Prophylactic Superdrained Deep Inferior Epigastric Perforator Flap: Systematic Review of Survival and Morbidity

Abstract

Background:

The deep inferior epigastric perforator (DIEP) flap is considered the gold standard option for autologous tissue reconstruction after total mastectomy. To minimize complication rates, such as venous congestion, adding a second venous anastomosis to support the flap (venous superdrainage) has gained popularity, although the degree of clinical benefit remains unclear. This study presents a systematic review to evaluate the complication profiles of dual venous anastomosis DIEP flap breast reconstruction.

Methods:

A systematic search of PubMed, Embase, and MEDLINE was performed to identify studies evaluating venous superdrainage in DIEP flap breast reconstruction. Seventeen studies were included, comprising 2964 flaps (1536 single-vein and 1428 dual-vein). Postoperative complications were extracted and reported descriptively, with direct comparisons highlighted when available.

Results:

Across 17 studies, including 2964 DIEP flaps, dual-venous anastomosis was associated with lower rates of venous-related complications. In the dual-vein group, complication rates were low, including venous congestion (0%–13%), venous thrombosis (0%–2.7%), total flap loss (0%–8.7%), fat necrosis (0%–17.4%), and partial flap loss (0%–13.3%). In contrast, single-vein cohorts demonstrated higher rates of key complications, particularly venous congestion (2.6%–55.1%), venous thrombosis (1.8%–18.8%), fat necrosis (4.9%–48.2%), partial flap loss (up to 44.8%), and total flap loss (up to 17.2%). Hematoma and infection rates were comparable between groups.

Conclusions:

Optimizing clinical outcomes after DIEP flap breast reconstruction remains an important clinical goal. These results suggest that prophylactic supercharging of the DIEP flap with 2 veins may be associated with lower complication rates in several comparative studies.

Takeaways.

Question: What is the impact of dual venous anastomosis on complication rates in deep inferior epigastric perforator flap breast reconstruction?

Findings: This systematic review of 17 studies, including 2964 flaps (1536 single-vein; 1428 dual-vein), showed that dual venous anastomosis was associated with lower rates of venous-related complications, including venous congestion (0%–13% versus 2.6%–55.1%), venous thrombosis (0%–2.7% versus up to 18.8%), fat necrosis (0%–17.4% versus up to 48.2%), and total flap loss (0%–2.74% versus up to 17.2%). Infection and hematoma rates were comparable.

Meaning: Dual venous anastomosis may improve flap reliability by reducing venous-related complications, although higher quality comparative studies are needed.

INTRODUCTION

Breast reconstruction following mastectomy plays a crucial role in the holistic recovery of women affected by breast cancer.^1–3 An autologous tissue approach to reconstructing the breast allows for meticulous shaping of the donor fat and skin into a texture and shape that resembles that of the original breast, which some women might prefer over breast implants or tissue expanders.^2,3 Several techniques for autologous tissue harvest have been described, with the appropriate size and properties to support successful breast reconstruction. Most commonly, surgeons opt to harvest the deep inferior epigastric perforator (DIEP) flap for autologous reconstruction.^4–9 Among the complication profile of DIEP flaps, microvascular insufficiency is the leading contributor to flap failure and reoperation rates, particularly venous congestion.^10–12

The use of an additional venous anastomosis, most commonly to the superficial inferior epigastric vein (SIEV) drainage system, referred to as “flap superdrainage,” is a widely adopted approach for salvage surgery when managing venous compromise.^12,13 To avoid these complications, prophylactic dual venous anastomoses have been used as a potential strategy. In addition to improving venous outflow and flap viability, an additional venous anastomosis may also reduce fat necrosis by improving microcirculatory perfusion within the flap. However, there remains ambiguity as to the efficacy of this approach in preventing venous insufficiency and improving patient outcomes. The aim of this systematic review is to comprehensively overview the complication profile of dual venous anastomosis DIEP flap breast reconstruction and provide a comparison to single venous anastomosis outcomes to evaluate the efficacy of prophylactic venous superdrainage.

