Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Invited Response on: Breast Reconstruction with SIEA Flaps: An Alternative in Selected Cases

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors

Dear Editor,

We thank the authors for their interest in our publication and contribution to our recently published paper on SIEA flaps in autologous breast reconstruction [1].

To begin with, the authors suggest that the SIEA flap should only be used as a hemi-flap, while they refer to an anatomical study on cadavers by Schaverien et al. [2]. We have acknowledged that the current literature on flap perfusion is controversial [3,4,5]. However, based on our clinical experience, we are confident that the SIEA flap can provide a reliable perfusion beyond the midline in selected cases which has been emphasized by other authors before [6, 7]. As stated in our publication, we further experienced that a good perfusion of the entire abdominal flap can especially be observed in obese patients which seems to correlate with a stronger developed superficial system. The sufficient perfusion capacity of the superficial system is further underlined by the low rate of fat necrosis, total and partial flap loss. Of course, decision making needs to be done individually and the flap should be evaluated thoroughly, while all perforators of the deep system are clamped. Even though the flap is still at its donor site at this point of time, we expect no relevant change of the perfusion capacity if the anastomosis is done by a well-trained and experienced microsurgeon.

The authors assert that we recognized a relationship between previous abdominal operations and complications. In contrast, our study demonstrates a successful autologous breast reconstruction with a SIEA flap in patients with a history of abdominal surgery. Based on a preoperative abdominal CT angiogram that showed a sufficient diameter and course of the SIEA, we included patients that had undergone an appendectomy, a cesarean section, laparoscopy, laparotomy or an inguinal hernia repair.

Given the well-known increased risk of overall complications and flap loss in obese patients, there was no relationship between flap necrosis and obesity in our study cohort [8,9,10]. We agree with the authors and have noted that an inverse correlation of the superficial and the deep system to the perfusion of the lower abdomen has been described by other authors before [6].

Almost every woman who undergoes autologous breast reconstruction has a history of breast cancer with multiple hospital stays and previous breast surgeries. Thus, despite all discussions on essential vessel diameter, perfusion capacity and so on, breast reconstruction needs to be as reliable as possible to avoid the necessity of further operations and restore health-related quality of life.


  1. 1.

    Grunherz L, Wolter A, Andree C et al (2019) Autologous breast reconstruction with SIEA flaps: an alternative in selected cases. Aesth Plast Surg.

  2. 2.

    Schaverien M, Saint-Cyr M, Arbique G et al (2008) Arterial and venous anatomies of the deep inferior epigastric perforator and superficial inferior epigastric artery flaps. Plast Reconstr Surg 121(6):1909–1919

  3. 3.

    Arnez ZM, Bajec J, Bardsley AF et al (1991) Experience with 50 free TRAM flap breast reconstructions. Plast Reconstr Surg 87(3):470–478 (discussion 9–82)

  4. 4.

    Chevray PM (2004) Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg 114(5):1077–1083 (discussion 84-5)

  5. 5.

    Wolfram D, Schoeller T, Hussl H et al (2006) The superficial inferior epigastric artery (SIEA) flap: indications for breast reconstruction. Ann Plast Surg 57(6):593–596

  6. 6.

    Holm C, Mayr M, Hofter E et al (2008) Interindividual variability of the SIEA Angiosome: effects on operative strategies in breast reconstruction. Plast Reconstr Surg 122(6):1612–1620

  7. 7.

    Ulusal BG, Cheng MH, Wei FC et al (2006) Breast reconstruction using the entire transverse abdominal adipocutaneous flap based on unilateral superficial or deep inferior epigastric vessels. Plast Reconstr Surg 117(5):1395–1403 (discussion 404-6)

  8. 8.

    Munhoz AM, Pellarin L, Montag E et al (2011) Superficial inferior epigastric artery (SIEA) free flap using perforator vessels as a recipient site: clinical implications in autologous breast reconstruction. Am J Surg 202(5):612–617

  9. 9.

    Otte M, Nestle-Kramling C, Fertsch S et al (2016) Conservative mastectomies and Immediate-DElayed AutoLogous (IDEAL) breast reconstruction: the DIEP flap. Gland Surg 5(1):24–31

  10. 10.

    Grinsell DG, McCoubrey GW, Finkemeyer JP (2016) The deep inferior epigastric perforator learning curve in the current era. Ann Plast Surg 76(1):72–77

Download references

Author information

Correspondence to Andreas Wolter.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest to disclose.

Statement of Human and Animal Rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed Consent

For this type of study, no formal consent is required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Grünherz, L., Wolter, A., Andree, C. et al. Invited Response on: Breast Reconstruction with SIEA Flaps: An Alternative in Selected Cases. Aesth Plast Surg (2020).

Download citation