BENEFITS OF SUPERDRAINAGE USING SIEV IN DIEP FLAP BREAST RECONSTRUCTION: A SYSTEMATIC REVIEW AND META-ANALYSIS KYEONG-TAE LEE, M.D., and GOO-HYUN MUN, M.D., Ph.D.*

Background: Superdrainage using superficial inferior epigastric vein (SIEV) has been often used to overcome occasional venous insufficiency in deep inferior epigastric perforator (DIEP) flap. However, a consensus regarding its clinical benefits is lacking. The aim of this review was to evaluate the efficacy of superdrainage using SIEV on clinical outcome in DIEP flap breast reconstruction by meta-analytic methodology. Methods: Medline, Ovid and Google Scholar were searched to obtain all relevant publications. Pooled risks for perfusionrelated complications were compared between the superdrainage group and control group by Mantel–Haenszel test. Results: Six studies representing 1,376 cases (842 superdrainage and 534 control group) were enrolled, all of which were retrospective cohort studies. Superdrainage had little influence on the risk of total flap loss (RR: 0.97, 95% CI: 0.36–2.57). There were trends toward decreasing risks of partial flap loss (RR: 0.59, 95% CI; 0.18–1.94) and fat necrosis (RR: 0.87, 95% CI: 0.58–1.30) in the superdrainage group, though they were not significant. The risk of partial flap necrosis in which partial flap loss and fat necrosis were combined, was reduced 20% in the superdrainage group, although statistical significance was not achieved (RR: 0.80, 95% CI: 0.57–1.11). The risk of flap congestion decreased significantly in the superdrainage group (RR: 0.06, 95% CI: 0.01–0.51). Conclusions: Although there is obvious benefit of SIEV superdrainage in reducing the risk of flap congestion, evidence supporting its use to prevent flap compromise is still insufficient. Further studies C 2015 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2015. would be required. V

According to the 2013 Plastic Surgery Statistical Report, the choice of deep inferior epigastric perforator (DIEP) flap has greatly increased, surpassing the use of the transverse rectus abdominis musculocutaneous (TRAM) flap and latissimus dorsi flap in the United States.1 In addition to several inherent advantages of the autologous flap, its minimal donor morbidity has made DIEP flap the most popular option for autologous breast reconstruction. Despite those attributes, a relatively high-risk of venous congestion and subsequent complications including flap loss or fat necrosis remain weaknesses. Incidence of venous congestions was reported up to 10% in large series of DIEP flap breast reconstructions.2–4 \To overcome this problem, much effort has been made, and superdrainage by additional anastomosis of the superficial inferior epigastric vein (SIEV) is one of them.5–7 Several anatomical and imaging studies demonstrated that the venous drainage of low anterior abdominal wall tissue relies mainly on the superficial venous system through SIEV and secondarily on deep system through DIEV.8–10 Owing to perforating veins interconnecting those two systems, the venous drainage of the DIEP flap, though it may not be Financial Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Ilwon-Dong 50, Gangnam-Gu, Seoul, 135710, South Korea *Correspondence to: Dr. Goo-Hyun Mun, MD, PhD, Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Ilwon-dong 50, Gangnam-gu, Seoul, South Korea. E-mail: [email protected] Received 1 December 2014; Revision accepted 25 March 2015; Accepted 7 April 2015 Published online 00 Month 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22420 Ó 2015 Wiley Periodicals, Inc.

physiologic, is usually sufficiently maintained after flap elevation. However, in cases that lack those perforating veins, the flaps had superficially dominant venous drainage, resulting in congestion of whole elevated flaps.11 Furthermore, when inappropriate perforators having suboptimal venous capacity are selected to be included or perforators are injured during pedicle dissection, venous drainage of the flap through DIEV would be insufficient, possibly causing flap congestion and subsequent flap failure. Under those circumstances, superdrainage using SIEV can supplement the drainage of the flap and prevent complications theoretically. The efficacy of superdrainage using SIEV on augmenting flap perfusion and reducing complications has been demonstrated in animal studies.12–16 However, debates as to whether superdrainage can actually prevent perfusion-related complications are still ongoing in clinical series. In spite of the apparent theoretical underpinning, most previous studies have failed to prove the efficacy of superdrainage on reducing perfusion-related complications.5,17–19 We hypothesized that this disjunction might be attributable to the limitation of a singlecenter study using a small number of cases. Therefore, a systematic review with meta-analysis using multiple studies could be helpful to obtain a clearer overview. In the present study, we reviewed relevant publications and evaluated the influence of superdrainage using SIEV anastomosis on clinical outcome in DIEP flap breast reconstruction by meta-analytic methodology. MATERIAL AND METHODS

