Advertisement

Does Two Venous Anastomoses Lead to Better Outcomes in Free Flap Reconstruction of the Head and Neck?

  • Cedric Hunter
  • David W. ChangEmail author
Chapter
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)

Abstract

Complex three-dimensional head and neck defects often require free tissue transfer for appropriate reconstruction after resection or trauma. Head and neck reconstruction requires key decision-making including appropriately selecting target vessels on the ipsilateral or contralateral side and the number of anastomoses to perform. Vascular thrombosis is a major complication of free flap surgery, with the largest problem being venous thrombosis. Literature support for multiple venous anastomoses is mixed. Some suggest that additional venous anastomoses lowers velocity through each vein increasing thrombosis risks, while others suggest that an additional anastomosis is protective and provides outflow when there is a thrombosis in single vein. Review of current published data including the meta-analyses and the physiologic studies suggests that performing two venous anastomoses may reduce the risk of flap failure and thrombotic complications compared to performing only a single venous anastomosis. While it is often sufficient to perform a single venous anastomosis, based on the included studies one should perform two venous anastomoses when technically feasible. However, this will have to be evaluated on a case by cases basis, as it is not always possible or prudent to perform two venous anastomoses. As a single venous anastomosis is sufficient the senior author routinely performs a single venous anastomosis unless the anatomy is favorable and a second anastomosis can be added in an expedient fashion.

Keywords

Free tissue flaps Venous thrombosis Head and neck cancer Head and neck reconstruction Microvascular anastomosis Microvascular free flap salvage 

References

  1. 1.
    Tran NV, Buchel EW, Convery PA. Microvascular complications of DIEP flaps. Plast Reconstr Surg. 2007;119(5):1397–405. discussion 1406–98CrossRefGoogle Scholar
  2. 2.
    Futran ND, Stack BC Jr. Single versus dual venous drainage of the radial forearm free flap. Am J Otolaryngol. 1996;17(2):112–7.CrossRefGoogle Scholar
  3. 3.
    Hanasono MM, Kocak E, Ogunleye O, Hartley CJ, Miller MJ. One versus two venous anastomoses in microvascular free flap surgery. Plast Reconstr Surg. 2010;126(5):1548–57.CrossRefGoogle Scholar
  4. 4.
    Ross GL, Ang ES, Lannon D, et al. Ten-year experience of free flaps in head and neck surgery. How necessary is a second venous anastomosis? Head Neck. 2008;30(8):1086–9.CrossRefGoogle Scholar
  5. 5.
    Ichinose A, Terashi H, Nakahara M, et al. Do multiple venous anastomoses reduce risk of thrombosis in free-flap transfer? Efficacy of dual anastomoses of separate venous systems. Ann Plast Surg. 2004;52(1):61–3.CrossRefGoogle Scholar
  6. 6.
    Riot S, Herlin C, Mojallal A, et al. A systematic review and meta-analysis of double venous anastomosis in free flaps. Plast Reconstr Surg. 2015;136(6):1299–311.CrossRefGoogle Scholar
  7. 7.
    Khaja SF, Rubin N, Bayon R. Venous complications in one versus two vein anastomoses in head and neck free flaps. Ann Otol Rhinol Laryngol. 2017;126(10):722–6.CrossRefGoogle Scholar
  8. 8.
    Demirkan F, Wei FC, Lutz BS, Cher TS, Chen IH. Reliability of the venae comitantes in venous drainage of the free radial forearm flaps. Plast Reconstr Surg. 1998;102(5):1544–8.CrossRefGoogle Scholar
  9. 9.
    Chaput B, Vergez S, Somda S, et al. Comparison of single and double venous anastomoses in head and neck oncologic reconstruction using free flaps: a meta-analysis. Plast Reconstr Surg. 2016;137(5):1583–94.CrossRefGoogle Scholar
  10. 10.
    Holm C, Dornseifer U, Sturtz G, Basso G, Schuster T, Ninkovic M. The intrinsic transit time of free microvascular flaps: clinical and prognostic implications. Microsurgery. 2010;30(2):91–6.PubMedGoogle Scholar
  11. 11.
    Hanasono MM, Ogunleye O, Yang JS, Hartley CJ, Miller MJ. Changes in blood velocity following microvascular free tissue transfer. J Reconstr Microsurg. 2009;25(7):417–24.CrossRefGoogle Scholar
  12. 12.
    Heitland AS, Markowicz M, Koellensperger E, Schoth F, Feller AM, Pallua N. Duplex ultrasound imaging in free transverse rectus abdominis muscle, deep inferior epigastric artery perforator, and superior gluteal artery perforator flaps: early and long-term comparison of perfusion changes in free flaps following breast reconstruction. Ann Plast Surg. 2005;55(2):117–21.CrossRefGoogle Scholar
  13. 13.
    Han Z, Li J, Li H, Su M, Qin L. Single versus dual venous anastomoses of the free fibula osteocutaneous flap in mandibular reconstruction: a retrospective study. Microsurgery. 2013;33(8):652–5.CrossRefGoogle Scholar
  14. 14.
    Bai S, Xu ZF, Duan WY, Liu FY, Huang DH, Sun CF. Single superficial versus dual systems venous anastomoses in radial forearm free flap: a meta-analysis. PLoS One. 2015;10(8):e0134805.CrossRefGoogle Scholar
  15. 15.
    Kroll SS, Schusterman MA, Reece GP, et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg. 1996;98(7):1230–3.CrossRefGoogle Scholar
  16. 16.
    Rodbard S. Flow through collapsible tubes: augmented flow produced by resistance at the outlet. Circulation. 1955;11(2):280–7.CrossRefGoogle Scholar
  17. 17.
    Ahmadi I, Herle P, Rozen WM, Leong J. One versus two venous anastomoses in microsurgical free flaps: a meta-analysis. J Reconstr Microsurg. 2014;30(6):413–8.CrossRefGoogle Scholar
  18. 18.
    Dornseifer U, Kleeberger C, Kimelman M, et al. Less is more? Impact of single venous anastomosis on the intrinsic transit time of free flaps. J Reconstr Microsurg. 2017;33(2):137–42.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Section of Plastic and Reconstructive Surgery, Department of SurgeryThe University of Chicago Medicine and Biological SciencesChicagoUSA

Personalised recommendations