J Reconstr Microsurg 2024; 40(05): 379-383
DOI: 10.1055/a-2181-7034
Original Article

The Influence of the Superficial Venous System on DIEP Flap Drainage in Breast Reconstruction

1   Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
2   Department of Plastic Surgery, São Paulo State Cancer Institute, São Paulo, Brazil
,
Renan Diego Américo Ribeiro
1   Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
2   Department of Plastic Surgery, São Paulo State Cancer Institute, São Paulo, Brazil
,
Eduardo Montag
1   Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
2   Department of Plastic Surgery, São Paulo State Cancer Institute, São Paulo, Brazil
,
Thiago Ueda
1   Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
2   Department of Plastic Surgery, São Paulo State Cancer Institute, São Paulo, Brazil
,
Alberto Yoshikazu Okada
1   Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
2   Department of Plastic Surgery, São Paulo State Cancer Institute, São Paulo, Brazil
,
Alexandre Mendonça Munhoz
1   Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
2   Department of Plastic Surgery, São Paulo State Cancer Institute, São Paulo, Brazil
,
Fabio de Freitas Busnardo
1   Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
2   Department of Plastic Surgery, São Paulo State Cancer Institute, São Paulo, Brazil
,
Rolf Gemperli
1   Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
2   Department of Plastic Surgery, São Paulo State Cancer Institute, São Paulo, Brazil
› Author Affiliations

Abstract

Background Autologous tissue has become the gold standard in breast reconstruction. The use of a deep inferior epigastric perforator (DIEP) flap has the advantages of giving a natural appearance to the reconstructed breast and being associated with lower morbidity at the donor site when compared with the transverse rectus abdominis myocutaneous flap. Venous complications such as venous thrombosis and insufficiency remain the main causes of flap loss and surgical revisions. The aim of this study was to evaluate the influence of superficial venous drainage of the DIEP flap and the addition of a second venous anastomosis have on flap survival.

Methods This was a retrospective cohort study collected from a prospective database maintained by our institution. Data was obtained from the medical records of female patients who underwent mastectomy and breast reconstruction with a DIEP flap between March 2010 and March 2017. We evaluated 137 DIEP patients with unilateral breast reconstructions. In 64 (46.7%) the deep venous system was chosen and 73 (53.3%) had an additional superficial vein anastomosed.

Results Out of the 137 patients evaluated, there were 16 (11.67%) cases of revision, 14 (10.21%) were due to venous thrombosis. Twelve cases (8.75%) of flap loss were reported. Reoperation rate was lower in the dual venous drainage group when compared with the single venous drainage group (p = 0.005), as was the rate of flap loss (p = 0.006) and reoperation due to venous thrombosis (p = 0.002). Out of the 125 DIEP flaps, fat necrosis was clinically identified in 7 (5.1%) cases, and the rate was lower in the dual venous drainage system group (p = 0.01).

Conclusion Dual venous drainage of a DIEP flap appears to reduce the rates of venous thrombosis, reoperation, total flap loss, and fat necrosis.



Publication History

Received: 04 April 2023

Accepted: 18 September 2023

Accepted Manuscript online:
26 September 2023

Article published online:
03 November 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Momoh AO, Colakoglu S, Westvik TS. et al. Analysis of complications and patient satisfaction in pedicled transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg 2012; 69 (01) 19-23
  • 2 Holmström H. The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report. Scand J Plast Reconstr Surg 1979; 13 (03) 423-427
  • 3 Boutros SG. Double venous system drainage in deep inferior epigastric perforator flap breast reconstruction: a single-surgeon experience. Plast Reconstr Surg 2013; 131 (04) 671-676
  • 4 Scheer AS, Novak CB, Neligan PC, Lipa JE. Complications associated with breast reconstruction using a perforator flap compared with a free TRAM flap. Ann Plast Surg 2006; 56 (04) 355-358
  • 5 Blondeel PN, Arnstein M, Verstraete K. et al. Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000; 106 (06) 1295-1299
  • 6 Nahabedian MY, Momen B, Galdino G, Manson PN. Breast reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 2002; 110 (02) 466-475 , discussion 476–477
  • 7 Chen CM, Halvorson EG, Disa JJ. et al. Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps. Plast Reconstr Surg 2007; 120 (06) 1477-1482
  • 8 Tran NV, Buchel EW, Convery PA. Microvascular complications of DIEP flaps. Plast Reconstr Surg 2007; 119 (05) 1397-1405 , discussion 1406–1408
  • 9 Russo AL, Taghian AG. Fat necrosis of the breast in the accelerated partial breast irradiation era: the need for a universal grading system. Breast Cancer Res Treat 2013; 140 (01) 1-11
  • 10 Scheflan M, Hartrampf CR, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982; 69 (05) 908-909
  • 11 Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989; 42 (06) 645-648
  • 12 Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; 32 (01) 32-38
  • 13 Enajat M, Rozen WM, Whitaker IS, Smit JM, Acosta R. A single center comparison of one versus two venous anastomoses in 564 consecutive DIEP flaps: investigating the effect on venous congestion and flap survival. Microsurgery 2010; 30 (03) 185-191
  • 14 Okada A, Pereira DD, Montag E. et al. Optimizing outcomes in free flap breast reconstruction in the community hospital setting: a stepwise approach to DIEP/SIEA flap procedures with banking a hemiabdominal flap. J Reconstr Microsurg 2017; 33 (07) 474-482
  • 15 Pignatti M, Pinto V, Giorgini FA. et al. Different hydraulic constructs to optimize the venous drainage of DIEP flaps in breast reconstruction: decisional algorithm and review of the literature. J Reconstr Microsurg 2021; 37 (03) 216-226
  • 16 Galanis C, Nguyen P, Koh J, Roostaeian J, Festekjian J, Crisera C. Microvascular lifeboats: a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction. Plast Reconstr Surg 2014; 134 (01) 20-27
  • 17 Rabey NG, Erel E, Malata CM. Double-pedicled abdominal free flap using an entirely new microvascular combination of DIEP and SIEA vascular pedicles for unilateral breast reconstruction: a novel addition to the Hamdi classification. Plast Reconstr Surg 2012; 130 (05) 767e-769e
  • 18 Hamdi M, Khuthaila DK, Van Landuyt K, Roche N, Monstrey S. Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast. J Plast Reconstr Aesthet Surg 2007; 60 (08) 904-912 , discussion 913–914
  • 19 Murray A, Wasiak J, Rozen WM, Ferris S, Grinsell D. Stacked abdominal flap for unilateral breast reconstruction. J Reconstr Microsurg 2015; 31 (03) 179-186