Plastic And Reconstructive Surgery Sher I Kashmir institute of Medical Sciences

1. Department of Plastic and
Reconstructive Surgery
Sheri Kashmir Institute of Medical
Sciences
Topic : Sup Circumflex Iliac Artery
Perforator Flap

2. Department of Plastic and
Reconstructive Surgery
Sheri Kashmir Institute of Medical
Sciences
• Presenter : Dr Junaid Khurshid

3. Femoral artery
• The femoral artery is a continuation of the internal
iliac artery
• Constitutes the major blood supply to the lower
limb
• In the thigh, the femoral artery passes through
the femoral triangle
• The medial and lateral boundaries of this triangle
are formed by the medial margin of adductor
longus and the medial margin of sartorius ,
respectively.

6. SCIA
• The SCIA is the smallest
branch of the femoral artery
• It arises distal to
the superficial epigastric
artery and courses
superolaterally over the
lateral surface of the pelvic
wall.
• It terminates by
anastomosing with
the DCIA, superior gluteal
and lateral circumflex
femoral arteries.

7. • The main function of the superficial circumflex iliac
artery is to provide blood supply for the skin and
subcutaneous tissue of the region below
the inguinal ligament.
• Additionally, it supplies the superficial inguinal
lymph nodes together with the superficial epigastric
artery.

9. Course
• Pierces the fascia lata lateral to the saphenous
opening
• Runs laterally within superficial fascia and parallel
to the inguinal ligament to the anterior superior
iliac spine

10. THE SUPERFICIAL CIRCUMFLEX ILIAC
ARTERY (GROIN) FLAP
• The groin flap is a vascularized axial flap
• Based on the superficial circumflex iliac artery
arising from the femoral artery just below the
inguinal ligament.
• It is used for covering soft tissue defects of the
hand.

11. Groin flap
• The pedicled groin flap is an extremely versatile and
reliable flap that was initially described in 1972 by
MacGregor and Jackson.
• It enjoys a revered place in the field of
reconstructive surgery because it was one of the
first axial-pattern flaps to be described and applied
in humans.

12. Localization Of SCIA

14. Present Status
• After several decades, many surgical techniques,
including pedicled flaps, have been supplanted by
new methods.
• Despite the advent of microsurgery, the pedicled
groin flap continues to be a venerable technique
with a variety of applications

15. Contd
• Development of various fasciocutaneous free flaps
during the 1980s decreased the attractiveness of
the groin flap
• These flaps can be used in reconstructing significant
defects of the forearm and hand where free tissue
transfer is not feasible.

16. Relevance
• Free tissue transfer is routinely used as a single
stage procedure, but not easy when there is
vascular compromise
• Lack of healthy vessels make these procedures
technically difficult in some situations

18. Marking
• Patient in spine position
• Mark ASIS
• Mark PT
• Join by line convex downwards
• Femoral artery located by careful palpation
• Point A marked 2 FB inferior to IL and 2FB lateral to
FA
• This is point where SCIA goes subcutaniously

19. Groin Flap Marking

20. Contd
• SCIA runs parallel to IL beyond this point
• Beyond ASIS flap Length restricted by width
• Ratio 1:1 beyond ASIS (random Portion of flap)
• Proximal to ASIS flap is axial pattern

21. Techinal Consideration
• For tubing width must be 12 times thickness
• Average 8 cm
• If thin flap needed in obese patient we need to raise
flap in random portion as it depends on sub dermal
plexus

22. Orientation
• Dorsal hand cranially
• Volar hand caudal
• Thumb laterally
Depends on orientation of closure
Don't compel flap to sit on the defect

24. Inset
• Tube flap for finger tips
• End on flap for hand or finger tip
A tip inset
B daisy chain inset for stumps on multiple fingers
with intact skin bridge
C open book inset for dorsum of hand
• Advancing flap for dorsum of hand leading edge
sutured to proximal edge of dorsum of hand

