SENSATE SUPERFICIAL INFERIOR EPIGASTRIC ARTERY FLAP INNERVATED BY THE ILIOHYPOGASTRIC NERVE FOR RECONSTRUCTION OF A FINGER SOFT TISSUE DEFECT TAKUMI YAMAMOTO, M.D.,1,2* NANA YAMAMOTO, M.D.,3 and ISAO KOSHIMA, M.D.1
In the era of perforator flaps, lower-abdominal/inguinal perforator flaps such as superficial circumflex iliac artery perforator (SCIP) flap and superficial inferior epigastric artery (SIEA) perforator flap are becoming popular with its longer vascular pedicle and usefulness in various reconstructions. SIEA flap’s region is innervated by the T12 nerve and the iliohypogastric nerve (IHN), but no sensate SIEA flap has been reported so far. In this report, we present a case in which a sensate SIEA flap innervated by the IHN was used for reconstruction of a finger soft tissue defect. A 55-year-old male suffering from the volar skin necrosis of the right ring finger underwent the volar soft tissue reconstruction using a free sensate SIEA flap because of hypoplastic SCIA. The SIEA flap included the IHN anterior branch, and neuroraphy was performed between the IHN and the third common digital nerve in an end-to-side manner after vascular anastomoses. The reconstructed volar skin could sensate 14 weeks after the surgery. At postoperative 6 months, Semmes-Weinstein test and moving 2point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap where the IHN was supposed to innervate. The IHN may be included in a SIEA flap, and a sensate SIEA flap may be a useful option when a SCIP flap is not available. Further anatomical C 2014 Wiley Periodicals, Inc. Microsurgery and clinical studies are required to clarify anatomy and clinical usefulness of the IHN. V 00:000–000, 2014.
With
CASE REPORT
1 Department of Plastic and Reconstructive Surgery, the University of Tokyo, Tokyo, Japan 2 Department of Plastic Surgery, Noda Hospital, Chiba, Japan 3 Department of Plastic Surgery, Toranomon Hospital, Tokyo, Japan *Correspondence to: Department of Plastic and Reconstructive Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–8655 Japan. E-mail: [email protected] Received 31 August 2014; Revision accepted 14 November 2014; Accepted 17 November 2014 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22360
A 55-year-old right handed male suffered from the right hand crush injury, when his right hand was caught in a press machine. The patient was hospitalized and treated conservatively using intravenous administration of prostaglandin E1 by orthopedic surgeons, because vascular insufficiency of the finger was suspected. Two weeks later, whole volar aspect of the right ring finger became necrotic, and the patient was referred to our department to salvage the finger (Fig. 1). Pin-prick test showed bleeding from the dorsal skin of the finger, but no bleeding from the volar skin. We offered several reconstructive methods for the treatment of the right ring finger necrosis, including local flaps, distant flaps, and free flaps. Among the methods offered, he desired reconstruction using a free skin flap from the groin, and we planned to perform a SCIP flap. Preoperative sound Doppler revealed signals, although weak, along lines that were supposed to be the SCIA’s courses, and signals along a line that was supposed to be the SIEA’s course. Since the patient had allergy to iodine, angiography or computed tomography angiography could not be performed. Operation was performed under general anesthesia 3 weeks after the injury. The necrotic tissue was debrided completely. After the debridement, there was a volar skin defect above the flexor tendons; the A2 pulley was necrotized and debrided, but others such as the A1/C1/ A3/C2 pulleys were intact and preserved. Both the radial and ulnar digital arteries/nerves were debrided distal to the metacarpophalangeal joint level. The third common digital artery and nerve were dissected for recipient artery and nerve, because the radial and ulnar digital
development of the perforator flap concept, traditional short-pedicle groin flap has evolved to superficial circumflex iliac artery perforator (SCIP) flap with a longer pedicle.1–4 SCIP flap can include the lateral femoral cutaneous nerve, deep fascia, the iliac bone, and lymph nodes with vascularity.3,4 Although SCIP flap has many advantages, the flap is not always available because of hypoplasia of the superficial circumflex iliac artery (SCIA).1,2 In such a case, the superficial inferior epigastric artery (SIEA) is usually dominant for vascularization of the groin and the lower abdominal region to compensate hypoplastic SCIA’s blood flow. When a surgeon faces a situation where the SCIA is hypoplastic, flap pedicle and/or design should be changed based on the SIEA anatomy in a free-style manner.1,2 SIEA flap, although not as useful as SCIP flap, is also a useful flap for reconstruction of soft tissue defect.5–7 Theoretically, SIEA flap’s region is innervated by the T12 nerve and the iliohypogastric nerve (IHN), but no sensate SIEA flap has been reported so far.8 In this case report, we present a case in which a sensate SIEA flap innervated by the IHN was used for reconstruction of a finger soft tissue defect.
