The indications and reliability of vein graft use in free flap transfer

BACKGROUND:

Adequate recipient vessels are critical for free flap success. There are, however, situations in which the local recipient vessels are inadequate. In these situations, vein grafts are required to allow pedicle extension to recipient vessels.

OBJECTIVES:

To determine the indications, technique, reliability and outcome of vein graft use in free flap transfer.

METHODS:

A retrospective review of 198 consecutive free flaps by a single surgeon.

RESULTS:

Vein grafts were required in 9.6% of free flaps. The most common indication was vein graft use in a planned preoperative fashion. The vein graft was most commony placed as an arteriovenous fistula loop. There was no statistically significant difference in survival between flaps with or without vein grafts.

CONCLUSION:

Vein graft use in free flap transfer is reliable, effective and often necessary for free flap survival.     

Internal mammary artery and vein: recipient vessels for free tissue transfer to the head and neck in the vessel-depleted neck

BACKGROUND: Microvascular free tissue transfer is a standard reconstructive option for postablative defects of the head and neck. However, the success of this surgery requires suitable recipient vessels in the cervical region. This form of reconstruction can be particularly challenging in the vessel-depleted neck. While the internal mammary artery and vein (IMA/V) have been used extensively in breast reconstruction, there are few reports describing their use in head and neck reconstruction. We report the first case series of the use of the internal mammary vessels for head and neck microvascular reconstruction. METHODS: We reviewed 5 cases of free tissue transfers to the head and neck in which extensive prior treatment precluded the use of more traditional recipient vessels in the neck or upper chest. RESULTS: A variety of free flaps were transferred for different reconstructive problems which included: chin/lower lip (n = 2), closure of widely patent tracheoesophageal puncture sites (n = 2), and pharyngoesophageal reconstruction following staged repair of a severe stenosis (n = 1). The radial forearm free flap was transferred in 4 patients and the rectus abdominus free flap in 1 patient. The IMA/V on the right side was prepared in all cases. All free flaps were successfully revascularized without the need for vein grafts and without the need for any microvascular revision procedures. CONCLUSION: The internal mammary artery and vein provide reliable, easily accessible recipient vessels for microvascular reconstruction in the vessel-depleted neck. The selection of free flap donor sites with long donor vessels facilitates the microvascular repair.     

Utility of arteriovenous loops before free tissue transfer for post-traumatic leg defects

Crush injuries of severe magnitude involving lower limbs require complex bone and soft tissue reconstructions in the form of microvascular free tissue transfers. However, satisfactory recipient vessels are often unavailable in the leg due to their vulnerability to trauma and post traumatic vessel disease (PTVD), which extends well beyond the site of original injury. In such situations, healthy recipient vessels for free flap anastomosis can be made available by constructing temporary arteriovenous loops with saphenous vein grafts, anastomosed to corresponding free flap vessels. Our study included 7 patients with severe crush injuries of leg due to rail and road traffic accidents. Long and short saphenous vein grafts were anastomosed to Femoral artery in the subsartorial canal in 2 cases and to large muscular branches and accompanying veins in rest of the cases. Free flap transfers were performed in the same sitting in 6 cases. One case showed insufficient dilatation of the vein loop and hence free flap transfer was staged. Free Latissimus dorsi, Gracilis and Rectus abdominis flaps were performed. There were two cases of flap necrosis – one in the case of a pathologic vein graft with staged flap transfer which showed vein thrombosis on re exploration. The other case of flap failure was caused by a hematoma underneath the flap. In another patient, secondary haemorrhage occurred on day 18, without any consequence to the flap. All the other cases had complete free flap survival. We consider the use of single stage arteriovenous loops, a valuable tool to increase the applications of free flap, whenever healthy recipient vessels are not available in the periphery of the trauma.KEY WORDS: Arteriovenous loops, staged free flaps, vein grafts     

Anterolateral thigh flap pedicle for interposition artery and vein grafts in head and neck reconstruction: a case report

The selection of receiving vessels is one of the most critical steps in ensuring a successful outcome in microvascular surgery. The use of interposition grafts in microsurgery offers the surgeon valuable options when the free flaps vascular pedicles are too short to be anastomosed directly to the recipient vessels. Here, we present a case in which artery and vein grafts were used in microsurgical reconstruction of an anterior maxillary defect with an iliac free flap. As donor vessels, we used the descending branch of the lateral circumflex femoral artery and one of the two venae commitantes. The flap survived without major or minor complications. The anterolateral thigh flap pedicle allowed us to harvest safe, reliable grafts easily, with a suitable vessel length and diameter.     

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.     

Factors predicting free flap complications in head and neck reconstruction.

