|Year : 2016 | Volume
| Issue : 2 | Page : 65-73
Microvascular anastomosis in oral and maxillofacial surgery
Farhana Girkar1, Gaurav Mittal1, Puneet Kalra2
1 Department of Oral and Maxillofacial Surgery, IDST, Modinagar, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Teerthankar Dental College, Moradabad, Uttar Pradesh, India
|Date of Web Publication||30-Nov-2016|
Building No. 1, B/109, Humera Park, Pathanwadi, Malad (East), Mumbai - 400 097
Source of Support: None, Conflict of Interest: None
In maxillofacial surgery, head and neck reconstruction of surgical defects caused by oral cancer is considered a challenging problem. Till recently, most oral and pharyngeal defects were closed primarily using skin flaps or tubed-pedicle flaps of skin from the trunk such as forehead flap, deltopectoral flap, pectoralis major myocutaneous flap; however, these were associated with compromised aesthetic and functional results. The advent of microvascular free tissue transfer over the past two decades has helped us overcome these disadvantages and has enabled the ablative surgeon to undertake surgical procedures that could not have been attempted in the past. Innovations in the field of microsurgery have resulted in better techniques, microscopes, and microinstruments, which have made free flap harvesting much easier. This article will review the various techniques of microvascular anastomosis used in head and neck reconstruction and analyze the newer techniques and methods employed today. It also attempts to provide a brief gist of the various free flaps used in head and neck reconstruction and the ones most expedient in the surgeons' arsenal.
Keywords: Microvascular anastomosis, microvascular free flaps, oral and maxillofacial surgery, reconstructive microsurgery
|How to cite this article:|
Girkar F, Mittal G, Kalra P. Microvascular anastomosis in oral and maxillofacial surgery. Arch Int Surg 2016;6:65-73
| Introduction|| |
The major contribution to head and neck reconstruction over the past two decades has been microvascular free tissue transfer. Free tissue transfers are usually located at the top of the reconstructive ladder and are considered when local or regional tissues are insufficient or suboptimal for reconstruction. A region of donor tissue is selected and isolated on a feeding artery and vein, which is then transferred to the region on the patient that requires reconstruction. The vessels that supply the free flap are anastomosed with microsurgery to matching vessels (artery and vein) in the reconstructive site.
The advances in the techniques and technology that popularized microsurgery began in the early 1960s. The first microvascular surgery, using a microscope to aid in the repair of blood vessels, was described by the vascular surgeon Jules Jacobson in 1960. Contemporary reconstructive microsurgery was introduced by an American plastic surgeon Dr. Harry J. Buncke in 1964. Although primarily developed and used by plastic surgeons, microsurgical techniques are now used by a number of surgical specialities.
This article will evaluate the most commonly used microvascular anastomotic techniques in oral and maxillofacial reconstruction with a brief emphasis on various flaps used for microvascular free tissue transfer.
| Selection of Recipient Vessels in Microvascular Anastomosis|| |
Free tissue transfer requires a thorough understanding of the relevant donor and recipient site anatomy of the main arterial and venous supply, major vessel variations, important associated structures, and the associated nerve supply.
The choice of recipient vessels depends upon many factors including vessel diameter, pedicle length, pedicle geometry, presence of atherosclerotic plaques, and evidence of traumatic dissection.
The most common recipient neck artery for microvascular free tissue transfer is the facial artery. This branch of the external carotid artery is commonly transected during neck dissection because it traverses the inferior border of the mandible or because it enters the submandibular triangle. Another commonly utilized branch of the external carotid is the superior thyroid artery. The transverse cervical artery from the thyrocervical trunk is another artery which can be used.
Recipient veins in the neck include the internal and external jugular veins, a stump of the facial or common facial veins, and the transverse cervical vein. Anastomosis to the external jugular (EJ) vein has shown a significantly higher failure rate than that to the internal jugular (IJ) system. Chalian et al. compared the EJ vein and the IJ system and found that venous thrombosis occurred only in the anastomoses to the EJ vein. When no recipient veins are available in the neck, the cephalic vein can be mobilized from the upper arm, as described by Urken.
| Technique of Microvascular Anastomosis|| |
The operative field is approximately at level with the surgeons' elbows. The recipient site is positioned for optimal exposure. The orientation of the flap pedicle is checked to ensure that the anastomosis will not be under excessive tension. The vessels to be anastomosed are positioned to allow tension-free, surface-to-surface apposition. The pedicle length and the orientation of the donor and recipient vessels are decided and low-pressure microvascular clamps are applied for vascular control [Figure 1].
Both sets of recipient vessels are checked for open branches near the anastomosis that need to be ligated. The cut edges of the vessels are checked for a clean, uniform edge and re-trimmed, if necessary, to avoid stray tissue ends encroaching into the lumen because these can be foci for thrombosis formation.