In the present meta-analysis, we investigated the potential benefits of superdrainage using SIEV on clinical

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flaps or in which DIEP flap-related data were not extractable from overall data were also excluded. Studies that evaluated the efficacy of double venous drainage without stating that SIEV was used for venous augmentation were excluded. When abstracts of studies met the inclusion criteria, their full text publications were examined further. Eventually, six studies5–7,17,18,20 were included and analyzed in this review (Fig. 1). Data Extraction

Figure 1. Study attrition diagram.

outcome and its drawbacks. Therefore, the primary outcome was perfusion-related complications, including postoperative flap congestion, total flap loss, partial flap loss, and fat necrosis. The secondary outcome was operative time. Using Medline, Ovid, and Google Scholar database, a literature search was performed to find studies published up to August 2014 that evaluated the efficacy of superdrainage using SIEV in the DIEP flap breast reconstruction. Search keywords were “Deep inferior epigastric perforator flap,” “DIEP flap” OR “abdominal flap” AND “superficial inferior epigastric vein,” “SIEV,” “superdrainage,” “venous augmentation” OR “venous supercharging.” References were also screened to retrieve relevant studies. A total of 57 studies were identified in the first search. Meticulous abstract review was performed to identify eligible materials for analysis. Both authors were involved in the process of study selection. Disagreements were settled by a thorough consensus discussion between the authors. Studies that met the following inclusion criteria were considered as candidates for this study; Clinical studies investigating the potential efficacy of superdrainage using SIEV in the DIEP flap breast reconstruction were considered as primary candidates. Only two-arm studies that compared clinical outcome of superdrainage group to control group were enrolled to estimate the relative risks (RRs) of complications. Exclusion criteria were: animal, imaging or cadaveric studies, single-arm studies, case reports or series with fewer than 10 cases, letters, comments, reviews, non-English language articles, and studies that were unrelated to our subjects. Studies that demonstrated the efficacy of superdrainage on flap salvage were also excluded. Because this review was focused on DIEP flap only, studies on other abdominal Microsurgery DOI 10.1002/micr

From the six studies finally included in this study, the following data were extracted in accordance with the guidelines of Meta-analysis of Observational Studies in Epidemiology21: the first author, publication year, study institution, patient number, case number, laterality of breast reconstruction (unilateral or bilateral), patients age, indication of superdrainage, specific technique including laterality of SIEV used and recipient veins for additional anastomosis, operative time and the incidence of each perfusion-related complication including postoperative flap congestion, total flap loss, partial flap loss, and fat necrosis. Statistical Analysis

Pooled RRs and corresponding 95% confidence intervals (CI) for perfusion-related complications were calculated by the Mantel–Haenszel test in RevMan 5.3. Mean difference (MD) and 95% CI were estimated for operation time of the two groups. The heterogeneity among studies was evaluated with the I2 test. When I2 ranged from 0 to 30%, studies included into the analysis were considered as being homogenous, for which a fixedeffects model was used. When the value of I2 exceeded 30%, a random effect model was used. The findings were presented as forest plots. Assessment of potential publication bias was conducted by generating funnel plots. RESULTS

Six studies representing 1,376 cases of DIEP flap breast reconstruction were analyzed (Table 1). All were retrospective cohort studies. No prospective or randomized-controlled studies were included. There were 842 cases undergoing superdrainage with SIEV as a study group and 534 conventional cases as a control group. Overall, flap survival rate was 98.8% on average, ranging from 98.0 to 100%. Mean incidence of partial flap loss and fat necrosis were 2.1% (0 to 6.3%) and 10.7% (7.2 to 18.8%), respectively. Incidence of flap congestion was 10.9% on average. With regard to the indication of superdrainage using SIEV, two5,6 of the six studies described it specifically, including one study on cases of sizable SIEV identified6 and one study on the

Benefits of SIEV Superdrainage in DIEP Flap Breast Reconstruction

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Table 1. General Characteristics of Included Studies Perfusion-related complications

Study

Study design

Enajat et al., 20107 Santanelli et al., 201217 Xin et al., 20125 Boutros et al., 20136 Lee et al., 201320 Al-Dhamin et al., 201418

Retrospective cohort Retrospective cohort Retrospective cohort Retrospective cohort Retrospective cohort Retrospective cohort

Case no.

