CLINICAL PAPERS

Surgical Delay-Induced Hemodynamic Alterations of the Superficial

Inferior Epigastric Artery Flap for Autologous Breast Reconstruction
Ryan D. Hoffman, BS,a Suma S. Maddox, MD,b Anna E. Meade, MD,c Hugo St. Hilaire, MD,b
Jamie C. Zampell, MD,d and Robert J. Allen, Sr, MDb

be significantly better than implant-based reconstruction in terms of

Background: The superficial inferior epigastric artery (SIEA) flap allows trans-
breast satisfaction and psychosocial well-being.6
fer of tissue without violating the rectus fascia. Traditionally it is best used in sin-
The DIEP flap is a popular option because of its decreased donor
gle stage reconstruction when vessel caliber is 1.5 mm; 56% to 70% of SIEAs are
site morbidity compared with free or pedicled transverse rectus abdom-
less than 1.5 mm and, therefore, not reliable. We aim to demonstrate the increased
inis myocutaneous flap reconstruction. However, it may not be ideal in
reliability of SIEA through surgical delay by quantifying reconstructive outcomes
patients with previous abdominal surgeries, insufficient perforators,
and delay-induced hemodynamic alterations.
perforators superior to the umbilicus, or perforators with a lengthy,
Methods: Patients presenting for autologous breast reconstruction between May
branching intramuscular course. The SIEA flap has gained increased inter-
2019 and October 2020 were evaluated with preoperative imaging and received
est as an alternative, muscle sparing abdominal flap.7–9 This flap was ini-
either delayed SIEA or delayed deep inferior epigastric (DIEP) reconstruction
tially used by Anita and Buch10 in 1971 as a free-tissue transfer for facial
based on clinical considerations, such as prior surgery and perforator size/
reconstruction. The SIEA flap is more advantageous to the DIEP flap in
location. Prospective data were collected on operative time, length of stay, and
terms of donor site morbidity because it does not require incision or exci-
complications. Arterial diameter and peak flow were quantified with Doppler ul-
sion of either the rectus abdominis muscle or fascia.9 This yields signifi-
trasound predelay and postdelay.
cantly improved abdominal wall function compared WITH DIEP flaps
Results: Seventeen delayed SIEA flaps were included. The mean age (± SD) was
and prevents any incidence of abdominal wall bulge after flap harvest.11,12
46.2 ± 10.55 years, and body mass index was 26.7 ± 4.26 kg/m2. Average hospi-
Yet despite reduction in abdominal wall morbidity, the SIEA flap
tal stay after delay was 0.85 ± 0.90 days, and duration before reconstruction was
has failed to attain the same popularity as other abdominally based flaps
6 days to 14.5 months. Delay complications included 1 abdominal seroma (n = 1,
as it has been shown to have higher rates of complications. When com-
7.7%). Superficial inferior epigastric artery diameter predelay (mean ± 95% con-
pared with DIEP or muscle sparing transverse rectus abdominis
fidence interval) was 1.37 ± 0.20 mm and increased to 2.26 ± 0.24 mm postdelay.
myocutaneous flaps, SIEA flaps have demonstrated significantly higher
A significant increase in diameter was noted 0.9 ± 0.22 mm ( P < 0.0001). Mean
failure rates up to 14%.13,14 The high failure rate of the SIEA is most
peak flow predelay was 14.43 ± 13.38 cm/s and 44.61 ± 60.35 cm/s (n = 4,
often attributed to arterial insufficiency, thrombosis, and spasm with re-
P = 0.1822) postdelay.
operation rates ranging from 6.2% to 20%.13–15 A major barrier to the
Conclusions: Surgical delay of the SIEA flap augments SIEA diameter, increas-
SIEA flap's widespread use is its small caliber. An arterial diameter of
