- Email: [email protected]
Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap
+ Models
ANNPLA-1456; No. of Pages 6 Annales de chirurgie plastique esthétique (2018) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
ORIGINAL ARTICLE
Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap ´ servation de la veine ´epigastrique infe ´ rieure superficielle pour Pre ´ vention des complications veineuses dans la reconstruction la pre ´ rieure mammaire par lambeau de perforateur ´epigastrique infe profond A. Al Hindi a,*, C. Ozil b, K. Rem a, J. Rausky a, V. Moris c, D. Guillier c, J.P. Binder a, M. Revol a, S. Cristofari a a
ˆ pital Saint-Louis, 1, avenue ClaudePlastic, Reconstructive and Aesthetic Surgery Department, AP—HP, ho Vellefaux, 75010 Paris, France b Clinique Blomet, 136 bis, rue Blomet, 75015 Paris, France c Plastic and Reconstructive department, CHU de Dijon, 14, rue Paul-Gaffarel, 21000 Dijon, France Received 5 April 2018; accepted 9 September 2018
KEYWORDS Breast reconstruction; DIEP flap; Flap salvage; Microsurgery; Venous congestion; SIEV
Summary Objective. — The aim of this study was to analyze our technique of intraoperative venous compromise management based on conservation of the superficial inferior epigastric vein (SIEV), and to undertake a retrospective review of our series of breast reconstructions by deep inferior epigastric perforator (DIEP) flap, followed by a review of other techniques reported in the literature. Materials and methods. — This retrospective study involves 198 breast reconstructions by DIEP flap performed between January 2010 and September 2017. Our surgical technique is related in detail, with a focus on venous compromise management. Operative time, re-intervention rate, hospital stay, and complications were all noted and analyzed, and a literature review dealt with other techniques of prevention and management of flap venous congestion.
* Corresponding author. E-mail address: [email protected] (A. Al Hindi). https://doi.org/10.1016/j.anplas.2018.09.004 0294-1260/# 2018 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004
+ Models
ANNPLA-1456; No. of Pages 6
2
A. Al Hindi et al. Results. — Among breast reconstructions by DIEP, 7.5% contained an episode of intraoperative venous compromise, as opposed to 6.5% postoperatively. The SIEV was used in 65% of cases of venous congestion. In our series, 15.1% of cases presented postoperative complications, and we observed a 2.5% flap failure rate (2%: venous thrombosis; 0.5%: arterial thrombosis). In all patients for whom venous drainage augmentation was performed, the flaps survived without partial loss. While average length of hospital stay in the group having undergone intraoperative secondary anastomosis was 7.5 days, in the group having undergone postoperative secondary anastomosis, it was 13.5 days. Conclusion. — In cases of intraoperative venous congestion, while a second venous anastomosis may immediately increase duration of an initial intervention by 1 hour and 45 minutes, it is nonetheless likely to pronouncedly decrease need for surgical revision, cases of failure, rate of partial necrosis and overall hospital stay. # 2018 Elsevier Masson SAS. All rights reserved.
MOTS CLÉS Reconstruction mammaire ; Lambeau DIEP ; Sauvetage de lambeau ; Microchirurgie ; Congestion veineuse
Re ´sume ´ Objectif. — Le but de notre étude est l’analyse de notre technique de prise en charge de la congestion veineuse peropératoire en préservant la veine superficielle épigastrique inférieure (SIEV), ainsi qu’une revue rétrospective de notre série de reconstructions mammaires autologues par lambeau de perforateur épigastrique inférieure profond (DIEP). Par ailleurs, nous avons effectué une revue d’autres techniques dans la littérature. Patients et me´thodes. — Il s’agit d’une étude rétrospective de 198 reconstructions mammaires par lambeau DIEP réalisées entre janvier 2010 et septembre 2017, notre technique chirurgicale est décrite avec une mise au point sur la prise en charge de la congestion veineuse. Le temps opératoire, le taux de reprise, la durée de séjour et les complications ont été enregistrés, puis une revue de la littérature a été réalisée pour d’autres techniques de prise en charge de la congestion veineuse. Re ´sultats. — Parmi les reconstructions mammaires réalisées par DIEP, 7,5 % ont eu un épisode de drainage veineux insuffisant peropératoire contre 6,5 % en postopératoire. La SIEV a été utilisée dans 65 % des cas. Notre taux de reprise globale est de 15,1 % pour toutes les complications postopératoires, le taux d’échec est de 2,5 %, divisé entre 2 % pour la thrombose veineuse et 0,5 % pour la thrombose artérielle. Chez les patientes ayant bénéficié d’une augmentation du drainage veineux, les lambeaux ont survécu sans nécrose partielle. La durée moyenne d’hospitalisation chez le groupe ayant eu une anastomose secondaire peropératoire est de 7,8 jours, contre 13,5 jours dans le groupe ayant subi une anastomose secondaire postopératoire. Conclusion. — En cas de congestion veineuse peropératoire, la réalisation immédiate d’une seconde anastomose veineuse semble augmenter la durée d’intervention initiale de 1 h 45 h, mais pourrait permettre de réduire à la fois le nombre de reprise chirurgicale, le taux d’échec, le taux de nécrose partielle et la durée d’hospitalisation globale. # 2018 Elsevier Masson SAS. Tous droits réservés.