Bilateral reconstruction

Patient’s agea (yrs)

Total flap loss

Partial flap loss

Fat necrosis

Postop. congestion

564

11.3%

50.6

2.0%

0.7%

9.9%

1.2%

247

0%

51.3

NA

3.2%

9.7%

NA

79

0%

51.8

1.3%

6.3%

NA

NA

352

90.9%

51.6

0%

NA

7.2%

0.9%

86

0%

44.3

1.1%

0%

17.4%

NA

48

41.7%

NA

2.1%

8.3%

18.8%

NA

a Mean value. No.; number, BMI; body mass index, DM; diabetes mellitus, NA; not applicable.

Table 2. Indication and Specific Technique of SIEV Superdrainage Used in the Studies Study

Indication of SIEV superdrainage

Specific technique of superdrainage

Enajat et al.,

Surgeon’s preference with considering size-match of veins, engorged SIEV or not presence of frank venous congestion during flap harvest or insetting

Santanelli et al.,17

NA

Xin et al.5

Cases requiring a large flap transfer including 4 zones without a dominant medial perforator

Boutros6

When a sizable SIEV was identified

Lee et al.20

Surgeon’s decision

Al-Dhamin et al.18

NA

Laterality of SIEV: contralateral SIEV preferred (97%) Recipient vein for SIEV: Cephalic vein preferred (82.8%), followed by IMV (9.6%), circumflex scapular vein (3.8%) and TDV (3.8%) Laterality of SIEV: NA Recipient vein for SIEV: Circumflex scapular vein, TDV, TAV, subscapular vein, lateral thoracic vein, cephalic and axillary vein Laterality of SIEV: NA Recipient vein for SIEV: TDV, lateral thoracic or intercostal vein (59.4%) another SIEV (28.1%), another DIEV (12.5%) Laterality of SIEV: NA Recipient vein for SIEV: internal mammary perforating vein or another lateral IMV besides medial one used for DIEV Laterality of SIEV: contralateral SIEV Recipient vein for SIEV: NA Laterality of SIEV: NA Recipient vein for SIEV: distal end of IMV (retrograde fashion)

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SIEV; superficial inferior epigastric vein, IMV; internal mammary vein, TDV; thoracodorsal vein, TAV; thoracoacromial vein, DIEV; deep inferior epigastric vein, NA; not applicable.

need of large DIEP flap without having dominant medial row perforators.5 The other four studies did not comment it in detail, just describing that it depended on surgeon’s decision or not describing at all. The surgical technique of superdrainage was diverse across studies (Table 2). Table 3 presents the results of brief comparison of clinical outcomes between superdrainage group and control group across six studies. In the study of Enajat et al.7 only the venous congestion rate was significantly different between the two groups, with similar incidence of other complications including total or partial flap loss, fat necrosis, hematoma, seroma, and infection. Santanelliet al.17 also reported comparable outcomes, with no significant difference in the incidence of

perfusion-related complications between the SIEV superdrainage group and control group. Xin et al.5 compared the outcomes of three different kinds of superdrainage technique using SIEV to the conventional method. The authors reported a similar rate of total flap loss and partial flap loss, although the operation time for the superdrainage group was 30 min longer than the conventional group. Boutros6 documented experience of dominant choice of superdrainage (88.4%) to single drainage (11.6%) for DIEP flap breast reconstruction, and described a significantly reduced incidence of venous congestion in the superdrainage group, with a similar rate of fat necrosis between the two groups. Similarly, Lee et al.20 also reported no statistically significant difference Microsurgery DOI 10.1002/micr

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Lee and Mun Table 3. Comparison of Clinical Outcome Between Superdrainage Group and Control Group Perfusion-related complication Total flap loss

Partial flap loss

Fat necrosis

Postop. congestion

Operation time (min) (mean 6 SD)

Study

Group

Case no.

