Galanis, Charles M.D.; Nguyen, Phuong M.D.; Koh, Justin B.A.; Roostaeian, Jason M.D.; Festekjian, Jaco M.D.; Crisera, Christopher M.D.
In appropriately selected patients, the free transverse rectus abdominis myocutaneous flap with various degrees of muscle sparing has become the preferred method for autologous breast reconstruction. Specifically, the deep inferior epigastric perforator (DIEP) flap has become an increasingly popular choice since its introduction in 1989.1 With increased understanding of relevant anatomy and flap physiology, reconstructive surgeons have found the DIEP flap to be a reliable and safe technique. Advantages to this technique include decreased postoperative pain, shorter hospitalization, increased abdominal strength, and faster recovery.2–6 Nonetheless, disadvantages to consider include the long and challenging dissection, increased venous congestion, and greater risk of total flap loss compared with pedicled reconstruction.7 The incidence of venous congestion in DIEP flaps ranges widely in the literature from 3 to 27 percent based in some part on the varying criteria used to make this diagnosis.3,7–9 However, the higher end of that range likely best represents the incidence of intraoperatively recognized venous congestion in DIEP flaps. To address this problem, a wide variety of techniques have been introduced to augment venous drainage for flaps at the time of primary surgery.
It has been shown that recognition of congestion intraoperatively with subsequent intervention at the time of initial surgery yields significantly improved outcomes compared with outcomes following postoperative intervention for venous congestion.10 In this article, we offer a comprehensive review of techniques available to address intraoperative venous congestion in DIEP flaps for breast reconstruction. We describe our approach assuming use of the internal mammary artery and vein as the primary recipient system, as this is our institutional preference. In so doing, we aim to provide a stepwise approach to the surgeon who encounters flap congestion before leaving the operating room.
DIAGNOSING FLAP CONGESTION
Given the risk of venous congestion and its potential consequences, the reconstructive surgeon’s ability to make the diagnosis is critical. Furthermore, differentiating global congestion from localized congestion is crucial, as it may guide management. Before and during flap dissection, capillary refill is the simplest method of assessing venous sufficiency. Bleeding at the edges of the flap can also provide a useful assessment tool. Following anastomosis and reperfusion, the flap will exhibit a transient period of hyperemia. This is a normal physiologic finding and may initially obscure flap examination at the skin paddle. During this time, a gentle Acland (vessel strip) test at the level of the anastomosis and Doppler assessment of both the pedicle and perforator(s) are excellent ways of assessing venous flow. In addition, the flap edges can be assessed for the briskness and character of bleeding. The preserved superficial inferior epigastric vein should also be repeatedly evaluated for engorgement, which might indicate insufficient flap drainage.
Many institutions and practices use preoperative imaging to assist in perforator selection for abdominally based breast reconstruction.11 They predominantly cite a benefit in preoperative planning and shorter operative time. However, there is not a consensus in terms of its effect on outcome or its impact on the incidence of venous congestion. At our institution, we choose to use this technique only in cases where the patient had prior abdominal surgery. It is certainly a topic worthy of further investigation in terms of its efficacy in preventing adverse outcomes.
We take several steps during the course of flap elevation both to prevent venous congestion and to preserve “bailout” options should congestion occur. We begin with our inferior incision and, as previously noted, take care to preserve the superficial inferior epigastric vein on both sides. The vein is meticulously dissected free from surrounding tissues and distally to its confluence with the femoral vein to provide maximum length. Except in rare cases where the superficial system presents itself as a significant arterial and venous conduit, we then ligate the superficial inferior epigastric vein and continue with our flap dissection.
In cases of unilateral reconstruction, we preserve perforator anatomy bilaterally. When we have adequately isolated medial and lateral row perforating vessels, we examine each in terms of size, caliber, and position. After selecting optimal candidates, we clamp the remaining perforators so as to isolate the flap on its intended blood supply. After 3 to 5 minutes, we examine both the capillary refill of the skin paddle and the quality of bleeding from the skin edges. If the capillary refill is greater than 2 to 3 seconds and the skin edges show healthy red bleeding, we are confident that the isolated vessels are sufficient. If the flap appears compromised, we will retest the flap after including additional reasonably situated perforators. If perfusion is still compromised or if all perforators appear inadequate, we may choose at this point to convert to a muscle-sparing (muscle-sparing 1 or muscle-sparing 2) or free transverse rectus abdominis myocutaneous flap to preserve adequate flow.
