The SIEA flap is named for the superficial inferior epigastric artery blood vessel that runs just under your skin in your lower abdomen. It’s also called a SIEP flap (superficial inferior epigastric perforator). It is very similar to a DIEP flap, except that a different section of blood vessels in the belly are moved with the fat and skin. Also, while a DIEP flap requires that a small incision be made in the layer that covers the rectus abdominis muscle, called the fascia, the SIEA flap doesn't require this incision.
An SIEA flap is considered a muscle-sparing type of flap. In fact, it doesn’t disturb the muscle at all, which is a good thing. In an SIEA flap, fat, skin, and blood vessels are cut from the wall of the lower belly and moved up to your chest to rebuild your breast. Your surgeon carefully reattaches the blood vessels of the flap to the blood vessels in your chest using microsurgery. Because the muscle isn’t disturbed, most women recover more quickly and have a lower risk of losing abdominal muscle strength with an SIEA flap compared to any of the TRAM flap procedures.
Most women aren’t eligible for a SIEA flap, though, for a few different reasons:
The superficial blood vessels are usually too small to support the flap.
These vessels have been cut during a previous C-section or hysterectomy.
These vessels don’t even exist.
During surgery, the surgeon will look at the blood vessels that can provide source blood to the flap — the SIEA flap vessels and the DIEP flap vessels. The set of vessels that provides the strongest blood flow to the flap determines whether the surgeon performs a SIEA flap or DIEP flap.
Because the SIEA flap procedure requires special surgical training and expertise in microsurgery, not all surgeons can do an SIEA flap and it's not available at all hospitals. If you're considering an SIEA flap, you may have to do research to find the surgeons and facilities that offer what you want. Your doctor may be able to refer you to plastic surgeons who specialize in SIEA flap reconstruction.
Tissue can be taken from your belly for breast reconstruction only once. So if you're thinking about prophylactic removal and reconstruction of the other breast, you might want to make that decision before you decide on reconstruction. If you have SIEA flap reconstruction on one breast and then later need reconstruction on your other breast, tissue for the second, later reconstruction will have to come your buttocks or back. Or you can have reconstruction with an implant.
Because skin, fat, and blood vessels are moved from the belly to the chest, having an SIEA flap means your belly will be tighter — as if you had a tummy tuck. Still, an SIEA flap does leave a long scar — from hipbone to hipbone — about one-third of the way between the top of your pubic hair and your navel. In most cases, the scar is below your bikini line. After the skin and fat are removed from your belly, the abdomen is closed. No mesh material is required to support the abdominal wall, as may be the case with a TRAM flap. Your navel is then brought back out through a separate incision and reshaped.
Again, SIEA flap breast reconstruction isn’t an option for most women because of the blood vessel size. It's also not a good choice for:
thin women who don't have enough extra belly tissue
women who already have had multiple abdominal surgeries
women who already have had certain abdominal surgeries, including colostomy (surgery that attaches the large intestine to an opening in the abdominal wall), or abdominoplasty (tummy tuck). This does not include midline incisions extending from the belly button to the pubic region or other routine abdominal operations.
women whose abdominal blood vessels are small or not in the best location to do an SIEA flap. (A new approach called the APEX FlapCM may be useful in this situation, but availability is very limited.)
SIEA flap reconstruction: What to expect
During SIEA flap reconstruction surgery, an incision is made along your bikini line. Then, a portion of skin, fat, and blood vessels is taken from the lower half of your belly and moved up to your chest and formed into a breast shape. No muscle is moved in a SIEA flap.
The tiny blood vessels in the flap, which is the tissue that now makes up your new breast, are matched to blood vessels in your chest and carefully reattached under a microscope.
SIEA flap reconstruction surgery takes about 6 to 8 hours.
After SIEA flap reconstruction surgery: You'll be moved to the recovery room after surgery, where hospital staff members will monitor your heart rate, body temperature, and blood pressure. If you're in pain or feel nauseated from the anesthesia, tell someone so you can be given medication.
