If no venous anastomosis is possible, a distal digital artery can be anastomosed to a proximal vein. 31 In the case of a replanted distal phalanx level amputation, an artery-only replant40 can be sustained by removing the nail plate41 or by a fishmouth incision42 in the tip of the finger.

Recently, leeches have gained popularity and are used when nail plate removal or drained fishmouth incisions are inadequate. The nail plate technique requires periodic abrasion of the nail bed and, along with the incisional technique, is more traumatic than the use of leeches. The atraumatic leeching permits vasodilation, anticoagulation, and decompression. Specific antibiotic cover should accompany leech therapy. (See Chapter 40).

SUTURING THE ANASTOMOSIS

The vessel's size and position and the surgeon's preference influence the choice of suturing technique.43-45 If the vessels are large and can be easily seen and turned, anastomoses may be done by placing sutures at 0, 180, 90, and 270 degrees (or 0, 120, and 240). Add interposing sutures for an 8- or 12-suture anastomosis. If space permits, rotating the double vascular clamp makes these suture placements easier.

When a vessel cannot be turned, a "back wall" technique is used.46,47 Beginning at the vessel's posterior wall, progressively place the sutures toward the front wall, where the anastomosis is completed.

A "running interrupted" technique48 involves placing sutures with large loops between each bite. The loops are cut later, and the surgeon and the assistant simultaneously tie the knots, creating the "interrupted" sutures.

The following manipulative techniques aid microvascular repair: 1. Place the assisting forceps longitudinally in the vessel lumen so that the needle can pass between the blades, helping to identify the lumen and provide necessary counterpressure. 2. Irrigate between the sutures to "balloon out"49 the anastomosis.

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