Background: Venous congestion remains a major threat to deep inferior epigastric perforator (DIEP) flap survival. While superdrainage via the superficial inferior epigastric vein (SIEV) is an established strategy, few reports describe temporary controlled drainage as a salvage option when a second venous anastomosis is not feasible. Methods: We present two cases of bilateral DIEP flap breast reconstruction complicated by early venous congestion due to superficial venous dominance. In each, a trimmed angiocatheter was inserted into the SIEV and secured to allow controlled venous outflow. Drainage was titrated based on clinical findings and perfusion monitoring, and catheters were weaned and removed once congestion resolved. Results: In Case 1, congestion was identified intraoperatively and managed with intermittent drainage every 30 minutes, later spaced and discontinued by postoperative day (POD) 2. The catheter was removed on POD 3, and both flaps survived without fat necrosis. In Case 2, congestion was detected postoperatively with declining tissue oximetry readings. Controlled drainage improved perfusion, and the catheter was removed on POD 3. The patient experienced delayed wound healing and a small focus of fat necrosis excised at revision, but flap viability was preserved. Conclusion: Controlled drainage using a trimmed angiocatheter provides a simple, reproducible option to augment venous outflow in DIEP flaps with superficial dominance. This minimally invasive approach may serve as an alternative to formal superdrainage, enabling flap salvage while avoiding additional anastomoses or prolonged operative time.
Keys et al. (Mon,) studied this question.