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

Abstract

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.

Lessons Learned from 30 Years of Transverse Myocutaneous Gracilis Flap Breast Reconstruction: Historical Appraisal and Review of the Present Literature and 300 Cases

“…Numerous studies evaluated the complexity of the DIEP flap angiosome and were able to decode its variability depending on a lateral or medial perforator row location [19]. Similar to venous supercharging in DIEP flaps the TMG flap can be supercharged using the distal end of the great saphenous vein [5,20]. We found supercharging of TMG flaps rarely necessary since flap sizes are lower compared to DIEP flaps where supercharging is often indicated in higher flap weights [21].…”

Association of Dual Venous Anastomosis with Reduced Risks for Flap Congestion in Microsurgical Lower Extremity Reconstruction: A Multicenter Study

“…Similar findings were also reported in several previous studies regarding deep inferior epigastric artery perforator flap-based breast reconstruction, showing that conducting multiple venous anastomosis or supercharging could be helpful in enhancing venous outflow and in reducing potential overloading of deep venous system. 20,21 These results suggest that this effect may be irrelevant to the choice of flaps. It can be assumed that compared with conducting single anastomosis, dual venous anastomoses might be associated with reduced risks for the development of flap congestion and subsequent flap failure in microsurgical lower extremity reconstruction, similar to microsurgical reconstruction of other regions as reported in previous meta-analyses.…”

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

“…Recent studies have identi ed that venous congestion without microsurgical failure is due to the insu cient super cial venous out ow via the deep venous system in TRAM/DIEP ap [19,20]. To resolve this problem, many authors have offered varying means of augmenting or supercharging the venous drainage of congested or compromised aps and have recommended the use of SIEV [19][20][21][22][23][24][25][26][27]. Although there is a known bene t of such salvaging procedure in reducing the risk of ap congestion, a consensus regarding the reproducibility of superdrainage effect in individual cases does not exist.…”

“…Much effort has been made to prevent such complication, and various strategies for salvage of aps with intraoperative venous congestion, including turbocharging or supercharging with the additional anastomosis of SIEV or accompanying deep inferior epigastric comitantes, have been introduced [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]. The bene ts of superdrainage on augmenting ap perfusion and reducing congestive failures have been demonstrated in previous literatures [19-21, 36, 37].…”