BACKGROUND: Despite improving outcomes, venous problems in the harvest of deep inferior epigastric artery perforator (DIEP) flaps remain the more common vascular complications. However, it is apparent that the venous anatomy of the anterior abdominal wall has not been described to the same extent as the arterial anatomy. Previous anatomical studies have focused on cadaveric anatomy or excisional specimens. The current study uses in vivo computed tomographic angiography to evaluate this anatomy, in combination with a cadaveric radiographic study. METHODS: Both cadaveric and in vivo studies were undertaken using eight whole fresh cadaveric specimens (16 sides) and 100 patients undergoing DIEP flap breast reconstruction (200 sides). The cadaveric component used direct catheter venography and the in vivo studies were undertaken using preoperative computed tomographic angiography, mapping in vivo venous flow. RESULTS: : The location, caliber, course, and distribution of the superficial and deep inferior epigastric veins were recorded. The dominance of each system and their direction of drainage were described. Mechanisms for poor venous drainage were postulated, including perforator size, midline crossover of the superficial inferior epigastric vein, and the superficial and deep inferior epigastric vein communications. The incidence of each of these anatomical factors was evaluated. CONCLUSION: The cause of venous compromise is multifactorial, with the current study showing that preoperative computed tomographic angiography may predict venous problems during flap harvest, by demonstrating perforator diameter, midline crossover, and deep-superficial venous communications.
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