Salvage of intraoperative deep inferior epigastric perforator flap venous congestion with augmentation of venous outflow: flap morbidity and review of the literature

The Effect of Venous Augmentation on Complication Rates in Deep Inferior Epigastric Perforator Breast Reconstruction

BACKGROUND

With the rising popularity of the deep inferior epigastric perforator (DIEP) flap in breast reconstruction, use of the superficial inferior epigastric vein (SIEV) to augment venous outflow has been proposed as a strategy to prevent venous congestion, a complication positively associated with flap volume. This study evaluated the impact of routine SIEV venous augmentation on the risk of vascular complications or operative fat necrosis in the context of flap size and operating time.

METHODS

A retrospective cohort study compared complication rates of patients with SIEV-augmented DIEP flaps to controls over a 3-year period. Outcomes assessed included vascular complications, defined as venous congestion or compromise requiring take-back, partial flap necrosis, total flap loss, as well as operative fat necrosis. Relative risk was modeled by Cox proportional hazard regression analysis. Sensitivity analysis was performed to assess for an interaction effect by flap mass.

RESULTS

The study sample included 197 patients with 316 flaps. The mean mass of the SIEV-augmented flaps was significantly greater than in the control group (832.9 vs. 653.9 g; p = 0.0007). After adjustment for flap characteristics, patient demographic factors, and comorbidities, pooled risk of vascular complication and operative fat necrosis was found to be significantly lower in the SIEV-augmented group compared to controls (hazard ratio = 0.33, 95% CI [0.11-1.00]; p = 0.0489). Sensitivity analysis demonstrated no effect interaction by flap weight (p = 0.5139).

CONCLUSION

Routine venous outflow augmentation via anastomosis of SIEV to the internal mammary vein perforator at the second intercostal space significantly reduced the risk of vascular complications and operative fat necrosis, regardless of flap weight. No significant increase in operative time was observed among cases in which augmentation was performed.

Ultrasound in Microsurgery: Current Applications and New Frontiers

Ultrasound has revolutionized reconstructive microsurgery, offering real-time imaging and enhanced precision allowing for preoperative flap planning, recipient vessel identification and selection, postoperative flap monitoring, and lymphatic surgery. This narrative review of the literature provides an updated evidence-based overlook on the current applications and emerging frontiers of ultrasound in microsurgery, focusing on free tissue transfer and lymphatic surgery. Color duplex ultrasound (CDU) plays a pivotal role in preoperative flap planning and design, providing real-time imaging that enables detailed perforator mapping, perforator suitability assessment, blood flow velocity measurement, and, ultimately, flap design optimization. Ultrasound also aids in recipient vessel selection by providing assessment of caliber, patency, location, and flow velocity of recipient vessels. Postoperatively, ultrasound enables real-time monitoring of flap perfusion, providing early detection of potential flap compromise and improved flap survival rates. In lymphatic surgery, ultra-high frequency ultrasound (UHFUS) offers precise mapping and evaluation of lymphatic vessels, improving efficacy and efficiency by targeting larger dilated vessels. Integrating ultrasound into reconstructive microsurgery represents a significant advancement in the utilization of imaging in the field. With growing accessibility of devices, improved training, and technological advancements, using ultrasound as a key imaging tool offers substantial potential for the evolution of reconstructive microsurgery.

Successful Intraoperative Salvage of a Venous Congested Deep Inferior Epigastric Perforator Flap Using a Cross-thoracic Saphenous Vein Graft

For autologous breast reconstruction using the deep inferior epigastric perforator flap, the internal mammary vessels are a common choice for recipient vessels. However, if these vessels are discovered to be inadequate, this may require the utilization of alternative vessels for successful salvage. Here, we demonstrate the use of a venous conduit for flap salvage in a patient undergoing bilateral deep inferior epigastric perforator flap breast reconstruction. Intraoperative venous congestion was identified on the left side. A contributing factor was an unresolvable size discrepancy between the deep inferior epigastric and the internal mammary venae comitantes. A saphenous vein graft can be used to drain the donor inferior epigastric vein to the contralateral internal mammary venae comitantes. In this discussion, adequate venous drainage was obtained with this approach, and the flap remained viable with good Doppler signals without further complications over a year postoperatively.

A systematic review of the scientific evidence of venous supercharging in autologous breast reconstruction with abdominally based flaps

BACKGROUND

Abdominally based free flaps are commonly used in breast reconstruction. A frequent complication is venous congestion, which might contribute to around 40% of flap failures. One way to deal with it is venous supercharging. The primary aim of this study was to investigate the scientific evidence for the effects of venous supercharging.

