FROM SIMPLE INTERRUPTED TO COMPLEX SPIRAL: A

SYSTEMATIC REVIEW OF VARIOUS SUTURE TECHNIQUES FOR

MICROVASCULAR ANASTOMOSES
MOHAMMED S. ALGHOUL, M.D.,1 CHAD R. GORDON, D.O.,1* RANDAL YETMAN, M.D.,1 GREGORY M. BUNCKE, M.D.,2
MARIA SIEMIONOW, M.D.,1 AHMED M. AFIFI, M.D.,1 and WONG K. MOON, M.D.3

Accomplishing successful microvascular anastomoses is undoubtedly one of the most critical steps in performing free tissue transfer. How-
ever, the ideal technique has often been a subject of debate. Therefore, our objective was to review the current literature in an attempt to
find objective evidence supporting the superiority of one particular technique. A PubMed and OVID on-line search was performed in No-
vember 2007 using the following keywords: microvascular anastomoses, microsurgical anastomosis, continuous suture, interrupted suture,
mattress suture, and sleeve anastomosis. Our literature review found no difference in short- and/or long-term patency rates between the
six main published techniques, which includes continuous suture, interrupted suture, locking continuous, continuous horizontal, horizontal
interrupted with eversion, and sleeve anastomoses. These findings were consistent for each technique as long as the microsurgeon main-
tained standard microsurgical principles and practice, including suture line eversion, minimized tension, and direct intima-to-intima contact.
Current literature supports no overall statistical difference in short- and/or long-term patency rates between any of the various techniques.
The choice to perform one suture technique over another ultimately depends on the plastic surgeon’s preference and microsurgical experi-
ence. To date, there are no human randomized, controlled clinical trials comparing the efficacy and clinical outcomes of each of the various
suture techniques, and therefore one’s comfort and familiarity should dictate his or her microsurgical technique. However, ‘ exposure to
many and mastery of one’’ simply provides the plastic surgery resident, fellow, or staff the technical flexibility needed for less-complicated
surgical planning when performing free tissue transfer. V C 2010 Wiley-Liss, Inc. Microsurgery 31:72–80, 2011.

Accomplishing successful microvascular anastomoses is
undoubtedly one of the most critical steps in performing
free tissue transfer, limb replantation, and/or composite tis-
sue allotransplantation. However, which of the various
suture techniques is superior is often a reason for debate.
The perfect microvascular anastomotic technique would
ideally be 1) easy to both perform and teach to residents, 2)
minimize ischemia time, 3) avoid vessel wall trauma, and
4) provide the best short- and long-term patency rates.
Overall, the simple interrupted suture technique is of-
ten considered by many to be the gold standard in end-
to-end microsurgical anastomoses. Studies in the 1960s
demonstrated the superiority of this technique over the
continuous suturing technique.1–4 The reduced patency
rate of the continuous suture technique was attributed to
lumen stenosis, decreased vessel compliance, and
decreased pulsatility.
In the late 1970s, Little and Salerno refuted this data
and reported similar patency rates using a continuous suture
technique.5 In fact, they reported that this technique had the
advantage of less overall operative time. Following this
publication, there has remained an ongoing debate as to
which microvascular suture technique is supreme.
Currently, there are numerous suture techniques for
microsurgical anastomoses described in the literature.
These include the standard interrupted suture,6 continuous
suture,5,7–17 locking continuous suture,13,18 interrupted
horizontal mattress suture,19,20 continuous horizontal mat-
tress suture,21,22 posterior-wall-first suture,23–25 and the
sleeve anastomosis.26–30 To determine the optimal tech-
nique, numerous investigations have been performed
comparing varying endpoints such as operative time,
blood flow velocity, anastomotic compliance, anastomotic
histology, and patency rates. Therefore, a systematic liter-
ature review from [January 1962 to August 2007] was
performed in an effort to 1) uncover any potential dis-
cordance between clinical practice and research data and
2) to identify data supporting the existence of an optimal
microvascular suture technique. Of note, other nonsuture
microvascular techniques have also been well-described
including microclips/microstaplers,31 glue,32 laser tissue
welding,33 and couplers,34 but these have been excluded
from this review for the purpose of standardization.

