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

We appreciate the continued interest in managing and innovating the role that the superficial inferior epigastric artery (SIEA) flap plays among increasing choices for the breast microsurgeon. Dr. Allen and his team continue to forge paths and increase awareness of various methods to optimize flap permutations, increase survival, and decrease morbidity for the patient.1 Fortunately, the seeds of creativity and innovation in breast microsurgery come from continuing to rethink past and existing options, and thus open future options in breast reconstruction. There is no one recipe that delivers the best success for the patient, and we advocate for the widespread use of the various flaps and combinations that exist today. Beyond the initial goal of microvascular success, the ultimate refinement exists foremost in aesthetic success for the breast reconstructive patient. The SIEA flap, in our experience, also has evolved in much a parallel fashion to Dr. Allen and his team, but we have been humbled by the SIEA flap and tend to avoid its liberal use due to its inherent physiologic shortcomings. For the SIEA flap, this arises from its vasospastic tendency, which may be worsened by its common mismatch to recipient vessels. There are also some limitations in flap insetting that make it resistant to salvage maneuvers, unlike other flaps, such as the deep inferior epigastric artery perforator (DIEP), profunda artery perforator, and lumbar artery perforator flaps, which we have embraced more willingly. The superficial inferior epigastric vein (SIEV), on the other hand, lends itself to various outflow drainage options, as already stated by the authors, such as retrograde drainage to the internal mammary vein, recruiting the additional deep inferior epigastric vein if available and anastomosing to the superficial inferior epigastric vein, and possibly using the mammary vein perforator as well, although the latter is subject to easy collapse. In contrast, the SIEA tends to originate anatomically as a curve if it is harvested as distal as possible, and we have often shortened it to make the flow more laminar, thus, perhaps avoiding mechanical kinks that could contribute to its higher failure rate. Like the authors, we also find that using the SIEA flap as an adjunct to other flaps, such as the DIEP flap, will increase and optimize vascular territory and reduce fat necrosis, which was the intention of our article.2 However, the SIEA-only flap can carry even the most technically and experienced microsurgeon toward an exercise in microsurgical humility. For that reason, despite its various advantages, we advocate caution in using the SIEA alone and respect its limited widespread application, unless it is used as an adjunct to another reliable flap, such as the DIEP. DISCLOSURE The authors have no commercial or financial associations related to this communication, and no commercial or financial conflicts of interest to report. No funding was received for the performance of this research or production of this communication.