We read with great interest the article entitled “Mechanical versus Hand-Sewn Venous Anastomoses in Free Flap Reconstruction: A Systematic Review and Meta-Analysis” by Zhu et al.1 They revealed that the mechanical anastomotic coupling device contributed to reduced operative time, decreased the probability of surgical reexploration, and mitigated flap loss. As mentioned in their article, one of the virtues of the coupler is reliable stenting for the anastomotic site by external rings. In contrast, one of the problems of hand-sewn venous anastomoses is that anastomotic sites are not tolerant of external pressure.
In the setting of free tissue transfer for the reconstruction of complex head and neck surgical defects, the selection of suitable recipient veins is crucial. Although the internal jugular vein tends to be selected because it offers several advantages,2 , 3 the external jugular vein is also suitable as a recipient vein. A recent study, which included a systematic review, showed no significant difference in the rate of thrombosis between the internal and external jugular veins.4 , 5Some studies have reported that it is better to perform multiple vein anastomoses with two different venous systems, such as the internal and external jugular systems6; however, the use of the external jugular vein as a recipient vein is associated with several disadvantages. First, it is easily damaged by external pressure. Second, because the external jugular vein is distant from the recipient artery, it is difficult to move the donor vein to the external jugular vein. To address these challenges, we used the external jugular vein anastomosis under the sternocleidomastoid muscle technique.
A 66-year-old man with a tongue mass was diagnosed with T3N2bM0 squamous cell carcinoma and underwent left hemiglossectomy and left functional neck dissection. Reconstruction with a profunda femoris artery perforator flap with two anastomosed veins was planned (Fig.1). Because the left external jugular vein was preserved, the external jugular vein anastomosis under the sternocleidomastoid muscle technique was performed. The external jugular vein was dissected distally to proximally to the lateral side of the sternocleidomastoid muscle. The dissection was performed carefully to avoid damaging the transverse cervical nerve, which goes between the external jugular vein and the sternocleidomastoid muscle. The external jugular vein was then passed under the sternocleidomastoid muscle and the internal jugular vein. Finally, the external jugular vein was anastomosed to the donor vein in an end-to-end manner (Fig. 2).
The external jugular vein anastomosis under the sternocleidomastoid muscle technique has two main advantages. First, using this technique, the anastomosed vein is located on the interior of the neck, which allows it to tolerate external pressure. Second, the external jugular vein can be moved to locations near the recipient artery (i.e., the superior thyroid artery, transcervical artery, or lingual artery), which makes venous anastomosis easier.
This communication highlights the possible application of the external jugular vein anastomosis under the sternocleidomastoid muscle technique in head and neck reconstruction. Although further clinical investigation will be required to confirm its efficacy, this method may be useful for venous anastomosis to the external jugular vein.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this communication.
Ryo Karakawa, M.D.
Department of Plastic and Reconstructive Surgery
Cancer Institute Hospital of Japanese Foundation
for Cancer Research
Mitsunobu Harima, M.D.
Takuya Iida, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
The University of Tokyo Hospital
Tokyo, Japan
REFERENCES
1. Zhu Z, Wang X, Huang J, et al. Mechanical versus hand-sewn venous anastomoses in free flap reconstruction: A systematic review and meta-analysis. Plast Reconstr Surg. 2018;141:1272–1281.
2. 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.
3. 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.
4. Francis DO, Stern RE, Zeitler D, Izzard M, Futran ND. Analysis of free flap viability based on recipient vein selection. Head Neck 2009;31:1354–1359.
5. Cheng HT, Lin FY, Chang SC. External or internal jugular vein? Recipient vein selection in head and neck free tissue transfer: An evidence-based systematic analysis. Plast Reconstr Surg. 2012;129:730e–731e.
6. Kiya K, Kubo T, Seike S, Hosokawa K. Free flap survival despite internal jugular vein thrombosis in head and neck reconstruction. Plast Reconstr Surg Glob Open 2018;6:e1647.
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