The superficial outside-flap shunt (SOS) technique for free deep inferior epigastric perforator flap salvage

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

“…Salvage intervention procedures included cephalic vein switch/anastomosis, vein graft, and superficial outside‐flap shunt (SOS) technique. (Davies et al, ) One unilateral breast reconstruction case underwent on‐table conversion to a contralateral TRAM after signs of congestion after raising the DIEP. Flap loss in the 4 cases was due to venous congestion ( n = 2), perforator damage during dissection ( n = 1), and arterial insufficiency ( n = 1).…”

“…(Ali et al, 2010;Sbitany, Mirzabeigi, Kovach, Wu, & Serletti, 2012;Wechselberger et al, 2001) Indeed, if the cause of congestion was a technical issue at the primary venous anastomosis, it is implausible that additional venous anastomoses within the flap would resolve congestion. Salvage options may follow treatment algorithms, (Davies et al, 2014;Galanis et al, 2014) with options including using a contralateral TRAM or additional venous anastomoses utilizing the SIEV lifeboat (Villafane, Gahankari, & Webster, 1999) via cephalic switch, vein graft, interposition of the SIEV to the IMV (Blondeel, 1999;Blondeel et al, 2000) or alternative vessels, (Wechselberger et al, 2001) reverse flow venous anastomosis, (Liu, Ashjian, & Festekjian, 2007) There is likely to be a link between venous congestion and fat necrosis. Fat necrosis incidence ranges from 5% to 35% (Kroll, 2000;Peeters, Nanhekhan, Van Ongeval, Fabre, & Vandevoort, 2009) and non-standardized definitions based combinations of clinical symptoms, signs, or imaging findings remain a challenge.…”

“…(Schaverien et al, ) If congestion is noted in the operating room or immediate postoperative period, salvage procedures such as supplementary venous anastomoses or conversion to a contralateral muscle‐sparing transverse rectus abdominus myocutaneous (TRAM) flap can be performed prevent flap failure. (Davies, O'Neill, & Wilson, ; Galanis et al, )…”

“…(Schaverien et al, 2010) If congestion is noted in the operating room or immediate postoperative period, salvage procedures such as supplementary venous anastomoses or conversion to a contralateral muscle-sparing transverse rectus abdominus myocutaneous (TRAM) flap can be performed prevent flap failure. (Davies, O'Neill, & Wilson, 2014;Galanis et al, 2014) This research aims to quantify anatomical features on preoperative CTA that predict postoperative venous congestion. Identifying "at risk" patients before surgery would provide a game-changing level of preoperative data to assist the contemporary reconstructive surgeon with flap planning decision-making.…”

Benefits of superdrainage using SIEV in DIEP flap breast reconstruction: A systematic review and meta‐analysis

“…Villafane et al reported their successful outcome of flap salvaging by using SIEV and described SIEV as a “lifeboat” for DIEP or TRAM flaps . Since then, not a few studies have demonstrated the experiences of successful salvage of congested DIEP flaps using SIEV with diverse techniques . As the experience of DIEP flap breast reconstruction has accumulated and the importance of SIEV in the venous drainage of abdominal flaps has been demonstrated, active applications of SIEV have been attempted, including prophylactic superdrainage using SIEV to reduce the incidence of flap congestion and subsequent complications.…”