Superficial Inferior Epigastric Artery Flap Research Articles

The anatomy of the superficial inferior epigastric artery: Cautious optimism and rightful reluctance for the championing of a minimally morbid abdominal flap

The Superficial Inferior Epigastric Artery (SIEA) flap has gained interest due to its potential as an abdominal breast reconstruction flap that incurs minimal donor site morbidity. Historical descriptions of its anatomy however paint the artery as small in calibre, with a restrictive angiosome and a high agenesis rate. This review examines the most contemporary anatomical data of the SIEA across clinical, cadaver and radiological modalities and balances the promise of encouraging anatomical data against the clinical practicalities of consistently and safely raising an SIEA flap.

LVAs in a Pedicled SIEA Flap for the Treatment of Recurrent Lymphocele of the Groin Using Superficial Veins of the Flap for Lymphovenous Anastomosis: A Case Report and Literature Review.

Persistent lymphocele of the groin is a complication of groin surgery that can severely impact the quality of life. The restoration of the interrupted lymphatic pathway is considered by many authors the ideal treatment to prevent a recurrence. However, multiple aspiration procedures and surgical revisions can compromise the availability of local veins needed for a lymphovenular bypass surgery. In addition, surgical debridement of a long-standing lymphocele can generate extensive dead space and contour deformity. A flap delivering additional venules for trans-flap lymphovenular anastomoses (LVAs) can overcome both problems by providing soft tissue and competent veins harvested outside the zone of injury. A successful case of severe groin lymphocele treated with trans-flap LVAs from an abdominal-based flap is presented. The patient was referred to us for a recurrent lymphocele developed in the right groin after lipoma excision that persisted despite multiple surgical attempts. After the identification of patent and draining inguinal lymphatic vessels, a pinch test was used to design a mini-abdominoplasty superficial inferior epigastric artery flap. The superficial veins of the cranial incision were identified and anastomosed to the lymphatic vessels after the pedicled flap harvested and insetted in the groin. The early restoration of lymphatic drainage and the optimal aesthetic outcome supports the combined approach offered by trans-flap LVAs as a valuable therapeutic option for severe and persistent lymphocele.

Reconstruction of Total Hand Degloving Injury with Combined Free and Pedicled Flaps and Ilizarov Minifixator.

Total hand degloving injuries present a significant challenge in treatment, with no consensus yet on the optimal choice of flap for coverage. Functional reconstruction necessitates careful consideration of syndactyly release, particularly after flap coverage. A 64-year-old woman sustained a total hand degloving injury and underwent extensive reconstructive surgery. Initially, a free superficial circumflex iliac perforator flap was applied to the thumb, whereas pedicled groin and superficial inferior epigastric artery flaps were used for the remaining fingers. However, partial necrosis at the edges of the pedicled flaps necessitated the adduction of the fingers, followed by suturing the skin flaps closed. This led to the formation of adduction contractures, requiring careful release and skin flap extension for effective syndactyly release. Subsequently, the innovative use of an Ilizarov minifixator was used for the dual purpose of interdigital widening and elongation of the flap. At the 27-month follow-up, the patient demonstrated significant functional recovery of the hand and fingers, showing the effectiveness of this multifaceted surgical approach. Despite some residual flexion contractures, the patient regained the ability to write and perform pinching motions with the thumb and middle finger, expressing satisfaction with the surgical outcome. In conclusion, for a functional reconstruction of the thumb and fingers, the thumb and other fingers should be covered separately. When the fingers are in adduction and there is insufficient skin stock for syndactyly release, using an external fixator to expand the interdigital spaces before the syndactyly release proved to be effective.

Coverage of large soft tissue defects of the lower limb and foot with superficial inferior epigastric artery flap.

