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Table of Contents
Year : 2021  |  Volume : 29  |  Issue : 4  |  Page : 240-241

An alternative method in augmenting venous drainage to salvage deep inferior epigastric artery perforator reconstruction

1 Department of Plastic, Reconstructive and Aesthetic Surgery, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Gazi University, Ankara, Turkey
Date of Submission09-Dec-2020
Date of Acceptance03-Jun-2021
Date of Web Publication22-Oct-2021

Correspondence Address:
Dr. Ayhan Isik Erdal
Department of Plastic, Reconstructive and Aesthetic Surgery, Erzurum Regional Training and Research Hospital, 25070, Erzurum
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_125_20

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How to cite this article:
Erdal AI, Genc IG, Ayhan MS. An alternative method in augmenting venous drainage to salvage deep inferior epigastric artery perforator reconstruction. Turk J Plast Surg 2021;29:240-1

How to cite this URL:
Erdal AI, Genc IG, Ayhan MS. An alternative method in augmenting venous drainage to salvage deep inferior epigastric artery perforator reconstruction. Turk J Plast Surg [serial online] 2021 [cited 2023 May 30];29:240-1. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/4/240/328965

  Introduction Top

The most commonly preferred vessels in free-flap breast reconstruction are internal mammary vessels.[1] In routine practice, the antegrade limb is used for anastomosis, and the retrograde limb is ligated. There are also some reports concerning the use of the retrograde limbs of vessels to augment arterial or venous flow.[2],[3],[4] Reported venous augmentation maneuvers are based on the use of the superficial inferior epigastric vein (SIEV), second concomitant vein of flap, second IMV, or a suitable subcutaneous vein.[5] In this case, we introduce a different modification to IMV anastomosis in the absence of previously mentioned alternative vein options.

  Case Report Top

We planned delayed autologous breast reconstruction for a 41-year-old female patient who had previously undergone modified radical mastectomy and adjuvant chemoradiation. Magnetic resonance angiography was performed for preoperative vascular mapping of deep inferior epigastric artery (DIEA) perforators (DIEPs). The major perforator artery on the right side was 2.7 mm in diameter, located 2 cm from the midline, and 1 cm inferior to the umbilicus. The two-team approach was used, one team for the preparation of recipient internal mammary vessels and another for DIEP flap harvesting. Approximately a 15-mm portion of the third rib over the internal mammary vessels was removed for better identification. The internal mammary artery and single IMV were identified. Vascular clamps were applied to the cranial sides of the vessels, and the caudal sides were ligated as usual. During flap harvest, SIEV was observed to be smaller than 1 mm in diameter. This finding suggested that the deep venous system was dominant. Unlike we usually see, there was a single comitant vein of the DIEA. The flap was transferred to the recipient site; single end-to-end arterial and venous anastomoses were performed. The patency of flap circulation was checked with inspection and indocyanine green angiography. Suction drains were placed, and the site was closed. The operation time was 6 h. Venous congestion was seen 30 min after extubation. An urgent reoperation was performed. There was no sign of thrombosis in vessels and anastomoses. Transient venous congestion attacks lasting for several minutes were observed in every 5–10 min, and therefore, we decided to augment the venous drainage. As commonly accepted, the first option for venous augmentation was to perform an additional anastomosis of the SIEV; however, there was no adequate SIEV in terms of diameter and flow. There was also not another large superficial vein in the flap. Moreover, there were only one IMV and only one comitant vein of DIEA. Since the IMV drainage was insufficient, we decided to create an additional anastomosis between one of the ligated side branches of the comitant vein of DIEA and ligated the retrograde limb of IMV. A small portion of the fourth rib over IMV was removed, and IMV was dissected and freed caudally. End-to-end anastomosis was performed at a point that was 2 cm from the edge of the comitant vein of DIEA [Figure 1] and [Figure 2]. No venous congestion episodes were seen after the additional anastomosis. The patient recovered uneventfully in the postoperative period. No major or minor complications were seen.
Figure 1: (Left) Image captured after additional anastomosis between one of the ligated side branches of the comitant vein of the deep inferior epigastric artery and the ligated retrograde limb of the internal mammary vein. (Right) Illustration of the arteries, veins, and anastomoses