25. Tube flap for circumferential defect on thumb
or finger

26. Result

27. Tube Flap

28. Advancing flap

29. Advantages
• Thin pliable skin
• Reliable blood supply
• Easy to perform even in hands of beginners
• Can raise flaps up to
...length 20 cm
.....width 15 cm
Close primarily to 10 cm
• Hidden donor site

30. History
• The first free skin flap in an animal model was
described by Goldwyn et al in 1963. This was
a groin flap in a dog.
• Daniel and Taylor accomplished the first
microvascular extremity reconstruction by free
transfer of a groin flap to the foot.
• Harii and colleaguesof Japan performed the first
microvascular fasciocutaneous transfer in the upper
extremity with a groin flap to the hand in 1973.

31. Free groin flap: the superficial
circumflex iliac artery Flap
• The groin flap has several advantages including
adequate skin thickness and minimal donor site
morbidity, making it the useable free flap for soft
tissue coverage of the hand and forearm
• The disadvantages of the flap include the short
pedicle and that the small size artery.

32. Chimeric groin free flaps: Design and
clinical application
Reconstruction of composite extremity defects or
through-and-through oral defects remains
challenging for surgeons.
• Chimeric flaps are ideal for repairing these lesions.
• Composite tissue defect or two defects in the
extremities or head and neck region

34. Contd.
• Musculo-cutaneous, or osteo-cutaneous chimeric
groin free flaps.
• The size and pedicles length of the chimeric groin
flaps based on the superficial circumflex iliac artery
(SCIA) were tailored to the lesions.

35. Advantage
• The innovative flap technique has advantages
including greater reliability, as well as the ability to
tailor the dimensions and flap paddles to specific
lesions and reconstruct two defects or one
composite defect using only one (chimeric) flap.

36. Chimeric Groin Flap

37. Possibilities of Chimeric Flap

38. Free groin flap disadvantages
• The free groin flap has gradually lost its relative
popularity because of the new free flaps available
as well as because of some of its inherent
disadvantages, including a short arterial pedicle,
variable arterial anatomy, the generally small caliber
of the included blood vessels, its bulkiness, and
numbness at the donor site.

40. SCIP FLAP
• Evolution of groin flap
• Described by Koshima et al 2004
• SCIP territory runs just above inguinal ligament
• Skin paddle is lateral and superior if compared with
SCIA falp
• SCIP vessels run below scarpas fascia
• Flap raised suprafacial

41. Advantages
• Concealment of the donor-site scar
• Primary closure of the donor site
• Availability of a large cutaneous flap (25 x 8 cm to 6
x 4 cm)
• Non-hair-bearing skin
• Longer arterial pedicle (3 to 13 cm)

42. Contd.
• typically requiring no vessel grafting
• seldom being a "bulgy" flap
• smaller are of numbness at the donor site
• less time required for flap dissection (0.5 to
1.5 hours).

43. Technical considerations
• Raising flap above inguinal region non hair bearing
tissues
• Dissect pedicle first, commit to raising the flap later
• Problem of larger recipient vessels can overcome by
more proximal dissection, even including SCIA
• Routine incorporation of superficial vein.

46. Medial Branch
• Durect cutanious
• Easy dissection
• Constant location
• Short pedicle
• 45 % axial perforator
• Limited flap territory
Lateral branch
• Intramuscular path
• Variable location
• Longer pedicle
• Axial perforator
• Larger flap territory
• Composite with bone

48. Source vessel of superficial medial branch
• SCIA 83 %
• SIEA 15%
• SFA 6%
• LCFA 1%

49. Advantages of raising the flap on
superficial fascia
• Preserves linking vessels
• Easily identifiable anatomical layer
• Avascular plane
• Allows to visualise the perforator branching
• Increased flap extensibility
• Donor site with deep fat better cosmesis
• Minimal trauma to the lymphatic system

50. Technique
• Skin traction allows to visualise plain between sup
and deep fascia
• Small lobule sup fat and large lobule deep fat

51. Dissection below sup fascia

52. Preoperative Preparation
• Designing and marking the course of perforators are
essential components of a successful perforator flap
transfer.
• The SCIA system is sometimes hypoplastic or
missing, requiring the reconstructive strategy to be
altered during surgery.
• Preoperative color Doppler ultrasound (US)
evaluation is very useful for planning the SCIP flap.

