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External or Internal Jugular Vein? Recipient Vein Selection in Head and Neck Free Tissue Transfer

An Evidence-Based Systematic Analysis

Cheng, Hsu-Tang M.D.; Lin, Fu-Yu M.D.; Chang, Sophia Chia-Ning M.D., Ph.D.

Author Information
Plastic and Reconstructive Surgery: April 2012 - Volume 129 - Issue 4 - p 730e-731e
doi: 10.1097/PRS.0b013e318245ead9
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Microvascular free tissue transfer has become the choice of reconstruction for complex head and neck defects. There are more free flap failure events as a result of venous thrombosis than as a result of arterial thrombosis. The selection of a recipient vein that is suitable for microvascular anastomosis in the head and neck region is one of the several essential components for successful free tissue transfer. Debate exists regarding venous thrombosis when anastomosis to the external jugular vein versus the internal jugular venous system is performed.1 Although the external jugular vein has a long segment and offers a greater degree of freedom on anastomosis, it has a relatively low flow rate and is subjected to considerable manipulation during neck dissection, which could lead to serious intimal damage. In contrast, the internal jugular vein with its multiple branches, a negative pressure with respiration, and the possibility of direct end-to-side anastomosis demonstrates its logical superiority in preventing venous thrombosis.2 However, there is no consensus on recipient vein selection in head and neck free tissue transfer.3

We performed a systematic literature review by searching the PubMed database from January of 2000 to December of 2010. We used the following keywords: “head and neck,” “free flap reconstruction,” “free tissue transfer,” and “venous anastomosis.” This search was supplemented by a review of reference lists of potentially eligible studies. We excluded the non-English articles, those with flap numbers less than 100, and venous anastomoses to two veins or two different venous systems. Two reviewers independently extracted data in two steps: titles and abstracts, and then full text articles. Numerical distribution of recipient veins with their number of venous thromboses were recorded (Table 1).15 The primary outcome was the venous thrombosis rate. Relevant studies were assigned a level of evidence according to the American Society of Plastic Surgeons Evidence Rating Scale for Therapy. Statistical analysis was performed using the chi-square 2 × 2 contingency with Yates correction. Values of p < 0.05 were considered significant.

Table 1
Table 1:
The Five Retrospective Comparative Studies

Through our electronic and reference search, we identified five retrospective comparative studies (level III evidence). We pooled 1409 free flaps for further survey. A total of 704 flaps (50.0 percent) were anastomosed to the internal jugular vein system and 705 flaps (50.0 percent) were anastomosed to the external jugular vein. Venous thrombosis rates were 4.83 and 5.25 percent, respectively (p > 0.05).

In this systematic review, we found no statistically significant difference in venous thrombosis rates based on recipient vein selection. Thus, this is a level II evidence-based systematic analysis. Recipient vein selection between the external jugular vein system and the internal jugular vein system has no impact on the outcome of head and neck free tissue transfer.

Hsu-Tang Cheng, M.D.

Department of Plastic Surgery, China Medical University Hospital, School of Medicine, China Medical University, Taichung, Taiwan

Fu-Yu Lin, M.D.

Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan

Sophia Chia-Ning Chang, M.D., Ph.D.

Department of Plastic Surgery, China Medical University Hospital, School of Medicine, China Medical University, Taichung, Taiwan


The authors hereby certify that no financial support or benefits have been received by any co-author, by any member of their immediate family, or any individual or entity with whom or with which they have a significant relationship from any commercial source that is related directly or indirectly to the scientific work which is reported in the article.


1. Chalian AA, Anderson TD, Weinstein GS, Weber RS. Internal jugular vein versus external jugular vein anastomosis: Implications for successful free tissue transfer. Head Neck 2001;23:475–478.
2. Nahabedian MY, Singh N, Deune EG, Silverman R, Tufaro AP. Recipient vessel analysis for microvascular reconstruction of the head and neck. Ann Plast Surg. 2004;52:148–155; discussion 156–157.
3. Ross GL, Ang ES, Golger A, et al.. Which venous system to choose for anastomosis in head and neck reconstructions? Ann Plast Surg. 2008;61:396–398.
4. Fukuiwa T, Nishimoto K, Hayashi T, Kurono Y. Venous thrombosis after microvascular free-tissue transfer in head and neck cancer reconstruction. Auris Nasus Larynx 2008;35:390–396.
5. Francis DO, Stern RE, Zeitler D, Izzard M, Fultran ND. Analysis of free flap viability based on recipient vein selection. Head Neck 2009;31:1354–1359.


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