ing the reliability of this flap for breast reconstruction. Superficial inferior epigas-
1.5 mm3 is the established threshold for reliable flap transfer and sur-
tric artery delay results in low rates of complications and no failures in our series.
vival, and the SIEA has been found to not meet this criterion in 56%
Although more patients are needed to assess increase in arterial flow, use of sur-
to 70% of the patients.8,9,16,17
gical delay can expand the use of SIEA flap reconstruction and reduce abdominal
Preoperative imaging, intraoperative algorithms, and flap modi-
morbidity associated with abdominal flap breast reconstruction.
fications have been implemented to improve SEIA flap success
Key Words: SIEA, breast reconstruction, delay rates.9,18 The delay phenomenon, in which vessels surrounding the
(Ann Plast Surg 2022;88: S414–S421)
main pedicle are ligated to augment the pedicle's blood supply, may
be a successful approach to augment the SIEA diameter, flow, and vas-
cular territory. However, other than the 1 case report by Hadad et al,19
B reast cancer affects 12% of women in the United States, equating to
1.38 million patients per year, making it the second most common
malignancy in women after skin cancer.1 About one-third of women di-
no prior studies have reported the use of the delay phenomenon to aug-
ment the SIEA to a reliable caliber for subsequent use it in autologous
agnosed with breast cancer undergo mastectomy for treatment.2 Post- breast reconstruction. The purpose of this study was to demonstrate that
mastectomy breast reconstruction has been shown to greatly benefit pa- the delay phenomenon can be used to enhance the SIEA caliber, making
tients' health-related quality-of-life, as well as improve psychosocial, it a more reliable flap option for breast reconstruction.
sexual, and physical well-being.1,3,4 Autologous breast reconstruction
accounts for 31% of postmastectomy breast reconstructions, with the deep
inferior epigastric (DIEP) perforator flaps comprising 30% of reconstruc- METHODS
tion.5 Patient-reported outcomes have shown autologous reconstruction to
This nonrandomized, prospective cohort study enrolled patients
presenting for breast reconstruction between May 2019 and October
Received November 1, 2021, and accepted for publication, after revision December
2020 to the practices of the 3 senior surgeons (R.A., J.Z., H.sH.) at a sin-
30, 2021. gle institution. Eligible study patients were women older than 18 years
From the aSchool of Medicine, bDivision of Plastic and Reconstructive Surgery, with clinical indications for either unilateral or bilateral breast recon-
Louisiana State University Health Sciences Center; cSchool of Medicine, Tulane struction after oncologic or prophylactic mastectomy. All included pa-
University, New Orleans; and dDepartment of Plastic and Reconstructive Surgery,
Ochsner Medical Center, Jefferson, LA.
tients were determined to be appropriate candidates for delayed autolo-
Conflicts of interest and sources of funding: none declared. gous breast reconstruction using the abdominal donor site through pre-
Reprints: Robert J. Allen Sr., MD, Department of Surgery, Division of Plastic and operative evaluation and shared decision making. Indications for
Reconstructive Surgery, 1542 Tulane ave, 7th floor, New Orleans, LA 70112. surgical delay included prior or current smoking status, prior abdominal
E-mail: boballen@diepflap.com.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
surgery, small DIEP perforators, or the need for augmented tissue vol-
ISSN: 0148-7043/22/8805–S414 ume. Patients undergoing definitive alloplastic breast reconstruction
DOI: 10.1097/SAP.0000000000003160 were excluded.

