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Ruiz-Moya et al. Assessment of DIEP flap using CTA with 3D reconstruction

technique for planning DIEP flap surgery. To our insufficiency, after significant results experiencing
knowledge, the present study is the first to attempt less congestion. However, a recent meta-analysis
[26]
to link the morphological characteristics of the has failed to demonstrate the efficacy of the SIEV
abdominal wall vessels with DIEP venous congestion supercharging to reduce the flap-related complication
[9]
by CTA and 3D virtual reconstruction. Unfortunately, rate. Whereas venous supercharging has proved its
according to the results obtained, this method has capacity to rescue DIEP flaps that exhibit congestion and
not demonstrated clinical utility to predict venous would eventually experience partial or total necrosis,
congestion. We hypothesize that further than a single the debate still continues about the convenience of
anatomical feature, a multifactorial origin leads to supercharging every flap as a preventive strategy for
venous congestion. During the dissection of a DIEP minimizing perfusion-related complications. [9]
flap, physiological adaptive changes can take place.
The diversion of flow through different pathways or The present study has some limitations that should be
vasodilatation are among them. Therefore, the considered. The low incidence of this phenomenon
[15]
pressure gradient between arterial perfusion and hinders prospective randomized controlled or
venous drainage is modified, resulting in an imbalance prospective nonrandomized trials. Although the
that may lead to venous congestion. sample size is relatively small, this is one of the largest
series specifically focused on congestive DIEP flaps
When a DIEP flap becomes congested, the main reported to date. Further studies are needed to clarify
effective strategy for enhancing drainage outflow is the congestive phenomenon. Pressure gradient
the pressure relief by venous supercharging of the is of paramount importance, and its assessment
SIEV, whereas supercharging the second DIEV is less along the flap could shed light on the subject. Larger
commonly performed. [24,25] This salvage procedure sample sizes may also led to statistically significant
decreases venous pressure, increases pressure differences when evaluating anatomical features.
gradient and overcomes the venous congestion.
Adding large caliber venous anastomosis in parallel In conclusion, this study provided new information
to the literature concerning the identification of
decrease the risk of venous congestion, because of the anatomical features associated with venous
the ability to provide a superior drainage. One of the congestion in DIEP flaps. No statistically significant
most popular modalities of venous supercharging is differences were found between venous congestion of
the anastomosis of the superficial epigastric vein to the flap and the suggested and accepted predisposing
the cephalic vein. Other common strategies include anatomical features. The congestive phenomenon
the anastomosis of the SIEV to a second internal is probably multifactorial, not being able to aim at
mammary vein, to an internal mammary perforator, any of them as the single cause. CTA was a useful
or end-to-side to one of the DIEVs of the flap. [10,25,26] tool for identifying the abdominal wall anatomy and
Less popular options include the anastomosis of the planning DIEP breast surgery, but not for preventing
SIEV to the thoracoacromial vein, to the contralateral the possible diffuse venous congestive phenomenon
intermammary vein (which may need a vein graft), of this flap preoperatively.
or to the toracodorsal vein (which may prevent the
use of a latissimus dorsi as a rescue surgery in case DECLARATIONS
the DIEP flap fails), among others. Notwithstanding,
carrying out a second venous anastomosis is time- Authors’ contributions
consuming, which represents the main drawback of Concept design, manuscript preparation, data analysis
this procedure, taking between 30 to 90 min. The and interpretation: A. Ruiz-Moya
[26]
experience of the surgeon and the use of coupler Data analysis and interpretation: R.A. Lopez-Garcia
devices may help to reduce this lapse of time. There Case material’s provide: D. Sicilia-Castro, T. Gomez-Cia
is another potential drawback, specifically associated Manuscript preparation and review: P. Infante-Cossio
with the use of the cephalic vein, which is the possibility
of triggering lymphedema in the upper extremity due to Financial support and sponsorship
the impairment of the lymphatic drainage. Women who None.
have received radiotherapy seem to be more likely to
develop this phenomenon. However, the overall risk Conflicts of interest
appears to be reasonably low, being able to consider There are no conflicts of interest.
the harvest of the cephalic vein a safe option. [25]
Patient consent
The systematic venous supercharging has been All patients signed informed consent to be included in
advocated to prevent the potential drainage the study.
Plastic and Aesthetic Research ¦ Volume 4 ¦ August 21, 2017 133