Internal thoracic vessels as recipient vessels for free flap reconstruction in head and neck surgery.

In rare cases the usage of the internal thoracic vessels as recipient vessels in reconstructive surgery of the head and neck region with free tissue transfer is a challenging but valid alternative if local recipient vessels are unusable.     

Rerouting the internal thoracic vessels as recipient vessels in head and neck reconstruction: Comparison of two anatomic approaches

IntroductionThe vessel-depleted neck situation is a challenge for the surgeon in search of suitable recipient vessels for microvascular reconstruction of the head and neck. The internal thoracic vessels (ITVs) have proven useful as “rescue” recipient vessel resource. The objective of this report is to assess the feasibility of using ITVs by rerouting the pedicle for free flap reconstruction of the head and neck by comparing two different approaches.Material and MethodsTwo surgical approaches were assessed: the classical one is parasternal, but cardiac surgeons commonly use median sternotomy. We conducted an anatomical study, comparing on the same subject the lengths and diameters of both internal thoracic artery (ITA) and internal thoracic vein (ITV) at the sixth, fifth, and fourth intercostal spaces (ICSs) through parasternal approach on one side and by median sternotomy on the other side.ResultsThe study was performed on 13 subjects. We found a superiority of length of the ITVs with the median sternotomy approach. Regarding the mean length of the ITA, the sternotomy approach allowed a significant greater length with 119/89/67 mm, compared with parasternal approach with 91/62/42 mm, respectively at the sixth, fifth, and fourth ICS (p<0.001). Similarly, we observed a significant greater length of the ITV with 116/85/63 mm versus 89/62/42 mm (p<0.001).The mean arterial and venous diameters were 2.9 mm and 2.1 mm in the sixth ICS, 3.3 mm and 2.3 mm in the fifth ICS, and 3.9 mm and 2.9 mm in the fourth ICS, respectively.ConclusionThese results help to guide the choice of surgical approach and the level of harvesting.     

The internal mammary artery and vein as recipient vessels for microvascular breast reconstruction

Current recipient vessels for microvascular breast reconstruction include the internal mammary and the thoracodorsal systems. This review will focus on the advantages of the internal mammary artery and vein and reasons for their preference.     

Free omental flap reconstruction of complicated head and neck wounds

Complicated wounds of the head and neck involve a severe deficiency of tissue in a contaminated or irradiated area that is predisposed to infection and necrosis. Reconstruction of these wound areas frequently requires multiple operations and prolonged hospitalization. We have successfully reconstructed complicated head and neck wounds in thirteen patients by means of a single-stage microvascular tissue transfer of the greater omentum with or without an attached segment of the stomach wall. There were 11 complete successes, two partial failures, and no complete failures. We describe four cases to illustrate the basic fundamentals of this reconstructive technique.     

胸廓内血管及其肋间穿支作为受区血管在游离皮瓣移植乳房再造中的临床应用

目的:研究胸廓内血管及其肋间穿支用作游离皮瓣乳房再造的受区血管的可能性及其应用。方法:新鲜成人女性尸体2具,自胸廓内动静脉起始处灌注乳胶颜料,观察胸廓内血管及其肋间穿支的基本走形、穿出点位置等。选择10例适合游离皮瓣乳房再造的乳腺癌患者开展胸廓内血管及其肋间穿支作为受区血管的临床手术研究,对患者的效果进行评估。结果:胸廓内血管走形稳定、血管直径较为理想,1~4肋间穿支直径达1mm以上,第3、4穿支较为粗大。10例乳房再造患者,随访6个月~1年,术后效果好,无严重并发症,无明显功能障碍,患者满意度高。结论:胸廓内血管及其肋间穿支是良好的游离皮瓣移植乳房再造的受区血管,解剖容易,不损伤重要组织,术后效果良好,值得进一步推广。     

Internal mammary artery perforator flap for head and neck reconstruction

Background: The internal mammary artery perforator (IMAP) flap is a useful modification of the classic deltopectoral flap that has a number of important roles in head and neck reconstruction. Methods and results: In this report, we describe the technique used to plan and raise the flap and demonstrate its use in three different clinical scenarios. Results and conclusions: The IMAP flap is a pedicled fasciocutaneous flap that is based on single or multiple internal mammary artery perforators. As such, it provides thin pliable tissue with a wide arc of rotation that is suitable for cutaneous, pharyngeal and tracheostomal reconstruction. Moreover, the flap is well‐vascularised, reliable and the donor site can be closed primarily.     

Autologous free tissue breast reconstruction using the internal mammary perforators as recipient vessels.

