BREAST

Breast Reconstruction Using the EntireTransverse Abdominal Adipocutaneous FlapBased on Unilateral Superficial or DeepInferior Epigastric Vessels

Betul Gozel Ulusal, M.D.Ming-Huei Cheng, M.D.

Fu-Chan Wei, M.D.Mark Ho-Asjoe, M.D.

Dennis Song, M.D.

Taipei, Taiwan

Background: Among various alternatives for autologous breast reconstruction, thesuperficial inferior epigastric artery abdominal flap provides the least donor-site mor-bidity, as dissection of the rectus abdominis sheath and muscle is not required.However, because of inconsistencies in the existence and size of the superficial inferiorepigastric artery, its use is limited. In addition, whether the perfusion from thesuperficial system is adequate across the midline is still a question to be answered.Methods: Over a period of 16 months, the authors performed a total of 44 breastreconstructions using either the deep inferior epigastric artery perforator flap (n � 30)or the superficial inferior epigastric artery flap (n � 14). In all cases, the superficialinferior epigastric artery system was explored first and used as the pedicle if thediameter of the available vessels was larger than 1 mm. If the vessels were unavailableor the diameters were smaller than 1 mm, the deep inferior epigastric artery and veinwere used as the pedicle. The diameter of the superficial inferior epigastric arteryranged between 0.8 and 3.0 mm, and the mean pedicle length was 6 cm. Thesuperficial inferior epigastric artery was not available in 21 cases (48 percent), and innine cases (20 percent) the diameter was smaller than 1 mm. In six cases where thesuperficial inferior epigastric artery was judged to be appropriate, laser Doppler studywas performed perioperatively to assess the perfusion of each zone (I through IV) fromthe deep and superficial systems consecutively. In all cases, the superficial and deepsystems ipsilateral to the defect were dissected. During inset, zone IV was not discardedroutinely, and 92.3 percent and 86.7 percent of the harvested superficial inferiorepigastric artery flap and deep inferior epigastric artery perforator flap, respectively,were used.Results: The flap survival rates were 93 and 100 percent in the superficial inferiorepigastric artery and deep inferior epigastric artery perforator groups, respectively.Adequate perfusion of all zones from the superficial system was documented by laserDoppler flowmetry, and the perfusion rates were comparable to the deep system.Conclusions: The entire abdominal adipocutaneous flap based on the unilateralsuperficial inferior epigastric artery is as reliable as one based on the deep inferiorepigastric artery perforator flap. As a result, initially, the superficial inferior epigastricartery flap should be explored, as it provides less donor-site morbidity. A sizablesuperficial artery and vein is sufficiently safe for microsurgical transfer, similar to thedeep inferior epigastric system. (Plast. Reconstr. Surg. 117: 1395, 2006.)

The lower abdomen has been the preferreddonor site for autologous breast reconstruc-tion, as it provides sufficient tissue volume to

create an aesthetically pleasing breast without theneed for implants. Recently, the free deep infe-rior epigastric artery perforator flap emerged as a

refinement of the free transverse rectus abdominismyocutaneous flap because, with minimal muscle dis-section, it greatly reduces the donor-site morbidity.1To further refine autologous reconstruction, the freesuperficial inferior epigastric artery flap has arisen toeliminate the problems related to anterior abdomi-nal muscle weakness while offering the same tissuevolume and quality as the deep inferior epigastricartery perforator flap.2,3

Described by Taylor and Daniel4 in 1975, thesuperficial inferior epigastric artery flap was ini-tially used as an adipocutaneous or adipose

From the Department of Plastic Surgery, Chang Gung Me-morial Hospital, Chang Gung Medical College, ChangGung University.Received for publication January 17, 2005; revised April 9, 2005.Copyright ©2006 by the American Society of Plastic Surgeons

DOI: 10.1097/01.prs.0000207401.78491.43

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flap.5–9 However, it was not until 1991 thatGrotting10 first reported the use of a free super-ficial inferior epigastric artery flap for breastreconstruction. Since that time, there have beenseveral reports of microvascular transfer of thesuperficial inferior epigastric artery flap forbreast reconstruction, and most of them usedthe superficial inferior epigastric artery flap as ahemi–lower abdomen flap.11–13 Whether the uni-lateral superficial inferior epigastric artery canreliably supply the entire transverse abdominalellipse is an issue that deserves exploration. Theprimary intention of this study was to investigatethe adequacy of perfusion from the unilateralsuperficial system across the midline.

