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J Reconstr Microsurg 2014; 30(06): 413-418
DOI: 10.1055/s-0034-1372368
Original Article WSRM 2013 Scientific Paper
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

One versus Two Venous Anastomoses in Microsurgical Free Flaps: A Meta-Analysis

Iraj Ahmadi
1   Department of Plastic and Reconstructive Surgery, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia
*   These Authors Contributed Equally To The Article.
,
Pradyumna Herle
2   Department of Medicine, Melbourne University, Parkville, VIC 3052, Australia
*   These Authors Contributed Equally To The Article.
,
Warren Matthew Rozen
3   Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Douglas, Townsville, Queensland, Australia
4   Department of Surgery, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
,
James Leong
1   Department of Plastic and Reconstructive Surgery, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia
4   Department of Surgery, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
› Author Affiliations
Further Information

Publication History

22 November 2013

24 November 2013

Publication Date:
24 June 2014 (online)

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Abstract

Background Various reports suggest the augmentation of venous drainage through performing two venous anastomoses as a means of reducing the rate of thrombosis in free flap surgery. However, some suggest dual venous drainage may actually reduce venous blood flow velocity causing a potential risk for thrombosis.

Methods  On the basis of the Preferred Reporting Items for Systematics Reviews and Meta-analysis statement, a systematic search was conducted using PubMed and Medline databases. A total of 12,190 articles relating to “free flaps” and “one versus two venous anastomoses” were found between January 1992 and November 2012. Of the 12,190 articles, 23 studies were included in a meta-analysis performed using STATA 11.2 (StrataCorp, College Station, TX). Studies with case control groups for both single and double venous anastomoses and clearly defined results for flap failure and venous thrombosis were included. 95% confidence interval (CI) were calculated for each study and pooled in both fixed and random-effects models for both flap failure and venous thrombosis events.

Results The analysis shows a significant reduction in flap failure (risk ratio, 0.64; 95% CI, 0.41–0.99; p = 0.03) and venous thrombosis (risk ratio, 0.66; 95% CI, 0.46–0.97; p = 0.047) when performing two venous anastomoses compared with one in free flap surgery.

Conclusion The results show that performing two venous anastomoses is associated with a reduction in the incidence of flap failure by 36% and venous thrombosis by 34% compared with one venous anastomoses. Given that the performing of an additional venous anastomoses confers a lower risk of complication and is technically feasible, where possible two venous anastomoses should be performed in free flap procedures, however, this should be decided on a flap by flap basis.

Keywords

venous anastomoses - one - two - single - dual

Note

This paper was presented at the WSRM 2013 in Chicago as a scientific paper.


 