If the selected perforators appear sufficient, we will remove the clamps and proceed to open the anterior fascia and dissect the pedicle. It is worth noting, however, that only after extensive pedicle dissection up to and including the selected perforators do we divide the remainder of the perforators. We save alternative perforators as “lifeboats” up until the moment we have performed the majority of the pedicle dissection. In this way, should an unintended injury occur during dissection, we retain other options for flap viability. The deep inferior epigastric artery and vein and the vena comitans are dissected to the iliac vessels. We choose to take the extra time in dissection to procure the maximal length of pedicle possible. This allows for a more facile technical anastomosis and also facilitates optimizing vessel lie during flap inset.
On completion of flap dissection, we carefully evaluate the size of our flap vessels in comparing them with the recipient vessels. We also reassess the ligated superficial inferior epigastric vein. An engorged, tense superficial inferior epigastric vein may suggest that the isolated perforators alone may not provide sufficient drainage. Furthermore, when preparing our veins under microscopic visualization, we pay particular attention to clearing off periadventitial tissue and to copiously irrigate the lumen and clear any particulate debris that would otherwise pose a thrombotic risk. Finally, at the time of venous anastomosis, we irrigate the internal mammary vessel to ensure a favorable, nontwisted lie.
CONGESTION FOLLOWING ANASTOMOSIS
Despite using all aforementioned techniques and preventative measures, the reconstructive surgeon will nonetheless encounter a congested perforator flap following anastomosis with the internal mammary system. We present the following as a step-by-step approach to address this problem (Fig. 1).
Assess Positioning of Anastomosis, Pedicle, and Flap
The first step in evaluating a free flap with congestion is a reassessment of positioning. For DIEP flap reconstruction following mastectomy, we prefer to use the contralateral deep system and to position the flap with the umbilical side down and out. We find this arrangement affords a natural lie for the pedicle into the internal mammary system and also creates an aesthetically pleasing breast mound. As previously mentioned, maximizing pedicle length through dissection to its takeoff, however, allows the reconstructive surgeon some flexibility in flap position. In the case of skin-sparing mastectomy, a small pocket relative to the size of the flap may hinder vascular sufficiency. In these cases, either the skin flaps or the flap itself may need to be altered for a nonconstricting inset. Once satisfied with our evaluation, we use absorbable sutures to secure the flap medially to the sternal border and laterally to the chest wall. This prevents the flap’s lateral displacement, which might damage and compromise its pedicle.
When satisfied with flap positioning, we turn our attention to the pedicle as it tracks toward the anastomosis. We inspect for kinks, a tortuous course, compression, or any point of excessive traction. At the level of the anastomosis, there is often an abrupt turn where the internal mammary vein turns anteriorly over the neighboring rib to its anastomosis with the deep inferior epigastric vein. In cases where this abrupt turn appears that it may compromise flow, we have positioned fatty tissue excised from the flap or open abdomen beneath the pedicle and mammary vessels to provide a more favorable lie (Fig. 2).
Finally, it is worth noting that if congestion primarily affects the portion of the flap farthest from the dissected perforators (zone IV), management is straightforward. Excising the affected tissue may alleviate the load on the flap and relieve any residual congestion.
Directly Assess Flow through the Anastomosis
In any case of flap congestion, after evaluating the flap and pedicle position, one must investigate the anastomosis itself. An Acland test to confirm appropriate refilling of the vein is a simple maneuver to test for patency of the venous anastomosis. A sterile Doppler probe can also be used to confirm active venous blood flow. In cases where the flow appears sluggish or compromised, we will excise the anastomosis and repeat it using fresh clean edges.
Use Vasoactive Agents to Dilate Vasculature
After confirming a patent anastomosis, an initial conservative method to address global flap malperfusion is to irrigate the vasculature with vasodilating agents. In cases of vessels in spasm, this simple maneuver may yield dramatic improvement and obviate the need for further intervention. The agent of choice at our institution has traditionally been papaverine. Lidocaine has also been used with some efficacy. However, we have recently used a solution containing 10 mg of verapamil (4 cc), 0.1 mg of nitroglycerin stick (10 cc), and 16 cc of normal saline with favorable results.
Use the Paired Internal Mammary Vein System
When faced with persistent congestion in the context of good flap and pedicle lie and a patent anastomosis, venous flow augmentation is necessary. In cases of a paired internal mammary vein system, our first choice is to augment venous flow by connecting the deep inferior epigastric vein and vena comitans to this second internal mammary vein. Another option is to connect the superficial inferior epigastric vein to the second internal mammary vein (Fig. 3).
