VENOUS COUPLER USE FOR FREE-FLAP BREAST RECONSTRUCTIONS: SPECIFIC ANALYSES OF TMG AND DIEP FLAPS  ERIC  FRED BODIN, M.D., Ph.D.,1* STEFANIA BRUNETTI, M.D.,2 CAROLINE DISSAUX, M.D.,1 ERIK A. SAULEAU, M.D., Ph.D.,3 SYBILLE FACCA, M.D., Ph.D.,2 CATHERINE BRUANT-RODIER, M.D., Ph.D.,1 and PHILIPPE LIVERNEAUX, M.D., Ph.D.2

Purpose: The purpose of this report was to present the results of comparisons of anastomotic data and flap complications in the use of venous coupler in breast reconstruction with the transverse musculocutaneous gracilis (TMG) flap and the deep inferior epigastric perforator (DIEP) flap. Methods: Over a three-year period, 95 patients suffering from breast cancer were treated with mastectomy and breast reconstruction using free flaps. We performed 121 mechanical venous anastomoses for 105 flap procedures (80 DIEP and 25 TMG). The coupler size, anastomotic duration, number of anastomoses and postoperative complications were assessed for the entire series. Results: The coupling device was perfectly suitable for all end-to-end anastomoses between the vein(s) of the flap and the internal mammary vein(s). No venous thrombosis occurred. The mean anastomotic time did not significantly differ between the DIEP (330 seconds) and TMG flap procedures (352 seconds) (P 5 0.069). Additionally, there were no differences in coupling time observed following a comparison of seven coupler sizes (P 5 0.066). The mean coupler size used during the TMG flap procedure was smaller than that used with the DIEP (2.4 mm versus 2.8 mm) (P < 0.001). The mean size was also smaller when double venous anastomoses were required compared to single anastomosis (2.4 mm versus 2.9 mm) (P < 0.001). The double branching was more frequent with the TMG flap (28%) than with the DIEP flap (11%). Conclusions: The coupler size used was smaller for the TMG procedure and when double venous anastomosis was performed. Additionally, anastomotic time was not affected by the flap type or coupler size used or by anastomosis number. C 2014 Wiley Periodicals, Inc. Microsurgery 35:295–299, 2015. V

Vascular microsutures play a key role in free flap transfers. Conventional hand suturing has long been the gold standard for artery and vein anastomoses; however, handsewn anastomoses are time demanding, and any flaw because of intimal injury can lead to thrombosis and flap loss. For more than 100 years, researchers have attempted to develop mechanical systems that simplify and secure microsurgical procedures. Nonpenetrating devices, such as staple and double-ring couplers, have recently displayed excellent results in extended clinical series.1–3 The microvascular anastomotic coupler system (Synovis Micro Companies Alliance, St. Paul, MN, USA), which was initially developed by Ostrup and Berggren,4,5 has demonstrated repeated efficiency with regard to speed and the maintenance of a low thrombosis rate during venous anastomosis.6–8 However, few clinical series have provided specific details regarding the flaps, anastomotic times and coupler sizes used. In this study, anastomotic time was prospectively measured, providing additional information pertaining to 1 Department of Plastic Surgery, Strasbourg Academic Hospital, Strasbourg, France 2 Department of Hand Surgery, Strasbourg Academic Hospital, Strasbourg, France 3 Department of Biostatistics, Strasbourg Academic Hospital, Strasbourg, France  de ric Bodin, M.D., Ph.D., Service de Chirurgie Plas*Correspondence to: Fre ^pital Civil, 1 place de l’ho ^pital, B.P. N 426, tique et Reconstructrice, Ho 67091 Strasbourg Cedex, France. E-mail: [email protected] Received 25 July 2014; Revision accepted 22 October 2014; Accepted 24 October 2014 Published online 8 November 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22350

Ó 2014 Wiley Periodicals, Inc.

use of the coupler system for breast reconstruction. Retrospective analysis of anastomotic data and flap complications were compared for two different breast reconstruction techniques: the transverse musculocutaneous gracilis (TMG) flap and the deep inferior epigastric perforator (DIEP) flap techniques. PATIENTS AND METHODS

