Usefulness of a first transferred free flap vascular pedicle for secondary microvascular reconstruction in the head and neck

The thoracoacromial axis in salvage head and neck reconstructive surgery, a case series

We present the surgical technique, relevant anatomy and a consecutive case series of salvage head and neck free flap reconstructions utilising the thoracoacromial axis. We demonstrated that the thoracoacromial axis is safe and reliable in salvage head and neck reconstruction with particular use in reconstruction of tracheoespophageal and pharyngolaryngectomy fistulae.

Feasibility and Safety of Microvascular Anastomoses Within Previously-Dissected Neck Regions

The selection of appropriate recipient vessels is important for the success of head and neck reconstruction. Vessels located outside of previously-dissected neck regions tend to be more frequently selected due to relative ease of preparation. However, some advantages are offered regarding dead space filling and formation by using vascular anastomoses within regions previously dissected, or reusing former free flap pedicle due to their proximity to the defect. We analyzed microsurgical anastomoses in patients requiring oral reconstruction who had previously undergone neck dissection. Contralateral vascular anastomoses were preoperatively planned in 10 cases of which 9 could be successfully performed (achievement rate, 90%). Ipsilateral side anastomoses were planned in 28 cases, with 26 anastomosed as planned (achievement rate, 92.9%). There was no statistically significant difference between the two groups. Vascular anastomosis within the scar region can be performed safely, based on preoperative planning and intraoperative judgment.

Head and Neck Reconstruction of the Vessel-Depleted Neck: A Systematic Review of the Literature

BACKGROUND

Damage of the vascular system secondary to radical neck dissection and/or radiotherapy or other treatments has a negative impact on microsurgical reconstruction. The search for adequate recipient vessels is hindered by the complexity of previous procedures.

METHODS

A systematic review of microsurgical head and neck reconstruction in the vessel-depleted neck was performed. The issues analyzed were indications for surgery, more frequently performed flaps, vascular systems used as recipient vessels, outcomes, and complications.

RESULTS

The eligibility criteria were fulfilled by 57 studies published between September 1993 and January 2020. In 8235 patients, 8694 flaps were performed, 925 of which were for a vessel-depleted neck. The most commonly used flap was the anterolateral thigh flap, used in 195 cases (30%), followed by the radial forearm free flap, used in 157 cases (24%). The potential recipient vessels were numerous for arteries (26 options) and veins (31 options). For the 712 flaps with an identifiable recipient artery, the superficial temporal artery was the most commonly used vessel (n = 142, 20%). The superficial temporal vein was the most commonly used vessel for 639 flaps with an identifiable recipient vein (n = 118, 18.5%). Complications amounted to 11%; 80 out of 716 flaps in papers that reported them. Flap losses were reported in 2% of cases.

CONCLUSIONS

Major microsurgical head and neck reconstruction for postoncologic defects depends on appropriate recipient vessels. Vein availability is paramount. Understanding the complexity of this problem is useful for preoperative planning, precise decision-making, and an accurate surgical approach.

Sequential reconstruction for recurrent head and neck cancer: A 10-year experience

Background

Most patients with head and neck cancer successfully undergo oncologic resection followed by free or local flap reconstruction, depending on the tumor’s size and location. Despite effective curative resection and reconstruction, head and neck cancer patients still face a high risk of recurrence and the possibility of a second primary cancer. Moreover, surgeons hesitate to perform sequential reconstruction following curative resection for several reasons. Few large-scale studies on this subject are available. Therefore, we retrospectively evaluated the outcome of sequential head and neck reconstruction to determine the possible risks.

Methods

In total, 467 patients underwent head and neck reconstruction following cancer resection at our center from 2008 to 2017. Of these cases, we retrospectively reviewed the demographic and clinical features of 58 who had sequential head and neck reconstruction following resection of recurrent cancer.

