Recent advances in application of venous superdrainage in perforator flaps_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

HE Anxin ¹ , BA Long ¹ ,  WEI Zairong ^1,2,3

1. Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563000, P. R. China;
2. The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine, Zunyi Medical University, Zunyi Guizhou, 563000, P. R. China;
3. Guizhou Biofabrication Laboratory, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563000, P. R. China;

Corresponding?author：

WEI Zairong, Email: zairongwei@163.com

Keywords：

Venous superdrainage; perforator flap; flap crisis; flap transplantation; soft tissue defect

DOI：

10.7507/1002-1892.202604045

Video：

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Objective To summarize the application, clinical value, and current limitations of venous superdrainage in perforator flap reconstruction. Methods The literature on venous superdrainage was reviewed, focusing on distal necrosis and venous outflow impairment in perforator flaps, the characteristics of the superficial venous system, the principles of venous superdrainage, and its application in different reconstruction sites. Results Venous superdrainage, by providing additional venous outflow channels to divert congested blood and reduce venous pressure, can significantly increase venous outflow of the flap (from approximately 4 mL/minute to 13.9 mL/minute in deep inferior epigastric perforator flaps). In breast reconstruction, selective anastomosis of the superficial inferior epigastric vein reduces venous congestion and related complications; in the distal lower extremity, prospective comparative studies of venous-supercharged propeller flaps and distally based sural flaps have shown significant reductions in venous congestion and distal necrosis. However, the benefits are influenced by individual venous anatomy and multiple factors, and identification of high-risk configurations and selection of target veins remain non-standardized. Conclusion Venous superdrainage has potential clinical value in certain high-risk configurations. However, its indications for prophylactic use, selection of target veins, and standardized implementation protocols require further clarification.

Citation： HE Anxin, BA Long, WEI Zairong. Recent advances in application of venous superdrainage in perforator flaps. Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(9): 1452-1457. doi: 10.7507/1002-1892.202604045 Copy

