SIEA flaps lead to an increase in abdominal seroma rates compared to DIEP flaps for breast

reconstruction.

Moradi P, Durrant C, Glass GE, Askouni E, Wood S, Rose V

Charing Cross Hospital, London

Introduction

• The transverse paddle of lower abdominal tissue remains the tissue of choice in breast reconstruction as it is unmatched for both its quality, quantity and aesthetic results.

Introduction

• The methods of autologous tissue breast reconstruction has evolved:– Pedicled TRAM– Free TRAM – Muscle-sparing free TRAM flaps, – DIEP – SIEA

Introduction

• Each variation in this progression has resulted in the harvest of decreasing amounts of rectus abdominis muscle and anterior rectus fascia

• Aims is to minimise donor site morbidity without compromising flap viability.

• The superficial inferior epigastric artery (SIEA) flap was described as early as 1975 by Taylor and Daniel

• Its use for breast reconstruction was first described in a case report by Grotting in 1991

• Wu (PRS 2008) has looked at SIEA patient’s subjective perception of abdominal wall function, and rated them more favourable than their DIEP flap counterparts– thus supporting the notion of improved abdominal

donor site morbidity.

• SIEA flaps may be associated with an increase in seroma rate compared to DIEP/TRAM flaps– Allen et al Seminars in Plastic surgery 2002– Granzow et al JPRAS 2006

• This has not been quantified in the literature.

The SIEA pedicle passes superiorly and laterally in the femoral triangle, supplying lymph nodes before piercing the cribiform fascia to travel in the subcutaneous tissue superficial to Scarpa's fascia.

• Granzow in their report of 228 SIEA flaps, report an increased seroma rate when compared to DIEP flaps, – attribute this to the course of the SIEA through the

groin lymphatic bed, which it nourishes.

Aim

• Does SIEA flap really result in lower donor site morbidity compared to DIEP flaps?

Aim

• In our SIEA and DIEP patients we evaluated:– Post-operative abdominal drain volumes– Abdominal donor site seroma rates– Length of hospital admission

Patients and Methods

• All patients who underwent breast reconstruction using lower abdominal autologous tissue at the Charing Cross Hospital between February and November 2009

Patients and Methods

• 39 patients (43 flaps) • 7 patients had a SIEP flap reconstruction– 6 unilateral and 1 bilateral.

• 28 patients had a DIEP flap reconstruction, – 27 unilateral and 1 bilateral.

Patients and Methods

• 4 patients (6 flaps) were excluded from our study:– 2 of which had a muscle-sparing TRAM

reconstruction – 2 had bilateral reconstructions where one side

utilised a SIEA and the other side a DIEP.

Patients and Methods

• SIEA flap utilised in 10/43 (23%) flaps, which is similar to other published studies – 31% Speigel et al PRS 2007– 30% Chevray et al PRS 2004

There were several anatomic criteria that had to be met for an SIEA flap reconstruction to be performed

1: SIEA with a palpable and visible arterial pulsation and a minimum external diameter of 1.0 mm at the level of the lower abdominal incision

2: CT angiography to visualise the caliber, location and direction of the SIEA

If the above criteria were met

• Minimal dissection of the SIE pedicle was performed at the level of the lower abdominal crease – to avoid unnecessary groin dissection

• DIEP flap raised in the usual manner. – microvascular clamps placed on the perforators

and the flap was isolated on the superficial inferior epigastric vessels.

• Clinical evaluation of the perfusion of the flap was performed and if deemed appropriate– SIEV were dissected to their origins from the

femoral vessels

Drain

• All patients had abdominal drains inserted, and cumulative drainage measurements were taken every 24 hours.

• Once the drainage was less than 40mls/24hours the drains were removed.

Results

• Mean drainage volume in the SIEA group was:– 2248mls

• Mean drainage volume in the DIEP group was:– 531mls

– P=0.029

Results

• Obesity (BMI>30) did not appear to influence drainage volumes in the DIEP (p=0.81) group.

• In the SIEA group, the obese did tend to drain more, although this did not reach significance (P=0.154).

Results

• Length of stay:– SIEA group 10.4 days – DIEP group 9.1 days • p=0.351

• Chevray (PRS 2004) were able to show that patients with a SIEA compared to DIEP reconstruction required an average of 1 day less in the hospital.

Results

• Outpatient percutaneous seroma aspiration:– 2/7 in the SIEA group – 1/28 in the DIEP group • p=0.095

Conclusion• The SIEA does not involve incision or excision

of rectus abdominis muscle or fascia: – Its harvest is the least invasive and quickest method

of obtaining lower abdominal tissue for breast reconstruction.

– The conclusion that abdominal donor-site morbidity is minimised is therefore reasonable

Conclusion

• In our series we found that the SIEA flap was associated with:– a significant increase in abdominal drain volume

relative to the DIEP flap, – which translated to an extra day in hospital