Plastic Surgery Research Council
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PSRC 60th Annual Meeting
Program and Abstracts

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Predicting Venous Congestion Before DIEP Breast Reconstruction
Christopher R. Davis, BSc, MB ChB, MRCS1, Lyn Jones, FRCS, FRCR2, Rachel Tillett, MSc, FRCS (Plast)3, Helen Richards, MRCS2, Sherif Wilson, FRCS (Plast)2.
1Stanford University, Stanford University, CA, USA, 2Southmead Hospital, Bristol, United Kingdom, 3Royal Devon and Exeter NHS Trust, Exeter, United Kingdom.

Purpose: The deep inferior epigastric perforator (DIEP) flap is an established technique for breast reconstruction. However, venous congestion remains the leading cause of flap failure. We aim to correlate pre-operative computed tomography angiography (CTA) findings with post-operative venous congestion to predict patients at risk of complications.
Methods: All patients undergoing DIEP breast reconstruction prospectively entered a study database from August 2009 to August 2013. Patients with post-operative venous congestion were matched with a similar cohort of complication-free patients. Pre-operative CTAs were re-interpreted by a radiologist, blinded to the subsequent clinical outcome. Inter-group comparisons were performed using unpaired two tailed T-tests and Mann-Whitney U tests.
Results: 240 DIEP flaps were performed in 202 patients over the four-year study. Venous congestion affected 15 flaps (6.25%). Pre-operative CTA demonstrated significantly more atypical venous connections between deep and superficial systems in cases complicated by post-operative venous congestion compared to controls (66.7% versus 8%; P<0.05). Atypical connections were narrow, tortuous, or incomplete. Similar CTA findings between groups included: Perforator number, size and position; SIEV size; cross midline venous connections; absent communications (P>0.05). A new classification of venous connections in DIEP flaps is proposed (Type 1: Normal 77%; Type 2: Absent 12%; Type 3: Atypical 11%). (Figure)
Conclusions: Pre-operative CTA identifies atypical venous connections between deep and superficial systems found to increase the risk of post-operative DIEP congestion. Identifying atypical venous connections prior to surgery maximizes flap survival and minimizes complications for patients considering DIEP breast reconstruction.


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