1
METHODS
Departement of Plastic Surgery, Cleveland Clinic, Cleveland, OH
2
The Buncke Clinic, San Francisco, CA A PubMed and OVID on-line search was performed
3
Department of Plastic Surgery, Grant Hospital, Columbus, OH
in November 2007 using the following keywords: micro-
Potential conflict of interest: All authors declare no conflict of interest.
vascular anastomoses, microsurgical anastomoses, contin-
*Correspondence to: Chad Gordon, D.O., Department of Plastic Surgery,
Cleveland Clinic, 9500 Euclid Avenue, Desk A-60, Cleveland, Ohio 44195. uous suture, interrupted suture, mattress suture, and
E-mail: gordonc@ccf.org sleeve anastomosis. Of them, only the english-written
Received 2 October 2009; Accepted 24 May 2010
Published online 28 November 2010 in Wiley Online Library (wileyonlinelibrary.
articles pertaining to the objective of this study were
com). DOI 10.1002/micr.20813 independently screened and assessed by three plastic
V
C 2010 Wiley-Liss, Inc.
 Suture Techniques For Microvascular Anastomoses 73

surgeons familiar with microsurgical technique (one jun-

ior plastic surgery resident, one senior plastic surgery res-
ident, and one attending). A resulting total of 40 articles
found in reputable surgical journals were worthy of inclu-
sion and our subsequent findings are summarized within
this manuscript.
A total of six different microvascular suture techniques
were identified. These include mainly 1) continuous suture,
2) interrupted suture, 3) locking continuous, 4) continuous
horizontal mattress, 5) interrupted horizontal mattress with
eversion, and 6) sleeve anastomosis. In addition, there are
multiple modifications of each technique worthy of discus-
sion. In fact, all six techniques described within this review
have either been investigated using small animal (i.e., rat)
and/or large animal models (i.e., dog).
Overall, the interrupted suture technique (see Fig. 1) is
the most common method used and taught for microsurgi-
cal suturing. In summary, the suture is passed full thickness
from the outside-in direction of one vessel end into the
lumen and then from the inside-out through the other vessel
end. Preferably, the knot is tied on the outside. An average
of eight sutures is needed to achieve an anastomotic
strength comparable with the native vessel wall.35 The ves-
sel ends can be bisected with two stay sutures placed at
1808 (12 o’clock and 6 o’clock positions) and then three
interrupted sutures are placed in between on each side, or
triangulated with three stay sutures placed at 1208 (10
o’clock, 2 o’clock, and 6 o’clock positions) using two
sutures in between all three. This must be done carefully
because underestimating the correct amount of sutures
requires additional sutures, which carries an increased
potential for lumen stenosis and/or thrombosis.
For the continuous suture technique (see Fig. 2), the
suture is passed from the outside-in direction of one vessel Figure 1. Schematic illustration of the simple interrupted technique.
end and then through the inside of the mirrored location on The vessel ends are bisected with two stay sutures placed at 1808 (the
the other vessel end in a running fashion. A total of one to posterior wall is finished) (A). The suture is passed full thickness from
two knots are square tied at the end. Several modifications the outside-in direction of one vessel end into the lumen and then from
the inside-out through the other vessel end (B). The knot is tied on the
of this technique exist and will be described later. Of note, outside and step B is repeated finishing the anterior wall (C).