Large soft tissue defects of the lower limb and foot are common occurrence in clinical practice and a considerable number of flaps have been used to treat them. However, there have been few reports using the superficial inferior epigastric artery (SIEA) flap. This review aims to present the experience of using the SIEA flaps for the repair of large soft tissue defects of the lower limb and foot. A retrospective review of data from 11 patients who underwent coverage of lower limb and foot defects exceeding 120 cm2 (15 × 9 cm) using SIEA flaps from March 2018 to July 2022 were retrospectively reviewed. The average size of the defects was 18 × 11 cm2 (range 15 × 9 cm2-32 × 16 cm2). Flap survival rates, surgical complications and overall long-term outcomes were recorded. All 11 flaps survived. One flap was partially necrotic at the edge and healed after several changes of dressing. Additionally, one flap presented with mild venous congestion. The mean follow-up period was 18 months (ranging from 12 to 30 months). The mean size of the flaps was 20 × 12 cm2 (range 17 × 9 cm2-34 × 18 cm2). The flaps were observed to be aesthetically pleasing and exhibited a well-defined texture. The donor wounds were successfully closed primarily, with only linear scarring remaining. The SIEA flap is characterised by concealed donor area, superficial vascular location, easy access and primary closure, which results in favourable aesthetic outcomes. It is an appropriate choice for the repair of large soft tissue defects of the lower limb and foot.

Superficial Inferior Epigastric Artery Flap: Vascular Pattern and Territory Across the Midline.

Superficial inferior epigastric artery (SIEA) flap offers a significant advantage of lower donor site morbidity over other abdominal-based flaps for breast reconstruction. However, the inconsistent anatomy and territory across the midline remains a major issue. This study aimed to investigate the SIEA and determine its pattern and territory across the midline. Twenty cadavers were studied. Ipsilateral dye was injected to the dominant SIEA. Dissection was performed to evaluate the SIEA origin, artery and vein pattern, vessel diameter, and dye diffusion territory. Overall, three SIEA patterns were identified: bilateral presence (45%), ipsilateral presence (30%), and bilateral absence (25%). The territory depended on the vessel course and dominant SIEA diameter, not on its common origin from the femoral artery, at the pubic tubercle level. Regarding the midline territory (pubic tubercle level to umbilicus), SIEA (type 1a) with a diameter of ≥1.4 mm on either side supplied at least half the distance, whereas SIEA with a diameter of <1 mm was limited to the suprapubic area. Designing a SIEA flap island across the midline is feasible when contralateral SIEA is present to augment the contralateral territory (e.g., type 1a SIEA) or in SIEA with a common/superficial external pudendal artery origin. Preoperative imaging studies are important for confirming the SIEA system. When the diameter at the origin of the SIEA flap is larger than 1.4 mm, the blood supply to the ipsilateral and contralateral sides is sufficient to enable safe flap elevation.

The Effect of Botulinum Toxin A on the NADPH Oxidase System and Ischemia-Reperfusion Injury.

Despite the increasing popularity of various materials for ischemia-reperfusion (I/R) injury mitigation, research on botulinum toxin type A (BoNTA) remains limited. This study assesses BoNTA's efficacy in protecting flaps from I/R injury by inhibiting the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase system and reducing reactive oxygen species (ROS) production. Seventy-six Sprague-Dawley rats were studied. We examined the effects of BoNTA on superoxide production in four rats using a lucigenin-enhanced chemiluminescence assay (LECL). Another group of 60 rats had their superficial inferior epigastric artery (SIEA) flaps treated with either BoNTA or saline and clamped for 0, 1, and 4 hours before reperfusion. Flap survival and histological outcomes were assessed five days post-operation. ROS production in SIEA flaps and femoral vessels was analyzed in 12 additional rats, post-I/R injury. The LECL results showed that the BoNTA group had significantly lower superoxide production compared to controls, with notable reductions at 4 hours. While no significant differences were noted at the 0 and 1-hour marks, the 4-hour mark showed significant protective effects in BoNTA-treated groups. The survival rate was 90% for BoNTA-treated rats versus 60% for controls ( P = 0.028). Significant reductions in ROS were also observed in the 4-hour I/R group. BoNTA effectively protects against I/R injury by inhibiting the NADPH oxidase system and reducing ROS levels. These results support further investigation into the specific mechanisms of NADPH oxidase inhibition by BoNTA and its potential clinical applications, given its safety profile. The findings from the present study are expected to provide a basis for clinical studies regarding this use of BoNTA.