Ó 2014 Wiley Periodicals, Inc.
2
Yamamoto et al.
Figure 1. Preoperative photograph of the right ring finger. Volar skin of the finger was necrotized due to crush injury. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
arteries/nerves were severely damaged proximal to the third common digital artery and nerve. Two dorsal cutaneous venous branches were dissected near the third web space. Recipient vessels were prepared in the regions without scar (Fig. 2). After confirming recipient vessels reliable by observing pulsation of the artery, SCIA was dissected at the left groin region. However, both superficial and deep branches of the SCIA were very small (smaller than 0.2 mm), and the SIEA was found pulsatile and enough large (0.5 mm) for a free flap pedicle. So, we decided to raise the SIEA flap in the same groin and the lower abdominal region. During dissection of the SIEA, the IHN anterior branch was found and included in the SIEA flap (Fig. 3A). The anterior branch further branched to a smaller medial branch and a larger lateral branch, and the lateral branch was included (Fig. 3B). The flap size was 9 cm 3 4 cm, and the pedicle length was 7 cm. The SIEA flap was thinned primarily not to injure the pedicle, and inset at the recipient right ring finger (Fig. 3C). To preserve perfusion and innervation of the distal finger, the SIEA was anastomosed to the third common digital artery in an end-to-side fashion, and endto-side neurorrhaphy was performed between the IHN and the third common digital nerve (Fig. 3D). Two branches of the superficial inferior epigastric vein were anastomosed to the two venous branches of the dorsal cutaneous vein in an end-to-end fashion. The SIEA flap showed good vascularity throughout a postoperative period, and the postoperative course was uneventful. The reconstructed volar skin could sensate 14 weeks after the surgery. At postoperative 6 months, Semmes-Weinstein test and moving 2-point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap, and 4.17 and 10 mm in the Microsurgery DOI 10.1002/micr
Figure 2. Soft tissue defect after debridement of necrotized volar skin of the right ring finger. The third common digital artery (arrow) and nerve (arrowhead) were dissected for recipient artery and nerve. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
distal portion of the flap (2.36 mm and 4 mm in control fingers) (Fig. 4). Postoperative range of motion of the ring finger’s metacarpophalangeal joint, the proximal interphalangeal joint, and the distal interphalangeal joint were 85/0, 50/0, and 45/0 degrees respectively. The right and left hand grip strength was 17 kg and 22 kg. We planned to perform secondary thinning of the flap for esthetic contouring but did not do, because the patient did not want nor require further thinning for daily usage of the hand. The patient complained no postoperative discomfort of the donor site, and was satisfied to come back to his work using the reconstructed finger. DISCUSSION
This report revealed that a SIEA flap could be transferred as a sensate flap. To our knowledge, this is the first report of a free sensate SIEA flap innervated by the IHN. Although only the IHN was used for innervation of the SIEA flap, it would be theoretically possible for a SIEA flap to be innervated by the T12 nerve; since a skin flap had to be changed from a SCIP flap to a SIEA flap due to hypoplastic SIEA, only the IHN happened to be found and included during elevation of the SIEA flap, and the T12 nerve was not intended to be included in the flap.8 Although not entirely dissected to confirm the course, the IHN anterior branch included in the flap seemed to run through the rectus abdominis muscle horizontally to a medial and a lateral direction as shown in Figure 3.8, 9 As demonstrated in the postoperative sensory recovery, the IHN seemed to innervate only the proximal portion of the SIEA flap; sensory recovery of the proximal portion of the SIEA flap where the IHN
