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One versus Two Venous Anastomoses in Anterolateral Thigh Flap Reconstruction after Oral Cancer Ablation

Chaput, Benoit M.D.; Herlin, Christian M.D., Ph.D.; de Bonnecaze, Guillaume M.D.; Carloni, Raphael M.D.; Laloze, Jerome M.D.; Bertheuil, Nicolas M.D.

Plastic and Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 807e–808e
doi: 10.1097/PRS.0000000000003101
Letters

Department of Plastic, Reconstructive, and Aesthetic Surgery, Rangueil Hospital Toulouse, France

Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, Montpellier, France

Department of Plastic, Reconstructive, and Aesthetic Surgery, Rangueil Hospital, Toulouse, France

Department of Plastic and Hand Surgery, CHU Rouen, Rouen, France

Department of Plastic, Reconstructive, and Aesthetic Surgery, Rangueil Hospital, Toulouse, France

Department of Plastic, Reconstructive, and Aesthetic Surgery, Hospital Sud, University of Rennes 1, Rennes, France

Correspondence to Dr. Chaput, Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, Avenue du Professeur Jean Poulhes, 31 000 Toulouse, France, benoitchaput31@gmail.com

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Sir:

We read with great interest the work by Lee et al. entitled “One versus Two Venous Anastomoses in Anterolateral Thigh Flap Reconstruction after Oral Cancer Ablation”1 and congratulate the authors for this very interesting series. The debate about the interest of the double venous anastomosis in free flaps remains a hot topic. Our team recently performed two meta-analyses2,3 on this subject, and we would like to discuss some points about this work.

We completely agree with the authors that using the double venous anastomosis provides a better outcome, as we confirmed by the meta-analysis with less flap failure and less surgical revision in comparison with single venous anastomosis. Our findings clearly support the backup theory in which the second vein provides security if one of the two veins becomes kinked or occluded and will also enable better venous drainage, allowing larger flap harvesting.

The term “venous congestion” is difficult to analyze in free anterolateral thigh flaps. It may include several entities, but in a large majority of cases, it represents a venous thrombosis. That is why, as explained by Grobbelaar in his Discussion,4 some data are lacking about the bulk of the flap or the thinning to distinguish clearly the cause of the venous congestion. In each surgical revision for venous congestion, Lee et al. should stipulate whether they find one or two venous thromboses, or any kinking effect.

In our unit over the past 4 years, we performed consecutively 50 free anterolateral thigh flaps for head and neck reconstruction with a systematic double venous anastomosis, except when there was only one vena comitans. Moreover, when two venae comitantes join together as a single vein, we divide the vein before the joining to perform two venous anastomoses. To avoid bias, there was no patient selection concerning tumor, comorbidities, or previous surgery. Our flap failure and surgical revision rates have largely decreased.

A frequent argument against anastomosing two veins is the increased operative time. In the study by Lee et al., the operative time was significantly longer; however, they did not use a venous coupler. Few articles have discussed the issue of operative time concerning the double anastomosis. Lin et al.5 did not find a significant difference in the length of the operations, whereas a significant difference was shown by Chen et al.6 (614 minutes versus 648 minutes; p = 0.035). Nonetheless, the increasingly frequent use of a venous coupler significantly reduces the time required to complete the second anastomosis by 5 to 15 minutes. Moreover, the cost of surgical revision and prolonged hospitalization resulting from a second surgical procedure (another free flap or pectoral muscle flap) adds to the global cost and must be considered in a cost-effectiveness analysis. Thus, hospitalization was significantly shorter in the two-vein group in the study by Lee et al.

We agree with the conclusion of Grobbelaar that this study will not change the surgical practice of most established microvascular surgeons, but we are convinced that for younger surgeons, attitudes will change, and they will move to double venous anastomosis to secure their reconstruction. A randomized controlled trial is required, but this will be difficult because several thousand patients are needed to identify a significant difference between the groups, considering a flap failure rate below 2 to 3 percent for anterolateral thigh flaps performed by a trained team.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

Benoit Chaput, M.D.

Department of Plastic, Reconstructive, and

Aesthetic Surgery

Rangueil Hospital

Toulouse, France

Christian Herlin, M.D., Ph.D.

Department of Plastic and Reconstructive Surgery

Lapeyronie University Hospital

Montpellier, France

Guillaume de Bonnecaze, M.D.

Department of Plastic, Reconstructive, and

Aesthetic Surgery

Rangueil Hospital

Toulouse, France

Raphael Carloni, M.D.

Department of Plastic and Hand Surgery

CHU Rouen

Rouen, France

Jerome Laloze, M.D.

Department of Plastic, Reconstructive, and

Aesthetic Surgery

Rangueil Hospital

Toulouse, France

Nicolas Bertheuil, M.D.

Department of Plastic, Reconstructive, and

Aesthetic Surgery

Hospital Sud

University of Rennes 1

Rennes, France

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REFERENCES

1. Lee YC, Chen WC, Chen SH, et alOne versus two venous anastomoses in anterolateral thigh flap reconstruction after oral cancer ablation.Plast Reconstr Surg2016138481–489
2. Riot S, Herlin C, Mojallal A, et alA systematic review and meta-analysis of double venous anastomosis in free flaps.Plast Reconstr Surg20151361299–1311
3. Chaput B, Vergez S, Somda S, et alComparison of single and double venous anastomoses in head and neck oncologic reconstruction using free flaps: A meta-analysis.Plast Reconstr Surg20161371583–1594
4. Grobbelaar AODiscussion: One versus two venous anastomoses in anterolateral thigh flap reconstruction after oral cancer ablation.Plast Reconstr Surg2016138490
5. Lin PY, Kuo YR, Chien CY, Jeng SFReconstruction of head and neck cancer with double flaps: Comparison of single and double recipient vessels.J Reconstr Microsurg200925191–195
6. Chen WF, Kung YP, Kang YC, Lawrence WT, Tsao CKAn old controversy revisited: One versus two venous anastomoses in microvascular head and neck reconstruction using anterolateral thigh flap.Microsurgery201434377–383
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