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

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.