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M i c ro v a s c u l a r S u r g e r y
Alessandro Cusano, DDS, MD,
Rui Fernandes, DMD, MD, FACS*
KEYWORDS
Free-tissue transfer Microvascular surgery
Section of Head Neck Surgery, Division of Oral Maxillofacial Surgery, Divison of Surgical Oncology, Department
of Surgery, University of Florida College of Medicine Jacksonville, 653-1 West 8th Street, Jacksonville, FL
32209, USA
* Corresponding author.
E-mail address: [email protected]
Oral Maxillofacial Surg Clin N Am 22 (2010) 7390
doi:10.1016/j.coms.2009.11.001
1042-3699/10/$ see front matter 2010 Published by Elsevier Inc.
oralmaxsurgery.theclinics.com
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Endemic with any new development is technological advance, and microvascular surgery is no
exception. The next section investigates some of
the current technology in microvascular surgery,
focusing on imaging assessment, anastomotic
technique, and flap monitoring as selective examples in the preoperative, operative, and postoperative settings, respectively.
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Fig. 1. Conventional intra-arterial digital subtraction angiography (DSA). (AD) DSA bilateral lower extremities
from renal arteries to runoff. (E) Left lower extremity with clear depiction of the trifurcation and 3-vessel runoff.
Fig. 2. Arterial CD-US of the right lower extremity in a 70-year-old man with a history of a right popliteal artery
aneurysm. Transverse and longitudinal images of the right popliteal artery are displayed. Mild aneurysmal dilatation of the artery can be seen. Directional flow is readily appreciated by the contrasting red and blue colors.
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Fig. 3. Preoperative MRA of the bilateral lower extremities in a 48-year-old woman with a squamous cell carcinoma of the right maxilla. (A) Thigh level image. (B) Lower leg level image. (C) Composed body shot. Good
3-vessel runoff is seen bilaterally. The patient went on to have uneventful resection and reconstruction with
an osteocutaneous free fibula flap. (D) Preoperative CT demonstrating tumor in the right maxilla. (E) Postablative
defect. (F) Osteocutaneous free fibula flap before pedicle ligation. (G) Flap inset. (H) Postoperative volumerendered three-dimensional CT reconstruction.
limitations of the other vascular imaging modalities. Complete noninvasive, angiographic visualization of the entire peripheral vascular tree from
abdominal aorta to distal lower extremities can
be completed in a single scan lasting less than
a minute.53 Unlike with MRA, patients with
implantable defibrillators, permanent pacemakers,
or intracranial aneurysm clips are not excluded;
and claustrophobia is almost not an issue. Furthermore, that CTA is less expensive, less user-dependent, and more widely available than the other
modalities, justifies its use in peripheral vascular
assessment.54 Radiation exposure and the use of
potentially nephrotoxic contrast agents deserve
consideration; however, the shortened scan times
with the new generation of scanners reduce the
level of risk.
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Fig. 4. CTA. (A) Selected axial cut at midcalf level demonstrating patency of all 3 runoff vessels. (B) Rotational
three-dimensional image of bilateral lower extremities (BLE) in the same patient, demonstrating good 3-vessel
runoff bilaterally. (C) Rotational three-dimensional image of BLE in a patient with poor visualization of all vessels
beyond mid leg, precluding use of a free fibula flap. (D) Volume-rendered rotational three-dimensional image of
BLE in another patient, allowing assessment of the vascular tree in relation to the surrounding bone. Poor 3vessel runoff is again seen. (E) Volume-rendered rotational three-dimensional image of right lower extremity,
demonstrating good 3-vessel runoff and clear visualization of the peroneal artery along the entire length of
the fibula.
1-mm slices. The CT data sets are then reformatted into a set of volume-rendered, rotational,
three-dimensional images, allowing visualization
of the cervical vasculature from multiple viewpoints (Fig. 8).54
The appeal of three-dimensional spiral CTA is
the simplicity of its interpretation. Full diagnostic
information is retained in the original set of axial
images, but by compiling the entire data set into
a single three-dimensional image, visual comprehension of the area of interest is enhanced.54 In
the same single image, CTA also allows the
assessment of the vasculature in relation to the
surrounding tissues, which may further benefit
preoperative planning.