Bilateral reconstruction

Enajat et al., 2010.7

Superdrainage

291

8.1%

2.1%

0.7%

8.6%

0%

383 6 122

Control P value Superdrainage

273

18.3%

0.7% 0.98

11.4% 0.26

173

0%

1.8% 0.38 NA

2.6% 0.006 NA

385 6 118 0.57 NA

Control P value Superdrainage

74

0%

32

0%

NA NA 396 6 42

47

0%

311 41

90.9% 90.2%

18

0%

Control P value Superdrainage

68

0%

17

NA

Control P value

31

NA

Santanelli et al., 201217

Xin et al., 20125

Boutros, 20136

Lee et al., 201320

Al-Dhamin et al., 201418

Control P value Superdrainage Control P value Superdrainage

11.5%a 16.2%a 0.429

NA NA 2.1%

8.5%

NA

NA NA NA

0% 0.998 0% 0% NA 0%

3.1% 0.643 NA NA NA 0%

NA NA 6.3% 16.7% 0.404 27.8%

NA NA 0.3% 4.9% 0.003 NA

366 6 72 NA NA NA NA NA

1.4% 0.998 0%

0% 0.999 5.8%

14.7% 0.194 17.6%

NA NA NA

NA NA NA

3.2% 1.00

9.6% 1.00

19.3% 1.00

NA NA

NA NA

a These figures indicate the incidence of partial flap necrosis, which that of partial flap loss and fat necrosis were combined. No.; number, SD; standard deviation, NA; not applicable.

in the incidence of total or partial flap loss and fat necrosis between the two groups. In the study by Al-Dhamin et al.18 the incidence of not only perfusion-related complications but also other complications including wound infection, dehiscence and hematoma was similar between the superdrainage group and the control group. The estimation of pooled RR was performed for each complication, including total flap loss, partial flap loss, fat necrosis, and postoperative flap congestion. Because the diagnosis criteria for dividing partial flap loss and fat necrosis were diverse and somewhat vague, we conducted additional analysis for the new category of partial flap necrosis, in which partial flap loss and fat necrosis were combined. As the heterogeneity across the studies remained low with an I2 value < 30%, a fixed effect model was employed for all analyses except for operation time (I2 5 66%), in which random effect model was used. The meta-analysis revealed little difference in the risk of total flap loss between the SIEV superdrainage and control groups (RR: 0.97, 95% CI: 0.36–2.57, P values 5 0.94) (Fig. 2). In the analysis for partial flap loss, a trend toward a decreasing risk in the superdrainage group was observed. However, it was not statistically significant (RR: 0.59, 95% CI; 0.18–1.94, P value 5 0.39) (Fig. 3). Similarly, in the analysis for fat necrosis, superdrainage using SIEV to reduce the risk of fat necrosis failed to Microsurgery DOI 10.1002/micr

achieve significant result (RR: 0.87, 95% CI: 0.58–1.30, P value 5 0.49) (Fig. 4). The risk of partial flap necrosis including partial flap loss and fat necrosis was decreased 20% in the superdrainage group compared to the control group, although it was not significantly different either (RR: 0.80, 95% CI: 0.57–1.11, P value 5 0.18) (Fig. 5). However, in the analysis for the risk of flap congestion, superdrainage did reduce the risk significantly (RR: 0.06, 95% CI: 0.01–0.51, P value 5 0.01) (Fig. 6). Comparison of the operation time between the two groups discerned a trend toward increased operation time in the superdrainage group compared to the conventional group, although the difference was not significant (MD: 14.87, 95% CI: 12.48–42.22) (Fig. 7). Potential publication bias was assessed by generating funnel plots. Figure 8 displays a funnel plot of the analysis for partial flap necrosis. A relatively symmetric shaped plot was observed, suggesting the low possibility of publication bias. All other analysis also showed similar symmetric-shaped funnel plots (graph not shown). DISCUSSION

Early experience of SIEV use in DIEP flap breast reconstruction has mainly focused on its use as a valuable option to salvage congested flaps. Villafane et al.

Benefits of SIEV Superdrainage in DIEP Flap Breast Reconstruction

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Figure 2. Forest plot evaluating the effect of SIEV superdrainage on the risk of total flap loss. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 3. Forest plot evaluating the effect of SIEV superdrainage on the risk of partial flap loss. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 4. Forest plot evaluating the effect of SIEV superdrainage on the risk of fat necrosis. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 5. Forest plot evaluating the effect of SIEV superdrainage on the risk of partial flap necrosis, which partial flap loss and fat necrosis were combined. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

reported their successful outcome of flap salvaging by using SIEV and described SIEV as a “lifeboat” for DIEP or TRAM flaps.22 Since then, not a few studies have demonstrated the experiences of successful salvage of

congested DIEP flaps using SIEV with diverse techniques.2–4,23–30 As the experience of DIEP flap breast reconstruction has accumulated and the importance of SIEV in the venous drainage of abdominal flaps has been Microsurgery DOI 10.1002/micr