Introduction Free flap transfer using the deep inferior epigastric perforator (DIEP) vessels is a widely applied method in breast reconstruction. Compared with other techniques, the DIEP flap entails less donor site morbidity. However, its main drawbacks are its failure rate (0.5% to 3.2% according to different studies), and a reoperation rate ranging from 14 to 16% [1—3]. Flap ischemia or loss is mainly caused by venous congestion or thrombosis [2]. The aim of our study was to analyze our technique of intraoperative venous compromise management by superficial inferior epigastric vein (SIEV) preservation, and to retrospectively review our series of breast reconstructions by DIEP flap.
We also reviewed the literature regarding other methods and techniques for intraoperative venous compromise management.
Methods One hundred and ninety-eight breast reconstructions by free transfer of DIEP flap were reviewed, concerning 183 patients from January 2010 until September 2017. Ten different surgeons in our center implemented the same general technique. After the patients selected for breast reconstruction by a DIEP flap had given their agreement, and angiography of the abdominal wall confirmed the existence and location of appropriate perforators.
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004
+ Models
ANNPLA-1456; No. of Pages 6
Intraoperative superficial inferior epigastric vein preservation
3 tion. In the event of venous insufficiency with permeable venous anastomosis or an engorged SIEV for no apparent reason, the SIEV was anastomosed secondarily. All postoperative complications including venous congestion, arterial thrombosis, hematoma, partial and total flap loss were duly recorded. Our main concern in this review was flap venous congestion, which can be defined as compromised venous drainage resulting in bluish discoloration of the flap, with increased capillary refill time (more than 3 s) (Fig. 1). We also reviewed the literature for methods other than SIEV microanastomosis used to salvage flaps intraoperatively.
Results Figure 1
Postoperative venous congestion of a DIEP flap.
Patients who smoked were advised to quit at least six weeks before the operation [4]. Whenever available, the superficial inferior epigastric veins (SIEVs) were dissected, but without being systematically anastomosed. The flap was harvested and left in place for 15 minutes to screen in situ for venous congestion before sectioning the pedicle. During this period of monitoring, we remodeled the flap by total excision of zone IV and partial excision of zone II and III by clinical estimation; we likewise remodeled the macroscopically poorly vascularized areas of the flap [5]. After sectioning of the pedicle, the vessels were rinsed with a heparinized saline solution. Once the anastomoses had been carried out, they were left in a bath of vasodilating agents, either Xylocaine or Papaverine, as preferred by the surgeon. Further flap remodeling was then carried out, and the flaps were continuously monitored throughout the opera-
Table 1
Venous congestion and/or venous thrombosis occurred in 28 cases (14%) of the 198 breast reconstructions carried out. In 13 cases (6.5%), it occurred postoperatively and necessitated reoperation. In 2 cases venous flow augmentation was necessary, whereas in the 11 other cases, simple anastomosis revision sufficed to alleviate the congestion. Nevertheless, four flaps (2%) were lost due to venous thrombosis. In the 15 other (7.5%) cases, venous congestion occurred intraoperatively, and was rectified either by changing the anastomosis site or by venous flow augmentation with a secondary anastomosis (Table 1). Causes of intraoperative or postoperative venous congestion include: venous thrombosis, inadequate venous drainage across different zones of the flap, and dominance of the superficial venous system rendering indispensable a secondary anastomosis of the SIEV (Video 1). The SIEV was used in 11 out of the 17 cases in which venous congestion necessitated rectification, whereas the deep inferior epigastric vein (DIEV) was used in the six other cases (Table 2). The most frequently used recipient vein was the cephalic vein, followed by the internal mammary vein, the lateral
Intraoperative vs postoperative flap salvage technique.
Flap salvage technique
Venous outflow augmentation
Changing the recipient vein
Total
Intraoperative Postoperative Total
12 2 14
3 0 3
15 2 17
Characters in bold: total.
Table 2
SIEV vs DIEV usage in correcting venous congestion.
Venous congestion timing Intraoperative Postoperative
Salvage technique Outflow augmentation Recipient vein change Outflow augmentation Recipient vein change Total
Frequency of usage SIEV
DIEV
9 0 2 0 11
3 3 0 0 6
SIEV: superficial inferior epigastric vein; DIEV: superficial inferior epigastric vein. Characters in bold: total.