In this retrospective study, all free flap transfers used for reconstruction following ablation of head and neck tumors in University Medical Centre Ljubljana between the years 1989 and 1999 were analysed. The data taken from the patients' charts covered the demographic profile, the tumor and free flap details (44 variables for each patient). Logistic regression model was used to identify factors associated with free flap failure and complications. One hundred and sixty-two patients with head and neck tumors underwent microsurgical reconstruction. One hundred and ninety-four free flaps were performed with an overall success rate of 85%. Two significant predictors of free flap complication were identified: diabetes and salvage free flap transfer. Patients with diabetes were five times more likely to develop complications associated with free flaps (p = 0.02). Free flap complications were four times more likely to develop after salvage free flap transfer (p = 0.04). In addition, two significant factors predicting free flap failure were identified: salvage free flap transfer (p = 0.019) and use of interposition vein grafts (p = 0.032). After this study we changed our strategy of free flap selection and preoperative evaluation of the patients with head and neck tumors requiring free tissue transfer. Between January 2000 and January 2005 we performed additional 105 free flaps for head and neck reconstruction after tumor resection in 101 patients and our success rate improved to 94.3%.     

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.     

Microsurgical free flap in head and neck reconstruction

Microsurgical free flaps are today considered state of the art in head and neck reconstruction after composite tumor resections. Free flaps provide superior functional and aesthetic restoration with less donor‐site morbidity. This article details our approach to this challenging and complex procedure. Free tissue transfer can be viewed as consisting of 4 essential stages: (1) defect assessment, (2) preparation of recipient vessels, (3) flap selection and harvest, and (4) flap inset and microsurgical anastomoses. The essential details of each step are highlighted. Meticulous attention to each step is important because each plays a crucial role in the overall success of the procedure. Workhorse flaps in our practice are the anterolateral thigh, radial forearm, fibula, and jejunum flaps. Unique issues related to postoperative care and monitoring of head and neck free flaps are discussed. The management of complications, in particular those threatening flap survival, are reviewed in detail. © 2009 Wiley Periodicals, Inc. Head Neck, 2010     

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.     

Flow-through anterolateral thigh flap for a free osteocutaneous fibula flap in secondary composite mandible reconstruction.

Head and neck reconstruction after tumour ablation and radiotherapy often requires complex surgery. The need for free composite tissue transfer and the poor quality of the recipient site increase the level of difficulty substantially. We report a case in which the mandible, floor of the mouth and skin of the neck needed to be reconstructed in a heavily irradiated field. A single osteocutaneous fibula flap was insufficient to reconstruct the defect, and a free anterolateral thigh (ALT) flap was also used for external neck skin resurfacing. As the recipient vessels in the ipsilateral neck had been heavily irradiated the free ALT flap was used as an interposition conduit for the free osteocutaneous fibula flap enabling it to reach the healthy recipient vessels in the contralateral neck without needing vein grafts.     

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.     

Head and neck reconstruction with a second free flap following resection of a recurrent malignancy

A retrospective analysis of 12 patients with a head and neck tumor recurrence within a previous free flap treated with extirpation and a second free flap is reported. A 15-year experience at Mayo Clinic, Rochester, from 1988 to 2003 of 12 patients (5 men, 7 women) who underwent 25 free flaps is reviewed. The overall flap survival rate was 92%, with a 100% survival rate in the first free-tissue transfer and 85% survival rate in the second free-tissue transfer. There was 1 minor complication (8%) and there were 2 major complications (15%) among the second free flaps. Overall, 10 of 13 (77%) second free flaps were anastomosed to ipsilateral neck vessels. Moreover, in 5 of 13 cases (38%) the same artery and in 7 of 13 cases (54%) the same vein were used for both the first and second free flaps. Reconstruction of the head and neck with a second free flap in patients with a recurrent tumor is safe and effective. The original recipient vessels can often be used for the second reconstruction.     

头颈部组织缺损显微外科重建的临床效果

目的介绍头颈部组织缺损的显微外科重建技术及其临床应用效果。方法选用血管蒂较长和血管口径较粗的游离组织瓣供区，选择口径粗大和位置合适的受区血管，将游离瓣制备成外露瓣，以利于术后血供的监测，在手术放大镜下行血管吻合，部分病例同时吻合2根静脉，以确保游离瓣的静脉回流。结果施行1007例共1066块游离组织瓣移植修复头颈部组织缺损，临床成功率为98．3％，术后血管危象的发生率为3．1％，抢救成功率为45．5％。结论应用显微外科技术施行游离组织瓣移植重建头颈部组织缺损，可获得良好的临床效果。     

Recipient vessels for microsurgical flaps to the groin and pelvis: a review

Reconstruction of large defects of the pelvis and groin sometimes requires microsurgical flaps when the otherwise rich supply of local options fails to be sufficient in difficult and complicated cases. Recipient vessels for microsurgical flaps to the groin and pelvis are important elements in planning such procedures. Seven groups have reported pelvis and groin microsurgical flap cases, and their recipient vessels have included the superior and inferior gluteal vessels, the femoral vessels, the deep perforators of the femoral system, the inferior epigastric vessels, intra-abdominal vessels, and interpositional vein grafts to distant recipient vessels. This review summarizes their experience and describes the recipient vessel options in the pelvic and groin region.     

