Superficial Circumflex Iliac Artery PerforatorFlap for Reconstruction of Limb DefectsIsao Koshima, M.D., Yuzaburo Nanba, M.D., Tetsuya Tsutsui, M.D., Yoshio Takahashi, M.D.,Katsuyuki Urushibara, M.D., Kiichi Inagawa, M.D., Tamiko Hamasaki, M.D., andTakahiko Moriguchi, M.D.Okayama, Japan

The superficial circumflex iliac artery perforator(SCIP) flap differs from the established groin flap in thatit is nourished by only a perforator of the superficialcircumflex iliac system and has a short segment (3 to 4 cmin length) of this vascular system. Three cases in which freesuperficial circumflex iliac artery perforator flaps weresuccessfully transferred for coverage of soft-tissue defectsin the limb are described in this article. The advantagesof this flap are as follows: no need for deeper and longerdissection for the pedicle vessel, a shorter flap elevationtime, possible thinning of the flap with primary defatting,the possibility of an adiposal flap with customized thick-ness for tissue augmentation, a concealed donor site, min-imal donor-site morbidity, and the availability of a largecutaneous vein as a venous drainage system. The disad-vantages are the need for dissection for a smaller perfo-rator and an anastomosing technique for small-calibervessels of less than 1.0 mm. (Plast. Reconstr. Surg. 113:233, 2004.)

The groin flap, nourished by the superficialcircumflex iliac artery, is historically importantbecause it was the first successful free flap.1With its concealed donor site, this flap used tobe especially popular for children and youngwomen. However, it is rarely used now becauseflap elevation is generally difficult because ofanatomical variation in the course and size ofthe pedicle vessel.

With the recent development of perforatorflaps, the major pedicle vessels of musculocu-taneous or fasciocutaneous flaps have been re-placed by small perforators and whole musclein musculocutaneous flaps, and fascia and ma-

jor vessels have been preserved without anydecrease in skin territories.2–4 This concept ofperforator flaps can be applied to the develop-ment of new superficial circumflex iliac arteryperforator (SCIP [skip]) flaps pedicled withonly a perforator with a small segment of thesuperficial circumflex iliac vessel.

In this article, we present three cases inwhich free superficial circumflex iliac arteryperforator flaps were successfully transferredfor coverage of defects in the limbs. This is thefirst successful transfer of the new free super-ficial circumflex iliac artery perforator flapwith anastomosis of a small distal segment ofthe superficial circumflex iliac system.

PATIENTS AND METHODS

Anatomy

On the basis of anatomic study (10 cadavers)and of clinical cases, it was determined that thesuperficial circumflex iliac artery and concom-itant vein have superficial and deep branches(Fig. 1, above). The superficial branch of thesuperficial circumflex iliac artery divides fromthe femoral artery and runs superolaterally toapproach the anterior superior iliac spine. Thisbranch locates proximally over the deep fasciaof the sartorius muscle and distally in the fattytissue. It gives off a few perforators (0.3 to 0.5in diameter) at the middle portion of the an-teromedial groin region.

From the Departments of Plastic and Reconstructive Surgery, Graduate School of Medicine and Dentistry, Okayama University, and KawasakiMedical School. Received for publication March 10, 2000; revised March 17, 2003.

Presented in part at the Third International Course on Perforator Flaps, in Munich, Germany, November 13, 1999; the Fourth InternationalCourse on Perforator Flaps, in Glasgow, United Kingdom, September 8, 2000; and the Sixth International Course on Perforator Flaps, in Taipei,Taiwan, October 25, 2002.

DOI: 10.1097/01.PRS.0000095948.03605.20

233

The deep branch of the superficial circum-flex iliac artery system also derives from thefemoral artery and vein and runs in a supero-lateral direction beneath the deep fascia of thesartorius muscle through the inguinal liga-ment. After penetrating the deep fascia at thelateral border of the sartorius muscle, the deepbranch enters the suprafascial layer to give offseveral perforators (0.5 to 0.8 mm in diameter)in the anterolateral portion of the groin re-

gion. When a superficial branch is long andlarge, the deep branch is usually short andsmall. Sometimes, in cases in which the super-ficial branch is absent, only the long and largedeep branch can be detected. The distal termi-nals of the superficial and deep branch some-times connect to the perforators from the deepcircumflex iliac system, deep inferior epigastricsystem, and lateral circumflex femoral system.Regarding the venous system, the superficialcircumflex iliac artery accompanies the con-comitant vein and also often accompanies acutaneous vein, which also runs parallel to thesuperficial circumflex iliac artery system in thesuperficial layer of fatty tissue.

