Background: The deep inferior epigastric perforator (DIEP) flap has become a popular option for breast reconstruction because of reduced donor-site morbidity. As the number of perforators per flap is reduced, vascular compromise may develop. Venous congestion can occur despite patent primary venous anastomosis.
Methods: A prospective series of 100 consecutive DIEP flaps in breast reconstruction were studied for vascular problems and outcomes.
Results: Ninety-nine flaps were successful. No arterial compromise occurred. Overall, venous congestion occurred in 15 flaps. Eleven flaps developed intraoperative venous congestion, but only five flaps required vascular bypass between the superficial epigastric vein and chest wall vein for additional drainage. One flap was lost because of the authors' failure to recognize and manage inadequate venous outflow by the chosen perforator vein. One flap suffered major fat necrosis because of postoperative thrombosis of the saphenous vein bypass. Overall, fat necrosis occurred in 12 flaps.
Conclusions: DIEP venous congestion, despite patent primary venous anastomosis, occurs in 5 percent of these flaps and can be managed successfully by a second venous bypass between the superficial epigastric vein and any chest wall vein. Failure to recognize and manage this can cause flap loss.