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Annals of Plastic Surgery • Volume 88, Supplement 5, June 2022 Delayed SIEA Flap Breast Reconstruction

Each patient was evaluated with a thorough history and physical
examination. Data regarding age, body mass index (BMI), tobacco sta-
tus, medical history, surgical history, primary breast pathology, oncologic
course, and past or ongoing treatment were prospectively collected and
reviewed. Each patient received preoperative radiologic imaging, either
with computer tomography-angiography (CTA) or magnetic resonance
angiography (MRA) to map the deep and superficial vascular systems
of the abdomen.
Preoperative imaging was initially reviewed, noting the presence,
location, course, and caliber of the DIEP artery and its perforators bilat-
erally. In addition, the presence, location, course, and caliber of the
SIEA were noted bilaterally. All patients with an identifiable SIEA on
either CTA or MRA were further evaluated with handheld Doppler or
color Doppler ultrasound. If an SIEA was identifiable by both radio-
graphic imaging and handheld Doppler/Doppler ultrasound, then pa-
tients were consented and scheduled for surgical flap creation procedure
based on the SIEA, with possible alternative DIEP-based reconstruc-
tion. Before surgery, a measurement of the diameter of the SIEA was
made using Doppler ultrasound when available. In instances where
Doppler ultrasound imaging was not available, measurements were
made intraoperatively using 1 mm microgrid or using preoperative
CTA/MRA. In select patients evaluated with Doppler ultrasound, peak
systolic blood flow velocity was measured for the SIEA (Fig. 1).
Depending on the course of each patient's oncologic treatment,
the SIEA flap delay procedure was performed either in an isolated pro-
cedure, or at the time of mastectomy and/or tissue expander placement.
Preoperatively, the flap was designed over the lower abdomen and the
locations of the SIEA and Superficial Inferior Epigastric Vein (SIEV)
at the inferior border of the flap, as well as any DIEA perforators were
marked based on imaging and handheld Doppler (Fig. 2). After the ab-
dominal donor site was prepped and draped, an initial incision was
made over the SIEA and SIEV and was carried down through the sub-
cutaneous tissue until the SIEA and SIEV were visualized (Fig. 2). The
size of the artery and its venae comitantes were noted. At this time, an
intraoperative decision was made based on arterial size visualization to
proceed with SIEA delay or to go with a DIEP flap. Of note, this decision
was made independently for each side in bilateral reconstruction patients.
For patients with an SIEA judged to be of adequate size (defined by the
authors as ≥0.8 mm), the borders of the flap were incised and carried
down to the anterior abdominal muscle except for a 4- to 5-cm skin
and subcutaneous bridge which was retained at the lateral most aspect
of each flap. A threshold of 0.8 mm was chosen as it represents the
smallest SIEA diameter detected routinely with handheld Doppler by
Ulusal et al. Of note, a threshold of 0.8 mm is smaller than the 1-mm
threshold for SIEA flap reconstruction used by Ulusal et al20 and would
increase the percentage of SIEA eligible patients in their cohort by 20%.
If the SIEA appeared diminutive (<0.8 mm) despite its presence
on imaging, then the flap was delayed based on the available DIEA per-
forators. For inclusion in this study, patients required at least 1 delayed
SIEA flap after this intraoperative algorithm. For SIEA patients, ab-
dominal flaps were elevated in a cranial to caudad fashion, dividing
all DIEP artery perforators and deep circumflex iliac artery perforators
(Fig. 2). Care was taken to preserve the inferiorly located superficial
vessels. An abdominal drain was placed, and all incisions were closed
(Fig. 2). The abdominal drain was removed when drain output fell to
20 mL/d or less, usually 1 to 2 weeks after discharge. Data were col-
lected on final flap selection (SIEA vs DIEP) operative time, length of
hospital stay, and any postoperative complications.
Delay was allowed for a minimum of 6 days, with total delay
time depending upon each patient's oncologic management. After delay
and at the time of breast reconstruction, select patients were reevaluated
with Doppler ultrasound to measure SIEA diameter and flow. At the
time of reconstruction, skin incisions were reopened and the SIEA
was dissected down to its takeoff from the femoral artery. If the SIEA
and superficial circumflex iliac artery (SCIA) were found to originate
from a larger common trunk, which has been suggested to occur in
32.6% of vessels, then the SCIA was ligated, and the trunk was har-
vested.21 The size of the SIEA was noted intraoperatively at the border
of the flap. Microsurgical reconstruction proceeded in the standard
fashion with anastomosis of the SIEA to either the contralateral internal
mammary artery (IMA) or IMA intercostal perforators, depending upon
size match and availability. For venous outflow, we used venae

FIGURE 1. Doppler ultrasound assessment of the SIEA. Before the delay procedure, Doppler ultrasound was used to locate the SIEA at
the edge of the proposed flap, near the inguinal ligament. Arterial pulsation was visualized and confirmed with the assistance of color
and Doppler signal features. The SIEA diameter (mm) was measured in cross section slices at this level. Peak systolic flow (cm/s) was then
assessed at the same location by measuring peak velocity on the Doppler signal waveforms as pictured.

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Hoffman et al Annals of Plastic Surgery • Volume 88, Supplement 5, June 2022

FIGURE 2. Flap creation procedure for surgical delay of left SIEA flap and right DIEP flap. A, Preoperative markings of abdominal flap
design including the location and course of the SIEA, SIEV, and DIEA perforators bilaterally. B, Incision over SIEA to verify arterial size
intraoperatively. C, Elevated left SIEA and right DIEP flaps. D, Skin closure of delayed flaps, note the lateral skin and fascial attachment left
during the delay procedure (arrow).

