Superficial vs. Deep Venous System in DIEP Flaps: Lessons from 25 Years of CTA-Guided Planning

Area of Science:

• Plastic Surgery
• Vascular Surgery
• Breast Reconstruction

Background:

• Venous congestion is a primary cause of complications in Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction.
• Anatomical variations in venous connections between superficial and deep systems can impact flap drainage and viability.
• Preoperative imaging and targeted surgical techniques are crucial for optimizing venous outflow in DIEP flaps.

Purpose of the Study:

• To investigate the impact of preoperative computed tomographic angiography (CTA) and superdrainage on outcomes in DIEP flap breast reconstruction over 25 years.
• To assess the influence of venous anatomy, specifically the superficial inferior epigastric vein (SIEV) connection to the deep system, on flap success.
• To evaluate the safety and efficacy of superdrainage guided by CTA and intraoperative findings.

Main Methods:

• Retrospective analysis of 208 DIEP flaps performed between 2000 and 2024.
• Routine use of CTA since 2006 to evaluate SIEV anatomy and its connection to deep veins.
• Superdrainage performed based on superficial venous dominance or intraoperative assessment; outcomes analyzed for venous congestion, necrosis, reoperations, and hospital stay.

Main Results:

• Significant reduction in venous complications post-CTA implementation (37.5% to 8.0%, p < 0.001).
• Superdrainage performed in 40.9% of post-CTA cases, with 90% planned preoperatively via CTA; no complications from second venous anastomosis.
• Flap outcomes correlated with venous drainage physiology, not perforator number or flap size; mean hospital stay decreased post-CTA (6 vs. 9 days, p < 0.001).

Conclusions:

• CTA-based evaluation of superficial and deep venous connections enhances preoperative planning for DIEP flaps, enabling safer, physiology-driven decisions.
• Intraoperative assessment remains vital when anatomical connections are absent.
• Surgical strategy in DIEP flap reconstruction should prioritize venous drainage physiology over anatomical metrics alone.