Operative Techniques

Preoperative Doppler examination is usefulto confirm the course of the superficial circum-flex iliac artery and localization of perforators.The dominant perforator of the superficial anddeep branches of the superficial circumflexiliac artery system is usually located at the cross-point 3 cm medial from the anterosuperioriliac spine and through the course of the su-perficial circumflex iliac artery. The flap is out-lined to include this point and a portion on theiliac spine. The first incision is made throughthe superior or inferior border of the outlineto detect the deep or superficial branch andthe perforators of the branch. Although bothbranches usually have dominant perforators, insome cases in which the superficial branch isshort or absent, the long and large deepbranch can be detected. When a superficialbranch is very long and large, the deep branchis usually short and small. Therefore, the per-forator of either dominant branch can be se-lected as a pedicle of the superficial circumflexiliac artery perforator flap.

During suprafascial flap elevation from thedistal side, several perforators of the superficialcircumflex iliac artery system can be easilyidentified under lower magnification with aloupe. The dominant perforator is dissecteddeeply to the level of the superficial or deepbranch of the superficial circumflex iliac arterysystem. The cutaneous vein in the adiposallayer is included as a venous drainage systemfor the flap, because the concomitant vein ofthe superficial circumflex iliac artery is some-times too small (�0.5 mm in diameter) toanastomose. After dissection of the perforatorand superficial circumflex iliac artery system,the other border of the flap is incised to elevate

FIG. 1. (Above) Schematic drawing of the perforator of thesuperficial circumflex iliac artery. D, deep branch of the su-perficial circumflex iliac artery; P1, perforator of the deepbranch; S, superficial branch of the superficial circumflexiliac artery; P2, perforator of the superficial branch; T, distalterminal of the deep branch; M, sartorius muscle. (Below)Schematic drawing of the groin perforator flap (G). A shortsegment of the deep branch (D) of the superficial circumflexiliac system was used as the pedicle.

234 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2004

it as an island flap. If necessary, thinning, exceptaround the perforator in the flap, is possible withremoval of fatty tissue with scissors. The key pointfor this operation is bloodless flap elevation todetect and preserve the perforators and bothsuperficial circumflex iliac artery branches.

Finally, the superficial circumflex iliac ar-tery, concomitant vein (usually one, sometimestwo), and superficial circumflex iliac cutane-ous vein are ligated. The proximal and distalportions of the perforator division of the su-perficial circumflex iliac artery system aretransected, and a free groin perforator flapwith a perforator and small segment of super-ficial circumflex iliac artery and concomitantvein (0.8 to 1 mm in diameter at the proximaltransected end) and the cutaneous vein (1.5mm) is transferred (Figs. 1, below, and 2). Asthe vascular dissection for the proximal side ofthe superficial circumflex iliac artery system isnot necessary, the flap can be elevated within ashort time, about 30 minutes. Usually, the do-

nor defect can be closed directly, but some-times a split-thickness skin graft is required.

Patients

Between March of 1995 and October of2002, 10 patients with defects in extremitieswere treated with a superficial circumflex iliacperforator flap (three island flaps and sevenfree flaps). There were two recipient sites inthe upper limbs, six in the legs, and two in theinguinal region. There were three male pa-tients and seven female patients, ranging inage from 12 to 77 years old. The flaps rangedfrom 8 to 20 cm in length and from 3 to 15 cmin width. Although one patient required sec-ondary skin grafting because of partial necrosis(case 7), there were no serious postoperativecomplications such as total necrosis or result-ing absorption of the transferred adiposal flap(Table I).

FIG. 2. Schematic drawing of the perforator of the superficial circumflex iliacsystem. A, femoral artery; V, femoral vein; F, free groin perforator flap; D, deepbranch of the superficial circumflex iliac artery; P1, perforator of the deepbranch; S, superficial branch of the superficial circumflex iliac artery; P2, per-forator of the superficial branch; T, distal terminal of the deep branch; M1,sartorius muscle; M2, tensor fasciae latae muscle.