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004
+ Models
ANNPLA-1456; No. of Pages 6
4
A. Al Hindi et al. Table 3 Secondary veins used for correcting venous congestion intraoperatively and during postoperative revision. Secondary vein used for correcting venous congestion
Frequency
IMV LMV CV CSV TDV
4 2 8 2 1 17
IMV: internal mammary vein; LMV: lateral mammary vein; CV: cephalic vein; CSV: circumflex scapular vein; TDV: thoracodorsal vein.
mammary vein, the circumflex scapular vein, and the thoracodorsal vein respectively (Table 3). All in all, revision surgery was necessary in 15.1% of cases (6.5% involved venous congestion). A 2.5% flap failure rate was observed. All failed flaps were repeatedly returned to the operating room for revision and/or hematoma evacuation prior to complete removal (Table 4). Flap loss due to venous thrombosis was occasioned by the small caliber of the SIEV, which rendered it impossible to dissect, and by the presence of a single draining vein in the DIEV pedicle. Hematoma rate requiring re-intervention was 5%, while partial necrosis rate was 5.5%. Neither of these complications occurred in flaps salvaged intraoperatively by a SIEV microvascular anastomosis. Mean operative time was 5 hours and 56 minutes, with a mean increase of 1 hour and 45 minutes in cases of secondary venous anastomosis. Mean hospital stay was 7 days, compared to 9 days for the group having undergone an intraoperative or postoperative secondary anastomosis. As regards the two secondary venous anastomosis groups, mean hospital stay was 7.8 days for the intraoperative group compared to 13.5 days for the postoperatively salvaged flap group (Table 4). For purposes of comparison, all breast reconstructions were divided into two groups, one group having been operTable 5
Table 4
Demographics and complications.
Mean age No. of flaps No. of bilateral breast reconstructions Mean operative time Return to OR rate (all complications) Venous congestion Hematoma Venous anastomosis revision Venous flow augmentation Intraoperatively Postoperatively Flap loss Due to arterial thrombosis Due to venous thrombosis Flap loss in the 2-vein group Partial flap loss Total The 2-vein group Mean hospital stay (days) Total Two vein group Intraoperative Postoperative
51 years old 198 15 (7.5%) 5 h 46 m 15.15% 6.5% 5% 6.5% 6% 1% 2.5% 0.5% 2% 0% 5,5% 0% 7 9 7.8 13.5
ated before January 2014 (n = 106), and the group after January 2014 (n = 98) (Table 5). The second breast reconstruction group presented a 1% rate of venous anastomosis revision compared to 9.4% for the first group (before January 2014), and also presented a higher rate of intraoperative salvage of DIEP (10.8%), compared to 1.8% for the first group.
Discussion In our series, 15.1% of cases presented postoperative complications, compared to 14 to 16% in the literature [3], out of which 7% involved microsurgical anastomosis, 6.5% venous congestion and 0.5% arterial thrombosis. We observed a 2.5% flap failure rate (2%: venous thrombosis; 0.5%: arterial thrombosis.
Comparison between all breast reconstructions, breast reconstructions before and after January 2014.
Breast Reconstruction by DIEP
All
Before January 2014
After January 2014
Mean age (years) No. of flaps Mean operative time Venous anastomosis revision Venous outflow augmentation Intraoperatively Postoperatively Total flap loss Due to arterial thrombosis Due to venous thrombosis Flap loss in the 2-vein group Partial flap loss
51.3 198 5 h 47 m 6.5%
51.2 106 6 h 25 m 9.4%
51.5 92 5 h 58 m 1%
6.25% 1% 2.5% 0.5% 2% 0% 5.56%
1.8% 1.8% 3.7% 0.9% 2.8% 0% 6.6%
10.8% 1% 0% 0% 0% 0% 4.3%
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004
+ Models
ANNPLA-1456; No. of Pages 6
Intraoperative superficial inferior epigastric vein preservation Since January 2014, 85 DIEP flaps have been carried out for breast reconstruction with no flap failure, a result indicating improved salvage techniques (Table 5). More comprehensively, we observed an elimination of flap failure (0%), pronouncedly reduced reoperation (3.2% vs. 15.1%), improved intraoperative salvage and a resultant increase in operative time. Intraoperative salvage is nonetheless ultimately time-saving; while it indeed entails one or two additional hours of surgery (dissection of a secondary vein, anastomosis [9]), it generally avoids any need for 4 to 6 hours of reoperation. That is one reason why we strongly recommend, if deemed necessary, increased intraoperative venous drainage rather then watchful waiting and postoperative monitoring of the flap. Moreover, patients in whom the SIEV was conserved and anastomosed presented with no partial flap necrosis, whereas the general rate is 5.5% (Table 1). This encouraging finding shows that prompt intraoperative management of venous congestion could also avoid other re-interventions for partial necrosis or late scar revision [6]. There exist a number of techniques for salvaging a free flap; while they are mainly intraoperative, some can also be applied postoperatively; the following have been reported in the literature.
5
Figure 2
Cephalic vein (CV) dissection.
Venous flow augmentation Several methods can be applied for venous drainage augmentation, mainly by SIEV [6] or vena comitans anastomosis [7] to a secondary IMV, to the caudal end of the primary IMV in a retrograde fashion, or to any other available vein. As was the case in our series, the cephalic vein is another option (Figs. 2—4) [8—10]. In 47% of cases where venous drainage augmentation occurred, it was anastomosed with the SIEV. Other veins that may be used include the lateral mammary, the circumflex scapular, the thoracodorsal, the external jugular, the basilic and perforators of the internal mammary veins.
