Contralateral SIEV as a vein graft to augment venous drainage of DIEP flaps: a single-surgeon experience in 206 DIEP fla
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Contralateral SIEV as a vein graft to augment venous drainage of DIEP flaps: a single-surgeon experience in 206 DIEP flaps Shameem A. Haque 1
&
Shadi Ghali 1
Received: 14 January 2020 / Accepted: 4 February 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Venous congestion can result in fat necrosis and flap failure in breast reconstruction with deep inferior epigastric perforator (DIEP) flaps. It is caused by the variable venous anatomy across the midline and between the superficial and deep system. In such situations, adding the superficial inferior epigastric vein (SIEV) as a secondary drainage can reduce the congestion of the flap [1]. Algorithms for venous supercharging the DIEP and deciding when to have been described [2, 3]. Some surgeons, to reduce the risk of fat necrosis, opt to routinely venous supercharge the DIEP flaps, always dissecting out the SIEV if available [4]. In our practice, bilateral SIEVs are dissected out routinely. Intraoperatively, the more engorged SIEV (ipsilateral or contralateral) is identified as the main source of secondary drainage of the flap. In general, the ipsilateral SIEV is used to supercharge the DIEP. This is then connected to the retrograde IMV. However, when the flap is large or thick, the ipsilateral SIEV length may be insufficient to reach the retrograde IMV, or indeed, even if it does reach and is relatively short, it may restrict the insetting of the flap. This then requires a vein graft. Sources of a vein graft have been described [5], some requiring further scars and morbidity for the donor site.
Shameem A. Haque and Shadi Ghali contributed equally in this paper. * Shameem A. Haque [email protected] 1
Department of Plastic and Reconstructive Surgery, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK
The senior author utilises the contralateral SIEV as a vein graft by disconnecting it from the contralateral side of the flap. The advantage of using this graft is it is readily available within the operative zone, does not involve further morbidity or donor sites, and usually gives sufficient length and calibre without the need for further harvest of a vein graft. This is anastomosed to the ipsilateral SIEV using the coupler device (Synovis GEM COUPLER) which is then connected to the recipient vein in the chest (usually the retrograde IMV) (Fig. 1). In situations where the contralateral SIEV is not available or in bilateral DIEPS, the superficial circumflex iliac vein (SCIV) is dissected out if available and is a second choice for readily available vein graft. In the series of 206 DIEPS, 168 (82%) of the flaps were augmented with the SIEV connected as a secondary vein. Of those augmented with the SIEV, a vein graft was required in 26 of the cases (15%), the contralateral SIEV being used in 25 cases and the contralateral SCIV in one case with no flap loss in these. Overall, total flap failure in this series was 1 out of 206 (0.004%). The senior author finds that dissecting out both, rather than just one o
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