Sensate SIEA Flap
3
Figure 3. A left SIEA (asterisk) flap included the IHN (black-arrow, dotted line) which came through the rectus abdominis muscle (whitearrow) (A). A schematic drawing of the sensate SIEA flap (B). The flap was transferred to a soft tissue defect of the right ring finger (C). A schematic drawing of the transferred sensate SIEA flap; neuroraphy was performed between the IHN and the third common digital nerve (black-arrowhead) in an end-to-side fashion (D). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
was supposed to innervate was significantly better than that of the distal portion where the T12 nerve was supposed to innervate. When used as a sensate flap innervated by the IHN, a surgeon would better design a SIEA flap horizontally, and should pay attention to a small nerve branch perforating the deep fascia during flap elevation. Both SCIP flap and SIEA flap can be raised as a sensate flap in the groin region. In a sensate SCIP flap, intercostal nerve is included to innervate the skin around and lateral to the anterior superior iliac spine.4 Since the lateral iliac region has a thick skin, a sensate SCIP flap innervated by the intercostal nerve tends to be a thick flap. Although donor site scar is concealable and esthetically more pleasing, a SCIP flap is difficult to be used as a free flap when the SCIA is hypoplastic.1,2 Since a SCIP flap has many advantages and is well investigated
regarding its vascular anatomy, we think that a SCIP flap is the first choice to elevate a flap in the groin region.1–4 When a SCIP flap cannot be raised due to hypoplasia of the SCIA, a SIEA flap should be used not to add additional donor scar at another site, and a surgeon should try to include the IHN in a SIEA flap if a sensate flap is required.2,5,9 Since functional preservation and restoration is the most important for hand reconstruction, a surgeon should consider well which is better for hand function as a whole to reconstruct or to amputate the ring finger with severe soft tissue injury. In this case, only the volar aspect of the ring finger was completely necrotized, and functional recovery was expected after soft tissue reconstruction. Therefore, we decided to reconstruct with a flap. There are many other flaps for reconstruction of this case including local/distant flaps and free flaps such as Microsurgery DOI 10.1002/micr
4
Yamamoto et al.
REFERENCES
Figure 4. Postoperative sensory recovery of a transferred SIEA flap. At postoperative 6 months, Semmes-Weinstein test and moving 2-point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap where the IHN was supposed to innervate. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
medial plantar flap, medialis pedis flap, and venous flap, that we offered as reconstructive options before the treatment.10–12 Because the patient desired a concealable donor site with less morbidity, we decided to use a flap from the lower-abdominal/inguinal region. SCIP flap and SIEA flap have a long pedicle suitable for various reconstructions, and their donor scars are well-concealable.1 Although further cases and anatomical studies are required to clarify anatomy of the IHN and clinical usefulness, a SIEA flap innervated by the IHN may be a useful option of a skin flap in the groin and the lower abdominal region, when a SCIP flap cannot be used.