the continuous locking suture technique (see Fig. 3) differs
from the conventional continuous technique because one
locks the suture after each pass in an effort to eliminate a The sleeve anastomosis (see Fig. 5) technique begins
deleterious purse-string effect. with meticulous adventitial trimming and sufficient gentle
The continuous horizontal mattress technique describes dilatation of the proximal (feeding) vessel end. This is
placing the first suture similarly to the conventional contin- followed by partial thickness bites (without entering the
uous suture; however, the needle’s direction is then vessel lumen) placed at a distance approximately one and
reversed to allow placement of a horizontal mattress fash- half times the vessel diameter from the vessel end. Next,
ion, which is then continued in an uninterrupted fashion these sutures (most often a total of two to three depend-
around the entire suture line (see Fig. 4). The interrupted ing on the vessel size) are passed through the inner side
horizontal mattress technique begins with creation of two of the distal vessel end in an inside-out fashion and then
fish mouth cuts at each of the two vessel ends, followed by tied. The proximal folded vessel is then gently tucked
eversion of the segments in between, and then suturing the inside the distal vessel with another forceps taking care
two ends with interrupted horizontal mattress sutures. This to avoid gripping the end of the proximal vessel. One
technique everts the edges around the anastomotic rim must be careful to avoid unintentional displacement of
allowing direct intima-to-intima contact. adventitia into the lumen.
Microsurgery DOI 10.1002/micr
74 Alghoul et al.
Figure 2. Schematic illustration of the continuous suture technique.
The vessel ends are bisected with two stay sutures and one end is
used to finish the posterior wall after flipping the clamps (A). Each
suture is passed from the outside of the donor vessel to the inside
of the recipient vessel (B). A total of two knots are tied at the end
of the procedure: one at the apex and one at the base (C).
RESULTS
Continuous Suture Versus Interrupted Suture
Two rat studies, one performed by Little and Salerno5
and the other by Moscona and Owen,7 were the first
experiments to report successful results with the continu-
ous suture technique. The study by Little and colleagues
involved running two anastomotic lines continuously, one
on each side without approximating the edges of both
vessels, until all sutures were in place. A total of two
square knots were tied at the completion: one at the apex
and one at the base. Their conclusions were that the con-
tinuous suture technique achieved similar patency rates to
the interrupted suture technique, had the advantage of
reducing total operative time, and provided even tension
distributed throughout the suture line.5
Microsurgery DOI 10.1002/micr
Figure 3. Schematic illustration of continuous locking technique.
The vessel ends are bisected with two stay sutures and one end is
used to finish the posterior wall after flipping the clamps (A). Each
suture is passed from the outside of the donor vessel to the inside
of the recipient vessel and locked after each pass (B). A total of
two knots are tied at the end of the procedure: one at the apex and
one at the base (C).
Moscona and Owen also reported similar results using a
slightly different technique. They placed one suture line cir-
cumferentially and tied one square knot at the end.7 As sim-
ilar, Timmons reported that his modified continuous suture
technique in the rat model had achieved a 100% patency,9
(Fig. 6). He concluded that success with this anastomosis
depended on attention to careful surgical technique.
Several animal studies have since evaluated the inter-
rupted and continuous suture techniques using arterial, ve-
nous, and arterio-venous anastomoses5,7–18,36 (Table 1).
Data were obtained using multiple conventional methods,
including arteriogram, Doppler ultrasonography, and histo-
logical studies. In summary, the patency rates were quite
similar using either of the two techniques and the histologi-

Figure 4. Schematic illustration of continuous horizontal mattress
technique. The first step is similar to the conventional continuous
suture in Figure 2 (A). Each suture is passed from the outside of
the donor vessel to the inside of the recipient vessel, the needle’s
direction is then reversed to allow placement of a horizontal mat-
tress fashion (B), which is then continued in an uninterrupted fash-
ion around the entire suture line (C).
cal sections showed continuous and smooth endothelium in
all of the anastomoses. However, total operative times were
shown to be consistently less with the continuous suture
technique.5,7,11,14,15,17,18 Furthermore, patency results were
independent of the modification to the continuous suture
technique and type of microsuture used.
