Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery 52 (2014) 477–478
Technical note
Fibrin-based tissue glue for the prevention of kinking at sites of microvascular anastomoses Kai-Chen Wang, Yao-Li Chen, Shih-Lung Lin ∗ Department of Surgery, Changhua Christian Hospital, No. 135, Nanxiao Street, Changhua City, Changhua County 500, Taiwan, ROC Accepted 1 February 2014 Available online 5 March 2014 Keywords: Fibrin glue; Tissue glue; Fixation
Introduction Postoperative changes to the angle of the anastomotic site can be self-induced by simply changing the position of the head. These changes include kinking, compression, and stretching of anastomosed vessels.1 We routinely apply fibrin-based glue to anastomotic sites during reconstructions of the head and neck with free tissue transfer to strengthen the anastomosed vessels and prevent torsion. This glue-based fixation technique also keeps the pedicled artery from lying on the carotid artery. In this way, the Doppler signal of the carotid will not interfere with that of the reconstructed artery. To our knowledge there have been few studies that have reported on the use of fibrin-based glue for fixation.2,3
Technique During the period April 2012 to April 2013 we routinely fixed vessels in free flaps with fibrin glue in patients who required end-to-side venous anastomosis or who had unusually long or short pedicles (n = 30). The anastomosis was established with interrupted 8/0 polypropylene (Prolene) sutures under a microscope. First we adjusted the anastomosed pedicle to an angle that would avoid kinking.
∗
Corresponding author. Tel.: +886 47238595. E-mail addresses: [email protected] (K.-C. Wang), [email protected] (Y.-L. Chen), [email protected] (S.-L. Lin).
Fig. 1. The anastomosis sprayed circumferentially to stop leakage.
We then sprayed a small amount of fibrin sealant (Tissucol Duo Quick; 2 ml/set) around the anastomosis with a 2-syringe application device and a pressure-controlled spray system to maintain the shape of the anastomosis and to stop blood from leaking (Fig. 1). If the pedicle was redundant, we adjusted it to a smooth and curved position and then sprayed additional tissue glue along the pedicle. About 3–10 s later a whitish membrane could be seen coating the vessel, which resulted in fixation of the pedicle to the bed of the wound (Fig. 2). If the pedicle was under tension, we moved the flap closer to the recipient vessel to reduce it. We then sprayed tissue glue along the pedicle as an adhesive. Among the 30 patients studied one developed a venous thrombosis. A tracheostomy tube had externally compressed the external jugular vein proximal to the anastomotic site, which caused the thrombus. We opened the anastomosis, removed the thrombus from the pedicle, and established an
0266-4356/$ – see front matter © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2014.02.001
478
K.-C. Wang et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 477–478
of a pedicle in various circumstances.4 An extended period of observation is needed to show the long-term effects and stability of this technique.
Patient consent All patients provided written informed consent and the study protocol was approved by the hospital’s institutional review board.
Conflict of interest There exist no conflicts of interest, for any authors, neither financial nor otherwise, regarding this paper.
References Fig. 2. A whitish membrane has formed that coats the vessel, which results in fixation of the pedicle to the wound bed.
end-to-end anastomosis between a branch vessel of the jugular vein and the pedicle. All the flaps survived and at the most recent follow-up all patients were alive and well. None had signs of thrombosis or bleeding. Because of its efficacy, tolerability, and lack of adverse effects, fibrin glue is a potentially valuable tool for the fixation
1. Yu P, Chang DW, Miller MJ, et al. Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head Neck 2009;31:45–51. 2. Cheng YS, Lin PY, Lin KH, et al. Innovative technique for preventing hepatic artery kinking in living donor liver transplantation. Liver Transpl 2013;19:664–5. 3. Campanelli G, Pascual MH, Hoeferlin A, et al. Randomized, controlled, blinded trial of Tisseel/Tissucol for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair: results of the TIMELI trial. Ann Surg 2012;255:650–7. 4. MacGillivray TE. Fibrin sealants and glues. J Card Surg 2003;18:480–5.