Once a satisfactory vessel segment is attained, adventitial cleaning is carried out with sharp curved microsurgical scissors [Figure 2].
|Figure 2: Donor and recipient vessel preparation: Trimming of the adventitia|
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After adequate preparation, the vessels are aligned for suture placement. Fine, non-absorbable sutures appropriate to the size and thickness of the vessels are used (most commonly 8-0, 9-0, or 10-0 nylon). These sutures should be placed an equal distance apart to distribute the tension evenly around the circumference of the anastomosis [Figure 3] and [Figure 4]. Arterial anastomoses are usually performed with interrupted sutures and venous anastomoses with continuous sutures.
| Types of Anastomosis|| |
The end-to-end anastomosis (EEA) is the simplest anastomosis concept, i.e. the sharply cut end of the donor vessel is sutured to the cut end of the recipient vessel. Alexis Carrel, originally described EEA for microvascular anastomosis, which involves placing two sutures 120–150° apart, followed by a third suture in a position to complete an isosceles triangle [Figure 5]. Additional sutures are then placed between the initial three sutures until the anastomosis is complete.
An alternative technique more commonly used today is the halfway estimation technique [Figure 6]. In this, the first two sutures are placed at approximately 180° or more from each other. The third suture is placed at a point halfway between the first two followed by the placement of the remaining sutures. Continuous running sutures can also be used for anastomosis [Figure 7].
|Figure 6: The halfway estimation technique for end-to-end vascular anastomosis|
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The end-to-side (ESA) is applied in situations where properly sized recipient vessels are unavailable, or the flow pattern of the selected recipient vessel must be maintained rather than sacrificing it for the sole purpose of supplying the flap. The most common ESA performed clinically in head and neck reconstruction is for venous outflow of a donor vein to the IJ vein.
To create the ESA [Figure 8], a venotomy appropriate to the size of the lumen of the donor vessel is created slightly larger than the cut end of the donor vessel in an elliptical or diamond shape. Two ends of the venotomy are sutured to the donor vessel [Figure 9]. The remaining sutures are then placed in a running fashion starting with the back wall [Figure 10] and [Figure 11]. When complete, the end is tied to the tail of the opposite “anchoring” suture. The same suturing technique is then performed on the front wall to complete the anastomosis. Alternatively, an interrupted suture technique may be performed on both walls [Figure 12].
|Figure 10: “Back-wall” sutures placed first from inside the lumen for end-to-side anastomosis|
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The type of anastomosis (EEA vs. ESA) in the head and neck has been controversial.,, Advantages of EEA are that laminar flow is maintained and the incidence of thrombus formation is reduced. However, more recent reports suggest that ESA does not increase the incidence of anastomotic failure and that blood flow rate is not significantly altered.,,, Ueda has demonstrated that the incidence of thrombosis was 1.8% (15 of 835) after EEA to various veins and 2.7% (3 of 113) after ESA to the IJ vein. There was no significant difference in the two. Another study retrospectively compared EEA and ESA from over 2000 microvascular anastomoses and found no significant difference in the failure rate of arterial or venous anastomoses. Advocates of the ESA technique cite additional benefits.,, These include multiple anastomoses to a single vessel, overcoming discrepancies in vessel size, avoidance of vessel retraction, etc.
End-to-side branch anastomosis
The technique of end-to-side branch anastomosis is a modification of the ESA, in which an arterial branch or venous tributary, located at the selected anastomotic site, is used as a recipient site vessel. The donor vessel is anastomosed to the side branch using a conventional EEA technique.
This method of anastomosis, if available, may be preferable to an ESA technique, especially if clinical conditions are suboptimal.
The end-in-end intussusception method, originally known as the sleeve anastomosis, was introduced into microsurgery by Lauritzen. This technique requires the upstream vessel to be placed inside the downstream vessel to make an overlap, or sleeve, in order to prevent leakage [Figure 13]. This technique is superior to end-to-end sutured anastomosis because it is faster, there is less intimal dissection, no aneurysms at the anastomotic site, and resistance to irradiation is greater.,
| Fixation Methods in Microvascular Anastomosis|| |
Various methods of anastomotic fixation have been investigated. The goal is to find simpler and faster techniques without decreasing the patency rates. Fixation methods which are used include sutured anastomosis, laser techniques, electrocoaptation, mechanical devices, adhesive anastomoses.
Suturing is the most versatile method of microvascular anastomoses and can be used in any clinical situation.
Laser-assisted microvascular anastomoses has been evaluated in various experimental models and in a few clinical series. The patency rates obtained are comparable with those obtained with conventional manual sutures with the advantage of shorter operative times, limited endothelial trauma with small thrombogenic risk, and no suture material to trigger a foreign-body reaction.,,
Electrocoaptive microvascular anastomoses involves producing an adherent and localized coagulam by the passage of high frequency electric current through the adjacent tissues. However the technique has not been widely used.
