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ORIGINAL ARTICLE
Year : 2015  |  Volume : 11  |  Issue : 2  |  Page : 40-44

Single cephalic vein as the only draining vein of radial forearm free flap: A comparative study of 154 cases


Department of Plastic Surgery, Shrirama Chandra Bhanj Medical College, Cuttack, Odisha, India

Date of Web Publication10-Mar-2016

Correspondence Address:
Nilamani Mohanty
Department of Plastic Surgery, Room No - 56, P.G. Hostel, Shrirama Chandra Bhanj Medical College, Mangalabag, Cuttack - 753 007, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0794-9316.178454

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  Abstract 

Background: Radial forearm free flap is the work horse in head and neck reconstruction. The venous drainage of the flap is by both superficial and deep group of veins.
Aim of the Study: To compare the efficacy of venous drainage by single superficial vein (cephalic vein) with dual vein (cephalic vein & venae comitantes) in radial forearm free flaps and its impact on flap survival. Patient and methods- A total of 154 patients undergoing radial forearm free flap for reconstruction following resections of head and neck cancer were studied prospectively . In group 1 (75 cases) only cephalic vein was used as the draining vein and in Group 2 (79 cases) both cephalic vein & one venaecomitantes were used as the draining vein. Patients with non availability of cephalic vein as a result of chemotherapy or injury were excluded from the study. Data were retrieved frompatients' files and analyzed using SPSS computer software version 15.0.
Observation and Results: The flap survival rate was 97.33% (73/75) in Group 1 versus 98.73% (78/79) in Group 2. The result is analysed statistically by using SPSS computer software version 15.0. and the P value > 0.50 (c2 with Yates' correction=0.00206555, df=1) stastically not significant.
Conclusion: Though two vein anastomosis may provide a more fail safe theoretical advantage, single superficial vein (Cephalic) provides effective and adequate drainage with less operative time and no additional morbidity.

Keywords: Allen's test, anastomosis, cephalic vein, radial forearm free flap, thrombosis


How to cite this article:
Mohanty N, Nayak BB. Single cephalic vein as the only draining vein of radial forearm free flap: A comparative study of 154 cases. Nigerian J Plast Surg 2015;11:40-4

How to cite this URL:
Mohanty N, Nayak BB. Single cephalic vein as the only draining vein of radial forearm free flap: A comparative study of 154 cases. Nigerian J Plast Surg [serial online] 2015 [cited 2019 Aug 19];11:40-4. Available from: http://www.njps.org/text.asp?2015/11/2/40/178454


  Introduction Top


Radial forearm free flap, otherwise known as the Chinese flap, is the workhorse in head and neck reconstruction. This fasciocutaneous flap supplied by the radial artery was first reported in 1978 by Dr. Yang Guofan and Dr.Gao Yuzzi, and was used for release of burn contractures mainly in the head and neck.[1] The flap is drained by two groups of veins. The superficial group is formed by the cephalic vein, which has larger caliber and subcutaneous location. The deep group is composed of two venae comitantes that accompany the radial artery and are interconnected with each other at regular intervals in a ladder-like pattern, which ultimately drains to the medial cubital vein. Both groups are connected to each other by the cubital perforating vein.[2],[3],[4],[5] Both the groups are equally effective in draining the radial forearm free flaps.[2],[6] Though there is a variability in the incidence of communication between the two groups by the communicating vein, the venous anatomy studied by Sader et al. showed that the communicating vein was invariably present in the antecubital fossa.[7] Because of thinness, pliability, long vascular pedicle and tolerance to radiotherapy, and ability to make it sensate one, this flap is commonly used for most oral, orofacial, tongue, maxilla, palate, and lip defects.[8],[9],[10],[11],[12],[13] The most important obvious disadvantage of this flap is the donor-site morbidity but several techniques have been described to reduce this complication.[14],[15],[16],[17],[18],[19],[20],[21],[22] The usual practice by most surgeons is to anastomose two veins if possible. Here, we describe the efficacy and reliability of a single vein (cephalic vein) as the only outflow channel in radial forearm free flap and compare it with dual venous drainage.


