Further Validation for Use of the Retrograde Limb of the Internal Mammary Vein in Deep Inferior Epigastric Perforator Flap Breast Reconstruction Using Laser-Assisted Indocyanine Green Angiography

ABSTRACT

We have previously described the use of the retrograde limb of the internal mammary vein (IMV) as an additional venous outflow tract in deep inferior epigastric perforator (DIEP) flap reconstruction. In the current study, we use the Novadaq SPY^® system, a novel intraoperative angiographic method, to further validate the use of the retrograde limb of the IMV. The Novadaq SPY^® system laser source was used with indocyanine green angiography to evaluate the arterial, anterograde venous, and retrograde venous anastomoses of 15 patients undergoing DIEP flap breast reconstruction. The number of perforators used, patient age, exposure to radiation, coupler size, and incidence of intraoperative congestion were recorded. All flaps survived, and there were no cases of intraoperative congestion. The average time required to perform the additional retrograde anastomosis was 12 minutes. Flow of indocyanine green not only revealed patency of our anastomoses but it confirmed unobstructed flow through the retrograde limb of the IMV. Our study further validates that the retrograde limb of the IMV does in fact achieve flow away from the DIEP flap and can therefore be used as an additional or alternative outflow tract in DIEP flap breast reconstruction surgery.

Retrograde IMV - breast reconstruction - indocyanine green angiography

REFERENCES

• 1 Blondeel N, Vanderstraeten G G, Monstrey S J et al.. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction.  Br J Plast Surg. 1997;  50 322-330
• 2 Agarwal J P, Gottlieb L J. Double pedicle deep inferior epigastric perforator/muscle-sparing TRAM flaps for unilateral breast reconstruction.  Ann Plast Surg. 2007;  58 359-363
• 3 Kroll S S. Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps.  Plast Reconstr Surg. 2000;  106 576-583
• 4 Kerr-Valentic M A, Gottlieb L J, Agarwal J P. The retrograde limb of the internal mammary vein: an additional outflow vessel in DIEP flap breast reconstruction.  J Plast Reconstr Surg. 2009;  124(3) 717-721
• 5 Reuthebuch O, Häussler A, Genoni M et al.. Novadaq SPY: intraoperative quality assessment in off-pump coronary artery bypass grafting.  Chest. 2004;  125 418-424
• 6 Sekijima M, Tojimbara T, Sato S et al.. An intraoperative fluorescent imaging system in organ transplantation.  Transplant Proc. 2004;  36 2188-2190
• 7 de Oliveira J G, Beck J, Seifert V, Teixeira M J, Raabe A. Assessment of flow in perforating arteries during intracranial aneurysm surgery using intraoperative near-infrared indocyanine green videoangiography.  Neurosurgery. 2008;  62(6 Suppl 3) 1300-1310
• 8 Desai N D, Miwa S, Kodama D et al.. Improving the quality of coronary bypass surgery with intraoperative angiography: validation of a new technique.  J Am Coll Cardiol. 2005;  46 1521-1525
• 9 Francisco B, Kerr-Valentic M, Agarwal J. Laser-assisted indocyanine green angiography (LA-ICGA) and DIEP breast reconstruction.  Accepted for publication in Plast Reconstr Surg.
• 10 Liu T S, Ashjian P, Festekjian J. Salvage of congested deep inferior epigastric perforator flap with a reverse flow venous anastomosis.  Ann Plast Surg. 2007;  59 214-217