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Background: The deep inferior epigastric perforator (DIEP) flap has emerged as a promising option for autologous breast reconstruction, promoting reduced donor site morbidity. However, venous congestion occurs in 2-15% of cases and often requires revascularization with the superficial inferior epigastric vein (SIEV), necessitating additional time for SIEV dissection. A method for predicting venous congestion and SIEV usage would increase surgeon efficiency and flap success. Since our institution has previously shown that increased suprascarpal fatpad thickness (>23 mm) is associated with increased SIEV caliber, we hypothesize that patients with increased suprascarpal fatpad thickness have a more dominant superficial venous draining system and will be more likely to require SIEV revascularization.
Methods: This is an IRB- approved retrospective study performed at NewYork-Presbyterian Hospital- Weill Cornell Medical College. Female patients who underwent unilateral or bilateral DIEP flap reconstruction from 2011 to 2015 by a single surgeon were included, with each flap treated individually. Radiographic measurements of suprascarpal fatpad thickness and SIEV diameter were collected per hemi-abdomen from pre-operative abdominal CTA imaging. The following clinical outcomes were investigated: intra-operative venous congestion and SIEV usage as well as post-operative flap revision, flap fat necrosis, and total flap failure. Statistical analysis explored if suprascarpal fatpad thickness correlated with clinical outcomes.
Results: There were 95 patients included who underwent a total 166 DIEP flap reconstructions. 63 cases were bilateral, 24 were unilateral, and 8 were stacked flap reconstructions. Mean age at surgery was 51.4 years ± 9.6 (35-75). Mean operative time was 9.7 hours ± 1.9 (5.5-15.0). Flaps were created off a mean 1.5 ± 1.0 (0-4) lateral perforators and 0.5 ± 0.9 (0-4) medial perforators. 7 (4.2%) flaps exhibited venous congestion after initial revascularization, while 4 (2.4%) required intra-operative SIEV salvage revascularization. Mean suprascarpal fatpad thickness was 20.6mm ± 10.8 (4.9-65.4) and mean SIEV diameter was 2.8mm ± 0.7 (1.5-5.7). Of the 7 patients with venous congestion, only 6 had pre-operative CTA imaging available. Decreased suprascarpal fatpad thickness was significantly associated with increased rates of venous congestion (p=0.049), while total fatpad thickness and subscapral fatpad thickness were not (p=0.096; p=0.701). All 6 cases of venous congestion occurred in flaps with suprascarpal fatpad thickness less than 18mm (p=0.009), with a mean suprascarpal fatpad thickness of 13.5mm ± 2.9 (9.7-17.6) and mean SIEV diameter of 2.8mm ± 0.3 (2.5-3.3). Venous congestion was not associated with any demographic variables (age, race, history of diabetes or hypertension, previous chemotherapy or radiation, or previous abdominal surgery; p>0.1). Patients were followed post-operatively for a mean 9.5 months ± 7.7 (0-32), with 16 (9.7%) flaps developing fat necrosis and 7 (4.2%) requiring return to the OR for fat necrosis excision and flap revision. There were 0 cases of total flap failure.
Conclusions: There is a significantly increased risk of venous congestion with thinner radiographic suprascapral fatpad thickness, specifically <18mm, suggesting that DIEP flap venous congestion is not related to dominance of the superficial draining system. We recommend SIEV dissection in all patients with suprascarpal fatpad thickness <18 mm.