Lee et al. measured the blood velocity profile in two
studies using high frequency pulsed Doppler ultrasonogra-
phy.12,16 Blood flow velocities were measured in both ar-
terial and arterio-venous anastomoses in dogs and did not
show any significant hemodynamic differences between
either the continuous and/or interrupted suture techniques.
Firsching et al. confirmed these findings in rats and
showed no remarkable difference in blood flow rates
between either technique.13
Suture Techniques For Microvascular Anastomoses 75
Figure 5. Schematic illustration of the sleeve anastomosis. Sufficient
gentle dilatation of the proximal (feeding) vessel end (A). Partial thickness
bites (without entering the vessel lumen) placed at a distance approxi-
mately one and half times the vessel diameter from the vessel and passed
through the inner side of the distal vessel end in an inside-out fashion and
then tied (B). The proximal folded vessel is gently tucked inside the distal
vessel with another forceps (C). Completed anastomosis (D).
Schlechter and Guyuron, on the other hand, showed in
rabbits a 45% reduction in the blood flow rate in the contin-
uous suture group when compared with both the interrupted
suture and continuous locking suture groups. Short-term
patency rates, however, were 100% in all groups.18 Another
study by Peerless et al. evaluating anastomotic compliance
found that the anastomotic diameter increased an average
of 35–40% in both the interrupted and continuous suture
groups at 6 weeks and that the continuous anastomoses
were more hemostatic.11 Of note, none of these studies
showed an increased incidence of aneurysm formation.
Finally, a clinical study from Memorial Sloan Kettering
Hospital, analyzed 200 free flaps performed using the con-
tinuous suture technique in both the arterial and venous
anastomoses and reported an overall 97.5% flap survival.37
Modified Continuous and Interrupted Suture
Two important technique modifications worth men-
tioning in this review are the continuous locking and spi-
Microsurgery DOI 10.1002/micr
76 Alghoul et al.
Figure 6. Schematic illustration of Timmon’s modified continuous suture
technique. After the first knot is tied (A), a short remnant is left on one
end and the other end is ran continuously to suture closed the posterior
wall. The suture is then pulled snug with each pass instead of keeping
the edges separated until the end. After the posterior wall is complete,
the suture is cut leaving behind a short remnant (B). A second knot is
tied (1808 to the first knot) using a second suture, and the remnant is tied
to the second knot (C). The suture is then ran along the anterior wall (D)
and tied to the first suture remnant completing the anastomosis (E).
ral interrupted techniques. Both modifications have the
advantage of speed without the additional worry of a
feared ‘‘purse-string’’ effect. Again, Schlechter and
Microsurgery DOI 10.1002/micr
Guyuron showed in rabbits that a continuous locking
technique is in fact as efficacious as the interrupted tech-
nique with no reduction in blood flow as compared with
the native blood vessel.18
The spiral-interrupted technique is a unique modifica-
tion that involves placing a loose running suture to form
a decrescendo spiral (loops) on the surface of the anasto-
mosis. This suture then becomes interrupted following
tangential cuts made through the loops. All suture seg-
ments are then tied individually as similar to the common
interrupted technique (see Fig. 7). This method allows
one to visualize the interior of the vessel wall during the
last few passes and provides shorter operative time when
compared with the interrupted suture technique.
Chen et al. compared the spiral technique to both the
interrupted and continuous techniques in rats. There was
no difference in patency among the groups except for the
continuous end-to-side venous anastomosis group, which
had a 50% thrombosis rate secondary to constriction at
the anastomosis site. Interestingly, total operative time
associated with the spiral interrupted group was signifi-
cantly shorter than the interrupted suture group, but lon-
ger than the continuous group.36
Posterior-Wall-First
The posterior-wall-first technique was first described
by Harris and Buncke, who published his results using a
simple interrupted technique.23 His description started
with the posterior wall first and then ended with the ante-
rior wall. Using this, his group achieved a 95% and 97%
success rate in 17 finger replantations and 20 composite
tissue transplants, respectively. His conclusion was that
this technique was applicable to any situation where 1808
flipping of the staged approximator clamp for optimal
posterior wall exposure becomes ‘‘technically difficult.’’
