An Algorithmic Approach to Dual-System Venous Drainage for DIEP Flap Breast Reconstruction

We read with great interest the article entitled “An Algorithmic Approach to Dual-System Venous Drainage for DIEP Flap Breast Reconstruction,” by Jabbour et al.,1 published in the July 2024 issue of the Journal. We would like to commend the authors for the rigueur of their methodology and the strength of their findings. As an addendum, we would like to share our experience with the double-vein deep inferior epigastric perforator (DIEP) flap, which we also recently published.2 We agree with the authors’ proposed algorithm, and present one of our own that develops in a very similar way. Always keeping in mind the importance of the superficial inferior epigastric vein (SIEV) anastomosis,3 we also rotate the flap by 90 degrees to position the SIEV just above the internal mammary vein (IMV), which allows us to proceed with the second venous anastomosis to the reverse IMV stump (Fig. 1).Fig. 1.: Intraoperative view of the insetting of the flap. In the cephalic portion, the mammary vessel (anterograde flow [IMV-a]) is anastomosed to the main pedicle (deep inferior epigastric vein [DIEV]). In the caudal portion, we supercharged the SIEV with the retrograde-flow IMV (IMV-r).We would like to note, however, that unlike the authors’ article, our article highlights, as the first in the literature, the use of SIEV-to–reverse IMV venous supercharging in a prophylactic fashion, instead of only limiting itself to retrospectively comparing single-vein versus double-vein groups. The question that remains unresolved about DIEP flap surgery is this: is it useful to supercharge the DIEP even in cases in which clinical intraoperative venous congestion is not observed after the raising of the flap? To answer this question, we excluded patients who lacked the SIEV and those with superficial predominance (noted in the operating room as quick congestion of the flap as soon as the SIEV is clipped). This allowed us to truly define our SIEV supercharging as prophylactic in lowering the risk of venous congestion and thrombosis. Our experience demonstrates that performing a second venous anastomosis to drain the flap’s superficial venous system in every DIEP procedure without superficial dominance significantly lowers the number of takebacks and prevents flap loss in a statistically significant manner. We also found no difference in operative time or ischemia time, further proving that this prophylactic supercharging does not add any risks to the flap or the patient. These findings may be due to the multifactorial nature of postoperative venous congestion. Sometimes, postoperative venous congestion is not caused by the absence of superficial dominance but by factors, such as pedicle position4 or incipient hematoma. For this reason, prophylactic superficial venous supercharging could be useful in preventing postoperative venous congestion and reducing the rates of re-exploration. Considering the multifactorial nature of venous congestion in DIEP flap reconstruction,5 we believe that our experience, although limited by its retrospective nature and small sample size, may pave the way for preventing flap complications in autologous breast reconstruction. This approach could spare our patients from the emotional and physical pain associated with additional procedures and ultimately unsatisfactory reconstructions. DISCLOSURE The authors have no financial interest in any of the products, devices, or drugs mentioned in this communication.