Pedicled SCIA and SIEA Mega Groin Flap-A Staged Reconstructive Approach for Large Forearm Defects

Objective: The pedicled combined superficial circumflex iliac artery and superficial inferior epigastric artery flap has a large vascular territory ideal for coverage of crush-degloving injuries of the upper extremity. We describe our technique of creating a bipedicled flap through a staged inset, first at the wrist and subsequently progressing up the forearm. This process allows primary thinning of the entire flap while facilitating a safe transfer of the flap. Methods: Three patients with crush-degloving injury of the forearm associated with open fractures of the radius and ulnar bones had their defects reconstructed using the aforementioned flap. Patient 3 also had avulsion of the ulnar artery and crush injury of the median and ulnar nerves. Patients 1 and 2 underwent flap delay and training for 1 week prior to inset. Patient 3 did not undergo delay due to the broad-based nature of the flap. The maximal flap size was 25 x 15 cm. The flap was raised thinly until the sufficient length was obtained for the first-stage inset. Over 2 weeks, further elevation and staged inset were performed to maintain uniform thinness and thereby maximize coverage. Results: Complete flap division was accomplished in 3 weeks. All flaps survived with no marginal flap necrosis. Donor sites were closed directly (n = 2) or skin grafted (n = 1). Conclusions: Staged insetting created a bipedicled construct, which allowed primary thinning of the base and bridging portion, thereby allowing maximal use of the entire flap. Maximising the flap was possible because our technique maintained a bipedicled circulation throughout the entire inset process.