METHODS

A systematic literature search was conducted in PubMed, CINAHL, Embase, and Cochrane library. The included articles were critically appraised, and certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

Thirty-six studies were included. Most studies had serious study limitations and problems with directness. Three studies report 'routine' use of venous supercharging and performed it prophylactically in patients who did not have clinical signs of venous congestion. Seventeen studies report on flap complications, of which one is a randomised controlled trial demonstrating statistically significant lower complication rates in the intervention group. The overall certainty of evidence for the effect of a venous supercharging on flap complications, length of hospital stay and operative time, in patients without clinical signs of venous congestion, is very low (GRADE ⊕ ⊕ ⊝ ⊝), and low on and surgical takebacks (GRADE ⊕ ⊕ ⊝ ⊝). Twenty-one studies presented data on strategies and overall certainty of evidence for using radiological findings, preoperative measurements, and clinical risk factors to make decisions on venous supercharging is very low (GRADE ⊕ ⊝ ⊝ ⊝).

CONCLUSION

There is little scientific evidence for how to predict in which cases, without clinical signs of venous congestion, venous supercharging should be performed. The complication rate might be lower in patients in which a prophylactic venous anastomosis has been performed.

TRIAL REGISTRATION

PROSPERO (CRD42022353591).

A Systematic Approach to Intraoperative Venous Congestion in the Deep Inferior Epigastric Artery Perforator (DIEAP) Flap

The deep Inferior epigastric artery perforator (DIEAP) flap is currently the gold standard for autologous breast reconstruction. This flap is susceptible to venous congestion, which can result in partial or complete flap loss. Apart from external causes, venous congestion may be caused by the flap's vascular architecture, either due to a dominance of the superficial venous system or due to impaired communication between the superficial and deep venous systems. This inefficient vascular architecture can be detected during surgery, and the venous outflow drainage can be improved through several techniques. We present two case reports of intraoperative venous congestion. In the first case, we performed an intra-flap rerouting, through a venous anastomosis between the superficial and the deep venous systems. In the second case, an extra-flap rerouting was executed, through a venous anastomosis between the superficial venous system and a recipient vein. We present the current institutional approach to DIEAP flap breast reconstruction, incorporating surgical insights for addressing intraoperative venous congestion.

Superficial outside-flap shunt (SOS) is associated with a low incidence of postoperative DIEP flap venous congestion: A single-institution retrospective cross-sectional study

INTRODUCTION

Venous congestion burdens up to 15% of deep inferior epigastric artery perforator (DIEP) flap breast reconstructions. For these cases, venous augmentation by superficial outside shunt (SOS) is associated with 100% success in secondary salvage surgeries. Intraoperative venous augmentation using other techniques yields a 0.3% rate of return to theater due to venous congestion, but there is no evidence assessing the effectiveness of the SOS technique applied preventively. Comparing this preventive approach to data prior to its implementation, we expect to find a reduced number of venous congested flaps with reduced flap losses and revision surgeries.

PATIENTS AND METHODS

This retrospective cross-sectional study involved DIEP flap breast reconstructions performed between 2011 and 2020. The control group included patients receiving additional venous anastomosis as a secondary salvage procedure. The "preventive SOS group" included patients who received preventive SOS during the main surgery. Age, body mass index (BMI), pregnancies, perioperative treatments (neoadjuvant or adjuvant chemo or radiotherapy), follow-up complications (arterial ischemia, venous congestion, hematomas, partial/total flap loss), and revision surgeries (breast debridement, flap remodeling) were recorded and compared.

RESULTS

Within 695 flaps performed, 397 flaps were included in the control group, and 298 flaps were included in the preventive SOS group. The groups were homogeneous for age (p = 0.418), BMI (p = 0.747), and flap weight (p = 0.064). Fifty-one flaps (12.8%) in the control group compared to zero (0.0%) in the preventive SOS group required return to theater (p < 0.001).

CONCLUSIONS

We reported encouraging preliminary results for SOS to prevent DIEP flap venous congestion. These results must be validated prospectively.

Efficacy of superficial inferior epigastric vein superdrainage in free TRAM and DIEP flap: An indocyanine green angiography study of 68 cases

BACKGROUND

This study aimed to evaluate the clinical efficacy of venous augmentation using superficial inferior epigastric vein (SIEV) in free transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flap and investigate the factors that hinder the venous superdrainage.

METHODS

A retrospective review of 62 free muscle-sparing (MS)-TRAM and 6 DIEP unilateral breast reconstructions from September 2017 to July 2022. Intraoperative indocyanine green angiography was performed on the harvested flap, with the SIEV contralateral to the pedicle side clamped and unclamped for 20 min. The relative ratio of hypoperfused area to the total flap area was calculated and compared quantitatively. The preoperative computed tomography (CT) angiography was reviewed to obtain information on the SIEV diameter and number of midline-crossing medial branches.

