Arterial Coupling for Microvascular Free Tissue Transfer in Head and Neck Reconstruction
Douglas A. Ross, MD; Jen Y. Chow, MD; Joseph Shin, MD; Richard Restifo, MD; John K. Joe, MD; Clarence T. Sasaki, MD; Stephen Ariyan, MD

Objective: To demonstrate the efficacy of arterial cou-

Design: We report our experience in head and neck reconstruction with the Unilink Microvascular Anastomotic System (Synovis MCA, Birmingham, Ala). Data were collected in a consecutive series of 49 patients undergoing composite resection of head and neck tumors followed by free tissue transfer. Setting: All patient care took place at Yale-New Haven

fers were monitored clinically and outcomes were recorded.
Main Outcome Measures: Flap survival and thrombosis of the arterial anastomoses were determined, as was median length of stay. Results: There were no flap failures in the series. Of the 50 coupled arterial anastomoses, the predominant coupler size used was 2.5 mm in diameter. Reconstructions included 36 radial forearm, 12 fibular osteocutaneous, and 2 rectus abdominus myocutaneous free flaps. One intraoperative arterial thrombosis occurred, requiring handsewn anastomosis, and another pulled away from the intact coupler in a steroid-dependent patient. There were no complications related to technical performance of the coupling device. The median length of stay was 14 days. Conclusion: While hand-sewn anastomoses in free tis-

Hospital, New Haven, Conn, a university-based tertiary care facility.
Patients: Forty-nine consecutive patients aged 43 to 85 years underwent a total of 50 microvascular free tissue transfers using the Unilink coupling device. There were 18 women and 31 men, and the following 3 types of flaps were performed: radial forearm (n = 36), fibula (n=12), and rectus abdominus (n = 2). Interventions: The Unilink coupling device was used in this case series. Each arterial and venous anastomosis was performed with the coupling device. Free tissue trans-

sue transfer remain the preferred technique for many microsurgeons, use of the coupler is a viable alternative to sutured anastomoses. Arch Otolaryngol Head Neck Surg. 2005;131:891-895 erating microscope, facilitating the use of microvascular FTTs. Our group has previously demonstrated success in microsurgery when using loupe magnification rather than microscopy because the former has significantly decreased both operative time and cost without marked change in patency rates.2 Other groups have developed alternatives to sutured anastomoses to improve patency rates. The objectives of such alternatives were to minimize vessel wall damage, decrease ischemia and surgical time, and ease the challenge of microsurgery. Nonpenetrating anastomosis techniques would allow for minimal endothelial disruption, which might favorably influence the patency rate. Released in 1962, the Nakayama device consisted of 2 metallic rings and 12 interlocking pins with corresponding holes.3 However, the device did not gain widespread accepWWW.ARCHOTO.COM

Author Affiliations: Sections of Otolaryngology–Head and Neck Surgery (Drs Ross, Chow, Joe, and Sasaki) and Plastic and Reconstructive Surgery (Drs Shin, Restifo, and Ariyan), Yale University School of Medicine, New Haven, Conn.

tissue transfers (FTTs) have become a mainstay of reconstruction following oncologic resections in the head and neck. Ever since 1960, when Jacobson and Suarez1 first reported their observations on the use of 7-0 silk to complete carotid artery anastomoses in dogs, the gold standard for performing microvascular anastomoses has been the penetrating suture with attached needle. Unfortunately, immediate reconstruction following extirpative cancer surgery is both labor and time intensive. Success of FTTs relies on the quality of the microvascular anastomosis; failure can lead to life-threatening flap necrosis, wound breakdown, and fistula formation. Numerous advancements have been made in the past 4 decades. Patency rates increased after the introduction of the op-




©2005 American Medical Association. All rights reserved.