Other salvage techniques when only one vein is available Other techniques include the superficial outside-flap shunt (SOS) [11]. Two to four centimeters of the DIEV are conserved cranially at the edge of the perforator and anastomosed with the SIEV, which shall have been dissected over 6 to 7 cm. The two veins must be dissected and preserved over a length sufficient to ensure tension-free anastomosis. The author reported a 5.8% reoperation rate, with successful salvaging of 7 flaps out of 16 (43.75%), while the other flaps were salvaged by the classical techniques discussed in this paper. Another team reported 8.65% of intraoperative venous congestion, 7.1% of the flaps were salvaged using the DIEV as a graft to anastomose the SIEV with a receiving vein large enough to ensure tension-free anastomosis. The rate of postoperative venous congestion was 4.32%; 71.4% were salvaged using the same method [12]. Other techniques include venesection for drainage, using a cannula. It replaces drainage by leeches [13]. The cannula is kept in the lumen of the SIEV for several days, and
Figure 3 Cephalic vein (CV) and superficial inferior epigastric vein (SIEV) anastomosis.
Figure 4
Venous congestion relieved.
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004
+ Models
ANNPLA-1456; No. of Pages 6
6
A. Al Hindi et al.
intermittent drainage is carried out until complete thrombosis of the vein has been achieved. The author reported successful application of this method in three DIEP flaps suffering venous congestion [14]. We are persuaded that systematic dissection of the SIEV is of vital importance when it is necessary to counteract venous congestion and or to salvage a flap with venous thrombosis [8]. While prompt venous drainage augmentation using the SIEV or applying another method intraoperatively may increase operative time, it generally avoids further surgical procedures for other complications and thereby reduces overall length of hospitalization [10].
Conclusion In the event of intraoperative venous congestion, even though immediate performance of a second venous anastomosis may increase the duration of the initial intervention by an average of 1 hour and 45 minutes, it is likely to pronouncedly decrease the need for surgical revision, cases of failure, rate of partial necrosis and overall hospital stay.
Disclosure of interest The authors declare that they have no competing interest.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j. anplas.2018.09.004.
References [1] Gill P, Hunt J, Guerra A, Dellacroce F, Sullivan S, Boraski J, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004;113(4):1153—60.
[2] Galanis C, Nguyen P, Koh J, Roostaeian J, Festekjian J, Crisera C. Microvascular lifeboats. Plast Reconstr Surg 2014;134(1):20— 7. [3] Enajat M, Rozen W, Whitaker I, Smit J, Acosta R. A single center comparison of one versus two venous anastomoses in 564 consecutive DIEP flaps: Investigating the effect on venous congestion and flap survival. Microsurg 2009;30(3):185—91. [4] Reinbold C, Rausky J, Binder J, Revol M. Urinary cotinine testing as pre-operative assessment of patients undergoing free flap surgery. Ann Chir Plast Esthet 2015;60(1):e51—7. [5] De Greef C. Reconstruction mammaire par lambeau DIEP : à propos de 100 cas. Ann Chir Plast Esthet 2005;50(1):56—61. [6] Ochoa O, Pisano S, Chrysopoulo M, Ledoux P, Arishita G, Nastala C. Salvage of intraoperative deep inferior epigastric perforator flap venous congestion with augmentation of venous outflow. Plast Reconstr Surg Glob Open 2013;1(7):e52. [7] Lee K, Mun G. Benefits of superdrainage using SIEV in DIEP flap breast reconstruction: a systematic review and meta-analysis. Microsurg 2015;37(1):75—83. [8] Sbitany H, Mirzabeigi M, Kovach S, Wu L, Serletti J. Strategies for recognizing and managing intraoperative venous congestion in abdominally based autologous breast reconstruction. Plast Reconstr Surg 2012;129(4):809—15. [9] Silhol T, Suffee T, Hivelin M, Lantieri L. Déroutage de la veine céphalique dans la reconstruction mammaire par lambeaux libres : note technique. Ann Chir Plast Esthet 2018;63(1):75— 80. [10] Landin L, Bolado P, Casado-Sanchez C, Bonastre J, GarciaRedondo M, Zharbakhsh S, et al. Safety of salvaging impending flap congestion in breast reconstruction by venous supercharging of the cephalic vein. Ann of Plast Surg 2015;74(1):52—6. [11] Davies A, O’Neill J, Wilson S. The superficial outside-flap shunt (SOS) technique for free deep inferior epigastric perforator flap salvage. J Plast Reconstr Aesthet Surg 2014;67(8):1094—7. [12] Ali R, Bernier C, Lin Y, Ching W, Rodriguez E, Cardenas-Mejia A, et al. Surgical strategies to salvage the venous compromised deep inferior epigastric perforator flap. Ann Plast Surg 2010;65(4):398—406. [13] Herlin C, Bertheuil N, Bekara F, Boissiere F, Sinna R, Chaput B. Leech therapy in flap salvage: systematic review and practical recommendations. Ann Chir Plast Esthet 2017;62(2):e1—3. [14] Stasch T, Goon P, Haywood R, Sassoon E. DIEP flap rescue by venesection of the superficial epigastric vein. Ann Plast Surg 2009;62(4):372—3.
