Investigation of Routine Venous Augmentation in Deep Inferior Epigastric Artery Perforator Flap and Intraoperative Decision Pathway

Abstract

Background

Data supporting use of prophylactic venous augmentation in the deep inferior epigastric perforator flap (DIEP) is limited. This study aims to assess the outcomes of single vein DIEP flaps compared with those with venous augmentation and present an intraoperative decision pathway.

Methods

A retrospective chart review was performed on patients who underwent DIEP flap reconstruction at a single institution from 2009 to 2023. Statistical analysis was performed and p-values less than 0.05 were considered statistically significant.

Results

A total of 1,099 patients had DIEP flap breast reconstruction resulting in 1,745 flaps. Two or more veins were utilized in 32.4%, whereas 67.6% had a single venous anastomosis. Prophylactic augmentation was documented for 24.5% of flaps. The rate of return to operating room was 5.8% with no significant difference found in the rate of return for all causes (p = 0.14) and suspected venous compromise (p = 0.95). Suspected venous compromise was documented in 41flaps (2.3%), with no significant difference between the single vein and prophylactic vein group (p = 0.95). There was no difference in rates of early (p = 0.10) or late flap loss (p = 0.15). Difference in operative duration was increased for flaps with prophylactic venous anastomoses (559.4 ± 127.8 vs. 505.6 ± 130.8 minutes; p < 0.001).

Conclusion

This study demonstrates no significant difference in postoperative complications as well as demonstrating prophylactic multivein anastomosis was associated with significantly longer operative times. With the use of an intraoperative decision pathway, one can determine which flaps will benefit from additional venous outflow and avoid unnecessary routine augmentation without benefit.

Keywords

DIEP flap - breast reconstruction - prophylactic venous augmentation - flap outcomes - intraoperative decision pathway

Publication History

Received: 12 April 2025

Accepted: 21 September 2025

Accepted Manuscript online:
09 October 2025

Article published online:
11 November 2025

• References

• 1 Myers PL, Nelson JA, Allen Jr RJ. Alternative flaps in autologous breast reconstruction. Gland Surg 2021; 10 (01) 444-459
• 2 Nahabedian MY, Patel K. Autologous flap breast reconstruction: surgical algorithm and patient selection. J Surg Oncol 2016; 113 (08) 865-874
• 3 Lee KT, Mun GH. Benefits of superdrainage using SIEV in DIEP flap breast reconstruction: a systematic review and meta-analysis. Microsurgery 2017; 37 (01) 75-83
• 4 Boutros SG. Double venous system drainage in deep inferior epigastric perforator flap breast reconstruction: a single-surgeon experience. Plast Reconstr Surg 2013; 131 (04) 671-676
• 5 Enajat M, Rozen WM, Whitaker IS, Smit JM, 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. Microsurgery 2010; 30 (03) 185-191
• 6 Xin Q, Luan J, Mu H, Mu L. Augmentation of venous drainage in deep inferior epigastric perforator flap breast reconstruction: efficacy and advancement. J Reconstr Microsurg 2012; 28 (05) 313-318
• 7 Nedomansky J, Nickl S, Radtke C, Haslik W, Schroegendorfer KF. Venous superdrainage in DIEP flap breast reconstruction: the impact of superficial inferior epigastric vein dissection on abdominal seroma formation. Plast Reconstr Surg 2018; 141 (02) 206e-212e
• 8 Vijayasekaran A, Mohan AT, Zhu L, Sharaf B, Saint-Cyr M. Anastomosis of the superficial inferior epigastric vein to the internal mammary vein to augment deep inferior artery perforator flaps. Clin Plast Surg 2017; 44 (02) 361-369
• 9 Wechselberger G, Schoeller T, Bauer T, Ninkovic M, Otto A, Ninkovic M. Venous superdrainage in deep inferior epigastric perforator flap breast reconstruction. Plast Reconstr Surg 2001; 108 (01) 162-166
• 10 Ali R, Bernier C, Lin YT. et al. Surgical strategies to salvage the venous compromised deep inferior epigastric perforator flap. Ann Plast Surg 2010; 65 (04) 398-406
• 11 Galanis C, Nguyen P, Koh J, Roostaeian J, Festekjian J, Crisera C. Microvascular lifeboats: a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction. Plast Reconstr Surg 2014; 134 (01) 20-27
• 12 Al Hindi A, Ozil C, Rem K. 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 2019; 64 (03) 245-250
• 13 Huang TC, Cheng HT. One-vein vs. two-vein anastomoses utilizing the retrograde limb of the internal mammary vein as supercharge recipient vessel in free DIEP flap breast reconstruction: a meta-analysis of comparative studies. J Plast Reconstr Aesthet Surg 2020; 73 (01) 184-199
• 14 Simion L, Petrescu I, Chitoran E. et al. Breast reconstruction following mastectomy for breast cancer or prophylactic mastectomy: therapeutic options and results. Life (Basel) 2024; 14 (01) 138
• 15 Choi EMO, Ribeiro RDA, Montag E. et al. The influence of the superficial venous system on DIEP flap drainage in breast reconstruction. J Reconstr Microsurg 2024; 40 (05) 379-383
• 16 Lombardo GAG, Cherubino M, Marchica P. et al. Prophylactic venous supercharging in deep inferior epigastric artery perforator flap surgery: a retrospective dual-center study. J Reconstr Microsurg 2025; 41 (04) 295-301
• 17 Pignatti M, Pinto V, Giorgini FA. et al. Different hydraulic constructs to optimize the venous drainage of DIEP flaps in breast reconstruction: decisional algorithm and review of the literature. J Reconstr Microsurg 2021; 37 (03) 216-226
• 18 Lee KT, Lee JE, Nam SJ, Mun GH. Ischaemic time and fat necrosis in breast reconstruction with a free deep inferior epigastric perforator flap. J Plast Reconstr Aesthet Surg 2013; 66 (02) 174-181
• 19 Kerr-Valentic MA, Gottlieb LJ, Agarwal JP. The retrograde limb of the internal mammary vein: an additional outflow option in DIEP flap breast reconstruction. Plast Reconstr Surg 2009; 124 (03) 717-721
• 20 Boczar D, Colon RR, Anzai L. et al. Single versus double venous anastomosis microvascular free flaps for head and neck reconstruction. J Craniofac Surg 2022; 33 (03) 784-786
• 21 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 (03) 281-284
• 22 Laporta R, Longo B, Sorotos M, Farcomeni A, Amorosi V, Santanelli di Pompeo F. Time-dependent factors in DIEP flap breast reconstruction. Microsurgery 2017; 37 (07) 793-799
• 23 Bartlett EL, Zavlin D, Menn ZK, Spiegel AJ. Algorithmic approach for intraoperative salvage of venous congestion in DIEP flaps. J Reconstr Microsurg 2018; 34 (06) 404-412
• 24 Sbitany H, Mirzabeigi MN, Kovach SJ, Wu LC, Serletti JM. Strategies for recognizing and managing intraoperative venous congestion in abdominally based autologous breast reconstruction. Plast Reconstr Surg 2012; 129 (04) 809-815