  Patients and Methods Top


This study was conducted on 154 patients between January 2010 and June 2014 operated for head and neck cancers where the defect was reconstructed with radial forearm free flap [Figure 1]. Fourteen of these patients had received preoperative radiation therapy. Single or double vein anastomoses were performed alternatively in the patients in a randomized manner. According to the number of veins draining the flap, the 154 patients were divided into two groups––group1 having 75 patients and group2 having 79 patients. The flap sizes in both the groups of patients were comparable (5×6–5.5×7 cm for single paddle, 4×5–5×6 cm and 4×6–5×6.5 cm for double paddle). The patients were evaluated on the basis of the recipient vessels, reexploration rate, vascular compromise, and flap survival rate.
Figure 1: Preoperative photograph showing carcinoma of the tongue

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In all cases, the flap was harvested from the nondominant forearm after the preliminary Allen's test and confirming the dominance of the ulnar artery. The flap was harvested under tourniquet control with recording of the ischemia time and was deflated before ligating the main vessel to confirm adequate flow to the flap and allow reperfusion for 10 min [Figure 2]. The cubital perforating vein was not included in the venous pedicles in all our flaps. The microvascular anastomosis was performed with 8-0 prolene interrupted sutures. Most anastomoses were performed in an end-to-end fashion. The radial artery anastomosed most commonly to the superior thyroid artery followed by the facial artery and transverse cervical artery[Figures3 and 4]. In Group 1, only the cephalic vein was anastomosed to the neck recipient vein, and the venous return through this vein after release of the arterial clamp was excellent [Video 1]. In Group 2, the cephalic vein and one of the venae comitantes were anastomosed to the neck recipient vein. All the anastomoses were performed by a single surgeon. The donor site was resurfaced with thick split skin graft (SSG) harvest from the back of the thigh after achieving meticulous hemostasis so as avoid any graft loss. Plaster of Paris (POP) slab was also applied over the donor area dressing to immobilize the hand.
Figure 2: Photograph of harvest of radial forearm free flap

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Postoperatively, all patients received low molecular heparin 50–100IU/kg subcutaneously for 3 days and aspirin 150 mg/day and dipyridamole (Persantine) 25 mg three times daily were started from the first postoperative day for 2 weeks. Postoperative monitoring was performed by clinical parameters such as flap color, turgor, temperature, and scratch test. In cases where the above parameters were doubtful, Doppler scan was performed to assess the anastomosis.

Statistical analysis

The data collected were analyzed using Statistical Package for the Social Sciences (SPSS) computer software version15.0 (SPSS Inc. 233 South Wacker Drive, 11th Floor Chicago, IL 60606-6412). The data were summarized in the form of proportions and frequency tables for categorical variables. Continuous variables were summarized using mean, median, mode, and standard deviation.

Chi-square (χ2) test was used to test the significance of associations between the predictor and outcome variables in the categorical variables.


  Observation and Results Top


Of the 154 patients who had undergone ablative surgery for squamous cell carcinoma of either the oral cavity or tongue followed by reconstruction by the radial forearm free flap, we had 124 males and 30 female patients in the age group of 18–75 years [Table 1]. The buccal mucosa constituted the predominant surgical defect with 83 cases, 42 cases had surgical defect in the tongue, 21 cases in the buccal mucosa and skin as double paddle, 4 cases in the alveolus and floor of the mouth, and 4 cases in the lower lip. The fasciocutaneous flap was used as the common modality of reconstruction in 148 patients while osteocutaneous and musculocutaneous flaps were used in the remaining patients [Table 2].{Table 1}{Table 2}

One of the tributaries of the internal jugular vein was used as the predominant recipient vein but other veins less commonly used were the external jugular vein and anterior jugular vein. The superior thyroid artery was used as the predominant recipient artery in 131 cases, and the facial and transverse cervical arteries were used in the rest of the cases.

Eleven patients required re-exploration. Out of them, four patients (1 Gr 1 and 3 Gr 2) were explored within 1 h of surgery due to excessive drainage with ligation of the offending bleeder. Four patients (2 Gr 1 and 2 Gr 2) developed venous congestion of the flap within the second postoperative day [Table 3]. The venous anastomosis was revised and additional anastomosis of one vena comitans was performed for Gr1. We had three complete failures (2 Gr1 and 1 Gr 2) occurring between the fourth postoperative day and seventh postoperative day, which could not be salvaged due to overt infection and septic thrombus of both the artery and vein due to leakage of saliva from the inset site. All these three flaps were debrided and reconstruction of the buccal mucosal defect was performed with pectoralis major myocutaneous flap. Though we had two failures in Group 1, the cephalic vein was not the primary contributing factor. Flap survival rate was 97.33% in Group 1 compared to 98.73% in Group 2. P value was not statistically significant (P >0.5).{Table 3}

The additional operative time taken for performing a second vein anastomosis was around 30 min.