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004
ANNPLA-1456; No. of Pages 6 Annales de chirurgie plastique esthétique (2018) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
ORIGINAL ARTICLE
Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap ´ servation de la veine ´epigastrique infe ´ rieure superficielle pour Pre ´ vention des complications veineuses dans la reconstruction la pre ´ rieure mammaire par lambeau de perforateur ´epigastrique infe profond A. Al Hindi a,*, C. Ozil b, K. Rem a, J. Rausky a, V. Moris c, D. Guillier c, J.P. Binder a, M. Revol a, S. Cristofari a a
ˆ pital Saint-Louis, 1, avenue ClaudePlastic, Reconstructive and Aesthetic Surgery Department, AP—HP, ho Vellefaux, 75010 Paris, France b Clinique Blomet, 136 bis, rue Blomet, 75015 Paris, France c Plastic and Reconstructive department, CHU de Dijon, 14, rue Paul-Gaffarel, 21000 Dijon, France Received 5 April 2018; accepted 9 September 2018
KEYWORDS Breast reconstruction; DIEP flap; Flap salvage; Microsurgery; Venous congestion; SIEV
Summary Objective. — The aim of this study was to analyze our technique of intraoperative venous compromise management based on conservation of the superficial inferior epigastric vein (SIEV), and to undertake a retrospective review of our series of breast reconstructions by deep inferior epigastric perforator (DIEP) flap, followed by a review of other techniques reported in the literature. Materials and methods. — This retrospective study involves 198 breast reconstructions by DIEP flap performed between January 2010 and September 2017. Our surgical technique is related in detail, with a focus on venous compromise management. Operative time, re-intervention rate, hospital stay, and complications were all noted and analyzed, and a literature review dealt with other techniques of prevention and management of flap venous congestion.
* Corresponding author. E-mail address: [email protected] (A. Al Hindi). https://doi.org/10.1016/j.anplas.2018.09.004 0294-1260/# 2018 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004
+ Models
ANNPLA-1456; No. of Pages 6
2
A. Al Hindi et al. Results. — Among breast reconstructions by DIEP, 7.5% contained an episode of intraoperative venous compromise, as opposed to 6.5% postoperatively. The SIEV was used in 65% of cases of venous congestion. In our series, 15.1% of cases presented postoperative complications, and we observed a 2.5% flap failure rate (2%: venous thrombosis; 0.5%: arterial thrombosis). In all patients for whom venous drainage augmentation was performed, the flaps survived without partial loss. While average length of hospital stay in the group having undergone intraoperative secondary anastomosis was 7.5 days, in the group having undergone postoperative secondary anastomosis, it was 13.5 days. Conclusion. — In cases of intraoperative venous congestion, while a second venous anastomosis may immediately increase duration of an initial intervention by 1 hour and 45 minutes, it is nonetheless likely to pronouncedly decrease need for surgical revision, cases of failure, rate of partial necrosis and overall hospital stay. # 2018 Elsevier Masson SAS. All rights reserved.
MOTS CLÉS Reconstruction mammaire ; Lambeau DIEP ; Sauvetage de lambeau ; Microchirurgie ; Congestion veineuse
Re ´sume ´ Objectif. — Le but de notre étude est l’analyse de notre technique de prise en charge de la congestion veineuse peropératoire en préservant la veine superficielle épigastrique inférieure (SIEV), ainsi qu’une revue rétrospective de notre série de reconstructions mammaires autologues par lambeau de perforateur épigastrique inférieure profond (DIEP). Par ailleurs, nous avons effectué une revue d’autres techniques dans la littérature. Patients et me´thodes. — Il s’agit d’une étude rétrospective de 198 reconstructions mammaires par lambeau DIEP réalisées entre janvier 2010 et septembre 2017, notre technique chirurgicale est décrite avec une mise au point sur la prise en charge de la congestion veineuse. Le temps opératoire, le taux de reprise, la durée de séjour et les complications ont été enregistrés, puis une revue de la littérature a été réalisée pour d’autres techniques de prise en charge de la congestion veineuse. Re ´sultats. — Parmi les reconstructions mammaires réalisées par DIEP, 7,5 % ont eu un épisode de drainage veineux insuffisant peropératoire contre 6,5 % en postopératoire. La SIEV a été utilisée dans 65 % des cas. Notre taux de reprise globale est de 15,1 % pour toutes les complications postopératoires, le taux d’échec est de 2,5 %, divisé entre 2 % pour la thrombose veineuse et 0,5 % pour la thrombose artérielle. Chez les patientes ayant bénéficié d’une augmentation du drainage veineux, les lambeaux ont survécu sans nécrose partielle. La durée moyenne d’hospitalisation chez le groupe ayant eu une anastomose secondaire peropératoire est de 7,8 jours, contre 13,5 jours dans le groupe ayant subi une anastomose secondaire postopératoire. Conclusion. — En cas de congestion veineuse peropératoire, la réalisation immédiate d’une seconde anastomose veineuse semble augmenter la durée d’intervention initiale de 1 h 45 h, mais pourrait permettre de réduire à la fois le nombre de reprise chirurgicale, le taux d’échec, le taux de nécrose partielle et la durée d’hospitalisation globale. # 2018 Elsevier Masson SAS. Tous droits réservés.
