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MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, e1ee2
CORRESPONDENCE AND COMMUNICATION Spatulated end-to-end microvascular anastomosis: A useful technique for overcoming vessel size discrepancy Dear Sir, Various techniques have been described to facilitate the microvascular anastomosis of vessels of differing sizes including increasing the diameter of the smaller vessel by mechanical dilation or by cutting the vessel end obliquely.1 Larger size discrepancies can be addressed with the fishmouth technique2 or the end-to-side technique.1 Kunlin3 described a technique of spatulating the smaller vessel in order to reduce vessel size mismatch which has gained widespread use in macrovascular surgery but which has had relatively limited exposure in plastic surgery.4,5 We have found this is a very useful technique for addressing vessel size mismatch and report our experience with this technique.
Method We perform the spatulated end-to-end anastomosis when there is significant vessel discrepancy that cannot be addressed sufficiently with either mechanical dilatation or by cutting the end of the smaller vessel obliquely. The end of the smaller diameter vessel is incised longitudinally to increase the luminal circumference to match that of the opposing vessel (Figure 1(1.1)). The first suture is placed at the apex of the incision on the smaller vessel (Figure 1(1.2)) and the anastomosis is then completed using interrupted sutures posterior wall first (Figure 1(1.3)).
Results We have used this technique for 22 arterial anastomoses and 2 venous anastomoses over a six year period in both
breast and head and neck reconstruction cases. The arterial anastomosis patency rate is 100%, however one of the venous anastomoses that we performed using this technique thrombosed on the first postoperative day necessitating revision. The majority of arterial anastomoses were performed in the breast reconstruction setting when anastomosing the smaller superficial inferior epigastric artery (spatulated) to the larger internal mammary artery. The venous anastomosis that failed was performed in a head and neck case to anastomose the larger peroneal vein from a free fibula flap to the smaller superficial temporal vein (spatulated). We have used this technique for vessel size discrepancy up to 5:1.
Discussion The spatulated end-to-end anastomosis is a very useful technique for overcoming significant vessel size mismatch. The sole anastomotic failure in this series occurred when a larger flap vein was anastomosed to a smaller donor vein and we would recommend care in planning if this combination is necessary. The senior author noted at re-exploration that the larger flap vein once filled had extended and produced a fold in the recipient vein and considers that this produced a functional obstruction to flow, stasis and ultimately throm bosis. We have used the technique successfully for substantial size discrepancy which would otherwise have necessitated end-to-side anastomosis. Arterial anastomoses have been performed from large supply vessel to a small flap vessel and vice versa. A small flap vein to large donor vein has also been successful. The spatulated end-to-end anastomosis is quicker, simpler to perform, and can be performed with relative ease in constrained spaces in contrast to end-to-side anastomosis. Furthermore, in contrast to the fish mouth technique,2 the current technique only requires a single longitudinal incision in the smaller vessel and is therefore simpler and more reliable to perform.
http://dx.doi.org/10.1016/j.bjps.2014.07.008 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ridha H, et al., Spatulated end-to-end microvascular anastomosis: A useful technique for overcoming vessel size discrepancy, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.07.008
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MODEL
e2
Correspondence and communication
Figure 1 (1.1): Shows the longitudinal incision in the smaller diameter vessel to increase the luminal circumference to match that of the opposing vessel. (1.2): Shows the first suture being placed at the apex of the incision on the smaller vessel. (1.3): The completed anastomosis.
Conflict of interest statement None.
Funding None declared.
Ethical approval Not required.
References 1. Sabapathy R. Microsurgery suture techniques. In: Wei FC, Mardini S, editors. Flaps and reconstructive surgery. 1st ed. Saunders Elsevier; 2009. pp. 81e91. 2. Harashina T, Irigaray A. Expansion of smaller vessel diameter by fish-mouth incision in microvascular anastomosis with
marked size discrepancy. Plast Reconstr Surg 1980;65(4): 502e3. 3. Kunlin J. Le traitement de l’arterite obliterante par la greffe veineuse longue. Arch Mal Coeur 1949;42:371. 4. Fossati E, Asurey N, Irigaray A. Application of Kunlin’s technique in vascular micro-anastomosis: experimental and clinical study. Microsurgery 1985;6(1):53e5. 5. Chevray PM. Breast reconstruction with superficial inferior epigastric flaps: a comparison with TRAM and DIEP flaps. Plast Reconstr Surg 2004:1077e83.
