Arteriovenous fistulas for microvascular head and neck reconstruction

BACKGROUND:

In head and neck cancer patients, multiple surgeries and radiation can leave the neck depleted of recipient vessels appropriate for microvascular reconstruction. The creation of temporary arteriovenous fistulas using venous interposition for subsequent microvascular reconstruction has rarely been reported in the head and neck. The authors report the largest series of temporary arteriovenous loops for head and neck reconstruction in vessel-depleted necks.

METHODS:

The authors performed a case series of major head and neck reconstructions using temporary arteriovenous fistulas with a saphenous vein graft. A subclavian surgical approach was used. All reconstructions were performed at least two weeks after the creation of the initial fistula.

RESULTS:

The authors have performed nine reconstructive cases for malignancy using five different free flaps. The subclavian and transerve cervical arteries were used, and the subclavian, internal jugular and cephalic veins were used for microanastomosis. Two cases of flap hematoma and one case of venous pedicle compression were recorded. No cases of flap failure were reported.

CONCLUSIONS:

Reconstruction using temporary arteriovenous fistulas is a reliable technique that can be used in the vessel-depleted neck, with excellent outcomes in experienced hands.     

Vessel-depleted neck: techniques for achieving microvascular reconstruction

BACKGROUND: In the neck, the recipient vessels most frequently used for microsurgical reconstruction are compromised by prior surgery and radiation. METHODS: We conducted a retrospective chart review of all patients who underwent microvascular reconstruction between July 2001 and June 2005. Donor vessels, vein grafts, and flap survival were examined. RESULTS: Fourteen of 197 patients (7%) were identified with a vessel-depleted neck. All patients had undergone a prior neck dissection and radiation (100%) or chemoradiation (42%). Free flap revascularization was achieved using the transverse cervical artery with a vein graft and a cephalic vein (4 patients), thoracoacromial artery and cephalic vein (3 patients), internal mammary artery and vein (3 patients), and inferior thyroid artery and cephalic vein (1 case). In 3 patients, the reverse flow thoracodorsal artery and cephalic vein were used to vascularize the scapular flap. CONCLUSION: The cephalic vein, transverse cervical, internal mammary, and thoracoacromial vessels represent reliable alternatives in the vessel-depleted neck.     

Use of the internal mammary vessels as recipient vessels for an omental flap in head and neck reconstruction

The availability of reliable recipient vessels for free flap transfer in head and neck reconstruction may be limited in cases of prior neck dissection or radiation therapy. One solution is to use the internal mammary vessels as recipients for a free omental flap. Five patients were treated with free omental flap transfer using the internal mammary vessels as recipient vessels during head and neck reconstruction. Two patients presented with a pharyngocutaneous fistula, 1 had mandibular osteomyelitis, 1 had primary esophageal cancer, and 1 had bilateral cervical radiation ulcers. All patients had received radiation therapy previously (average dose, 75.4 Gy), and 4 had undergone neck dissection (3 bilateral and 1 ipsilateral). All patients were reconstructed using a free omental flap. Four patients had a second free flap combined with the free omental flap (3 free jejunal flaps and 1 free fibular osteocutaneous flap). The mean follow-up was 26.4 months. All free flaps took entirely, the only complication ileus requiring reoperation in 1 patient. The internal mammary vessels are reliable recipient vessels for a free omental flap in head and neck reconstruction. This procedure is a good option for patients in whom previous surgery or radiation therapy has compromised local recipient vessels.     

Microvascular surgery in the previously operated and irradiated neck

Microvascular reconstruction of head and neck defects can be extremely challenging in patients with a history of prior neck dissection and/or irradiation. We reviewed of 261 head and neck free flaps performed between 2004 and 2007 at a tertiary cancer center. One hundred twenty-four (52%) free flaps were performed in patients with a history of prior neck dissection and/or irradiation. The ipsilateral external carotid artery or one of its branches was not available in 43 (19%) cases: 13 with no history of prior neck dissection or irradiation, and 30 with a history of prior neck dissection and/or irradiation (P = 0.03). The ipsilateral internal/external jugular veins (IJ/EJ) were not available in 37 (16%) cases: 11 with no history of prior neck dissection or irradiation, and 26 with a history of prior neck dissection and/or irradiation (P = 0.002). Strategies for dealing with lack of a recipient vessels included anastomosis to contralateral neck vessels, transverse cervical vessels, internal mammary vessels, the cephalic vein, and the pedicle of another free flap. We propose an algorithm for locating recipient vessels adequate for microvascular anastomosis should the ipsilateral external carotid arterial and/or the internal/external jugular venous systems not be available, such as in the setting of prior neck dissection or irradiation.     