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Figure 6. Forest plot evaluating the effect of SIEV superdrainage on the risk of postoperative flap congestion. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 7. Forest plot comparing overall operation time between superdrainage group and control group. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 8. Funnel plot of the analysis for the risk of partial flap necrosis. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

demonstrated, active applications of SIEV have been attempted, including prophylactic superdrainage using SIEV to reduce the incidence of flap congestion and subsequent complications. Several studies have investigated the potential efficacy of prophylactic venous superdrainage using SIEV.5–7,17,18,20 However, none succeeded in demonstrating significant benefits of SIEV superdrainage in reducing the incidence of perfusion-related complications including total or partial flap loss, although those in decreasing the flap congestion rate were shown by some studies.6,7 At first, we considered that this might be because all relevant studies were single-institution studies each with a small number of patients, which may not be large enough to detect statistically significant differences between groups considering the low incidence of perfusion-related complications in DIEP flap breast Microsurgery DOI 10.1002/micr

reconstruction series. However, the present meta-analysis using six studies of 1,400 cases also failed to demonstrate the efficacy of SIEV superdrainage in reducing the risk of flap-related complications. As expected, SIEV superdrainage remarkably reduced the risk of flap congestion. By augmenting venous drainage through SIEV, elevated DIEP flaps can have original dual venous drainage system, which was similar to the situations before flap elevation. In addition, even though DIEV would not show a fair function for various reasons, such as fallacious selection of perforators having insufficient venous capacity, perforator injury during dissection or lacking proper communicating veins between superficial and deep system, venous drainage of the flap can maintain sufficient owing to SIEV, which can be a “back-up” or “life-boat” to prevent flap congestion as mentioned previously. Meanwhile, no significant changes were observed in the risks of other perfusion-related complications after venous superdrainage. Especially, the risk of total flap loss was little affected by SIEV superdrainage. One possible explanation is that total flap failure obviously could be occurred due to not only venous congestion, but also arterial thrombosis that could not be protected by venous superdrainage. Excellent outcome of flap salvaging also may contribute to this result. In spite of the relatively high incidence of flap congestion in the control group, congested flaps can be successfully salvaged by using various methods, eventually leading to comparable flap survival rate. In contrast with the analysis for total flap loss, relatively apparent trends toward decreasing risks of partial flap loss, fat necrosis, and partial flap necrosis were

Benefits of SIEV Superdrainage in DIEP Flap Breast Reconstruction

observed in the superdrainage group, although they did not reach statistical significance. It is likely that though the high incidence of venous congestion in the control groups might have been camouflaged by the high rate of successful flap salvaging, the sequelae of venous congestion may have remained as a form of partial flap loss or fat necrosis, eventually generating those differences. Another explanation for the decreased risk of partial flap necrosis in the superdrainage group can be inferred from previous animal studies. Most animal studies regarding this topic have demonstrated that venous augmentation using SIEV significantly increased the rate of flap survival area compared to conventional methods.12,14–16 It can be assumed that SIEV superdrainage might extend reliable vascular territory, possibly contributing to the reduction of partial flap necrosis rate, especially in cases that require the transfer of large DIEP flaps beyond its original perforasome. Long operation time has been addressed as one of the drawbacks of superdrainage procedure. A trend toward increased operation time in the superdrainage group was observed in this study. However, the difference was relatively small (15 min) probably due to the wide use of coupler, and not statistically significant. Therefore, a potential impact of those elongated operation time may not be considerable, although it needs to be evaluated further. Overall, the present study suggests that, although the risk of total flap loss remains stationary, SIEV superdrainage does reduce the risk of flap congestion remarkably and that of congestion-related sequelae to some extent. Given the relatively acceptable opportunity cost of this procedure such as the slightly elongated operation time, the extension of its indication can be considered to reduce the incidence of flap congestion and related complications. Of course, the risks and benefits of routinely performing venous augmentation need to be investigated further. Signs inferring that the vena comitans of perforators do not function properly might have to be carefully examined intra-operatively or immediate postoperatively. Engorged SIEV after flap elevation has been addressed as a sign of inadequate venous drainage through the deep system in several studies.4,24,28,29 Large caliber of SIEV before flap elevation may also suggest the flaps are superficially dominant and requiring superdrainage,2,8,22 although this remains debatable.31,32 Brisk bleeding from SIEV or flat DIEV after anastomosis might also have to be examined cautiously.29 Furthermore, in cases having known risk factors of perfusion-related complications or unfavorable conditions to flap perfusion, such as obesity, smoking, and vertical infraumbilical scars, prophylactic superdrainage using SIEV might be considered as a reliable option. The present study is the first meta-analysis regarding this topic with the largest number of cases analyzed.

