Abstract
Deep inferior epigastric perforator (DIEP) flaps are the current gold standard for autologous breast reconstruction. A delay technique for single-perforator DIEP flap reconstruction had been previously described to improve tissue transfer reliability. However, the importance of the thoracoepigastric system in this procedure is unknown. We describe a case of 2-stage bilateral DIEP flap breast reconstruction in a 49-year-old obese woman, wherein unilateral (left) interruption of the thoracoepigastric vein during stage 1 delay unexpectedly yielded markedly improved outcomes compared with the opposing (right) side with an intact thoracoepigastric vein. Slight transient venous congestion was noticed immediately in the left hemiabdomen after interruption of the ipsilateral thoracoepigastric vein concomitant with ligation of the superficial inferior epigastric vein, venae comitantes of the superficial inferior epigastric artery, and superior epigastric veins. The left hemiabdominal DIEP flap was uneventfully harvested and transferred 3 weeks later. On the right side with an intact thoracoepigastric system, complete elevation of the hemiabdomen tissue during stage 2 resulted in extensive venous congestion in situ, which improved after an intraflap anastomosis between the dilated stump of the right superficial inferior epigastric vein and a branch of the right deep inferior epigastric vein. Preservation of the thoracoepigastric system as part of the previously described DIEP delay protocol may cause insufficient flap delay, as the intact superficial system prevents maturation of venous drainage through the pedicle pathway. We propose thoracoepigastric vein interruption as a critical step in optimizing the delay of DIEP flap reliability, particularly in patients with dominant superficial venous systems.