In comparison with the deep inferior epigas-tric artery perforator flap, the superficial inferiorepigastric artery flap is not widely used becauseof inconsistencies in vessel diameter, pediclelength, and availability. Previous studies havedemonstrated that the superficial inferior epi-gastric artery was not present in 35 percent ofcases.4 In addition, donor-site morbidity of thedeep inferior epigastric artery perforator flap isnot completely eliminated, and Blondeel et al.have demonstrated that 5 to 20 percent of rectusabdominis muscles may be damaged followingdeep inferior epigastric artery perforatorharvest.14 However, despite these setbacks, thesuperficial inferior epigastric artery flap providesseveral advantages over other methods of autol-ogous breast reconstruction. Superficial inferiorepigastric artery reconstruction results in lesspain, quicker recovery, and no loss of functionbecause the dissection involves elevating the adi-pocutaneous abdominal tissue above the rectussheath.11,13 Therefore, the superficial inferiorepigastric artery flap merits further investigationto enhance its utility.

PATIENTS AND METHODSBetween March of 2000 and July of 2001, a

total of 44 breast reconstructions were performedin 43 patients by using either the superficial infe-rior epigastric artery flap (n � 14) or the deepinferior epigastric artery perforator flap (n � 30)at Chang Gung Memorial Hospital. One patientunderwent bilateral breast reconstruction withtwo deep inferior epigastric artery perforatorflaps. Twenty-three patients underwent immedi-ate reconstruction (deep inferior epigastric arteryperforator flap, n � 14; superficial inferior epi-gastric artery flap, n � 9) and 21 patients (deepinferior epigastric artery perforator flap, n � 16;

superficial inferior epigastric artery flap, n � 5)underwent delayed reconstruction.

Information regarding patient demographics,flap harvesting and ischemia time, flap volumeand weight, postoperative complications, and hos-pital stay was collected from the operation notesand the medical records. The comparison be-tween superficial inferior epigastric artery anddeep inferior epigastric artery perforator groupswas performed using the unpaired t test (p �0.05).

Surgical TechniqueThe superficial inferior epigastric artery15–17

arises from the femoral artery either directly or bymeans of a common trunk with the superficialcircumflex iliac artery 2 to 5 cm below the inguinalligament. It pierces the cribriform fascia one fin-ger’s breadth beneath the inguinal ligament andascends vertically or slightly laterally in the sub-cutaneous tissues up to 15 cm. The medialbranches of the superficial inferior epigastric ar-tery anastomose with musculocutaneous perfora-tors from the epigastric arcade and the lateralbranches anastomose with intercostal arteries.The venous drainage of this region is mainlythrough the medial epigastric vein and vena co-mitantes of the superficial inferior epigastricartery.15–17

Before the operation, the ipsilateral superfi-cial epigastric vessels and perforators from thedeep system were identified using a hand-heldpencil Doppler. Once a suitable number of per-forators were identified, an abdominal ellipse wasdrawn using the bilateral anterior superior iliacspines as the transverse limits and the pubic tu-bercle and the umbilicus as the vertical limits ofthe flap. Flap zones ipsilateral to the defect sitewere called zone I and zone II, whereas the con-tralateral sites were named zone III and zone IV.A two-team approach was used in most cases. Thefirst team raised the flap and the second teamprepared the chest skin pocket and recipient ves-sels.

In all cases, the internal mammary artery andvein were used as recipient vessels. An incisionthrough the sternal origins of the pectoral muscleswas performed and 2 � 1 cm of the third ribcartilage was removed to expose the internal mam-mary vessels. The vessels were prepared for mi-crosurgical anastomosis under the operation mi-croscope.