1.	Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and applications[J]. Ann Plast Surg, 2003, 50(1): 90-99.
2.	Boissiere F, Gandolfi S, Riot S, et al. Flap venous congestion and salvage techniques: a systematic literature review[J/OL]. Plast Reconstr Surg Glob Open, 2021, 9(1): e3327. doi: 10.1097/GOX.0000000000003327.
3.	Yanaga H, Tai Y, Kiyokawa K, et al. An ipsilateral superdrainaged transverse rectus abdominis myocutaneous flap for breast reconstruction[J]. Plast Reconstr Surg, 1999, 103(2): 465-472.
4.	魏在榮. 皮瓣命名方式探討[J/OL]. 中華損傷與修復雜志(電子版), 2011, 6(3): 337-341. doi: 103.877/cma.j.issn.1673-9450.2011.03.003.
5.	Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforator flaps: history, controversies, physiology, anatomy, and use in reconstruction[J/OL]. Plast Reconstr Surg, 2009, 123(4): 132e-145e. doi: 10.1097/PRS.0b013e31819f2c6a.
6.	Wang P, Lin F, Ma Y, et al. Predictors of the surgical outcome of propeller perforator flap reconstruction, focusing on the effective safe distance between the perforator and the wound edge[J/OL]. BMC Musculoskelet Disord, 2021, 22(1): 643. doi: 10.1186/s12891-021-04522-z.
7.	Lee Z, Abdou SA, Ramly EP, et al. Larger free flap size is associated with increased complications in lower extremity trauma reconstruction[J]. Microsurgery, 2020, 40(4): 473-478.
8.	van den Heuvel MGW, Buurman WA, Bast A, et al. Review: ischaemia-reperfusion injury in flap surgery[J]. J Plast Reconstr Aesthet Surg, 2009, 62(6): 721-726.
9.	Eltzschig HK, Eckle T. Ischemia and reperfusion-from mechanism to translation[J]. Nat Med, 2011, 17(11): 1391-1401.
10.	Jackson SP, Darbousset R, Schoenwaelder SM. Thromboinflammation: challenges of therapeutically targeting coagulation and other host defense mechanisms[J]. Blood, 2019, 133(9): 906-918.
11.	Bray MA, Sartain SE, Gollamudi J, et al. Microvascular thrombosis: experimental and clinical implications[J]. Transl Res, 2020, 225: 105-130.
12.	Black CM. Anatomy and physiology of the lower-extremity deep and superficial veins[J]. Tech Vasc Interv Radiol, 2014, 17(2): 68-73.
13.	Hill BG, van Rij AM. The lower limb perforator veins in normal subjects[J/OL]. J Vasc Surg Venous Lymphat Disord, 2022, 10(3): 669.e1-675.e1. doi: 10.1016/j.jvsv.2022.01.010.
14.	Rozen WM, Pan WR, Le Roux CM, et al. The venous anatomy of the anterior abdominal wall: an anatomical and clinical study[J]. Plast Reconstr Surg, 2009, 124(3): 848-853.
15.	Rozen WM, Ashton MW. The venous anatomy of the abdominal wall for Deep Inferior Epigastric Artery (DIEP) flaps in breast reconstruction[J]. Gland Surg, 2012, 1(2): 92-110.
16.	Park SO, Imanishi N, Chang H. The anatomic features and role of superficial inferior epigastric vein in abdominal flap[J]. Arch Plast Surg, 2022, 49(4): 482-487.
17.	Paganini F, Matarazzo S, Corsini B, et al. Superficial vs. deep venous system in DIEP flaps: lessons from 25 years of CTA-guided planning[J/OL]. J Clin Med, 2025, 14(17): 5972. doi: 10.3390/jcm14175972.
18.	Meissner MH. Lower extremity venous anatomy[J]. Semin Intervent Radiol, 2005, 22(3): 147-156.
19.	del Pinal F, Taylor GI. The deep venous system and reverse flow flaps[J]. Br J Plast Surg, 1993, 46(8): 652-664.
20.	Isaac J, Walker L, Ali SR, et al. Exploring the venous supply of the face: an illustrated overview of contemporary literature[J]. JPRAS Open, 2024, 43: 92-104.
21.	Honda K, Omori K, Kishimoto Y. Anatomical variations in the superficial venous system of the neck: an image-based study using contrast-enhanced computed tomography[J]. Surg Radiol Anat, 2024, 46(5): 669-677.
22.	Rothenberger J, Amr A, Schiefer J, et al. A quantitative analysis of the venous outflow of the deep inferior epigastric flap (DIEP) based on the perforator veins and the efficiency of superficial inferior epigastric vein superdrainage[J]. J Plast Reconstr Aesthet Surg, 2013, 66(1): 67-72.
23.	Hansson E, Ramakrishnan V, Morgan M. A systematic review of the scientific evidence of venous supercharging in autologous breast reconstruction with abdominally based flaps[J/OL]. World J Surg Oncol, 2023, 21(1): 379. doi:10.1186/s12957-023-03254-9.
