Does Two Venous Anastomoses Lead to Better Outcomes in Free Flap Reconstruction of the Head and Neck?

Abstract

Complex three-dimensional head and neck defects often require free tissue transfer for appropriate reconstruction after resection or trauma. Head and neck reconstruction requires key decision-making including appropriately selecting target vessels on the ipsilateral or contralateral side and the number of anastomoses to perform. Vascular thrombosis is a major complication of free flap surgery, with the largest problem being venous thrombosis. Literature support for multiple venous anastomoses is mixed. Some suggest that additional venous anastomoses lowers velocity through each vein increasing thrombosis risks, while others suggest that an additional anastomosis is protective and provides outflow when there is a thrombosis in single vein. Review of current published data including the meta-analyses and the physiologic studies suggests that performing two venous anastomoses may reduce the risk of flap failure and thrombotic complications compared to performing only a single venous anastomosis. While it is often sufficient to perform a single venous anastomosis, based on the included studies one should perform two venous anastomoses when technically feasible. However, this will have to be evaluated on a case by cases basis, as it is not always possible or prudent to perform two venous anastomoses. As a single venous anastomosis is sufficient the senior author routinely performs a single venous anastomosis unless the anatomy is favorable and a second anastomosis can be added in an expedient fashion.