Under loupe magnification, the first incisionwas made at the inferior abdominal mark into the

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subcutaneous tissue to identify the ipsilateral su-perficial inferior epigastric artery and vein in thesubcutaneous tissue. Once they were identified,the dissection proceeded proximally to their ori-gin at the femoral vessels. This helped to identifythe vessel diameters and pedicle length. The pe-riod elapsed until this stage was recorded for eachpatient. If the diameter of the superficial vesselswas considered to be sufficient, the abdominal flapwas then raised above the deep abdominal fasciaand rectus abdominis perforators were identifiedand isolated. At this stage, perfusion of each zonewas evaluated by application of microsurgicalclamps to the perforators from the deep system(Fig. 1). If the perfusion was satisfactory, superfi-cial vessels were preferred as pedicles. However, ifthe superficial inferior epigastric artery could notbe identified or its diameter was inadequate (�1mm), the rectus perforators were dissected further

and adipocutaneous tissue was harvested as a deepinferior epigastric artery perforator flap. Based onprevious experience of the senior author(M.H.C.) in more than 600 microsurgery cases,any pulsatile vessel 1.0 mm or larger is suitable andsafe for microsurgical anastomosis.

In six cases with sizable and pulsatile superfi-cial inferior epigastric artery vessels (�1 mm),laser Doppler measurements were obtained toquantitate the perfusion of each zone from boththe deep and superficial systems. A laser Dopplermachine (Periflux 5000; Perimed, Stockholm,Sweden) was connected to the center of each zoneusing probes (Fig. 2), and readings were takenbefore (preclamp group) and after clamping su-perficial (deep inferior epigastric artery perfora-tor group) and deep systems (superficial inferiorepigastric artery group) consecutively (Figs. 1 and3). Each vessel was clamped and data were gath-

Fig. 1. Perioperative identification of the vessels from the deep and superficial systems (above). Microclamps applied to the deepand superficial systems for comparison of the flap circulation for each system (below). (Above, left) Superficial artery and veinmarked with vessel loops. (Above, right) Perforators from the deep inferior epigastric system. (Below, left) Clamped superficialinferior epigastric artery and vein. (Below, right) Clamped perforators from the deep inferior epigastric artery.

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ered after a stabilization period of 10 minutes. Thereadings then were obtained for 10 minutes foreach vessel, and the average value of perfusion wascalculated. Comparisons were performed usingthe Mann-Whitney nonparametric test.

RESULTSThe mean age of the patients in the superficial

inferior epigastric artery and deep inferior epi-gastric artery perforator groups was 42.0 and 39.9years, respectively (p � 0.43). The dimensions ofthe superficial inferior epigastric artery and deepinferior epigastric artery perforator flaps rangedfrom 300 cm2 to 444 cm2 (mean, 368.5 cm2) and260 cm2 to 494 cm2 (mean, 400 cm2), respectively(Table 1). The weight of the used flap over theweight of the total flap for the superficial inferiorepigastric artery flap was 473 � 48.8/553.2 �68.33 g (86.7 percent), and this ratio was 510.4 �42.1/552.8 � 71.0 g (92.3 percent) for the deepinferior epigastric artery perforator flap. Therewas no statistical difference between the twogroups with respect to weight of the harvested flap(p � 0.43) (Table 1).

The venous anastomosis was performed first,followed by the arterial anastomosis without usinga coupler device. All anastomoses were performedin end-to-end fashion. Size discrepancies did notcreate significant difficulties and were usuallyovercome by obliquely cutting the vessel end,stripping the adventitia, and mechanically dilatingthe vessel with the smaller diameter. In bothgroups, mean operation time was 8 hours. The

Fig. 2. Laser probe applications to each flap zone (I through IV) to quantitatively analyze the perfusion rates.

Fig. 3. Data showing the laser Doppler index of each flap zone (Ithrough IV) when perfused by the superficial system, the deepsystem, and both systems.

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mean ischemia time for deep inferior epigastricartery perforator and superficial inferior epigas-tric artery flaps was 102 minutes and 100 minutes,respectively. Dissecting out the superficial systemthrough the femoral arteries lasted approximately30 minutes. There was no statistical differencebetween groups with respect to operation time orischemia time (p � 0.81) (Table 1).

