Sir: The need for venous flow augmentation is relatively common in deep inferior epigastric perforator flap surgery, particularly so in irradiated internal mammary vessels and the presence of a dominant superficial venous system. Sbitany et al.1 showed in their large series of 1201 free deep inferior epigastric perforator and transverse rectus abdominis musculocutaneous flaps that 11 of these flaps (0.9 percent) exhibited intraoperative venous congestion. Previously described recipient venous sources include the lateral thoracic vein,2 external jugular vein,3 thoracodorsal vein, intercostal vein, cephalic vein,4 and basilic vein. By far the most commonly used is the cephalic vein, which is the first-choice vessel in our practice, as it has consistent anatomy, lying in the subcutaneous tissue above the brachial fascia on the anterolateral aspect of the arm. If the contralateral deep inferior epigastric perforator flap is used, the superficial inferior epigastric vein will lie in the upper lateral quadrant of the flap after inset. This is ideally placed for anastomosis after a cephalic vein turndown. Previous relevant techniques described include the deltopectoral groove, infraclavicular fossa, and anterior axillary skin incision.5 These incisions lead to visible scarring. The indication for venous augmentation is based on multiple intraoperative factors such as the flap perfusion when islanded on the abdomen, the tension or turgor of the superficial inferior epigastric vein, and the degree of flap venous congestion after anastomosis. We do not routinely perform augmentation in all cases; we do so only when there is a need for improving venous outflow. An L-shaped incision is marked out on the medial aspect of the arm with the vertical passing parallel to but posterior to the anterior axillary fold (Fig. 1). The length of the horizontal limb varies according to the length of cephalic vein required. This in turn depends on the type of mastectomy scar. A longer length will be required for a periareolar skin-sparing mastectomy when compared with a more traditional horizontal/oblique mastectomy incision. With careful dissection, the cephalic vein is easily identified sitting on top of the brachial fascia. The vein is then dissected out cranially, ligating any branches in the process. Using optimal retraction, our incision allows the vein to be followed into the deltopectoral groove. It is easier to follow the vein from distal to proximal into the deltopectoral groove in the chest rather than identifying the vein from under the mastectomy flap and dissecting laterally. The vein is then turned down through a subcutaneous tunnel from the flap recipient site. This novel incision has been performed in seven cases over the past 2 years. We have had no donor-site morbidity, although bruising in the upper arm is common. The upper arm incision is a novel aesthetically pleasing technique, which is simple and easily performed. Dissecting the vein from lateral to medial allows for easy identification of the vein under the mastectomy flap. The resulting scar is not seen when standing with arms by the side, and heals well (Figs%. 2 and 3). This technique averts the need for visible deltopectoral incisions or multiple stab incisions in the upper arm when a greater length is required. It is often particularly useful in irradiated axillae, whereby dissection of the cephalic vein in the deltopectoral groove can often be challenging.Fig. 1: Illustrations depicting the upper arm incision.Fig. 2: A well-hidden scar in the patient while standing.Fig. 3: A closeup of the healed scar.DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.
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Sep 21, 2023
Nicol Zielinska + 4
