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

Abstract

Minimizing invasiveness has become a primary goal in autologous breast reconstruction, with a shift toward perforator-based flaps over musculocutaneous flaps to reduce donor site morbidity. The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard due to its reliable perfusion and high-level esthetic outcomes; however, it requires intramuscular dissection, which might be tedious and carry the risk of abdominal wall weakening. At the recipient site, traditional anastomosis techniques often involve the removal of costal cartilage, contributing to a higher morbidity and discomfort or long-lasting localized pain. A 56-year-old female patient presenting with a recurrent right breast tumor was referred to our department for a bilateral skin-reducing mastectomy and immediate autologous reconstruction. Preoperative imaging revealed small DIEA perforators and the presence of a suitable perforator of the superficial branch of the superficial circumflex iliac artery (SCIP-SB) bilaterally. Intraoperative ICG evaluation confirmed adequate flap perfusion based on the SCIP-SB, allowing for flap harvest based on these vessels without opening the rectus fascia or performing intramuscular dissection. At the recipient site, on the right side, an internal mammary artery perforator was preserved and used for anastomosis, while on the left side, we isolated the internal mammary vessels in a rib-sparing fashion. This approach minimized morbidity at donor and recipient sites, improving postoperative comfort and recovery. The patient reported mild pain and no complications post-surgery and expressed high satisfaction at 6 months. This case highlights how focusing on the reduction of morbidity at different stages of the reconstructive procedure may allow obtaining better patient-centered outcomes. In this perspective, the SCIP-SB flap represents a viable, minimally invasive option, expanding the possible reconstructive choices in autologous breast reconstruction.