Successful free flap salvage upon venous congestion in bilateral breast reconstruction using a venous cross‐over bypass: A case report

Abdominal free flaps such as the muscle sparing transverse rectus abdominis myocutaneous (ms‐TRAM) or deep inferior epigastric artery perforator (DIEP) flap represent the gold standard in autologous breast reconstruction. We describe a salvage procedure during bilateral free flap breast reconstruction due to insufficient venous drainage using a venous cross‐over bypass. A 54‐year‐old woman with a thrombosis of the left subclavian port‐system in the medical history was elected for simultaneous bilateral breast reconstruction with ms‐TRAM and DIEP flaps. Intraoperatively, a venous congestion of the DIEP flap, which was connected to the left cranial internal mammary vessels, appeared. In the absence of sufficient ipsilateral venous recipient vessels, we performed a salvage procedure requiring a 15 cm small saphenous vein graft and presternal subcutaneous tunneling. The flap vein was anastomosed end‐to‐end with the contralateral caudal internal mammary vein using a coupler system. The postoperative course was uneventful and both flaps survived. We describe the cross‐over venous emergency bypass as a useful tool in unexpected venous thrombosis during bilateral free flap breast reconstruction.