title: The microvascular anastomotic coupler for venous anastomoses in free flap breast reconstruction improves outcomes.
abstract: BACKGROUND
  Venous couplers are ubiquitous around the world and are a useful tool for the reconstructive microsurgeon. A systematic review of coupler performance studies demonstrated a thrombosis rate range of 0% to 3%, whilst the average time of using the device is 5 minutes. There is sparse published data on cost analysis and the impact of operator experience on the anastomotic coupler device success. Improvements in outcomes other than time benefits have also not been shown. This study aims to address these deficiencies in the literature.
  
  
  METHODS
  A retrospective clinical study was undertaken, aiming to compare equivalent groups of patients that had free flap surgery with venous micro-anastomoses with those that had sutured anastomoses. The cohort comprised all patients undergoing microsurgical breast reconstruction at the St Andrew's Centre for Plastic Surgery & Burns from January 2009 to December 2014.
  
  
  RESULTS
  Between January 2010 to December 2014, 1,064 patients underwent 1,206 free flap breast reconstructions. The average age of patients was 50 years. Seventy percent of patients underwent mastectomy and immediate reconstruction during this period with the remaining 30% having a delayed reconstruction. The 1,206 free flaps comprised of 83 transverse myocutaneous gracilis (TMG) flaps, and 1,123 deep inferior epigastric artery perforator (DIEP) flaps. In total the coupler was used in 319 flaps, 26% of the cohort. There was a statistically significant clinical benefit in using the anastomotic coupler for venous anastomosis. Overall, the return to theatre rate was 12.69% whilst the overall flap loss rate was 0.75%. The overall coupler failure rate was significantly less at 1.4% whilst sutured vein failure rate was 3.57% (P=0.001).
  
  
  CONCLUSIONS
  The anastomotic coupler for venous anastomosis in free flap surgery is associated with reduced operating times, reduced take-backs to theatre and cost benefits. This is the first study to demonstrate clear clinical benefits to anastomotic couplers, and suggests that these may be the gold standard for venous microanastomosis. With increasing experience with their use and technological advances, these outcomes may continue to improve.
authors.affiliation: 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK.
authors.forename: Edmund
authors.initials: E
authors.lastname: Fitzgerald O'Connor
authors.affiliation: 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK.
authors.forename: Warren Matthew
authors.initials: WM
authors.lastname: Rozen
authors.affiliation: 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Chowdhry
authors.affiliation: 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK.
authors.forename: Nakul Gamanlal
authors.initials: NG
authors.lastname: Patel
authors.affiliation: 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK.
authors.forename: Whitney T H
authors.initials: WT
authors.lastname: Chow
authors.affiliation: 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK.
authors.forename: Matthew
authors.initials: M
authors.lastname: Griffiths
authors.affiliation: 1 St Andrew's Anglia Ruskin (StAAR) Research Unit, 2 St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex CM1 7ET, UK.
authors.forename: Venkat V
authors.initials: VV
authors.lastname: Ramakrishnan
keywords: Suture; free flap; microsurgery; microvascular; rib; vessel