Between January 2011 and February 2014, 95 patients were treated with free-flap breast reconstruction procedures at the Strasbourg University Hospital. The same leading surgeon performed 80 DIEP and 25 TMG flap procedures. A total of 105 free flaps were indicated for unilateral (n 5 85) or bilateral (n 5 10) reconstruction in immediate or delayed settings. The patients were 48 years old on average (range, 20–63 years) with a mean body mass index of 20.8 kg/cm2 (range, 18.1–33.3 kg/cm2). Eighty-six percent of the patients underwent previous adjuvant chemotherapy, and 78% underwent adjuvant radiotherapy at the recipient site. All of the patients were nonsmokers, and none were suffering from vascular disease or diabetes. A microvascular anastomotic coupler device (Synovis Micro Companies Alliance, St. Paul, MN, USA) was used in 121 cases to connect veins. Single end-to-end venous anastomosis was performed in 89 cases. Double end-toend venous anastomosis was required in the remaining 16 cases to ensure for proper venous drainage (15.2%). These double connections were considered necessary by the leading surgeon during nine DIEP flap procedures (11%) and seven TMG flap procedures (28%).

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Bodin et al. Table 1. Differences in Flap Type and Number of Venous Anastomoses Among Series Evaluated DIEP

Number of patients (%) Unilateral reconstructions Bilateral reconstructions Number of flaps (%) Number of coupler anastomoses (%) Single anastomosis group Double anastomosis group

73 66 7 80 89

(77%) (70%) (7%) (76%) (74%)

71 (59%) 18 (15%)

TMG 22 19 3 25 32

(23%) (20%) (3%) (24%) (26%)

18 (15%) 14 (11%)

TOTAL 95 (100%) 85 (90%) 10 (10%) 105 (100%) 121 (100%) 89 (74%) 32 (26%)

The anastomotic coupling device was made of highdensity polyethylene and surgical-grade stainless steel pins, which were available in sizes ranging from 1 to 4 mm, every 0.5 mm. Additionally, the coupling device allowed for intima-to-intima contact so that no foreign material was exposed at the flow surface. A gauge provided by the coupler’s manufacturer was used to measure vein diameter. The external vein diameter should have matched the internal diameter of the ring. In the case of a venous size mismatch, the smaller diameter was chosen. Classical arterial anastomosis was carried out with 9/0 or 8/0 nylon sutures. The recipient sites were internal mammary arteries and veins that were dissected in the second or third intercostal spaces. All of the subjects were grouped depending on their flap type (DIEP or TMG) and the number of anastomoses per flap (single or double anastomoses). These data are listed in Table 1. Operating times, ischemic times and postoperative complications were noted for the 105 flap reconstructions. Coupler size and duration of venous anastomosis were measured for all 121 single or double venous anastomoses. These two parameters were analyzed depending on the flap type and number of anastomoses per flap. Comparison of coupling times among the seven coupler sizes was also performed. After verifying the group variance homogeneity with the nonparametric Fligner–Killeen test, the Kruskal– Wallis test (for paired data when comparing coupling times and ring sizes between the first and second anastomoses) was used for statistical analyses. When necessary, pairwise comparisons were carried out using a Benjamini–Hochberg P-value adjustment. Significance was determined by a threshold value of P < 0.005. RESULTS

The utilized microvascular coupling system was perfectly suitable for all venous anastomoses performed in our series. The mean operating time was 261 minutes (range, 185–460 minutes) for the observed unilateral flaps and 422 minutes (range, 360–470 minutes) for the bilateral flaps. The flap ischemia time was 32.3 minutes on Microsurgery DOI 10.1002/micr

Table 2. Procedure Durations and Outcomes Parameters (Unit) Operating duration for unilateral flaps (minutes) Operating duration for bilateral flaps (minutes) Ischemic duration (minutes) Flap complication [Number (%)] Surgical revision [Number (%)] Arterial insufficiency [Number (%)] Venous insufficiency [Number (%)] Total flap loss [Number (%)] Skin or fat necrosis [Number (%)]