comitantes associated with the SIEA or more frequently the SIEV if it
was larger. Flaps were routinely deepithelialized. If flap weights were
in excess of what was required for reconstruction, or if the edges of
the flap demonstrated poor perfusion intraoperatively, these distal most
areas, corresponding to the lateral hemiabdomen, were trimmed. Stan-
dardized flap monitoring was conducted for the duration of inpatient
hospital stay. After reconstruction, data were collected on operative
time, length of hospital stay, and postoperative complications through
the immediate postoperative period until the time of second stage pro-
cedures. Drains were removed when output was less than 20 mL/d
serosanguinous output usually at the first follow up appointment 1 week
after hospital discharge.
Predelay and postdelay measurements of the SIEA diameter and
peak systolic blood flow were compared with 2-tailed paired Student t
test in GraphPad Prism8. Measurements for each patient were made
using Doppler ultrasound scan when available. For patients without ul-
trasound assessment, intraoperative measurements were determined
using a microsurgical 1 mm grid. If intraoperative measurements were
not recorded, measurements were made on MRA/CTA scans.
RESULTS
Demographics
Thirteen women receiving a total of 24 flaps for autologous
breast reconstruction were included in this study (Table 1). The mean age
(± SD) was 46.2 ± 10.55 years, and the mean BMI was 26.7 ± 4.26 kg/
m2. Most patients had never smoked tobacco (77%), whereas 2 (15.3%)
were former smokers and 1 (7.7%) was a current smoker. See Table 1 for
information regarding comorbidities, medical history, and prior abdominal
surgeries. Of the 13 women included, 12 (92.3%) had prior or concurrent
breast pathology and 2 (15.4%) had a positive BRCA mutation with a fam-
ily history of breast cancer. In regard to oncologic management, 11 (84.6%)
had bilateral mastectomies, 2 had unilateral mastectomy (15.4%), 7
(53.8%) underwent sentinel lymph node biopsy, and 4 (30.7%) under-
went axillary node dissection. Four patients (30.7%) did not receive
chemotherapy, whereas 6 (46.3%) and 4 (30.7%) received neoadjuvant
and adjuvant chemotherapy respectively. Nine (69.2%) patients were
treated with adjuvant radiation therapy. Of the 13 women, 4 (30.7%) re-
ceived bilateral SIEA flaps, 7 (53.8%) received an SIEA on 1 side with
a contralateral DIEP, and 2 (15.3%) received unilateral SIEA flaps, to-
taling to 17 delayed SIEA flaps for inclusion in this study (Table 1).
Mean SIEA flap mass was 638.8 ± 185.8 g (Table 2).
Operative Details
The mean operative duration of the flap creation/delay procedure
was 172 minutes. For isolated delay procedures, average duration was
115 minutes, whereas delay performed at the time of mastectomy aver-
aged 288 minutes (Table 2). Most delay procedures were performed ei-
ther outpatient (n = 5, 38.5%) or with overnight hospital stay (n = 6,
46.3%). The length of surgical delay before definitive reconstruction
averaged 105.9 ± 135.5 days but varied widely from 6 days to
14.5 months, depending on each patient's oncologic management plan.
For definitive reconstruction after delay, the average operative duration
was 408 minutes with hospital length of stays ranging from 3 to 6 days
(Table 2).
Postoperative Complications
The delay procedure resulted in no reported postoperative com-
plications for 11 (76.5%) patients. Despite the use of abdominal binders
and abdominal drains, patients frequently developed a seroma cavity
between the flaps and the rectus fascia, but the majority of these
seromas were clinically insignificant, and the fluid was drained at the

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Annals of Plastic Surgery • Volume 88, Supplement 5, June 2022 Delayed SIEA Flap Breast Reconstruction

