This case demonstrates the importance of preserving alternative vessels in cases of microvascular breast reconstruction. It also shows that a superficially dominant hemiflap can become congested, even when harvested as a non-DIEP flap with most of the normal deep circulation preserved. The senior author has previously reported a technique for venous augmentation in a DIEP flap by draining the SIEV to one of the venae comitantes.3 Other options for venous augmentation include an interposition vein graft from the SIEV, superficial circumflex iliac vein, or contralateral pedicle to the cephalic vein4 or to recipient thoracodorsal, lateral thoracic, or intercostal veins.5
Internal mammary perforators should be added to the list of venous augmentation recipient vessels. We recommend routine dissection and preservation of the superficial inferior epigastric vessels during flap harvest, and close communication with the breast surgeons to preserve any sizable internal mammary perforators found during the mastectomy. No additional recipient vessel dissection is necessary. If these vessels had not been preserved in this case, salvage of the congested flap would have been more technically difficult.
No financial support or benefits have been received by any of the authors, by any member of their immediate families, or by any individual or entity with whom or with which the authors have a relationship from any commercial source that is related directly or indirectly to the scientific work reported in this article.
Brian D. Cohen, M.D.
Nicholas Vendemia, M.D.
New York, N.Y.
Jason A. Spector, M.D.
New York, N.Y.
Christine H. Rohde, M.D.
New York, N.Y.
1. Park MC, Lee JH, Chung J, Lee SH. Use of internal mammary vessel perforator as a recipient vessel for free TRAM breast reconstruction. Ann Plast Surg
2. Saint-Cyr M, Chang DW, Robb GL, Chevray PM. Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg
3. Rohde C, Keller A. Novel technique for venous augmentation in a free inferior epigastric perforator flap. Ann Plast Surg
4. Niranjan NS, Khandwala AR, Mackenzie DM. Venous augmentation of the free TRAM flap. Br J Plast Surg
5. Wechselberger G, Schoeller T, Bauer T, Ninkovic M, Otto A, Ninkovic M. Venous superdrainage in deep inferior epigastric perforator flap breast reconstruction. Plast Reconstr Surg
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