Anterograde Flow Rerouting in Venous Supercharged DIEP Flap

Algorithmic Approach for Intraoperative Salvage of Venous Congestion in DIEP Flaps

We read with great interest the article by Bartlett et al entitled “Algorithmic approach for intraoperative salvage of venous congestion in DIEP flaps.”[1] In their article, the authors presented a very interesting intraoperative algorithm to improve the venous outflow in cases of venous congestion in patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction. In this short communication, we want to comment on our experience in this matter. We agree with the authors that the different venous supercharging techniques should always be customized to each patient in accordance with the patient's anatomy.[2] Among the intraflap rerouting procedures, they stated that the anterograde flow is their preferred choice because it permits physiological blood circulation. Furthermore, they reported that in cases of venous congestion, their first venous source for the rerouting is the superficial inferior epigastric vein (SIEV).

They have also reported that the second nonanastomosed deep inferior epigastric (DIEV) vein comitans (DIEVc) can be anastomosed to the SIEV with a retrograde or an anterograde flow only in those few cases when a convergence or a side branch is present in DIEVc.

We share the authors' opinion; however, according to this interesting algorithm, it emerges that the only possibility to connect the SIEV to the DIEVc is through the retrograde flow, as Liu et al have already described it.[3] We believed that this could be clarified. We strongly believe that the intraflap anterograde venous flow rerouting should always be performed even if converges or side branches are not available. In our practice, in cases of venous insufficiencies of the deep system due to the dominancy of the SIEV, we perform an intraflap venous rerouting anastomosing the SIEV to the DIEVc in anterograde fashion.[4]

The DIEVc is clipped distally, sparing an adequate course in which the transverse interconnections between the DIEV and the DIEVc are identified. Then the SIEV is anastomosed proximally to the DIEVc.

In this case, the venous flow will be anterograde rerouted from the SIEV to the DIEV through the transverse interconnection between the DIEV and the DIEVc.

When the SIEV is too short, the DIEVc is dissected from the main DIEP pedicle in a way to obtain extra length, reducing the tension in the anastomosis. Moreover, as opposed to the authors' description, in the cases in which an interpositional vein graft is required, we prefer to harvest the distal course of the DIEVc or the contralateral SIEV when available, but never the ipsilateral SIEV because is already employed to enhance the venous return.

• References

• 1 Bartlett EL, Zavlin D, Menn ZK, Spiegel AJ. Algorithmic approach for intraoperative salvage of venous congestion in DIEP flaps. J Reconstr Microsurg 2018; 34 (06) 404-412
• 2 Xin Q, Luan J, Mu H, Mu L. Augmentation of venous drainage in deep inferior epigastric perforator flap breast reconstruction: efficacy and advancement. J Reconstr Microsurg 2012; 28 (05) 313-318
• 3 Liu TS, Ashjian P, Festekjian J. Salvage of congested deep inferior epigastric perforator flap with a reverse flow venous anastomosis. Ann Plast Surg 2007; 59 (02) 214-217
• 4 Zeltzer AA, Andrades P, Hamdi M, Blondeel PN, Van Landuyt K. The use of a single set of internal mammary recipient vessels in bilateral free flap breast reconstruction. Plast Reconstr Surg 2011; 127 (06) 153e-154e