and 1 (5.8%) case of dehiscence managed conservatively with local

TABLE 1. Demographics from delayed SIEA breast wound care. Two (11.8%) flaps demonstrated clinically detectable
reconstruction patients amounts of fat necrosis addressed at the second stage (Table 2).
Patients 13 Hemodynamic Alterations
Age (mean ± SD), y 46.2 ± 10.55
In order to assess delay-induced hemodynamic alterations within
BMI (mean ± SD), kg/m2 26.7 ± 4.26 the SIEA flap, SIEA diameter was assessed just before delay, and at the
Smoking, n (%) time of reconstruction. The SIEA diameter increased in all 17 flaps
Never 10 (77) from a predelay mean (±95% confidence interval [CI]) of
Former 2 (15.3) 1.37 ± 0.20 mm to a postdelay mean of 2.26 ± 0.24 mm (Fig. 3). This
Current 1 (7.7) represents a statistically significant increase averaging 0.9 ± 0.22 mm
Cardiovascular Hx, n (%) ( P < 0.0001). There was no significant correlation by linear regression
HTN 2 (15.3) between length of delay and absolute ( P = 0.57) or relative ( P = 0.26)
Wolf-Parkinson-White 1 (7.7) increase in arterial diameter. Delay-induced changes in peak systolic
flow were quantified in 4 patients. Mean flow (±95% CI) before delay
Pulmonary Hx, n (%)
was 14.43 ± 13.38 cm/s and increased to 44.61 ± 60.35 cm/s (n = 4,
Lung mass 1 (7.7)
P = 0.1822, Fig. 3). Although flow increased in all flaps, this represents
Endocrine Hx, n (%) a nonstatistically significant increase of 26.99 ± 9.66 cm/s (Table 3).
Thyroid disease 3 (23.1)
Psychiatric Hx, n (%)
Depression 2 (15.3)
DISCUSSION
Anxiety 1 (7.7) When combined, the use of the SIEA flap in the setting of surgi-
cal delay represents an excellent option for autologous breast recon-
Sleep disturbances 1 (7.7)
struction with several attractive benefits. The SIEA may be harvested
Abdominal surgery Hx, n (%)
while completely avoiding violation of the rectus abdominus muscle
Appendectomy 2 (15.3) or fascia, potentially reducing abdominal wall morbidity such as herni-
Cholecystectomy 3 (23.1) ation, bulging, weakness, and pain.11,12 Preserving the abdominal wall
Exploratory laparotomy 1 (7.7)
Adrenalectomy 1 (7.7)
Hysterectomy 2 (15.3)
TABLE 2. Operative Details from delayed SIEA breast
Tubal ligation 2 (15.3) reconstruction procedures
Cesarean section 1 (7.7)
Breast surgery, n (%) Delay procedure
Bilateral mastectomy 11 (84.6) Operative time (mean ± SD), min 172.1 ± 108.6
Unilateral mastectomy 2 (15.3) Flap creation only 115 ± 48
Nipple-sparing mastectomy 4 (30.7) Flap creation + mastectomy 288 ± 123
Skin-sparing mastectomy 2 (15.4) Length of stay (mean ± SD), d 0.85 ± 0.90
Sentinel lymph node biopsy 7 (53.8) 0 5 (38.5)
Axillary node dissection 4 (30.7) 1 6 (46.3)
Chemotherapy, n (%) 2 1 (7.7)
None 4 (30.7) 3 1 (7.7)
Neoadjuvant 6 (46.2) Complications, n (%)
Adjuvant 4 (30.7) None 12 (92.3)
Radiation Abdominal seroma requiring drainage 1 (7.7)
None 4 (30.7) Reconstruction
Adjuvant 9 (69.2) Operative time (mean ± SD), min 408.5 ± 135.5
Flaps, n (%) Length of stay (mean ± SD), d 3.8 ± 0.8
Total flaps 24 (100) 3 5 (38.5)
SIEA flaps 17 (70.8) 4 7 (53.8)
DIEP 7 (29.2) 6 1 (7.7)
Reconstruction Length of delay (mean ± SD), d 105.9 ± 135.4
Bilateral SIEA 4 (30.7) SIEA flaps, n 17
SIEA/DIEP 7 (53.8) SIEA flap weight (mean ± SD). g 638.8 ± 185.8
Unilateral SIEA 2 (15.3) SIEA complications, n (%)
None 13 (76.5)
Dehiscence 1 (5.8)
time of reconstruction. Only 1 (7.7%) patient developed an infected ab- Hematoma 1 (5.8)
dominal seroma that was drained in the office setting. Fat necrosis 2 (11.8)
After delayed reconstruction with 17 SIEA flaps, we report no Reoperation/reexploration 1 (5.8)
instances of flap loss or anastomotic revision (Table 2). Thirteen (76.5%) Anastomosis revision 0 (0)
SIEA flaps were without any postoperative complications. Other complica- Flap loss 0 (0)
tions included 1 (5.8%) instance of hematoma requiring return to the OR,

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Hoffman et al Annals of Plastic Surgery • Volume 88, Supplement 5, June 2022

FIGURE 3. Delay-induced hemodynamic alterations in SIEA cross-sectional diameter and peak blood flow velocity. Paired data points for
a single patient connected with line. Left graph showing diameter in mm of the SIEA. Dotted line denotes 1.5 mm suggested
threshold for SIEA diameter. Right graph showing SIEA peak flow as measured in Figure 1.

