Microvascular Flap Reconstruction of the Head and Neck

Spontaneous sensory recovery in non-innervated radial forearm flaps used for head and neck reconstruction

Although several studies have reported the use of reinnervated microvascular free flaps for oro-pharyngeal reconstruction, it has been known for some time that non-innervated flaps demonstrate spontaneous sensory recovery. This study sought to evaluate the degree of such spontaneous recovery in 50 radial forearm flaps used for mucosal reconstruction of head and neck ablative defects. The recovery of sensation to pinprick, light touch and temperature was tested a mean of 38 months (range 15-71) after surgical insetting. Two-point discrimination was also sought. Although 18 flaps (36%) remained anaesthetic, partial recovery in one or more modalities was present in 28 patients (56%). A recovery in all modalities of sensation in at least two-thirds of the flap area was recorded in 4 patients (8%). The mean 2-point static discrimination for fascio-cutaneous flaps was 18.9mm.

Effects of vinblastine on healing in microvascular anastomosis

Reconstructive microsurgical procedures are getting more common in cancer patients. Adjuvant therapies, such as chemotherapy, radiotherapy, and immune therapy, are usually combined with surgical approaches to improve outcomes. This study was designed to investigate the effects of preoperative chemotherapy on healing in microvascular anastomosis. As a commonly preferred drug for neoadjuvant cancer treatment, vinblastine was used on rats in our study. Ninety-three Sprague-Dawley rats were used and randomly allocated into two groups as 72 experimental and 21 control rats. Vinblastine 2 mg/kg was administered as a single dose intraperitoneally on day 0 in the experimental group. Leukocytes and erythrocytes were counted on days 0, 1, 3, 5, 7, 10, and 15 in 6 rats of the experimental and 6 rats of the control group. We found that the neutropenia period ended on approximately day 7. After applying the medication, the experimental group (n = 72) was divided into three main groups (n = 24). We performed end-to-end femoral artery anastomosis on days 7 or 14 or 21, respectively, in each group. Each main group was divided into three subgroups (n = 8), and then we tested patency and took biopsies on days 7 or 14 or 21, respectively, in each subgroup. Histopathologic evaluation was carried out. The comparison of patency tests and pathologic examination indicated that there was no statistically significant difference between the two groups.

Free flaps for head and neck reconstruction in non-oncological patients: experience of 200 cases

Two hundred free flaps for reconstructing the head and neck regions in 192 patients with non-oncological pathology were studied. Pathological entities included Romberg's disease, hemifacial microsomia, acquired facial palsy, trauma, and burn sequelae. Indications for selecting a specific free flap for reconstructing each case, details of anastomoses, reexploration, flap success, operative time, length of hospitalization, and complications were studied. The long-term results of cosmetic and function were also obtained. Patient age ranged from 6 to 40 years. The most common diagnosis was Romberg's disease 39% (n = 75), followed by hemifacial microsomia 20% (n = 40). The free flap most frequently used was the scapular 32% (n = 64), followed by the groin free flap 21% (n = 42). A total of 190 flaps (95%) were successful, whereas only 10 (5%) were lost. The mean operative time was 5:30 h and the average hospital stay was only 6 days. There were no major complications and no deaths in the study group. The patients were followed for at least 1 year in all cases. It is concluded that free flaps are safe and reliable procedures for reconstructing complex head and neck non-oncological defects.

Complications after microsurgical tissue transfer in the head and neck region

In recent years, the use of microsurgically re-anastomosed free transplants has become a proven technique for the reconstruction of defects in the head and neck region, which is demanding from both aesthetic and functional points of view. A retrospective catamnestic study on 227 free tissue transfers in the Department for Oral and Maxillofacial Surgery at the University of Tübingen showed good healing with relatively low failure rates of the transplants used. A significant proportion of local complications, arising postoperatively, was to some degree due to pre-existing medical conditions, tumour-specific pretreatments and the particular wound-healing situation found in head and neck interventions. The highest relative rate of complications at the site of origin was seen amongst osteomuscular transplants (20%) whilst (fascio) cutaneous and visceral transplants were found to result in a low percentage of problems (4%). In contrast, the healing of iliac crest transplants was accompanied by various local complications in 12% of the cases, slightly higher than 20% amongst (fascio) cutaneous and abdominal transplants and well above 30% for latissimusdorsi and scapular transplants. General complications, in particular of a respiratory and/or psychiatric nature, were found in 23% of the patients.

Internal jugular vein thrombosis following modified neck dissection: implications for head and neck flap reconstruction

BACKGROUND

The incidence of internal jugular vein thrombosis (IJVT) following a modified neck dissection remains uncertain. The effect of, or consequences following, IJVT upon pedicled and free flap head and neck reconstructions remains unexplored.

