Salvage of a Congested DIEP Flap: A New Technique

Abstract

Sir: Venous congestion of free flaps is a major cause of flap failure. We discuss the use of a new operative technique of a reverse-flow anastomosis of a deep inferior epigastric vein to an intrinsic flap vein for salvage of a deep inferior epigastric perforator (DIEP) flap. A 52-year-old woman underwent delayed left breast reconstruction with a DIEP flap 4 years after mastectomy, chemotherapy, and radiotherapy for ductal carcinoma. She had no other significant medical history, and her body mass index was 27. The 440-g flap was raised on one perforator of the lateral row identified by preoperative duplex scan, with end-to-end anastomosis of the deep inferior epigastric artery and one comitans vein to the internal mammary vessels. A 2-mm Synovis coupler was used for the venous anastomosis. No significant superficial vein was found, and no other significant perforator was present in the flap. The ischemia time was 34 minutes. In the second postoperative hour, the flap was reexplored because of clinical evidence of a hematoma. A 300-ml hematoma was evacuated. The flap remained congested over the next hour, demonstrating insufficient venous outflow. This outflow was augmented by anastomosis of an intrinsic flap vein to a segment of the remaining unused vena comitans of the deep inferior epigastric artery. This segment was dissected from the pedicle until the first large communicating branch between the two comitans veins. The flow through this segment was in a reverse direction (Fig. 1).Fig. 1.: Schematic representation of the operative technique.Reverse flow was confirmed before anastomosis by gentle irrigation with saline. The flap recovered immediately and the patient made an uneventful recovery (Fig. 2).Fig. 2.: The flap immediately after anastomosis of the intrinsic flap vein.It is well documented that some DIEP flaps drain dominantly by means of the superficial veins, and this is a common cause of venous congestion and flap failure,1 but such was not the case here. However, the venous outflow of the single perforator chosen was clearly insufficient even in this relatively small flap. This needed to be augmented without sacrifice of the current venous drainage. A recipient vein was needed for the intrinsic flap vein that we had dissected. We considered the following options: Grafting the intrinsic flap vein to the cephalic vein. This would have required additional scarring on the arm and resulted in a significant discrepancy of lumen size for anastomosis. Using a vein graft anastomosed end to side onto the first vena comitans draining into the internal mammary vein. This may have jeopardized the flow through this vein and required two anastomoses. Anastomosing the intrinsic flap vein to the second comitans vein end to end. This allowed drainage from the flap by retrograde flow through the second vena comitans. This required only one anastomosis, with minimal size discrepancy, and proved to be a much quicker and simpler solution. We recommend that this technique for salvaging a congested DIEP free flap. Negin Shamsian, M.R.C.S. Elaine Sassoon, F.R.C.S.(Ed.), F.R.C.S.(Eng.) Richard Haywood, F.R.C.S.(Plast.) Stoke Mandeville Hospital Norwich, England