RESULTS

The participants were categorized into three groups: 42 patients in Group 1 (>3% decrease in hypoperfused area), 20 patients in Group 2 (change in hypoperfused area ranging from -3% to 3%), and six patients in Group 3 (>3% increase in hypoperfused area). The mean number of midline-crossing branches (p = 0.002) and mean difference in the diameter of bilateral SIEVs (p = 0.039) were significantly greater in Group 1 than in the other groups.

CONCLUSIONS

Thirty-eight percent (26/68 cases) resulted in sustained or aggravated perfusion after SIEV superdrainage. Superdrainage using the contralateral SIEV in free MS-TRAM/DIEP flap is recommended when there are more than two midline-crossing medial branches of SIEV and when the caliber of SIEV is relatively greater compared with the pedicle side.

Use of the superficial inferior epigastric vein in breast reconstruction with a deep inferior epigastric artery perforator flap

Background

Autologous breast reconstruction is highly regarded in reconstructive surgery after mastectomy. DIEP flap reconstruction represents the gold standard for autologous breast reconstruction. The major advantages of DIEP flap reconstruction are its adequate volume, large vascular caliber and pedicle length. Despite reliable anatomy, there are procedures where the plastic surgeon's creativity is required, not only to shape the new breast, but also to overcome microsurgical challenges. An important tool in these cases is the superficial epigastric vein (SIEV).

Methods

150 DIEP flap procedures performed between 2018 and 2021 were retrospectively evaluated for SIEV use. Intraoperative and postoperative data were analyzed. Rate of anastomosis revision, total and partial flap loss, fat necrosis and donor site complications were evaluated.

Results

In a total of 150 breast reconstructions with a DIEP flap performed in our clinic, the SIEV was used in 5 cases. The indication for using the SIEV was to improve the venous drainage of the flap or as a graft to reconstruct the main artery perforator. Among the 5 cases, no flap loss occurred.

Conclusions

Use of the SIEV is an excellent method to expand the microsurgical options in breast reconstruction with DIEP flap surgery. It provides a safe and reliable procedure to improve venous outflow in cases of inadequate outflow from the deep venous system. The SIEV could also provide a very good option for fast and reliable application as an interposition device in case of arterial complications.

[Anatomical types and anastomosis methods of concomitant veins of deep inferior epigastric artery]

Objective

To summarize the anatomical types of the concomitant veins of deep inferior epigastric artery and the corresponding choice of anastomosis methods, and to evaluate the indications and safety of various methods.

Methods

Between October 2015 and June 2021, 296 female patients received breast reconstruction with autologous free lower abdominal flap, including 154 cases of immediate breast reconstruction and 142 cases of delayed breast reconstruction. The average age of the patients was 36.5 years, ranged from 26 to 62 years. Unilateral free deep inferior epigastric artery perforator flap transplantation was performed in 172 cases, and unilateral free muscle-sparing rectus abdominis myocutaneous flap transplantation was performed in 124 cases. The internal thoracic vessels were selected as the recipient vessels in all cases. The length of vascular pedicle ranged from 9.5 to 13.0 cm, with an average of 11.2 cm. The concomitant veins of deep inferior epigastric artery included three anatomical types: one-branch type in 26 cases (8.8%), two-branch type in 180 cases (60.8%), and Y-shaped structure in 90 cases (30.4%). Anastomosis of inferior epigastric artery was performed with the proximal end of internal thoracic artery, while that of vein should be adjusted according to the diameter, length, wall thickness, and branches of the vein. The specific classification of venous anastomosis included: ① The sole concomitant vein of deep inferior epigastric artery was anastomosed with the internal mammary vein (26 cases); ② The two concomitant veins of deep inferior epigastric artery were anastomosed with the internal mammary vein respectively (151 cases); ③ The larger one of two concomitant veins of deep inferior epigastric artery was anastomosed with the internal mammary vein, and the other one was ligated and discarded (29 cases); ④ The two concomitant veins of deep inferior epigastric artery were Y-shaped, and the common trunk segment was directly anastomosed with the internal mammary vein (31 cases); ⑤ The smaller branch of the concomitant veins of Y-shaped structure was ligated, and the thicker branch was anastomosed with the internal mammary vein (17 cases); ⑥ The concomitant veins of Y-shaped structure were anastomosed with the internal mammary veins respectively (42 cases).

Results

Among the patients who underwent venous anastomosis according to scheme ④, 3 cases had venous crisis of flap after operation, of which 1 case was successfully rescued by emergency exploration; the other 2 cases had flap necrosis, of which 1 case survived after being repaired by pedicled latissimus dorsi flap, and 1 case closed the wound directly. Flaps with other venous anastomosis protocols survived completely. All 296 patients were followed up 12-70 months, with an average of 37.5 months. The reconstructed breast has good shape, good elasticity, and no skin flap contracture. The donor site of the flap only left linear scar, and the abdominal wall function was not affected.

