Arch Plast Surg.  2020 Sep;47(5):473-482. 10.5999/aps.2019.01319.

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

  • 1Clinical School of Medicine, University of Cambridge, Cambridge, UK
  • 2School of Medicine, National Taiwan University, Taipei, Taiwan
  • 3Department of Plastic and Reconstructive Surgery, Alexandria Faculty of Medicine, Alexandria University Hospital, Alexandria, Egypt
  • 4Department of Plastic and Reconstructive Surgery, Addenbrooke’s University Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  • 5Plastic and Reconstructive Surgery Unit, Surgery Department, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
  • 6Cambridge Breast Unit, Addenbrooke’s University Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  • 7Anglia Ruskin University School of Medicine, Chelmsford, UK


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.


Tertiary breast reconstruction; Microsurgical free flap; SIEA-DIEP flap; Bipedicled free flap
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