title: Salvage of intraoperative deep inferior epigastric perforator flap venous congestion with augmentation of venous outflow: flap morbidity and review of the literature.
abstract: BACKGROUND
  Breast reconstruction with deep inferior epigastric perforator (DIEP) flaps has gained considerable popularity due to reduced donor-site morbidity. Previous studies have identified the superficial venous system as the dominant outflow to DIEP flaps. DIEP flap venous congestion occurs if superficial venous outflow via the deep venous system is insufficient for effective flap drainage. Although augmentation of venous outflow through a second venous anastomosis may relieve venous congestion, effects on flap morbidity remain ill defined.
  
  
  METHODS
  A retrospective analysis of 1616 patients who underwent 2618 DIEP flap breast reconstructions between March 2005 and January 2012 was performed. Patients with intraoperative venous congestion underwent a second venous anastomosis. Preoperative demographic data and methods used to relieve venous congestion were recorded. Incidence of flap morbidity was calculated and compared with a group of 418 controls having 639 DIEP flap breast reconstructions with no venous congestion.
  
  
  RESULTS
  Venous augmentation was required to relieve venous congestion in 87 (3.3%) DIEP flaps on 81 patients. The superficial inferior epigastric vein or accompanying deep inferior epigastric venae comitantes was used to augment venous outflow. Preoperative comorbidities were similar between both groups. Patients requiring a second venous anastomosis had a longer operative time and length of hospital stay. Overall, flap morbidity, delayed wound healing, fat necrosis, and flap loss were similar to controls.
  
  
  CONCLUSIONS
  Arterial and venous anatomies play unique roles in flap reliability. DIEP flap venous congestion must be treated expeditiously with venous augmentation to relieve venous congestion and mitigate flap morbidity.
authors.affiliation: PRMA Plastic Surgery, San Antonio, Tex.
authors.forename: Oscar
authors.initials: O
authors.lastname: Ochoa
authors.affiliation: PRMA Plastic Surgery, San Antonio, Tex.
authors.forename: Steven
authors.initials: S
authors.lastname: Pisano
authors.affiliation: PRMA Plastic Surgery, San Antonio, Tex.
authors.forename: Minas
authors.initials: M
authors.lastname: Chrysopoulo
authors.affiliation: PRMA Plastic Surgery, San Antonio, Tex.
authors.forename: Peter
authors.initials: P
authors.lastname: Ledoux
authors.affiliation: PRMA Plastic Surgery, San Antonio, Tex.
authors.forename: Gary
authors.initials: G
authors.lastname: Arishita
authors.affiliation: PRMA Plastic Surgery, San Antonio, Tex.
authors.forename: Chet
authors.initials: C
authors.lastname: Nastala