Fig. 5. A 32-year-old man referred for reconstructive evaluation several years after resection of an odontogenic
myxoma of the right maxilla. He presented with complaints of right midfacial deficit (A), persistent oronasal
fistula (B), and dissatisfaction with obturator. A three-dimensional stereolithographic model was obtained to
facilitate assessment of the defect and planning of the reconstruction (C). He went on to have uneventful reconstruction with an osteocutaneous free fibula flap (DF). (G) Postoperative volume-rendered three-dimensional CT
reconstruction.
to take a look back at the origin of surgical technique and to view its evolution to modern-day
applications.
Microvascular anastomosis continues to be the
most critical determinant of successful free-tissue
transfer, with technical errors occurring during
anastomosis accounting for most free-flap failures. Simple interrupted suture placement remains
the gold standard, although other methods have
been described, with the aim of simplifying anastomotic technique, reducing operative time, and
increasing patency rates. The most widely
accepted of these is the microvascular
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and with an additional clockwise turn of the applicator handle the completed anastomosis is
ejected (Fig. 10).
Theoretically, the patency rates of coupled
anastomoses should compare favorably with
those that are hand-sewn. By achieving intimato-intima contact of the vessel ends without the
presence of intraluminal foreign material (ie,
suture), the coupler device should theoretically
reduce the risk of thrombosis. In addition, the
rigidity of the plastic rings has been suggested to
stent open the anastomosis, increasing luminal
diameter in a region that might otherwise be
slightly constricted.59 Furthermore, viewing the
lumen of both vessels in their entirety before their
apposition provides the surgeon with the added
confidence that a successful anastomosis will be
achieved. Nevertheless, with success rates of
free-tissue transfer now in the high 90% range irrespective of anastomotic method used, it might be
questioned whether the theoretic advantage has
translated into any clinically significant benefit. In
terms of patency, the question is valid. However,
if time is considered as an additional outcome variable, the argument might differ.
The biggest advantage of using the coupler
device rather than the traditional hand-sewn
method is the reduction in time taken to complete
the anastomosis. Anastomoses performed with
the coupler device are consistently completed in
less than 7 minutes,58 which is unattainable with
traditional methods. Another advantage of the
coupler is its ability to manage size discrepancy.58
By selecting a coupler with a ring size equal to the
diameter of the smaller vessel, and then pleating
the wall of the larger vessel evenly over the pins,
an anastomosis free of leakage is created, which
may not have occurred had it been hand-sewn.
The microvascular anastomotic Coupler system
continues to be most commonly used for veins,
and it has been approved for use in an end-toend and end-to-side fashion. Its use for arterial
anastomoses remains controversial. It has been
suggested that the inherent thickness of the arterial wall renders it impliable for eversion onto the
pins, complicating the procedure and significantly
reducing luminal diameter if indeed an intact anastomosis can be achieved.58
Recently, however, Chernichenko and colleagues60 reported a retrospective review of 127
free-tissue transfers in which a coupler device
was used for the arterial and venous anastomoses.
Their flap survival rate was 97.6% and they reported
only 4 complications related to arterial insufficiency. With these results they concluded that for
arterial anastomoses use of a coupler is a safe alternative to the traditional hand-sewn method.
Fig. 7. (A) Gunshot wound of the lower face with gross deficit of hard and soft tissue. (B) Volume-rendered threedimensional CT image of the defect. (C) Preoperative contouring of reconstruction plate to fit the stereolithographic model. (DF) Uneventful reconstruction with osteocutaneous free fibula flap. (G) Volume-rendered
three-dimensional CT image of the reconstruction. (H) Postoperative clinical photograph.
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Fig. 8. CTA of the neck. (A) Selected sagittal view. (B) Volume-rendered rotational three-dimensional image
(different patient) enhancing visualization of the cervical vasculature.
these techniques are no different from the traditional method of clinical examination, and they
have failed to demonstrate any significant benefit
in comparison.