Introduction Free flap transfer using the deep inferior epigastric perforator (DIEP) vessels is a widely applied method in breast reconstruction. Compared with other techniques, the DIEP flap entails less donor site morbidity. However, its main drawbacks are its failure rate (0.5% to 3.2% according to different studies), and a reoperation rate ranging from 14 to 16% [1—3]. Flap ischemia or loss is mainly caused by venous congestion or thrombosis [2]. The aim of our study was to analyze our technique of intraoperative venous compromise management by superficial inferior epigastric vein (SIEV) preservation, and to retrospectively review our series of breast reconstructions by DIEP flap.
We also reviewed the literature regarding other methods and techniques for intraoperative venous compromise management.
Methods One hundred and ninety-eight breast reconstructions by free transfer of DIEP flap were reviewed, concerning 183 patients from January 2010 until September 2017. Ten different surgeons in our center implemented the same general technique. After the patients selected for breast reconstruction by a DIEP flap had given their agreement, and angiography of the abdominal wall confirmed the existence and location of appropriate perforators.
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004
+ Models
ANNPLA-1456; No. of Pages 6
Intraoperative superficial inferior epigastric vein preservation
3 tion. In the event of venous insufficiency with permeable venous anastomosis or an engorged SIEV for no apparent reason, the SIEV was anastomosed secondarily. All postoperative complications including venous congestion, arterial thrombosis, hematoma, partial and total flap loss were duly recorded. Our main concern in this review was flap venous congestion, which can be defined as compromised venous drainage resulting in bluish discoloration of the flap, with increased capillary refill time (more than 3 s) (Fig. 1). We also reviewed the literature for methods other than SIEV microanastomosis used to salvage flaps intraoperatively.
Results Figure 1
Postoperative venous congestion of a DIEP flap.
Patients who smoked were advised to quit at least six weeks before the operation [4]. Whenever available, the superficial inferior epigastric veins (SIEVs) were dissected, but without being systematically anastomosed. The flap was harvested and left in place for 15 minutes to screen in situ for venous congestion before sectioning the pedicle. During this period of monitoring, we remodeled the flap by total excision of zone IV and partial excision of zone II and III by clinical estimation; we likewise remodeled the macroscopically poorly vascularized areas of the flap [5]. After sectioning of the pedicle, the vessels were rinsed with a heparinized saline solution. Once the anastomoses had been carried out, they were left in a bath of vasodilating agents, either Xylocaine or Papaverine, as preferred by the surgeon. Further flap remodeling was then carried out, and the flaps were continuously monitored throughout the opera-
Table 1
Venous congestion and/or venous thrombosis occurred in 28 cases (14%) of the 198 breast reconstructions carried out. In 13 cases (6.5%), it occurred postoperatively and necessitated reoperation. In 2 cases venous flow augmentation was necessary, whereas in the 11 other cases, simple anastomosis revision sufficed to alleviate the congestion. Nevertheless, four flaps (2%) were lost due to venous thrombosis. In the 15 other (7.5%) cases, venous congestion occurred intraoperatively, and was rectified either by changing the anastomosis site or by venous flow augmentation with a secondary anastomosis (Table 1). Causes of intraoperative or postoperative venous congestion include: venous thrombosis, inadequate venous drainage across different zones of the flap, and dominance of the superficial venous system rendering indispensable a secondary anastomosis of the SIEV (Video 1). The SIEV was used in 11 out of the 17 cases in which venous congestion necessitated rectification, whereas the deep inferior epigastric vein (DIEV) was used in the six other cases (Table 2). The most frequently used recipient vein was the cephalic vein, followed by the internal mammary vein, the lateral
Intraoperative vs postoperative flap salvage technique.
Flap salvage technique
Venous outflow augmentation
Changing the recipient vein
Total
Intraoperative Postoperative Total
12 2 14
3 0 3
15 2 17
Characters in bold: total.
Table 2
SIEV vs DIEV usage in correcting venous congestion.
Venous congestion timing Intraoperative Postoperative
Salvage technique Outflow augmentation Recipient vein change Outflow augmentation Recipient vein change Total
Frequency of usage SIEV
DIEV
9 0 2 0 11
3 3 0 0 6
SIEV: superficial inferior epigastric vein; DIEV: superficial inferior epigastric vein. Characters in bold: total.
