The Spare Parts Anastomosis: Branch Point Spatulation Technique to Alleviate SIEA Mismatch.

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Sir: Size mismatch can be a challenging technical dilemma during microsurgical anastomosis. Although coupling devices accommodate venous mismatch, arterial discrepancy can be less forgiving. This is particularly true of the superficial inferior epigastric artery (SIEA) flap when connecting to the internal mammary artery, the recipient vessel of choice because of the shorter pedicle length inherent in the SIEA flap.1 The small vessel diameter and tendency toward spasm have led to increased rates of reexploration, revision, and thrombosis in some series. To address the differences in arterial wall, published techniques aim to either increase the aperture of the vessel, as in spatulation2; redistribute the vessel wall through differential stitches, with horizontal mattress sutures; take advantage of orientation, such as telescoping techniques3; or use an interpositional graft.4 Recently, we have been incorporating a novel branch point spatulation technique with SIEA flaps to augment the vessel aperture. Similar to branch patches described in the transplantation literature, branching points are incorporated into the vessel opening, instead of discarded (Fig. 1).5 These spare parts are thus efficiently used. Small branch points are typically seen in the SIEA slightly after the vessel makes a 90-degree turn into the femoral artery. Three to 4 mm of the branch point is included. Once the branch point is encountered, the SIEA is followed for a few more millimeters and divided. Under the microscope, the intervening segment between the branch point and the main SIEA trunk is opened and trimmed to fit the recipient vessel (Fig. 2).Fig. 1.: SIEA harvest with the branch point retained. A micro clip was placed after 3 to 4 mm of length was saved to find the vessel.Fig. 2.: Drawing of the branch point spatulation. The anastomosis is opened under the microscope at the SIEA opening and adjacent branch point. Trimming is generally necessary to match the internal mammary artery and ensure intima-to-intima contact.Our previously published criteria with high success rates placed greater importance on SIEA palpability over size for two reasons. Palpability of the artery suggests high inflow and a superficially dominant system. Venae comitantes intimately associated with the SIEA may mask the true size of the vessel and can betray visual assessments. In the event that the vessel is strongly palpable yet the arterial mismatch persists, this technique can save operative time and abdominal morbidity by providing a more facile arterial anastomosis. We have found that, in our hands, a mismatch between arteries of 3:1 may easily be accommodated. Branch point spatulation may increase the vessel lumen 30 to 50 percent, depending on the size of the branch point. In the last five consecutive SIEA flaps where this technique has been used this past year, only one revision promptly after anastomosis was necessary because of clot propagating from a proximally damaged side wall on an irradiated internal mammary artery vessel and not the actual anastomosis. No flap failures or take-backs occurred. Future examination is required to examine the branching pattern of the SIEA at the femoral artery takeoff. In addition, clinical review of the success rates of autologous-based breast reconstruction with the branch spatulation anastomosis is necessary. However, our preliminary experience suggests that this technique is a vital tool and may serve to provide facility to a wider range of surgeons who want to use the SIEA flap regularly. Theoretically, this method may be applied in any arterial mismatch when a branch point is present. Disclosure Dr. Song receives royalties from Elsevier for Plastic Surgery, 3rd Edition, and Plastic Surgery, 4th Edition, and from Biomet Microfixation for Sternalock. None of the other authors has any financial interest to disclose. No funding was received for this article. Kenneth L. Fan, M.D.James M. Economides, M.D.Cara K. Black, B.A.David H. Song, M.D., M.B.A.Department of Plastic SurgeryMedStar Georgetown University HospitalWashington, D.C.