Accepted Manuscript The superficial outside-flap shunt (SOS) technique for free deep inferior epigastric perforator flap salvage Alex J. Davies , MRCS Jennifer K. O’Neill , FRCS(Plast) Sherif M. Wilson , FRCS(Plast) PII:

S1748-6815(14)00212-5

DOI:

10.1016/j.bjps.2014.04.034

Reference:

PRAS 4179

To appear in:

Journal of Plastic, Reconstructive & Aesthetic Surgery

Received Date: 29 January 2014 Revised Date:

18 April 2014

Accepted Date: 26 April 2014

Please cite this article as: Davies AJ, O’Neill JK, Wilson SM, The superficial outside-flap shunt (SOS) technique for free deep inferior epigastric perforator flap salvage, British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.04.034. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT TITLE The superficial outside-flap shunt (SOS) technique for free deep inferior epigastric perforator flap salvage

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AUTHORS Alex J Davies MRCS Jennifer K O’Neill FRCS(Plast)

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Sherif M Wilson FRCS(Plast)

AFFILIATION

Kingdom

CORRESPONDING AUTHOR

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Alex J Davies

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Department of Plastic and Reconstructive Surgery, Frenchay Hospital, Bristol, United

Department of Plastic and Reconstructive Surgery Frenchay Hospital

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Bristol United Kingdom

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Tel +44 117 970 1212

Email [email protected]

PRESENTED AT

British Association of Plastic, Reconstructive and Aesthetic Surgeons and Irish Association of Plastic Surgeons Winter Scientific Meeting, Dublin, Ireland, 29th November 2013

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ACCEPTED MANUSCRIPT ABSTRACT A common cause for loss of a deep inferior epigastric perforator (DIEP) flap is venous congestion secondary to inadequate outflow via the deep perforating vessels. Further anastomosis of the superficial venous system provides effective outflow and

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salvage of the congested DIEP. Multiple methods have been described requiring dissection of additional recipient venous systems or around the perforating vessels in order to provide a vein onto which the superficial system may be anastomosed. These are potentially associated with increased morbidity and risk of damage to the

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pedicle. We describe an alternative technique of harvesting an additional length of deep inferior epigastric pedicle cranial to the perforator onto which an anastomosis

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may be performed. This avoids the need for additional dissection of recipient vessels or further handling of the perforator, its venae comitantes and the main pedicle of the flap thus reducing the risk of damage.

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KEY WORDS

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DIEP flap venous congestion; venous augmentation; flap salvage; microsurgery

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ACCEPTED MANUSCRIPT ARTICLE The free deep inferior epigastric perforator (DIEP) flap is a popular method of autologous breast reconstruction. It has advantages over free TRAM flaps in that it avoids dissection of the anterior abdominal wall. In Allen’s initial description of the

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DIEP flap1 it was proposed that harvesting of the rectus abdominis muscle as in a TRAM flap leads to a significant donor morbidity and that some 10-20% of patients do not return to work. The recti are responsible for initiating abdominal flexion and increasing intra-abdominal pressure. They also provide resistance for the contraction

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of the internal obliques and so their sacrifice leads to decreased rotational strength. A systemic review of abdominal function found less morbidity on isometric

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dynomometry and physiotherapy measures in DIEP flaps compared to TRAM flaps, as well as decreased incidence of ventral hernia or bulge2.

However it has been reported that in two percent of DIEP flaps that the deep perforator veins have not been adequate to provide venous drainage of the flap

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resulting in compromise from venous congestion3. Multiple methods of augmentation of the venous drainage of DIEP flaps have been described. These mostly involve further dissection to provide a further donor vessel onto which the superficial system

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can be anastomosed, this may also require harvesting of a vein graft. This is potentially associated with increased morbidity and takes time during which the flap

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can become further compromised. More recently there have been efforts to anastomose the superficial system to the deep system via the perforating vessel thus preventing the need for further dissection of a new donor vessel. We report a new technique of draining the superficial system into the pedicle without further dissection of the perforating veins.

Surgical Technique Patients are assessed preoperatively with CT Angiography to assess the number, size and position of suitable perforators as well as links to and drainage of the

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ACCEPTED MANUSCRIPT superficial inferior epigastric system. The position of suitable perforators are then confirmed on the day of surgery with preoperative Doppler ultrasound and marked on the patient. At the time of flap raising the superficial inferior epigastric veins (SIEV) are evaluated

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and a 6-7 cm length preserved and raised with the flap for use in flap salvage if required.

The perforators and deep inferior epigastric artery (DIEA) pedicle are then identified and dissected. Once the origin of the perforator has been identified as it branches

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from the main pedicle a further 2-4 cm of deep inferior epigastric vessels is dissected out cranial to the pedicle and divided. This is raised with the flap for use in venous

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augmentation. The pedicle is then anastomosed to the internal mammary vessels and the flap inset.

It is our experience that the dissection of the extra cranial length of vessel does not expose a significant number of lateral intercostal nerves, however loupe

motor nerves.

