Philadelphia, Pa. From the University of Pennsylvania.
Plast Reconstr Surg. 2012 Apr;129(4):809-815. doi: 10.1097/PRS.0b013e318244222d.
Despite common superficial venous system dominance of the abdominal wall, the majority of transverse rectus abdominis musculocutaneous (TRAM)/deep inferior epigastric perforator (DIEP) flaps drain adequately, due to communicating veins with the deep system. In cases where such connections are inadequate, it is necessary for the surgeon to correctly recognize resultant congestion as an intrinsic flap issue, and treat it intraoperatively.
A retrospective analysis of 1201 consecutive TRAM/DIEP free flaps over a 5-year period was performed. All cases of inadequate venous outflow not due to technical anastomotic problems or venous thrombosis were identified and analyzed.
From a cohort of 1201 patients undergoing free TRAM and DIEP flap breast reconstruction, 11 (0.9 percent) exhibited intraoperative congestion due to persistent superficial venous system dominance, despite patent deep vein anastomosis. Most commonly (five flaps), anastomosis of the superficial inferior epigastric vein (SIEV) to a proximally dissected vena comitans of the flap deep inferior epigastric vein system (DIEV) was performed; thus, a superficial to deep venous loop was created within the flap. Intraoperative salvage rate was 100 percent.
In this series, intraoperative congestion is most commonly due to a superficially dominant flap. In such flaps, the deep venous anastomosis is patent, and yet adequate venous drainage cannot be achieved due to the lack of communicating vessels between the two systems, or due to inadequate perforator selection. Anastomosis of the SIEV to a proximally dissected vena comitans of the DIEV on the flap was performed most commonly in our series. This allows anastomosis of two veins in close proximity, and avoidance of using a second recipient vein.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
尽管腹壁的浅静脉系统通常占主导地位，但由于与深部系统的交通静脉，大多数横行腹直肌肌皮瓣（TRAM）/深部腹壁下动脉穿支皮瓣（DIEP）的引流效果良好。在这种情况下，如果连接不足，外科医生有必要正确地将由此产生的充血视为皮瓣的固有问题，并在手术中进行治疗。
对 5 年内连续 1201 例 TRAM/DIEP 游离皮瓣进行回顾性分析。所有因技术吻合问题或静脉血栓形成导致静脉回流不足的病例均被识别并进行分析。
在 1201 例接受游离 TRAM 和 DIEP 皮瓣乳房重建的患者中，11 例（0.9%）表现出术中充血，尽管深静脉吻合通畅，但仍存在浅静脉系统持续占主导地位的情况。最常见的（5 例）是将腹壁浅静脉（SIEV）吻合到皮瓣深部腹壁下动脉穿支静脉系统（DIEV）近端解剖的伴行静脉，从而在皮瓣内形成浅静脉到深静脉的循环。术中抢救成功率为 100%。
在本系列中，术中充血最常见的原因是皮瓣的浅静脉优势。在这种皮瓣中，深静脉吻合是通畅的，但由于两个系统之间缺乏交通血管，或者由于穿支选择不足，无法实现足够的静脉引流。在本系列中，最常见的是将 SIEV 吻合到皮瓣 DIEV 的近端解剖伴行静脉，这允许在接近的位置吻合两条静脉，并避免使用第二条受体静脉。
临床问题/证据水平：治疗，IV。