TABLE IPatient Data

Case Age (yr) Sex Defect Flap Flap Size (cm) Complications

1 12 F Great toe Free SCIP 13 � 5 —2 63 M Elbow VIBGr-SCIP adiposal 20 � 15 —3 61 F Great toe Free SCIP adiposal 10 � 5 —4 48 F Great toe Free SCIP 10 � 5 —5 26 M Foot Free SCIP 15 � 7 —6 25 F Forearm sarcoma Free SCIP 13 � 7 —7 31 M Great toe Free SCIP 14 � 4 Partial necrosis8 77 F Proximal thigh Island SCIP 20 � 10 —9 40 F Inguinal region Island SCIP adiposal 12 � 4 —

10 59 F Inguinal region Island SCIP adiposal 8 � 3 —

SCIP, superficial circumflex iliac perforator; VIBGr, vascularized iliac bone graft.

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CASE REPORTS

Case 1: Coverage for the Foot with a SuperficialCircumflex Iliac Artery Perforator Flap with a Scar

A 12-year-old girl sustained a degloving injury of the rightlittle finger, and the defect had been resurfaced with a pedi-cled groin flap 3 years earlier. After the patient complainedof a bulky little finger, the finger was repaired with a free thinosteo-onychocutaneous flap from the left great toe. As a widescar caused by the previous groin flap remained on the leftgroin region, simultaneous resurfacing of the defect on thegreat toe was planned with a free superficial circumflex iliacartery perforator flap including the scar.

In the groin region, a perforator and its original deepbranch (4 cm in length) of superficial circumflex iliac arterywere selected as the pedicle of this superficial circumflex iliacartery perforator flap. The flap, 13 � 5 cm, including all thescar tissue, was transferred to resurface the great toe. Thedeep branch was anastomosed to the first metatarsal vesseland dorsal cutaneous vein of the foot. The donor groin defectwas closed directly with scar revision.

The postoperative course was uneventful, and the osteo-onychocutaneous flap to create the little finger survived com-pletely. The superficial circumflex iliac artery perforator flapshowed partial superficial necrosis of the scarred portion.After completion of epithelization, flap debulking includingresection of the scarred skin was performed. Five years afterthe operation, there has been no erosion, tenderness, ordysfunction of the repaired donor toe and foot (Figs. 3 and4).

Case 5: Skin Coverage for the Lateral Aspect of theFoot with Use of the Perforator of the Deep Branch

A 26-year-old man had an arteriovenous malformationwith frequent phlegmon and severe pain on the medial aspect

FIG. 3. Case 1. (Above) A 12-year-old girl with a great toedefect resulting from a free osteo-onychocutaneous flaptransfer for reconstruction of the little finger. (Below) The toe21⁄2 years after the primary surgery.

FIG. 4. Case 1. (Left) A wide groin scar caused by a previous pedicled groin flap. This was used as a free groinperforator flap for repair of the toe defect. (Right) The donor site 21⁄2 years after the flap transfer.

236 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2004

of the right foot. After a complete resection of this lesion, themedial tarsal artery and concomitant vein were prepared asthe recipient vessels.

The flap was obtained from the left groin region. Super-ficial and deep branches of the superficial circumflex iliacartery system were present, and the deep branch had a dom-inant perforator near the anterior superior iliac spine. Thedominant perforator involving a short length (3 cm) of thesuperficial circumflex iliac artery and concomitant vein,which was a transected segment of the deep branch, wasselected as a pedicle of the flap. A free superficial circumflexiliac artery perforator flap, 15 � 7 cm in size, was transferred,and the deep branch was anastomosed to the medial tarsalartery and concomitant vein. The donor defect was closeddirectly.

The postoperative course was smooth, and no complica-tions occurred. Four months after the operation, there was noreappearance of the malformation, no pain, and no dysfunc-tion in walking (Fig. 5).

Case 8: Island Superficial Circumflex Iliac ArteryPerforator Flap for Recurrent Liposarcoma in theProximal Thigh Defect

A 77-year-old woman had a recurrent liposarcoma origi-nating within the left tensor fasciae latae muscle. After a wideresection involving a full-thickness tensor fasciae latae mus-cle, an island superficial circumflex iliac artery perforatorflap, measuring 20 � 10 cm and pedicled with a perforator

arising from the deep branch of the superficial circumflexiliac artery system, was transferred to cover the defect. Thedonor defect of the groin region was covered with a split-thickness skin graft. Postoperatively, the flap survived com-pletely and there was no recurrence of the tumor (Figs. 6 and7).

