INTRODUCTION
Restoring form and function is essential for any skin defect, but it can be particularly challenging when it involves the face 1. This is because the face is crucial for the patient’s appearance and identity, and it also affects some of the most important functions, such as breathing, speaking, seeing, and eating. Facial defects can result from burns, trauma, or surgical resections of locally cancers 1. While simple defects can be adequately treated with primary suturing, skin grafts, or local flaps, more complex defects require the expertise of plastic surgeons specialized in microsurgery 1-5. This is because certain areas of the head and neck, such as the lips, eyelids, or nose, need specific characteristics like flexibility and thinness that only some free flaps can provide 1-4. Among all free flaps, the superficial circumflex iliac artery perforator (SCIP) flap has seen increasing interest from microsurgeons due to its numerous advantages 3-5. It features a well-hidden donor site and allows for the harvesting of a medium to large-sized skin island with a particularly thin thickness, which is well-suited for certain facial areas. If necessary, it can be harvested in a composite manner with lymphatic, muscular, or bony tissue 5. The aim of this review is to provide a detailed analysis of the use of the SCIP flap for reconstructing various types of facial defects and to assess the real advantages and disadvantages of using this free flap in facial reconstruction.
MATERIALS AND METHODS
The current review adhered to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 6,7. The authors used PubMed to identify items focused on the use of the SCIP flap for facial soft tissue reconstruction. For the literature search, the keywords “SCIP flap” and “head and neck reconstruction” were combined as follows: “SCIP FLAP” AND “head and neck reconstruction”. All case reports and original articles focused on the use of SCIP flap for facial reconstruction were included in the review. 5 PubMed search results were excluded by title or abstract. Additionally, studies involving cadavers, anatomical descriptions, and review articles were also excluded. Therefore, among the 23 remaining PubMed studies, 14 were screened by carefully reading and were excluded. At the end the final number of records included in the review was 8 (Fig. 1).
RESULTS
A total of 8 items were included in the review (Tab. I). All the studies were case reports or case series published in English. The entire study population consisted of 30 cases of patients who underwent oncological resections of the face. The defects affected the ear (8/30), mouth (6/30), eyelids (3/30), facial skin (3/30), nose (1/30), chin (1/30), and cheek (1/30). The average SCIP flap size was 14.3 x 6.3 cm 9, and the mean pedicle length reported was 9 cm 8. Reported complications included venous congestion (5 cases), wound dehiscence (5 cases), wound infections (5 cases), venous thrombosis (1 case), partial necrosis (1 case), and facial nerve palsy caused by intentional neurectomy (1 case) 13. The mean follow-up period reported was 17.3 months 9.
DISCUSSION
Koshima et al. first described the superficial circumflex iliac artery perforator (SCIP) flap in 2004 4. Since then, only a few cases of facial reconstruction using the SCIP flap have been reported in the literature. This limited usage is likely due to unresolved issues, such as selecting the appropriate branch of the superficial circumflex iliac artery (SCIA). Most authors prefer to base the skin island on the superior branch 8,10,13-15. Conversely, some favor the deep branch pedicle, arguing that it offers a larger angiosome for the soft tissue component and a longer pedicle than the superficial branch 9. Despite these challenges, the SCIP flap provides several advantages for facial reconstruction, as detailed in Table II. It can yield a very thin and pliable skin island when harvested in a suprafascial plane, making it particularly suitable for covering complex head and neck defects 8,9,12-14. Additionally, once the pedicle is clearly visualized, the flap can be further thinned to the desired extent 8. The flap is also highly versatile; it can be harvested with the deep branch in a chimeric form that includes bone tissue, an often-needed component in facial reconstructions 8-10,12,15. Another variant of the flap includes its sensitive version. By preserving and anastomosing the cutaneous branches of the intercostal nerves, a sensitive SCIP flap can be created 8,15. One of its greatest advantages is the minimal donor site morbidity, with all authors reporting straightforward primary closure and no major complications 8-15. Unlike other flaps, particularly the latissimus dorsi flap and the radial forearm flap, which remain widely used in head and neck reconstruction, the SCIP flap does not lead to functional limitations or damage major vessels 8,13,14. However, the SCIP flap does have several limitations (see Table III) that may explain why it is not yet more widely utilized. Harvesting the SCIP flap is technically complex and requires significant microsurgical expertise 7,14. The flap features a short pedicle and smaller vessels compared to other free flaps, with suitable recipient vessels for end-to-end anastomosis often being absent, especially in the arteries 8,10,13,15. When small vessels are unavailable, supermicrosurgical end-to-side anastomosis may be considered as an alternative 10,15. Additionally, for extensive reconstructions, the SCIP flap may not be appropriate 8. Similar to the SCIP flap, the latissimus dorsi flap is also not ideal for covering large defects.
