DIEP or SIEA? An Algorithm for Flap Selection

The advantages of breast reconstruction using the deep inferior epigastric perforator (DIEP) flap have been well-established. Requiring incision of the rectus abdominis muscle and fascia but not excision of these structures, the DIEP flap has greatly reduced donor-site morbidity. The superficial inferior epigastric artery (SIEA) flap has the ability to virtually eliminate donor-site morbidity because it requires neither incision or excision of the rectus abdominis muscle and fascia. Despite this distinct advantage, the SIEA flap has yet to establish itself as a reliable flap for breast reconstruction. A retrospective study was conducted to compare these two methods of breast reconstruction and to determine whether there is a difference in outcome.

This study evaluated 139 women who underwent breast reconstruction with DIEP and/or SIEA flaps over a 3-year period. This included 96 DIEP flaps and 95 SIEA flaps for a total of 191 flaps. For all DIEP flaps, outcome included fat necrosis (2.1%), arterial thrombosis (0.0%), venous congestion (1.0%), and total flap loss (5.3%). No abdominal bulges or hernias were detected.

After incurring 5 total SIEA flap losses due to arterial thrombosis, the senior author decided to attempt the SIEA flap only in cases where the SIEA diameter was > 1.5 mm. With this new algorithm in effect beginning February 2004, 25 of the total 95 SIEA flaps were performed and 57 of the total 96 DIEP flaps were performed. For the 25 SIEA flaps, outcome included fat necrosis in two (8.0%), arterial thrombosis in none (0.0%), venous congestion in one (4.0%), and total flap loss in none (0.0%). For the 57 DIEP flaps, outcome included fat necrosis in one (1.8%), arterial thrombosis in none (0.0%), venous congestion in one (1.8%), and total flap loss in one (1.8%).

These results demonstrate that there is no significant difference in fat necrosis, arterial thrombosis, venous congestion, or total flap loss after DIEP or SIEA flap reconstruction, as long as the SIEA is of adequate diameter (> 1.5 mm).

Furthermore, one DIEP patient developed an abdominal bulge, but no bulges were observed in the SIEA patients. This suggests that the SIEA flap is a reliable flap with comparable or even better outcomes than the DIEP flap, when used appropriately.