Effective Evaluation of SCIV and SIEV as Donor Vessels by Preoperative Ultrasound in Planning of Thin SCIP Flaps

We read with great interest the article entitled “Characteristics of the Superficial Circumflex Iliac Artery Perforator Flap in a Western Population and a Practice Approach for Free Flap Reconstruction” by Messa et al.[1] I strongly agree with the importance of superficial circumflex iliac artery perforator (SCIP) flap as a useful option for thin soft tissue reconstruction. Another key to successful reconstruction using thin SCIP flap is to get a reliable venous pedicle to avoid flap congestion. Superficial circumflex iliac vein (SCIV) is widely used vascular pedicle of SCIP flaps because venae comitantes of superficial circumflex iliac artery (SCIA) is sometimes too small and insufficient as venous outflow, especially for a large SCIP flap.[2] However, SCIV is sometimes deep below the superficial fascia, and it is difficult if not impossible to include SCIV in all the cases of thin and super thin SCIP flap. To address this challenge, we suggest to perform preoperative ultrasound to evaluate SCIV or superficial inferior epigastric artery (SIEV) or both as a vascular pedicle of SCIP flap checking their course, depth, and caliber.

To get the reliable venous outflow of thin and super thin SCIP flap, It is crucial to examine the course, depth, and caliber of SCIV and SIEV in addition to SCIA by preoperative ultrasound and computed tomography and so on. [Fig. 1] shows the course of SCIV and SIEV and SCIA before reconstructive surgery of burn patients ([Fig. 1]). In this case, SCIV is deep below the superficial fascia and distant from a superficial branch of SCIA. On the other hand, SIEV is above the superficial fascia, just below the dermis, and near the superficial branch of SCIA. In this case, SIEV runs medial to anterior superior iliac spine (ASIS), and this region is known to have reliable pure skin perforator from SCIA[3] so it is ideal to design a skin paddle medial to ASIS. In this case, we use superficial branch of SCIA for SCIP flap, so SIEV is more reasonable as donor vessels of thin and super thin SCIP flap than SCIV. Moreover, unused SCIV could be a good candidate of a vein graft which enables surgeons to avoid additional scar.

Fig. 1 SCIV is deep below the superficial fascia and distant from a superficial branch of SCIA. On the other hand, SIEV is above the superficial fascia, just below the dermis and near the superficial branch of SCIA. In this case, SIEV runs medial to ASIS and this region is known to have reliable pure skin perforator from SCIA3 so it is ideal to design a skin paddle medial to ASIS. ASIS, anterior superior iliac spine; SCIA, superficial circumflex iliac artery; SCIV, superficial circumflex iliac vein; SIEV, superficial inferior epigastric artery.

Preoperative ultrasound of SCIV and SIEV enables microsurgeons to get more reliable venous donor pedicle and possible vein grafts of thin and very thin SCIP flaps. Of course, SCIV is good candidate of a venous pedicle in most cases and there are individual differences about the course and depth and caliber of SCIV and SIEV. Therefore, further studies are required to get more anatomical information about venous drainage system of inguinal region.

Publication History

Received: 24 January 2022

Accepted: 27 January 2021

Article published online:
23 March 2021

• References

• 1 Messa IV CA, Carney III MJ, Tantillo K. et al. Characteristics of the superficial circumflex iliac artery perforator flap in a western population and a practice approach for free flap reconstruction. J Reconstr Microsurg 2020; (e-pub ahead of print). DOI: 10.1055/s-0040-1719051.
• 2 Berner JE, Nikkhah D, Zhao J, Prousskaia E, Teo TC. The versatility of the superficial circumflex iliac artery perforator flap: a single surgeon's 16-year experience for limb reconstruction and a systematic review. J Reconstr Microsurg 2020; 36 (02) 93-103
• 3 Narushima M, Yamasoba T, Iida T. et al. Pure skin perforator flaps: the anatomical vascularity of the superthin flap. Plast Reconstr Surg 2018; 142 (03) 351e-360e