musculature is especially desirable in younger patients. For example, in
Figure 4, we demonstrate the use of delayed SIEA reconstruction in a
36-year-old BRCA-positive woman, with excellent reconstructive out-
comes. When harvesting the abdominal donor tissue on the superficial
system, the vascular pedicle enters the flap at its inferior aspect allowing
for a lower abdominal scar, especially when compared with patients
with dominant DIEA perforators superior to the umbilicus.
Combining surgical delay adds to the benefits of this approach.
Surgical delay increases the area of perfusion by opening choke vessels
and augmenting arterial inflow. Surgical delay increased SIEA cross-
sectional diameter in all patients with an average gain of
0.9 ± 0.22 mm. Before delay, only 47% of SIEA diameters were at or
above the previously established 1.5 mm diameter threshold for im-
proved outcomes.9 After delay, 100% of SIEAs were at or above this
threshold. Therefore, surgical delay represents an incredibly useful
technique for increasing the diameter of the SIEA, facilitating anasto-
mosis and consistent size match-up to the IMA. Spiegel and Khan9 sug-
gested that, when a diameter of 1.5 mm at the lower abdominal incision
is used as a threshold for SIEA based reconstruction, the SIEA is appro-
priate in approximately 31% of cases, whereas it is absent in 42% of the
population. In addition, Ulusal et al suggest that the SIEA is absent in
48% of patients, appropriate for use at a threshold of >1 mm in 32%
of cases, and diminutive (<1 mm) in 20% of cases.20 We demonstrate
that delay of the SIEA flap with an arterial diameter of at least
0.8 mm reliably enlarges SIEA diameter to 1.5 mm or greater and can
expand its use by at least 20% to a greater cohort of patients thereby re-
ducing morbidity associated with autologous breast reconstruction.
Peak systolic blood flow velocity through the SIEA increased in
all 4 patients, yet there was great variability in the magnitude of this in-
crease in flow, and as such, the delay induced changes in flow were not
statistically significant. This variability may partially be explained in
that 1 patient presenting for unilateral reconstruction had the entire ab-
dominal flap delayed on a single left SIEA, while the other 3 patients
had at least 1 perfusing vessel per hemiabdomen. This patient demon-
strated a much greater increase in SIEA flow when compared with
the other 3 (Fig. 3). These data demonstrate that blood flow into the flap
is likely increased to a variable degree by the delay procedure. Of note,
some hemodynamic changes were likely occurring that were not di-
rectly quantified in this study. For instance, the delay phenomenon
likely opens choke vessels, increasing the vascular territory supported
by a single vessel. Indocyanine green angiography angiography or infra-
red thermography-based perfusion assessment could be used in future
studies to visualize such likely effects of surgical delay.22 In addition,
the delay procedure allows for substantial flap volumes to be harvested.

TABLE 3. Delay-induced hemodynamic alterations in SIEA cross-sectional diameter and peak systolic blood flow velocity

Diameter (n = 17)
Predelay (mean ± 95% CI), mm 1.37 ± 0.20 < 0.0001
Postdelay (mean ± 95% CI), mm 2.26 ± 0.24
Increase (mean ± 95% CI), mm 0.9 ± 0.22
Flow (n = 4) Predelay (mean ± 95% CI), cm/s 14.43 ± 13.38 0.1822
Postdelay, (mean ± 95% CI), cm/s 44.61 ± 60.35
Increase, (mean ± 95% CI), cm/s 26.99 ± 49.66

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Annals of Plastic Surgery • Volume 88, Supplement 5, June 2022 Delayed SIEA Flap Breast Reconstruction

FIGURE 4. Bilateral delayed SIEA reconstruction. First row: Preoperative images of 36 year old female with BRCA gene mutation and
invasive ductal carcinoma of left breast. Second row: Images taken 70 days postoperatively after surgical delay of bilateral SIEA flaps
with concurrent bilateral nipple sparing mastectomy and tissue expander placement. Third row: images 160 days after SIEA-based
autologous breast reconstruction. Fourth row: Images 54 days after second stage with removal of skin islands at inframammary fold
and dog ear excision.