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magnification is used and care is taken to identify and preserve any lateral intercostal

Occasionally it is noted that the flap develops global congestion either before the

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pedicle is divided or after anastomosis of the vessels. In this case the SIEV is assessed bilaterally and if noted to be engorged a diagnosis of flap anatomical

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superficial vascular dominance is made. The preserved length of SIEV can easily be brought underneath the flap to meet with the additional length of DIEV and an end-to-end anastomosis performed. This allows forward flow from the superficial system directly into the pedicle and thus into the internal mammary veins (Fig. 1 and 2). The preserved lengths of SIEV and DIEV allow for a tension free anastomosis even with periumbilical perforators which are anatomically distant to the SIEV. No further dissection of a recipient vessel is needed.

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ACCEPTED MANUSCRIPT Results At our institution the senior author has performed 308 DIEP reconstructions in 258 patients between March 2007 and November 2013. Of these 18 (5.8 percent) flaps have developed venous compromise. Early in our series two flaps were lost when

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venous congestion went unnoticed. These losses lead to a heightened awareness of this potential problem and an interest in finding techniques for addressing it. Of the further 16 flaps that subsequently become congested the technique described in this article was successfully used to salvage seven of these, the rest being salvaged by

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the other techniques summarised in the discussion below. We have had no incidence

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of flap loss secondary to venous congestion using salvage techniques.

Discussion

It has been noted that even in the presence of an adequate anastomosis between the pedicle and recipient vessel that free DIEP flaps may become congested as the

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outflow through the pedicle may be insufficient to drain the flap fully. The concept of anatomical superficial system dominance has been described whereby the main outflow of the flap is via the superficial veins rather than via the venae comitantes

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accompanying the perforating artery3. Anastomosis and drainage of the superficial system is an effective and proven method by which a globally congested DIEP flap

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secondary to superficial dominance may be salvaged. A well recognised conduit for draining the superficial system is the SIEV4. This vein is present in up to 95 percent of DIEP flaps5. Multiple methods have been described in order to augment the venous drainage via the SIEV. Blondeel et al describe the use of an interposition vein graft, usually from saphenous vein, joining the SIEV to the internal mammary vein3,6. Weschselberger et al describe diverting the venous output from the SIEV through other recipient venous systems including the thoracodorsal, lateral thoracic and intercostal vein7. Barnett et al in turn described the division of the cephalic vein as another recipient system8. The list was further added to by Niranjan

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ACCEPTED MANUSCRIPT et al who described anastomosing the SIEV to the lateral pectoral vein, as well as interposition grafting to the opposite pedicle9. These techniques have all proven to be effective means of augmenting the venous drainage of the superficial system. However they all require the dissection of a further

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recipient venous system and/or the harvesting of a vein graft and their associated morbidities. Furthermore the time taken to dissect out these vessels leaves the compromised flap at further risk.

Rhode et al describe a novel technique that avoids dissection of new donor vessels

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by using the perforator as an in situ vein graft10. The perforator often exists as a central artery with two surrounding venae comitantes5. They perform a dissection at

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the point where the pedicle enters the underside of the flap dividing one of the venae comitantes and using this to anastomose the SIEV on to. Liu et al commented that this dissection around the base of the flap puts the perforator at risk of complete flap failure by potential damage to the remaining perforating vessels11. They report an

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adaptation of the technique whereby the venae comitantes is divided at the proximal end of the perforator as it branches from the deep inferior epigastric pedicle. This results in reverse flow through the venae comitantes however the presence of DIEP

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venae comitantes intercommunications (H-shunt) provides flow into the second venae comitantes and hence into the DIEV.

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We feel that dissection and handling of the perforator and its venae comitantes should be minimal in order to prevent damage and total loss of an already compromised flap. Anastomosis of the venae comitantes at the level of the perforating vein is also more technically challenging compared to the level of the main pedicle (DIEV). We have found that the routine harvesting of an additional length of DIEV as it passes cranially beyond the perforator acts as a further in situ vein graft connected directly to the IMV. It has the advantage of not requiring any dissection or handling of the perforator or the proximal pedicle. If a sufficient length of SIEV is preserved at the

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ACCEPTED MANUSCRIPT time of flap raising then this can easily reach the additional length of DIEV and an anastomosis can be performed without tension or technical difficulty even when the dominant perforator is periumbilical and therefore sits right underneath that flap furthest away from its periphery. No interposition vein grafting is needed and the

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method is not reliant on reverse flow or venae comitante intercommunications. Therefore variations in the anatomy of the perforator and its accompanying venae comitante do not need to be taken into account and will not prevent the use of this technique.

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The harvesting of an addition length of DIEV beyond the perforator takes minimal time to perform adding little to the overall length of the operation. If the flap becomes

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congested intraoperatively then this method of augmenting the superficial system is immediately available and time is not wasted dissecting out an alternative receiving venous system or vein graft.

Occasionally DIEP flaps become congested in the postoperative period and the

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surgeon can be reassured that with an expeditious return to theatre for flap exploration that augmentation of the superficial system can be performed rapidly as the vessels are already prepared. Again this prevents unnecessary delay in

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salvaging a compromised flap.