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004
+ Models
ANNPLA-1456; No. of Pages 6
4
A. Al Hindi et al. Table 3 Secondary veins used for correcting venous congestion intraoperatively and during postoperative revision. Secondary vein used for correcting venous congestion
Frequency
IMV LMV CV CSV TDV
4 2 8 2 1 17
IMV: internal mammary vein; LMV: lateral mammary vein; CV: cephalic vein; CSV: circumflex scapular vein; TDV: thoracodorsal vein.
mammary vein, the circumflex scapular vein, and the thoracodorsal vein respectively (Table 3). All in all, revision surgery was necessary in 15.1% of cases (6.5% involved venous congestion). A 2.5% flap failure rate was observed. All failed flaps were repeatedly returned to the operating room for revision and/or hematoma evacuation prior to complete removal (Table 4). Flap loss due to venous thrombosis was occasioned by the small caliber of the SIEV, which rendered it impossible to dissect, and by the presence of a single draining vein in the DIEV pedicle. Hematoma rate requiring re-intervention was 5%, while partial necrosis rate was 5.5%. Neither of these complications occurred in flaps salvaged intraoperatively by a SIEV microvascular anastomosis. Mean operative time was 5 hours and 56 minutes, with a mean increase of 1 hour and 45 minutes in cases of secondary venous anastomosis. Mean hospital stay was 7 days, compared to 9 days for the group having undergone an intraoperative or postoperative secondary anastomosis. As regards the two secondary venous anastomosis groups, mean hospital stay was 7.8 days for the intraoperative group compared to 13.5 days for the postoperatively salvaged flap group (Table 4). For purposes of comparison, all breast reconstructions were divided into two groups, one group having been operTable 5
Table 4
Demographics and complications.
Mean age No. of flaps No. of bilateral breast reconstructions Mean operative time Return to OR rate (all complications) Venous congestion Hematoma Venous anastomosis revision Venous flow augmentation Intraoperatively Postoperatively Flap loss Due to arterial thrombosis Due to venous thrombosis Flap loss in the 2-vein group Partial flap loss Total The 2-vein group Mean hospital stay (days) Total Two vein group Intraoperative Postoperative
51 years old 198 15 (7.5%) 5 h 46 m 15.15% 6.5% 5% 6.5% 6% 1% 2.5% 0.5% 2% 0% 5,5% 0% 7 9 7.8 13.5
ated before January 2014 (n = 106), and the group after January 2014 (n = 98) (Table 5). The second breast reconstruction group presented a 1% rate of venous anastomosis revision compared to 9.4% for the first group (before January 2014), and also presented a higher rate of intraoperative salvage of DIEP (10.8%), compared to 1.8% for the first group.
Discussion In our series, 15.1% of cases presented postoperative complications, compared to 14 to 16% in the literature [3], out of which 7% involved microsurgical anastomosis, 6.5% venous congestion and 0.5% arterial thrombosis. We observed a 2.5% flap failure rate (2%: venous thrombosis; 0.5%: arterial thrombosis.
Comparison between all breast reconstructions, breast reconstructions before and after January 2014.
Breast Reconstruction by DIEP
All
Before January 2014
After January 2014
Mean age (years) No. of flaps Mean operative time Venous anastomosis revision Venous outflow augmentation Intraoperatively Postoperatively Total flap loss Due to arterial thrombosis Due to venous thrombosis Flap loss in the 2-vein group Partial flap loss
51.3 198 5 h 47 m 6.5%
51.2 106 6 h 25 m 9.4%
51.5 92 5 h 58 m 1%
6.25% 1% 2.5% 0.5% 2% 0% 5.56%
1.8% 1.8% 3.7% 0.9% 2.8% 0% 6.6%
10.8% 1% 0% 0% 0% 0% 4.3%
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004
+ Models
ANNPLA-1456; No. of Pages 6
Intraoperative superficial inferior epigastric vein preservation Since January 2014, 85 DIEP flaps have been carried out for breast reconstruction with no flap failure, a result indicating improved salvage techniques (Table 5). More comprehensively, we observed an elimination of flap failure (0%), pronouncedly reduced reoperation (3.2% vs. 15.1%), improved intraoperative salvage and a resultant increase in operative time. Intraoperative salvage is nonetheless ultimately time-saving; while it indeed entails one or two additional hours of surgery (dissection of a secondary vein, anastomosis [9]), it generally avoids any need for 4 to 6 hours of reoperation. That is one reason why we strongly recommend, if deemed necessary, increased intraoperative venous drainage rather then watchful waiting and postoperative monitoring of the flap. Moreover, patients in whom the SIEV was conserved and anastomosed presented with no partial flap necrosis, whereas the general rate is 5.5% (Table 1). This encouraging finding shows that prompt intraoperative management of venous congestion could also avoid other re-interventions for partial necrosis or late scar revision [6]. There exist a number of techniques for salvaging a free flap; while they are mainly intraoperative, some can also be applied postoperatively; the following have been reported in the literature.
5
Figure 2
Cephalic vein (CV) dissection.
Venous flow augmentation Several methods can be applied for venous drainage augmentation, mainly by SIEV [6] or vena comitans anastomosis [7] to a secondary IMV, to the caudal end of the primary IMV in a retrograde fashion, or to any other available vein. As was the case in our series, the cephalic vein is another option (Figs. 2—4) [8—10]. In 47% of cases where venous drainage augmentation occurred, it was anastomosed with the SIEV. Other veins that may be used include the lateral mammary, the circumflex scapular, the thoracodorsal, the external jugular, the basilic and perforators of the internal mammary veins.