24.	Tao Y, Ding M, Wang A, et al. Basic perforator flap hemodynamic mathematical model[J/OL]. Plast Reconstr Surg Glob Open, 2016, 4(5): e714. doi:10.1097/GOX.0000000000000689.
25.	Roux E, Bougaran P, Dufourcq P, et al. Fluid shear stress sensing by the endothelial layer[J/OL]. Front Physiol, 2020, 11: 861. doi:10.3389/fphys.2020.00861.
26.	Baeyens N, Bandyopadhyay C, Coon BG, et al. Endothelial fluid shear stress sensing in vascular health and disease[J]. J Clin Invest, 2016, 126(3): 821-828.
27.	Pignatti M, Pinto V, Giorgini FA, et al. Meta-analysis of the effects of venous super-drainage in deep inferior epigastric artery perforator flaps for breast reconstruction[J]. Microsurgery, 2021, 41(2): 186-195.
28.	Lombardo GAG, Cherubino M, Marchica P, et al. Prophylactic venous supercharging in deep inferior epigastric artery perforator flap surgery: a retrospective dual-center study[J]. J Reconstr Microsurg, 2025, 41(4): 295-301.
29.	Huang H, Bast JH, Otterburn DM, et al. Delineating the risk factors of venous congestion: an analysis of 455 DIEP flaps with radiographic correlation[J]. J Plast Reconstr Aesthet Surg, 2022, 75(6): 1886-1892.
30.	Ruiz-Moya A, Lopez-Garcia RA, Sicilia-Castro D, et al. Anatomical features associated with venous congestion in DIEP flap using CT angiography with three-dimensional reconstruction[J]. Plast Aesthet Res, 2017, 4: 127-134.
31.	Zhu Y, Yoo H, Min S, et al. Efficacy of superficial inferior epigastric vein superdrainage in free TRAM and DIEP flap: an indocyanine green angiography study of 68 cases[J]. J Plast Reconstr Aesthet Surg, 2023, 84: 385-391.
32.	Kramer A, Lava CX, Li KR, et al. Indocyanine green angiography for detecting quantitative perfusion changes in deep inferior epigastric perforator flap breast reconstruction with second venous drainage[J]. Ann Plast Surg, 2024, 93(2): 215-220.
33.	馬小睦, 徐伯揚, 付蘇, 等. 腹壁淺靜脈超回流在單蒂腹壁下動脈穿支皮瓣乳房再造中的作用[J]. 中華整形外科雜志, 2023, 39(4): 366-374.
34.	Chaput B, Bertheuil N, Grolleau JL, et al. Comparison of propeller perforator flap and venous supercharged propeller perforator flap in reconstruction of lower limb soft tissue defect: a prospective study[J]. Microsurgery, 2018, 38(2): 177-184.
35.	Herlin C, Bekara F, Bertheuil N, et al. Venous supercharging reduces complications and improves outcomes of distally based sural flaps[J]. J Reconstr Microsurg, 2017, 33(5): 343-351.
36.	Khajuria A, Koshima I, Kannan RY. The role of supermicrosurgery and arborization capture in improving free-styled propeller flap survival[J/OL]. Plast Reconstr Surg Glob Open, 2021, 9(12): e3974. doi: 10.1097/GOX.0000000000003974.
37.	張馳, 游興, 呂美娟, 等. 超回流技術在逆行股前外側斜支皮瓣修復小腿上段軟組織缺損的應用[J]. 中華顯微外科雜志, 2019, 42(3): 209-212.
38.	楊銳, 高偉航, 張子陽, 等. 靜脈超引流技術在逆行旋股外側動脈降支穿支皮瓣修復膝關節軟組織缺損中的應用效果[J]. 中華創傷雜志, 2025, 41(4): 387-390.
39.	Wu WJ, Zheng L, Zhang J, et al. Venous superdrainage using superficial circumflex iliac vein in deep circumflex iliac artery perforator flap with iliac crest for oromandibular reconstruction[J]. Int J Oral Maxillofac Surg, 2022, 51(1): 38-43.
40.	Boczar D, Colon RR, Anzai L, et al. Single versus double venous anastomosis microvascular free flaps for head and neck reconstruction[J]. J Craniofac Surg, 2022, 33(3): 784-786.
41.	Brunetti B, Salzillo R, De Bernardis R, et al. Conjoined thoracodorsal perforator-supercharged dorsal intercostal artery perforator propeller flap for reconstruction of a complex upper back defect: case report and review of the literature on supercharged pedicled perforator flaps[J/OL]. Microsurgery, 2024, 44(1): e31129. doi: 10.1002/micr.31129.
42.	Kim YJ, Choi WY, Cheon JS, et al. Clinical applications of the intercostal artery perforator flap for trunk reconstruction[J]. Arch Plast Surg, 2023, 50(3): 233-239.
43.	李海, 張程, 鄧呈亮, 等. 靜脈超回流薄型旋髂淺動脈穿支皮瓣修復四肢軟組織缺損創面20例[J]. 中華顯微外科雜志, 2025, 48(4): 382-387.
44.	Zheng J, Xi S, Ding M, et al. Effects of venous superdrainage and arterial supercharging on dorsal perforator flap in a rat model[J/OL]. PLoS One, 2016, 11(8): e0160942. doi: 10.1371/journal.pone.0160942.

1. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and applications[J]. Ann Plast Surg, 2003, 50(1): 90-99.
2. Boissiere F, Gandolfi S, Riot S, et al. Flap venous congestion and salvage techniques: a systematic literature review[J/OL]. Plast Reconstr Surg Glob Open, 2021, 9(1): e3327. doi: 10.1097/GOX.0000000000003327.
3. Yanaga H, Tai Y, Kiyokawa K, et al. An ipsilateral superdrainaged transverse rectus abdominis myocutaneous flap for breast reconstruction[J]. Plast Reconstr Surg, 1999, 103(2): 465-472.
4. 魏在榮. 皮瓣命名方式探討[J/OL]. 中華損傷與修復雜志(電子版), 2011, 6(3): 337-341. doi: 103.877/cma.j.issn.1673-9450.2011.03.003.
5. Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforator flaps: history, controversies, physiology, anatomy, and use in reconstruction[J/OL]. Plast Reconstr Surg, 2009, 123(4): 132e-145e. doi: 10.1097/PRS.0b013e31819f2c6a.
6. Wang P, Lin F, Ma Y, et al. Predictors of the surgical outcome of propeller perforator flap reconstruction, focusing on the effective safe distance between the perforator and the wound edge[J/OL]. BMC Musculoskelet Disord, 2021, 22(1): 643. doi: 10.1186/s12891-021-04522-z.
7. Lee Z, Abdou SA, Ramly EP, et al. Larger free flap size is associated with increased complications in lower extremity trauma reconstruction[J]. Microsurgery, 2020, 40(4): 473-478.
8. van den Heuvel MGW, Buurman WA, Bast A, et al. Review: ischaemia-reperfusion injury in flap surgery[J]. J Plast Reconstr Aesthet Surg, 2009, 62(6): 721-726.
9. Eltzschig HK, Eckle T. Ischemia and reperfusion-from mechanism to translation[J]. Nat Med, 2011, 17(11): 1391-1401.
10. Jackson SP, Darbousset R, Schoenwaelder SM. Thromboinflammation: challenges of therapeutically targeting coagulation and other host defense mechanisms[J]. Blood, 2019, 133(9): 906-918.
11. Bray MA, Sartain SE, Gollamudi J, et al. Microvascular thrombosis: experimental and clinical implications[J]. Transl Res, 2020, 225: 105-130.
12. Black CM. Anatomy and physiology of the lower-extremity deep and superficial veins[J]. Tech Vasc Interv Radiol, 2014, 17(2): 68-73.
13. Hill BG, van Rij AM. The lower limb perforator veins in normal subjects[J/OL]. J Vasc Surg Venous Lymphat Disord, 2022, 10(3): 669.e1-675.e1. doi: 10.1016/j.jvsv.2022.01.010.
14. Rozen WM, Pan WR, Le Roux CM, et al. The venous anatomy of the anterior abdominal wall: an anatomical and clinical study[J]. Plast Reconstr Surg, 2009, 124(3): 848-853.
15. Rozen WM, Ashton MW. The venous anatomy of the abdominal wall for Deep Inferior Epigastric Artery (DIEP) flaps in breast reconstruction[J]. Gland Surg, 2012, 1(2): 92-110.
16. Park SO, Imanishi N, Chang H. The anatomic features and role of superficial inferior epigastric vein in abdominal flap[J]. Arch Plast Surg, 2022, 49(4): 482-487.
17. Paganini F, Matarazzo S, Corsini B, et al. Superficial vs. deep venous system in DIEP flaps: lessons from 25 years of CTA-guided planning[J/OL]. J Clin Med, 2025, 14(17): 5972. doi: 10.3390/jcm14175972.
18. Meissner MH. Lower extremity venous anatomy[J]. Semin Intervent Radiol, 2005, 22(3): 147-156.
19. del Pinal F, Taylor GI. The deep venous system and reverse flow flaps[J]. Br J Plast Surg, 1993, 46(8): 652-664.
20. Isaac J, Walker L, Ali SR, et al. Exploring the venous supply of the face: an illustrated overview of contemporary literature[J]. JPRAS Open, 2024, 43: 92-104.
21. Honda K, Omori K, Kishimoto Y. Anatomical variations in the superficial venous system of the neck: an image-based study using contrast-enhanced computed tomography[J]. Surg Radiol Anat, 2024, 46(5): 669-677.
22. Rothenberger J, Amr A, Schiefer J, et al. A quantitative analysis of the venous outflow of the deep inferior epigastric flap (DIEP) based on the perforator veins and the efficiency of superficial inferior epigastric vein superdrainage[J]. J Plast Reconstr Aesthet Surg, 2013, 66(1): 67-72.
23. Hansson E, Ramakrishnan V, Morgan M. A systematic review of the scientific evidence of venous supercharging in autologous breast reconstruction with abdominally based flaps[J/OL]. World J Surg Oncol, 2023, 21(1): 379. doi:10.1186/s12957-023-03254-9.
