Plastic and Reconstructive Surgery • August 2019
3. Teichgraeber JF, Seymour-Dempsey K, Baumgartner JE, Xia
JJ, Waller AL, Gateno J. Molding helmet therapy in the treat-
ment of brachycephaly and plagiocephaly. J Craniofac Surg.
2004;15:118–123.
4. Vecchione L, Smith DM, Losee JE. Neonatal mandibular
molding: A novel method of treating congenital open bite.
Plast Reconstr Surg. 2010;125:648–651.
5. Prevedello DM, Kassam AB, Carrau RL, et al. Transpala-
tal endoscopic endonasal resection of a giant epignathus
skull base teratoma in a newborn: Case report. J Neurosurg.
2007;107(Suppl):266–271.
Coffee and Free Flaps: Foes No More
Sir:
P ossibly because of acquired preferences from mentors,
many microsurgeons continue to fear the vasospastic
effects of caffeine on a fresh anastomosis. Although sup-
porting evidence is equivocal, the Hagen-Poiseuille law is
often used to justify these fears, as small changes in ves-
sel caliber (radius) may confer large alterations in blood
flow. Some studies have demonstrated peripheral vaso-
constrictive effects of caffeine; many others have found
no significant impact on anastomosis following micro-
vascular repair.1–3 Near-infrared spectroscopy allow for
contemporaneous detection of circulatory fluctuations.
Using near-infrared spectroscopy, we examined the effect
of early postoperative coffee consumption on perfusion.
We routinely apply ViOptix (ViOptix, Inc., Newark,
Calif.) tissue oximetry, a form of near-infrared spectros-
copy, on our free flap reconstructions. Perfusion changes
on ViOptix in three consecutive autologous breast recon-
struction patients (mean age, 52 years) were examined after
patients consumed a single 5.25-oz coffee (approximately
Fig. 1. ViOptix tissue oximetry readings for two abdominal free flaps for bilateral breast recon-
struction [above, superficial inferior epigastric artery flap (channel 1); below, deep inferior epi-
gastric perforator flap (channel 2)]. The screen shot captures oximetry readings within 1.5 hours.
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Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
100 mg caffeine/8 oz) on postoperative day 1. Two
patients underwent immediate unilateral reconstruction
with muscle-sparing transverse rectus abdominis myocuta-
neous flaps, and one patient underwent delayed bilateral
reconstruction with superficial inferior epigastric artery
and deep inferior epigastric perforator flaps. The average
flap ischemia time was 53.5 minutes (range, 42 to 60 min-
utes). End-to-end anastomosis to the internal mammary
artery and single anastomoses to the internal mammary
vein was performed for all flaps except for the first muscle-
sparing transverse rectus abdominis myocutaneous flap,
which had dual internal mammary vein and thoracodor-
sal venous anastomoses. Skin paddles, all zone 1, were part
of a vertical reduction pattern intended for future nipple-
areola complex reconstruction. Care was taken not to
place sensors directly over perforators, because doing so
may limit sensitivity. All patients were regular coffee drink-
ers, confirmed before surgery. Because caffeine has an
approximately 5-hour half-life, flaps were monitored for 6
to 8 hours after caffeine administration. Figure 1 depicts
flap oximetry after the coffee consumption by the patient
who underwent delayed bilateral reconstruction. Minimal
oximetry changes were noted (average change, 3 percent;
range, 1 to 6 percent) (Fig. 2). The greatest change (6
percent) occurred in a patient who consumed decaffein-
ated coffee. All flaps survived without complication or
reoperation.
Like other xanthines, caffeine’s mechanism of action
varies by tissue. Systemic increases in sympathetic tone
result from caffeine antagonism at adenosine recep-
tors, but endothelial vasodilation results from caffeine-
induced increases in nitric oxide.4 The patency of femoral
artery anastomosis in rats is not influenced by systemic
 Volume 144, Number 2 • Viewpoints
Fig. 2. Minimal change 6 to 8 hours after coffee consumption.
administration of caffeine.2 Multiple studies on digital ves-
sels, including those using laser Doppler flow monitoring,
have shown no response of blood flow to caffeine.3 Corti et
al. found a rise in muscle sympathetic tone activity following
caffeinated coffee, decaffeinated coffee, and intravenous
caffeine administration in both habitual and nonhabitual
coffee drinkers.5 However, only nonhabitual patients expe-
rienced increases in blood pressure; habitual coffee drink-
ers ultimately develop tolerance to acute, caffeine-induced,
hemodynamic changes. Given that 90 percent of Ameri-
cans consume caffeine daily, withholding coffee to patients
who regularly drink it makes little sense.3 Although sur-
geons may not find coffee restriction problematic, it may
negatively impact well-being during recovery by inducing
withdrawal effects. This article challenges dogma: restrict-
ing normal, dietary caffeine consumption may not be fac-
tually based, and is clinically irrelevant in habitual coffee
drinkers. Larger clinical studies are required.
DOI: 10.1097/PRS.0000000000005854
Vikas Kotha, B.S.
Christovalantis Lakhiani, M.D.
Department of Plastic Surgery
Georgetown University Medical Center
Washington, D.C.
Dong Won Lee, M.D.
Department of Plastic and Reconstructive Surgery
and Institute for Human Tissue Restoration
Yonsei University College of Medicine
Seoul, Republic of Korea
Kenneth L. Fan, M.D.
David H. Song, M.D., M.B.A.
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Department of Plastic Surgery
Georgetown University Medical Center
Washington, D.C.