Value 261 (range, 185–460) 422 (range, 360–470) 32.3 (range 17–70) 11 (10.5%) 4 (3.8%) 4 (3.8%) 0 2 (1.9%) 8 (7.6%)

average (range, 17–70 minutes) (Table 2). A total of 10 flap procedures (9.5%) resulted in postoperative complications. The arterial thrombosis surgical revision rate was 3.8% (4/105) with a total of two flap failures (1.9%). No venous thrombosis was observed in this series. The most frequent flap complications, with the exception of arterial thrombosis, were partial necrosis (four cases) and cytosteatonecrosis (four cases) (Table 2). The coupler ring size was 2.75 mm on average and ranged from 1.5 to 4 mm. The 1-mm ring size was not used. The 3 mm (53/121; 43.8%) and 2.5 mm sizes (38/121; 31.4%) were used the most frequently (Table 3). Additionally, the mean coupler size was statistically smaller for the TMG flaps compared with the DIEP flaps (2.4 mm versus 2.8 mm, P < 0.001) (Table 4). A second mechanical venous anastomosis was performed in 15.2% of the cases (16/105) to increase flap perfusion. The coupler sizes were not significantly different between the first and second anastomoses (P 5 0.16). However, when comparing mean coupler sizes in cases of single anastomosis (2.9 mm) with that in cases of double anastomosis (2.4 mm), the differences were statistically significant (P < 0.001). The average venous anastomosis time using a coupler was 336 seconds (range, 308–420 seconds). The average times for each coupler size are presented in Table 3. No significant differences in anastomosis time were observed among the seven coupler sizes as shown by the Kruskal– Wallis test (P 5 0.066). The average coupling time was 330 seconds (range, 140–831 seconds) for the DIEP flap series and 352 seconds (range 265–660 seconds) for the TMG flap series; however, this difference was not statistically significant (P 5 0.069) (Table 4). Anastomosis times did not significantly differ between the first versus the second anastomoses and the single versus the double anastomoses. DISCUSSION

The DIEP flap is one of the most popular types of autologous breast reconstruction because of the minimal functional

Venous Coupler Use for TMG and DIEP Flaps

297

Table 3. Venous Anastomosis Times According to Coupler Sizes Coupler size in mm TOTAL 1 1.5 2 2.5 3 3.5 4

Mean anastomosis time in seconds (Range)

Total of Anastomosis number (%)

336 (140–831) –/– 356 (198–615) 394 (240–660) 308 (80–600) 342 (40–831) 311 (180–460) 420

121 0 3 (2.5%) 16 (13.2%) 38 (31.4%) 53 (43.8%) 10 (8.3%) 1 (0.8%)

Anastomosis number (%) used in DIEP

1 2 22 45 10 1

Anastomosis number (%) used in TMG

81 0 (1.2%) (2.5%) (27.2%) (55.6%) (12.3%) (1.2%)

40 0 2 (5%) 14 (35%) 16 (40%) 8 (20%) 0 0

Comparison of anastomotic times among the seven sizes as evaluated by the Kruskal–Wallis test. No significant differences were observed (P 5 0.066).

sequelae at the donor site.9 When the abdominal wall is not usable because of a previous surgery or a lack of excess skin, the TMG flap technique is a good alternative to ensure for natural and durable breast reconstruction.10,11 However, microvascular suturing remains a critical step, contributing to increased risks of thrombosis and flap failure. Free-flap reconstructions performed with hand-sewn anastomoses have an estimated failure rate of 4.1%, according to Khouri et al.12 In the breast reconstruction field, the coupler mechanical system has been utilized for more than 10 years.13,14 All published results regarding the venous coupler have shown that it saves time compared to hand-sewn anastomoses without increasing complication rates.2,15,16 Despite these findings, there is a lack of data concerning the coupling times, ring sizes, and number of anastomoses per flap. This study is the first to provide specific anastomotic data and outcomes for the use of venous coupler with the TMG flap. Furthermore, it is a unique comparative analysis of coupler time measurements and coupler sizes between the TMG flap and the DIEP flap. The first clinical study that evaluated 100 free tissue transfers performed with a coupler reported an average anastomosis time of 4 minutes.17 A recent literature review that was conducted by Grewal et al. indicated a mean coupling time of 5.02 minutes for both arteries and veins together.18 In the 1000-case study performed by Rozen et al., who eval-

