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Farajzadeh et al. Plast Aesthet Res 2024;11:32 https://dx.doi.org/10.20517/2347-9264.2024.24 Page 3 of 11

Figure 1. Harvest of the SIEA (yellow bulldog) and SIEV (green bulldog) to their origin in a DIEP flap provides adequate length to allow
for multiple different recipient vessel options (intra-flap branch or runoff, caudal IM vessels, etc.). DIEP: deep inferior epigastric artery
perforator; SIEA: superficial inferior epigastric artery.

row and centricity of deep perforators utilized. Sbitany et al. described assessment of flap perfusion on the
deep system in situ, and hypoperfusion of the suprascarpal fat or persistent skin hyperemia as an indicator
to augment with the superficial system . While the superficial system should be used in cases that
[9]
demonstrate clinical hypoperfusion, it can also be utilized to minimize morbidity by limiting the number of
deep perforators harvested. Larger flaps that might otherwise require multiple perforators or perforator
rows can be harvested on a single dominant perforator while using the SIEA and SIEV for additional
perfusion [Figure 2]. Such techniques can help to limit the fascial incisions and to optimize the perfusion of
a large amount of tissue harvested on a single perforator based on individual anatomy.

The use of both the deep and superficial system in DIEP flaps with a superficial dominant system or
diminutive deep system has also been supported. Hembd et al. demonstrated a significantly lower rate of fat
necrosis and flap failure with SIEA/SIEV DP-DIEP flaps compared with SIEA flaps . From these findings,
[10]
the authors advocate for the use of a dual-plane system over superficial-only perfusion if preoperative
imaging demonstrates deep system perforators <1.0 mm in size or with intraoperative findings of venous
[10]
congestion or ICG hypoperfusion .
CONJOINED FLAPS
The conjoined flap combines different flap territories that are in close proximity, thus enabling optimization
of the balance of perfusion and the amount of tissue harvested [12,13] . Often referred to as bipedicled flaps, a
single piece of tissue is harvested, including more than one perforasome based on separate pedicles.
Conjoined flaps are most commonly harvested from the abdomen as bipedicled DIEP flaps but can also be
from different donor sites. The use of an additional vascular pedicle allows the surgeon to increase the
amount of skin and soft tissue harvested while minimizing the risk of fat necrosis in watershed areas.