MATERIAL AND METHODS

Search Strategy and Selection Process

A systematic review of the published literature was performed to assess the survival and morbidity of breast reconstruction with dual venous anastomosis DIEP flaps. A thorough literature search was performed in the MEDLINE (1946 to June 2024) and Embase (1974 to June 2024) databases using Ovid. The medical subject headings terms and keywords used in the search strategy are displayed in Table 1. The search strategy was designed to capture all forms of prophylactic venous augmentation, regardless of the venous system used, and was not limited to SIEV-based superdrainage.

Table 1.

Search Strategy Used for Database Queries

Themes	MeSH Terms and Keywords Used in Search Strategy
1	(DIEP OR “deep inferior epigastric*”)
2	(“breast reconstruct*” OR “mamm?plast*”)
3	((“venous augment*” OR “supercharg*” OR “superdrain*” OR “drainage augment*” OR “double venous*” OR “double venous system drain*” OR “retrograde*” OR “bipedicled” OR “second pedicle” OR “ve?nous anastomos*” or “two veins*) OR (((“dual” OR “both” OR “two” OR “second*” or “addition*”) adj6 (“anastomos*” adj3 (“arter*” or “venous*” or “vein*” or “vessel*”)))
4	(mortality OR postoperative complications OR intraoperative complications OR treatment outcome OR “survival*” OR “necros*” OR “infection*” OR “thrombos*” OR “flap loss*” OR “venous congestion*” OR “re?operat*” or “fail*”)

MeSH, medical subject headings.

The citations yielded from the above search were then added to the Covidence systematic review management software, deduplicated, and independently screened by title and abstract for selection by 2 reviewers (P.B.-P. and A.W). Full texts of relevant publications were obtained and evaluated independently by 2 reviewers (P.B.-P. and A.W.). Conflicts were resolved through team consensus. Full-text articles of randomized controlled trials, retrospective or prospective cohort studies, case series with a sample size greater than 10, and case control studies reporting data on the survival rate as well as complications of superdrained DIEP flaps for breast reconstruction were included for data extraction. Studies reporting comparative data between single- and dual-vein techniques were specifically identified and analyzed when available. Studies were further categorized as comparative (reporting both single- and dual-vein cohorts) or noncomparative (reporting dual-vein outcomes only). Studies describing salvage venous superdrainage exclusively were excluded. Animal studies, case reports, isolated abstracts and commentaries, systematic reviews and meta-analyses, and articles published in a language other than English were excluded. References of the included articles from the original search were screened, and the full text of relevant citations was included.

Data Collection Process

Data were extracted independently by 2 authors (P.B.-P. and A.W.), and team consensus was achieved if any disagreements arose. Demographic data, patient characteristics, relevant surgical characteristics, and postoperative outcomes were collected. When available, data were extracted separately for single and dual venous anastomosis groups. Outcome definitions were recorded as reported by the original studies due to variability in definitions across the literature.

Synthesis Methods

The primary outcome was the identification of complication rates in dual venous anastomosis DIEP flaps, including venous congestion, venous thrombosis, fat necrosis, partial and total flap loss, infection, hematoma, and reoperation rates. Given the heterogeneity in study design, outcome definitions, and reporting, results were synthesized descriptively without formal meta-analysis. Comparative findings between single- and dual-vein techniques were emphasized when reported within individual studies, whereas noncomparative data were used to contextualize overall complication profiles. Weighted means (based on study sample size) were calculated for baseline characteristics.

RESULTS

Study characteristics are summarized in Supplemental Digital Content 1. (See table, Supplemental Digital Content 1, which displays the characteristics of the included studies, https://links.lww.com/PRSGO/F332.) Seventeen studies were retained for inclusion, with most studies being retrospective cohort studies (n = 10), followed by case-control studies (n = 3), and one each of a prospective cohort study, randomized prospective study, case series, and cohort study (Fig. 1).^14–30 Superdrained cohort sizes ranged from 17 to 311 flaps. A range of donor and recipient veins was used for the second venous anastomosis, with the SIEV most commonly used as the donor vessel (13 of 17 studies) and the internal mammary vein as the most frequent recipient vessel (9 of 17 studies).

Fig. 1.

PRISMA flow diagram of study selection. PRISMA, preferred reporting Items for systematic reviews and meta-analyses.