You'll then be admitted to a hospital room. For an SIEA flap, you usually stay in the hospital for about 5 days.
Your doctor will give you specific instructions to follow for your recovery. For detailed information on how to care for the dressings, stitches, staples, and surgical drains, visit the Mastectomy: What to Expect page.
It can take about 6 to 8 weeks to recover from SIEA flap reconstruction surgery. Your doctor may recommend that you wear a compression girdle for up to 8 weeks after surgery. Because you've had surgery at two sites on your body (your chest and your belly), you might feel worse than someone who had only mastectomy and it will probably take you longer to recover. You'll likely have to take care of three incisions: on your breast, your lower abdomen, and around your navel. If you had axillary dissection under your arm at the same time, there will be a fourth incision to take care of. You'll probably have drains in your reconstructed breast and in your abdominal donor site -- and under your arm if you had lymph nodes removed.
As with any abdominal surgery, you may find that it's difficult or painful to sit down or get up from a sitting position. It also might be hard to get in and out of bed. Your doctor or physical therapist can show you how to move until your abdominal area heals. If you have severe pain, ask your doctor about medications you can take.
It's important to take the time you need to heal. Follow your doctor's advice on when to start stretching exercises and your normal activities. You usually have to avoid lifting anything heavy, strenuous sports, and sexual activity for about 6 weeks after SIEA flap reconstruction.
It sometimes takes as long as a year or more for your tissue to completely heal and for your scars to fade, and you may decide to have additional “finishing” work done, such as reshaping the flap or reconstructing a nipple.
SIEA flap surgery risk
Like all surgery, SIEA flap surgery has some risks. Many of the risks associated with SIEA flap surgery are the same as the risks for mastectomy. However, there are some risks that are unique to SIEA flap reconstruction.
Tissue breakdown: In rare instances, the tissue moved from your belly to your breast area won't get enough circulation and some of the tissue might die. Doctors call this tissue breakdown “necrosis.” Some symptoms of tissue necrosis include the skin turning dark blue or black, a cold or cool-to-the-touch feeling in the tissue, and even the eventual development of open wounds. You also may run a fever or feel sick if these symptoms are not addressed immediately. If a small area of necrosis is found, your surgeon can trim away the dead tissue. This is done in the operating room under general anesthesia or occasionally in a minor procedure setting. If most or all of the flap tissue develops necrosis, your doctor may call this a “complete flap failure,” which means the entire flap would need to be removed and replaced. Sometimes the flap can be replaced within a short timeframe, but in most cases the surgical team will remove all the dead tissue and allow the area to heal before identifying a new donor site to create a new flap.
Lumps in the reconstructed breast: If the blood supply to some of the fat used to rebuild your breast is cut off, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis. These fat necrosis lumps may or may not go away on their own. They also might cause you some discomfort. If the fat necrosis lumps don't go away on their own, it's best to have your surgeon remove them. After having mastectomy and reconstruction, it can be a little scary to find another lump in your rebuilt breast. Having them removed can give you greater peace of mind, as well as ease any discomfort you might have.
Hernia or muscle weakness at the donor site: A hernia happens when part of an internal organ (often a small piece of the intestine) bulges through a weak spot in a muscle. Most hernias occur in the abdomen. They usually develop when someone who has a weak spot in an abdominal muscle strains the muscle, perhaps by lifting something heavy.
If you have an SIEA flap, you have a small risk of hernia. Your risk of hernia is much lower with an SIEA flap than with any type of TRAM flap. This is because an SIEA flap uses no muscle to rebuild your breast. Still, after any abdominal surgery, there is some risk of hernia.
Hernias can be painful and can cause a noticeable bulge in your abdomen. Hernias usually are treated by surgically repairing the opening in the muscle wall. The surgery is generally done on an outpatient basis.
— Last updated on June 29, 2022, 3:04 PM