Microsurgery DOI 10.1002/micr
1. Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Urushibara K, Inagawa K, Hamasaki T, Moriguchi T. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg 2004;113:233–240. 2. Hong JP, Sun SH, Ben-Nakhi M. Modified superficial circumflex iliac artery perforator flap and supermicrosurgery technique for lower extremity reconstruction: A new approach for moderate-sized defects. Ann Plast Surg 2013;71:380–383. 3. Iida T, Narushima M, Yoshimatsu H, Yamamoto T, Araki J, Koshima I. A free vascularised iliac bone flap based on superficial circumflex iliac perforators for head and neck reconstruction. J Plast Reconstr Aesthet Surg 2013;66:1596–1599. 4. Iida T, Narushima M, Yoshimatsu H, Mihara M, Kikuchi K, Hara H, Yamamoto T, Araki J, Koshima I. Versatility of lateral cutaneous branches of intercostal vessels and nerves: Anatomical study and clinical application. J Plast Reconstr Aesthet Surg 2013;66:1564–1568. 5. Stevenson TR, Hester TR, Duus EC, Dingman RO. The superficial inferior epigastric artery flap for coverage of hand and forearm defects. Ann Plast Surg 1984;12:333–339. 6. Nasir S, Aydin MA. Versatility of free SCIA/SIEA flaps in head and neck defects. Ann Plast Surg 2010;65:32–37. 7. Nasir S, Aydin MA. Reconstruction of soft tissue defect of lower extremity with free SCIA/SIEA flap. Ann Plast Surg 2008;61:622–626. 8. Klaassen Z, Marshall E, Tubbs RS, Louis RG Jr, Wartmann CT, Loukas M. Anatomy of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve contributions. Clin Anat 2011;24:454–461. 9. Dias RJ1, Souza Ld, Morais WF, Carneiro AP. SEP-diagnosed neuropathy of the lateral cutaneous branch of the iliohypogastric nerve: Case report. Arq Neuropsiquiatr 2004;62:895–898. 10. Kayalar M, Levent K, Sugun TS, Gurbuz Y, Savran A, Kaplan I. Syndactylizing arterialized venous flaps for multiple finger injuries. Microsurgery 2014;34:527–534. 11. Okada M, Saito H, Kazuki K, Nakamura H. Combined medialis pedis and medial plantar fasciocutaneous flaps for coverage of soft tissue defects of multiple adjacent fingers. Microsurgery 2014;34: 454–458. 12. Lin CT, Chen SG, Chen TM, Dai NT, Chang SC. Free fasciocutaneous flaps for reconstruction of complete circumferential degloving injury of digits. Microsurgery 2013;33:191–197.
In the era of perforator flaps, lower-abdominal/inguinal perforator flaps such as superficial circumflex iliac artery perforator (SCIP) flap and superficial inferior epigastric artery (SIEA) perforator flap are becoming popular with its longer vascular pedicle and usefulness in various reconstructions. SIEA flap’s region is innervated by the T12 nerve and the iliohypogastric nerve (IHN), but no sensate SIEA flap has been reported so far. In this report, we present a case in which a sensate SIEA flap innervated by the IHN was used for reconstruction of a finger soft tissue defect. A 55-year-old male suffering from the volar skin necrosis of the right ring finger underwent the volar soft tissue reconstruction using a free sensate SIEA flap because of hypoplastic SCIA. The SIEA flap included the IHN anterior branch, and neuroraphy was performed between the IHN and the third common digital nerve in an end-to-side manner after vascular anastomoses. The reconstructed volar skin could sensate 14 weeks after the surgery. At postoperative 6 months, Semmes-Weinstein test and moving 2point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap where the IHN was supposed to innervate. The IHN may be included in a SIEA flap, and a sensate SIEA flap may be a useful option when a SCIP flap is not available. Further anatomical C 2014 Wiley Periodicals, Inc. Microsurgery and clinical studies are required to clarify anatomy and clinical usefulness of the IHN. V 00:000–000, 2014.