This study therefore describes a single institution’s experience with fully coupled microvascular anastomoses. S.0-mm coupler was used in 8. (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 131. In this retrospective review of 50 microvascular FTTs.. Because this was a retrospective review. tumor location. allowing for the exact extent of the defect to be known before harvesting and fashioning of the donor flap. the ends of 2 vessels are each passed through rings made of high-density polyethylene. The device can be used without fear of foreign body reaction or long-term sequelae. 43-85 years). while the 3. mounting the artery has not. who was assisted by 1 of 2 assistant surgeons (J. All rights reserved.5-mm intervals and can be applied successfully to vessels in the same range of sizes.) 3.Table 1. cervical esophagus. The 6 stainless steel pins on each ring impale the vessel walls and evert them at a 90° angle. when Östrup and Berggren4 introduced their modified version as the Unilink Microvascular Anastomotic System (Synovis MCA. METHODS A retrospective review was undertaken of all cases of microsurgical free flap reconstruction performed by the Yale Head and Neck Reconstruction team from November 2001 through December 2003.S. Wash).0-mm coupler in just 1. The 2.R.0 mm (2) 2. history of radiation therapy. time of operation. skin resurfacing. small diameters. Inpatient and outpatient medical records were reviewed and evaluated. J. Each reconstruction was performed by the same lead surgeon (D.9 Couplers in laboratory animal anastamoses have been more successful than hand-sewn anastamoses.5. including floor of mouth. but not arterial. we have begun to perform all anastomotic FTTs with the Unilink coupling device in the belief that faster.COM ©2005 American Medical Association. anastomoses.A. A total of 50 arterial anastomoses were completed. and the 2. Some authors have observed vessel wall thinning following arterial coupling without noting any clinically significant sequelae. Indications for reconstruction are listed in Table 2. .). orbit. or J. and coupling device diameter. the Unilink coupler is the most commonly used nonsuture anastomotic system.. Ala).5-mm coupler was used in 41 cases. signed informed consent was obtained from each patient. DeLacure et al17 described 7 attempted arterial anastomoses for head and neck reconstructions with FTTs but abandoned 2 secondary to perceived vessel wall thickness.0 mm (1) 2. All but 1 FTT had double venous and a single arterial anastomoses. a radiation oncology team for intraoperative brachytherapy implantation.5 mm (10) 3.R. when necessary. the arterial anastomotic coupling times were also noted. The recipient vessels were the superior thyroid (n=31) and the facial (n=19) arteries. The reconstructions were for a variety of defects. mechanically coupled anastomoses show a 50% increase of burst strength 16 weeks after surgery compared with sutured vessels. The rings may then be mechanically approximated when the pins of each ring insert into the holes of the other to create a secure vascular anastomosis. or better than. have severely limited the acceptance of arterial microvascular coupling. sutured anastomoses.ARCHOTO. and R.K.0 mm (2) 3. Forty-nine consecutive patients underwent a total of 50 microvascular FTTs using the Unilink coupling device. impliability. and rectus abdominus (n=2).A. The surgical teams included an ablative team (led by C. tance until 1986. more reliable techniques will further the evolution of head and neck reconstruction. Notably. To use this device.) Radial forearm fasciocutaneous free flap (36) Fibula osteocutaneous free flap (12) Rectus abdominus myocutaneous free flap (2) Coupler Size (No.0 mm (2) 2.S.0 mm (1) 2.5 were used to perform the microanastomoses..5 mm (1) 3. independent of previous irradiation.5. all relevant information was extracted and filed into the Excel spreadsheet program (Microsoft.5 mm (21) 2. In the last 3 cases.A. Forty-five operative times were available for the 50 coupled anastomoses.A.0 mm (1) Concerns regarding technical performance of the anastomoses. complications.6 Blair et al7. Although use of the coupler with venous anastomoses has previously been well described.R. only total operative times including both surgical extirpation and ensuing graft harvest and transfer were obtainable. Approved by the Food and Drug Administration. in which 2 of 16 coupled arteries thrombosed and none ruptured or developed pseudoaneurysms.6 Shindo et al16 have reported a small series of arterial anastomoses. and outcomes were reviewed and compared with prior historical controls and results in the published literature.S or S.). Redmond. Loupes with original magnification 3.0 to 3. Operative data.) Superior thyroid artery (25) Facial artery (11) Superior thyroid artery (5) Facial artery (7) Superior thyroid artery (1) Facial artery (1) Origin of Flap (No.T.5 mm (6) 2.10-15 The Unilink coupling device has been accepted for use in venous. tongue. with an average age of 64 years (range. and high-pressure flow across the anastomosis. Three types of flaps were performed: radial forearm (n=36).0 mm at 0. including vessel wall thickness.) and.8 have previously shown that the postoperative histologic features of healing following use of the microvascular coupling device are identical to those of sutured vessels. we found that the use of microvascular coupling for FTT reconstruction following head and neck oncological surgery is equivalent to.J. In light of the laboratory successes in arterial anastomoses. This system is available with inner diameters ranging from 1. type of FTT. There were 18 women and 31 men. Data strata included patient age. OCT 2005 892 WWW. and narrowed lumen diameter. sex.5 mm (3) 3. in both laboratory and clinical studies. Prior to surgery. fibula (n=12). In addition. Flap Donor Site and Type of Vascular Anastomosis Arterial Anastomosis (No. the coupled anastomosis is more expedient than hand suturing vessels. The ablative team typically completed surgical extirpation prior to the start of reconstruction. Birmingham. length of stay (LOS). and mandible only (Table 1). tonsil. a reconstructive team (D.). recipient vessels.