The flap survival rate in the deep inferior epi-gastric artery perforator group was 100 percent.One total flap failure was seen in the superficialinferior epigastric artery, and the survival rate was93 percent. Reexploration was performed in onepatient (3.3 percent) in the deep inferior epigas-tric artery perforator group and in three patients(21 percent) in the superficial inferior epigastricartery group. In the latter, the patient in case 1underwent reexploration on postoperative day 13because of compression of the pedicle by hema-toma and resultant venous congestion. Eventually,this flap was necrosed, probably because of pro-longed flap congestion and delayed reexplora-tion. The patient in case 2 underwent reexplora-tion on postoperative day 1 because of hematoma(caused by release of a hemoclip) and was suc-cessfully salvaged. The last patient (case 3) hadarterial insufficiency, and anastomosis was re-peated with an interpositional vein graft. This pa-tient developed fat necrosis in zone IV. The di-ameter discrepancies between the donor and therecipient arteries in cases 1, 2, and 3 were 0.7, 1,and 0.5 mm, respectively, which is close to themean values.

The mean hospital stay was 8.9 days in bothgroups. At a mean follow-up of 3 months, onepatient from each group developed fat necrosis,the amount of which was 7 percent and 3.3 percentof the used flap in the superficial inferior epigas-tric artery and deep inferior epigastric artery per-forator groups, respectively (Table 1). Theamount of fat necrosis was quantified by palpationand mammography.

With the aid of a vernier caliper, the meandiameters of the internal mammary artery andinternal mammary vein were documented as 3.16and 2.65 mm, respectively (Table 2). The diame-ter of the superficial inferior epigastric arteryranged between 0.8 and 3 mm (mean, 2.0 mm).The measurements were taken at the site consid-ered most appropriate for use in microsurgicalanastomosis and before division of the pedicle.The superficial inferior epigastric artery did notanatomically exist in 21 cases (48 percent), and innine cases (20 percent) its diameter was less than1 mm. The mean discrepancy between the inter-nal mammary artery and the deep inferior epigas-tric artery was less than the superficial inferiorepigastric artery (0.25 versus 0.65 mm). However,the mean differences between donor and recipi-ent veins for both systems were similar (0.46 mm)(Table 2).

Laser Doppler AssessmentUsing the Mann-Whitney nonparametric test,

no statistical difference was found in the laserDoppler index of each zone when perfused fromthe deep or superficial system (p � 0.05). In thedeep inferior epigastric artery perforator group,the laser Doppler index between zone I and zone

Table 1. Patient Demographics, Flap Number and Dimensions, Ischemia Time, Complications, andSuccess Rates

Flap

PatientAge(yr)

No.of

FlapsFUW/TFW (g)

(%)Mean FlapSize (cm)

MeanPedicleLength(cm)

IschemiaTime(min)

Reexploration(%)

FatNecrosis

(%)

SuccessRate(%)

DIEA (n � 30) 39.9 30 473.0/553.2(86.7)

11 � 33.5 6 100 1 (3.3) 1 (3.3) 100

SIEA (n � 14) 42 14 510.4/552.8(92.3)

12.5 � 32 11 102 3 (21) 1 (7) 93

TFW, weight of the total flap; FUW, weight of the used flap; DIEA, deep inferior epigastric artery; SIEA, superficial inferior epigastric artery.

Table 2. Mean Diameters of Donor and RecipientVessels and Size Discrepancies between Them

Recipient(mm) Donor (mm)

Recipient/Donor Artery

Difference(mm)

Recipient/Donor VeinDifference

(mm)

IMA (2.65) SIEA (2.0) 0.65 0.46IMV (3.16) SIEV (2.7) (0–1.5) (0–0.8)IMA (2.65) DIEA (2.9) 0.25 0.46IMV (3.16) DIEV (2.7) (0–1.0) (0–0.6)IMA, internal mammary artery; IMV, internal mammary vein; SIEA,superficial inferior epigastric artery; SIEV, superficial inferior epi-gastric vein; DIEA, deep inferior epigastric artery; DIEV, deep infe-rior epigastric vein.

