Intraoperative venous congestion in free transverse rectus abdominis musculocutaneous and deep inferior epigastric artery perforator flaps during breast reconstruction: A systematic review

BACKGROUND: Even with patent deep inferior epigastric vein anastomoses, venous congestion can occur during free transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flap surgery and lead to flap compromise if not recognized and managed. OBJECTIVES: To identify the incidence of intraoperative venous congestion and describe the best available prevention and treatment methods. METHODS: Systematic electronic searches of the PubMed database including Medline were performed to identify studies published until 2014. The following keywords were used: "DIEP" or "free TRAM" and "venous insufficiency" or "venous congestion". Supplemental searches were conducted to identify referenced studies. Statistical analysis using the chi(2) test was performed. RESULTS: Nine studies representing 4747 free abdominal flaps cases were included and demonstrated an overall incidence of intraoperative venous congestion of 2.8%. The incidence in DIEP flaps (3.3%) was significantly higher than that in the free TRAM flaps (1.0%). All nine articles reported using the superficial inferior epigastric vein to treat venous insufficiency. CONCLUSION: The risk for developing intraoperative venous congestion following free abdominal flap breast reconstruction is influenced by inadequate perforator selection and persistent dominance in the superficial venous system. The solution is establishing another venous draining route using the superficial inferior epigastric vein.