Superficial Inferior Epigastric Artery (SIEA) Flap For Autologous Breast Reconstruction: A Single-Institution Experience With Technical Pearls

Introduction Autologous abdominal tissue transfer is considered the gold standard for breast reconstruction, providing natural composition and texture. The superficial inferior epigastric artery (SIEA) flap represents the least invasive option, sparing both the rectus muscle and fascia. However, its adoption remains limited due to concerns regarding arterial complications and donor site morbidity. We aimed to describe our experience with SIEA flaps in carefully selected patients and present technical pearls to optimise outcomes. Methods A retrospective chart review was performed of all breast cancer patients undergoing abdominal-based free flap breast reconstruction at a single institution from January 2020 to September 2025. Patients were selected for SIEA reconstruction based on preoperative computed tomography angiography (CTA) demonstrating a dominant superficial system (SIEA diameter ≥1.5 mm) with inadequate deep inferior epigastric artery perforator (DIEP) anatomy. Demographic data, comorbidities, adjuvant therapies, operative details, and complications were recorded. Outcomes were compared descriptively with contemporaneous DIEP flap reconstructions. Categorical variables were analyzed using Fisher's exact test, with statistical significance set at p<0.05. Given the small SIEA cohort size (five flaps in five patients), this study should be considered hypothesis-generating rather than definitive. Results During the study period, 170 flaps were performed in 161 patients; 165 DIEP flaps (97%) in 156 patients and five SIEA flaps (3%) in five patients. All SIEA reconstructions were unilateral and immediate. Mean patient age was 48.4 years (SIEA) versus 53.5 years (DIEP). Mean hospital length of stay was 10 days for SIEA patients versus eight days for DIEP patients. At the recipient site, no arterial insufficiency, venous thrombosis, or flap failure occurred in the SIEA cohort. Donor site seroma occurred in 1/5 (20%) SIEA flaps versus 3/165 (1.8%) DIEP flaps (p=0.058). No abdominal dehiscence or hernia occurred in the SIEA group. Overall complication rates were 20% (1/5) for SIEA versus 5.5% (9/165) for DIEP flaps (p=0.264). The limited sample size precludes definitive statistical conclusions. Conclusion In highly selected patients with favourable superficial arterial anatomy on preoperative CTA, SIEA flaps can achieve successful breast reconstruction with minimal donor site morbidity. Careful patient selection, meticulous surgical technique incorporating specific technical pearls, and appropriate recipient vessel selection are essential to optimise outcomes. While the trend toward increased seroma formation warrants attention, the complete absence of abdominal wall weakness represents a significant advantage. Larger multi-institutional studies are needed to establish definitive comparative outcomes.