Results

Our study included 43 males (74.1%) and 15 females (25.9%). The mean age at the initial operation was 55.4±15.3 years, while the mean age at the most recent operation was 59.0±14.3 years. The interval between the first and second operations was 49.2±62.4 months. Twelve patients (20.7%) underwent surgery on the tongue, and 12 (20.7%) had procedures on the oropharynx. Thirty-four patients (58.6%) received a sequential free flap reconstruction, and 24 patients (41.4%) were treated using locoregional flaps. No cases of flap failure occurred.

Conclusions

Our findings suggest that patients who need additional operations with recurrent head and neck cancer could optimally benefit from sequential curative resections and reconstructions.

Transverse cervical vascular pedicle: It's extended use as 'second-line' recipient vessels in thoracic and upper arm reconstructions in addition to head-and-neck reconstructions

Background:

Selection of recipient vessels is one of the key factors for a successful microvascular reconstruction. Non-availability of primary recipient vessels in the vicinity necessitates surgeon to approach a remote second-line vascular access. Transverse cervical vessels (TCV) have been described as second-line vascular access for head-and-neck reconstructions. Due to its location, their use can be extended to the proximal chest and upper arm reconstructions.

Aim:

The aim of the study is to analyse the reliability of TCV as second-line recipient vessels for the upper arm and chest reconstructions in addition to the head-and-neck reconstructions.

Materials and Methods:

During 2010–2017, 14 TCV were explored as the choice of second-line recipient pedicle for specific indications. Clinical experience with different reconstructions discussed.

Results:

Out of 14 transverse cervical arteries, 13 were of adequate size for anastomosis. About 12 successful reconstructions were performed involving the head and neck (7), proximal thorax (3) and upper arm (2) for indications such as scarring from different aetiology (8), previous free flaps (2) and sacrificed vessels (2). In one case, the arterial anastomosis was shifted to superior thyroid artery. All the chest and upper arm reconstructions needed a realignment of the pedicle without any kink. Transverse cervical vein (TCv) could be used only 5/14 times either alone or along with external jugular vein (EJV). In other cases, EJV alone was used. All the 12 flaps survived without any vascular event.

Conclusions:

Transverse cervical vessels are reliable second-line recipient vessels in the head and neck; in addition, they are of use in the upper arm and proximal chest defects.

Feasibility and Outcomes of the Third or More Episodes of Sequential Microvascular Reconstruction for Recurrent or Second Primary Oral Cancer

BACKGROUND

This study was a robust examination of the clinical outcomes and technical feasibility of sequential microvascular reconstruction for recurrent or second primary oral cancer.

METHODS

A retrospective, cross-sectional analysis of adult patients undergoing microvascular reconstruction of head and neck oncologic defects was performed at Chang Gung Memorial Hospital, spanning 10 years. The patients were divided into three groups as follows: first episode, second episode, and third or more episodes of reconstruction. Demographics, operative details, and clinical outcomes were compared.

RESULTS

The study cohort included 3186, 319, and 62 patients who respectively received first, second, and third or more episodes of reconstruction. The most common tumor sites were the tongue (36.9 %) and the buccal region (36.8 %), with squamous cell carcinoma as the prevalent histology. The anterior lateral thigh was the most popular donor site used (76.1 %). The third or more episodes of microvascular reconstruction were associated with an increased incidence of flap failure (8.1 %) relative to the first (1.9 %; p = 0.003) and the second (1.6 %; p = 0.01) episodes. Re-exploration of venous occlusion (9.7 vs. 3.2 %), neck wound infections (53.2 vs. 35.5 %), fistula (17.7 vs. 8.1 %), and hospital stay (28.9 ± 14.6 vs. 25.3 ± 10.1) also showed significantly higher values for the third or more episodes group than for the first episode group.

CONCLUSIONS

Sequential microvascular reconstruction for recurrent or second primary oral cancer is associated with an increased incidence of postoperative complications. However, in appropriate candidates for repeat ablation, microvascular reconstruction remains the gold standard for attaining functional and cosmetic outcomes.