Baseline patient characteristics are summarized in Supplemental Digital Content 2. (See table, Supplemental Digital Content 2, which displays the baseline patient characteristics of the included studies, https://links.lww.com/PRSGO/F332.) Compared with the single-vein group, patients undergoing dual venous anastomosis had a higher burden of comorbidities, including smoking (16.9% versus 7.8%), hypertension (18.8% versus 10.7%), and diabetes (7.3% versus 5.4%), as well as a slightly higher body mass index (BMI) (26.4 versus 25.7).

Risk of Bias Assessment

Using ROBINS-I (risk of bias in non-randomised studies of interventions), 1 study was rated as having a low risk, 12 as having a moderate risk, and 4 as having a high risk of bias.³¹

Venous Thrombosis

Venous thrombosis was defined as an intraluminal venous clot confirmed intraoperatively or by Doppler assessment. Three studies, including 409 dual-vein flaps, reported rates ranging from 0% to 2.7%, compared with 1.8% to 18.8% in single-vein cohorts (n = 445). A significant reduction was reported by Choi et al¹⁶ (2.7% versus 18.75%, P = 0.002), whereas Eom et al¹⁷ and Enajat et al²² found no difference.

Venous Congestion

Venous congestion was defined as a clinical diagnosis characterized by flap edema, color change, or abnormal capillary refill, identified intraoperatively or postoperatively, with or without the need for reexploration. Five studies, including 670 dual-vein flaps, reported an incidence ranging from 0% to 13%, compared with 2.6% to 55.1% in single-vein cohorts (n = 451). Four studies demonstrated significantly (P < 0.05) lower rates with dual venous anastomosis, representing the most consistent complication reduction of all evaluated outcomes.^17,19,22,25

Infection

Infection was defined as a clinically diagnosed surgical-site infection requiring antibiotic therapy, with or without surgical intervention, as reported by the original studies. Four studies, including 363 superdrained DIEP flaps, evaluated infection based on clinical assessment during follow-up, with reported incidence ranging from 0% to 12.7%. Three studies reported infection in single-vein cohorts (n = 356). Overall, infection rates were comparable between groups, with no significant difference observed between single and dual venous anastomosis cohorts.

Hematoma

Hematoma was defined as a postoperative blood collection at the donor or recipient site, with or without the need for surgical evacuation. Four studies, including 362 superdrained DIEP flaps, evaluated hematoma, with reported incidence ranging from 0% to 7.22%. Three studies reported this complication in single-vein cohorts (n = 356). Overall, hematoma rates were similar between single and dual venous anastomosis groups, with no consistent trend observed.

Fat Necrosis

Fat necrosis was defined as clinically or radiographically identified areas of adipose tissue necrosis within the reconstructed breast. Eleven studies, including 1078 superdrained DIEP flaps, reported incidences ranging from 0% to 17% (weighted mean ~5%), compared with 4.9% to 48.2% in single-vein cohorts (n = 1244). Three studies reported significantly lower rates with dual venous drainage.^14,16,25

Partial Flap Loss

Partial flap necrosis was defined as loss of viability of a portion of the flap not meeting criteria for total flap loss, identified by clinical examination or portable ultrasound. Eight studies, including 541 superdrained DIEP flaps, reported incidences ranging from 0% to 13.3%, compared with up to 44.8% in single-vein cohorts (n = 541). One study demonstrated a significant reduction with dual venous anastomosis (8.7% versus 44.8%, P = 0.004).²⁵

Total Flap Loss

Total flap loss was defined as complete necrosis of the transferred flap without successful salvage. Twelve studies, including 997 superdrained DIEP flaps, reported incidence ranging from 0% to 8.7%, compared with up to 17.2% in single-vein cohorts (n = 754). Some studies demonstrated significantly lower rates with dual venous drainage, although results were inconsistent and occasionally influenced by high control event rates.^{16,17,21,25,30}

Take-back Surgery and Overall Complications

Reoperation data were inconsistently reported but generally suggested fewer reexplorations in dual-vein cohorts.^{16,17,19,21,30} Overall complication rates were variably defined. (See table, Supplemental Digital Content 3, which displays the complications in DIEP flaps, https://links.lww.com/PRSGO/F332.) Five studies, including 483 superdrained DIEP flaps, reported overall complication rates ranging from 3.1% to 71.7%, compared with higher or comparable rates in single-vein cohorts comprising 820 flaps. Selected studies demonstrated lower complication rates with dual venous drainage (eg, 8.1% versus 21.3%), whereas others reported no difference or higher rates, resulting in overall heterogeneous findings without a consistent direction of effect.