Increased Production of Abdominal Donor Site Fluid Following Microsurgical Breast Reconstruction With Superficial Inferior Epigastric Artery Versus Deep Inferior Epigastric Artery Perforator Flaps.

Introduction and aims Donor site seroma following abdominal flap harvest for breast reconstruction is common in both deep inferior epigastric artery perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps. We tested the hypothesis that there is increased donor site fluid following SIEA dissection compared to DIEP. Materials and methods Of60 SIEA breast reconstructions performed by one surgeon in 50 patients (2004-2019), complete data were available for 31 patients. Eighteen unilateral SIEAs were matched with 18 unilateral DIEPs. Thirteen bilateral flap harvests involving an SIEA were matched with 13 bilateral DIEP controls. Their cumulative abdominal drain outputs, times to drain removal, hospital stay, and number and volume of seroma aspirations were compared. Results Patients who underwent an SIEA flap harvest had significantly increased drain output compared to only a DIEP flap harvest (SIEA=1,078 mL, DIEP=500 mL, p<0.001), which remained significant after controlling for confounding variables (p=0.002). There was increased time until drain removal (SIEA=11 days, DIEP=6 days, p=0.010), and patients who underwent an SIEA harvest were 14 times more likely to be discharged with a drain in situ (odds ratio (OR)=14.6, 95% confidence interval (CI)=2.8203-75.9565, p=0.0014). There was no significant difference in the number or volume of outpatient aspirations, length of hospital admission, or total seroma volume. Conclusion This study demonstrated that SIEA harvest is a significant predictor of increased abdominal drain output postoperatively. This accounted for longer periods before drain removal and more patients discharged with an abdominal drain in situ and should be an important consideration for reconstructive surgeons. There was no demonstrable difference in the number or volume of seroma aspirations after drain removal for either group.

Management of radiation-induced angiosarcoma of the breast with total mastectomy and superficial inferior epigastric artery flap reconstruction: a case report

Background: Radiation-induced angiosarcoma of the breast is a rare but serious long-term complication of radiation, often from adjuvant therapy for previous breast cancer treatment. Early lesions typically appear benign and are often misattributed to breast trauma, however the disease is rapidly progressive and has a high recurrence rate and poor prognosis. Common imaging modalities such as mammography and ultrasound are often not sensitive, though magnetic resonance imaging may be more reliable. Once the diagnosis is confirmed via histopathologic evaluation of a core-needle or punch biopsy, surgical treatment should not be delayed. Reconstruction with free flap provides an advantage over other reconstructive techniques by allowing for adequate coverage of the large defect left by maximal resection of previously-irradiated tissue with ideal oncologic and wound healing outcomes.

Impact of Intraoperative Hypothermia on Autologous Breast Reconstruction.

Studies have identified perioperative hypothermia as a risk factor for impaired wound healing, increased hospital length of stay, and surgical site infection. This study examines the effect of intraoperative hypothermia on postoperative outcomes in autologous microvascular free flap breast reconstruction. This was a retrospective review of 55 patients who experienced intraoperative hypothermia, defined as less than 35.0°C core body temperature and 99 normothermic patients who underwent autologous-based microvascular free flap breast reconstruction from 2013 to 2021. Demographics, comorbidities, smoking status, intraoperative warming devices, type of autologous reconstruction, hypothermia (and its duration), and length of surgery were collected. The outcomes assessed were infection rate, reoperation within 90 days, skin necrosis, wound healing complications, hematoma, seroma, and readmission within 90 days. In the study population of 154 consecutive patients, 8.4% had type 1 or type 2 diabetes and 3.2% were current smokers. A total of 90.3% of patients (139) underwent deep inferior epigastric perforator flap reconstruction, 7.1% (11) superficial inferior epigastric artery flap reconstruction, and 4 (2.6%) another free flap type. A total of 35.7% of the patients (55) experienced intraoperative hypothermia defined as less than 35.0°C. In the hypothermic group, a higher proportion of patients had wound healing complications (52.7% vs 29.3%, P < 0.05), hematoma (16.4% vs 5.1%, P < 0.05), and readmission for postoperative complications (34.5% vs 14.1%, P < 0.05). There was also a trend toward higher incidence of seroma (7.3% vs 5.1%), surgical site infection (12.7% vs 9.1%), skin necrosis (12.7% vs 9.1%), and unplanned reoperation within 90 days (10.9% vs 7.1%). Further analysis via Firth logistic regression demonstrated intraoperative hypothermia predicted postoperative hematoma (odds ratio [OR], 3.68; 95% confidence interval [CI], 1.17-11.60; P < 0.05), readmission within 90 days (OR, 3.20; 95% CI, 1.45-7.08; P < 0.05), and wound healing complications (OR, 2.69; 95% CI, 1.36-5.33; P < 0.05). This study demonstrates that intraoperative hypothermia is a significant risk factor for postoperative wound healing complications, hematoma, and readmission within 90 days in autologous breast reconstruction. Because of a finite amount of donor sites, it is important to find ways to minimize the risk of postoperative complications. Our results support that maintaining strict normothermia during autologous breast reconstruction can significantly improve patient outcomes and reduce morbidity.

Abandoning the SIEA Flap for the Dual-Plane DIEP Reduces Fat Necrosis and Flap Failure.

Despite its limitations in abdominally based breast reconstruction, using the superficial inferior epigastric artery (SIEA) flap or system can be advantageous in specific clinical scenarios. To optimize outcomes in these cases, the authors performed a retrospective review of their flap series to advocate a new algorithm to use the superficial system. A retrospective analysis was performed on 1700 consecutive free abdominal flaps for the presence of a dominant superficial system or poor deep inferior epigastric artery perforators (DIEP) on clinical examination or angiography. In this setting, the authors analyzed the primary outcome measures of fat necrosis and flap failure with use of the superficial system alone versus a "dual-plane DIEP," where there was an intraflap anastomosis performed between the DIEP pedicle and SIEA pedicle. A multivariable analysis was performed with 21 other potentially confounding variables and compared with outcomes with traditionally perfused DIEP flaps. Fat necrosis was present in 13% of 506 DIEP flaps, 34.1% of 41 SIEA system flaps, and 2.7% of 37 dual-plane DIEP flaps. Superficial system-only flaps were independent predictors of fat necrosis (OR, 6.55; P < 0.001) and flap failure (OR, 9.82; P = 0.002) compared with dual-plane DIEP flaps when used for the same indications. In settings of superficial dominance or need to augment perfusion to lateral zones in abdominal free flaps, performing a dual-plane DIEP flap instead of using the superficial system vasculature alone with an SIEA flap can decrease the odds of fat necrosis and flap failure to equal that of a standard DIEP flap. Therapeutic, III.

Experimental study of the effects of nitroglycerin, botulinum toxin A, and clopidogrel on bipedicled superficial inferior epigastric artery flap survival

Beneficial effects could be achieved by various agents such as nitroglycerin, botulinum toxin A (BoTA), and clopidogrel to improve skin flap ischaemia and venous congestion injuries. Eighty rats were subjected to either arterial ischaemia or venous congestion and applied to a bipedicled U-shaped superficial inferior epigastric artery (SIEA) flap with the administration of nitroglycerin, BoTA, or clopidogrel treatments. After 7 days, all rats were sacrificed for flap evaluation. Necrotic area percentage was significantly minimized in flaps treated with clopidogrel (24.49%) versus the ischemic flaps (34.78%); while nitroglycerin (19.22%) versus flaps with venous congestion (43.26%). With ischemia, light and electron microscopic assessments revealed that nitroglycerin produced degeneration of keratinocytes and disorganization of collagen fibers. At the same time, with clopidogrel administration, there was an improvement in the integrity of these structures. With venous congestion, nitroglycerin and BoTA treatments mitigated the epidermal and dermal injury; and clopidogrel caused coagulative necrosis. There was a significant increase in tissue gene expression and serum levels of vascular endothelial growth factor (VEGF) in ischemic flaps with BoTA and clopidogrel, nitroglycerin, and BoTA clopidogrel in flaps with venous congestion. With the 3 treatment agents, gene expression levels of tumor necrosis factor-α (TNF-α) were up-regulated in the flaps with ischemia and venous congestion. With all treatment modalities, its serum levels were significantly increased in flaps with venous congestion and significantly decreased in ischemic flaps. Our analyses suggest that the best treatment option for ischemic flaps is clopidogrel, while for flaps with venous congestion are nitroglycerin and BoTA.