Conclusion

The method of direct anastomosis of concomitant veins of deep inferior epigastric artery with Y-shaped structure is relatively risky, and the vessels are prone to be twisted and compressed, leading to the occurrence of venous crisis. It can improve the safety of surgery if only one large vein is anastomosed or two veins are separated to anastomose respectively.

Unilateral immediate deep inferior epigastric artery perforator flap breast reconstruction following skin sparing mastectomy: A comparative study on revision surgeries to improve breast symmetry

BACKGROUND

The number of revision surgeries to improve breast asymmetry after deep inferior epigastric perforator (DIEP) flap breast reconstruction is still high worldwide with impact on both patients and healthcare systems. These procedures include fat grafting, contralateral breast symmetrization, scar revision, flap repositioning and remodeling. A previously published DIEP flap insetting algorithm has proven to be effective in selecting patient-tailored strategies to achieve excellent aesthetic outcomes. This study investigated whether this insetting algorithm was effective in reducing revision surgeries in patients undergoing SSM and immediate DIEP flap breast reconstruction to achieve the goal of a one-stage reconstruction.

METHODS

This retrospective case-control study included 60 patients (group A) treated without the DIEP flap standardized insetting algorithm and 60 patients (group B) treated with the standardized insetting algorithm, which considers among its variables the type of breast to be reconstructed, abdominal tissue thickness, rotation due to harvesting side. Demographic data, operative data, complications and number of revision surgeries were recorded.

RESULTS

One hundred and twenty primary and 106 revision surgeries were performed. Groups were homogenous for age (p = .32), body mass index (p = .77), flap weight (p = .7), operative time (p = .87) and early complications (p = .78). When excluding isolated nipple reconstruction from the revision surgeries, one-stage reconstruction was successfully performed in 26 patients in group A (43.3%) and 39 patients (65.0%) in group B, with a statistically significant difference between the groups (p = .003).

CONCLUSIONS

The introduction of a standardized insetting algorithm for immediate unilateral DIEP flap breast reconstruction can be effective in reducing the number of revision surgeries for breast asymmetry, making a one-stage reconstruction an achievable and reliable target.

Prospective Longitudinal Patient-Reported Satisfaction and Health-Related Quality of Life following DIEP Flap Breast Reconstruction: Effects of Reconstruction Timing

BACKGROUND

Without reconstruction, mastectomy alone can produce significant detrimental effects on health-related quality of life. The magnitude of quality-of-life benefits following breast reconstruction may be unique based on timing of reconstruction. Facilitated by the BREAST-Q questionnaire, characterization of how reconstruction timing differentially affects patient-reported quality of life is essential for improved evidence-based clinical practice.

METHODS

Consecutive DIEP flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two different time intervals postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision/symmetry procedures, respectively. Postoperative flap and donor-site complications were recorded prospectively. Stratified by timing (immediate versus delayed) of reconstruction, preoperative clinical data, operative morbidity, and BREAST-Q scores were compared at all time points.

RESULTS

Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Collectively, breast satisfaction, psychosocial well-being, and sexual well-being scores significantly (p < 0.001) increased postoperatively versus baseline. Chest and abdominal physical well-being scores returned to baseline levels by postoperative time point B. Preoperatively, patients undergoing delayed breast reconstruction reported significantly (p < 0.05) lower breast satisfaction, psychosocial well-being, and sexual well-being scores compared to immediate reconstruction patients. Postoperatively, delayed and immediate reconstruction patients reported similar quality-of-life scores. Outcome satisfaction and flap and donor-site morbidity were similar between groups irrespective of timing of reconstruction.

CONCLUSIONS

In this prospective study, patient-reported outcomes demonstrate significant improvements in breast satisfaction, psychosocial well-being, and sexual well-being among patients following DIEP flap reconstruction. Moreover, preoperative differences in quality-of-life scores among delayed/immediate reconstruction patients were eliminated postoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Superior gluteal artery perforator flap salvaged via hyperbaric oxygen therapy

The superior gluteal artery perforator (SGAP) flap can be challenging and in common with all flaps can develop venous and arterial insufficiency. Several prior studies have demonstrated the successful utility of hyperbaric oxygen therapy (HBOT) in the salvage of compromised flaps, mainly with deep inferior epigastric perforator, latissimus dorsi or transverse rectus abdominis myocutaneous flaps. SGAP flaps are autologous alternatives to abdominal-based flaps and provides adequate adipose tissue for breast reconstruction. We report a case of a woman in her 50s who underwent a delayed bilateral breast reconstruction using SGAP free flaps. Postoperatively, venous congestion of her right breast flap was noted for which she was referred for HBOT. An acceptable aesthetic result was achieved following 17 HBOT treatments. This is the first case we can find in the published literature of ischaemic SGAP free flap being salvaged by HBOT.