18 Yet the success of such reconstructions is dependent on multiple variables. Including vessel preparatory time. OCT 2005 893 ©2005 American Medical Association. Even after significant dilation.0-mm coupler did not provide adequate flow. While those arteries with the thickest vessel walls may have appeared to have intimal tearing when mounted on the coupler ring. The FTTs were monitored every 2 hours for the first 24 hours. Use of the traditional handWWW. pharynx SCC. the last 3 arterial anastomoses took 7. Although times for anastomoses were not recorded early in our experience.5 mm in diameter.COM (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 131. except during revascularization in those patients with venous thromboses. tongue SCC. A single postoperative hematoma occurred in this same patient where the 2. Patients were kept well hydrated with crystalloid fluids to maintain adequate blood volume and pressure. Previously irradiated patients did not present with an increased rate of anastomotic complications. This enthusiasm has been attributed to advances in techniques and instrumentation as well as more reliable donor sites. Doppler ultrasonographic findings. and subsequent thrombosis. then every 12 hours. All patients were treated with 81 mg/d of aspirin for 2 weeks postoperatively. pulse palpation. and 5 days of intravenous heparin anticoagulation without further complications. None of the patients manifested any short. Unfortunately the t test did not show statistical difference between the 2 groups (P=. had a rupture of the anastomosis requiring emergent neck exploration and ligation of the bleeding vessel. patients were followed up for 1 to 17 months. When venous congestion was later noted. No intravenous dextran 40 or heparin sodium was used. In contrast to the hand-sewn technique. and dermal bleeding to needlestick were used to clinically assess vascular patency. recoupling. mandible Mucoepidermoid cancer. on postoperative day 12. Following discharge. each occurring on the second postoperative day. the patient did well without any further difficulties. bucca SCC. though their average LOS was increased. Available total operative times (45 of 50 cases) were also examined (Table 3). In fact. We performed a total of 100 venous couplings and encountered only 2 venous thromboses. Postoperatively. The average and median total operative times decreased between the former and the latter. though the vessel was tied off. and finally every 24 hours in successive days.0-mm ring size coupler occurred. The coupler was found intact. (%) of Patients Presenting With Recurrence 2/3 (67) 2/10 (20) 5/18 (28) 1/5 (20) 1/2 (50) 1/4 (25) 12/45 (24) 0 0 0 0 0 Diagnosis SCC. adequate neovascularization had taken place. Duration of the first 23 cases were compared with the last 22. surgical exploration revealed pedicle com- pression as the vein traveled over the thyroid cartilage to the contralateral internal jugular vein. including the quality and reliability of the vessel anastomoses. respectively. then every 3 hours until the third postoperative day. these anastomoses comprise the critical portion of free flap reconstruction. from 661 minutes and 645 minutes to 597 minutes and 606 minutes. facial skin Total SCC Mucoepidermoid cancer. RESULTS Table 2. floor of mouth Total Mucoepidermoid Cancer Osteosarcoma mandible Other benign causes No. (%) of Patients 3 (6) 10 (20) 18 (36) 5 (10) 2 (4) 3 (6) 4 (8) 45 (90) 1 (2) 2 (4) 3 (6) 1 (2) 1 (2) Abbreviations: SCC. allowing the superior thyroid (donor) artery to bleed into the neck potential space. The only other arterial complication occurred in a steroiddependent. requiring resection of the coupler and repeated coupling following further dilation of the vessels to 2. gingiva. and 7 minutes. 6. Color. capillary refill. 16. and the anastomosis was hand sewn. Each FTT was performed with a single arterial and 2 venous anastomoses. the vessel ends were generally easily approximated with satisfactory flow. Both patients were emergently reexplored and underwent successful thrombectomy. floor of mouth SCC.10). Fortunately. the last 3 cases were timed. Two groups were then analyzed: the first 23 cases performed compared with the last 22. lip. All rights reserved. Of the 50 arterial anastomoses. causing compression.or long-term foreign body reaction.All arteries were dilated with the tips of a curved microneedle holder because its spring-action handle provided increased dilating force compared with the standard vessel dilator. minimal preparation was required prior to anastomosis. the thicker walls of arteries sometimes remain more resistant to piercing by the coupler pins. which propagated to the coupling site. All patients were discharged only after tracheal decannulation and either demonstration of adequate oral nutrition or per enterogastric tube placement. immunosuppressed renal transplant patient who. The other observed venous complication involved a twist in the venous pedicle. Indications for Reconstruction No. turgor. tonsil SCC. COMMENT Free tissue transfers for head and neck reconstruction have grown in popularity over the past 20 years.ARCHOTO.2 days).1 days). unpaired t test was used to measure statistical differences. The 2-tailed. . and the FTT was able to survive without its initial donor arterial supply. No flap failures were encountered in our series. respectively. followed by examinations every 6 hours. The total operative times were evaluated. In the first patient. lack of ipsilateral venous access required a venous anastomosis to the contralateral neck. 21. stasis. Only nominal removal of vessel adventitia was necessary prior to mounting on the coupler rings. Median LOS was 14 days (mean. 1 intraoperative thrombosis of a 2. Those patients receiving previous radiation had a median LOS of 22 days (mean. mandible SCC. squamous cell carcinoma. but the radial (recipient) artery had torn away from the coupler pins.