Operative Time

Operative time was reported in 7 studies and was generally longer with dual venous anastomosis, with differences ranging from 0.1 to 105 minutes (mean difference: 34 min) (Table 2). (Supplemental Digital Content 2, https://links.lww.com/PRSGO/F332). Although several studies reported statistically significant increases (P < 0.001), findings were inconsistent across series.^{14,17,21,24–26,30}

Table 2.

Total Operative Time of DIEP Flap Surgery With and Without Superdrainage

Study ID, Year	Superdrained DIEP Flap, min	Single Venous Anastomosis DIEP Flap, min	Time Difference Between Groups, min	Statistical Significance
Lombardo et al30	272.3	272.2	0.1	No statistical difference
Ahmed et al21	509	460	49	P < 0.001
Lee et al14	402.5	367	35.5	P < 0.001
Tokumoto et al24	600.6	582.7	17.9	P = 0.1
Ayestaray et al25	510	405	105	P < 0.001
Enajat et al22	385	383	2	P = 0.57
Xin et al20	396	366	30	P < 0.05

DISCUSSION

The DIEP flap has become a widely adopted technique for autologous breast reconstruction due to its reduced donor-site morbidity, shorter hospital stay, and decreased postoperative pain.³² When sufficient abdominal tissue is available, the flap can be shaped to achieve a natural breast contour without implants. However, postoperative complications related to venous insufficiency remain clinically significant by compromising flap viability and aesthetic outcomes.

Venous insufficiency is a critical concern in free flap surgery and may require urgent intervention. Surgical reexploration with thrombectomy, revision of the venous anastomosis, or vein grafting can restore venous outflow.³³ Adjunctive techniques such as thrombolysis or leech therapy have also been described.^34,35 Despite these interventions, venous-related flap failure rates have been reported between 0% and 5.15% in most series, with some studies reporting rates as high as 15.6%.^{4,16,27,36–38}

In this context, the use of a second venous anastomosis (dual venous drainage, or superdrainage) has been proposed to improve venous outflow and reduce complication rates. Although traditionally described as a salvage technique, superdrainage may also be performed intraoperatively in response to inadequate venous return, planned preoperatively based on imaging findings (eg, dominant superficial venous system), or applied prophylactically in all patients.

The primary objective of this study was to compare complication profiles between single and dual venous anastomoses in DIEP flap breast reconstruction. Across 17 studies, including 2964 flaps (1536 single-vein and 1428 dual-vein), direct comparisons within the included studies consistently demonstrated lower rates of venous-related complications in the dual-vein group. Importantly, only a subset of included studies provided direct comparative data, whereas the remaining studies contributed descriptive outcomes for dual-vein techniques. In comparative analyses, dual venous anastomosis was associated with reduced rates of venous congestion (0%–13% versus 2.6%–55.1%), venous thrombosis (0%–2.7% versus up to 18.8%), fat necrosis (0%–17.4% versus up to 48.2%), and total flap loss (0%–8.7% versus up to 17.2%). These findings support the hypothesis that improved venous outflow plays a central role in flap survival and overall complication reduction.

From a health economics perspective, the routine use of a second venous anastomosis must be balanced against the associated increase in operative time and procedural costs. In the present review, the additional operative time reported for dual venous anastomoses ranged from minimal differences to more than 100 minutes, with a weighted mean increase of 34.4 minutes. Based on an estimated operating room cost of $36.50 per minute, this corresponds to an additional procedural cost of approximately $1255.60.³⁹ Furthermore, the cost of an additional venous coupler should also be considered. With an estimated device cost of approximately $240.40, a second venous anastomosis may increase total procedural costs to nearly $1500.⁴⁰ Nevertheless, these additional expenses must be interpreted in the context of the considerable financial burden associated with flap-related complications and reoperations. Previous analyses have demonstrated that readmission following free flap reconstruction may exceed $35,000, whereas reoperation costs may approach $10,000.⁴¹ Compared with the baseline cost of reconstruction, such complications may more than double overall healthcare expenditures. Consequently, even a modest reduction in complication or flap failure rates could potentially justify the increased operative time and costs associated with dual venous drainage.