Correspondence to Dr. Song
Department of Plastic Surgery
Georgetown University Medical Center
3800 Reservoir Road NW 1PHC
Washington, D.C. 20007
drdavidsong@gmail.com
Instagram: @drdavidsong
Twitter: @drdavidsong
‍‍DISCLOSURE
Dr. Song receives royalties from Elsevier for Plastic Sur-
gery, 3rd and 4th Editions, and Biomet Microfixation for
Sternalock. The other authors have no financial disclosures,
commercial associations, or any other conditions posing a con-
flict of interest to report.
REFERENCES
1. Terai N, Spoerl E, Pillunat LE, Stodtmeister R. The effect of
caffeine on retinal vessel diameter in young healthy subjects.
Acta Ophthalmol. 2012;90:e524–e528.
2. Shaughness G, McKittrick J, Akelina Y, Strauch RJ. Caffeine
does not reduce blood flow following arterial anastomosis in
the rat. J Reconstr Microsurg. 2016;32:657–660.
3. Knight R, Pagkalos J, Timmons C, Jose R. Caffeine con-
sumption does not have an effect on digital microvascular
perfusion assessed by laser Doppler imaging on healthy vol-
unteers: A pilot study. J Hand Surg Eur Vol. 2015;40:412–415.
4. Umemura T, Ueda K, Nishioka K, et al. Effects of acute
administration of caffeine on vascular function. Am J Cardiol.
2006;98:1538–1541.
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5. Corti R, Binggeli C, Sudano I, et al. Coffee acutely increases
sympathetic nerve activity and blood pressure independently
of caffeine content: Role of habitual versus nonhabitual
drinking. Circulation 2002;106:2935–2940.
Greater Saphenous Vein-Patch Interposition to
Facilitate Flow-Sparing Microanastomosis of
Calcified Arteries in the Distal Lower Extremity
Sir:
C alcified atherosclerosis, affecting donor and/or
recipient vessels, is a known predictor of microvascu-
lar complications and flap loss following lower extremity
free tissue transfer.1 Among the mechanisms implicated
in this association, the tendency toward intimal separa-
tion during passage of transmural sutures and relative
loss of vascular compliance increase the risk of anasto-
motic failure due to thrombosis and pedicle kinking,
respectively.2 Although operative planning/recipient-
vessel selection should facilitate microanastomoses out-
side of calcified zones, avoidance of this situation is not
always possible and may be limited further by pedicle
length requirements and/or diffuse calcific disease.
Fig. 1. Intraoperative photograph depicting transposition and
inset of the greater saphenous vein patch into the calcified pos-
terior tibial artery of the left lower extremity. Proximal and distal
control of the recipient artery is obtained using vascular clamps,
with application of minimum occlusive pressure to avoid frac-
tures of the calcified arterial wall. In the setting of diffuse athero-
sclerosis, creation of a single-pass, slit arteriotomy is preferred
over other excisional techniques that impart mechanical crush
and/or delaminating stress on the intima. The lumen must be
carefully inspected for the presence of intimal flaps (arrow),
which require meticulous débridement and inside-to-outside
transmural fixation, during anastomosis, to prevent propaga-
tion of a false passage. To optimize flow through the patch, the
donor vein is beveled at a 30-degree angle and inset into the
arteriotomy, with the toe secured proximally, using tapered 9-0
nylon. Heel and sidewall sutures are left long and tied sequen-
tially to ensure precise placement of full-thickness bites under
direct visualization.
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Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Fig. 2. Flow-sparing anastomotic arrangement demonstrating
the flexible greater saphenous vein patch interposed between
the calcified lateral circumflex femoral donor and posterior tib-
ial recipient arteries. The two donor vena comitans are shown
coupled to the posterior tibial vein and the divided limb of
the greater saphenous vein, thereby permitting flap outflow
through both the deep and superficial venous systems, respec-
tively. Optimal geometric arrangement of the calcified arterial
pedicle is achieved without kinking or turbulence at the anas-
tomoses. GSV, greater saphenous vein; LCFA, lateral circumflex
femoral artery; PTA, posterior tibial artery; VC, vena comitans.
Incidentally, numerous technical modifications
have been described to improve the reliability of micro-
vascular anastomosis in this setting. These include (1)
circumferential excision of the arterial stump to reduce
shear stress on the vessel wall, (2) preservation of adven-
titia to control leaks along the rigid suture line, and (3)
use of an inside-to-outside microsuture technique to
ensure full-thickness intimal approximation.2 A unique
challenge arises, however, when end-to-side anastomosis
of calcified donor/recipient arteries is required to pre-
serve inflow in patients with compromised distal perfu-
sion. In this scenario, lack of vessel elasticity renders the
feasibility of anastomosis/arrangement of ideal pedicle
geometry nearly impossible. Although strategies that
incorporate T or Y flow-through grafts have been pro-
posed to eliminate end-to-side configurations between
calcified arterial limbs, these techniques often necessi-
tate distant donor-graft harvest and fail to address size
mismatch caused by global calcification and/or plaques
within the recipient vessel lumen.2
In our experience, flow-sparing microanastomo-
sis/optimal pedicle arrangement in the distal leg can
be reliably achieved through greater saphenous vein
patch interposition between the calcified donor/recipi-
ent arteries. The greater saphenous vein is easily identi-
fied in the same field by means of direct subcutaneous
undermining anterior/proximal to the medial malleo-
lus. Beveled division of the distal vein optimizes the lumi-
nal cross-section/angle needed to facilitate laminar flow
through the graft. Once recipient control is obtained,
a longitudinal arteriotomy—corresponding in length to
the diameter of the patch—is created using an angled