SCIP Flap -Dr Junaid Khurshid

Versatile flap for reconstruction of various areas of body

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.

4. 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.

5. 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. 

6. 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

7. 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.

8. 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.

9. Localization Of SCIA

10. 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

11. 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.

12. 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

13. 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

14. Groin Flap Marking

15. 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

16. 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

17. Orientation Dorsal hand cranially Volar hand caudal Thumb laterally Depends on orientation of closure

18. 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

19. Tube flap

20. Result

21. Tube Flap

22. Advancing flap

23. 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

24. 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 colleagues of Japan performed the first microvascular fasciocutaneous transfer in the upper extremity with a groin flap to the hand in 1973.

25. 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.

26. 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 

27. 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.

28. 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.

29. Chimeric Groin Flap

30. Possibilities of Chimeric Flap

31. 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.

32. 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

33. 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)

34. 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).

35. 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.

36. 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

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

38. 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

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

40. Dissection below sup fascia

41. 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.

42. 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.

43. CASE 1 Compound defect right leg

44. 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

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

46. Flap after final Inset

47. 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

48. 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

49. The appearance of foot before surgery.

50. SCIP flap sized 15 × 4 cm 2  was harvested from left inguinal region. The vascular pedicle of the flap was deep branch of superficial circumflex iliac artery .

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

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

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

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

55. Resection

56. Marking

57. Raising Flap

58. Inset

59. 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)

60. 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)

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

62. 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

63. 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

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

65. 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. 

66. After initial debridement

67. 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 .

68. 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

69. 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

70. 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 .

71. 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.

72.   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

73. 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

74. 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.

75.  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.

76. 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.

77. Final outcome 5 month post procedure

78. 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.

79. Case 6 Salvage Of Thumb Reimplant

80. Cutter injury repoted 6 hours after injury

81. Revascularization Done

82. Colour post procedure changes 3 Days

83. Soft tissue over thumb removed

84. 6 by 10 cm groin flap planned

85. Groin Flap In Situ

86. Final outcome