DISCUSSION

Since the groin flap was first described in1972 by McGregor and Jackson,5 numerousstudies6–12 have been published regarding itsanatomy and application. On the basis of thesestudies, it has been proved that the anatomy ofthe superficial circumflex iliac artery systemhas variations, such as the point of derivationand running patterns of the pedicle vessel.These vascular variations have made the use ofthe free groin flap unpopular despite its con-cealed donor site and minimal morbidity.

On the basis of our studies, superficial anddeep branches of the superficial circumflexiliac artery system have been proven to exist.Regarding the superficial branch, Smith et al.6and O’Brien et al.7 noted in some cases6 and in15 percent of cadaver dissections7 that the ves-

FIG. 5. Case 5. (Above, left) A 26-year-old man had an arteriovenous malformation with severe pain in the foot. (Above, right)Outline of the superficial circumflex iliac artery perforator flap. (Below, left) The elevated flap. The arrowhead shows the perforatorof the deep branch. (Below, right) One month after transfer.

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sel split into two branches: one superficial, sup-plying the skin, and the other lying deep to thefascia lata, supplying muscles. Harii11 noted

that in many cases the superficial circumflexiliac artery gives off a superficial branch whenit reaches the medial border of the sartorius.Acland10 also pointed out that the superficialcircumflex iliac artery usually has a superficialbranch, which has not been mentioned by oth-ers, and it deserves special attention because itsometimes provides the only convincing bloodsupply to the flap. Salmon13 reported that thesuperficial circumflex iliac artery passes ob-liquely upward and outward toward the glutealregion and on its way distributes four or fivecutaneous perforators. He noted that some ofthese perforators pass through the superficialinguinal lymph nodes before terminating inthe skin.

On the basis of our results, the essentialpedicle of groin flap is assumed to be not thesuperficial circumflex iliac artery itself but adominant perforator of the superficial or deepbranch of the superficial circumflex iliac arterysystem, and this perforator is responsible forthe vascular territory of the groin flap. Wefound that only one dominant perforator and ashort length of the deep branch are enough tonourish a relatively large groin flap. A superfi-cial circumflex iliac artery perforator flap dif-fers from a conventional groin flap in that itincludes a short distal segment of the superfi-cial circumflex iliac artery system with a domi-nant perforator, whereas a conventional groinflap uses a whole length of the superficial cir-cumflex iliac artery system, including the su-perficial and/or deep branches. Therefore,when a large flap is required, the perforator of

FIG. 6. Case 8. (Above) A 77-year-old woman with recurrentliposarcoma on the left thigh region. The tumor was widelyresected. A superficial circumflex iliac artery perforator flap,measuring 20 � 10 cm, was outlined. (Below) A superficial cir-cumflex iliac artery perforator flap with a perforator of the deepbranch of the superficial circumflex iliac system was elevated.

FIG. 7. Case 8. (Left) Schematic drawing of the arc of the superficial circumflex iliac artery perforator flap. (Center and right)Postoperative appearance.

238 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2004

both branches should be used, and when asmall flap or adiposal flap is needed, a perfo-rator with either branch can be used.

Regarding localization of the perforator,Chuang et al.12 described a two-finger widthrule; that is, two finger widths medial to theanterosuperior iliac spine, the perforator ofthe deep branch of the superficial circumflexiliac artery emerges from beneath the deepfascia to continue to a more superficial course,and the distal portion of the deep branch en-ters the sartorius. This may be helpful in deter-mining localization and in use of a Dopplerprobe.

A conventional groin flap with thick fattytissue cannot be easily thinned with removalof a great amount of fatty tissue in one stage,because the pedicle vessel, the superficialcircumflex iliac artery system, anatomicallyruns subfascially or in the deep layer of thefatty tissue. As a result, the distal portion ofthe superficial circumflex iliac artery wouldbe damaged on removal and cause partialnecrosis. For this reason, a thin groin flaphas not yet been popularized. However, re-section of a considerable amount of fattytissue in a superficial circumflex iliac arteryperforator flap is easy because a short seg-ment (3 cm in length) of the distal portion ofthe superficial circumflex iliac artery systemand the pedicle of perforator flap will hardlybe damaged with removal of the fat, as in thecase of the groin flap.