Perforator flaps have become popular for autologous free tissue breast reconstruction because they reduce the donor site morbidity. It is possible to apply the this principle to the recipient site.We present our experience of using the perforating vessels from the internal mammary artery and vein as recipient vessels for autologous free tissue breast reconstruction flaps in 21 out of 54 consecutive cases (39%). We discuss the technique and its advantages.     

Algorithm in choosing recipient vessels for perforator free flap in breast reconstruction: the role of the internal mammary perforators.

INTRODUCTION: Although the internal mammary (IM) vessels are our first choice as recipient vessels for free flap breast reconstruction, attempts to reduce surgical morbidity led us to adopt an algorithm when choosing recipient vessels. MATERIALS AND METHODS: The IM vessels give direct perforators to the breast. They can be found either superficial or deep to the pectoralis major muscle. If they are of a reasonable calibre they can be considered as recipient vessels. When the perforators are not suitable, the IM vessels are used for the microanastomosis. This protocol was adopted for our patients between June 1999 and December 2002. RESULTS: Breast reconstruction with free flaps was performed on 298 patients with perforator flaps. IM and thoracodorsal (TD) vessels are used in 88% and 3% of cases, respectively. IM perforators were successfully used in 30 cases (9%). The IM perforators used were located at the level of the second and third intercostal space in nine (30%) and 21 (70%) cases, respectively. The average diameters of those perforators were 1 mm (0.5-1.3 mm) for the artery and 1.7 mm (1-3 mm) for the vein. CONCLUSIONS: The IM perforators can be used as recipient vessels for free flaps. This spares the IM vessels for eventual cardiac bypass surgery, avoiding recipient site morbidity and decreasing the postoperative discomfort.     

Use of internal mammary vessel perforator as a recipient vessel for free TRAM breast reconstruction

Breast reconstruction is a cosmetically critical procedure for women and it must be undertaken to balance the shape, size, and position of the breast with the other breast. Since the first introduction of the free abdominoplasty flap in 1979, the transverse rectus abdominis musculocutaneous (TRAM) flap technique has been a widely accepted method of breast reconstruction after mastectomy. In breast reconstruction with a free flap, the selection of suitable recipient vessels is the critical decision to be made by the surgeon. The most common recipient vessel for free flap breast reconstruction is the axillary system. However, when used as a recipient, the axillary system may limit flap movement and flexibility in breast shaping. The use of the internal mammary vessels as a recipient site attains ideal breast symmetry. However, the technique requires partial rib resection and eliminates the opportunity for a potential coronary artery bypass graft, which requires the internal mammary artery. Based on these considerations, the selection of suitable recipient vessels constitutes an important requirement for successful free tissue transfer. The authors have performed breast reconstruction with the TRAM flap anastomosed to the internal mammary perforator vessel and conclude that these perforators could be useful as recipient vessels, especially in the case of immediate breast reconstruction with the free TRAM flap.     

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.     

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.     

Free flaps for head and neck cancer reconstruction: Does the use of both large cervical vessels as recipient vessels and the employment of end-to-side technique enhance flap survival?

This study specifically investigates whether the use of both large cervical vessels (the external carotid artery and the internal jugular vein) as recipient vessels with end-to-side anastomosis enhance free flap survival in head and neck cancer reconstruction, when compared with the use of other standard smaller neck recipient vessels and end-to-end anastomosis. A total of 84 consecutive patients were included and were divided into two groups (42 in each group) according to the recipient vessels. The overall vessel thrombosis rate was 6% (five of 84 cases) and the overall flap loss rate was 2.4% (two of 84 cases) yielding a flap salvage rate of 60%. Vessel thrombosis occurred in three cases of the smaller vessels group and in two cases of the large cervical vessels group. This was not statistically significant.     

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.     

Sternocleidomastoid myofascial flap for head and neck reconstruction

Background. The use of the sternocleidomastoid (SCM) muscle in the repair of soft tissue defects arising after surgery for neoplasms of the head and neck has been a subject of controversy. We describe a variant of the SCM muscle flap called the “SCM myofascial flap” and report our experience with this flap in head and neck reconstruction. Methods. Six patients underwent head and neck reconstruction with the SCM myofascial flap. The head and neck defects included partial laryngeal, pharyngeal defects, and concave soft tissue neck defects after resection. Results. Follow-up of the patients ranged from 6 to 91 months. In the case of laryngeal and pharyngeal reconstruction, all had a good voice and were able to eat by mouth without aspiration. Two of the four patients were decannulated. The only complication was a laryngocutaneous fistula. Conclusion. We have used this flap with success, in soft tissue augmentation and in laryngeal and pharyngeal reconstruction following tumor resection. The technique and the results of our experience are discussed. We believe that in selected cases, the SCM myofascial flap is ideal for reconstruction of head and neck defects. © 1994 John Wiley & Sons, Inc.