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IV showed a statistically significant difference,which indicated a lower perfusion in zone IV com-pared with zone I (p � 0.04). However, no differ-ence was noted when the flap was perfused by bothsystems (preclamp) or only by the superficial in-ferior epigastric artery system (p � 0.05). Further-more, no statistically significant difference wasnoted in the laser Doppler index between differ-ent zones in the superficial inferior epigastric ar-tery group. Compared with the preclamp group,the deep inferior epigastric perforator group andthe superficial inferior epigastric artery groupshowed lower cutaneous perfusion rates in zonesI, III, and IV, but this difference was not statisticallysignificant (p � 0.05).

Patients were asked to express agreement ordisagreement by means of a five-point Likert scaleto evaluate the aesthetic satisfaction at a mean

follow-up of 11.2 months. The mean calculatedvalue from the responses was 4.14 � 0.17, whichindicated adequate patient satisfaction. No donor-site morbidity was encountered (Figs. 4 and 5).

DISCUSSIONWithin the 30 minutes of exploration, we were

able to identify the usable superficial inferior epi-gastric artery in 32 percent of the patients. Thefirst 15 minutes of exploration were carried out toidentify the superficial inferior epigastric artery. Ifthe superficial inferior epigastric artery wassmaller than 1 mm or was not anatomically avail-able, no further dissection was carried out and adecision was made against using this vessel. If apulsatile superficial inferior epigastric artery wasfound with a diameter larger than 1 mm, furtherdissection was performed within the next 15 min-

Fig. 4. Preoperative (above) and 14-month postoperative (below) views of the breast, with acceptable aesthetic outcome.(Above, left) Preoperative anterior view; (above, right) preoperative oblique view; (below, left) postoperative anterior view; (below,right) postoperative oblique view.

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utes to obtain the appropriate pedicle length anddiameter for use as a flap pedicle.

In cases where the vessels were appropriate, wewere able to eliminate the need for dissecting therectus abdominis perforator for a deep inferiorepigastric perforator artery flap and the rectusfascia was maintained (Fig. 6). As a result, al-though the overall operation time was not ex-tended significantly, the probability of using thesuperficial inferior epigastric artery flap seemedjustifiable and advantageous.

The superficial inferior epigastric artery flapcan be designed transversely, vertically, or ob-

liquely on the anterior abdominal wall. How-ever, because flap survival beyond the midlineof a few centimeters was reported to beunpredictable,9,16 except in selected cases, thisflap is usually raised and used as a hemi–lowerabdominal flap.11,13,18 If the entire abdominalflap was needed, bilateral dissection of the su-perficial system was recommended.12 Whetherthe superficial system is sufficient for supplyingthe entire transverse abdominal flap is the mainconcern of this technique. In our study, thesuperficial inferior epigastric artery was dis-sected unilaterally (Fig. 7) and, although zoneIV was not routinely discarded and an average of92.3 percent of transverse abdominal tissue wasused, no partial necrosis was detected, and therate and percentage of fat necrosis was compa-rable to the deep inferior epigastric artery per-forator group (p � 0.58) (Table 1).

In this series, none of our patients had under-gone a previous abdominal operation, which is acontraindication for application of the superficialinferior epigastric artery flap. Vertical surgical in-cisions in the midline may injure the anastomoticnetwork, and perfusion beyond the midline maybe compromised. Also, any operations transectingthe superficial inferior epigastric artery lying rightabove Scarpa’s fascia (superficial fascia layer),such as an inguinal hernia operation, a cesarean

Fig. 5. (Left) Preoperative and (right) 5-month postoperative views of the breast and abdomen,with acceptable aesthetic outcomes.

Fig. 6. Totally protected and maintained Scarpa’s fascia follow-ing the harvest of a superficial inferior epigastric artery flap.

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section, or a groin dissection, may preclude theuse of this flap.

