Plastic and Reconstructive Surgery • August 2014 Use of Polyglycolic Acid Nerve Conduit (Neurotube) to Alleviate Pedicle Kinking in Microvascular Anastomosis Sir:
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e read with interest the article by Holliday and Davison1 regarding the use of polyglycolic acid nerve conduit (Neurotube; Synovis, Birmingham, Ala.) in microvascular anastomosis. The authors presented a case of mandibular reconstruction with a free fibula flap in which the kinking of the pedicle was avoided by using a Neurotube. Kinking of the vascular pedicle is a major reason for free flap failure, and several methods have been adopted by the microsurgeon to avoid this condition, including wrapping of the pedicle with a piece of fat, fascia, or muscle.2 The main advantage of the presented method is that the Neurotube is more rigid and therefore can better maintain the straightness of the pedicle. In contrast, potential limitations of using a Neurotube are the compression of the anastomosis and the cost of the device. In this communication, we present an alternative cost-free method to avoid kinking of the vascular pedicle using a segment of a 4-0 polydioxanone (Ethicon, Inc., Somerville, N.J.) suture, which is fixed to the adventitia of the pedicle with a 9-0 nylon suture. The 4-0 polydioxanone suture is quite rigid and works as a “rod,” preventing kinking of the vessels. The suture can be applied either on the pedicle or in continuity with the recipient vessels (Fig. 1). Advantages of this method are (1) no risk for anastomosis compression, (2) the suture works as a guide for the pedicle orientation and thus during the flap inset twisting of the pedicle can be avoided, and (3) the cost is much lower compared with the Neurotube device. We performed this technique in 11 free flaps (seven anterolateral thigh flaps and four fibula flaps) where there was a high risk of kinking of the pedicle: seven for lower limb reconstruction and four for head and neck reconstruction after tumor ablation. Selection criteria for performing this method were
the large length of the pedicle and the prediction of its right angling after the inset of the flap. All flaps survived well and no complications occurred with this method. In conclusion, the use of the rod technique can be used in cases where the risk of kinking and twisting of the pedicle is high. The simplicity of the method, the low cost, and the fact that there is no risk of anastomosis compression make this method ideal, which potentially may increase the success rate of the free tissue transfer. DOI: 10.1097/PRS.0000000000000394
Stamatis Sapountzis, M.D. Department of Plastic and Reconstructive Surgery Queen Victoria Hospital East Grinstead, United Kingdom, and Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan
Fabio Nicoli, M.D. Pedro Ciudad, M.D. Kidakorn Kiranantawat, M.D. Seong Yoon Lim, M.D. Matthew Yeo Sze Wei, M.D. Hung Chi Chen, M.D., Ph.D. Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan Correspondence to Dr. Sapountzis Department of Plastic and Reconstructive Surgery Queen Victoria Hospital East Grinstead, Sussex RH19 3DZ, United Kingdom [email protected] Correspondence to Dr. Chen Department of Plastic and Reconstructive Surgery China Medical University Hospital/China Medical University 2, Yuh-der Road Taichung, Taiwan [email protected]
DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this communication. REFERENCES
Fig. 1. Smooth curve of the vascular pedicle after fixation of the polydioxanone suture on the adventitia.
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1. Holliday MA, Davison SP. Use of polyglycolic acid nerve conduit (neurotube) to alleviate pedicle kinking in microvascular anastomosis. Plast Reconstr Surg. 2014;133: 241e–242e. 2. Sader C, Hart R, Trites JR, Phillips T, Rigby MH, Taylor SM. Fat graft pedicle stabilization in head and neck microvascular reconstruction. Plast Reconstr Surg. 2010;125: 893–895.
W
e read with interest the article by Holliday and Davison1 regarding the use of polyglycolic acid nerve conduit (Neurotube; Synovis, Birmingham, Ala.) in microvascular anastomosis. The authors presented a case of mandibular reconstruction with a free fibula flap in which the kinking of the pedicle was avoided by using a Neurotube. Kinking of the vascular pedicle is a major reason for free flap failure, and several methods have been adopted by the microsurgeon to avoid this condition, including wrapping of the pedicle with a piece of fat, fascia, or muscle.2 The main advantage of the presented method is that the Neurotube is more rigid and therefore can better maintain the straightness of the pedicle. In contrast, potential limitations of using a Neurotube are the compression of the anastomosis and the cost of the device. In this communication, we present an alternative cost-free method to avoid kinking of the vascular pedicle using a segment of a 4-0 polydioxanone (Ethicon, Inc., Somerville, N.J.) suture, which is fixed to the adventitia of the pedicle with a 9-0 nylon suture. The 4-0 polydioxanone suture is quite rigid and works as a “rod,” preventing kinking of the vessels. The suture can be applied either on the pedicle or in continuity with the recipient vessels (Fig. 1). Advantages of this method are (1) no risk for anastomosis compression, (2) the suture works as a guide for the pedicle orientation and thus during the flap inset twisting of the pedicle can be avoided, and (3) the cost is much lower compared with the Neurotube device. We performed this technique in 11 free flaps (seven anterolateral thigh flaps and four fibula flaps) where there was a high risk of kinking of the pedicle: seven for lower limb reconstruction and four for head and neck reconstruction after tumor ablation. Selection criteria for performing this method were
the large length of the pedicle and the prediction of its right angling after the inset of the flap. All flaps survived well and no complications occurred with this method. In conclusion, the use of the rod technique can be used in cases where the risk of kinking and twisting of the pedicle is high. The simplicity of the method, the low cost, and the fact that there is no risk of anastomosis compression make this method ideal, which potentially may increase the success rate of the free tissue transfer. DOI: 10.1097/PRS.0000000000000394
Stamatis Sapountzis, M.D. Department of Plastic and Reconstructive Surgery Queen Victoria Hospital East Grinstead, United Kingdom, and Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan
Fabio Nicoli, M.D. Pedro Ciudad, M.D. Kidakorn Kiranantawat, M.D. Seong Yoon Lim, M.D. Matthew Yeo Sze Wei, M.D. Hung Chi Chen, M.D., Ph.D. Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan Correspondence to Dr. Sapountzis Department of Plastic and Reconstructive Surgery Queen Victoria Hospital East Grinstead, Sussex RH19 3DZ, United Kingdom [email protected] Correspondence to Dr. Chen Department of Plastic and Reconstructive Surgery China Medical University Hospital/China Medical University 2, Yuh-der Road Taichung, Taiwan [email protected]
DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this communication. REFERENCES
Fig. 1. Smooth curve of the vascular pedicle after fixation of the polydioxanone suture on the adventitia.
332e
1. Holliday MA, Davison SP. Use of polyglycolic acid nerve conduit (neurotube) to alleviate pedicle kinking in microvascular anastomosis. Plast Reconstr Surg. 2014;133: 241e–242e. 2. Sader C, Hart R, Trites JR, Phillips T, Rigby MH, Taylor SM. Fat graft pedicle stabilization in head and neck microvascular reconstruction. Plast Reconstr Surg. 2010;125: 893–895.