Maximizing the Versatility of Thin Flap from the Groin Area as a Workhorse Flap: The Selective Use of Superficial Circumflex Iliac Artery Perforator (SCIP) Free Flap and Superficial Inferior Epigastric Artery (SIEA) Free Flap with Precise Preoperative Planning.

This study aimed to evaluate the usefulness of the selective use of the superficial circumflex iliac artery perforator (SCIP) and the superficial inferior epigastric artery (SIEA) flap as a workhorse flap from the groin area with precise preoperative surgical planning. A total of 79 free flap reconstructions were performed in the study period; 35 SCIP free flaps and 19 SIEA free flaps were performed in the study period. Detailed preoperative surgical planning was performed using computed tomography (CT) angiography and color Doppler ultrasound. Detailed anatomical information of the flaps and reconstructive outcomes were evaluated. Flap characteristics between SCIP free flaps and SIEA free flaps were similar. The average transverse distance of the perforator from anterior superior iliac spine was 15.91 cm in SCIP free flaps and 43.15 cm in SIEA free flaps. The overall flap success rate was 96.4%. Majority of the patients achieved satisfactory contour without debulking surgery. Donor site morbidity was minimal with one case of wound dehiscence. The selective use of the SCIP and SIEA free flap in groin area is a safe and useful technique. The surgical outcomes were reliable and similar between the SCIP and SIEA free flaps. Preoperative vascular planning using CT angiography and color Doppler ultrasound is essential for selecting the proper flap.

Surgical Delay-Induced Hemodynamic Alterations of the Superficial Inferior Epigastric Artery Flap for Autologous Breast Reconstruction.

The superficial inferior epigastric artery (SIEA) flap allows transfer of tissue without violating the rectus fascia. Traditionally it is best used in single stage reconstruction when vessel caliber is 1.5 mm; 56% to 70% of SIEAs are less than 1.5 mm and, therefore, not reliable. We aim to demonstrate the increased reliability of SIEA through surgical delay by quantifying reconstructive outcomes and delay-induced hemodynamic alterations. Patients presenting for autologous breast reconstruction between May 2019 and October 2020 were evaluated with preoperative imaging and received either delayed SIEA or delayed deep inferior epigastric (DIEP) reconstruction based on clinical considerations, such as prior surgery and perforator size/location. Prospective data were collected on operative time, length of stay, and complications. Arterial diameter and peak flow were quantified with Doppler ultrasound predelay and postdelay. Seventeen delayed SIEA flaps were included. The mean age (± SD) was 46.2 ± 10.55 years, and body mass index was 26.7 ± 4.26 kg/m2. Average hospital stay after delay was 0.85 ± 0.90 days, and duration before reconstruction was 6 days to 14.5 months. Delay complications included 1 abdominal seroma (n = 1, 7.7%). Superficial inferior epigastric artery diameter predelay (mean ± 95% confidence interval) was 1.37 ± 0.20 mm and increased to 2.26 ± 0.24 mm postdelay. A significant increase in diameter was noted 0.9 ± 0.22 mm (P < 0.0001). Mean peak flow predelay was 14.43 ± 13.38 cm/s and 44.61 ± 60.35 cm/s (n = 4, P = 0.1822) postdelay. Surgical delay of the SIEA flap augments SIEA diameter, increasing the reliability of this flap for breast reconstruction. Superficial inferior epigastric artery delay results in low rates of complications and no failures in our series. Although more patients are needed to assess increase in arterial flow, use of surgical delay can expand the use of SIEA flap reconstruction and reduce abdominal morbidity associated with abdominal flap breast reconstruction.