53. Contd.
• CT angiograms are not suitable for delineating the
course of the superficial and deep branches of SCIA
system, owing to the short perforator length of the
major vessels in this lesion.
• The handheld Doppler system is similarly inferior to
color Doppler US in preoperative identification of
SCIP flap perforators because it cannot provide
precise information on the subcutaneous tissue
layer.

54. CASE 1 Compound defect right leg

55. After the defect was measured, markings for groin flap were made.
In this patient, groin flap was harvested from the contra lateral side
for ease of two-team approach

56. Flap elevation started from lateral to medial side . As the flap
is raised from lateral side, the perforator to the skin is
identified

57. Flap after final Inset

58. Case 2
• Superficial Circumflex Iliac Artery Perforator Flap for
Dorsalis Pedis Reconstruction
• A 67-year-old man presented with a third-degree
burn, which exposed his extensor tendons

59. • Reconstruction of dorsalis pedis with soft tissue is
challenging because it needs to
• preserve thin structure
• ensure that the patient will be able to wear shoes

60. The appearance of foot before surgery.

61. SCIP flap sized 15 × 4 cm2 was harvested from left inguinal
region. The vascular pedicle of the flap was deep branch of
superficial circumflex iliac artery.

62. The appearance of foot, 3 months
after surgery.

63. The appearance of left inguinal region, 3
months after surgery.

64. Merits
• Thinness,
• Short surgical duration
• Less invasiveness at the donor site
• These characteristics make the SCIP flap especially
suitable for dorsalis pedis reconstruction.

65. Case 3
• Superficial circumflex iliac artery perforator flap
for reconstruction of oral
• defects after tumor resection

66. Resection

67. Marking

68. Raising Flap

69. Inset

70. Reconstructive algorithm for intra-
oral soft-tissue defects
• Limited volume is needed
• - If donor site morbidity is not an issue:
(suprafascial) RFFF
• - If donor site morbidity is an issue (e.g. young
patient, woman): alternatives are:
ALT (more volume; visible scar)
SCIP (minimal volume; no visible scar; ideal for
the floor of the mouth)

71. • Substantial volume needed (e.g. hemi- or total
glossectomy):
• - First choice: ALT (low donor site morbidity)
• - Second choice: rectus abdominis free flap
(greater donor site morbidity)

72. • In case of recurrence after
radio(chemo)therapy or surgery:
• ALT or RFFF (greater pedicle length and larger
vessel caliber)

73. SCIP For Oral Cavity
• There is no need for a deeper and longer dissection
of the SCIA system
• Only the dominant perforator and a short length of
the superficial or deep branch are required to
nourish the flap
• Thinning of the flap may be performed with primary
defatting in one stage
• The flap elevation time for a microsurgeon is equal
to that of conventional Flap

74. Contd
• The patient is maintained in the supine position,
which allows a two-team approacht
• Large cutaneous vein is available as a venous
drainage system
• The SCIP flap can be elevated in combination with
bone, nerves, and lymph node

75. Disadvantages
• Anastomose the smaller and short pedicle vessel
• Location of the pedicle is variable.
• Supermicrosurgery is necessary

76. Case 4 Penile Reconstruction
• A 69-year-old man with genital amputation.
underwent hematoma evacuation and primary
repair in the Department of General Surgery and
penis replantation in the dept of urology
• Presented with a necrotic change in the penis
(corpus carvenosum and urethra). The patient was
therefore transferred to the Department of Plastic
and Reconstructive Surgery.

