Cephalic Vein Transposition versus Vein Grafts for Venous Outflow in Free-flap Breast Reconstruction

Abstract

Introduction:When recipient veins for free-flap breast reconstruction are unavailable or inadequate, vein grafts or cephalic vein transposition (CVT) an option to provide alternate venous outflow. There are no comparative data to elucidate the indications and outcomes for each. We hypothesize that the CVT is as reliable as vein grafts when indicated.Methods:All consecutive cases where a CVT or venous vein grafts were used for free-flap breast reconstruction between 2000 and 2012 were reviewed. Patient demographics, operative notes, indications, and flap survival were compared between the 2 groups.Results:Ten patients underwent a CVT and 38 patients received a vein graft for insufficient venous outflow. There were no differences in average age, body mass index, or comorbid conditions between the groups. Similarly, there was no difference in previous radiotherapy, timing of reconstruction, or side of reconstruction. A CVT was used for salvage following venous thrombosis in 7 patients (70.0%) and for primary venous outflow in the remaining patients due to inability to use the internal mammary vein. Vein grafts were performed primarily in 31 patients, 22 for augmenting venous drainage (supercharge), 9 for the dominant venous outflow, and 7 for salvage of a thrombosis. One patient in each group suffered a complete loss of the free flap (cephalic: 10.0% vs vein graft: 14.3%, P = 0.36).Conclusions:The CVT is a reliable alternate venous outflow that can be used as a primary recipient vein or as a salvage option following venous thrombosis. Surgeons should consider a CVT when primary recipient veins are compromised or unavailable.

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

“…After thorough evaluation of all the articles retrieved on the subject of venous superdrainage, we have come down to 11 studies on various functional factors, [6][7][8][9][10][11][12][13][14][15][16] 18 studies reporting on the results of a single center on hydraulic constructs, 2,5,[17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] one review of the literature, 33 six studies on treatment algorithms, 1,15,[34][35][36][37] and one meta-analysis 38 (►Table 1).…”

“…Xin 10 Figus 11 Minqiang 12 Sadik 13 Gravvanis 14 Vijayasekaran 15 Akita 16 Single technique and/or center experience Tutor 20 Tran 21 Guzzetti 22 Enajat 19 Stasch 23 Kerr-Valentinic 32 Blondeel 2 Momeni and Lee 24 Boutros 29 Sbitany 17 Ochoa 26 Chang 31 Santanelli 5 Unukovych 27 Hindi 25 Hillberg 28 Kim 30 Prospective randomized A comparative study between DIEAP and thoracoacromial venous supercharged deep inferior epigastric artery perforator flaps Eom 34 Davis 37 La Padula 36 (Continued)…”

“…as recipient vein, instead of the DIEV a vein of the chest so that the excessive venous output will be drained by an independent route, without the risk of engorging the flap's main pedicle. 31,32,43 In the literature, the only prospective and randomized study on the subject 40 reported a reduced venous congestion, and consequent necrosis of DIEP flaps when an adjunctive extra-flap anastomosis between the SIEV and the thoracoacromial vein was performed.…”

Autologous Latissimus Dorsi Breast Reconstruction Flap Salvage: Microvascular Anastomosis with Serratus Branch

“…Autologous flap failure is an infrequent but serious complication that may require immediate surgical intervention. Previous groups have documented flap salvage using primary anastomosis techniques, 2 conversion to a free flap, 2 , 3 vein graft techniques, 2 , 4 or by harvesting a new flap altogether. 5 Although flap salvage by anastomosis to the serratus branch of the thoracodorsal artery has been previously recognized, 2 we are not aware of any groups attempting this flap salvage technique.…”

A method using the cephalic vein for superdrainage in breast reconstruction

“…In general, the serratus anterior muscle branch of the thoracodorsal vein (SA) is anastomosed to the drainage vein (recipient vein), although blood vessel anastomosis can occasionally be difficult. Some reports have described a method using the cephalic vein (CV) for superdrainage (Audolfsson et al, ; Barnett, Carlisle, & Gianoutsos, ; Chang, Fearmonti, Chang, & Butler, ; Enajat, Rozen, Whitaker, Smit, & Acosta, ; Landin et al, ; Mehrara et al, ; Powell, Prousskaia, & Wilson, ). However, the suggestions of superdrainage, and which vein should be used, have been points of debate.…”