Although the vascular anatomy of the super-ficial inferior epigastric artery was well studied,19

this study is the first documenting the reliability ofcutaneous perfusion in all zones (I through IV) ofthe abdominal flap by using laser Doppler flow-metry. According to our data, unlike the deepinferior epigastric artery perforator flap, the lackof significant cutaneous perfusion differencesamong the four zones from the superficial systemverified that the mean circulation through its vastanastomotic network in the superficial layer is ad-equate to provide a more consistent flap circula-tion than the deep inferior epigastric artery per-forator flap.

One confounding factor in the widespread useof this flap is the possibility of patient habitusaffecting the ability of the superficial inferior epi-gastric artery to supply a four-zone adipocutane-ous flap. In this study, all patients were Asian, withcharacteristically thin body habitus and abdomi-nal fat thickness less than that found in Westernwomen. There exists the possibility that increasedbody mass index may negatively affect the micro-circulation and thus choke vessels in the midline.For instance, increased abdominal fat may alterintravascular pressures, leading to readjustment offlow and changes in the size of the areas that canbe perfused. Consequently, the unilateral super-ficial inferior epigastric artery may be inadequateto supply the adipocutaneous tissue beyond themidline. There have been no studies to date in-vestigating the effect of body mass index on del-icate free perforator flaps. It is worthwhile to fur-ther investigate and clarify this issue.

In our study, we used the internal mammaryartery and vein as recipient vessels, and a discrep-

ancy existed to an extent between the internalmammary and superficial system vessels (Table 2).To overcome this problem, several methods weredescribed. Recently, Allen suggested using the in-ternal mammary perforator, superficial to the pec-toralis major muscle, for a better match indiameter,13 and Antia and Buch6 proposed includ-ing a cuff of femoral artery and vein in their earlyreports.

Compared with rectus perforators, the super-ficial inferior epigastric artery is located more lat-erally and enters through the superficial part ofthe flap.15–17 Although the artery and medially lo-cated vein are close to each other, they do notenter the flap at the same point. Therefore, espe-cially when the entire abdominal flap is harvested,inset may become more difficult because of thelimited arc of rotation. We used superficial infe-rior epigastric vessels ipsilateral to the defect side,and the cephalic border of the flap was usuallyinset downward, pointing to the inframammarycrease, and zone IV of the flap was located on thesuperolateral area of the reconstructed breast.None of our patients required vein grafting, anda mean pedicle length of 6 cm was sufficient toprevent tension on the anastomosis.

On the basis of the results of our study, itappears feasible to transfer tissue across the mid-line based on the unilateral superficial inferiorepigastric artery in selected patients with vessels ofappropriate size. Considering that there is a sizediscrepancy between the internal mammary ves-sels and the superficial system and that pediclelocation relative to the flap presents difficulty dur-ing insetting, it is reasonable to conclude that it istechnically more challenging and requires alonger training period. The reexploration ratesfor the superficial inferior epigastric artery flap inthe literature are between 3.7 and 20 percent, andthe failure rates are between 7.4 and 12.6percent.1–3,9,12 In view of the above difficulties, themost likely complication with the superficial infe-rior epigastric artery flap is anastomosis failure.Considering the reexploration rates in our series,one might advocate that the superficial inferiorepigastric artery flap is not as reliable as the deepinferior epigastric artery perforator flap (21 per-cent versus 3.3 percent). However, in the super-ficial inferior epigastric artery group, the reasonfor reexploration in two cases and failure in onewas “hematoma,” which is not a flap-specific com-plication. Only one anastomosis failure was seen inthis group and was successfully salvaged. Besides,there was no statistically significant difference be-tween the deep inferior epigastric artery perfora-

Fig. 7. Superficial inferior epigastric artery flap after division ofthe unilaterally dissected pedicle.

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tor and superficial inferior epigastric arterygroups in terms of the rate of anastomosis failureand fat necrosis (p � 0.58).

The exploration of the superficial inferior epi-gastric artery before dissection of the deep systemdoes not significantly prolong the overall opera-tive time and, when the benefits regarding donor-site morbidity are considered, we believe this flapis worth performing when a suitable superficialinferior epigastric artery is available.