77. After initial debridement

78. • For the reconstruction of the urethra and glans, a
SCIP flap of 6×2.5 cm was elevated from the right
inguinal area.
• For microsurgery, the superficial circumflex iliac
artery perforator and one vena comitans were
exposed as the donor vessels
• The penile dorsal artery and one penile dorsal vein
were exposed as the recipient vessels.
• This was followed by microanastomosis.

79. • For reconstruction of the penile shaft, an
anterolateral thigh (ALT) flap of 14×6 cm was
elevated.
• One descending branch of the left lateral
circumflex femoral artery and two vena comitans
served as the donor vessels.
• One deep circumflex iliac artery and two vena
comitans served as the recipient vessels for the
reconstruction

81. Outcome
• Both flaps had a warm ischemic time of 60 minutes.
• Primary closure was performed all of the donor
sites.
• Three weeks postoperatively, the patient had the
urethral foley catheter removed.
• The neourethra was functioning well.
• Four months postoperatively, the patient had no
complications such as urethral stricture.
• A good recovery was also achieved with no
aesthetic deficits at the donor site

82. Comments
• The free radial forearm flap is a very common
material for penile reconstruction.
• Its major problems are donor-site morbidity with
large depressive scar after skin grafting, urethral
fistula due to insufficiency of suture line for the
urethra, and need for microvascular anastomosis.

83. Contd
• Penoscrotal reconstruction can be done with
superficial circumflex iliac artery perforator
propeller flap
• Combined bilateral island SCIP flaps for the urethra
and penis is developed for gender identity disorder
(GID) patients.
• Possible one-stage reconstruction for a longer
urethra of 22 cm in length without insufficiency,
even for GID female-to-male patients.
• A disadvantage is poor sensory recovery.

84. Advantages of Urethral Reconstruction Using a
Superficial Circumflex Iliac Artery
• SCIP flap enables surgeons to achieve a one-stage
reconstruction
• due to the proximity of the surgical sites, it makes
the surgical preparation easier
• donor site closed primarily
• minimizes the aesthetic and functional deficits of
the donor sites

85. Case 5
Foot Reconstruction With Chimeric Superficial
Circumflex Iliac Perforator Flap Including External
Oblique Fascia
After a degloving injury of the foot, it was
covered using a chimeric SCIP flap. A piece of
fascia lying above the vessels can be seen to
protect them

86. Chimeric Superficial Circumflex Iliac Perforator Flap
Including External Oblique Fascia: A Refinement of
Conventional Harvesting
• SCIP flap, consisting of a chimeric flap with a piece
of the external oblique muscle fascia.
• The purpose of this design is to cover and protect
the vascular anastomosis
• lengthening the pedicle with this design makes the
flap more versatile.

88. • A, During dissection, after performing the upper
incision, a branch toward the external oblique
muscle fascia is isolated and a cuff of the fascia is
drawn with a marking pen. The green underground
is placed below the superficial branch of the SCIA.
•
• B, The whole flap is raised and the pedicle is
dissected until reaching the femoral vessels. The
piece of the fascia showing the corresponding
branch arising from the main pedicle.

90. Drawing of the branches arising from the femoral
vessels.
• A, Perforators of the SCIP flap arise from the
superficial branch.
• B, Deep branch of the superficial circumflex iliac
flap is spared.
• C, Branches toward the external oblique muscle
fascia should be spared during harvesting of the
flap.
• D, Femoral vessels.

92. Final outcome 5 month post procedure

93. Comments
• Postoperative picture of the left foot 5 months
after surgery. The piece of split skin graft placed
over the fascia, in the area of the anastomosis, of
1 × 2 cm (in the ankle, the most proximal scar) was
hypertrophied.

94. Case 7 Salvage Of Thumb Reimplant

95. Cutter injury repoted 6 hours after
injury

96. Revascularization Done

97. Colour post procedure changes 3 Days

98. Soft tissue over thumb removed

99. 6 by 10 cm groin flap planned

100. Groin Flap In Situ

101. Final outcome