The advantages of the superficial circumflexiliac artery perforator flap are as follows: (1)deeper and longer dissection of the superficialcircumflex iliac artery system to the femoralartery, as in the groin flap, is unnecessary; (2)only the dominant perforator and a shortlength of the superficial or deep branch arerequired to nourish the flap; (3) flap elevationtime is short; (4) thinning of the flap may beperformed with primary defatting; (5) thin-ning to create a customized adiposal flap withvolume reduction may be performed in onestage; (6) there is minimal donor-site morbid-ity, and the site is in a concealed area; and (7)a large cutaneous vein is available as a venousdrainage system. The disadvantages are thatsupermicrosurgery is necessary to dissect andto anastomose the smaller and short pediclevessels.

Finally, there is some opinion that the “tra-ditional” groin flap is no longer a popular free-flap donor site, because the pedicle is short,

the vessels are small, and there is some variabil-ity of the anatomy of the vascular pedicle. Thesuperficial circumflex iliac artery perforator(SCIP) flap cannot overcome these disadvan-tages and creates an even shorter pedicle withsmaller vessels. Furthermore, it has no signifi-cant donor-site morbidity associated with thetraditional groin flap.

We believe we are now in the revolutionarystage of supermicrosurgery, as was the casewith free flaps with the use of microsurgery inthe 1970s. The supermicrosurgical techniques,including smaller vascular dissection and anas-tomosis, will develop and be popularized in thenext 10 years. Development of new perforatorflaps with smaller vessels is essential for thenext step of minimally invasive reconstructivesurgery.

Isao Koshima, M.D.Plastic and Reconstructive SurgeryGraduate School of Medicine and DentistryOkayama University2-5-1 ShikataOkayama CityOkayama 700-8551, Japanplakoshi@cc.okayama-u.ac.jp

ACKNOWLEDGMENTS

This study was supported in part by grant H14-7 from theScientific Councils of the Japanese Ministry of Health, Wel-fare, and Labor. The authors thank Dr. Kenzo Arakawa,former associate professor of dermatology, Okayama Univer-sity, for his support of this work, and Aiko Fukuda of thesecretarial department of Kawasaki Medical School, for herassistance in drawing the figures.

REFERENCES

1. Daniel, R. K., and Taylor, G. I. Distant transfer of anisland flap by microvascular anastomoses. Plast. Recon-str. Surg. 52: 111, 1973.

2. Koshima, I., and Soeda, S. Inferior epigastric skin flapwithout rectus abdominis muscle. Br. J. Plast. Surg. 42:645, 1989.

3. Koshima, I., Moriguchi, T., Soeda, S., Kawata, S., Ohta, S.,and Ikeda, A. The gluteal perforator-based flap forrepair of sacral pressure sores. Plast. Reconstr. Surg. 91:678, 1993.

4. Angrigiani, C., Grilli, D., and Siebert, J. Latissimus dorsimusculocutaneous flap without muscle. Plast. Reconstr.Surg. 96: 1608, 1995.

5. McGregor, I. A., and Jackson, I. T. The groin flap. Br. J.Plast. Surg. 25: 3, 1972.

6. Smith, P. J., Foley, I., McGregor, I. A., and Jackson, I. T.The anatomical basis of the groin flap. Plast. Reconstr.Surg. 49: 41, 1972.

7. O’Brien, B. M., McLeod, A. M., Hayhurst, J. W., andMorrison, W. A. Successful transfer of a large islandflap from the groin to the foot by microvascular anas-tomoses. Plast. Reconstr. Surg. 52: 271, 1973.

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8. Harii, K., Ohmori, K., Torii, S., et al. Free groin skinflaps. Br. J. Plast. Surg. 28: 225, 1975.

9. Taylor, G. I., and Daniel, R. K. The anatomy of severalfree flap donor sites. Plast. Reconstr. Surg. 56: 243, 1975.

10. Acland, R. D. The free iliac flap: A lateral modifica-tion of the free groin flap. Plast. Reconstr. Surg. 64:30, 1979.

11. Harii, K. The free iliac flap: A lateral modification of the

free groin flap (Discussion). Plast. Reconstr. Surg. 64:257, 1979.

12. Chuang, D. C. C., Colony, L. H., Chen, H. C., and Wei,F. C. Groin flap design and versatility. Plast. Reconstr.Surg. 84: 100, 1989.

13. Salmon, M. The lower limb. In G. I. Taylor and M.Tempest (Eds.), Arteries of the Skin. London: ChurchillLivingstone, 1988. Pp. 38-41.

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