Clinical examination is regarded as the gold
standard for postoperative monitoring of flap
perfusion. It typically entails frequent interval
assessment of flap color, capillary refill, turgor,
warmth, and bleeding to pinprick. Based on these
measures alone, the experienced observer is able
to ascertain the status of flap circulation. However,
it is rare that an experienced observer performs
the assessment. Most of the time, the welfare of
the flap is at the mercy of the inexperienced
discretion of the support clinicians and staff, who
may lack experience and judgment regarding the
Fig. 9. 1.5-mm microvascular anastomotic Coupler device. (A) Coupler as it appears on removal from the manufacturers packaging. The different-sized couplers are color-coded with a blue shaft denoting a 1.5-mm coupler.
(B) Coupler removed from plastic housing (for illustration purposes only). The Coupler is seen in its open position,
with clear visualization of polyethylene rings and stainless-steel spikes.
Fig. 10. Coupler instrumentation and technique. (A) Measuring gauge and applicator device. (B) Loaded applicator in open position (actual Coupler absent). (C) Loaded applicator in closed position following clockwise
turn of the applicator handle (actual Coupler absent). (D) Intraoperative photograph depicting 2 venous anastomoses completed with the microvascular anastomotic Coupler system. A hand-sewn arterial anastomosis is also
seen.
>7 days postoperatively), at which time reexploration was too late, resulting in a flap salvage
rate of 0%.
In 1988, Swartz and colleagues67 devised
a method of providing continuous real-time monitoring of flap perfusion that proved to be the solution to the problem of the buried flap.
Cook-Swartz Implantable Doppler
probe system
Swartzs original device consisted of a 1.0-mm
Doppler probe secured with a small amount of silicone to a polytetrafluoroethylene (Gore-Tex; WL
Gore and Associates, Flagstaff, AZ, USA) cuff
that was then wrapped around the flap vessel
and secured to itself by suture.67 It has since
evolved into the Cook-Swartz implantable Doppler
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Fig. 12. A 57-year-old man with squamous cell carcinoma of the left mandible treated with segmental mandibular
resection, ipsilateral neck dissection, and reconstruction with osteocutaneous free fibula flap. (A) Harvested free
fibula flap before pedicle ligation. (B) Pedicle ligated and fibula osteotomized according to defect dimensions.
(C) Osseous component of flap inset. (D) Hand-sewn arterial anastomosis and coupled venous anastomosis complete
with implantable Doppler placed on the venous pedicle. (E) Cook-Swartz implantable Doppler probe in position
with internal segment, retention tabs, and external segment clearly visualized. (F) Postoperative volume-rendered
three-dimensional CT image of the reconstruction.
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5.
6.
SUMMARY
The quality and sophistication of head and neck
reconstruction have increased exponentially in
recent decades. The progression from randompattern skin flaps to axial-pattern skin flaps to
musculocutaneous and osteomusculocutaneous
composite flaps reflected the need at that time to
incorporate more bulk of tissue into the reconstruction. By doing so, surgeons were able to
better address the larger, more complex defects
while maintaining a robust blood supply to the flap.
The advent of microvascular surgery freed the
surgeon from the constraints of locoregional tissue
and prompted the exploration of distant tissue as
new potential donor sites. The evolution of musculocutaneous flaps to fasciocutaneous flaps to
perforator flaps to free-style free flaps reflects
a second wave of progression, which in contrast
to the first is dominated by the desire to reduce
tissue bulk.
With free-style free flaps being essentially skin
flaps raised from potentially any site with a Dopplerable perforator, the development has come
full circle. The distinction, however, is that the
development has come through the knowledge
and experience that have been afforded by technological advance.
Technological development has been integral to
the refinement of microvascular technique. This
article has reviewed several tools that have simplified practice and improved performance. As the
complexity and sophistication of this technical
surgical art develop, advancement in technology
will remain a key to progress in the field.
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