letters GUIDELINES
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor. Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested. Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence. The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.
Letters Microvascular Lifeboats: A Stepwise Approach to Intraoperative Venous Congestion in DIEP Flap Breast Reconstruction Sir:
W
e read with interest the article by Galanis et al.1 and wish to congratulate the authors for providing readers with a succinct review of techniques available for salvaging a congested deep inferior epigastric perforator (DIEP) flap. It is clear that not all DIEP flaps fail because of problems with the anastomosis but that some exhibit superficial system dominance2 whereby venous drainage through the perforating vessels is insufficient to drain the flap and the main drainage is by means of the superficial system. Anastomosis of the superficial inferior epigastric vein is successful in draining such flaps. In addition to Copyright © 2015 by the American Society of Plastic Surgeons
638e
Fig. 1. Illustration of anastomosis of the superficial inferior epigastric vein (SIEV) to an additional 2 to 3 cm of deep inferior epigastric vein (DIEV) to provide flow of an engorged superficial system into the deep system. Note how no dissection is carried out around the fragile perforating vessels around the base of the flap. DIEA, deep inferior epigastric artery. [Reprinted from Davies AJ, O’Neill JK, Wilson SM. The superficial outside-flap shunt (SOS) technique for free deep inferior epigastric perforator flap salvage. J Plast Reconstr Aesthet Surg. 2014;67:1094–1097. Copyright 2014, with permission from Elsevier.]
anastomosing the superficial inferior epigastric vein to an extrinsic drainage system, with the inherent added morbidity, it can be anastomosed to the deep system, thus creating an intrinsic shunt. The authors describe the techniques of Rohde and Keller3 and Liu et al.,4 who advocate draining the superficial inferior epigastric vein into the venae comitantes accompanying the perforator. However, we feel that dissection and handling of the perforator and its venae comitantes should be minimal to prevent damage and total loss of an already compromised flap. Anastomosis of the venae comitantes at the level of the perforating vein is also more challenging compared with the level of the deep inferior epigastric vein pedicle. We wish to bring to the attention of your readers a technique (recently published) that we have found effective for providing drainage of the superficial into the deep system without the need for dissection of the perforator and its venae comitantes at the base of the flap.5 Once the origin of the perforator has been identified as it branches from the main pedicle, a further 2 to 4 cm of deep inferior epigastric vein is dissected out cranial to the pedicle and divided. This allows the preserved length of superficial inferior epigastric vein to be brought underneath the flap to meet with the additional length of deep inferior epigastric vein and an anastomosis is performed. This allows forward flow from the superficial system directly into the pedicle and thus into the internal mammary veins (Fig. 1). We have had no incidents of flap loss secondary to venous congestion using this technique and have found it to be safe, quick, and effective for augmenting the venous outflow of a congested DIEP flap. DOI: 10.1097/PRS.0000000000001045
www.PRSJournal.com
Volume 135, Number 3 • Letters Alex Davies, M.R.C.S. Jennifer K. O’Neill, F.R.C.S.(Plast.) Sherif M. Wilson, F.R.C.S.(Plast.) Department of Plastic and Reconstructive Surgery Southmead Hospital Bristol, United Kingdom Correspondence to Dr. Davies Department of Plastic and Reconstructive Surgery Southmead Hospital Bristol BS10 5NB, United Kingdom
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Galanis C, Nguyen P, Koh J, Roostaeian J, Festekjian J, Crisera C. Microvascular lifeboats: A stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction. Plast Reconstr Surg. 2014;134:20–27. 2. Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg. 2000;106:1295–1299. 3. Rohde C, Keller A. Novel technique for venous augmentation in a free deep inferior epigastric perforator flap. Ann Plast Surg. 2005;55:528–530. 4. Liu TS, Ashjian P, Festekjian J. Salvage of congested deep inferior epigastric perforator flap with a reverse flow venous anastomosis. Ann Plast Surg. 2007;59:214–217. 5. Davies AJ, O’Neill JK, Wilson SM. The superficial outside-flap shunt (SOS) technique for free deep inferior epigastric perforator flap salvage. J Plast Reconstr Aesthet Surg. 2014;67:1094–1097.
Microvascular Lifeboats: A Stepwise Approach to Intraoperative Venous Congestion in DIEP Flap Breast Reconstruction Sir: n 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 fartoo-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
I
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.
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. DOI: 10.1097/PRS.0000000000001065
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.
