Minimally Invasive Bilateral Autologous Breast Reconstruction by Double SCIP-SB Flap: A Breakthrough in Patient-Centered Surgical Innovation

In the ever-evolving landscape of autologous breast reconstruction, the pursuit of techniques that maximize functional and esthetic outcomes while minimizing patient morbidity has become a central tenet. A recent case report published in Microsurgery (2025) by Martini et al. introduces a highly compelling advancement in this domain: Minimally Invasive Bilateral Autologous Breast Reconstruction using Double SCIP-SB Free Flaps with Internal Mammary Perforator and Rib-Sparing Anastomoses.

This report not only documents the surgical nuances of a complex bilateral procedure but also embodies a pivotal shift toward truly patient-centric microsurgery. Through careful flap selection and innovative anastomosis approaches, the authors challenge conventional reliance on DIEP flaps and costal cartilage resection—offering instead a future-forward technique with reduced morbidity and enhanced patient satisfaction.

Rethinking the Gold Standard: Beyond DIEP Flaps

Traditionally, the deep inferior epigastric artery perforator (DIEP) flap has been revered as the gold standard in autologous reconstruction, prized for its robust vascularity and favorable esthetic results. However, DIEP harvesting entails rectus fascia incision and intramuscular dissection—procedures associated with postoperative abdominal wall weakening, pain, and longer recovery times. Bilateral DIEP reconstructions are further complicated by variability in perforator size and reliability.

In this case, a 56-year-old woman with recurrent breast cancer underwent a bilateral skin-reducing mastectomy. Preoperative CTA showed small DIEA perforators but robust superficial branches of the superficial circumflex iliac artery (SCIP-SB) bilaterally. Rather than proceed with DIEP, the surgical team pivoted to a less invasive SCIP-SB approach, thereby avoiding rectus fascia violation altogether.

SCIP-SB: A Minimally Invasive Marvel

Initially described by Koshima et al. in 2004, the SCIP flap has found increasing favor in extremity and head and neck reconstruction. Martini’s team expands its application into bilateral breast reconstruction—a formidable technical feat considering the large tissue volumes required.

Key to this technique is the use of indocyanine green (ICG) angiography intraoperatively to assess flap perfusion. This allowed confident harvest of large SCIP-SB flaps (22×18 cm and 21×16 cm, weighing 510 g and 489 g) without relying on DIEA perforators.

The vascular pedicle—despite being shorter and narrower than DIEP—was successfully matched to recipient vessels using advanced microvascular techniques, including the “Open-Y” modification to address size mismatch.

Rib-Sparing and IMAP Anastomoses: A New Paradigm in Recipient Site Management

Equally transformative is the recipient vessel strategy employed. Traditionally, exposure of the internal mammary vessels requires partial rib cartilage removal—an invasive step associated with pain, sensation loss, and aesthetic dissatisfaction.

Instead, Martini et al. used two techniques:

On the right, an internal mammary artery perforator (IMAP), identified preoperatively, served as the recipient vessel—preserving the main internal mammary artery for future cardiac use.
On the left, rib-sparing internal mammary dissection allowed access without compromising the costal cartilage.

Both approaches align with modern reconstructive goals: minimizing structural disruption while preserving future surgical options.

Clinical Outcomes: A Testament to Patient-Centered Surgery

The patient recovered without complications and reported only mild pain. At six months, she expressed high satisfaction with the aesthetic results and declined further nipple reconstruction, indicating emotional closure and acceptance. This case powerfully demonstrates how surgical decisions based on individual anatomy and patient preferences yield superior outcomes—not just in form and function, but in lived experience.

Broader Implications: A Blueprint for the Future

The success of the double SCIP-SB flap highlights a broader movement in reconstructive microsurgery:

Precision planning with CTA and ICG to tailor approaches.
Adoption of flap types previously underutilized in breast surgery (e.g., SCIP).
Shift away from high-morbidity recipient vessel exposure techniques.

While the SCIP-SB flap may not suit all patients—especially those requiring large-volume reconstructions—it represents a viable alternative in selected cases, especially when DIEA perforators are suboptimal.

The technique demands significant expertise in flap harvest and perforator assessment. However, for experienced microsurgeons, it opens a promising frontier in bilateral reconstruction with minimized morbidity and maximized patient satisfaction.

Key Points Highlighted

SCIP-SB flaps offer a minimally invasive alternative to DIEP for autologous breast reconstruction.
Avoidance of rectus muscle dissection significantly reduces donor site morbidity.
Use of IMAP and rib-sparing techniques minimizes recipient site trauma.
Open-Y technique addresses vessel size mismatch, ensuring safe microvascular anastomosis.
Patient-reported satisfaction was high, with mild postoperative pain and no complications.
The approach prioritizes aesthetic, functional, and psychological recovery—hallmarks of patient-centric reconstruction.

References

Martini, F., Meroni, M., & Scaglioni, M.F. (2025). Minimally Invasive Bilateral Autologous Breast Reconstruction by Double SCIP-SB Free Flap With Internal Mammary Perforator and Rib-Sparing Internal Mammary Anastomoses: A Case Report. Microsurgery, 45:e70058. https://doi.org/10.1002/micr.70058

FAQs for Patients Searching Online

1. What is a double SCIP-SB flap in breast reconstruction?
A double SCIP-SB flap uses tissue from both sides of the lower abdomen, based on the superficial circumflex iliac artery branch, to reconstruct both breasts with minimal scarring and discomfort.

2. Is rib-sparing breast reconstruction less painful?
Yes, rib-sparing techniques avoid removing chest cartilage, leading to significantly less postoperative pain and quicker recovery.

3. Can I avoid muscle damage in breast reconstruction?
Yes, the SCIP-SB flap does not require cutting through abdominal muscles, preserving strength and reducing risk of bulge or hernia.

4. Who is a candidate for minimally invasive breast reconstruction?
Patients with suitable lower abdominal tissue and good vascular anatomy, verified by imaging, are ideal candidates.

5. What are internal mammary perforator (IMAP) vessels used for in breast surgery?
IMAP vessels can serve as safe recipient sites for flap connections without damaging ribs or major arteries, promoting comfort and function.

6. Will I have visible scars after SCIP-SB flap surgery?
Scars are discreetly placed along the lower abdomen (similar to a tummy tuck) and under the breast fold, making them less visible.

7. What is the recovery time after a double SCIP-SB breast reconstruction?
Recovery is often faster than traditional DIEP flap surgeries, with most patients resuming daily activities in 3–4 weeks.

8. Can I still have heart surgery if I undergo breast reconstruction?
Yes, rib-sparing and IMAP-based techniques preserve the internal mammary artery for potential future heart bypass procedures.

9. How is perfusion of the flap confirmed during surgery?
Surgeons use indocyanine green (ICG) imaging during the operation to ensure blood flow through the flap is adequate.

10. What are the long-term results of minimally invasive breast reconstruction?
Patients report high satisfaction, low pain, and natural-looking results—often avoiding the need for further revisions.