570. the total operative times for which were available in 45 of the 49 cases. the rigid plastic rings form a stent at the site of anastomosis. 570. the vessel walls are each everted 90°. min Average Median Time. We believe that this minimum diameter permits reasonably rapid flow across the anastomosis.ARCHOTO. a the fibula osteocutaneous free flap. we chose to continue with the coupling and observed that in each case except 1. 935. which is highly thrombogenic. as was the case in our single intraoperative thrombotic event. 15 involved the use of a radial forearm fasciocutaneous free flap. and 2. 526.5 mm. All rights reserved. we experienced only a single intraoperative thrombotic event during the course of 49 coupled arterial anastomoses. we have dilated donor and recipient arteries to accommodate a ring size no smaller than 2. 715. who developed a postoperative hematoma requiring emergency neck exploration and ligation of the involved vessel. This patient had been a recipient of a cadaveric renal transplant and therefore had been receiving long-term. 645. min Time. 595 651 646 602 603 Fibula osteocutaneous free flap (n = 10) First 5* Last 5† 570. However. 815. permitting complete visualization of the 2 lumens. 725. Use of the mechanical coupling device for arterial anastomoses is a controversial topic. no leaks occurred at the coupling site. 630 598. 686. The first complication was caused by compression of the flap pedicle as it traveled over the thyroid cartilage to gain vascular access to WWW. Although some authors believe that the technical challenges and learning curve associated with its use outweigh potential benefits. For our FTTs. Unrecognized back-walling of a stitch may cause lumen stenosis and thrombosis. Since that time. 823. or rectus abdominus FTTs) arteries. Given her predisposition for impaired wound healing. which were approximated to one another and therefore never exposed to blood flow following coupling. fibular. 506. 596. in which a 2. a fibula osteocutaneous free flap. When mounted on the coupler rings. 720. OCT 2005 894 ©2005 American Medical Association. respectively. 693. Each of these risks are effectively addressed with the use of the coupler. she may have had the same result even following a hand-sewn anastomosis. high-dose prednisone and immunosuppressants. 570. 570 460.0-mm coupler was used. each with 6 pins that insert into the other. 589. 609. neither of the 2 venous complications we experienced was attributable to the coupler device. 511. preventing vessel spasm and thrombosis at a common and important site for both complications. particularly when couplers measuring less than 2. Of the first 23 recorded cases. The maleto-female interlocking design of the couplers. 685. we used 2 coupled end-to-side venous anastomoses to the internal jugular veins or its large tributaries.Table 3. min Flap Origin Radial forearm fasciocutaneous free flap (n = 33) First 18* Last 15† 570. thereby eliminating the risk of compromised blood flow secondary to uneven suturing or inadvertent suture placement through the back wall. Traumatic tearing or cracking of the intima has also been previously reported. 665. 18 involved the use of a radial forearm fasciocutaneous free flap and 5. the anastomosis remained patent and without leakage. In our series. Uneven placement of sutures may lead to either anastomotic leak or stasis and increased risks for hematoma or thrombosis.5 mm were used. 600. 690. In addition. We did not encounter any technical difficulties or clinically relevant complications while dilating the donor (superior thyroid or facial) or recipient (radial forearm. Shindo et al16 reported 2 thromboses in 16 arterial anastomoses. Other authors have also noted difficulty manipulating the thick vessel walls when everting them onto the pins and have suggested that this may have led to decreased laminar blood flow and possibly even complete obstruction of the vessel lumen following completion of the coupled anastomosis. 683. Inadequate eversion of the vessel may lead to luminal exposure of adventitia. 630. Others have previously demonstrated the utility and safety of coupled venous anastomoses. we cannot comment on the actual rate of thromboses because a thrombotic event in a single vein may not have been clinically significant owing to adequate compensation of the other venous anastomosis. serves to hold the anastomosis tightly in place. 550. 758. 660. †“Last” denotes those 22 cases with available total operative times in the second half of the series. sewn method presents several potential perils. a rectus abdominus myocutaneous free flap. However. we have found the coupler to be effective and efficient as a method for microvascular anastomoses. 635 408 408 661 645 597 606 *“First” denotes those cases done in the first half of the consecutive series.COM (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 131. 603. We postulate that anastomotic thromboses secondary to intimal tears were unlikely to occur because the trauma was likely restricted to the areas of eversion. This detailed view of the intima allows for accurate and even placement on the 6 pins of each coupler ring. preventing the formation of large thrombi and quickly clearing smaller clots. while Berggren et al19 reported 1 in 5 and Ahn et al20 described 5 of 29. 719. 5. 580. The notable exception occurred in the steroid-dependent patient. 646. 660.20 We share this concern regarding increased thickness and decreased pliability of arterial vessel walls. 630. Therefore. Total Operative Times Operative Times. Our experience has indicated that couplers below this diameter were more likely to restrict blood flow. Of the 22 cases. 658 697 657 630 658 Rectus abdominus myocutaneous free flap (n = 2) Last 2† Overall total operative times (P . 642.05) First 23* Last 22† 181. Although this also occurred in our experience. 667. .