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Hoffman et al
In the 17 delayed SIEA flaps included, flap mass ranged from 400–1000 g,
with a mean (± SD) flap mass of 638.8 ± 185.8 g (Table 2).
Together, these data point to the utility of the SIEA flap as an al-
ternative to the DIEP flap which may be particularly desirable in youn-
ger women, those with unfavorable perforator anatomy, or those with
prior abdominal surgery. Since 1989, the senior author has performed
348 autologous breast reconstruction procedures using the SIEA flap.23
Consideration of delayed SIEA as the first choice more than doubled
the frequency of SIEA use in the senior author's practice. It is advanta-
geous to approach patients early in their oncologic and reconstructive
course if a delay procedure is planned so that preoperative imaging
can be obtained, and the flaps may be delayed at the time of mastectomy
or before mastectomy. Our patient population did not express concern
over the delay procedure when the benefits of surgical delay and possi-
ble alternatives were discussed. The authors have also had no issues
with insurance approval for the delay procedure either at the time of
mastectomy or performed in an isolated operation. Our patients report
minimal pain after the delay procedure, and while the delay procedure
was often performed on an outpatient basis in our patients (38.5%), rais-
ing delayed flaps at the time of mastectomy provides the added benefit
of postoperative observation if the oncologic breast surgeon indicates
need for an overnight hospital stay.
We demonstrate that the beneficial effects of the delay are seen
within 6 days, but reconstruction can be performed at any time greater
than 6 days after delay as dictated by the patient's oncologic manage-
ment. It is important to note that many patients will develop an abdom-
inal seroma cavity underneath the delayed flaps even with the use of ab-
dominal binders and drains as this area is rich in lymphatics. Most
seromas (93.3%) in our patient population were subclinical and were
drained at the time of reconstruction. For reconstructions delayed over
a greater period of time, this seroma may contribute to the formation
of a pseudo-epithelium on the underside of the flap, which may be ad-
dressed at the time of reconstruction.
There were several notable limitations to this study. First, the
sample size of 13 patients with 17 successful flaps allowed for demon-
stration of a robust increase in SIEA diameter and satisfactory recon-
structive outcomes due to surgical delay, however only 4 patients had
complete predelay and postdelay flow measurements as flow was not
examined in initial patients in the study and ultrasound availability
was limited. In addition, as previously stated, the methodology for mea-
suring SIEA diameter was not consistent. Ultrasound was the preferred
method for diameter measurement, and the only modality used to ac-
quire flow data. To limit measurement bias, a single medical student
performed all ultrasound measurements, but the ultrasound machine
was only available for 8 of 17 predelay measurements and 6 of 17
postdelay measurements. When ultrasound was not available, intraoper-
ative measurements were used in 1 predelay and 10 postdelay measure-
ments using a microsurgical 1 mm grid, followed by CTA or MRA-
based measurements, which were used for 8 predelay and 1 postdelay
measurements. This study would have benefitted from a more consis-
tent diameter assessment modality.
One benefit to using multiple modalities stems from comparison
between modalities. For example, the authors found that CTA/MRA
were useful in detecting a superficial system but did not allow for con-
fident predictions of arterial size. A recent study using multi-detector
row CTA to measure SIEA intraluminal diameter suggests that 70.8%
of SIEA's are greater than 2 mm at the takeoff from the femoral artery
and suggests this criterion can be used to select SIEA candidates.21
Yet Spiegel and Khan9 have shown that the arterial size at the lower bor-
der of the proposed flap is more predictive of flap reliability since SIEA
diameter can diminish as the vessel courses into the flap. We felt that
CTA/MRA measurements often overestimated SIEA diameter when
compared with intraoperative visualization. In addition, Doppler ultra-
sound was more effective at detecting the size and location of the SIEA
when compared with Doppler signal alone, but ultrasound assessment
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Annals of Plastic Surgery • Volume 88, Supplement 5, June 2022
requires time, costly equipment, and a competent imager, limiting its
feasibility in practice. The authors therefore endorse using imaging
for preoperative screening to predict SIEA candidacy, but highly recom-
mend direct intraoperative visualization of the SIEA at the inferior bor-
der of the proposed flap before committing to SIEA-based delayed re-
construction (Fig. 2B). The SIEA size at its origin is larger than its di-
ameter at the inferior flap border. In some patients, the SIEA and
SCIA were found to originate from a common trunk. In such cases,
the SCIA was ligated and the SIEA was harvested along with the trunk
to gain even greater diameter for anastomosis. SIEA-based reconstruc-
tion was not attempted in any patient with an SIEA diameter less than