This is often the case when the vessels are short and
turning of the staged-clamps causes unwanted vessel wall
tension and trauma. A second similar study by Hou et al.
also compared this technique to the conventional inter-
rupted suture technique in rats and found no difference in
suturing time and/or patency rate.24
In 2006, Watanabe et al. described a new modifica-
tion combining a posterior-wall-first continuous technique
with an anterior (conventional) interrupted suture in rats.
There was in fact no significant difference in the patency
rates and/or operative times between either group.25 How-
ever, Adani et al. described a second modification of the
continuous technique in rabbits, which also avoided
‘‘flipping the clamps,’’ and again sutured the posterior-
wall-first. Their method included using two stay sutures
placed at 6 and 12 o’clock and then retraction in opposite
directions. This in turn rotates the vessels 908 (in respect
to the surgeon) and exposes the medial and lateral walls
for suturing. A continuous suture is then performed on
 Table 1. A Summarized Comparison Table of Various Microsurgical Techniques
Primary Techniques Number of
investigator compared Vessels investigated Animal anastomoses Microsuture used Study endpoints Patency rates (%) Time (min)

Little and IS/CS, Carotid 1.0–1.5 mm Rat 20 10-0 Nylon Angiography Blood 90/100 (10 days) 55/20
Salerno5 end-to-side flow studies
Hamilton Only CS, Femoral artery Rabbit 27 arterial 10-0 Nylon – 92.6 arterial –
and O’Brien8 end-to-end and vein and 25 and 84 venous
venous
Moscona IS/CS, Renal artery Rat 30 10-0 Nylon Histology 100/73.3 15/7
and owen7 end-to-end 0.7–0.9 mm
Timmons9 Only CS, Carotid artery Rat 10 10-0 Nylon Histology 100 –
end-to-side 1.0 mm
Mao et al.10 IS/CS, Carotid artery Rat 42 10-0 Nylon Measuring from 100/100 6 months –
end-to-end 1.0–1.3 mm photographic prints
Peerless et al.11 IS/CS, Carotid artery Rat 50 10-0 Nylon and Measuring diameter 100/100 (6 weeks) 50/28
end-to-side 1.0 mm 10-0 Prolene
Lee et al.12 IS/CS, Saphenous artery Dog 20 10-0 Nylon Blood flow velocity 100/100 (13 weeks) –
end-to-end 1.0 mm and Arteriography
Firsching et al.13 IS/CL, Carotid artery Rat 40 10-0 Nylon IS Electromagnetic 100/100 (3–4 months) –
end-to-end and 10-0 flowmeter and
Polyglactin CL Histology
Wacatly et al.14 IS/CL, Superficial epigastric Rat 20 10-0 Nylon Distal empty and 100/100 22/12
end-to-side vein to femoral refill tests
artery
Chen et al.15 IS/CS, Carotid, SEA, and Rabbit 57 and 42 10-0 Nylon and Milking test 91/89 93.5/93.5 87.5/96 11.2/7 12.3/7.9
end-to-end femoral arteries. and Rat 12-0 Nylon Angiography 23.7/16.2
Femoral and SEV Histology
veins 0.7–2.0 mm 4 weeks
Adani et al.17 IS/CS, Femoral artery and Rabbit 20 (40 arterial 10-0 Nylon Clinical assessement 100/100 arterial 10.5/8.7 artery
end-to-end femoral vein and 40 venous) 1 week 90/75 venous 11.7/11.2 vein
0.8–1.3 mm
Lee et al.16 IS/CS Median artery, Dog 30 9-0 Nylon High-frequency 100/100 (11 weeks) –
interpossition pulsed Doppler
vein graft and ultrasonography
Schlechter IS/CS/CL, Femoral artery Rabbit 60 10-0 Nylon Milking test Blood flow 100 10 days 22.5/11.5/10.5
et al.18 end-to-end
Abbreviations: IS: Interrupted suture; þCS: Continuous suture.
