Abandoning the SIEA Flap for the Dual-Plane DIEP Reduces Fat Necrosis and Flap Failure

BACKGROUND: Despite its limitations in abdominally based breast reconstruction, using the superficial inferior epigastric artery (SIEA) flap or system can be advantageous in specific clinical scenarios. To optimize outcomes in these cases, the authors performed a retrospective review of their flap series to advocate a new algorithm to use the superficial system. METHODS: A retrospective analysis was performed on 1700 consecutive free abdominal flaps for the presence of a dominant superficial system or poor deep inferior epigastric artery perforators (DIEP) on clinical examination or angiography. In this setting, the authors analyzed the primary outcome measures of fat necrosis and flap failure with use of the superficial system alone versus a "dual-plane DIEP," where there was an intraflap anastomosis performed between the DIEP pedicle and SIEA pedicle. A multivariable analysis was performed with 21 other potentially confounding variables and compared with outcomes with traditionally perfused DIEP flaps. RESULTS: Fat necrosis was present in 13% of 506 DIEP flaps, 34.1% of 41 SIEA system flaps, and 2.7% of 37 dual-plane DIEP flaps. Superficial system-only flaps were independent predictors of fat necrosis (OR, 6.55; P < 0.001) and flap failure (OR, 9.82; P = 0.002) compared with dual-plane DIEP flaps when used for the same indications. CONCLUSION: In settings of superficial dominance or need to augment perfusion to lateral zones in abdominal free flaps, performing a dual-plane DIEP flap instead of using the superficial system vasculature alone with an SIEA flap can decrease the odds of fat necrosis and flap failure to equal that of a standard DIEP flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.