title: Venous coupler size in autologous breast reconstruction--does it matter?
abstract: BACKGROUND
  Autologous microvascular breast reconstruction is an increasingly common procedure. While arterial anastomoses are traditionally being hand-sewn, venous anastomoses are often completed with a coupler device. The largest coupler size possible should be used, as determined by the smaller of either the donor or recipient vein. While its efficacy has been shown using 3.0-mm size and greater couplers, little is known about the consequences of using coupler sizes less than or equal to 2.5 mm.
  
  
  METHODS
  A retrospective chart review of patients undergoing autologous breast reconstruction was conducted at NYU Medical Center between November 2007 and November 2011. Flaps were divided into cohorts based on coupler size used: 2.0 mm, 2.5 mm, and 3.0 mm. Outcomes included incidence of arterial or venous insufficiency, hematoma, fat necrosis, partial flap loss, full flap loss, and need for future fat grafting.
  
  
  RESULTS
  One-hundred ninety-seven patients underwent 392 flaps during the study period. Patients were similar in age, type of flap, smoking status, and radiation history. Coupler size less than or equal to 2.0 mm was found to be a significant risk factor for venous insufficiency (P = 0.038), as well as for development of fat necrosis (P = 0.041) and future need for fat grafting (P = 0.050). In multivariate analysis, body mass index was found to be an independent risk factor for skin flap necrosis (P = 0.010) and full flap loss (P = 0.035).
  
  
  CONCLUSIONS
  Complications were significantly increased in patients where couplers of 2.0 mm or less were used, therefore to be avoided whenever possible. When needed, more aggressive vessel exposure through rib harvest, the use of thoracodorsal vessels or hand-sewing the anastomosis should be considered in cases of internal mammary vein caliber of 2.0 mm or less.
  
  
  OBJECTIVE
  Therapeutic.
  
  
  METHODS
  Level III.
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York, NY, USA.
authors.forename: P Niclas
authors.initials: PN
authors.lastname: Broer
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York, NY.
authors.forename: Katie E
authors.initials: KE
authors.lastname: Weichman
authors.affiliation: Department of Surgery, Long Island Jewish Hospital, Manhasset, NY.|Department of Surgery, North Shore University Hospital, Manhasset, NY.
authors.forename: Neil
authors.initials: N
authors.lastname: Tanna
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York, NY.
authors.forename: Stelios
authors.initials: S
authors.lastname: Wilson
authors.affiliation: Department of Epidemiology and Biostatistics, Yale University, New Haven, CT.
authors.forename: Reuben
authors.initials: R
authors.lastname: Ng
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York, NY.
authors.forename: Christina
authors.initials: C
authors.lastname: Ahn
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York, NY.
authors.forename: Mihye
authors.initials: M
authors.lastname: Choi
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York, NY.
authors.forename: Nolan S
authors.initials: NS
authors.lastname: Karp
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York, NY.
authors.forename: Jamie P
authors.initials: JP
authors.lastname: Levine
authors.affiliation: Institute of Reconstructive Plastic Surgery, New York University, New York, NY.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Allen
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000714:Anastomosis, Surgical / Q000295:instrumentation; D015331:Cohort Studies; D016208:Databases, Factual; D004867:Equipment Design; D004869:Equipment Safety; D005260:Female; D058752:Free Tissue Flaps / Q000098:blood supply / Q000637:transplantation*; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D016462:Mammaplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D008323:Mammary Arteries / Q000601:surgery; D008866:Microsurgery / Q000009:adverse effects / Q000295:instrumentation*; D008875:Middle Aged; D009519:New York City; D011183:Postoperative Complications / Q000503:physiopathology / Q000628:therapy; D011379:Prognosis; D012189:Retrospective Studies; D013525:Surgical Instruments; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D014680:Veins / Q000601:surgery