17:521-525. In fact. The UNILINK instrument system for fast and safe microvascular anastomosis. 16. Microsurgery. Steyers CM.55:105-110. Berggren A. Although Ryan and Hochman21 reported a median LOS of just 9 days following FTT reconstruction after head and neck surgery. Ahn CY. Maynard JA.11:243-245.15:421-423. 11. Ragnarsson R. Rice DH. Strength of microvascular anastomoses: comparison between the unilink anastomotic system and sutures.122:529-532. 333 Cedar St. Berman P.20 with just 2 complications in 50 coupled arterial anastomoses while maintaining an average LOS similar to that previously reported. 1989. Arterial end-to-side anastomosis with the UNILINK system. 10.10) because it reflects both extirpation and FTT rather than FTT alone. which falls at the low end of the average LOS of 14 to 28 days following FTT. All rights reserved. Scand J Plast Reconstr Surg Hand Surg. all located in New Haven. Acosta R. Section of Otolaryngology. we have shown couplers to be a safe alternative to hand-sewn arterial anastomoses. Jakobsson O. 7. Franzen L. Scand J Plast Reconstr Surg Hand Surg. Plast Reconstr Surg. 1989. skilled microsurgeons have had no difficulty in quickly mastering the technique. Microvascular anastomosis of interpositional vein grafts with the UNILINK system: a comparative experimental study. CT 065208041 (douglas. Microsurgery. Blair WF. Mendenhall HV. van Schilfgaarde R. Sasson HN. 2005. Urken ML. II: a histologic study in arteries and veins. Markowitz BL. Lamprecht EG. In addition to the low rate of complications. 1989. Ann Plast Surg. Berggren A. Ostrup LT. 1996. 1989. A simple new apparatus for small vessel anastomosisi (free autograft of the sigmoid included). Bolander L. A microvascular anastomotic device. 3. Clinical experience with the Unilink/3M Precise microvascular anastomotic device. Rotational correction and recoupling reestablished venous outflow. Ostrup L. Mechanical anastomosis of small arteries and veins with the unilink apparatus: a histologic and scanning electron microscopic study. . (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 131. Akimoto S.115:970-976. 13. Sinha UK. Berggren A.ross@yale.93:1481-1484. Surgery. Sasaki CT.80:274-283. Zeebregts C. Microsurgery. 2003. 12. Funding/Support: This study was supported in part by the McFadden. Wong RS. they chose to discharge most of their patients prior to resumption of eating by mouth and tracheal decannulation.COM ©2005 American Medical Association. Falconer DP. Ostrup L. Financial Disclosure: None. Jacobson JI. 2005.16. Our experience suggests that the technique is also valid for arterial anastomoses. New Haven. Suarez EL. Shindo ML. J Reconstr Microsurg. Ragnarsson R. Morecraft RJ. Length of stay after free flap reconstruction of the head and neck. Ragnarsson R.10:2939. Gable RH. there was a decrease in total operative time. Berggren A. Ostrup LT.85:412-418. 14. accepted May 2. 1994. we are continuing to collect data in a prospective trial to adequately compare coupler vs hand-sewn anastomosis operative times.19. We believe that the operative time required for coupling will be less than that for hand-sewn anastomoses. 17. Ariyan S. though the validity of this data is limited (P=. Nalbone VP. Östrup LT. Microvenous grafts to arterial defects: the use of mechanical or suture anastomoses. Microsurgery in anastomosis of small vessels. 