Ming-Huei Cheng, M.D.Department of Plastic Surgery

Chang Gung Memorial Hospital5, Fu-Hsin Street

Kwei-Shan, Tao-Yuan, Taiwanminghueicheng@hotmail.com

REFERENCES1. Koshima, I., and Soeda, S. Inferior epigastric artery skin flaps

without rectus abdominis muscle. Br. J. Plast. Surg. 42: 645,1989.

2. Volpe, A. G., Rothkopf, D. M., and Walton, R. L. The versatilesuperficial inferior epigastric flap for breast reconstruction.Ann. Plast. Surg. 32: 113, 1994.

3. Arnez, Z. M., Khan, U., Pogorelec, D., and Planinsek, F.Rational selection of flaps from the abdomen in breast re-construction to reduce donor site morbidity. Br. J. Plast. Surg.52: 351, 1999.

4. Taylor, G. I., and Daniel, R. K. The anatomy of several freeflap donor sites. Plast. Reconstr. Surg 56: 243, 1975.

5. Stern, H. S., and Nahai, F. The versatile superficial inferiorepigastric artery free flap. Br. J. Plast. Surg. 95: 270, 1992.

6. Antia, N. H., and Buch, V. I. Transfer of an abdominaldermo-fat graft by direct anastomosis of blood vessels. Br. J.Plast. Surg. 24: 15, 1971.

7. Hester, T. R., Nahia, F., Beegle, P. E., and Bostwick, J. I. Bloodsupply of the abdomen revisited, with emphasis on the su-

perficial inferior epigastric artery. Plast. Reconstr. Surg. 74:657, 1984.

8. Boeckx, W. D., de Coninck, A., and Vanderlinden, E. Tenfree flap transfers: Use of intraarterial dye injection to outlinea flap exactly. Plast. Reconstr. Surg. 57: 716, 1976.

9. Stevenson, T. R., Hester, T. R., Duus, E. C., and Dingman, R.O. The superficial inferior epigastric artery for coverage ofhand and forearm defects. Ann. Plast. Surg. 12: 333, 1984.

10. Grotting, J. C. The free abdominoplasty flap for immediatebreast reconstruction. Ann. Plast. Surg. 27: 351, 1991.

11. Chevray, P. M. Breast reconstruction with superficial inferiorepigastric artery flaps: A prospective comparison with TRAMand DIEP flaps. Plast. Reconstr. Surg. 114: 1077, 2004.

12. Arnez, Z. M., Khan, U., Pogorelec, D., and Planinsek, F.Breast reconstruction using the free superficial inferior epi-gastric artery (SIEA) flap. Br. J. Plast. Surg. 52: 276, 1999.

13. Allen, R. J. Breast reconstruction with superficial inferiorepigastric artery flaps: A prospective comparison with TRAMand DIEP flaps. Plast. Reconstr. Surg. 114: 1084, 2004.

14. Blondeel, P. N., Arnstein, M., Verstraete, K., et al. Venouscongestion and blood flow in free transverse rectus abdo-minis myocutaneous and deep inferior epigastric perforatorflaps. Plast. Reconstr. Surg. 106: 1295, 2000.

15. Reardon, C. M., O’Ceallaigh, S., and O’Sullivan, S. T. Ananatomical study of the superficial inferior epigastric vesselsin humans. Br. J. Plast. Surg. 57: 515, 2004.

16. Cormack, G. C., George, B., and Lamberty, H. The ArterialAnatomy of Skin Flaps. New York: Churchill Livingstone, 1986.P. 377.

17. Hester, T. R., Nahia, F., Beegle, P. E., and Bostwick, J. I. Bloodsupply of the abdomen revisited, with emphasis on the su-perficial inferior epigastric artery. Plast. Reconstr. Surg. 74:657, 1984.

18. Rizzuto, R. P., and Allen, R. J. Reconstruction of a partialmastectomy defect with the superficial inferior epigastricartery (SIEA) flap. J. Reconstr. Microsurg. 20: 441, 2004.

19. Taylor, G. I. Blood supply of the abdomen revisited, withemphasis on the superficial inferior epigastric artery (Dis-cussion). Plast. Reconstr. Surg. 74: 657, 1984.

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