Suture Techniques For Microvascular Anastomoses

Microsurgery DOI 10.1002/micr

77
78 Alghoul et al.
Figure 7. Schematic illustration of the spiral anastomosis. A loose
running suture is placed to form a decrescendo spiral (loops) on
the surface of the anastomosis (A). This suture then becomes inter-
rupted following tangential cuts made through the loops (B). All
suture segments are then tied individually as similar to the common
interrupted technique (C).
each side completing the anastomosis. Although the arte-
rial anastomoses in this model achieved 100% patency,
the venous anastomoses had a 10 and 25% thrombosis
rate in the interrupted suture and modified continuous
suture groups, respectively.17
Mattress Sutures
In two separate studies, Simsek et al. and Tetik et al.
both compared the continuous horizontal suture technique
to conventional methods.21,22 Simsek compared this tech-
nique to interrupted suture, standard continuous suture,
and continuous horizontal mattress suture in rats. The
data showed no significant difference in early and/or late
patency between either of the groups. Furthermore, both
Microsurgery DOI 10.1002/micr
continuous techniques showed no difference in total oper-
ative time, but they were both significantly less than the
interrupted group. Interestingly, the average oozing dura-
tion of the continuous mattress suture group was signifi-
cantly shorter than the other two.21
The study by Tetik et al. compared the same techniques
in rats and found similar patencies among them. In fact, the
continuous horizontal mattress anastomosis took signifi-
cantly less time to perform when compared with the con-
ventional continuous group. However, this group had an
unexplained increase in pseudoaneurysm formation.22
Not surprisingly, other innovative modifications have
since followed, in particular, the interrupted horizontal
mattress with eversion. It involves two fish mouth cuts at
each vessel end, everting both segments, and then sutur-
ing those everted segments with interrupted horizontal
mattress suture. Two studies recently published describing
this modification in rats found no significant difference
between early and late patency rates, bleeding times and/
or pseudoaneurysm formation rates. However, the total
operative times were significantly shorter in both eversion
technique groups.19,20
Sleeve Anastomosis
The sleeve anastomosis has often been reported to be
beneficial because of its shorter operative time and its
absent need for vessel clamp flipping for posterior wall
suturing. However, it can only be utilized if the proximal
vessel is smaller than or equal in diameter to the distal
vessel, and hence, has a distinct advantage when there is
vessel size discrepancy. The sleeve anastomosis was first
described by Lauritzen (1984), whose studies in fact
reported high patency rates.26 In fact, numerous animal
and clinical studies published since its introduction show
patency rates equal to the conventional interrupted suture
technique.28–30
However, other experimental studies that have since
modified the original technique show less successful pat-
ency rates.27 The main concerns with this technique are
1) the degree of stenosis at the anastomosis and 2) the
potential for decreased blood flow when the two vessels
are similar in size. Despite these concerns, multiple stud-
ies following Lauritzen’s technique in conjunction with
minor modifications have achieved excellent patency
rates.27–29
For example, Kanaujia et al. showed in rats employ-
ing Mercox injection (in both arterial and venous anasto-
moses) that vessel stenosis occurred only temporarily
using the sleeve technique and was absent at 4 weeks.29
Successful application of the sleeve anastomosis is deter-
mined by extreme attention to minor technical details.
Emphasis over sufficient, but gentle, dilation of the vessel
ends was stressed numerous times as of utmost impor-

tance. In addition, sutures must not be used to drag one
vessel into another.