With
CASE REPORT
1 Department of Plastic and Reconstructive Surgery, the University of Tokyo, Tokyo, Japan 2 Department of Plastic Surgery, Noda Hospital, Chiba, Japan 3 Department of Plastic Surgery, Toranomon Hospital, Tokyo, Japan *Correspondence to: Department of Plastic and Reconstructive Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113–8655 Japan. E-mail: [email protected] Received 31 August 2014; Revision accepted 14 November 2014; Accepted 17 November 2014 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22360
A 55-year-old right handed male suffered from the right hand crush injury, when his right hand was caught in a press machine. The patient was hospitalized and treated conservatively using intravenous administration of prostaglandin E1 by orthopedic surgeons, because vascular insufficiency of the finger was suspected. Two weeks later, whole volar aspect of the right ring finger became necrotic, and the patient was referred to our department to salvage the finger (Fig. 1). Pin-prick test showed bleeding from the dorsal skin of the finger, but no bleeding from the volar skin. We offered several reconstructive methods for the treatment of the right ring finger necrosis, including local flaps, distant flaps, and free flaps. Among the methods offered, he desired reconstruction using a free skin flap from the groin, and we planned to perform a SCIP flap. Preoperative sound Doppler revealed signals, although weak, along lines that were supposed to be the SCIA’s courses, and signals along a line that was supposed to be the SIEA’s course. Since the patient had allergy to iodine, angiography or computed tomography angiography could not be performed. Operation was performed under general anesthesia 3 weeks after the injury. The necrotic tissue was debrided completely. After the debridement, there was a volar skin defect above the flexor tendons; the A2 pulley was necrotized and debrided, but others such as the A1/C1/ A3/C2 pulleys were intact and preserved. Both the radial and ulnar digital arteries/nerves were debrided distal to the metacarpophalangeal joint level. The third common digital artery and nerve were dissected for recipient artery and nerve, because the radial and ulnar digital
development of the perforator flap concept, traditional short-pedicle groin flap has evolved to superficial circumflex iliac artery perforator (SCIP) flap with a longer pedicle.1–4 SCIP flap can include the lateral femoral cutaneous nerve, deep fascia, the iliac bone, and lymph nodes with vascularity.3,4 Although SCIP flap has many advantages, the flap is not always available because of hypoplasia of the superficial circumflex iliac artery (SCIA).1,2 In such a case, the superficial inferior epigastric artery (SIEA) is usually dominant for vascularization of the groin and the lower abdominal region to compensate hypoplastic SCIA’s blood flow. When a surgeon faces a situation where the SCIA is hypoplastic, flap pedicle and/or design should be changed based on the SIEA anatomy in a free-style manner.1,2 SIEA flap, although not as useful as SCIP flap, is also a useful flap for reconstruction of soft tissue defect.5–7 Theoretically, SIEA flap’s region is innervated by the T12 nerve and the iliohypogastric nerve (IHN), but no sensate SIEA flap has been reported so far.8 In this case report, we present a case in which a sensate SIEA flap innervated by the IHN was used for reconstruction of a finger soft tissue defect.
Ó 2014 Wiley Periodicals, Inc.
2
Yamamoto et al.
