Superficial Inferior Epigastric Artery Flap in Breast Reconstruction

  • Edward I. ChangEmail author


Autologous breast reconstruction is considered by many to be the most optimal means of reconstruction both in terms of patient satisfaction and reconstructing the breast with the most natural feel and appearance that remains durable with time. The abdomen remains the most popular donor site; however, the abdominal tissue can be harvested in a number of different ways. A traditional full muscle transverse rectus abdominus myocutaneous (TRAM) flap can be harvested both as a pedicle and a free flap but sacrifices the entire muscle. Variations on the theme have evolved to preserve as much of the muscle as possible in order to limit the donor site morbidity. The muscle-sparing TRAM and the deep inferior epigastric perforator (DIEP) flaps are based on the deep inferior epigastric vessels with variable amounts of muscle and fascia preservation. However, the superficial inferior epigastric artery (SIEA) flap is yet another modification that does not violate the muscle or fascia at all and is based off the superficial system. The SIEA flap has distinct advantages and disadvantages compared to flaps based off the deep inferior epigastric pedicle, but remains a reasonable and viable option for autologous free flap breast reconstruction in the properly selected patient.


Free flap breast reconstruction Superficial inferior epigastric artery flap 

Supplementary material

Video 20.1

The superficial inferior epigastric artery (SIEA) flap harvest (MP4 307215 kb)