DISCUSSION
Perfecting one’s ability to consistently perform suc-
cessful microvascular anastomoses is a fundamental skill
acquired during plastic surgery training. Several factors
come into play when deciding which type of anastomosis
to perform. In this setting, the microsurgeon’s experience
and comfort level should take precedence. The type of
vessel used (artery vs. vein), the number of anastomoses
required, the warm ischemia time, the availability of
adequate vessel length, and the presence of size discrep-
ancy are all important consideration factors when plan-
ning a microvascular anastomosis. With this in mind, the
goal of our systematic review was to 1) familiarize plas-
tic surgeons-in-training with different anastomotic techni-
ques available for use in their microsurgical armamentar-
ium and 2) to present evidence-based studies to support
their safety and efficacy.
One major disadvantage that historically placed the
continuous suture technique out of favor was its feared
potential of causing anastomotic lumen narrowing.1,2 A
purse-string effect may narrow the anastomosis and could
eventually lead to decreased flow and/or thrombosis.
Most of the experimental studies presented here, compar-
ing interrupted versus continuous, clearly show that the
continuous suture technique is as effective as the inter-
rupted technique with equivalent patency. This applies to
arterial, arterio-venous, and veno-venous anastomoses.
However, if the anastomosis needs to be revised for any
reason peri-operatively, the continuous suture must be
taken down entirely and redone completely as compared
with the interrupted technique, which may add unfavor-
ably to one’s total operative time.
Often times, the clinical setting may influence the
microsurgeon’s decision on which type of anastomosis to
perform. Although total operative time may not be an
issue when dealing with one anastomosis, using the
sleeve or the continuous technique may save one signifi-
cant time in the setting of multiple digit replantation, for
example. Likewise, vessel size discrepancy may favor the
sleeve anastomosis, which has been shown in several
studies to be as effective as the simple interrupted anasto-
mosis.26,28–30
There are a few important points worth mentioning in
this review of the literature in regards to the simple inter-
rupted and continuous suture techniques. First, compari-
son in anastomotic compliance was not performed in
veno-venous anastomoses. Second, the reduction in the
anastomotic area seemed to be greater in the continuous
suture technique, but this difference did not have any he-
modynamic significance and did not affect flow rates
Suture Techniques For Microvascular Anastomoses 79
and/or patency.12,16 Also, studies that performed histolog-
ical evaluation showed no difference in re-endothelializa-
tion between either of the two techniques.7,9,13,15 Finally,
both techniques were successfully described in both end-
to-end and end-to-side configurations but were not
directly compared.5,9,11,14
However, one should know that the end-to-end versus
end-to-side experiments presented here employed the in-
terrupted suture technique in both groups.38–40 Therefore,
based on our review, a statement cannot be made to
favor either technique’s patency rate and/or ease of per-
formance when comparing end-to-end and end-to-side
configurations. More importantly, one should realize that
end-to-side anastomoses are indicated when it is neces-
sary to preserve vessel patency/flow that would be other-
wise sacrificed in an end-to-end configuration, such as in
the case of lower extremity reconstruction, for example.
CONCLUSION
In summary, a plastic surgeon’s decision to perform a
specific microvascular technique ultimately depends on his/
her preference, operative experience, and the availability of
a suitable recipient target vessel. It appears from our litera-
ture review that careful, precise microsurgical technique is
the only determinant in achieving consistent, successful
long-term results. To date, there are no human randomized,
controlled clinical trials (i.e., high level evidence) compar-
ing the efficacy and clinical outcomes of each of the various
microsurgical techniques, and therefore one’s comfort and
experience should dictate his or her technique. However,
‘‘exposure to many and mastery of one’’ during residency/
fellowship training simply provides him/her with the
invaluable technical flexibility to deal with complex micro-
vascular dilemmas in the future.
ACKNOWLEDGMENTS
The authors would like to dedicate this manuscript in
memory of Harry Buncke, M.D., for his endless dedica-
tion and insurmountable passion for microsurgery.
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