Figure 1. Preoperative photograph of the right ring finger. Volar skin of the finger was necrotized due to crush injury. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
arteries/nerves were severely damaged proximal to the third common digital artery and nerve. Two dorsal cutaneous venous branches were dissected near the third web space. Recipient vessels were prepared in the regions without scar (Fig. 2). After confirming recipient vessels reliable by observing pulsation of the artery, SCIA was dissected at the left groin region. However, both superficial and deep branches of the SCIA were very small (smaller than 0.2 mm), and the SIEA was found pulsatile and enough large (0.5 mm) for a free flap pedicle. So, we decided to raise the SIEA flap in the same groin and the lower abdominal region. During dissection of the SIEA, the IHN anterior branch was found and included in the SIEA flap (Fig. 3A). The anterior branch further branched to a smaller medial branch and a larger lateral branch, and the lateral branch was included (Fig. 3B). The flap size was 9 cm 3 4 cm, and the pedicle length was 7 cm. The SIEA flap was thinned primarily not to injure the pedicle, and inset at the recipient right ring finger (Fig. 3C). To preserve perfusion and innervation of the distal finger, the SIEA was anastomosed to the third common digital artery in an end-to-side fashion, and endto-side neurorrhaphy was performed between the IHN and the third common digital nerve (Fig. 3D). Two branches of the superficial inferior epigastric vein were anastomosed to the two venous branches of the dorsal cutaneous vein in an end-to-end fashion. The SIEA flap showed good vascularity throughout a postoperative period, and the postoperative course was uneventful. The reconstructed volar skin could sensate 14 weeks after the surgery. At postoperative 6 months, Semmes-Weinstein test and moving 2-point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap, and 4.17 and 10 mm in the Microsurgery DOI 10.1002/micr
Figure 2. Soft tissue defect after debridement of necrotized volar skin of the right ring finger. The third common digital artery (arrow) and nerve (arrowhead) were dissected for recipient artery and nerve. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
distal portion of the flap (2.36 mm and 4 mm in control fingers) (Fig. 4). Postoperative range of motion of the ring finger’s metacarpophalangeal joint, the proximal interphalangeal joint, and the distal interphalangeal joint were 85/0, 50/0, and 45/0 degrees respectively. The right and left hand grip strength was 17 kg and 22 kg. We planned to perform secondary thinning of the flap for esthetic contouring but did not do, because the patient did not want nor require further thinning for daily usage of the hand. The patient complained no postoperative discomfort of the donor site, and was satisfied to come back to his work using the reconstructed finger. DISCUSSION
This report revealed that a SIEA flap could be transferred as a sensate flap. To our knowledge, this is the first report of a free sensate SIEA flap innervated by the IHN. Although only the IHN was used for innervation of the SIEA flap, it would be theoretically possible for a SIEA flap to be innervated by the T12 nerve; since a skin flap had to be changed from a SCIP flap to a SIEA flap due to hypoplastic SIEA, only the IHN happened to be found and included during elevation of the SIEA flap, and the T12 nerve was not intended to be included in the flap.8 Although not entirely dissected to confirm the course, the IHN anterior branch included in the flap seemed to run through the rectus abdominis muscle horizontally to a medial and a lateral direction as shown in Figure 3.8, 9 As demonstrated in the postoperative sensory recovery, the IHN seemed to innervate only the proximal portion of the SIEA flap; sensory recovery of the proximal portion of the SIEA flap where the IHN
Sensate SIEA Flap
3
Figure 3. A left SIEA (asterisk) flap included the IHN (black-arrow, dotted line) which came through the rectus abdominis muscle (whitearrow) (A). A schematic drawing of the sensate SIEA flap (B). The flap was transferred to a soft tissue defect of the right ring finger (C). A schematic drawing of the transferred sensate SIEA flap; neuroraphy was performed between the IHN and the third common digital nerve (black-arrowhead) in an end-to-side fashion (D). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
was supposed to innervate was significantly better than that of the distal portion where the T12 nerve was supposed to innervate. When used as a sensate flap innervated by the IHN, a surgeon would better design a SIEA flap horizontally, and should pay attention to a small nerve branch perforating the deep fascia during flap elevation. Both SCIP flap and SIEA flap can be raised as a sensate flap in the groin region. In a sensate SCIP flap, intercostal nerve is included to innervate the skin around and lateral to the anterior superior iliac spine.4 Since the lateral iliac region has a thick skin, a sensate SCIP flap innervated by the intercostal nerve tends to be a thick flap. Although donor site scar is concealable and esthetically more pleasing, a SCIP flap is difficult to be used as a free flap when the SCIA is hypoplastic.1,2 Since a SCIP flap has many advantages and is well investigated
regarding its vascular anatomy, we think that a SCIP flap is the first choice to elevate a flap in the groin region.1–4 When a SCIP flap cannot be raised due to hypoplasia of the SCIA, a SIEA flap should be used not to add additional donor scar at another site, and a surgeon should try to include the IHN in a SIEA flap if a sensate flap is required.2,5,9 Since functional preservation and restoration is the most important for hand reconstruction, a surgeon should consider well which is better for hand function as a whole to reconstruct or to amputate the ring finger with severe soft tissue injury. In this case, only the volar aspect of the ring finger was completely necrotized, and functional recovery was expected after soft tissue reconstruction. Therefore, we decided to reconstruct with a flap. There are many other flaps for reconstruction of this case including local/distant flaps and free flaps such as Microsurgery DOI 10.1002/micr
4
Yamamoto et al.