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Figure 2: Illustration of the flap and recipient arteries, veins, and anastomoses

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  Discussion Top

At our institution, we routinely use DIEP flaps for autologous breast reconstruction. Venous congestion is one of the most common causes of partial or total flap loss, fat necrosis, and wound dehiscence. Paying extreme attention to prevent venous problems in each step of the procedure is essential. While harvesting the flap, we dissect and preserve SIEV and monitor whether the ligated SIEV is engorged. An engorged SIEV may indicate the dominance of the superficial venous system.

At the step of perforator selection, we prefer the perforator that is the largest and closest to the center of the flap. After dissection, indocyanine green angiography is performed to check the flow at the margins of the flap. We usually perform two venous anastomoses if there are two concomitant veins of DIEA and two IMVs. Reports concerning the branching pattern of IMV indicate left-side bifurcates to be higher than the right-side ones, and the most common bifurcation site of the right IMV is the fourth intercostal space.[6] These findings explain why only one IMV was present on the anastomosis level in our report. The absence of the second IMV was the primary cause for using the retrograde limb. The presence of venous congestion, the absence of suitable SIEV, and the second concomitant vein of DIEA forced us to make this modification. The reason for venous congestion despite a patent flap flow may be explained by the high pressure or stenosis in the anterograde limb. Elimination of venous congestion with the use of a retrograde limb supports these scenarios.

It is a well-known fact that there are communications between the two concomitant veins, and they can unify to form a single large caliber DIEV in proximity of the femoral vein.[7] However, in our case, we considered single DIEV as an anatomical variation. Despite our search and examination, we could not find any pedicle segment where two separate concomitant veins could be obtained before unification by shortening the pedicle.

The use of retrograde limb is already defined procedure in the literature.[2],[3],[4] However, in our case, both anterograde and retrograde limbs were anastomosed to a single comitant vein, and our modification appears to have not been previously published in the literature.

Anastomosis of the retrograde limb of IMV to the branching point of the single comitant vein of DIEA was found effective to augment venous drainage and salvage of the DIEP flap in the absence of well-known options.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Nahabedian M. The internal mammary artery and vein as recipient vessels for microvascular breast reconstruction. Ann Plast Surg 2012;68:537-8.  Back to cited text no. 1
Stalder MW, Lam J, Allen RJ, Sadeghi A. Using the retrograde internal mammary system for stacked perforator flap breast reconstruction: 71 breast reconstructions in 53 consecutive patients. Plast Reconstr Surg 2016;137:265e-277e.  Back to cited text no. 2
Al-Dhamin A, Bissell MB, Prasad V, Morris SF. The use of retrograde limb of internal mammary vein in autologous breast reconstruction with DIEAP flap: Anatomical and clinical study. Ann Plast Surg 2014;72:281-4.  Back to cited text no. 3
Sugawara J, Satake T, Muto M, Kou S, Yasumura K, Maegawa J. Dynamic blood flow to the retrograde limb of the internal mammary vein in breast reconstruction with free flap. Microsurgery 2015;35:622-6.  Back to cited text no. 4
Chen CK, Tai HC, Chien HF, Chen YB. Various modifications to internal mammary vessel anastomosis in breast reconstruction with deep inferior epigastric perforator flap. J Reconstr Microsurg 2010;26:219-23.  Back to cited text no. 5
Lee CD, Butterworth J, Stephens RE, Wright B, Surek C. Location of the internal mammary vessels for microvascular autologous breast reconstruction: The “1-2-3 Rule”. Plast Reconstr Surg 2018;142:28-36.  Back to cited text no. 6
Rozen WM, Ashton MW. The venous anatomy of the abdominal wall for Deep Inferior Epigastric Artery (DIEP) flaps in breast reconstruction. Gland Surg 2012;1:92-110.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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