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Despite this, there are some limitations to generalize the results of this study. First, although 1,376 cases from six studies were summed and analyzed, the number of cases may not be adequately large to detect statistical significance in perfusion-related complications between the two groups. For example, in the analysis for partial flap necrosis, presuming that the average incidence of partial flap necrosis was approximately 12% and the protective effect of SIEV superdrainage was 20% as demonstrated in this meta-analysis, the expected reduction of partial flap necrosis rate in the superdrainage group would be 12–9.6%. As a result, a total of 2,624 cases in each group would be needed to have a power of 80% to detect a difference at a 5 0.05 level of significance. Larger studies would be required to obtain more solid conclusions. Diverse surgical techniques of SIEV superdrainage across the studies might be another obstacle in evaluating its homogenous efficacy. In particular, the laterality of SIEV used for superdrainage can influence its effects on flap perfusion and clinical outcome. As a matter of fact, Rothenberger et al.33 demonstrated in their clinical experimental study that supercharging with contralateral and ipsilateral SIEV have different effects on venous drainage of flaps, with contralateral SIEV producing better improvement of venous drainage, especially in contralateral flap tissue, although their results need to be verified by large-scaled clinical outcome studies. Furthermore, the laterality of breast reconstruction can also affect the choice of laterality of SIEV, and may have to be considered when interpreting the results. For example, ipsilateral SIEV used in bilateral breast reconstruction and contralateral SIEV used in unilateral breast reconstruction may have different effects on venous drainage of the flaps. However, as the majority of the included studies in the present review did not specify the laterality of SIEV used, we could not evaluate the impact of ipsilateral and contralateral SIEV separately, which is one of the main limitations of this study. Two studies provided data concerning laterality of SIEV used.7,20 Both studies representing 47% of total cases of this meta-analysis used the contralateral SIEV mostly and showed a similar rate of perfusion-related complications between the superdrainage group and the control group. Given that the contralateral SIEV can have better efficacy than the ipsilateral one, it might be inferred that the superdrainage using SIEV may not have a significant influence on the clinical outcome regardless of the laterality of SIEV, though further studies would be required. The choice of perforator rows harvested might also influence the outcome and needs to be considered, which could not be evaluated in this study due to difficulty in data extraction. The role of SIEV can be varied depending on the rows of perforators harvested. SIEV did not play a significant role for augmentation of flap perfusion Microsurgery DOI 10.1002/micr

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in medial row perforator-based DIEP flaps,34 however its efficacy might be different in lateral row based flaps. As another limitation, the low level of evidence of the six included studies also weakened the strength of this meta-analysis. All included studies were retrospective cohort studies. None had level I or II evidence. Especially, for evaluating the benefits of prophylactic venous augmentation using SIEV with minimizing the impact of other confounding factors, random assignment of cases into two groups is an essential prerequisite. However, no studies featured a randomized controlled design. Some studies commented that the case assignment depended on the surgeons’ preference or decision. However, there is a possibility that cases with a high risk of venous congestion or suffering from intraoperative congestion may be assigned for superdrainage according to surgeons’ judgment. Considering the possibility of this selection bias, the comparable outcomes of the superdrainage group to the control group might be interpreted as that the superdrainage using SIEV has some clinical benefits. Further well-controlled studies and their meta-analysis would be needed. CONCLUSIONS

The present review demonstrated that superdrainage using SIEV reduces the risk of flap congestion notably, while having little influence on flap survival. With regard to partial flap necrosis including partial flap loss and fat necrosis, general trends toward decreased risks were observed. However, statistical significance was not achieved and further studies would be needed. The significance of the present review is that it provides a basis for further large-scaled well-controlled studies and their meta-analysis.

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Microsurgery DOI 10.1002/micr

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Microsurgery DOI 10.1002/micr

Benefits of superdrainage using SIEV in DIEP flap breast reconstruction: A systematic review and meta-analysis.

Superdrainage using superficial inferior epigastric vein (SIEV) has been often used to overcome occasional venous insufficiency in deep inferior epiga...
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