6:215-222. REFERENCES 1. Berggren A. Over the course of 2 years. A microvascular anastomotic device. In conclusion.129:189-193. Clinical experience with non-penetrating vascular clips in free-flap reconstructions. Tamiya T. 1993. Yale University School of Medicine. 1960. 4. DeLacure MD. Our series clearly demonstrates the reliability of arterial coupling. 9. Ostrup LT. Ann Plast Surg. 2.10:40-46. Arch Otolaryngol Head Neck Surg. 52:918-931. Lewis TW. The second complication occurred as a result of an unrecognized twist in the vascular pedicle. 6. Br J Plast Surg. Clinical experience with the 3M microvascular coupling anastomotic device in 100 free-tissue transfers. et al. Ryan MW. OCT 2005 895 WWW. Yamamoto K. Submitted for Publication: December 29. Arch Otolaryngol Head Neck Surg.22:405-415. Correspondence: Douglas A. Shaw WW. Plast Reconstr Surg. 1994. the total operative times presented herein provide only a general impression of the learning curve associated with the use of couplers for arterial anastomoses. Ragnarsson R. our median LOS was 2 weeks. Costantino PD. I: a hemodynamic evaluation in rabbit femoral arteries and veins. Buchbinder D. 19.110:210-216. Evaluation of the Unilink microvascular anastomotic device in the dog. most find it less challenging than hand sewing vessels. Arch Otolaryngol Head Neck Surg. 1990. Ostrup L. Nakayama K. Campus Box 208041. Gilbert RW. Hochman M. Gilbert RW. 15. 170:521-523. et al. Ostrup LT. 8. 18. Microvascular free flaps in head and neck reconstruction: report of 200 cases and review of complications. 1995. 1990.27:35-39. Klintenberg C. Harmon. Berggren A. Berggren A. Gilbert RW. 1986. Use of a mechanical microvascular anastomotic device in head and neck free tissue transfer.23:23-28. Brown TD. Restifo R. Our complication rate is far lower than many previously reported in the literature. 1994. 1989. Laryngoscope. 1987. Ross DA. and Mirikitani Endowments. Weinberg H. Surg Forum. 5. the need for bilateral rather than unilateral neck dissection. Berggren A. though we currently do not have enough data to prove this hypothesis.the contralateral neck. the adequacy of initial margins. Ragnarsson R.10:21-28. Clinical experience with a microvascular anastomotic device in head and neck reconstruction. 2002. Am J Surg. To fully examine the question of operative time. and the FTT survived without further complication. 2004. At our institution. the improved pedicle geometry allowed the flap to be salvaged after thrombectomy and recoupling. Steyers CM. 21. Given the wide variation in operative times for head and neck surgery (eg. Conn. final revision received March 28. Use of the operating microscope and loupes for head and neck free microvascular tissue transfer: a retrospective comparison. the degree of difficulty depending on site and extent of disease. Microvascular anastomoses in irradiated vessels: a comparison between the Unilink system and sutures.edu). Blair WF. 1962. 1989. Microsurgery.120:633-640. 20. Lidman D. Ragnarsson R.5 mm mechanical microcoupling device in free tissue transfer. and we recommend that it be considered as a valid alternative to hand-sewn anastomoses. Stofman GM. Berns S. 2000. Markowitz BL. and the varying difficulty of donor site harvests). Clinical use of the 3M 2. Once repositioned. MD. Arch Otolaryngol Head Neck Surg. Plast Reconstr Surg.ARCHOTO. Ross.