  • References

  • 1 Hallock GG. Both superficial and deep extremity veins can be used successfully as the recipient site for free flaps. Ann Plast Surg 2000; 44 (6) 633-636
    CrossrefPubMedSearch in Google Scholar
  • 2 Yang G, Chen B, Gao W , et al. Forearm free skin flap transplantation. Natl Med J China 1981; 61 (1) 139-141
    PubMedSearch in Google Scholar
  • 3 Alan Turner MJ, Smith WP. Double venous anastomosis for the radial artery forearm flap. Improving success and minimising morbidity. J Craniomaxillofac Surg 2009; 37 (5) 253-257
    CrossrefPubMedSearch in Google Scholar
  • 4 Mühlbauer W, Herndl E, Stock W. The forearm flap. Plast Reconstr Surg 1982; 70 (3) 336-344
    CrossrefPubMedSearch in Google Scholar
  • 5 Demirkan F, Wei F-C, 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) 1544-1548
    CrossrefPubMedSearch in Google Scholar
  • 6 Khashaba AA, McGregor IA. Haemodynamics of the radial forearm flap. Br J Plast Surg 1986; 39 (4) 441-450
    CrossrefPubMedSearch in Google Scholar
  • 7 Futran ND, Stack Jr BCJ. Single versus dual venous drainage of the radial forearm free flap. Am J Otolaryngol 1996; 17 (2) 112-117
    CrossrefPubMedSearch in Google Scholar
  • 8 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) 1548-1557
    CrossrefPubMedSearch in Google Scholar
  • 9 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) 61-63
    CrossrefPubMedSearch in Google Scholar
  • 10 Enajat M, Rozen WM, Whitaker IS, Smit JM, Acosta R. A single center comparison of one versus two venous anastomoses in 564 consecutive DIEP flaps: investigating the effect on venous congestion and flap survival. Microsurgery 2010; 30 (3) 185-191
    CrossrefPubMedSearch in Google Scholar
  • 11 Rohleder NH, Wolff KD, Hölzle F , et al. Secondary maxillofacial reconstruction with the radial forearm free flap: a standard operating procedure for the venous microanastomoses. Ann Surg Oncol 2011; 18 (7) 1980-1987
    CrossrefPubMedSearch in Google Scholar
  • 12 Ross GL, Ang ESW, Golger A , et al. Which venous system to choose for anastomosis in head and neck reconstructions?. Ann Plast Surg 2008; 61 (4) 396-398
    CrossrefPubMedSearch in Google Scholar
  • 13 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009; 151 (4) 264-269 , W64
    CrossrefPubMedSearch in Google Scholar
  • 14 Tang Z, Zhou Z, Wang D , et al. Free radial forearm flaps: An overview of our clinical experience and exploration of relevant issues. IEEE 2012; 1: 524-528
    PubMedSearch in Google Scholar
  • 15 Selber JC, Sanders E, Lin H, Yu P. Venous drainage of the radial forearm flap: comparison of the deep and superficial systems. Ann Plast Surg 2011; 66 (4) 347-350
    CrossrefPubMedSearch in Google Scholar
  • 16 Eom JS, Sun S-H, Lee TJ. Selection of the recipient veins for additional anastomosis of the superficial inferior epigastric vein in breast reconstruction with free transverse rectus abdominis musculocutaneous or deep inferior epigastric artery perforator flaps. Ann Plast Surg 2011; 67 (5) 505-509
    CrossrefPubMedSearch in Google Scholar
  • 17 Jandali S, Wu LC, Vega SJ, Kovach SJ, Serletti JM. 1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction. Plast Reconstr Surg 2010; 125 (3) 792-798
    CrossrefPubMedSearch in Google Scholar
  • 18 Lin P-Y, Kuo Y-R, Chien C-Y, Jeng S-F. Reconstruction of head and neck cancer with double flaps: comparison of single and double recipient vessels. J Reconstr Microsurg 2009; 25 (3) 191-195
    Thieme ConnectPubMedSearch in Google Scholar
  • 19 Liu Y, Jiang X, Huang J , et al. Reliability of the superficial venous drainage of the radial forearm free flaps in oral and maxillofacial reconstruction. Microsurgery 2008; 28 (4) 243-247
    CrossrefPubMedSearch in Google Scholar
  • 20 Liu Y, Zhao YF, Huang JT , et al. Analysis of 13 cases of venous compromise in 178 radial forearm free flaps for intraoral reconstruction. Int J Oral Maxillofac Surg 2012; 41 (4) 448-452
    CrossrefPubMedSearch in Google Scholar
  • 21 Lorenzo AR, Lin C-H, Lin C-H , et al. Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg 2011; 64 (5) 649-655
    CrossrefPubMedSearch in Google Scholar
  • 22 Nakatsuka T, Harii K, Asato H , et al. Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection. J Reconstr Microsurg 2003; 19 (6) 363-368 discussion 369
    Thieme ConnectPubMedSearch in Google Scholar
  • 23 Smit JM, Whitaker IS, Liss AG, Audolfsson T, Kildal M, Acosta R. Post operative monitoring of microvascular breast reconstructions using the implantable Cook-Swartz doppler system: a study of 145 probes & technical discussion. J Plast Reconstr Aesthet Surg 2009; 62 (10) 1286-1292
    CrossrefPubMedSearch in Google Scholar
  • 24 Spector JA, Levine S, Levine JP. Free tissue transfer to the lower extremity distal to the zone of injury: indications and outcomes over a 25-year experience. Plast Reconstr Surg 2007; 120 (4) 952-959
    CrossrefPubMedSearch in Google Scholar
  • 25 Tsai Y-T, Lin T-S. The suitability of end-to-side microvascular anastomosis in free flap transfer for limb reconstruction. Ann Plast Surg 2012; 68 (2) 171-174
    CrossrefPubMedSearch in Google Scholar
  • 26 Yamashiro M, Hasegawa K, Uzawa N , et al. Complications and Outcome of Free Flap Transfers for Oral and Maxillofacial Reconstruction: Analysis of 213 Cases. Int J Oral Sci 2009; 6 (1) 46-54
    CrossrefPubMedSearch in Google Scholar
  • 27 Zhang T, Lubek J, Salama A , et al. Venous anastomoses using microvascular coupler in free flap head and neck reconstruction. J Oral Maxillofac Surg 2012; 70 (4) 992-996
    CrossrefPubMedSearch in Google Scholar
  • 28 Joo Y-H, Sun D-I, Park J-O, Cho K-J, Kim M-S. Risk factors of free flap compromise in 247 cases of microvascular head and neck reconstruction: a single surgeon's experience. Eur Arch Otorhinolaryngol 2010; 267 (10) 1629-1633
    CrossrefPubMedSearch in Google Scholar
  • 29 Khouri RK, Cooley BC, Kunselman AR , et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102 (3) 711-721
    Search in Google Scholar
  • 30 Sun G, Lu M, Hu Q, Tang E, Yang X, Wang Z. Clinical application of thin anterolateral thigh flap in the reconstruction of intraoral defects. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115 (2) 185-191
    CrossrefPubMedSearch in Google Scholar
  • 31 Xin Q, Luan J, Mu H, Mu L. Augmentation of venous drainage in deep inferior epigastric perforator flap breast reconstruction: efficacy and advancement. J Reconstr Microsurg 2012; 28 (5) 313-318
    Thieme ConnectPubMedSearch in Google Scholar