Use of the superficial inferior epigastric vein in breast reconstruction with a deep inferior epigastric artery perforator flap

The Transverse Rectus Abdominis Myocutaneous (TRAM) flap has been the gold standard for breast reconstruction until recently. Not only autologous but also immediate reconstructions are now preferred to offer the patient a natural and cosmetically acceptable result. This study summarises the prospectively gathered data of 100 free DIEP flaps used for breast reconstruction in 87 patients. Primary reconstructions were done in 35% of the patients. Well-known risk factors for free-flap breast reconstruction were present: smokers 23%, obesity 25%, abdominal scarring 28% and previous radiotherapy 45%. Free DIEP flaps vascularised by a single (52%), two (39%) or three (9%) perforators were preferentially anastomosed to the internal mammary vessels at the level of the third costochondral junction. Of 74 unilateral DIEP flaps, 41 (55%) flaps were well vascularised in zone IV. Two flaps necrosed totally. Partial flap loss and fat necrosis occurred in 7% and 6% of all flaps, respectively. One patient presented with a unilateral abdominal bulge. Mean operating time was 6 h 12 min for unilateral reconstruction and mean hospital stay was 7.9 days. These data indicate that the free DIEP flap is a new but reliable and safe technique for autologous breast reconstruction. This flap offers the patient the same advantages as the TRAM flap and discards the most important disadvantages of the myocutaneous flap by preserving the continuity of the rectus muscle. The donor site morbidity is reduced, a sensate reinnervation is possible, postoperative pain is less, recovery is quicker and hospital stay is reduced. The more complex nature of this type of surgery, leading to increased operating time, is balanced by the permanent and gratifying results achieved.

A series of 240 deep inferior epigastric perforator (DIEP) flaps and 271 free transverse rectus abdominis myocutaneous (TRAM) flaps from two institutions was reviewed to determine the incidence of diffuse venous insufficiency that threatened flap survival and required a microvascular anastomosis to drain the superficial inferior epigastric vein. This problem occurred in five DIEP flaps and did not occur in any of the free TRAM flaps. In each of these cases, the presence of a superficial inferior epigastric vein that was larger than usual was noted. It is therefore suggested that if an unusually large superficial inferior epigastric vein is noted when a DIEP flap is elevated, the vein should be preserved for possible use in flap salvage. Anatomical studies with Microfil injections of the superficial venous system of the DIEP or TRAM flap were also performed in 15 cadaver and 3 abdominoplasty specimens to help determine why venous circulation (and flap survival) in zone IV of the flaps is so variable. Large lateral branches crossing the midline were found in only 18 percent of cases, whereas 45 percent had indirect connections through a deeper network of smaller veins and 36 percent had no demonstrable crossing branches at all. This absence of crossing branches in many patients may explain why survival of the zone IV portion of such flaps is so variable and unpredictable.