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Page 14 of 26 Chen et al. Plast Aesthet Res 2023;10:24 https://dx.doi.org/10.20517/2347-9264.2022.136

A broad range of techniques for augmenting venous outflow in abdominally-based autologous breast
reconstruction has been widely reported in the literature. The vena comitantes of the ipsilateral DIEA, vena
comitantes of the contralateral DIEA, ipsilateral SCIV, ipsilateral SIEV, and contralateral SIEV serve as
potential sources for donor veins in venous super-drainage, with the ipsilateral SIEV being the most
common . The most frequently used recipient vessel is the second internal mammary vein (if available),
[113]
or the retrograde inframammary vein (IMV) due to their location allowing for optimal flap positioning on
the chest. At our institution, for all DIEP flaps, we routinely preserve sufficient length on the SIEV and
retrograde IMV to allow for anastomosis if necessary. Given the ease of supercharging the flap during the
initial microsurgery, it is prudent to perform this anastomosis early if there is any level of concern for
superficial venous dominance. Other potential recipients include the intercostal perforating vein,
thoracodorsal vein, cephalic vein, thoracoacromial vein and lateral superficial thoracic vein - however, all of
these systems require more time for dissection and may necessitate significant flap rotation to allow for
anastomosis [113,114] .

According to cadaveric and imaging studies, over 75 percent of females will have both lateral and medial
vena comitantes to the inframammary artery (IMA) present above the lower border of the 4th intercostal
space (ICS). If the lateral IMV is of adequate caliber for anastomosis, this may be used as the recipient vessel
[115]
for venous supercharging . Multiple studies have demonstrated that the caudal end of the IMV can
accommodate retrograde flow, and have promoted the assumption that the IMV is valveless [116-119] . However,
an anatomic study by Mackey and Ramsey on 32 human cadavers found that 1 to 3 valves were present in
[120]
the IMV of 44% of female cadavers and 42% of male cadavers . Additionally, valves were found between
the preferred point of distal anastomosis and the next draining vein in 9% of 2nd ICS and 5% of 3rd ICS.
While it is possible that valvular incompetence allowed for retrograde flow in prior studies, the findings by
Mackey and Ramsey indicate that retrograde flow may not be guaranteed in the caudal end of the IMV, and
that more dynamic studies are required to validate this technique . In our experience, the lateral IMV is
[120]
often diminutive, even if present. In these cases, we routinely preserve sufficient length on the retrograde
end of the medial IMV and utilize this for secondary venous anastomosis. Although some authors may raise
concern that retrograde outflow may be diminished due to the presence of valves, we have found that there
is sufficient collateralization from the intercostal system and IMV perforators to allow for adequate outflow.

If no other recipient veins are available, it may be possible to perform venous turbo-drainage via an intra-
flap anastomosis. Rohde and Keller have described a turbo-drainage technique in which a superficial to
deep venous loop is created within the flap by anastomosing the ligated SIEV to the proximal end of one of
the vena comitantes of the DIEA . This allows blood from the superficial system to drain directly into the
[121]
deep system via anterograde venous flow through the vena comitantes, and eventually through the original
DIEV-IMV anastomosis. This technique requires minimal additional accommodations for vessel length or
flap positioning. It is also suitable for cases in which the superficial venous system is overdominant.

If venous congestion persists despite venous outflow augmentation or there are no viable alternate recipient
veins, mechanical leeching can be considered. This method entails intraoperatively placing an angiocatheter
in the dominant vein, which is brought up to the skin as a venostomy for controlled manual drainage. The
angiocatheter should be flushed periodically and aspirated at hourly intervals for the next 3-6 days based on
clinical examination of the flap [122,123] . Bank et al. have also reported a case of successful resolution of venous
congestion with mechanical leeching guided by ViOptix measurements . Once congestion resolves, the
[124]
angiocatheter can be removed and the vein can be allowed to clot. Although this method eliminates the
infection risks associated with leech therapy, it still requires blood products due to volume depletion by
aspiration. Furthermore, studies on mechanical leeching for venous congestion have so far reported high