uated only venous use, the anastomosis performance time was 4 minutes with couplers, 15 minutes with staples and 22 minutes with hand-sewn sutures.2 Considering specific breast reconstructions, Jandali et al. reported an average venous coupling duration of 3 minutes (with a range of 2–6 minutes).16 However, time was only measured for 20 cases near the end of the retrospective review. In the current study, we present a breast reconstruction series including 121 venous coupling time measurements. The average mechanical anastomosis duration was 336 seconds. Specifically, it was 330 seconds for the DIEP flap series and 352 seconds for the TMG flap series. However, statistical analysis showed that this small difference was not significant. We agree with authors who have suggested that there is a learning curve associated with the use of coupling devices.17,19,20 Our first 10 coupling times were an average of eight minutes.21 Another original objective of this study was to evaluate the influence of ring size on coupling times. Statistical analyses did not reveal any differences between the seven diameters assessed. The choice of ring size is essential for mechanical anastomosis. The outer diameter of the vessel should match the inner ring diameter. Using a ring that is too large can result in the stressing or tearing of the vessel wall, and using one that is too small can reduce the lumen size and lead to thrombosis. The utilized coupler

Table 4. Venous Anastomosis Times and Coupler Sizes According to Flap Type TOTAL Mean/median (range) Coupler size in mm Single anastomosis coupler size in mm Double anastomosis coupler size in mm Mean anastomosis time in second Single anastomosis coupler time in second Double anastomosis coupler time in second

DIEP Mean / median (range)

TMG Mean / median (range)

2.75/3.0 (1.5–4) 2.9/3.0 (1.5–4)

2.8/3.0 (1.5–4) 2.9/3 (2.5–4)

2.4/2.0 (2–3.5) 2.6/2.5 (2–3.5)

2.4/2.5 (1.5–3)

2.5/2.5 (1.5–3)

2.2/2.0 (1.5–3)

336/317 (140–831)

330/300 (140–831)

352/360 (265–660)

331/300 (140–831)

334/300 (180–831)

364/325 (180–660)

349/346 (180–615)

359/331 (180–615)

337/360 (198–540)

P-value (DIEP vs. TMG) P < 0.001

P 5 0.069

Microsurgery DOI 10.1002/micr

298

Bodin et al.

diameter varies from 1 to 4 mm, which permits the anastomoses of small vessels ranging from 0.8 to 4.3 mm in diameter. Zhang et al. reported on 178 microvascular free-flap transfers for head and neck reconstructions. The majority of the couplers that were used in their study were 2 mm (19.5%), 2.5 mm (22.1%), and 3 mm (22.1%) in diameter.22 In the current study, sizes of 2.5 mm (31.4%) and 3 mm (43.8%) were the most frequently used. Comparatively, Knight et al. most often used a 2.5 mm coupler (65.3%) for free TRAM flaps.23 However, Jandali et al. mainly used a 3 mm coupler (85.2%),16 which is most likely because they performed abdominal flap and specifically gluteal flap procedures, and these areas are known to have a greater abundance of large veins.24,25 In our series, the mean coupler size for the DIEP flaps was 2.8 mm on average, and the mean coupler size for the TMG flaps was 2.4 mm. This difference was statistically significant and confirmed the intuitive feeling that nearly one size less is required with the TMG flap. It is understood that sizes of 2.4 and 2.8 mm represent average values that do not exist in the market. Therefore, when the most used size for the DIEP flaps was 3.0 mm (55.6%), the most used size for the TMG flaps was logically 2.5 mm (40%). All of the published results indicate that the coupler device is perfectly adapted for free-flap anastomoses and, in particular, for breast reconstructions. Notably, the middle sizes are the most frequently utilized. In the current study, the incidence of complications was in line with other published results. We encountered two flap losses (1.9%) that were because of arterial thrombosis. Notably, these flap losses were not associated with the coupling device. The venous thrombosis rate after mechanical suturing has been reported to range from 0% to 4%.8,22 Jandali et al. observed only six instances of venous thrombosis (0.6%) and no flap failures.16 Rozen et al. reported a venous thrombosis rate of 2.9% without total flap loss.2 In the Zhang et al. series, the total coupler venous thrombosis rate was 4.0%, with a 2.9% flap-failure rate.22 They performed a second venous branching with a coupler in 77% of their cases. Additionally, the thrombosis rate was 8.6% with single branching and 1.7% with double branching. Therefore, performing a second venous anastomosis limits complications in difficult cases. The coupler device facilitates this procedure and saves time, as demonstrated by our finding that second anastomosis procedures were performed as fast as the first ones. Broer et al. have shown that a coupler size of less than or equal to 2.0 mm is more likely to result in venous insufficiency (6.7%) compared with the 2.5 mm (2.3%) and 3.0 mm (1.1%) sizes.26 In this study, we did not observe venous insufficiency, especially with TMG flaps which required smaller coupler sizes. However, it Microsurgery DOI 10.1002/micr