  1. 1.
    Hartrampf CR Jr, Bennett GK. Autogenous tissue reconstruction in the mastectomy patient. A critical review of 300 patients. Ann Surg. 1987;205(5):508–19.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Grotting JC, Urist MM, Maddox WA, Vasconez LO. Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction. Plast Reconstr Surg. 1989;83(5):828–41.PubMedCrossRefGoogle Scholar
  3. 3.
    Wilkins EG, August DA, Kuzon WM Jr, Chang AE, Smith DJ. Immediate transverse rectus abdominis musculocutaneous flap reconstruction after mastectomy. J Am Coll Surg. 1995;180(2):177–83.PubMedGoogle Scholar
  4. 4.
    Khouri RK, Ahn CY, Salzhauer MA, Scherff D, Shaw WW. Simultaneous bilateral breast reconstruction with the transverse rectus abdominus musculocutaneous free flap. Ann Surg. 1997;226(1):25–34.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg. 1999;52(2):104–11.PubMedCrossRefGoogle Scholar
  6. 6.
    Hamdi M, Weiler-Mithoff EM, Webster MH. Deep inferior epigastric perforator flap in breast reconstruction: experience with the first 50 flaps. Plast Reconstr Surg. 1999;103(1):86–95.PubMedCrossRefGoogle Scholar
  7. 7.
    Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg. 2004;114(5):1077–83.PubMedCrossRefGoogle Scholar
  8. 8.
    Gill PS, Hunt JP, Guerra AB, Dellacroce FJ, Sullivan SK, Boraski J, Metzinger SE, Dupin CL, Allen RJ. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg. 2004;113(4):1153–60.PubMedCrossRefGoogle Scholar
  9. 9.
    Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg. 2006;117(3):737–46.PubMedCrossRefGoogle Scholar
  10. 10.
    Schaverien MV, Perks AG, McCulley SJ. Comparison of outcomes and donor-site morbidity in unilateral free TRAM versus DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg. 2007;60(11):1219–24.PubMedCrossRefGoogle Scholar
  11. 11.
    Chun YS, Sinha I, Turko A, Yueh JH, Lipsitz S, Pribaz JJ, Lee BT. Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction. Plast Reconstr Surg. 2010;126(4):1133–41.PubMedCrossRefGoogle Scholar
  12. 12.
    Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg. 2009;124(3):752–64.PubMedCrossRefGoogle Scholar
  13. 13.
    Chang EI, Chang EI, Soto-Miranda MA, Zhang H, Nosrati N, Robb GL, Chang DW. Comprehensive analysis of donor-site morbidity in abdominally based free flap breast reconstruction. Plast Reconstr Surg. 2013;132(6):1383–91.PubMedCrossRefGoogle Scholar
  14. 14.
    Wan DC, Tseng CY, Anderson-Dam J, Dalio AL, Crisera CA, Festekjian JH. Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg. 2010;126(2):367–74.PubMedCrossRefGoogle Scholar
  15. 15.
    Patel KM, Shuck J, Hung R, Hannan L, Nahabedian MY. Reinforcement of the abdominal wall following breast reconstruction with abdominal flaps: a comparison of synthetic and biological mesh. Plast Reconstr Surg. 2014;133(3):700–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Holm C, Mayr M, Höfter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg. 2006;117(1):37–43.PubMedCrossRefGoogle Scholar
  17. 17.
    Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg. 2005;115(2):436–44.PubMedCrossRefGoogle Scholar
  18. 18.
    Nelson JA, Guo Y, Sonnad SS, Low DW, Kovach SJ 3rd, Wu LC, Serletti JM. A comparison between DIEP and muscle-sparing free TRAM flaps in breast reconstruction: a single surgeon's recent experience. Plast Reconstr Surg. 2010;126(5):1428–35.PubMedCrossRefGoogle Scholar
  19. 19.
    Selber JC, Nelson J, Fosnot J, Goldstein J, Bergey M, Sonnad SS, Serletti JM. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: part I. Unilateral reconstruction. Plast Reconstr Surg. 2010;126(4):1142–53.PubMedCrossRefGoogle Scholar
  20. 20.
    Selber JC, Fosnot J, Nelson J, Goldstein J, Bergey M, Sonnad S, Serletti JM. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: part II. Bilateral reconstruction. Plast Reconstr Surg. 2010;126(5):1438–53.PubMedCrossRefGoogle Scholar
  21. 21.
    Wu LC, Bajaj A, Chang DW, Chevray PM. Comparison of donor-site morbidity of SIEA, DIEP, and muscle-sparing TRAM flaps for breast reconstruction. Plast Reconstr Surg. 2008;122(3):702–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Rozen WM, Chubb D, Grinsell D, Ashton MW. The variability of the superficial inferior epigastric artery (SIEA) and its angiosome: a clinical anatomical study. Microsurgery. 2010;30(5):386–91.PubMedGoogle Scholar
  23. 23.
    Dorafshar AH, Januszyk M, Song DH. Anatomical and technical tips for use of the superficial inferior epigastric artery (SIEA) flap in breast reconstructive surgery. J Reconstr Microsurg. 2010;26(6):381–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Henry FP, Butler DP, Wood SH, Jallali N. Predicting and planning for SIEA flap utilisation in breast reconstruction: an algorithm combining pre-operative computed tomography analysis and intra-operative angiosome assessment. J Plast Reconstr Aesthet Surg. 2017;70(6):795–800.PubMedCrossRefGoogle Scholar
  25. 25.
    Holm C, Mayr M, Höfter E, Raab N, Ninkovic M. Interindividual variability of the SIEA angiosome: effects on operative strategies in breast reconstruction. Plast Reconstr Surg. 2008;122(6):1612–20.PubMedCrossRefGoogle Scholar
  26. 26.
    Selber JC, Samra F, Bristol M, Sonnad SS, Vega S, Wu L, Serletti JM. A head-to-head comparison between the muscle-sparing free TRAM and the SIEA flaps: is the rate of flap loss worth the gain in abdominal wall function? Plast Reconstr Surg. 2008;122(2):348–55.PubMedCrossRefGoogle Scholar
  27. 27.
    Turin SY, Walton RL, Dumanian GA, Hijjawi JB, LoGiudice JA, Alghoul M. Current practices in the management of postoperative arterial vasospasm in microsurgery. J Reconstr Microsurg. 2018;34(4):242–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Sarik JR, Banks J, Wu LC, Serletti JM. Superficial inferior epigastric artery: learning curve versus reality. Plast Reconstr Surg. 2016;137(1):1e–6e.PubMedCrossRefGoogle Scholar
  29. 29.
    Coroneos CJ, Heller AM, Voineskos SH, Avram R. SIEA versus DIEP arterial complications: a cohort study. Plast Reconstr Surg. 2015;135(5):802e–7e.PubMedCrossRefGoogle Scholar
  30. 30.
    Chang EI, Chang EI, Soto-Miranda MA, Zhang H, Nosrati N, Crosby MA, Reece GP, Robb GL, Chang DW. Comprehensive evaluation of risk factors and management of impending Flap Loss in 2138 breast free flaps. Ann Plast Surg. 2016;77(1):67–71.PubMedCrossRefGoogle Scholar
  31. 31.
    Masoomi H, Clark EG, Paydar KZ, Evans GR, Nguyen A, Kobayashi MR, Wirth GA. Predictive risk factors of free flap thrombosis in breast reconstruction surgery. Microsurgery. 2014;34(8):589–94.PubMedCrossRefGoogle Scholar
  32. 32.
    Garza RM, Shenaq D, Song DH, Park JE. Superficial inferior epigastric artery flap salvage technique using deep inferior epigastric artery graft. Plast Reconstr Surg Glob Open. 2018;6(1):e1528.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Park JE, Shenaq DS, Silva AK, Mhlaba JM, Song DH. Breast reconstruction with SIEA flaps: a single-institution experience with 145 free flaps. Plast Reconstr Surg. 2016;137(6):1682–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Plastic and Reconstructive SurgeryUniversity of Texas MD Anderson Cancer CenterHoustonUSA

Personalised recommendations