Repair of a wide lower extremity defect with cross-leg free transfer of latissimus dorsi and serratus anterior combined flap: a case report

Composite tissue loss in extremities involving neurovascular structures has been a major challenge for reconstructive surgeons. Reconstruction of large defects can only be achieved with microsurgical procedures. The success of free flap operations depends on the presence of healthy recipient vessels. In cases with no suitable donor artery and vein or in which even the use of vein grafts would not be feasible, the lower limb can be salvaged with a cross-leg free flap procedure. We present a case with a large composite tissue loss that was reconstructed with cross-leg free transfer of a combined latissimus dorsi and serratus anterior muscle flap. This case indicates that this large muscle flap can survive with the cross-leg free flap method and this technique may be a viable alternative for large lower extremity defects that have no reliable recipient artery.     

Free transfer of latissimus dorsi myocutaneous flap using wrist vessels as carriers for the treatment of Lumbo-Sacral Scar Contracture Deformity

Summary After excision of extensive post infection back scarring, there were no local flaps and no satisfactory recipient vessels for closure of the defect. A latissimus dorsi free flap was carried on the radial artery and cephalic vein and used to effect the reconstruction. The pedicle was divided at four weeks. The back deformity was corrected completely. By means of microsurgical techniques, free transfer of the latissimus dorsi myocutaneous flap is commonly used to repair a large soft tissue defect following excision of scar contracture deformity [1]. This was a problem in one of our cases where no vessels were available for anastomosis in the recipient site, and thus wrist vessels were used as carriers to revascularize the flap with success.     

Superiority of end-to-side anastomosis with the internal jugular vein: the experience of 80 cases in head and neck microsurgical reconstruction.

The authors report their experience with 80 head and neck reconstructions using free-tissue transfer in which end-to-side anastomosis with the internal jugular vein was carried out. An end-to-side anastomosis with the internal jugular vein has the following advantages. Firstly, the technique overcomes the problems of vessel size discrepancy. It is effectively applied for free jejunal transfer or combined flap transfer based on a single vascular pedicle, of which the size of the proximal end of the drainage vein is very large. Secondly, the internal jugular vein has wide capacity to be the recipient of two or more end-to-side anastomoses. It is effectively used for free radial forearm or rectus abdominis myocutaneous flaps in which two or more drainage veins can be included. Thirdly, the respiratory venous pump effect may act directly on the venous drainage of the transferred flap through the internal jugular vein. In our institution, these advantages have made it the technique of choice in head and neck reconstructive microsurgery.     

Vein conduit for end-to-side anastomosis of a calcified vessel in lower extremity free flap reconstruction

BackgroundAs the microsurgical and interventional revascularization techniques are evolving, traditionally amputated limbs are now challenged to salvage. However, a calcified recipient vessel is a common but challenging problem encountered in lower extremity reconstruction.MethodsAn end-to-side anastomosis of a vein graft (1.5–3.5 cm in length) was performed to the recipient vessel when it was difficult to clamp the recipient vessel near the defect because of the inelastic and hard vessel wall. The vascular clamp was applied to the vein graft, and the flap's pedicle was anastomosed to the vein graft.ResultsA total of 18 free flaps (10 ALT cases, 4 TDAP cases, 2 PAP cases, and 2 SCIP cases) were anastomosed with a bridge vein graft to the heavily calcified recipient vessels (7 ATA cases, 3 PTA cases, 7 DPA cases, and 1 MPA case). Overall flap survival rate was 83.3%. Limb salvage rate was 93.7%, and anastomosis patency rate was 94.4%ConclusionVein conduit in an end-to-side anastomosis of severely calcified recipient vessels shows a reasonable limb salvage rate. It acts as a buffer, which makes microscopic vessel manipulation easier. If vessel calcification is the only drawback for a free flap reconstruction, then a vein graft needs to be prepared instead of an amputation. This method may extend the surgical option to more high-risk patients in lower extremity microsurgical reconstruction and increase the limb salvage rate.     

Free-tissue transfer in plastic surgery (emergencies excluded). Apropos of a 10-year experience]

Over a period of ten years the authors have performed 176 elective free tissue transfers. Flaps used were 99 latissimus dorsi, 46 chinese forearm flaps, 12 fibula, 6 toes, 5 omentum, 4 parascapular, and 4 others flaps. Recipient sites were lower limbs in 106 cases, head and neck in 50 cases, forearm and hand in 13 cases, thorax, abdomen, and buttocks in 7 cases. The overall failure rate was 5.7 per cent. Analysis of these failures taught us some original principles. Among these principles, the risk of vascular thrombosis is very important when a venous graft is performed on one end of the artery of a low blood flow flap such as chinese forearm or fibular flaps when the other end of this artery is ligated. When such a graft is done we think that the best way to avoid thrombosis is to suture the other end of the flap artery to a recipient vessel which can be even the distal end of the flap vein itself. Pretransfer expansion of a latissimus dorsi flap was successfully performed in 4 cases. Migrating semi-free flap method, in which the vascular pedicle of a flap is temporarily sutured to recipient vessels located far from the defect, was performed in 12 cases, in most cases on lower limbs where this method constitutes a modern variant of the cross-leg. Folded free-flap method, in which a flap is folded on itself during some days before excision of the recipient site, was performed in 14 cases. Analysis of this series also allowed us to review in detail our usual strategic principles for vascular anastomoses in the head and lower limbs.