, Calif.). If tissue oxygen saturation is sufficient (≥30 percent), we harvest the SIEA flap. If not, we convert the SIEA flap to a DIEP flap. We appreciate that the learning curve of the SIEA flap is steeper than that of the DIEP flap; however, the reliability of the SIEA flap can be improved with the technical tips described above. The SIEA flap is still an important option for breast reconstruction in selected patients and has the potential for wider applications as the ultimate donor-site–sparing procedure.2 DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Shimpei Miyamoto, M.D. Masahide Fujiki, M.D. Division of Plastic and Reconstructive Surgery National Cancer Center Hospital Tokyo, Japan