is not possible to be completely certain that 100% of the venous anastomoses were patent because 15.2% of the flaps had double branching. Furthermore, we showed that the coupler size used was statistically smaller for double venous anastomosis, probably because the leading surgeon intuitively found it necessary to ensure for venous return using a small venous diameter. This was particularly noted with the TMG flap procedure. The coupler size used with the TMG flap was smaller than that used with the DIEP flap (2.4 versus 2.8, respectively). Double venous anastomoses were thus more frequent during the TMG compared with the DIEP procedure (28% versus 11%, respectively). To limit venous congestion, we agree with Broer et al., who have suggested performing vessel modifications via beveling or fish-mouthing.26 Inclusion of a collateral branch is another method for increasing distal vessel diameter.21 In addition, performing double branching allows for flap vascularization to be secured because the diameter of the coupler used is less than or equal to 2.0 mm. The need for double venous branching is most likely to occur with small vessels when breast reconstruction is performed with a TMG flap or superficial epigastric artery (SIEA) flap and when perforators from the internal mammary vessels are used as recipient vessels. In the anatomical study performed by Wong et al., the mean vessel diameter of the main gracilis muscle pedicle was an average of 2.3 mm for veins and 2.25 for arteries.27 Similarly, Reardon et al. found that the vein of the SIEA flap measured 2.1 mm and that the artery was 1.9 mm in diameter.28 In the case of slight venous mismatch, the smaller appropriate coupler size is generally chosen to avoid tearing. However, to ensure for an appropriate vessel match, the internal thoracic artery and vein must be dissected in the third or the fourth intercostal spaces for the TMG and SIEA flaps. Indeed, Tan et al. have shown that the diameter of the internal mammary artery is 2.15 and 1.91 mm in the third and the fourth right intercostal spaces, respectively.29 Vessel mismatch can also be reduced by choosing perforators from internal mammary vessels as recipient sites. When possible, this procedure is more conservative, and it has been reported that internal mammary perforator tunica media is less likely to be damaged by degenerative lesions compared with the internal mammary artery.30 Intercostal vein perforator diameters ranging from 1.4 to 2.99 mm have been reported in several studies.30,31 According to Tan et al., the diameters of the arteries arising from the first and the second intercostal spaces are approximately 1.5 and 1.3 mm, respectively.29 CONCLUSION

The coupler size used was smaller for the TMG procedure and when double venous anastomosis was

Venous Coupler Use for TMG and DIEP Flaps

performed. The coupling duration time was not modified by the flap type, coupler size, and the anastomosis number.

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Microsurgery DOI 10.1002/micr

Venous coupler use for free-flap breast reconstructions: specific analyses of TMG and DIEP flaps.

The purpose of this report was to present the results of comparisons of anastomotic data and flap complications in the use of venous coupler in breast...
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