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

  • Yu, Ya-han (Clinical School of Medicine, University of Cambridge) ;
  • Ghorra, Dina (Department of Plastic and Reconstructive Surgery, Alexandria Faculty of Medicine, Alexandria University Hospital) ;
  • Bojanic, Christine (Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge University Hospitals NHS Foundation Trust) ;
  • Aria, Oti N. (Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge University Hospitals NHS Foundation Trust) ;
  • MacLennan, Louise (Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge University Hospitals NHS Foundation Trust) ;
  • Malata, Charles M. (Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge University Hospitals NHS Foundation Trust)
  • Received : 2019.09.21
  • Accepted : 2019.12.29
  • Published : 2020.09.15

Abstract

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.

Keywords

References

  1. Spear SL, Travaglino-Parda RL, Stefan MM. The stacked transverse rectus abdominis musculocutaneous flap revisited in breast reconstruction. Ann Plast Surg 1994;32:565-71. https://doi.org/10.1097/00000637-199406000-00002
  2. Arnez ZM, Scamp T. The bipedicled free TRAM flap. Br J Plast Surg 1992;45:214-8. https://doi.org/10.1016/0007-1226(92)90080-H
  3. DellaCroce FJ, Sullivan SK, Trahan C. Stacked deep inferior epigastric perforator flap breast reconstruction: a review of 110 flaps in 55 cases over 3 years. Plast Reconstr Surg 2011; 127:1093-9. https://doi.org/10.1097/PRS.0b013e318205f223
  4. Malata CM, Rabey NG. Decision making in double-pedicled DIEP and SIEA abdominal free flap breast reconstructions: an algorithmic approach and comprehensive classification. Front Surg 2015;2:49.
  5. Hamdi M, Khuthaila DK, van Landuyt K, et al. Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast. J Plast Reconstr Aesthet Surg 2007;60:904-14. https://doi.org/10.1016/j.bjps.2007.02.016
  6. Francis EC, Chan JY, Hussey AJ. A novel stacked SIEA flap for unilateral immediate breast reconstruction. J Reconstr Microsurg Open 2017;2:e49-51. https://doi.org/10.1055/s-0037-1602390
  7. Patel NG, Rozen WM, Chow WT, et al. Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping. Gland Surg 2016;5:115-21.
  8. Figus A, Fioramonti P, Ramakrishnan V. Stacked free SIEA/DIEP flap for unilateral breast reconstruction in a thin patient with an abdominal vertical midline scar. J Reconstr Microsurg 2007;23:523-5. https://doi.org/10.1055/s-2007-1022692
  9. Chang EI, Kronowitz SJ. Dual-pedicle flap for unilateral autologous breast reconstruction revisited: evolution and optimization of flap design over 15 years. Plast Reconstr Surg 2016;137:1372-80. https://doi.org/10.1097/PRS.0000000000002075
  10. Malata CM, Moses M, Mickute Z, et al. Tips for successful microvascular abdominal flap breast reconstruction utilizing the "total rib preservation" technique for internal mammary vessel exposure. Ann Plast Surg 2011;66:36-42. https://doi.org/10.1097/SAP.0b013e3181e19daf
  11. Arnez ZM, Khan U, Pogorelec D, et al. Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap. Br J Plast Surg 1999;52:276-9. https://doi.org/10.1054/bjps.1999.3100
  12. Cormack GC, Lamberty BG. The arterial anatomy of skin flaps. Edinburgh: Churchill Livingstone; 1994.
  13. Miyagi K, Di Candia M, Patel AJK, et al. Avoiding pitfalls in microvascular breast reconstruction. In: Shiffman MA, editor. Breast reconstruction. New York: Springer; 2016. p. 571-92.