Head and neck reconstruction using cephalic vein transposition in the vessel‐depleted neck

In microvascular reconstructive surgery the patency of the recipient vessels is the key to successful outcome. In head and neck surgery there is often a lack of adequate recipient vessels as a result of chemoradiation therapy and ablative surgery. To overcome this it is crucial to identify vessels of adequate length and diameter outside the field of injury. We report our experience with cephalic vein transposition for drainage of seven free flaps—six intestinal and one osteocutaneous—for head and neck reconstruction. In five cases the cephalic vein was used during the free flap transfer and in two cases in salvage re‐exploration surgery. All flaps survived completely. The anatomical course and location of the cephalic vein allow good patency and straightforward harvesting. Its vascular properties are predictive of reduced incidence of complications such as flap congestion and failure. We suggest that the cephalic vein offers a high venous flow drainage system for large free flaps and advocate its use in free intestinal transfer in the vessel‐depleted neck as well as in re‐exploration surgery. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.     

Cephalic vein: Saviour in the microsurgical reconstruction of breast and head and neck cancers

Background:

Reconstruction with microvascular free flaps is considered the reconstructive option of choice in cancer of the head and neck regions and breast. Rarely, there is paucity of vessels, especially the veins, at the recipient site. The cephalic vein with its good caliber and constant anatomy is a reliable recipient vein available in such situations.

Materials and Methods:

It is a retrospective study from January 2010 to July 2012 and includes 26 patients in whom cephalic vein was used for free-flap reconstruction in head and neck (3 cases) and breast cancers (23 cases).

Results:

All flaps in which cephalic vein was used survived completely.

Conclusion:

Cephalic vein can be considered as a reliable source of venous drainage when there is a non-availability/unusable of veins during free-flap reconstruction in the head and neck region and breast and also when additional source of venous drainage is required in these cases.KEY WORDS: Breast reconstruction, cephalic vein, free flap, head and neck reconstruction     

Use of single saphenous interposition vein graft for primary arterial circuit and secondary recipient site in head and neck reconstruction: a case report

BACKGROUND: Autologous vein grafts are a valuable tool in microsurgical free tissue transfer. Interposition vein grafts offer the surgeon greater freedom when placing the free flap and choosing the recipient vessels, providing valuable options in case recipient vessels are not available for those patients with large wounds. Free flaps transferred to head and neck regions carry a higher risk of failure, which may be expected to increase more with the use of vein grafts. METHODS: We present our case with the double use of a single vein graft for both primary arterial conduit in end-to-end fashion and secondary end-to-side recipient site in the microsurgical reconstruction of a complicated head and neck defect. RESULTS: All these anastomoses and flaps survived perfectly, and the patient was discharged 14 days after the transfer of the second flap. CONCLUSION: Although the anastomosis of 2 flaps to a single vein graft was successful in our case, it represents a higher risk option than different recipient vessels. We provide this alternative procedure in selected patients, as there is no other receipt vessel or recipient blood flow strong enough to supply more than 1 flap.     

Muscle-sparing abdominal free flaps in head and neck reconstruction

BACKGROUND: Our aim in this retrospective case series was to review the indications, results, and complications of abdominal muscle-sparing free flaps in head and neck cancer reconstruction. METHODS: A retrospective review of all head and neck cancer defects reconstructed with abdominal muscle-sparing free tissue transfers from 1999 to 2004 was performed. Data collected included patient demographics, etiology and site of the defect, reconstructive technique, flap size, recipient vessels, complications, reconstructive technique, and clinical follow-up. RESULTS: Sixteen patients underwent reconstruction with the deep inferior epigastric perforator (DIEP) flap (n = 11), the superficial inferior epigastric artery (SIEA) flap (n = 4), or the superficial circumflex iliac artery (SCIA) flap (n = 1). Average age was 61 years (range, 41-77 years). The average hospital stay was 7.6 days (range, 6-14 days). The average defect size was 74.5 cm(2) (range, 30-240 cm(2)). No subsequent abdominal wall hernias or other donor site complications occurred after a mean follow-up of 21 months. CONCLUSIONS: Muscle-sparing abdominal free flaps are attractive options for head and neck cancer reconstruction. The SIEA and SCIA free flaps have the distinct advantage of eliminating abdominal hernias and other morbidity related to the excision of rectus abdominus fascia or muscle. In addition, the incisions are very low on the abdomen and are more cosmetically pleasing to the patient.     

