Microvascular lifeboats: a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction.

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Sir: In the article by Galanis et al. entitled “Microvascular Lifeboats: A Stepwise Approach to Intraoperative Venous Congestion in DIEP Flap Breast Reconstruction,”1 the authors provide an excellent algorithm for addressing a failing flap. Unfortunately, this is a far-too-common complication that every microsurgeon will face many times throughout a career. As with any crisis scenario, having a set protocol to follow greatly improves troubleshooting and outcomes. The team from Los Angeles provides just this with detailed technique and theory for each step. They begin by describing how to diagnose venous congestion followed by steps to prevent occurrence. This is then followed by solutions of increasing complexity. One of these solutions suggests connecting the superficial inferior epigastric vein to the second deep inferior epigastric vein. As depicted (Fig. 1), this would create retrograde flow through one of the branches of the deep inferior epigastric vein system. We have had both success and failure with this method. Failures occur when the valvular distribution within the deep inferior epigastric vein prevents the flow from the superficial inferior epigastric vein (red valves added to depict flow limitations). However, if the second deep inferior epigastric vein is divided close to the flap and connected to the superficial inferior epigastric vein with flow between the branches of the deep inferior epigastric vein, the valves would then be avoided and anterograde flow maintained (green arrow). Knowledge that the solution presented can be sabotaged by a valve(s) within the deep inferior epigastric vein can help with troubleshooting problems after use of this lifeboat solution. We commend the authors on this methodical and systematic thought process in the salvage of a complex operation.Fig. 1: The deep inferior epigastric flap as depicted in Figure 4 from the original article with an anastomotic connection between the deep inferior epigastric vein (DIEV) and the superficial inferior epigastric vein (SIEV). The locations of valves (red) within the deep inferior epigastric vein and an alternative anastomotic location from the superficial inferior epigastric vein to the deep inferior epigastric vein (green) are shown. DIEA, deep inferior epigastric artery; IMV, inframammary vein; IMA, inframammary artery.DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Naveed N. Nosrati, M.D. Sunil S. Tholpady, M.D., Ph.D. Juan Socas, M.D. Department of Surgery Division of Plastic Surgery Indiana University Adam C. Cohen, M.D. Jason R. Cacioppo, M.D. Indianapolis, Ind.