Clinical series of vessels anastomosed with mechanical coupling devices [Figure 14] have shown equal or greater patency rates and faster anastomosis of either normal or irradiated vessels. They are commonly accepted in venous anastomoses, however, their use in arterial anastomoses remains limited. Yap et al. reported no statistically significant difference between the two techniques. Chernichenko et al. reported a failure rate of 1% in 134 patients with venous ESA with a coupling device. Delacure et al. reported 100% success rate with the use of microvascular anastomotic coupling device (MACD) in venous ESA. Reddy et al. successfully reviewed the use of nonpenetrating vascular closure staple (VCS Anastoclip) in microvascular anastomosis over a 13 year period in 819 free flap reconstructions and reported that the VCS device is as effective as sutured anastomoses in free tissue transfer surgery. A number of different types of adhesives for microvascular anastomoses have been investigated such as cyanoacrylic adhesives, polyurethane resin, adhesive tapes, and fibrinogen adhesives.,, Pearl et al. showed, in an experimental model, that microvascular anastomosis with a biologic sealant adhesive significantly reduces hemorrhage and reduces operative time, while allowing a flap survival comparable to that obtained with standard techniques. These adhesives can be used as alternatives to conventional suturing, however, further studies need to be conducted regarding their efficacy.
| Microvascular Anastomoses in Previously Irradiated Vessels|| |
Radiotherapy is known to impair wound healing by decreasing the number of blood vessels in tissue by progressive thrombosis, resulting in tissue ischemia by decreasing fibroblast proliferation and production of collagen and by destroying epithelial cells. Most clinical studies have demonstrated that prior radiotherapy in the head and neck does not adversely affect flap survival and anastomotic patency., However, in some studies perivascular fibrosis and endothelial damage have been described., More recent studies have further elucidated the anatomic and physiologic changes associated with the effect of radiation on arteries and veins. Herle et al., in their study, reported that preoperative radiation in excess of 60 Gy is associated with a statistically significant increased risk of flap complications, failure, and fistula.
Guelincks  has proposed the following guidelines for anastomosis of irradiated recipient vessels:
- Limit dissection of recipient vessels to reduce manipulation and injury
- Restrict electrocoagulation of arterial side branches
- Use small-gauge needles and suture materials
- Pass the microneedle from inside to outside to minimize intramural dissection and injury
- Shorten the period of vessel cross-clamping to minimize stasis and microthrombi
- Flush vessels with a heparinized solution during the anastomosis and before restoring blood flow.
| Microvascular Grafts and Prosthesis|| |
Sometimes, it is not possible to repair a vessel by anastomosing the cut ends, such as in cases of traumatic loss or when additional vessel resection is needed. In such cases, grafts of autogenous veins are the most common substitute circulatory conduits. The use of interposition vein grafts is an effective means of increasing the length of the vascular pedicle.,,, Early studies evaluating the use of interposition vein grafts for microvascular reconstruction in the head and neck demonstrated a 30% failure rate compared with a 5% failure rate when no interposition vein grafts were used. Recent studies have demonstrated that there is no difference in survival after free tissue transfer with and without the use of vein grafts. In a study of 340 patients, Germann and Steinau demonstrated that the incidence of flap survival with vein grafts (55 patients) and without vein grafts (275 patients) were equal (96.2 and 96.7%, respectively). However, the percentage of flaps requiring revision of the anastomosis was greater for free flaps with vein grafts than without (14.8 and 8.7%, respectively).
Despite the success with autogenous vein grafts, experimental investigation of synthetic materials to replace small vessels continues. The most common materials tested for this purpose are fibrous polyurethane (PU) and microporous or expanded polytetrafluoroethylene (PTFE). However, more studies need to be conducted regarding their efficacy.
| Microvascular Free Flaps Commonly Used in Maxillofacial Reconstruction|| |
Radial forearm flap
The radial forearm fasciocutaneous flap (RFFF) which is the “workhorse” microvascular flap for the head and neck was first described by Yang, in 1981. It provides a large, thin, pliable, predominantly hairless flap for intraoral and oropharyngeal lining. It is commonly used for the tongue, floor of mouth, lip and hard palate reconstruction. The entire skin in the volar aspect of the forearm can be harvested with the long pedicle, permitting anastomosis to the contralateral neck also. Microvascular anastomosis of large-caliber radial vessels ensures successful transfer of this flap.
Other advantages of this flap are the presence of large diameter superficial veins (cephalic or basilic) and deep venous system (the venae comitantes). Studies have shown that the smaller venae comitantes give reliable venous outflow, however, due to their smaller caliber, microvascular anastomosis is difficult compared to the cephalic vein. Functional recovery from the forearm defect is quite acceptable and there is minimal residual discomfort.