H. Ridha A.N. Morritt S.H. Wood Department of Plastic and Reconstructive Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK E-mail address: [email protected] 24 April 2014
Please cite this article in press as: Ridha H, et al., Spatulated end-to-end microvascular anastomosis: A useful technique for overcoming vessel size discrepancy, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.07.008
MODEL
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, e1ee2
CORRESPONDENCE AND COMMUNICATION Spatulated end-to-end microvascular anastomosis: A useful technique for overcoming vessel size discrepancy Dear Sir, Various techniques have been described to facilitate the microvascular anastomosis of vessels of differing sizes including increasing the diameter of the smaller vessel by mechanical dilation or by cutting the vessel end obliquely.1 Larger size discrepancies can be addressed with the fishmouth technique2 or the end-to-side technique.1 Kunlin3 described a technique of spatulating the smaller vessel in order to reduce vessel size mismatch which has gained widespread use in macrovascular surgery but which has had relatively limited exposure in plastic surgery.4,5 We have found this is a very useful technique for addressing vessel size mismatch and report our experience with this technique.
Method We perform the spatulated end-to-end anastomosis when there is significant vessel discrepancy that cannot be addressed sufficiently with either mechanical dilatation or by cutting the end of the smaller vessel obliquely. The end of the smaller diameter vessel is incised longitudinally to increase the luminal circumference to match that of the opposing vessel (Figure 1(1.1)). The first suture is placed at the apex of the incision on the smaller vessel (Figure 1(1.2)) and the anastomosis is then completed using interrupted sutures posterior wall first (Figure 1(1.3)).
Results We have used this technique for 22 arterial anastomoses and 2 venous anastomoses over a six year period in both
breast and head and neck reconstruction cases. The arterial anastomosis patency rate is 100%, however one of the venous anastomoses that we performed using this technique thrombosed on the first postoperative day necessitating revision. The majority of arterial anastomoses were performed in the breast reconstruction setting when anastomosing the smaller superficial inferior epigastric artery (spatulated) to the larger internal mammary artery. The venous anastomosis that failed was performed in a head and neck case to anastomose the larger peroneal vein from a free fibula flap to the smaller superficial temporal vein (spatulated). We have used this technique for vessel size discrepancy up to 5:1.
Discussion The spatulated end-to-end anastomosis is a very useful technique for overcoming significant vessel size mismatch. The sole anastomotic failure in this series occurred when a larger flap vein was anastomosed to a smaller donor vein and we would recommend care in planning if this combination is necessary. The senior author noted at re-exploration that the larger flap vein once filled had extended and produced a fold in the recipient vein and considers that this produced a functional obstruction to flow, stasis and ultimately throm bosis. We have used the technique successfully for substantial size discrepancy which would otherwise have necessitated end-to-side anastomosis. Arterial anastomoses have been performed from large supply vessel to a small flap vessel and vice versa. A small flap vein to large donor vein has also been successful. The spatulated end-to-end anastomosis is quicker, simpler to perform, and can be performed with relative ease in constrained spaces in contrast to end-to-side anastomosis. Furthermore, in contrast to the fish mouth technique,2 the current technique only requires a single longitudinal incision in the smaller vessel and is therefore simpler and more reliable to perform.
http://dx.doi.org/10.1016/j.bjps.2014.07.008 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ridha H, et al., Spatulated end-to-end microvascular anastomosis: A useful technique for overcoming vessel size discrepancy, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.07.008
+
MODEL
e2
Correspondence and communication
Figure 1 (1.1): Shows the longitudinal incision in the smaller diameter vessel to increase the luminal circumference to match that of the opposing vessel. (1.2): Shows the first suture being placed at the apex of the incision on the smaller vessel. (1.3): The completed anastomosis.
Conflict of interest statement None.
Funding None declared.
Ethical approval Not required.
References 1. Sabapathy R. Microsurgery suture techniques. In: Wei FC, Mardini S, editors. Flaps and reconstructive surgery. 1st ed. Saunders Elsevier; 2009. pp. 81e91. 2. Harashina T, Irigaray A. Expansion of smaller vessel diameter by fish-mouth incision in microvascular anastomosis with
marked size discrepancy. Plast Reconstr Surg 1980;65(4): 502e3. 3. Kunlin J. Le traitement de l’arterite obliterante par la greffe veineuse longue. Arch Mal Coeur 1949;42:371. 4. Fossati E, Asurey N, Irigaray A. Application of Kunlin’s technique in vascular micro-anastomosis: experimental and clinical study. Microsurgery 1985;6(1):53e5. 5. Chevray PM. Breast reconstruction with superficial inferior epigastric flaps: a comparison with TRAM and DIEP flaps. Plast Reconstr Surg 2004:1077e83.
H. Ridha A.N. Morritt S.H. Wood Department of Plastic and Reconstructive Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK E-mail address: [email protected] 24 April 2014
Please cite this article in press as: Ridha H, et al., Spatulated end-to-end microvascular anastomosis: A useful technique for overcoming vessel size discrepancy, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.07.008
