SIEA versus DIEP Arterial Complications: A Cohort Study

Background: The authors analyzed arterial complications in patients undergoing breast reconstruction with superficial inferior epigastric artery (SIEA) flaps compared with deep inferior epigastric artery perforator (DIEP) flaps. The variability, caliber, and angiosome of the SIEA are cited as limitations. Experts currently limit SIEA reconstruction to cases with favorable arterial anatomy on preoperative imaging. Methods: In this retrospective cohort study, consecutive flaps for breast reconstruction from the initial 7 years of a single microsurgeon's practice (2007 to 2013) were reviewed. Preoperative imaging was not used. Consistent intraoperative criteria for SIEA flap selection were used. All complications were abstracted independently in duplicate using a standardized form and a priori criteria. Results: One hundred sixty-nine free flaps (SIEA, n = 44; DIEP, n = 125) were performed on 112 patients for unilateral or bilateral breast reconstruction. Significantly more SIEA flaps required reexploration versus DIEP flaps (20 percent versus 7 percent; p = 0.03). Arterial insufficiency was significantly higher among SIEA flaps (14 percent versus 1 percent; p = 0.001). There was no difference in venous insufficiency (p = 0.92). Significantly more SIEA flaps had necrosis requiring intervention (p = 0.03). Ultimately, significantly more SIEA flaps failed completely (14 percent versus 2 percent; p < 0.01). All SIEA flap failures were attributable to arterial thrombosis. Conclusions: Compared with DIEP flaps, SIEA flaps had significantly higher proportions of reexploration, arterial complication, necrosis, and failure. No difference in venous complications was found. DIEP outcomes agree with existing literature from specialized centers. Complications and failures in SIEA flaps were attributed to arterial thrombosis. Given the authors' practice setting, SIEA flaps are no longer performed.