The Pruitt-Inahara carotid shunt as an assisting tool to anastomose the arterial free flap pedicle to the internal carotid artery in the vessel-depleted neck

Microvascular free tissue transfer in head and neck reconstruction requires suitable recipient vessels which are frequently compromised by prior surgery or radiotherapy to the neck. This article details a new technique of arterial free flap pedicle anastomosis to the internal carotid artery in a vessel-depleted neck. A 63-year-old female was referred because of recurrence of squamous cell carcinoma of the tongue, which involved the left-sided tongue base and pharynx with circumferential involvement of the homolateral external carotid artery. This artery and its branches were excluded as potential recipients. To close the defect after tumor excision, a free vertical rectus abdominis muscle arterial flap pedicle was anastomosed to the homolateral internal carotid artery with the help of a Pruitt-Inahara outlying carotid shunt. The venous anastomosis was performed to the internal jugular vein. The VRAM flap survived without complications. This procedure is to be considered an alternative rescue technique for salvage reconstruction in vessel depleted necks.     

Posterolateral cervical vein as a recipient vein in reconstructive microvascular surgery of the head and neck

Free flaps are becoming the preferred method of choice for head and neck reconstruction. However, many patients who have undergone radiotherapy and radical neck dissection or who require treatment for recurrent tumor, often present difficulty in choosing recipient vessels. The authors have noted a potential recipient vein coursing vertically along the anterior ridge of the trapezius muscle. They used this vein as the recipient vein in two patients; the two free flaps were transferred successfully without complications. This vein, which they provisionally named the posterolateral cervical vein (PLCV), is considered an important option as a recipient vein in head and neck reconstruction when more commonly used recipient cervical veins are unavailable.     

Free flaps to the head and neck

Early attempts at microvascular reconstruction in the head and neck area with free tissue flaps failed, leading some authors to feel that these techniques would have a limited role, especially when such flaps had to be used in recipient sites in which they were in contact with saliva or when the microvascular anastomoses had to be done with recipient vessels that had been irradiated. Today, however, many aspects of neck and facial reconstruction routinely use composite free tissue transfer. These methods are the first choice for reconstruction in traumatic amputations and repair of large mandibular defects, and for some facial contour and skin loss situations. Free composite tissue transfer is an excellent alternative for esophageal reconstruction (small bowel) and has great potential for facial animation (free muscle) and total nose reconstruction (dorsalis pedis).     

Recipient vessel analysis for microvascular reconstruction of the head and neck

The selection of recipient vessels that are suitable for microvascular anastomosis in the head and neck region is one of many components that is essential for successful free tissue transfer. The purpose of this study was to evaluate a set of factors that are related to the recipient artery and vein and to determine how these factors influence flap survival. A retrospective review of 102 patients over a 5-year consecutive period was completed. Indications for microvascular reconstruction included tumor ablation (n = 76), trauma (n = 13), and chronic wounds or facial paralysis (n = 13). The most frequently used recipient artery and vein included the facial, superficial temporal, superior thyroid, carotid, and jugular. Various factors that were related to the recipient vessels were analyzed and included patient age, recipient artery and vein, diabetes mellitus, tobacco use, the timing of reconstruction, the method of anastomosis, previous radiation therapy, creation of an arteriovenous loop, and use of an interposition vein graft. Successful free tissue transfer was obtained in 97 of 102 flaps (95%). Flap failure was the result of venous thrombosis in 4 and arterial thrombosis in 1. Statistical analysis demonstrated that anastomotic failure was associated with an arteriovenous loop (2 of 5, P = 0.03) and tobacco use (3 of 5, P = 0.03). Flap failure was not related to patient age, choice of recipient vessel, diabetes mellitus, previous irradiation, the method of arterial or venous anastomosis, use of an interposition vein graft, or the timing of reconstruction.     

