PURPOSE: It has become an increasingly popular option to use the deep inferior epigastric perforator flap (DIEP) for post-mastectomy reconstruction.  Decreased abdominal wall morbidity and excellent reconstructive results are two key advantages that these flaps have to offer.  However, the DIEP flap may have a greater incidence of venous congestion.  The purpose of this study is to evaluate a new option for venous outflow, the retrograde limb of the internal mammary vein (IMV) as a recipient vein in DIEP breast reconstruction.

METHOD: A series of fifteen DIEP flaps in 13 breast reconstruction patients were prepared by anastomosing the deep inferior epigastric artery with the internal mammary artery (IMA) and one vena comitante with the antegrade IMV.  An additional venous anastomosis was then made between the second vena comitante and the remaining IMV in a retrograde direction. Nine of the thirteen patients were treated with radiation therapy.  Venous congestion was assessed over a 15-minute period, and intraoperative duplex ultrasound was utilized to demonstrate the direction of venous blood flow away from the flap and into the retrograde IMV. Anastomotic couplers (sizes ranging from 1.0 to 2.0) were used for the venous anastamoses in twelve patients.  One patient undergoing bilateral reconstruction had their venous connections sewn.

RESULTS: Fifteen DIEP flaps for breast reconstruction were completed using the retrograde IMV over a four-month period. The post-operative days in the hospital averaged 5 (range 4-9 days).  There was one incidence of post-operative cellulites which resolved uneventfully with antibiotics.  No evidence of venous congestion was observed. Furthermore, retrograde blood flow was demonstrated using intraoperative duplex imaging.  All of the fifteen flaps in the series were successful.

CONCLUSION: The clinical course of the DIEP flaps with the additional retrograde outflow was robust and without development of venous congestion.  There were few post-operative complications.  The retrograde IMV provides a large caliber vessel which should improve venous outflow when compared to an antegrade IMV anastomosis alone.  Intraoperative duplex ultrasound confirmed these findings, and supports the use of a retrograde venous IMV anastomosis in DIEP breast reconstruction.  Our proposed technique has been implemented on all of the senior author’s DIEP flaps.  Further data collection will provide long term results on the anticipated benefits this technique.