In Cases of a Nonpaired Internal Mammary Vein System, Consider a Superficial Inferior Epigastric Vein–to–Deep Inferior Epigastric Vein and Vena Comitans Anastomosis
In the event that there is no paired internal mammary vein system, one might consider connecting the superficial inferior epigastric vein to the deep inferior epigastric vein and vena comitans (Fig. 4). This flow option is particularly attractive in cases where the superficial inferior epigastric vein appears congested, suggesting a significant superficial drainage system. By joining the superficial inferior epigastric vein and deep inferior epigastric vein and vena comitans, the superficial and deep venous systems are more effectively drained together.12
In Cases of a Nonpaired Internal Mammary Vein System, Consider Superficial Inferior Epigastric Vein or Deep Inferior Epigastric Vein and Vena Comitans to Divided Internal Mammary Vein (Retrograde and Antegrade Flow)
Another option to consider in the scenario of persistent congestion without an additional mammary vein is to use the distal internal mammary vein stump as a retrograde conduit (Fig. 5). The deep inferior epigastric vein and vena comitans or superficial inferior epigastric vein can be used. This technique has been shown to be successful in multiple series, including a case in which venous congestion was diagnosed intraoperatively.13,14 Although retrograde flow might seem an unlikely solution, the relative paucity of valves in the internal mammary system and alternative drainage through the proximal intercostal system may explain this method’s efficacy. Nonetheless, this is still a topic of ongoing debate in the literature.15
In Cases Where the Superficial Inferior Epigastric Vein Appears Engorged, Consider Using Alternative Outflow Targets for the Superficial System
The superficial system may be the dominant path of venous drainage in the abdominal perforator flap.12 If the superficial inferior epigastric vein is considerably engorged in the context of an open deep system outflow, the surgeon may abort the deep inferior epigastric vein–to–internal mammary vein anastomosis and directly connect the superficial inferior epigastric vein to the internal mammary vein (assuming a nonpaired system) (Fig. 6). Alternatively, the surgeon may leave the deep inferior epigastric vein connected to the internal mammary vein and consider alternative recipients for the superficial inferior epigastric vein. A jump graft may be needed. Targets may include the thoracodorsal, external jugular, lateral thoracic, intercostal, cephalic, thoracoacromial, or even the contralateral internal mammary vein, among others.9,16,17
If Congestion Persists, Consider an Alternate Recipient Vein
If congestion persists in spite of the maneuvers described, the surgeon must consider the possibility of a deficiency in the internal mammary drainage system. In these instances, only alternative outflow may successfully alleviate any venous congestion. There are numerous options, each of which has been shown to be an effective alternative to the internal mammary vein. These include the thoracodorsal,18 cephalic,18,19 external jugular,18 lateral thoracic,9 intercostal,20 circumflex scapular,21,22 and basilic22 veins.
Even with Use of an Alternate Recipient Drainage System or in Cases Where No Alternate Recipient Is Available, Consider a Temporary Venous Catheter
Multiple groups have reported use of angiocatheters to cannulate and temporarily decompress the venous system in both pedicled and free tissue transfer autologous breast reconstruction. In the case of the DIEP flap, the superficial inferior epigastric vein can be cannulated with an angiocatheter, which is then tunneled externally for drainage. On resolution of congestion, which may occur at 3 to 5 days postoperatively, the vein will clot and the catheter can be removed. Essentially, this method mimics the decompressive benefits of leech therapy without assuming the infectious risks of that modality.23 As with leech therapy, however, transfusion requirement with its inherent morbidity may still be encountered. Although case reports and case series offer encouraging results with catheter use, there is a relative paucity of data. We have not used this technique in our institution but feel that it warrants inclusion in a discussion of tools available to the surgeon to address intraoperatively detected venous congestion.23–26 If no vein is available for cannulation, the surgeon may elect to use leech therapy immediately postoperatively to alleviate congestion until sufficient neovasculogenesis can assume the burden.23
Venous congestion represents a significant obstacle for successful breast reconstruction with the DIEP flap. The ability to recognize impaired venous drainage is critical. Early diagnosis and management, preferably at the time of the initial operation, offers the best chance for flap survival. Here, we present a comprehensive review of the tools available to the surgeon to address this problem during the initial reconstructive operation. From this review of tools, we propose an algorithmic approach to the problem of intraoperative venous congestion in autologous breast reconstruction with the free DIEP flap.
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