METHODS

Twenty-nine preserved internal jugular veins in 24 patients undergoing modified neck dissection were available for prospective study. All patients required a pedicled or free flap reconstruction and received a modified, unilateral or bilateral cervical lymphadenectomy. The patency of all jugular veins was determined preoperatively and postoperatively using a combination of computed tomography (CT) scanning, high-resolution ultrasound, and color-flow Doppler (CFD).

RESULTS

The IJVT rate was 14%. The presence of a pedicled myocutaneous flap and left-sided jugular dissections may represent risks to the postoperative patency of the internal jugular vein. Preoperative radiotherapy did not appear to impact negatively upon the thrombosis rate.

CONCLUSIONS

Thrombosis of the internal jugular vein may result in significant morbidity for the postoperative oncologic patient. An internal jugular-dependent-free-tissue transfer may risk venous compromise of the flap, whereas the use of a pedicled flap may place the jugular at increased risk for thrombosis. Strategies for deep venous system microvascular recipient recruitment in the head and neck are discussed. Wherever possible, we employ two deep venous systems, the internal jugular, and subclavian (via the external jugular) for flap drainage.

Recovery of sensation in the radial forearm free flap in oral reconstruction

The purpose of this study was to find out to what extent sensory function recovers in a free radial forearm flap used for intraoral reconstruction after surgery for oral cancer. In 40 free radial forearm flaps we investigated the perception of light touch, two-point discrimination, pain, directional sensation, and temperature between 6 months and 11 years after flap transfer to the oral cavity. Four flaps (10 percent) were anesthetic, 21 flaps (52.5 percent) recovered partly, and 15 flaps (37.5 percent) had perception of all sensory modalities tested in at least two-thirds of the flap area. All patients with positive sensation in the surrounding area subsequently had good sensory recovery in the flap. This suggests that recovery of sensation in a nonreinnervated free flap is due to nerve ingrowth from the surrounding mucosa. The present results suggest that sensory function in intraoral free radial forearm flaps returns again. Further study is necessary to define the use of neurofasciocutaneous radial forearm flaps in reconstruction of the oral cavity.

Complications in head and neck microsurgery

Microvascular surgery plays a vital role in head and neck reconstruction. This paper deals with the complications arising from this form of surgery. They can be classified as general complications, anastomotic problems, and specific problems related to particular donor and recipient sites.

Dual free flap transfer using forearm flap for mandibular reconstruction

To reconstruct a composite mandibular defect, we have simultaneously transferred a vascularized bone graft or osteocutaneous flap together with a forearm flap. The radial forearm flap, being thin, pliable, and having a long vascular stalk, served as mucosal lining and/or an interpositional flap acting as a vascular bridge. Between 1982 and 1989, we used this procedure in 17 patients with a mandibular defect or deformity which developed following treatment of oral cancer. Our clinical experience has demonstrated that this dual free tissue transfer has many advantages. It is useful for obtaining a good alveolar ridge in patients with a composite mandibular defect. It is applicable in cases where only a single pair of recipient vessels are present and may be useful when the recipient vessels are positioned some distance from the defect.

Irradiation and free tissue transfer in head and neck cancer

The aim of this study was to analyze the effects of surgery, irradiation, and free tissue transfer in locally advanced head and neck cancer patients. Forty-one patients with head and neck cancer were treated with surgery, irradiation, and free tissue transfer for reconstruction from 1977 to 1987. The age range was 38 to 78 years with a median age of 61. Patients were staged using the AJCC (1978) staging system. Eighty-four percent of the patients were in stage III or IV. The common sites of primary tumors were the oral cavity (22) and oropharynx (10). Forty patients had squamous cell carcinoma and 1 patient had basal cell carcinoma. Six patients had preoperative irradiation, and the rest had postoperative irradiation. The most common surgical procedures were partial glossectomy and neck dissection (17 patients) and wide excision of the primary and neck dissection (17 patients). The most common types of free tissue transfer were dorsalis pedis (13 patients) and scapular flaps (6 patients). The primary site was controlled in 22 patients (54%) and the neck in 36 patients (88%). Three patients (7.3%) had flap failure which required further surgical management. Eighteen patients are living with no evidence of disease with a median follow-up of 18 months (5-101 months), 10 patients are living with disease with a median follow-up of 9 months (3-40 months), 9 patients are dead of disease with a median survival of 13 months (6-54 months), and 4 patients are lost for follow-up. This study shows that free tissue transfer before or after irradiation is of benefit with few complications.