The Value of BMI for Breast Reconstructions with the SIEA Flaps: Predicting the Ideal Intercostal Plane for the End-to-End Microvascular Anastomosis and the Possibility of Utilizing the TDA as a Salvage Recipient Choice.

The superficial inferior epigastric artery (SIEA) diameter and the matching degree between the donor and the recipient arteries in terms of diameter are key factors affecting the outcome of the procedure in breast reconstructions with the SIEA flaps. A diameter of the SIEA ≥ 1.5mm and a matching degree ≥ 1:2 (50%) of the diameters of the donor and the recipient arteries are recognized standards for the SIEA and the internal mammary artery (IMA) to achieve an end-to-end anastomosis. However, further refinements of the population characteristics and the ideal microscopic anastomosis intercostal planes are currently lacking for the criteria. In this study, based on 20 sides of hemiabdomen with computed tomography angiography (CTA) data suggesting the presence of the SIEA, we analysed the diameters of the donor and the recipient arteries as well as their matching degrees. The correlations between the parameters above and body mass index (BMI) were assessed. Based on the lower bounds of the 95% confidence intervals of the matching degrees and the two critical nodes of 50% and 67%, we theoretically evaluated the possibility of an end-to-end anastomosis of the SIEA and the IMA at different levels of BMIs and intercostal spaces, and predicted the possible intraoperative management measures for the SIEA. The SIEA diameter, the thoracodorsal artery (TDA) diameter, and the diameters of the IMA at the 2nd to the 5th intercostal levels were positively correlated with the BMI (p <0.05). A value of BMI ≥ 24kg/m2 could indirectly reflect the application premise of the diameter of the SIEA ≥ 1.5mm. The matching degrees of the SIEA with the TDA or the IMA at the 2nd to the 5th intercostal level were linearly and positively correlated with the BMI (p < 0.001). Based on the confidence interval analysis, we predicted different management techniques that might be needed intraoperatively for the SIEA at different BMI levels, when the SIEA and the IMA or the TDA were to be anastomosed in an end-to-end way. For patients with preoperative CTA data suggesting the presence of the SIEA in the second-stage breast reconstructions, when a value of BMI ≥ 24kg/m2 is met, the SIEA and the IMA can theoretically achieve an end-to-end anastomosis at the 3rd to the 5th intercostal level, and when 24kg/m2 ≤ BMI ≤ 25kg/m2, due to the large difference in diameters, the SIEA and the IMA at the 2nd intercostal level might need to adopt an end-to-side anastomosis or switch to the TDA recipient site. Based on this study's findings and aesthetic effect considerations, we think that the 3rd and the 4th intercostal planes are ideal choices for the end-to-end anastomosis. As a salvage recipient option, the TDA can theoretically achieve an end-to-end anastomosis with the SIEA at a value of BMI ≥ 24g/m2. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Harvesting Composite Arterial and Vein Grafts from Deep Inferior Epigastric Artery and Vein: A Safe Five-Step Method of Preparation.

As the use of stacked flaps and options for autologous breast reconstruction increase, the level of complexity in autologous breast reconstruction has risen. Frequently, these reconstruction types present technical challenges such as vessel mismatches and short pedicle length. In this study, the authors introduce their five steps of harvesting composite deep inferior epigastric artery (DIEA) and deep inferior epigastric vein (DIEV) grafts to overcome such challenges. The authors performed a retrospective review of patients who underwent microvascular reconstruction using DIEA/DIEV grafts from 2012 to 2020. The grafts were harvested using the five steps, as follows: step 1, a transverse, paramedian skin incision was made at the level of suprapubic crease; step 2, an oblique fasciotomy was made on the lateral rectus border; step 3, DIEA/DIEV vessels were identified and exposed past the confluence of two venae comitantes; step 4, DIEA/DIEV grafts were harvested while sparing motor nerves; and step 5, fascial closure was performed. A total of 40 DIEA/DIEV grafts were used in 25 patients (lumbar artery perforator flaps, n = 25; lateral thigh flaps, n = 1; superficial inferior epigastric artery flaps, n = 12; and flap salvage, n = 2) for breast reconstruction. The average time of harvest was 28 minutes, and there were two flap losses. In the authors' experience, DIEA/DIEV grafts can be safely harvested and used in flaps with short pedicles and small vessel size. Although the authors' experience was limited to breast reconstruction, the DIEA/DIEV grafts can be used for other types of reconstruction, especially for head and neck reconstruction.