Musculocutaneous flaps in head and neck reconstruction.

The introduction of musculocutaneous flaps to head and neck reconstructive surgery is described. The flaps available are listed, and the most important ones described and illustrated. Both the latissimus dorsi and pectoralis major flaps are felt to have a role in head and neck reconstruction, though they have largely been superseded by microvascular free flaps such as the radial forearm flap.     

Intraoperative evaluation of blood flow in the internal mammary or thoracodorsal artery as a recipient vessel for a free TRAM flap

Although the free microvascular transverse rectus abdominis musculocutaneous (TRAM) flap is in routine use for breast reconstruction, little is known of its hemodynamics. The purpose of this study was to determine whether any differences exist when the free TRAM flap is anastomosed to the thoracodorsal or internal mammary vessels. The study comprised 25 patients receiving a free TRAM flap for breast reconstruction. The thoracodorsal vessels were used as recipients in 21 patients and the internal mammary vessels were used in 4 patients. Blood flow rate was measured directly in the donor and recipient arteries, and after anastomosis by a transit-time ultrasonic flowmeter (CardioMed). Two- and 3-mm probes were used. The blood flow rate in the donor artery (deep inferior epigastric) before flap dissection was 11 +/- 6 ml per minute (mean +/- standard deviation). The rate was significantly (p < 0.05) lower (5 +/- 3 ml per minute) in the recipient thoracodorsal artery than in the donor, but after transplantation it increased to 14 +/- 5 ml per minute (p < 0.05), attaining the same value as the donor artery. The blood flow rate in the intact internal mammary artery was significantly higher (25 +/- 10 ml per minute) than in the donor and thoracodorsal arteries, but after anastomosis it dropped to the same value (12 +/- 3 ml per minute; p < 0.05) as the donor artery. The intake of blood in TRAM flaps supplied by the intemal mammary artery seems to be no greater than that in free flaps anastomosed to thoracodorsal vessels, although the flow in the internal mammary artery was much higher. The authors concluded that the blood supply in a free TRAM flap is independent of the flow in the recipient artery and that thoracodorsal vessels, although often in a scarred bed and radiated, are as suitable for anastomosing a free TRAM flap as are internal mammary vessels.     

Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection

Microvascular free tissue transfer has gained world-wide acceptance as a means of reconstructing post-oncologic surgical defects in the head and neck region. Since 1977, the authors have introduced this reconstructive procedure to head and neck reconstruction after cancer ablation, and a total of 2372 free flaps were transferred in 2301 patients during a period of over 23 years. The most frequently used flap was the rectus abdominis flap (784 flaps: 33.1 percent), followed by the jejunum (644 flaps: 27.2 percent) and the forearm flap (384 flaps: 16.2 percent). In the reported series, total and partial flap necrosis accounted for 4.2 percent and 2.5 percent of cases, respectively. There was a significant statistical difference ( p < 0.05) in complete flap survival rate between immediate and secondary reconstruction cases. The authors believe that the above-mentioned three flaps have been a major part of the armamentarium for head and neck reconstruction because of a lower rate of flap necrosis, compared to other flaps.     

Selection of recipient vessels in microsurgical free tissue reconstruction of head and neck defects

The development of microsurgical techniques has facilitated proper management of extensive head and neck defects and deformities. Bone or soft tissue can be selected to permit reconstruction with functional and aesthetic results. However, for free tissue transfer to be successful, proper selection of recipient vessels is as essential as the many other factors that affect the final result. In this article selection strategies for recipient vessels for osteocutaneous free flaps, soft tissue free flaps, previously dissected and irradiated areas, recurrent and subsequent secondary reconstructions, simultaneous double free flap transfers in reconstruction of extensive composite head and neck defects, and the selection of recipient veins are reviewed in order to provide an algorithm for the selection of recipient vessels for head and neck reconstruction.     