Other salvage techniques when only one vein is available Other techniques include the superficial outside-flap shunt (SOS) [11]. Two to four centimeters of the DIEV are conserved cranially at the edge of the perforator and anastomosed with the SIEV, which shall have been dissected over 6 to 7 cm. The two veins must be dissected and preserved over a length sufficient to ensure tension-free anastomosis. The author reported a 5.8% reoperation rate, with successful salvaging of 7 flaps out of 16 (43.75%), while the other flaps were salvaged by the classical techniques discussed in this paper. Another team reported 8.65% of intraoperative venous congestion, 7.1% of the flaps were salvaged using the DIEV as a graft to anastomose the SIEV with a receiving vein large enough to ensure tension-free anastomosis. The rate of postoperative venous congestion was 4.32%; 71.4% were salvaged using the same method [12]. Other techniques include venesection for drainage, using a cannula. It replaces drainage by leeches [13]. The cannula is kept in the lumen of the SIEV for several days, and
Figure 3 Cephalic vein (CV) and superficial inferior epigastric vein (SIEV) anastomosis.
Figure 4
Venous congestion relieved.
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004
+ Models
ANNPLA-1456; No. of Pages 6
6
A. Al Hindi et al.
intermittent drainage is carried out until complete thrombosis of the vein has been achieved. The author reported successful application of this method in three DIEP flaps suffering venous congestion [14]. We are persuaded that systematic dissection of the SIEV is of vital importance when it is necessary to counteract venous congestion and or to salvage a flap with venous thrombosis [8]. While prompt venous drainage augmentation using the SIEV or applying another method intraoperatively may increase operative time, it generally avoids further surgical procedures for other complications and thereby reduces overall length of hospitalization [10].
Conclusion In the event of intraoperative venous congestion, even though immediate performance of a second venous anastomosis may increase the duration of the initial intervention by an average of 1 hour and 45 minutes, it is likely to pronouncedly decrease the need for surgical revision, cases of failure, rate of partial necrosis and overall hospital stay.
Disclosure of interest The authors declare that they have no competing interest.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j. anplas.2018.09.004.
References [1] Gill P, Hunt J, Guerra A, Dellacroce F, Sullivan S, Boraski J, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004;113(4):1153—60.
[2] Galanis C, Nguyen P, Koh J, Roostaeian J, Festekjian J, Crisera C. Microvascular lifeboats. Plast Reconstr Surg 2014;134(1):20— 7. [3] Enajat M, Rozen W, Whitaker I, Smit J, Acosta R. A single center comparison of one versus two venous anastomoses in 564 consecutive DIEP flaps: Investigating the effect on venous congestion and flap survival. Microsurg 2009;30(3):185—91. [4] Reinbold C, Rausky J, Binder J, Revol M. Urinary cotinine testing as pre-operative assessment of patients undergoing free flap surgery. Ann Chir Plast Esthet 2015;60(1):e51—7. [5] De Greef C. Reconstruction mammaire par lambeau DIEP : à propos de 100 cas. Ann Chir Plast Esthet 2005;50(1):56—61. [6] Ochoa O, Pisano S, Chrysopoulo M, Ledoux P, Arishita G, Nastala C. Salvage of intraoperative deep inferior epigastric perforator flap venous congestion with augmentation of venous outflow. Plast Reconstr Surg Glob Open 2013;1(7):e52. [7] Lee K, Mun G. Benefits of superdrainage using SIEV in DIEP flap breast reconstruction: a systematic review and meta-analysis. Microsurg 2015;37(1):75—83. [8] Sbitany H, Mirzabeigi M, Kovach S, Wu L, Serletti J. Strategies for recognizing and managing intraoperative venous congestion in abdominally based autologous breast reconstruction. Plast Reconstr Surg 2012;129(4):809—15. [9] Silhol T, Suffee T, Hivelin M, Lantieri L. Déroutage de la veine céphalique dans la reconstruction mammaire par lambeaux libres : note technique. Ann Chir Plast Esthet 2018;63(1):75— 80. [10] Landin L, Bolado P, Casado-Sanchez C, Bonastre J, GarciaRedondo M, Zharbakhsh S, et al. Safety of salvaging impending flap congestion in breast reconstruction by venous supercharging of the cephalic vein. Ann of Plast Surg 2015;74(1):52—6. [11] Davies A, O’Neill J, Wilson S. The superficial outside-flap shunt (SOS) technique for free deep inferior epigastric perforator flap salvage. J Plast Reconstr Aesthet Surg 2014;67(8):1094—7. [12] Ali R, Bernier C, Lin Y, Ching W, Rodriguez E, Cardenas-Mejia A, et al. Surgical strategies to salvage the venous compromised deep inferior epigastric perforator flap. Ann Plast Surg 2010;65(4):398—406. [13] Herlin C, Bertheuil N, Bekara F, Boissiere F, Sinna R, Chaput B. Leech therapy in flap salvage: systematic review and practical recommendations. Ann Chir Plast Esthet 2017;62(2):e1—3. [14] Stasch T, Goon P, Haywood R, Sassoon E. DIEP flap rescue by venesection of the superficial epigastric vein. Ann Plast Surg 2009;62(4):372—3.
Please cite this article in press as: Al A, et al. Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap. Ann Chir Plast Esthet (2018), https://doi.org/10.1016/ j.anplas.2018.09.004