REFERENCES
Figure 4. Postoperative sensory recovery of a transferred SIEA flap. At postoperative 6 months, Semmes-Weinstein test and moving 2-point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap where the IHN was supposed to innervate. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
medial plantar flap, medialis pedis flap, and venous flap, that we offered as reconstructive options before the treatment.10–12 Because the patient desired a concealable donor site with less morbidity, we decided to use a flap from the lower-abdominal/inguinal region. SCIP flap and SIEA flap have a long pedicle suitable for various reconstructions, and their donor scars are well-concealable.1 Although further cases and anatomical studies are required to clarify anatomy of the IHN and clinical usefulness, a SIEA flap innervated by the IHN may be a useful option of a skin flap in the groin and the lower abdominal region, when a SCIP flap cannot be used.
Microsurgery DOI 10.1002/micr
1. Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Urushibara K, Inagawa K, Hamasaki T, Moriguchi T. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg 2004;113:233–240. 2. Hong JP, Sun SH, Ben-Nakhi M. Modified superficial circumflex iliac artery perforator flap and supermicrosurgery technique for lower extremity reconstruction: A new approach for moderate-sized defects. Ann Plast Surg 2013;71:380–383. 3. Iida T, Narushima M, Yoshimatsu H, Yamamoto T, Araki J, Koshima I. A free vascularised iliac bone flap based on superficial circumflex iliac perforators for head and neck reconstruction. J Plast Reconstr Aesthet Surg 2013;66:1596–1599. 4. Iida T, Narushima M, Yoshimatsu H, Mihara M, Kikuchi K, Hara H, Yamamoto T, Araki J, Koshima I. Versatility of lateral cutaneous branches of intercostal vessels and nerves: Anatomical study and clinical application. J Plast Reconstr Aesthet Surg 2013;66:1564–1568. 5. Stevenson TR, Hester TR, Duus EC, Dingman RO. The superficial inferior epigastric artery flap for coverage of hand and forearm defects. Ann Plast Surg 1984;12:333–339. 6. Nasir S, Aydin MA. Versatility of free SCIA/SIEA flaps in head and neck defects. Ann Plast Surg 2010;65:32–37. 7. Nasir S, Aydin MA. Reconstruction of soft tissue defect of lower extremity with free SCIA/SIEA flap. Ann Plast Surg 2008;61:622–626. 8. Klaassen Z, Marshall E, Tubbs RS, Louis RG Jr, Wartmann CT, Loukas M. Anatomy of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve contributions. Clin Anat 2011;24:454–461. 9. Dias RJ1, Souza Ld, Morais WF, Carneiro AP. SEP-diagnosed neuropathy of the lateral cutaneous branch of the iliohypogastric nerve: Case report. Arq Neuropsiquiatr 2004;62:895–898. 10. Kayalar M, Levent K, Sugun TS, Gurbuz Y, Savran A, Kaplan I. Syndactylizing arterialized venous flaps for multiple finger injuries. Microsurgery 2014;34:527–534. 11. Okada M, Saito H, Kazuki K, Nakamura H. Combined medialis pedis and medial plantar fasciocutaneous flaps for coverage of soft tissue defects of multiple adjacent fingers. Microsurgery 2014;34: 454–458. 12. Lin CT, Chen SG, Chen TM, Dai NT, Chang SC. Free fasciocutaneous flaps for reconstruction of complete circumferential degloving injury of digits. Microsurgery 2013;33:191–197.