Case Volume-Dependent Changes in Operative Morbidity following Free Flap Breast Reconstruction: A 15-Year Single-Center Analysis

BACKGROUND

Operative morbidity is a common yet modifiable feature of complex surgical procedures. With increasing case volume, improvement in morbidity has been reported through designated procedural processes and greater repetition. Defined as a volume-outcome association, improvement in breast reconstruction morbidity with increasing free flap volume requires further characterization.

METHODS

A retrospective analysis was conducted among consecutive free flap patients using a two-microsurgeon model between January of 2002 and December of 2017. Patient demographics and operative characteristics were obtained from medical records. Complications including unplanned surgical intervention (take-back) and flap loss were obtained from prospectively kept databases. Individual surgeon operative volume was estimated by considering overall practice volume and correcting for the number of surgeons at any given time.

RESULTS

During the study period, 3949 patients met inclusion criteria. A total of 6607 breasts underwent reconstruction with 6675 free flaps. Mean patient age was 50 ± 9.4 years and mean body mass index was 28.8 ± 5.0 kg/m2. Bilateral reconstruction was performed on 2633 patients (66.5 percent), with 4626 breasts (70.5 percent) reconstructed in the immediate setting. Overall, breast and donor-site complications were reported in 507 breasts (7.7 percent) and 607 cases (15.4 percent), respectively. Take-back was required in 375 cases (9.5 percent), with complete flap loss occurring in 57 cases (0.9 percent). Based on annual flaps per surgeon, the incidence of complications decreased with increasing volume (slope = -0.12; p = 0.056).

CONCLUSION

Through procedural efficiency and execution of defined clinical processes using a two-microsurgeon model, increases in microsurgical breast reconstruction case volume result in decreased morbidity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The influence of venous system patterns on DIEP flap viability for breast reconstruction

A deep inferior epigastric artery perforator (DIEP) flap has unique variations in the anatomy of the vascular supply, and this idea has been adapted to the venous system. Venous system patterns, including connections between the superficial and deep inferior epigastric vein (SDC) or connections of the superficial inferior epigastric vein across the midline-crossing linking veins (MCLV), have gradually become recognized as a cause of fat necrosis and induration due to venous congestion. Therefore, it is important to select patients who are appropriate for transplantation by evaluating blood flow in the flap based on these patterns. The subjects were 52 consecutive patients who underwent DIEP flap breast reconstruction. Relationships of fat necrosis and induration of a transplanted flap and venous system patterns (presence of SDC on the contralateral side: cSDC or MCLV, direction and diameter of perforator vein) in the flap were investigated. Logistic regression and univariate and multivariate analyses were used to identify predictors of fat necrosis and induration of the flap. Fat necrosis and induration were detected in 17.4 and 34.8% of cases, respectively. These incidences were significantly linked to the absence of cSDC and MCLV patterns in the flap. Patients without a cSDC or MCLV pattern had harder fat tissue in Zone II, especially in the distal portion. These results suggest that the absence of a cSDC or MCLV pattern causes complications such as fat necrosis and induration in a transplanted flap. If neither pattern is detected before surgery, improvement of venous drainage is recommended.

Post-mastectomy Breast Reconstruction with Autologous Tissue: Current Methods and Techniques

Breast reconstruction is an option that should be considered for any patient facing a mastectomy. Autologous breast reconstruction provides the benefits of excellent longterm results, natural appearance, natural feel, and the best opportunity for sensory restoration. These factors lead many patients to choose autologous tissue over implant-based reconstruction. With improved anatomic and technical knowledge, the donor site morbidity previously associated with abdominally based autologous reconstruction has been significantly reduced. Today, the DIEP flap is the preferred autologous method allowing restoration of a “natural,” aesthetic breast with potential for sensation while simultaneously minimizing abdominal donor site morbidity. Alternative flaps and adjunctive procedures provide options when dealing with patients who present with challenging clinical scenarios because of an inadequate abdominal donor site. This paper reviews current methods employed by a high volume breast reconstruction practice to achieve these goals.