639e
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor. Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested. Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence. The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.
Letters Microvascular Lifeboats: A Stepwise Approach to Intraoperative Venous Congestion in DIEP Flap Breast Reconstruction Sir:
W
e read with interest the article by Galanis et al.1 and wish to congratulate the authors for providing readers with a succinct review of techniques available for salvaging a congested deep inferior epigastric perforator (DIEP) flap. It is clear that not all DIEP flaps fail because of problems with the anastomosis but that some exhibit superficial system dominance2 whereby venous drainage through the perforating vessels is insufficient to drain the flap and the main drainage is by means of the superficial system. Anastomosis of the superficial inferior epigastric vein is successful in draining such flaps. In addition to Copyright © 2015 by the American Society of Plastic Surgeons
638e
Fig. 1. Illustration of anastomosis of the superficial inferior epigastric vein (SIEV) to an additional 2 to 3 cm of deep inferior epigastric vein (DIEV) to provide flow of an engorged superficial system into the deep system. Note how no dissection is carried out around the fragile perforating vessels around the base of the flap. DIEA, deep inferior epigastric artery. [Reprinted from Davies AJ, O’Neill JK, Wilson SM. The superficial outside-flap shunt (SOS) technique for free deep inferior epigastric perforator flap salvage. J Plast Reconstr Aesthet Surg. 2014;67:1094–1097. Copyright 2014, with permission from Elsevier.]
anastomosing the superficial inferior epigastric vein to an extrinsic drainage system, with the inherent added morbidity, it can be anastomosed to the deep system, thus creating an intrinsic shunt. The authors describe the techniques of Rohde and Keller3 and Liu et al.,4 who advocate draining the superficial inferior epigastric vein into the venae comitantes accompanying the perforator. However, we feel that dissection and handling of the perforator and its venae comitantes should be minimal to prevent damage and total loss of an already compromised flap. Anastomosis of the venae comitantes at the level of the perforating vein is also more challenging compared with the level of the deep inferior epigastric vein pedicle. We wish to bring to the attention of your readers a technique (recently published) that we have found effective for providing drainage of the superficial into the deep system without the need for dissection of the perforator and its venae comitantes at the base of the flap.5 Once the origin of the perforator has been identified as it branches from the main pedicle, a further 2 to 4 cm of deep inferior epigastric vein is dissected out cranial to the pedicle and divided. This allows the preserved length of superficial inferior epigastric vein to be brought underneath the flap to meet with the additional length of deep inferior epigastric vein and an anastomosis is performed. This allows forward flow from the superficial system directly into the pedicle and thus into the internal mammary veins (Fig. 1). We have had no incidents of flap loss secondary to venous congestion using this technique and have found it to be safe, quick, and effective for augmenting the venous outflow of a congested DIEP flap. DOI: 10.1097/PRS.0000000000001045
www.PRSJournal.com
Volume 135, Number 3 • Letters Alex Davies, M.R.C.S. Jennifer K. O’Neill, F.R.C.S.(Plast.) Sherif M. Wilson, F.R.C.S.(Plast.) Department of Plastic and Reconstructive Surgery Southmead Hospital Bristol, United Kingdom Correspondence to Dr. Davies Department of Plastic and Reconstructive Surgery Southmead Hospital Bristol BS10 5NB, United Kingdom
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Galanis C, Nguyen P, Koh J, Roostaeian J, Festekjian J, Crisera C. Microvascular lifeboats: A stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction. Plast Reconstr Surg. 2014;134:20–27. 2. Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg. 2000;106:1295–1299. 3. Rohde C, Keller A. Novel technique for venous augmentation in a free deep inferior epigastric perforator flap. Ann Plast Surg. 2005;55:528–530. 4. Liu TS, Ashjian P, Festekjian J. Salvage of congested deep inferior epigastric perforator flap with a reverse flow venous anastomosis. Ann Plast Surg. 2007;59:214–217. 5. Davies AJ, O’Neill JK, Wilson SM. The superficial outside-flap shunt (SOS) technique for free deep inferior epigastric perforator flap salvage. J Plast Reconstr Aesthet Surg. 2014;67:1094–1097.
Microvascular Lifeboats: A Stepwise Approach to Intraoperative Venous Congestion in DIEP Flap Breast Reconstruction Sir: n 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 fartoo-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
I
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.
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. DOI: 10.1097/PRS.0000000000001065
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.
639e
