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Page 4 of 15 Inchauste. Plast Aesthet Res 2023;10:27 https://dx.doi.org/10.20517/2347-9264.2022.139

[21]
flap perfusion and anastomotic patency . Operative microscopes provide better visualization of vessel
intima to evaluate damage or tears, management of small side branches, or dissection within fibrotic or
radiated fields. This is especially important when first learning microsurgery.

Suture technique:

Now it is time to perform the vascular anastomosis. There has been debate regarding the ideal suture
technique. Simple interrupted suture for microvascular anastomosis remains the gold standard, but
numerous techniques have been described. The six most published suture techniques are simple
interrupted, continuous, locking continuous, continuous horizontal, horizontal interrupted with eversion,
and sleeve anastomoses . Publications comparing anastomotic suture techniques have shown no difference
[21]
in short and/or long-term patency rates. Each technique has been found to be successful if microsurgical
principles of suture line eversion with direct intima-to-intima contact and minimal tension are maintained.
The suture technique is less important than maintaining the above principles. Suture style depends more on
surgeon preference and experience than the superiority of one technique over another.

Hand sewn versus coupler anastomosis:

Vascular anastomoses were historically handsewn with sutures. Nakayama first described a microvascular
anastomotic coupling device in 1962 . Microvascular anastomotic coupling device (MACD) is a well-
[22]
established alternative to hand-sewn venous anastomosis. The device has an interlocking ring-pin design to
complete the anastomosis with reliable vessel eversion and intima-to-intima contact. The coupling device
ring acts as a rigid stent and protects against vessel collapse. However, the rigid ring can act as a potential
twisting or kinking point as well if not positioned appropriately. Hand-sewn venous anastomosis is
technically demanding due to the thin, fragile nature of vein walls. Studies comparing venous anastomosis
techniques (coupler versus hand sewn) show comparable revision and thrombosis rates [9,22,23] but do
demonstrate shorter anastomosis times with the use of MACD [22,23] . The use of a coupling device to
complete a venous anastomosis is successful in approximately 99% of attempts with a less than 1%
conversion rate to hand-sewn anastomosis . The shorter anastomosis time translates to shorter operative
[23]
time and potential cost savings. A study compared the cost of disposable products and operating room time
between hand-sewn venous anastomosis and MACD. This study demonstrated cost saving due to decreased
operative time despite the higher disposable cost with MACD . The use of a coupler device for venous
[24]
anastomosis has been widely adopted as the standard.

Microsurgeons have reported the use of MACD for arterial anastomosis as well. Studies demonstrate
anastomotic completion rates with MACD are lower with a higher conversion to hand-sewn anastomosis
compared to venous anastomosis . Vessel size mismatch, end-to-side anastomosis, thicker arterial wall, or
[25]
nonpliable artery were the most common reasons surgeons reported for failure to complete an arterial
anastomosis with a coupling device. The literature also describes intimal cracking or tearing during eversion
onto the coupler ring pins as reasons for conversion as well . The use of a coupling device for arterial
[25]
anastomosis can be done, but proper vessel selection is critical. Successful arterial coupling requires
adequate vessel size, minimal vessel size mismatch, and a pliable vessel that can be everted. Hand-sewn
anastomosis remains the most popular technique for arterial anastomosis.

End-to-end versus end-to-side anastomosis: