Reply: Breast Reconstruction Using the Superficial Circumflex Iliac Artery Superficial Branch Perforator Flap

We thank Berkane et al. for their interest in our work, and we appreciate their letter and their questions, which have encouraged a constructive discussion on this topic. Our study1 demonstrated that the superficial circumflex iliac artery (SCIA) superficial branch perforator (SCISP) flap is a feasible alternative to the deep inferior epigastric perforator (DIEP) flap in a select group of patients. This approach offers several advantages, including a lower morbidity to the abdominal wall, since the rectus fascia does not need to be opened. In addition, the flap usually features a reduced dissection time, as the vessels are located more superficially. The flap was harvested as a full-thickness abdominal flap, similar to the standard DIEP flap, for 2 main reasons: first, to maximize the volume of tissue available for breast reconstruction; and second, to allow for inspection of the perforators of the deep system. Despite harvesting a full-thickness flap, we did not observe any clinically significant fat necrosis in the breast. We believe this was due to the presence of anastomoses connecting the deep and superficial vascular systems, a concept also observed when the superficial vein is used for drainage.2 However, in 1 patient, a small area of fat necrosis was detected incidentally on magnetic resonance imaging during postoperative oncological follow-up. As Berkane et al. note, the superficial circumflex iliac perforator flap pedicle is often considered short; however, in our experience, an average length of 8 cm is generally sufficient for breast reconstruction when using the internal mammary vessels as recipient vessels. Although microsurgical anastomosis in this region can be challenging due to the restricted and sometimes deep operative field, we prefer using the main internal mammary vessels rather than the perforators. We have found that using the perforators yields a less reliable inflow and increases the need for revision surgery. To optimize the surgical field, we perform meticulous dissection and partial rib resection, which provides ample space for the anastomosis and facilitates vessel handling. In our experience, the benefits of this approach outweigh any potential risk of thoracic instability, which has not been observed in our patient cohort. Regarding flap arrangement, we position the flap so that the distal edge lies medially on the thorax, which helps minimize tension on the pedicle and allows for a tension-free anastomosis. This orientation, combined with careful flap rotation and inset, enables us to achieve the desired breast contour while accommodating the pedicle length. In our series, we did not observe any cases of lymphedema or lymphocele following SCISP flap harvest. This can be attributed to the dissection at the level of the superficial fascia in the inguinal region; therefore, the lymphatics and lymph nodes are spared, and injury to the lymphatic drainage is avoided. This technique has already been described.3 Our data demonstrate that, although the superficial branch of the SCIA is consistently present, its perforators are not always sufficient to perfuse the entire hemi-abdomen reliably. This limitation means that, when compared with the DIEP flap, the SCISP flap cannot be considered equivalent in terms of reliability. However, in cases where the superficial vessels are of high caliber, the SCISP flap becomes a viable alternative for reconstruction. Furthermore, as the authors suggested, in cases where the superficial inferior epigastric artery and the SCIA share a common trunk, this common trunk can further increase the size of the caliber. To further enhance the reliability of this technique, we are currently engaged in detailed mapping of the perforasome. As the authors suggested, our goal is to define the vascular territories more accurately and to implement defined zones, thereby improving patient selection and making the SCISP flap a more dependable option in clinical practice. DISCLOSURE The authors have no financial interests or conflicts of interest to declare in relation to the content of this communication.