CONCLUSIONS
Currently, the literature on the use of the SCIP flap for facial reconstruction remains somewhat limited. The SCIP flap offers several advantages, including an exceptionally thin and “moderately sized” skin island, the option to include bone tissue, minimal donor site morbidity, and a scar that can be easily concealed. Although the relatively short and small-caliber pedicle poses a challenge, with careful management, the SCIP flap could be an excellent choice for selected cases of facial reconstruction. Table IV provides some recommendations to enhance the effectiveness of facial reconstruction using this flap.
Conflict of interest statement
The authors declare no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Author contributions
All authors have contributed equally to the work.
History
Received: September 15, 2024
Accepted: November 11, 2024
Figures and tables
Figure 1. The PRISMA Flow Diagram (from Moher et al., 2009, mod.) 7.
| Authors and year | Article | Anatomical defect | Recipient artery | Recipient vein | Main size | Mean pedicle length | Mean follow-up period |
|---|---|---|---|---|---|---|---|
| Scaglioni et al. 8, 2024 | Head and neck reconstruction with the superficial circumflex iliac artery perforator (SCIP) free flap: Lessons learned after 73 cases | Mouth (5) | Superior thyroid artery | External jugular vein | 46 cm2 | 9 cm | 11 months |
| Ear (2) | Facial artery | Internal jugular | |||||
| Superficial temporal artery | Superficial temporal vein | ||||||
| Zubler et al. 9, 2022 | The osteocutaneous SCIP flap: a detailed description of the surgical technique and retrospective cohort study of consecutive cases in a tertiary European centre | Cheek with orbital floor and maxilla (1) | Facial artery | Facial vein | 14.3 x 6.3 cm | - | 17.3 months |
| Lida et al. 10, 2014 | Versatility of the superficial circumflex iliac artery perforator flap in head and neck reconstruction | Face (2) | Facial artery (2) | Facial vein (3) | 12.8 x 6.3 cm | 7.1 cm | - |
| Upper eyelid (1) | Superficial temporal artery (4) | Internal jugular (1) | |||||
| Ear (3) | Superficial temporal vein (2) | ||||||
| Lida et al. 11, 2016 | A pilot study demonstrating the feasibility of supermicrosurgical end-to-side anastomosis onto large recipient vessels in head and neck reconstruction | Face (1) | Facial artery (1) | Facial vein (2) | - | - | - |
| Eyelid (1) | Superficial temporal artery (4) | Superficial temporal vein (3) | |||||
| Ear (3) | |||||||
| Lida et al. 12, 2019 | A free vascularised iliac bone flap based on superficial circumflex iliac perforators for head and neck reconstruction | Mouth with orbital floor and maxilla (1) | Facial artery (1) | Facial vein (1) | - | - | - |
| Choi et al. 13, 2019 | Thin superficial circumflex iliac artery perforator flap and supermicrosurgery technique for face reconstruction | Preauricular region (1) | Superficial temporal artery (2) | Superficial temporal vein | 75.6 cm2 | 4.6 cm | 16.7 months |
| Check (2) | Nasolabial artery (1) | ||||||
| Nose (1) | Angular artery (1) | ||||||
| Chin (1) | Inferior labial artery (1) | ||||||
| Postauricolar region (1) | Postauricular artery (1) | ||||||
| He et al. 14, 2015 | Superficial circumflex iliac artery perforator flap: identification of the perforator by computed tomography angiography and reconstruction of a complex lower lip defect | Lower lip (1) | Superior thyroid artery (1) | Superior thyroid vein (1) | 9 x 6 cm | 4.8 cm | - |
| Lida et al. 15, 2014 | Superficial circumflex iliac perforator (SCIP) flap: variations of the SCIP flap and their clinical applications | Upper eyelid (1) | Superficial temporal artery (1) | Superficial temporal vein (1) | - | - | - |
| Easy primary closure of the donor site 8,9,10,13,14 |
| Minimal donor site morbidity 8,9,12,13,14 |
| It is ideal for the reconstruction of specific areas of the face 8,10,13. |
| The flap can be harvested with bone tissue, which allows a valuable and versatile option for osteoplastic reconstructions 8,9,12. |
| Technical complexity 8,14 |
| limited tissue volume 8,15 |
| short pedicle 9,10,12,13,14,15 |
| Requires experience in supermicrosurgery 10,14,15. |
| Vessel mapping with Doppler and computed tomography angiography of the donor site are essential to exclude any disadvantageous individual anatomical variation 8,9,14 |
| The SCIP flap dissection should be performed above the deep fascia, utilizing a perforator from the superficial circumflex iliac artery 8,13. Excluding the deep fascia may enhance the skin’s pliability and simultaneously reduce the flap’s thickness 13 |
| Including the superficial vein, typically located in the medial part of the skin paddle, to enhance venous drainage 9,15 |
| If the small SCIP pedicle needs to be connected to larger vessels (such as the facial artery) employ the open-Y technique 8 |
| The use of indocyanine green perfusion imaging (ICG) appears to lower the risks of partial or complete flap failures 8, 10 |
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