British Journal of Oral and Maxillofacial Surgery 52 (2014) 477–478
Technical note
Fibrin-based tissue glue for the prevention of kinking at sites of microvascular anastomoses Kai-Chen Wang, Yao-Li Chen, Shih-Lung Lin ∗ Department of Surgery, Changhua Christian Hospital, No. 135, Nanxiao Street, Changhua City, Changhua County 500, Taiwan, ROC Accepted 1 February 2014 Available online 5 March 2014 Keywords: Fibrin glue; Tissue glue; Fixation
Introduction Postoperative changes to the angle of the anastomotic site can be self-induced by simply changing the position of the head. These changes include kinking, compression, and stretching of anastomosed vessels.1 We routinely apply fibrin-based glue to anastomotic sites during reconstructions of the head and neck with free tissue transfer to strengthen the anastomosed vessels and prevent torsion. This glue-based fixation technique also keeps the pedicled artery from lying on the carotid artery. In this way, the Doppler signal of the carotid will not interfere with that of the reconstructed artery. To our knowledge there have been few studies that have reported on the use of fibrin-based glue for fixation.2,3
Technique During the period April 2012 to April 2013 we routinely fixed vessels in free flaps with fibrin glue in patients who required end-to-side venous anastomosis or who had unusually long or short pedicles (n = 30). The anastomosis was established with interrupted 8/0 polypropylene (Prolene) sutures under a microscope. First we adjusted the anastomosed pedicle to an angle that would avoid kinking.
∗
Corresponding author. Tel.: +886 47238595. E-mail addresses: [email protected] (K.-C. Wang), [email protected] (Y.-L. Chen), [email protected] (S.-L. Lin).
Fig. 1. The anastomosis sprayed circumferentially to stop leakage.
We then sprayed a small amount of fibrin sealant (Tissucol Duo Quick; 2 ml/set) around the anastomosis with a 2-syringe application device and a pressure-controlled spray system to maintain the shape of the anastomosis and to stop blood from leaking (Fig. 1). If the pedicle was redundant, we adjusted it to a smooth and curved position and then sprayed additional tissue glue along the pedicle. About 3–10 s later a whitish membrane could be seen coating the vessel, which resulted in fixation of the pedicle to the bed of the wound (Fig. 2). If the pedicle was under tension, we moved the flap closer to the recipient vessel to reduce it. We then sprayed tissue glue along the pedicle as an adhesive. Among the 30 patients studied one developed a venous thrombosis. A tracheostomy tube had externally compressed the external jugular vein proximal to the anastomotic site, which caused the thrombus. We opened the anastomosis, removed the thrombus from the pedicle, and established an
0266-4356/$ – see front matter © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2014.02.001
478
K.-C. Wang et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 477–478
of a pedicle in various circumstances.4 An extended period of observation is needed to show the long-term effects and stability of this technique.
Patient consent All patients provided written informed consent and the study protocol was approved by the hospital’s institutional review board.
Conflict of interest There exist no conflicts of interest, for any authors, neither financial nor otherwise, regarding this paper.
References Fig. 2. A whitish membrane has formed that coats the vessel, which results in fixation of the pedicle to the wound bed.
end-to-end anastomosis between a branch vessel of the jugular vein and the pedicle. All the flaps survived and at the most recent follow-up all patients were alive and well. None had signs of thrombosis or bleeding. Because of its efficacy, tolerability, and lack of adverse effects, fibrin glue is a potentially valuable tool for the fixation
1. Yu P, Chang DW, Miller MJ, et al. Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head Neck 2009;31:45–51. 2. Cheng YS, Lin PY, Lin KH, et al. Innovative technique for preventing hepatic artery kinking in living donor liver transplantation. Liver Transpl 2013;19:664–5. 3. Campanelli G, Pascual MH, Hoeferlin A, et al. Randomized, controlled, blinded trial of Tisseel/Tissucol for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair: results of the TIMELI trial. Ann Surg 2012;255:650–7. 4. MacGillivray TE. Fibrin sealants and glues. J Card Surg 2003;18:480–5.