Effect of Venous Superdrainage on Colon Interposition for Esophageal Reconstruction

When performing esophageal reconstruction, a colonic pedicle graft is chosen as the next candidate to the stomach because of complications arising from the operation time and vascular anastomosis. Vascular anastomosis is not necessarily required for pedicle grafts, but it is necessary to perform additional vascular anastomosis in some cases. We herein report a case of superdrainage in which anastomosis of the colonic vein and the right internal thoracic vein was effective against congestion. A 68-year-old man with thoracic esophageal cancer and pyloric antrum gastric cancer was referred to our hospital. Complete resection was performed with subtotal esophageal resection and total gastrectomy. We added superdrainage (right internal thoracic vein - ileocolic vein) to the colonic pedicle graft, which showed congestion, and performed esophageal reconstruction. Venous superdrainage using a colonic pedicle graft is effective for esophageal reconstruction.

Meta-analysis of the effects of venous super-drainage in deep inferior epigastric artery perforator flaps for breast reconstruction

INTRODUCTION

Venous congestion is the most common vascular complication of the deep inferior epigastric artery perforator (DIEP) flaps. Adding a second venous drainage by anastomosing a flap vein and a recipient vein (super-drainage) is considered the solution of choice. Evidence to support this procedure, had not yet been confirmed by an analysis of the literature. We aimed to provide this evidence.

MATERIALS AND METHODS

We searched the literature (MedLine, Scopus, EMBASE, Cochrane Library, and Google Scholar), for studies discussing venous congestion and venous super-drainage in DIEP flap for breast reconstruction. Thirteen of the 35 articles compared results between one or two venous anastomoses. Meta-analysis was performed following PRISMA guidelines. Pooled risk ratio (RRs) for congestion, fat necrosis, partial necrosis, and total necrosis with corresponding 95% confidence intervals (CI) were calculated using a fixed-effect model with the Mantel-Haenszel method. The need to return to surgery (95% CI) was estimated with a random effect model using the DerSimonian and Liard method.

RESULTS

We showed a statistically significant advantage of super-drainage to reduce the venous congestion of the flap (RR: 0.12, 95% CI: 0.04-0.34, p-value <.001), partial flap necrosis (RR: 0.50, 95% CI: 0.30-0.84, p-value .008), total flap necrosis (RR: 0.31, 95% CI: 0.11-0.85, p-value .023), and the need to take the patient back to surgery for perfusion-related complications (RR: 0.45, 95% CI: 0.21-0.99, p value .048).

CONCLUSIONS

Performing a second venous anastomosis between the SIEV and a recipient vein (venous superdrainage) reduces venous congestion and related complications in DIEP flaps for breast reconstruction.

Outpatient Microsurgical Breast Reconstruction

Background:

The extensive nature of perforator-based breast reconstructions, combined with the need for postoperative flap monitoring, often leads to long hospitalizations. We present an early report demonstrating the feasibility and advantages of a modified operative technique and recovery protocol, allowing us to perform outpatient breast reconstructions with the DIEP flap. This follow-up comprises the experience gained, which is expanded to other perforator-based flaps and not limited to DIEP breast reconstructions.

Methods:

We have implemented a general protocol in patients undergoing breast reconstruction with autologous flaps, promoting early mobilization and discharge by improving postoperative pain and decreasing opioid requirements. This protocol includes intraoperative local anesthesia, a microfascial incision for DIEP harvest with rib preservation, along with prophylactic anticoagulation.

Results:

Ninety-two consecutive patients underwent autologous tissue-based breast reconstruction with DIEP, IGAP, and PAP flaps. No intraoperative complications were reported. All patients were discharged within 23 hours, without evidence of flap compromise. One patient required operative takeback for evacuation of a hematoma on postoperative day 4. No partial or total flap losses were documented. The aim of any procedure should be to get to the patient back to the preoperative status as quickly as possible, as prolonged hospitalizations are associated with higher incidences of infection, deep venous thrombosis, overall dissatisfaction, and higher overall costs of care.

Conclusions:

By using a modified operative technique, multimodal pain control, and postoperative anticoagulant therapy, outpatient perforator-flap–based breast reconstructions can be performed with high success and low complication rates.

Different Hydraulic Constructs to Optimize the Venous Drainage of DIEP Flaps in Breast Reconstruction: Decisional Algorithm and Review of the Literature

BACKGROUND

 Venous congestion is the most common perfusion-related complication of deep inferior epigastric artery perforator (DIEP) flap. Several hydraulic constructs can be created for venous superdrainage in case of flap venous engorgement or as a preventive measure. These can be classified based on the choice of the draining vein of the flap, either a second deep inferior epigastric vein (DIEV) or a superficial inferior epigastric vein (SIEV), and of the recipient vein, either a vein of the chest or the DIEV.

METHODS

 We conducted a comprehensive systematic literature review in Medline, Scopus, EMBASE, Cochrane Library, and Google Scholar to find publications that reported on venous congestion in DIEP flap. The keywords used were DIEP Flap, breast reconstruction, venous congestion, supercharging, superdrainage, SIEV, and DIEV.