0.8 mm at the flap border, and our algorithm allows for conversion to
DIEP based reconstruction when needed.
CONCLUSIONS
The combination of surgical delay with SIEA flap autologous
breast reconstruction shows significant clinical utility and benefit.
The SIEA historically carries a reputation for being a tricky flap with
a steep learning curve. We demonstrate that surgical delay of the SIEA
flap augments SIEA diameter, and although more patients are needed to
assess increase in arterial flow, use of surgical delay can expand SIEA
flap reconstruction to a larger patient population, reducing abdominal
morbidity associated with autologous breast reconstruction. We recom-
mend surgeons take advantage of the benefits demonstrated here by in-
corporating surgical delay in SIEA based breast reconstruction, espe-
cially in instances where the artery is at or below 1.5 mm at the inferior
boarder of the flap.
REFERENCES
1. Berlin NL, Wilkins EG, Alderman AK. Addressing continued disparities in access
to breast reconstruction on the 20th anniversary of the Women's Health and Can-
cer Rights Act. JAMA Surg. 2018;153:603–604.
2. Miller KD, Siegel RL, Lin CC, et al. Cancer treatment and survivorship statistics,
2016. CA Cancer J Clin. 2016;66:271–289.
3. Eltahir Y, Werners LLCH, Dreise MM, et al. Quality-of-life outcomes between
mastectomy alone and breast reconstruction: comparison of patient-reported
BREAST-Q and other health-related quality-of-life measures. Plast Reconstr
Surg. 2013;132:201e–209e.
4. Elder EE, Brandberg Y, Björklund T, et al. Quality of life and patient satisfaction
in breast cancer patients after immediate breast reconstruction: a prospective
study. Breast. 2005;14:201–208.
5. Plastic Surgery Statistics Report American Society of Plastic Surgeons. 2019.
6. Phan R, Hunter-Smith DJ, Rozen WM. The use of patient reported outcome mea-
sures in assessing patient outcomes when comparing autologous to alloplastic
breast reconstruction: a systematic review. Gland Surg. 2019;8:452–460.
7. Allen R Sr. Breast Reconstruction with the SIEA Flap. 1990:Presentation at
Southeastern Society of Plastic and Reconstructive Surgeons.
8. Herrera FA, Selber JC, Buntic R, et al. How often is the superficial inferior epigas-
tric artery adequate? An observational correlation. J Plast Reconstr Aesthet Surg.
2010;63:e310–e311.
9. Spiegel AJ, Khan FN. An intraoperative algorithm for use of the SIEA flap for
breast reconstruction. Plast Reconstr Surg. 2007;120:1450–1459.
10. Antia NH, Buch VI. Transfer of an abdominal dermo-fat graft by direct anastomo-
sis of blood vessels. Br J Plast Surg. 1971;24:15–19.
11. Egeberg A, Rasmussen MK, Sørensen JA. Comparing the donor-site morbidity
using DIEP, SIEA or MS-TRAM flaps for breast reconstructive surgery: a meta-
analysis. J Plast Reconstr Aesthet Surg. 2012;65:1474–1480.
12. Nahabedian MY, Momen B. Lower abdominal bulge after deep inferior epigastric
perforator flap (DIEP) breast reconstruction. Ann Plast Surg. 2005;54:124–129.
13. Coroneos CJ, Heller AM, Voineskos SH, et al. SIEA versus DIEP arterial compli-
cations: a cohort study. Plast Reconstr Surg. 2015;135:802e–807e.
14. Selber JC, Samra F, Bristol M, et al. 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;122:348–355.
15. Park JE, Shenaq DS, Silva AK, et al. Breast reconstruction with SIEA flaps: a
single-institution experience with 145 free flaps. Plast Reconstr Surg. 2016;137:
1682–1689.
16. Arnez ZM, Khan U, Pogorelec D, et al. Breast reconstruction using the free super-
ficial inferior epigastric artery (SIEA) flap. Br J Plast Surg. 1999;52:276–279.
© 2022 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 88, Supplement 5, June 2022
17. Lohasammakul S, Turbpaiboon C, Lohsiriwat V, et al. Anatomy of superficial in-
ferior epigastric vessels: revival of superficial inferior epigastric (SIEA) flap. Plast
Reconstr Surg Glob Open. 2017;5(suppl 2):4–5.
18. Piorkowski JR, DeRosier LC, Nickerson P, et al. Preoperative computed tomogra-
phy angiogram to predict patients with favorable anatomy for superficial inferior
epigastric artery flap breast reconstruction. Ann Plast Surg. 2011;66:534–536.
19. Hadad I, Ibrahim AM, Lin SJ, et al. Augmented SIEA flap for microvascular
breast reconstruction after prior ligation of bilateral deep inferior epigastric arter-
ies. J Plast Reconstr Aesthet Surg. 2013;66:845–847.
20. Ulusal BG, Cheng M-H, Wei F-C, et al. Breast reconstruction using the entire
transverse abdominal adipocutaneous flap based on unilateral superficial or deep
© 2022 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
Delayed SIEA Flap Breast Reconstruction
inferior epigastric vessels. Plast Reconstr Surg. 2006;117:1395–1403; discussion
1404-6.
21. Kita Y, Fukunaga Y, Arikawa M, et al. Anatomy of the arterial and venous systems
of the superficial inferior epigastric artery flap: a retrospective study based on
computed tomographic angiography. J Plast Reconstr Aesthet Surg. 2020;73:
870–875.
22. Hennessy O, Potter SM. Use of infrared thermography for the assessment of free
flap perforators in autologous breast reconstruction: a systematic review. JPRAS
Open. 2020;23:60–70.
23. Healy C, Allen RJ Sr. The evolution of perforator flap breast reconstruction:
twenty years after the first DIEP flap. J Reconstr Microsurg. 2014;30:121–125.
www.annalsplasticsurgery.com S421