Several reversed fasciocutaneous flaps are currently utilized in plastic surgery including radial forearm, sural artery, and lateral arm flaps. Venous outflow is contingent on a favorable circuitous flow through communicating veins. Venous congestion is a recognized complication and inclusion of secondary draining veins is often recommended.

We advocate placing a draining angiocath into the distal end of the vein—at the opposite pole from the venous anastomosis—which can be aspirated to alleviate any venous congestion. This technique is demonstrated in four patients.

The first patient undergoing limb salvage with a reversed sural artery flap developed on-table venous congestion. Every 30 minute aspiration of 5cc lead to complete resolution of congestion and 100% flap survival with uneventful limb salvage. In a second patient, venous congestion was alleviated with drainage, however only 50% of the flap was salvaged. The remainder of the wound was successfully skin grafted after 1 month of VAC application. For the third patient, an angiocath was placed prophylactically but was clinically not utilized as the flap clinically remained viable. Similarly, in a radial forearm reversed flap for dorsum of hand coverage, drainage was initiated on table for 1 hour until the flap equilibrated. Subsequently the angiocath was removed at 24 hrs without any untoward effect. In the fourth patient, flap congestion was transient and improved without any drainage.

This simple technique is previously reported by others in the literature for drainage of TRAM flaps by placement of an angiocath in an adequately sized subcutaneous vein, but finds it extension useful in reversed flaps which are by design predisposed to congestion. Conceptually a draining angiocath in the distal vein of a reversed flap seems sound. It may be used to mechanically “leech” a flap until it equilibrates. Conversely, decreased venous pressure may alter the physiology of the flap, preventing the cross-communicating veins from reversing flow. Further clinical and bench work would serve to elucidate the applicability of this technique in both pedicled and free reversed flaps.