RESULTS

 Based on the studies found in the literature, we developed an algorithm to guide the surgeon's decision when choosing the veins for the superdrainage anastomosis.

CONCLUSION

 Several alternatives for venous anastomosis in superdrainage are available. We propose an algorithm to simplify the choice. The use of the ipsilateral SIEV to be connected to a vein of the chest appears to be advantageous. The anatomical position that allows the easiest anastomosis dictates which chest vein to favor.

The Outpatient DIEP: Safety and Viability following a Modified Recovery Protocol

Background

Breast reconstruction with autologous tissue is considered the current state-of-the-art choice following mastectomies, and the deep inferior epigastric perforator (DIEP) flap is often among the favored techniques. Commonly referred to patients as a combination between a tummy tuck and a breast augmentation, it significantly differs by the required expertise and long hospital stays. We present a series attesting to the feasibility and effectiveness of performing this type of reconstruction in an outpatient setting following our recovery protocol.

Methods

Patients undergoing DIEP flap breast reconstruction followed a recovery protocol that included intraoperative local anesthesia, microfascial incision technique for DIEP harvest, double venous system drainage technique, rib and chest muscle preservation, and prophylactic anticoagulation agents.

Results

Fourteen patients totaling 27 flaps underwent breast reconstruction following our protocol. All patients were discharged within the initial 23 hours, and no take-backs, partial, or total flap failures were recorded. A case of abdominal incision breakdown was seen in 1 patient during a postoperative visit, without evidence of frank infection. No further complications were observed in the 12-week average observation period.

Conclusion

With the proper use of a microfascial incision, complemented by rib sparing and appropriate use of injectable anesthetics, routine breast reconstructions with the DIEP flap can be safely performed in an outpatient setting with discharge in the 23-hour window.

Predicting venous congestion before DIEP breast reconstruction by identifying atypical venous connections on preoperative CTA imaging

BACKGROUND

Venous congestion is the principle cause of flap failure after microsurgical breast reconstruction. We aim to correlate preoperative computed tomography angiography (CTA) findings with postoperative venous congestion to predict patients at risk of congestion.

METHODS

All patients undergoing deep inferior epigastric perforator (DIEP) breast reconstruction between August 2009 and August 2013 underwent preoperative CTA and prospectively entered the study. Patients with postoperative venous congestion were matched with a similar cohort of complication-free patients. Preoperative CTAs were randomized and re-interpreted by a radiologist, blinded to the subsequent clinical outcome. Inter-group comparisons were performed.

RESULTS

Two hundred and forty DIEP flaps were performed in 202 patients over the 4-year study. Venous congestion affected 15 flaps (6.3%). Preoperative CTA showed significantly more atypical venous connections between deep and superficial systems in congested flaps compared to controls (66.7% vs. 8%; P < .0001), with a positive predictive value of 83%. Atypical connections were narrow, tortuous, or incomplete. Patients with congestion-free flaps had more normal connections (80% vs. 26.7%; P < .001) and more cranial perforators (P = .02). Similar CTA findings between groups included perforator size and lateral position, superficial inferior epigastric vein size, crossing of midline, and absent connections (P > .05).

CONCLUSIONS

Preoperative CTA identifies atypical venous connections between deep and superficial systems that increase the risk of postoperative DIEP congestion five-fold. Identifying atypical venous connections maximizes the chances of flap survival and minimizes complications for patients considering DIEP breast reconstruction.

Anastomosis of the Superficial Inferior Epigastric Vein to the Internal Mammary Vein to Augment Deep Inferior Artery Perforator Flaps

Use of the retrograde limb of the internal mammary vein has been described previously as a lifeboat for venous congestion but not prophylactically. Maximizing the length of the deep inferior artery perforator (DIEP) flap pedicle, identifying and dissecting the superficial inferior epigastric vein proximally in every patient, and taking advantage of the retrograde internal mammary vein are all technical details that facilitate the additional venous anastomosis and flap inset. Performing a second venous anastomosis routinely using the superficial inferior epigastric vein to the retrograde internal mammary vein helps with flap inset.

Effects of Venous Superdrainage and Arterial Supercharging on Dorsal Perforator Flap in a Rat Model

Objective

To comparatively assess the effects of venous superdrainage and arterial supercharging on dorsal perforator flap survival.

Materials and Methods

Sixty male Sprague-Dawley rats (450–550g) were randomly divided into three groups (n = 20), including control group (Control) and experimental groups A (venous superdrainage, Exp. A) and B (arterial supercharging, Exp. B). At postoperative day 7, survival areas of the flaps were evaluated and all animals underwent angiography. Laser Doppler was used to evaluate flap perfusion from 0h to 7days after surgery. Histology with hematoxylin and eosin staining was used to count microvessels. Tissue of “Choke vessels”was excised for quantification of hypoxia inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF) by western blot assay at 6h and 7days after surgery.