24. Tao Y, Ding M, Wang A, et al. Basic perforator flap hemodynamic mathematical model[J/OL]. Plast Reconstr Surg Glob Open, 2016, 4(5): e714. doi:10.1097/GOX.0000000000000689.
25. Roux E, Bougaran P, Dufourcq P, et al. Fluid shear stress sensing by the endothelial layer[J/OL]. Front Physiol, 2020, 11: 861. doi:10.3389/fphys.2020.00861.
26. Baeyens N, Bandyopadhyay C, Coon BG, et al. Endothelial fluid shear stress sensing in vascular health and disease[J]. J Clin Invest, 2016, 126(3): 821-828.
27. Pignatti M, Pinto V, Giorgini FA, et al. Meta-analysis of the effects of venous super-drainage in deep inferior epigastric artery perforator flaps for breast reconstruction[J]. Microsurgery, 2021, 41(2): 186-195.
28. Lombardo GAG, Cherubino M, Marchica P, et al. Prophylactic venous supercharging in deep inferior epigastric artery perforator flap surgery: a retrospective dual-center study[J]. J Reconstr Microsurg, 2025, 41(4): 295-301.
29. Huang H, Bast JH, Otterburn DM, et al. Delineating the risk factors of venous congestion: an analysis of 455 DIEP flaps with radiographic correlation[J]. J Plast Reconstr Aesthet Surg, 2022, 75(6): 1886-1892.
30. Ruiz-Moya A, Lopez-Garcia RA, Sicilia-Castro D, et al. Anatomical features associated with venous congestion in DIEP flap using CT angiography with three-dimensional reconstruction[J]. Plast Aesthet Res, 2017, 4: 127-134.
31. Zhu Y, Yoo H, Min S, et al. Efficacy of superficial inferior epigastric vein superdrainage in free TRAM and DIEP flap: an indocyanine green angiography study of 68 cases[J]. J Plast Reconstr Aesthet Surg, 2023, 84: 385-391.
32. Kramer A, Lava CX, Li KR, et al. Indocyanine green angiography for detecting quantitative perfusion changes in deep inferior epigastric perforator flap breast reconstruction with second venous drainage[J]. Ann Plast Surg, 2024, 93(2): 215-220.
33. 馬小睦, 徐伯揚, 付蘇, 等. 腹壁淺靜脈超回流在單蒂腹壁下動脈穿支皮瓣乳房再造中的作用[J]. 中華整形外科雜志, 2023, 39(4): 366-374.
34. Chaput B, Bertheuil N, Grolleau JL, et al. Comparison of propeller perforator flap and venous supercharged propeller perforator flap in reconstruction of lower limb soft tissue defect: a prospective study[J]. Microsurgery, 2018, 38(2): 177-184.
35. Herlin C, Bekara F, Bertheuil N, et al. Venous supercharging reduces complications and improves outcomes of distally based sural flaps[J]. J Reconstr Microsurg, 2017, 33(5): 343-351.
36. Khajuria A, Koshima I, Kannan RY. The role of supermicrosurgery and arborization capture in improving free-styled propeller flap survival[J/OL]. Plast Reconstr Surg Glob Open, 2021, 9(12): e3974. doi: 10.1097/GOX.0000000000003974.
37. 張馳, 游興, 呂美娟, 等. 超回流技術在逆行股前外側斜支皮瓣修復小腿上段軟組織缺損的應用[J]. 中華顯微外科雜志, 2019, 42(3): 209-212.
38. 楊銳, 高偉航, 張子陽, 等. 靜脈超引流技術在逆行旋股外側動脈降支穿支皮瓣修復膝關節軟組織缺損中的應用效果[J]. 中華創傷雜志, 2025, 41(4): 387-390.
39. Wu WJ, Zheng L, Zhang J, et al. Venous superdrainage using superficial circumflex iliac vein in deep circumflex iliac artery perforator flap with iliac crest for oromandibular reconstruction[J]. Int J Oral Maxillofac Surg, 2022, 51(1): 38-43.
40. Boczar D, Colon RR, Anzai L, et al. Single versus double venous anastomosis microvascular free flaps for head and neck reconstruction[J]. J Craniofac Surg, 2022, 33(3): 784-786.
41. Brunetti B, Salzillo R, De Bernardis R, et al. Conjoined thoracodorsal perforator-supercharged dorsal intercostal artery perforator propeller flap for reconstruction of a complex upper back defect: case report and review of the literature on supercharged pedicled perforator flaps[J/OL]. Microsurgery, 2024, 44(1): e31129. doi: 10.1002/micr.31129.
42. Kim YJ, Choi WY, Cheon JS, et al. Clinical applications of the intercostal artery perforator flap for trunk reconstruction[J]. Arch Plast Surg, 2023, 50(3): 233-239.
43. 李海, 張程, 鄧呈亮, 等. 靜脈超回流薄型旋髂淺動脈穿支皮瓣修復四肢軟組織缺損創面20例[J]. 中華顯微外科雜志, 2025, 48(4): 382-387.
44. Zheng J, Xi S, Ding M, et al. Effects of venous superdrainage and arterial supercharging on dorsal perforator flap in a rat model[J/OL]. PLoS One, 2016, 11(8): e0160942. doi: 10.1371/journal.pone.0160942.

Chinese Journal of Reparative and Reconstructive Surgery

Recent advances in application of venous superdrainage in perforator flaps

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