The “Dual-Plane” DIEP Flap: Measuring the Effects of Superficial Arterial and Venous Flow Augmentation on Clinical Outcomes

The “Dual-Plane” DIEP Flap: Measuring the Effects of Superficial Arterial and Venous Flow Augmentation on Clinical Outcomes.

We read with interest the article by Sbitany et al,[1] in which they describe their experience of anastomosing the superficial vascular system to the deep system to help improve the vascularity of deep inferior epigastric perforator (DIEP) flaps. The authors fail to mention in their paper the percentage of flaps that required the use of the “dual-plane” technique for either arterial or venous insufficiency or both.

The cause of poor perfusion in DIEP flaps continues to be debated. In their study of blood flow in abdominal flaps, Blondeel et al first noticed that poor perfusion was related to venous insufficiency and not arterial compromise.[2] Such flaps often demonstrate superficial system dominance, whereby drainage through the perforating vessels is insufficient to drain the flap, and the main drainage is by means of the superficial inferior epigastric vein (SIEV). Anastomosis of the SIEV is successful in draining such flaps. This anastomosis can be performed in either the extrinsic drainage system or the deep system, thus creating an internal shunt.

Furthermore, the authors describe the use of the medial or lateral branch of the deep pedicle, whichever is not supplying the dominant deep perforator, as the recipient supply for the superficial system. In their seminal study of the vascular anatomy of the rectus abdominis muscle, Moon and Taylor describe three patterns of supply based on the number of inferior vessel branches that form the deep inferior epigastric artery.[3] Their results demonstrated the classical thought of medial and lateral branches (type 2 system) in 57% of cases, whereas in 29% of cases, only a single inferior vessel (type 1 system) is present. In type 1 systems, the “dual-plane” technique could not be performed as described by the authors. Further study suggests that the incidence of type 1 systems may indeed be much higher than previously thought. Molina et al in their study of 150 abdominal-based breast reconstructions found that a type 1 pattern of branching was seen in 56% of hemiabdomens.[4]

We previously described our technique of anastomosing the SIEV to a cranial extension of the deep inferior epigastric vein beyond the perforator.[5] This allows a forward flow of the superficial system directly into the pedicle and can be readily performed in type 1 vascular systems. We have found this technique to be quick, safe, and effective for augmenting the venous outflow of a congested DIEP flap. In our series of 308 DIEP flaps, we did not demonstrate any arterial insufficiency where there was patent arterial inflow through the pedicle. It is therefore our experience that any superficial system dominance is purely venous and that the deep arterial system is capable of perfusing the ipsilateral flap. We therefore question the need for performing an arterial anastomosis of the deep system to the ipsilateral superficial system as described by the authors.

• References

• 1 Sbitany H, Lentz R, Piper M. The “dual-plane” DIEP flap: measuring the effects of superficial arterial and venous flow augmentation on clinical outcomes. J Reconstr Microsurg 2019; 35 (06) 411-416
• 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 (06) 1295-1299
• 3 Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988; 82 (05) 815-832
• 4 Molina AR, Jones ME, Hazari A, Francis I, Nduka C. Correlating the deep inferior epigastric artery branching pattern with type of abdominal free flap performed in a series of 145 breast reconstruction patients. Ann R Coll Surg Engl 2012; 94 (07) 493-495
• 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 (08) 1094-1097