Head and neck reconstruction: a review of 117 cases

The reconstruction of defects of the head and neck, no matter the cause, begins with a careful assessment of the patient and the defect. Ideally, it ends with the successful execution of the reconstructive procedure that optimally restores form and function with minimal morbidity. There are several treatment possibilities that differ in their indications, technical difficulty, safety, and incidence of complications. This is a review over a period of 13 years of 117 cases of head and neck reconstruction performed by the author. Sixty-eight patients were treated with five different musculocutaneous pedicled flaps, mainly during the first half of the 13-year period. Those based on the pectoral major and latissimus dorsi were the most frequently utilized, mainly in pharyngolaryngeal reconstructions and sometimes as osteomyocutaneous flaps for oromandibular defects. Forty-nine patients had microvascular reconstructive procedures with 12 different types of free flaps. The latissimus dorsi flap was used for reconstruction of the scalp and after excision of intracranial lesions, whereas the serratus anterior or rectus abdominis free flaps were utilized for reconstruction of complex defects of the middle-third of the face. The radial forearm flap and the free jejunum have become the choice for intraoral and pharyngoesophageal reconstruction, respectively. Good results were obtained in both functional and social rehabilitation of the patients. There were three flap losses due to thrombosis of the microvascular anastomosis. There was no surgical mortality. The indications for each pedicled and free flap are discussed. Received: 27 October 1999 / Accepted: 22 June 2000     

Microvascular histopathology in head and neck oncology.

A histological study of both recipient and flap vessels was performed in 30 patients with head and neck cancer, and relevant preoperative risk factors were assessed. A total of 35 free flaps were transferred in 30 patients; 16 patients had preoperative radiotherapy, 13 were smokers, eight had hypertension and six had peripheral vascular disease. No significant venous pathology was found in either the flap or the neck veins. However, over two-thirds of the neck arteries and one-half of the flap arteries were found to have microscopic arterial pathology. The only pre-existing factor significantly influencing vessel pathology was hypertension (P=0.007). All flaps survived, although in two there was some loss of the skin paddle. This study reveals that the majority of patients undergoing microsurgery in the head and neck region have pre-existing arterial damage in both the flap and the recipient arteries, but this does not have a significant effect on the overall patency of the microvascular anastomoses.     

Lateral thoracic artery as recipient vessel for head and neck free flap reconstruction in the vessel depleted neck: A case report

Vessel depleted necks present a challenge to identifying suitable recipient vessels for microvascular head and neck reconstruction. Many alternative recipient vessels have been described. The purpose of this report is to describe the feasibility of using the lateral thoracic artery as a recipient vessel for head and neck free flap reconstruction in vessel depleted necks. In this report we describe surgery for a 62 year old male with osteoradionecrosis of the right mandibular body in which we performed right segmental mandibulectomy with free fibular flap reconstruction in a vessel depleted neck. We used the lateral thoracic artery which was ~10 cm in length. It provided good reach to the neck, proper blood flow, and acceptable vessel diameter of ~1.5 mm at 6 cm above the clavicle. The patient had an uncomplicated postoperative course and the flap was viable and well healed at 2 months follow‐up. The lateral thoracic artery could be considered as one of the options for recipient vessels for microvascular reconstruction in patients with vessel depleted necks.     

Mandibular-facial reconstruction with segmentally split serratus anterior composite flaps

Oncologic or traumatic head and neck defects with missing mandible, facial skin, and oral mucosa are especially well suited to reconstruction with a composite tissue unit, based on the subscapular-thoracodorsal vessels, that carries any combination of skin, bone, and muscle to restore vascularized skeletal structures, oral lining, and skin cover. The subscapular-thoracodorsal vascular pedicles supply segmentally split units of the lower serratus muscle and ribs on which it originates. Also, one or two skin paddles for cover and lining flaps are carried either by the cutaneous scapular and parascapular branches of the circumflex scapular vessels or by surgically split segments of the latissimus dorsi musculocutaneous flap. The composite flap can be designed in a variety of combinations to meet recipient defect needs and allow retained innervated segments of the component muscles in situ for preservation of donor motor function. The common subscapular-thoracodorsal vascular pedicle can be transferred either as a microvascular free flap or by pedicle transposition through a subpectoral-subplatysmal tunnel to the mandibular-facial defect. This versatile reconstructive unit illustrates many of the refinements of contemporary flap reconstructions.