It is well understood in the literature that patient characteristics, including smoking, BMI, and diabetes, influence flap viability.^42–44 In the current review, weighted mean baseline characteristics suggested that patients undergoing dual venous anastomosis were slightly older (50.1 versus 48.6 y), had a higher BMI (26.4 versus 25.7 kg/m²), and had higher reported rates of smoking, diabetes, hypertension, and prior radiotherapy than patients in the single-vein cohorts (Supplemental Digital Content 2, https://links.lww.com/PRSGO/F332). Although these differences may reflect the selection of higher risk patients for superdrainage, most included studies did not adjust for these potential confounders when reporting recipient-site outcomes. Gill et al²⁷ reported a significantly higher rate of breast complications in patients who were active smokers and those with hypertension, as well as a higher complication rate in patients with diabetes. Given that venous insufficiency and flap loss are likely multifactorial, addressing modifiable risk factors regardless of surgical approach is paramount to enhance chances of success.

Adjunct oncological treatments, particularly radiotherapy, may further impact outcomes. Although radiotherapy has been associated with increased complications in implant-based reconstruction,⁴⁵ its effect on autologous reconstruction remains controversial.^46,47 In the present review, only limited data were available to assess the interaction between radiotherapy and venous augmentation. Although 1 study reported increased complications with postoperative radiotherapy,²⁷ the small proportion of dual-vein cases precludes definitive conclusions regarding a potential protective effect of superdrainage in this setting. Given the increasing use of neoadjuvant and adjuvant therapies, further investigation is warranted.

Several systematic reviews and meta-analyses have previously compared single- and dual-vein DIEP flaps.^10,48,49 However, these studies often pooled prophylactic and salvage superdrainage, limiting interpretability. In contrast, the present review aimed to better characterize outcomes specifically in the context of dual venous drainage, while incorporating both comparative and noncomparative studies. This broader inclusion strategy increases sample size and generalizability but introduces heterogeneity that must be acknowledged.

This study has several limitations. First, there was substantial heterogeneity in patient populations, surgical techniques, definitions of complications, and reporting methods across studies, which precluded formal meta-analysis. Second, most included studies were retrospective and nonrandomized, introducing selection bias and limiting causal inference. Third, variability in the type of second venous system used (eg, SIEV versus DIEV versus other recipient veins) limits the ability to determine the optimal venous configuration. Fourth, definitions of key outcomes, such as venous congestion (typically a clinical diagnosis) and venous thrombosis (often confirmed intraoperatively), were not standardized across studies, further complicating comparisons.

Finally, although this review emphasizes direct comparisons between single- and dual-vein techniques where available, many findings are based on nonrandomized data and should be interpreted with caution. High-quality prospective or randomized studies are needed to definitively determine whether routine dual venous anastomosis should be recommended in DIEP flap breast reconstruction.

CONCLUSIONS

This systematic review of 2964 DIEP flaps demonstrates that dual venous anastomosis was associated with a substantial reduction in venous-related complications, with relative decreases of up to approximately 80%–90% for venous congestion (0%–13% versus 2.6%–55.1%), approximately 85% for venous thrombosis (0%–2.7% versus up to 18.8%), and approximately 60%–70% for fat necrosis (0%–17.4% versus up to 48.2%), alongside lower rates of total flap loss (0%–8.7% versus up to 17.2%). These benefits were observed despite use in higher risk patients. Although dual venous drainage increases operative time by a weighted mean of 34.4 minutes (≈$1255), this additional cost may be offset by the high costs associated with complication-associated readmissions (>$35,000). Overall, dual venous anastomosis seems to be a clinically beneficial and cost-effective strategy to improve flap reliability, pending confirmation from prospective studies.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Supplementary Material

gox-14-e8185-s001.pdf ^{(213KB, pdf)}