  Discussion Top


There are situations in which the reconstructive surgeon has a single vein in the donor flap. This has never been a contraindication for executing a free flap. The positive side is that the surgeon knows that he has to focus only on this anastomosis. Ichinose et al. reported a failsafe draining method of utilizing two independent venous systems and two independent recipient neck venous systems.[23] Though there are few studies on a single vein draining a free flap, all show consistently good results as compared to multiple draining channels.[24],[25] Our study focuses on the cephalic vein and not on venae comitantes because of its large caliber and ease of finding a better matching recipient vein in the neck. In a radial free flap scenario, not only are the results comparable but also the single cephalic vein has a host of other advantages. It has a large caliber (2.5–4 mm) as compared to the 1–2 mm diameter of venae comitantes.[3],[26],[27],[28] It is easy to harvest because of its subcutaneous location. More length of vein can be taken than the arterial length without compromising the vascularity of forearm flexors in situ ations where a shorter length of the radial artery but longer length of the vein is required so that more number of perforators can be spared by harvesting the cephalic vein. It is easy to perform anastomosis because of the large caliber of the cephalic vein, good caliber-matching with recipient veins at the inset site, more comfortable hand positioning as anastomosis lies lower down in the neck, and due to the long pedicle that affords flexibility in selection of recipient vessels in the neck.[29] This anastomosis can be comfortably performed with a loupe, which is particularly helpful in centers where the operating microscope is not available. Hence, the execution of anastomosis takes less time. The only issue is its close association with superficial radial nerve and its branches warranting careful dissection in the distal forearm. In our series we were able save the nerve in all our cases. Some surgeons who do not use the cephalic vein routinely have to dissect the radial nerve, which is closely related to the vein. For them, using this vein does not add significantly to the operating time to incorporate the cephalic vein. In fact, more time may be required for longer venous pedicle and shorter arterial pedicle to dissect the extra length of the artery to gain venous length, ligating the additional perforators. In hairy patients when the paddle is placed more ulnar-ward to avoid hair, we always had tributaries draining into the cephalic vein. Hence, the venous axis did not change in this group. Cephalic vein anastomosis may not be feasible in patients who had chemotherapy. We had eight such patients where anastomosis of a single vena comitans was performed without any problem. We observed that the size of one of the venae comitantes was larger than usual. This could be a compensatory phenomenon. However, this group was not a part of our study.

Song et al. in the original description of this flap introduced the primary venous drainage of the radial forearm free flap by the superficial system.[30] Dual venous drainage system theoretically provides a failsafe mechanism, which preserves partial venous drainage in the event of thrombus of one venous pedicle.[23],[31] In our experience, there is no practical advantage of dual vein anastomosis. The drainage capacity of the cephalic vein alone adequately handles the volume of flow generated by the radial artery.[2],[32],[33] Magnetic flow probe studies showed no significant difference between the superficial system and deep system's individual ability to drain the radial forearm free flap.[33] However, the study by Selber et al. contradict this concept.[34],[35] Since the venae comitantes are frequently small in diameter and friable in nature, anastomosis is technically difficult.[18] Finding a suitable vein of similar caliber is also an issue.

Moreover, additional vein anastomosis does add time to an already lengthy general anesthesia in patients who are often at a high risk for perioperative complications because of their underlying state of health.[26],[36],[37] Additional venous pedicles decrease the venous pressure within the flap. Because the venous pressure is logarithmically related to venous flow, this will decrease as well. The risk of thrombosis may be increased with additional venous defects at the site of supplemental venous anastomosis. The combination of venous stasis and multiple endothelial defects may potentiate the venous thrombotic risk.[36] In our study, this theory of increased thrombotic risk with dual vein anastomosis was also disproved. We believe that the surgeon might get a little complacent while doing two veins, which could be the factor for increased thrombosis. The surviving flaps with single vein anastomosis imply that all the venous anastomoses are functional. However, the same cannot be said about dual vein anastomosis because if at least one vein is functional, it will go unrecognized unless both the veins are thrombosed.


  Conclusion Top


The cephalic vein as the only superficial outlet channel is an effective and reliable draining vein of the radial forearm flap and the results are comparable to that of dual vein anastomosis. Anastomosis of a second vein increases the operating time without changing the outcome. Hence, in view of the ease of anastomosis and reliability of a single cephalic vein, which shortens the operating time, second vein anastomosis need not be contemplated unless there is a doubt about the first vein. It is the quality of anastomosis and not the number that matters.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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36.
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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