Evidence-Based Analysis of Vein Graft Interposition in Head and Neck Free Flap Reconstruction

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Sir:FigureVein graft interposition is an accepted technique for microvascular reconstruction. However, in head and neck free flap reconstruction, vein grafting has rarely been addressed in the literature because of the relative infrequency of its use. In head and neck reconstruction, vein graft interposition was reportedly to be used in the following situations: (1) when the distance from the defect to the recipient vessels was greater than the length of the flap pedicle; (2) when vessel caliber mismatch existed between the recipient vessels and the flap pedicle; (3) when there were threatened or prior failed flaps; (4) when there were preirradiated graft beds; (5) for tumor recurrence; and (6) for trauma.1–3 Whether vein graft interposition increases the risk of free flap loss in head and neck reconstruction remains controversial.4 We decided to evaluate the existing literature, looking at the influence of vein graft interposition on free flap outcome in head and neck reconstruction through a systematic review. We searched the PubMed database for articles published from January of 1990 to June of 2011. Our keywords included “free flap reconstruction” or “free tissue transfer,” and “vein graft.” This search was supplemented by a review of reference lists of potentially eligible studies. We excluded non-English articles, studies from the same institute with overlapping duration, and studies that also included free flap reconstruction in other body parts. Two reviewers independently extracted data in two steps: titles and abstracts, and then full-text articles. Numerical distribution of procedures with or without vein graft and the number of flap losses were recorded (Table 1).1–3,5 The primary outcome was the flap failure rate. Relevant studies were assigned a level of evidence according to the American Society of Plastic Surgeons Evidence Rating Scale for Therapy.Table 1: The Four Retrospective Comparative StudiesThrough our electronic and reference search, we identified four retrospective comparative studies (level III evidence) that compared head and neck free flap reconstruction with and without vein graft interposition. We pooled 2102 free flaps for further survey. A total of 65 flaps (3.1 percent) used vein graft interposition and 2037 flaps (96.9 percent) did not. The overall flap failure rate was 5.2 percent. The flap failure rates were 23.1 percent in the vein graft group and 4.6 percent in the no–vein graft group. Although the pooled data showed that vein graft interposition was associated with an increased incidence of free flap failure, we could not conclude a causal relationship between vein graft interposition and flap failure. Vein graft interposition in head and neck free flap reconstruction was uncommon. The increased flap failure rates may be the result of the underlying factors that necessitated the use of vein grafts in the first place. Deliberate preoperative planning and delicate preparation for the recipient vessels and flap pedicles make it possible to avoid the use of vein grafts. 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 DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.