Selective Microvascular Tissue Transfection Using Minicircle DNA for Systemic Delivery of Human Coagulation Factor IX in a Rat Model Using a Therapeutic Flap.

Gene therapy is a promising treatment for protein deficiency disorders such as hemophilia B. However, low tissue selectivity and efficacy are limitations of systemic vector delivery. The authors hypothesized that selective transfection of rat superficial inferior epigastric artery flaps could provide systemic delivery of coagulation factor IX, preventing the need for systemic vector administration. Minicircle DNA containing green fluorescent protein, firefly luciferase, and human coagulation factor IX was created. Vector constructs were validated by transfecting adipose-derived stromal cells isolated from Wistar rat superficial inferior epigastric artery flaps and evaluating transgene expression by fluorescence microscopy, bioluminescence, and enzyme-linked immunosorbent assay. Minicircle DNA luciferase (10 and 30 μg) was injected into murine (wild-type, C57/BL/6) inguinal fat pads (n = 3) and followed by in vivo bioluminescence imaging for 60 days. Wistar rat superficial inferior epigastric artery flaps were transfected with minicircle DNA human coagulation factor IX (n = 9) with plasma and tissue transgene expression measured by enzyme-linked immunosorbent assay at 2 and 4 weeks. Transfected adipose-derived stromal cells expressed green fluorescent protein for 30 days, luciferase for 43 days, and human coagulation factor IX (21.9 ± 1.2 ng/ml) for 28 days in vitro. In vivo murine studies demonstrated dose-dependence between minicircle DNA delivery and protein expression. Ex vivo rat superficial inferior epigastric artery flap transfection with minicircle DNA human coagulation factor IX showed systemic transgene expression at 2 (266.6 ± 23.4 ng/ml) and 4 weeks (290.1 ± 17.1 ng/ml) compared to control tissue (p < 0.0001). Rat superficial inferior epigastric artery flap transfection using minicircle DNA human coagulation factor IX resulted in systemic transgene detection, suggesting that selective flap or angiosome-based tissue transfection may be explored as a treatment for systemic protein deficiency disorders such as hemophilia B.

Superficial Inferior Epigastric Artery (SIEA) Flap is the Armamentarium for the Coverage of Large Complex Wounds on Dorsum of Hand in a Regional Medical College Hospital

As hand is a functional part of the body, dorsal surface of digits, hand and wrist is prone to injury causing complex wound. Thin, mobile and supple skin of the dorsal wrist and hand make significant for hand functions and aesthetic. Aims of the study were feasibility of the flap in terms of survivability of Superficial Inferior Epigastric artery (SIEA) flap, complications of flap and measurement of functional &amp; aesthetic outcomes to achieve the reconstruction goal in hugely burden regional medical college hospital. 11 SIEA flaps were done in Rajshahi Medical College Hospital from August 2019 to July 2021 on both hands among both male and female patients. Only 2 (18.18%) flaps were lost partially. Almost all the wounds were covered successfully with good functional and aesthetic outcome. So, SIEA flap is the one of the best workhorses for extensive dorsal complex wound in overburdened regional medical hospital in Bangladesh.

Application of superficial inferior epigastric artery flaps to repair oral and maxillofacial defects with the aid of digital three-dimensional reconstruction technique

