Investigation of routine venous augmentation in deep inferior epigastric artery perforator flap and intraoperative decision pathway

Authors: Meyer A, Bird C, Nazir N, Collins M, Lai EC, Farmer R, Butterworth J, Holding J

Affiliation: University of Kansas Medical Center

Journal: Journal of Reconstructive Microsurgery, Sept 2025

PMID: 41067263

Key takeaways

• In 1,745 DIEP flaps (1,099 patients), 32.4% used ≥2 veins;

  • 24.5% of all flaps (427/1745) had prophylactic augmentation (extra outflow without clinical congestion).

  • 8% (n=140) of flaps were augmented due to signs of congestion

• Routine augmentation did not reduce returns to OR, venous compromise, or flap loss versus single-vein anastomosis.

• Operative time was longer with augmentation (~559 vs 506 minutes; p<0.001).

• Authors propose a selective decision pathway; add outflow only for documented congestion.

Background

Whether DIEP flaps benefit from routine second-vein outflow remains debated; evidence for prophylactic augmentation is limited and practice varies.

Objective

Compare single-vein versus venous-augmented DIEP outcomes and present a practical intraoperative decision pathway.

Methods

• Design/setting: Retrospective cohort, single academic center, 2009–2023.

• Cohort: 1,099 patients / 1,745 DIEP flaps.

  • Prophylactic augmentation = additional venous outflow without intraoperative congestion.

• Endpoints: Return to OR (any cause; venous suspicion), suspected venous congestion, early/late flap loss, operative time.

• Stats: Bivariate comparisons; p<0.05 significant.

Results

• Venous strategy distribution: 1 vein 67.6% (1180/1745); ≥2 veins 32.4% (565/1745).

  • Prophylactic augmentation 24.5% (427/1745).

  • Required augmentation for congestion 8.0% (140/1745).

• Return to OR (any cause): 5.6% (97/1745) overall

  • No difference one vein vs ≥2 veins (p=0.14) or one vein vs prophylactic subset (p≈0.09–0.10).

• Suspected venous compromise: 2.3% (41/1745); no difference single vs augmented (p=0.48) or single vs prophylactic (p=0.95). None of the required-augmentation flaps re-returned for venous suspicion.

• Flap loss: Early loss 1.5% (27/1745) and late loss 2.2% (38/1745); no significant differences between groups.

• Operative time: Longer with ≥2 veins (557.4±124.6 min) vs single vein (505.6±130.7; p<0.001); prophylactic ≈559.4 min vs single (p<0.0001).

• Flap size: Actual flap weight was not reported. BMI was higher in multi-vein and prophylactic groups (e.g., multi-vein > single-vein; prophylactic > single-vein), suggesting surgeons more often augmented prophylactically in higher-BMI patients

Conclusion

Routine prophylactic venous augmentation in DIEP reconstruction does not improve returns to OR, venous congestion, or flap survival, and prolongs operative time. Reserve additional outflow for declared congestion using a structured pathway.

Strengths & limitations

• Strengths: Large single-center experience; clear operational definitions; reporting of early/late events and operative time.

• Limitations: Retrospective; potential selection bias (e.g., higher BMI in prophylactic group); 14-year practice evolution; no multivariable adjustment.

Critiques and questions

• Confounding: Prophylactic cases showed higher BMI; multivariable or propensity analyses would clarify causality.

• Event granularity: Standardized perfusion metrics (ICG/thermal imaging) and flap-weight data would contextualize outflow needs.

• External validity: The proposed pathway is sensible; prospective implementation could test whether unnecessary second anastomoses decline without missed congestion events, but a large study would be needed to be adequately powered.