Bilateral Spatulated Y-Shaped Microvascular Anastomosis - A Practical Technique for Overcoming Vessel Size Discrepancies

Background: Microvascular free tissue transfer has become the most common option for reconstruction in head and neck cancer. However, size discrepancies between the donor and recipient vessels are still a challenge to overcome in the microvascular surgical field. Herein, we describe a useful technique for overcoming vascular-size mismatch through a ＂bilateral spatulated Y-shaped anastomosis＂ procedure. Materials and Methods: This surgical technique includes the preparation of two recipient veins or two small concomitant veins for drain outflow by bilateral spatulated side-to-side anastomoses when significant vessel discrepancy (≧1:2) is noted. The ends of two vessels with smaller diameters were longitudinally incised to increase the luminal circumference to match that of the opposing vessel. The first suture is placed at the apex of the incision on both sides of the smaller vessels, and then, the vasculoplasty is completed using interrupted sutures, which results in a single larger lumen. The two smaller vessels, which are now fused into one neo-lumen, possess a circumference similar to that of the opposite vessel for anastomosis. This technique was applied in nine patients for head and neck reconstruction. Results: The nine cases included six radial forearm flaps (RF flap) and three anterolateral thigh flaps (ALT flap). Recipient vein selection is limited due to radical neck dissection, leaving us only one large-caliber external jugular vein. This technique was used to overcome venous size discrepancies ＞ 1:2 in all of our cases. The resulting anastomosis patency rate was 100%. No venous anastomosis failed or flap circulation was compromised. Conclusion: ＂Bilateral spatulated Y-shaped anastomosis＂ can be applied in head and neck cases with size discrepancies ＞50%.