Mandibular reconstruction with composite microvascular tissue transfer

Microvascular free tissue transfer has provided a variety of methods of restoring vascularized bone and soft tissue to difficult defects created by tumor resection and trauma. Over 7 years, 26 patients have undergone 28 free flaps for mandibular reconstruction, 15 for primary squamous cell carcinoma of the floor of the mouth or tongue, 7 for recurrent tumor, and 6 for other reasons [lymphangioma (1), infection (1), gunshot wound (1), and osteoradionecrosis (3)]. Primary reconstruction was performed in 19 cases and secondary in 9. All repairs were composite flaps including 12 scapula, 5 radial forearm, 3 fibula, 2 serratus, and 6 deep circumflex iliac artery. Mandibular defects included the symphysis alone (7), symphysis and body (5), symphysis-body-ramus condyle (2), body or ramus (13), and bilateral body (1). Fourteen patients had received prior radiotherapy to adjuvant or curative doses. Eight received postoperative radiotherapy. All patients had initially successful vascularized reconstruction by clinical examination (28) and positive radionuclide scan (22 of 22). Bony stability was achieved in 25 of 26 patients and oral continence in 24 of 26. One complete flap loss occurred at 14 days. Complications of some degree developed in 22 patients including partial skin necrosis (3), orocutaneous fistula (3), plate exposure (1), donor site infection (3), fracture of reconstruction (1), and fracture of the radius (1). Microvascular transfer of bone and soft tissue allows a reliable reconstruction--despite previous radiotherapy, infection, foreign body, or surgery--in almost every situation in which mandible and soft tissue are absent. Bony union, a healed wound, and reasonable function and appearance are likely despite early fistula, skin loss, or metal plate or bone exposure.

Comparison of latissimus dorsi and rectus abdominis free flaps

This review of 41 latissimus dorsi and 7 rectus abdominis free flaps describes the advantages and disadvantages of these two donor tissues. Flap survival was over 95%. Rectus abdominis carries the greatest area of skin of all the free flaps and makes salvaging of extremities with massive soft tissue loss possible, and it also provides the most elegant small free muscle flap. The latissimus dorsi is suitable for nearly any defect of the body except the foot and the hand because of bulkiness of the tissue and poor development of sensation, and the face because of poor colour match.

Reconstructive surgery in the treatment of intraoral cancer

Patients with intraoral cancer present to various specialties. A series of 63 patients shows the importance of modern reconstructive surgery for patients treated by tumor excision. The reasons why a variety of techniques must be available to the patient are discussed. The advantages and disadvantages of some of these methods of reconstruction are reviewed.

The regeneration of adrenergic nerves in a free microvascular groin flap in the rat

The regeneration of adrenergic nerves in free microvascular groin flaps in the rat was investigated. The adrenergic nerves were revealed with glyoxylic acid-induced fluorescence and with formaldehyde-induced fluorescence methods. In the control specimens taken from the contralateral groin, adrenergic nerves were seen in the erector pili muscles and as networks around arteries and arterioles. In the free flap four weeks postoperatively, a few regenerating adrenergic nerves were observed at the margins under the flap and following the pedicle. Eight weeks postoperatively many tiny regenerating nerves were observed to invade the flap at the margins and under it. Many regenerating nerves were observed to reinnervate the artery and vein, forming a nerve plexus in the pedicle. The number of single nerve fibres invading the flap at the margins decreased sixteen weeks postoperatively, but more nerves were observed along arterioles in the flap and pedicle. Twenty-four weeks postoperatively some regenerating adrenergic nerves were observed around arteries and arterioles in different areas in the flap and in erector pili muscles. A rich network of nerves remained around the pedicle. However, the reinnervation of the vasculature of the flap remained patchy and inadequate, and many arteries and arterioles remained without innervation.

The effects of radiation therapy in microvascular anastomoses

The otolaryngologist, as a head and neck surgeon, commonly cares for patients with upper aerodigestive tract malignancies. Therapy of these neoplasms often requires wide excision. One standard reconstructive procedure utilizes pedicled regional flaps, both dermal and myodermal which have some disadvantages. The shortcomings of these pedicled regional flaps have led to the use of the vascularized free flap in certain cases. The occasional case may lead to catastrophe if microanastomoses fail when combined with radiation. Notwithstanding, many surgical series have reported success when radiation has been given. The present investigation was undertaken to assess the effects of radiation therapy on microvascular anastomoses when radiation is administered pre- or postoperatively or when nonradiated tissue is transferred to an irradiated recipient site. These effects were observed serially in an experimental rat model using a tubed superficial epigastric flap that adequately reflected tissue viability and vascular patency. The histologic changes were then noted over a three month period after completion of both radiation and surgery. This study adds credence to the observation of the lack of deleterious effects of radiation on experimental microvascular anastomotic patency whether the radiation is given before or after surgery or if radiated tissue is approximated to nonradiated vessels.