Objective: To explore the application value of digital three-dimensional(3D) reconstruction technology in the repair of oral and maxillofacial defects with superficial inferior epigastric artery (SIEA) flap. Methods: Twelve cases of oral cancer patients, including 8 males and 4 females; aged (57.4±12.6) years, were selected from the Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Bengbu Medical College from January 2018 to October 2019 and were proposed to repair with SIEA flap. There were 10 cases of squamous cell carcinoma, one case of adenoid cystic carcinoma and 1 case of mucinous epidermal carcinoma. The data were imported into AW4.7 software for post-processing. The left or right dominant donor area was selected to clarify the origin, diameter, alignment, and location of penetration point of the flap blood supply, and digital 3D reconstruction technology was used to guide the flap preoperative design. Results: Eleven cases were repaired by SIEA flap in 12 patients, one case was repaired by superficial iliac artery flap because the source artery was undiscovered, one case had venous vascular crisis after surgery, and the rest of the flap survived. In 11 patients repaired with SIEA flap, there was no significant difference between the preoperative SIEA diameter measured by CTA [(1.0±0.3) mm] and the actual measured value [(1.1±0.3) mm] (P>0.05). The follow-up was 6 to 12 months, with an average of 10 months, and the donor-receiver areas were all healed in phase Ⅰ. No obvious complications occurred, and the abdominal scar was hidden. Conclusions: In the SIEA flap repair oral and maxillofacial defect reconstruction surgery, the use of digital 3D reconstruction technology can objectively reflect the diameter and the location of the superficial artery of the abdominal wall before surgery, effectively reduce the difficulty and risk of flap surgery.

Pedicled Split Hypogastric Flap (Superficial Inferior Epigastric Artery flap): A New Technique for Coverage of Nonadjacent Defects in the Hand.

Flap coverage of soft tissue defects on both surfaces of the hand or of nonadjacent defects in the hand is a challenge. Two flaps are needed or if a single flap is used, the intervening normal area or part of the flap must be deepithelialized or the flap tunneled under the normal bridge segment. We are presenting a new technique whereby the hypogastric flap based on the superficial inferior epigastric artery is split into 2 components for the coverage of such defects. The hypogastric flap is separated into a cutaneous component and an adipofascial component at the level of Scarpa fascia. The flaps are separated almost to the base to increase mobility. Now it can be used to cover 2 defects separated by 5 to 7 cm or for defects in the dorsum and the palm. We have used it in 3 patients, in 2 for the coverage of palmar and dorsal aspect of the hand and in one for the coverage of nonadjacent defects on the dorsum of the hand and distal forearm after postburn contracture release. We achieved good results with no flap-related complications.

The Superficial Inferior Epigastric Artery Based Abdominal Flap for Reconstruction of Extensive Defects of the Hand and Forearm: A Modified Design With Primary Closure of the Donor Site.

The reconstruction of the hand and forearm targets the restoration of their function and aesthetic appearance. Inferiorly based abdominal flaps are reliable and versatile flaps that can cover large defects of the forearm and hand. Here we present a modified abdominal flap design based exclusively on the superficial inferior epigastric artery (SIEA) to reconstruct the hand and forearm's extensive defects. The donor site is closed primarily. This is a retrospective study of the patients who underwent reconstruction of hand and forearm defects with SIEA flap from 2006 to 2018. The flap was designed on the ipsilateral hemiabdomen with a narrow pedicle based on the SIEA. We describe the anatomical basis and the outcomes of SIEA flap for reconstruction of the hand and forearm's extensive defects. Forty-eight soft tissue defects of the hand and forearm were reconstructed with the SIEA-based abdominal flap. Twenty-nine (60.41%) dorsal defects, 4 (8.33%) volar defects, 4 (8.33%) circumferential defects, 6 (12.5%) hand amputation stump, and 5 (10.41%) finger and thumb defects were covered using the SIEA flap. Forty-seven (97.91%) flaps had complete survival, whereas 1 (2.08%) flap had distal necrosis at the time of division. One (2.08%) flap had marginal necrosis, and 1 (2.08%) flap had distal necrosis after the division. The donor site was closed primarily in all patients. One (2.08%) patient had wound dehiscence at the abdominal donor site. All flaps gave excellent coverage with a satisfactory contour. Abdominal flap based on SIEA is a safe, reliable, and versatile flap for the reconstruction of extensive soft-tissue defects of the hand and forearm. An ability to provide a large amount of skin and soft tissue and the abdominal donor site's primary closure make it a favorable option for upper limb reconstruction in regions with limited resources and technical expertise.