Fibula osseocutaneous flap
This flap was first described by Taylor in 1975 for lower extremity reconstruction, but it was Hidalgo, in 1989, who introduced the fibula osseocutaneous flap (FOCF) for mandibular reconstruction. This flap is widely used for oromandibular reconstruction following oncological resections or trauma, and is an emerging choice after maxillary section.
The fibula provides the longest segment of bone with 20–30 cm available for harvest. In addition, the segmental blood supply of the bone permits multiple osteotomy. The bone is also of adequate width and height to allow placement of osseointegrated dental implants. Donor site morbidity with this graft is minimal, unless the distal osteotomy site is within 6 cm of the ankle. In addition, the location of the graft allows simultaneous harvest by a second team at the time of tumor resection.
Experiences in pediatric patients have been encouraging because it is one of the safest flaps to harvest in pediatric population with iliac crest and scapula causing growth disorders later in life.
One of the major disadvantages of fibular free flap is the limited availability of the skin and soft tissue necessary for reconstruction of mucosal defects. Donor site morbidity is a problem, mainly involving split-thickness skin grafts or primary closure. Another disadvantage of the fibula flap is the low quality of vessels seen in patients with peripheral vascular disease such as arteriosclerosis. In these cases, the scapula may be a better option.
Iliac crest osteocutaneous flap
The iliac crest osteocutaneous flap (ICOF), which is based on the deep circumflex iliac artery and vein (DCIA and DCIV), was described by Taylor's dye injection studies in 1979. Along with the skin and bone, the flap can include the internal abdominal oblique muscle based on the ascending branch of the DCIA. This allows the flexibility of a thin, mobile soft tissue component along with the relatively immobile cutaneous and osseous constituents of the flap.
The greatest advantage of DCIA-based flaps is the quality and quantity of the bone that can be harvested. The ilium is well-suited for reconstruction of nearly all but the largest mandibular defects. It is best suited for defects (up to 16 cm) of the mandibular ramus and body because of its natural curvature and the ease of designing patterns to reconstruct the mandibular angle without osteotomies.
The disadvantages of this flap include unpredictable and inflexible skin paddle, lesser length of bone stock, and the risk of postoperative donor site pain and hernia. Iliac crest is now only a second-line option and has fallen behind the fibula as the donor site of choice for mandibular reconstruction.
The scapular flap provides a small segment of the scapula, along with a large portion of the skin and soft tissues. This flap is useful for restoring the bony and soft tissue contours of the face and achieving rigid support for the velum, oronasal separation, support for the orbit, and obliteration of the maxillary sinus. The flap is based over the circumflex scapular artery and vein. It has a long vascular pedicle of 6–14 cm, and arterial diameter is 1.5–4.5 mm. Elevation of the flap is rapid and easy, and thickness is variable (1.5–3 cm).
Drawbacks of this flap include the limited amount of bone and soft tissue available. In many centers, the fibula has replaced both the scapula and iliac crest as the flap of choice for mandibular reconstruction. In large volume centers, it is not favored much because the two-team approach cannot be used and the repositioning of the patient for flap harvest is time consuming.
Anterolateral thigh flap
The anterolateral thigh flap (ALTF) is based on the cutaneous perforators of the descending branch of the lateral circumflex femoral artery, a branch of the profunda femoris. No special preoperative evaluation is needed prior to flap harvesting. The maximum area that this flap can support is up to 800 cm 2, consisting of skin from the level of the greater trochanter of the femur to a line 3 cm above the patella.
One great advantage of this flap is the possibility of harvesting a very thin flap (as little as 5 mm of thickness) while maintaining the suprafascial vascular plexus based on the perforating vessels. Other advantages include low donor site morbidity, simultaneous harvest, large volume of skin and soft tissue available, a long pedicle, acceptability of site for the scar, and ability to harvest as subcutaneous, fasciocutaneous, musculocutaneous, or adipofacial flap, thus giving multiple applications for this flap. The variation in vascular anatomy and the inconsistent location of cutaneous perforators has impeded this flap's overall acceptance for head and neck reconstruction.
| Conclusion|| |
The use of microvascular techniques for free tissue transfer has revolutionized reconstruction and expanded the range of options for reconstructing large anatomic defects in patients. Microsurgery is complex and technically demanding, however, with careful preparation and proper execution, it can be beneficial to the patient and rewarding to the surgeon. There appears to be an increasing number of surgeons actively involved in microvascular reconstruction and, essentially, the technique of microvascular surgery has been perfected over the past few years. It results in excellent postoperative cosmetic and functional results and the success of microvascular anastomosis is >95%.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]