Results

In the Exp. A group, almost all flaps survived (98.2±1.6%); in the Exp. B and control group, survival areas accounted for 78.8±8.5% and 60.3±7.8%, respectively (P <0.001). In addition, Exp. A animals showed improved anastomosis of choke vessels 2 compared with the Exp. B and Control groups. Furthermore, flap blood flow and partial pressure of oxygen in the Exp. A group were significantly higher compared with values obtained for the Exp. B and Control groups, from 6 hours to 7 days after surgery. More microvessels were found in the Exp. A group (11.65±1.33) than in Exp. B (9.25±0.34) and control (7.25±0.91) animals on POD 7. The relative expression level of HIF-1α and VEGF were significant at 6h and 7days after surgery.

Conclusions

Venous superdrainage in rat dorsal perforator flap is more effective than arterial supercharging in promoting flap survival, and could effectively alter hemodynamics in the microcirculation and stimulate blood vessel formation.

DIEP flap salvage by cannula venesection of the superficial inferior epigastric vein

The deep inferior epigastric perforator (DIEP) flap is a technique of autologous breast reconstruction that is gaining popularity. The main advantage of the DIEP flap over the traditional transverse rectus abdominis myocutaneous (TRAM) flap is that there is a lower incidence of abdominal wall donor-site morbidity with the DIEP flap. However, venous congestion is the most dreaded complication of DIEP flap surgery which requires prompt intervention. In this case report, we present a simple but effective procedure to salvage the congested DIEP flap. A 55-year-old female underwent left breast reconstruction with DIEP flap and developed venous congestion during surgery. Cannula venesection of the superficial inferior epigastric vein (SIEV) was performed intraoperatively followed by intermittent aspiration of blood for 3 days. A satisfactory aesthetic result was achieved with no evidence of fat necrosis. This procedure eliminated the need for performing an additional microvascular anastomosis, required less operative time, and allowed augmentation of the venous drainage of the congested flap.

LEVEL OF EVIDENCE

Level V, therapeutic study.

[Benefit of simultaneous contralateral breast symmetry procedure with unilateral breast reconstruction using DIEP flaps. About 33 cases]

BACKGROUND

After unilateral breast reconstruction, a procedure on the contralateral breast is often needed to achieve symmetry. Here, we present a single surgeon's experience with performing contralateral symmetry procedures simultaneously with DIEP flap.

METHODS

We evaluated 33 consecutive patients (mean age, 52.1 years) who underwent DIEP flap unilateral breast reconstruction and a simultaneous contralateral breast procedure performed and 2 patients with delayed controlateral symmetry procedures. A single-stage breast cancer reconstruction is successful if after the original reconstruction no correction for revision of breast mound, or contralateral breast procedures are performed, under general anesthetic, to complete the reconstruction.

RESULTS

In 24 patients (73%), breast reconstruction was completed after a single stage with one general anesthetic, and in 8 patients (24%), revisions were performed with two general anesthetic (7 patients) and three general anesthetic in one case. Reconstructions requiring more than one general anesthetic were due to 4 of 39 (10%) postoperative complications. Mean operating time was 485 minutes.

CONCLUSIONS

For patients who need contralateral reduction mammoplasty or mastopexy for symmetry, performing these procedures and breast reconstruction simultaneously facilitates single-stage breast reconstruction in most patients.

Intraoperative venous congestion in free transverse rectus abdominis musculocutaneous and deep inferior epigastric artery perforator flaps during breast reconstruction: A systematic review

BACKGROUND

Even with patent deep inferior epigastric vein anastomoses, venous congestion can occur during free transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flap surgery and lead to flap compromise if not recognized and managed.

OBJECTIVES

To identify the incidence of intraoperative venous congestion and describe the best available prevention and treatment methods.

METHODS

Systematic electronic searches of the PubMed database including Medline were performed to identify studies published until 2014. The following keywords were used: "DIEP" or "free TRAM" and "venous insufficiency" or "venous congestion". Supplemental searches were conducted to identify referenced studies. Statistical analysis using the χ(2) test was performed.

RESULTS

Nine studies representing 4747 free abdominal flaps cases were included and demonstrated an overall incidence of intraoperative venous congestion of 2.8%. The incidence in DIEP flaps (3.3%) was significantly higher than that in the free TRAM flaps (1.0%). All nine articles reported using the superficial inferior epigastric vein to treat venous insufficiency.

CONCLUSION

The risk for developing intraoperative venous congestion following free abdominal flap breast reconstruction is influenced by inadequate perforator selection and persistent dominance in the superficial venous system. The solution is establishing another venous draining route using the superficial inferior epigastric vein.