The authors strongly feel that each case must be approached individually and a

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chosen method of venous augmentation may not be suitable in every patient. Damen et al state that the incorporation of algorithms into surgical practice simplifies the decision-making processes involved in microsurgical breast reconstruction12. They present an algorithm that they have found useful for guiding their treatment of flap venous congestion. Their algorithm recognises the importance of identifying and treating superficial system dominance by opening the SIEV on the congested side. With such a large number of techniques described as well as the addition of our own for draining the superficial system we in turn suggest a simple algorithm that

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ACCEPTED MANUSCRIPT surgeons may use in deciding which method to use depending upon the individual anatomy of a particular patient with compromise of a DIEP flap (Fig. 3).

Conclusion

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Our technique does not require harvest of a further recipient vein or vein graft and allows anastomosis to the pedicle without disturbing the flow from the perforator. We have found it to be a safe, quick and effective technique for augmenting the venous

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outflow of a congested DIEP flap.

Conflict of Interest: None

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Funding: None

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Ethical Approval: N/A

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ACCEPTED MANUSCRIPT REFERENCES

1 Allen RJ, Treece P. Deep inferior epigastric flap for breast reconstruction. Ann Plast Surg. 1994;32:32-8 2 Atisha D, Alderman AK. A systematic review of abdominal wall function following

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abdominal flaps for postmastectomy breast reconstruction. Ann Plast Surg. 2009;63:222-30

3 Blondeel PN, Arnstein M, Verstraete K et al. Venous congestion and blood flow in

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free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg. 2000;106:1295-9

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4 Villafane O, Gahankari D, Webster M. Superficial inferior epigastric vein (SIEV): ‘lifeboat’ for DIEP/TRAM flaps. Br J Plast Surg. 1999;52:599

5 Reardon CM, O’Ceallaigh S, O’Sullivan ST. An anatomical study of the superficial inferior epigastric vessels in humans. Br J Plast Surg. 2004;57:515-9 6 Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal

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experience. Br J Plast Surg. 1999;52:104-11 7 Weshselberger G, Schoeller T, Bauer T et al. Venous superdrainage in deep inferior epigastric perforator flap breast reconstruction. Plast Reconstr Surg.

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2001;108:162-6

8 Barnett GR, Carlisle IR, Gianoustsos MP. The cephalic vein: an aid in free TRAM

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flap breast reconstruction. Report of 12 cases. Plast Reconstr Surg. 1996;97:71-6 9 Nirnajan MS, Khandwala AR, Mackenzie DM. Venous augmentation of the free TRAM flap. Br J Plast Surg. 2001;54:335-7 10 Rohde C, Keller A. Novel technique for venous augmentation in a free deep inferior epigastric perforator flap. Ann Plast Surg. 2005;55:528-30 11 Liu TS, Ashjian P, Festekjian J. Salvage of congested deep inferior epigastric perforator flap with a reverse flow venous anastomosis. Ann Plast Surg. 2007;59:214-7

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ACCEPTED MANUSCRIPT 12 Damen THC, Morritt AN, Zhong T, Ahmad J, Hofer SOP. Improving outcomes in microsurgical breast reconstruction: lessons learnt from 406 consecutive DIEP/TRAM

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flaps performed by a single surgeon. J Plast Reconstr Aesthet Surg. 2013;66:1032-8

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ACCEPTED MANUSCRIPT FIGURE LEGENDS

Fig. 1. Illustration of anastomosis of the superficial inferior epigastric vein (SIEV) to an additional 2 – 3 cm of deep inferior epigastric vein (DIEV) in order to provide flow

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of an engorged superficial system into the deep system. Note how no dissection is carried out around the fragile perforating vessels around the base of the flap.

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Fig. 2. Intraoperative photograph of the underside of the DIEP flap demonstrating anastomosis of the superficial inferior epigastric vein (SIEV) to the deep inferior

branch from the main pedicle.

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epigastric vein (DIEV) that has been preserved cranially to where the perforators

Fig. 3. Surgical algorithm for deciding which method to use in the salvage of a

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text of the article.

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congested DIEP flap. Individual techniques are described and referenced within the

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ACCEPTED MANUSCRIPT

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DIEV DIEA DIEV

SIEV 7 - 8 cm

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Flap

2 - 3 cm

Anastomosis

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ACCEPTED MANUSCRIPT

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Long  super&icial  system?  

Anastomosis  of   super&icial  system  to   additional  drainage   system  extrinsic  to  &lap  

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Anastomosis  of   super&icial  system  to   deep  system  

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Short  super&icial   system?  

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DIEP  &lap  congested?  

To  additional  length  of   DIEV  (SOS  technique)  

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To  perforator  

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Antegrade  &low  to  venae   commitantes  at  base  of   &lap  

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Reverse  &low  venous   anastomosis  

Antegrade  &low  of  IMV  

Second  venae   commitantes  of  IMV  

Cephalic  vein  

Thoracodorsal  vein  or   its  branches  

 

The superficial outside-flap shunt (SOS) technique for free deep inferior epigastric perforator flap salvage.

A common cause for loss of a deep inferior epigastric perforator (DIEP) flap is venous congestion secondary to inadequate outflow via the deep perfora...
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