Preferential use of end-to-side arterial anastomoses in free flap transfers

In our early clinical experience with free flaps, we used end-to-end arterial anastomoses and in 9 our of 24 we had complete failures--7 of which were due to early arterial thrombosis. Contrarily, in 41 consecutive free flaps with end-to-side anastomoses we have not had a single failure. At the same time that we began using the end-to-side anastomoses, we also began using the latissimus dorsi free flap as our flap of first choice, and we agree that this was probably an additional reason for our improved success rate. The use of end-to-side anastomoses has the following advantages: (1) a high success rate; (2) preservation of all existing vessels in an injured extremity; (3) greater freedom of operative planning; and (4) technical simplicity in terms of access to the vessels. For us, these advantages have made end-to-side anastomosis the technique of choice in the transfer of free flaps.