Differences of the midline-crossing venous drainage pattern in supraumbilical and infraumbilical regions: Angiographic study using fresh cadavers.

Seong Oh Park,Nobuaki Imanishi,Hak Chang,Raffaele Serra

doi:10.1371/journal.pone.0242214

Seong Oh Park, Nobuaki Imanishi + Show 2 more

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https://doi.org/10.1371/journal.pone.0242214

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Abstract

Current clinical and anatomical studies show that the venous problem associated with the deep inferior epigastric perforator flap results from poor midline-crossing. We examined the venous anatomy of the infraumbilical midline area and the dynamic venous flow of the deep inferior epigastric perforator flap in nine fresh cadavers. All nine abdominal specimens were harvested between the subcostal margin and the groin crease. Two specimens were used to analyze the abdominal venous anatomy, one of which was divided into two hemi-abdominal specimens. The remaining seven specimens were harvested as deep inferior epigastric perforator flaps with one major paraumbilical perforator. Venous cannulation and serial angiographic agent injection were performed in several conditions. Each specimen was radiographed using a soft X-ray system. For additional information, computed tomography (CT) angiography-visualized superficial inferior epigastric veins (SIEVs) and the supraumbilical branch were analyzed. We noted that the venous drainage between the bilateral SIEVs was easier to configure in the supraumbilical area than in the infraumbilical area. Only one to two short polygonal venous networks connect the bilateral superficial inferior epigastric veins in the supraumbilical area; however, long and multiple polygonal venous networks connect the bilateral superficial inferior epigastric veins in the infraumbilical area, which could be a predisposing factor for venous congestion. The mean distance from the umbilicus upper border to evident supraumbilical midline crossover was 18.39±4.03 mm (range: 10.10–28.49) in CT angiograms. In cadaver specimens, the mean distance was 10.87±4.85 mm (range: 4.6–18.9). Supraumbilical midline crossover was more favorable than infraumbilical midline crossover in venous flow.

Highlights

One of the most common complications of the deep inferior epigastric perforator (DIEP) flap, which is most commonly used for breast reconstruction, is poor venous drainage
We reviewed preoperative computed tomography (CT) angiography performed from March 2019 to February 2020 for DIEP flap perforator mapping
The supraumbilical midline area was well visualized from an early period. (Fig 1A, red ellipse) More advanced cannulation and injection into the medial branch of the superficial inferior epigastric veins (SIEVs) allowed the veins in the infraumbilical midline area to be visualized (Fig 1B)

Summary

Introduction

One of the most common complications of the deep inferior epigastric perforator (DIEP) flap, which is most commonly used for breast reconstruction, is poor venous drainage. Superdrainage using the contralateral superficial inferior epigastric vein (SIEV) shows a beneficial effect in lowering partial flap loss and fat necrosis [7,8,9,10]. A tendency of lower partial flap loss and fat necrosis was observed [11]. This suggests that the venous drainage issues associated with the DIEP flap arise from poor midline crossing; studies on the venous anatomy of the abdominal wall support this [2,3,12,13]. Hydrogen peroxide priming has shown more detailed venous anatomy and elucidated the anatomical cause of venous drainage problems of the DIEP flap [2]

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