Invasive basal cell carcinoma in a xeroderma pigmentosum patient: facing secondary and tertiary aggressive recurrences

Xeroderma pigmentosum (XP) is characterized by photohypersensitivity of sun-exposed tissues and several thousand-fold increased risk of developing malignant neoplasms of the skin and eyes. Inherited molecular defects in nucleotide excision repair genes cause the autosomal recessive condition XP. A 56-year-old woman with XP presented with an extensive multirecurrence basal cell carcinoma in the left naso-orbital region. At the time of the first visit, the patient had already received several interventions with local reconstructive techniques, a full course of radiotherapy, and bilateral neck dissection. A large tumor resection and free flap reconstruction were performed. Three years 9 months afterward, an aggressive recurrence occurred, and a second resection was needed. A new free flap was transferred, and microvascular anastomoses were done to the pedicle of the previously transferred flap. Nine months later, the patient returned with frontal bone tumoral lesions, and third microsurgical intervention was done. At that time, the reconstruction was practiced by a composite chimeric flap with a rib portion. Its pedicle was anastomosed to the one of the second free flaps. The objective of this article was to report the authors' experience concerning a unique case of XP requiring a complex reconstruction of the anterior skull base. Xeroderma pigmentosum patients need an early diagnosis and removal of cutaneous tumor lesions as some of them behave aggressively, especially those affecting the face. Free flaps are good solutions for reconstruction and should proceed from non-sun-exposed areas of the body. If reconstructed areas are highly radiated and/or skin tumors affect deep anatomical areas, complications are frequent.

New Refinements in Greater Omentum Free Flap Transfer for Severe Secondary Lymphedema Surgical Treatment

Lymphedema is a chronic debilitating disease, affecting a considerable part of the population; it results from impairment of the lymphatic system. It is highly prevalent among patients subjected to axillary and groin nodal dissection after surgery for breast cancer, abdominopelvic surgery, and lymphadenectomy after melanoma surgery. Interestingly, among the surgical treatment options for lymphedema, groin lymph node transfer is gaining popularity; however, in some cases, dissection at this site can cause significant morbidity, including possible development of iatrogenic lymphedema. To avoid these complications, new donor nodal groups are being proposed (eg, submental or supraclavicular). We have used the greater omentum as a lymph node and lymph vessel donor site. Dissection of the omentum is easy to perform and can even be done in patients who have undergone previous abdominal surgeries. We present refinements in the surgical technique for free omentum transfer in the management of secondary lymphedema: the first free omental flap dissection performed laparoscopically and the use of a primary flap as the recipient pedicle of a free greater omentum flap for anatomical repair after chest osteoradionecrosis and simultaneous functional repair of chronic lymphedema.

Transverse cervical vessels as recipient vessels in oral and maxillofacial microsurgical reconstruction after former operations with or without radiotherapy

Background

The purpose of this study was to investigate the reliability and outcome of using the transverse cervical vessel (TCV) as a recipient vessel for microvascular reconstruction in patients whose vessels in the neck region are unavailable because of previous surgery or radiotherapy.

Methods

Between January 2012 and August 2014, secondary head and neck reconstruction was performed using the TCV as a recipient vessel in eight patients who had undergone previous neck dissection and radiation therapy (n = 5). Five patients had a recurrent carcinoma, one had undergone an operation for scar release and two had been treated surgically for a second primary cancer. The anterolateral thigh flap (ALT), anteromedial thigh flap (AMT), and fibular flap were used for the reconstruction. Clinical data were recorded for each patient.

Results

All of the ipsilateral transverse cervical arteries were found to be free of disease. The second free flap was revascularized using the TCVs (n = 6) or the external (n = 1) or internal (n = 1) jugular vein. The free flaps used for the reconstruction included the ALT flap (n = 6), AMT flap (n = 2), and fibular flap (n = 1). All of the flaps survived without vascular events, and the patients healed without major complications. The mean follow-up time was 11 months. One patient died of distant metastases during follow-up.

Conclusions

In patients who have previously undergone neck surgery with or without radiotherapy, the TCVs are reliable and easily accessible recipient vessels for microsurgical reconstruction in the oral and maxillofacial region. If the transverse cervical vein is unavailable, the internal or external jugular vein should be dissected carefully to serve as an alternative for microvascular anastomoses.

The thoracoacromial trunk: alternative recipient vessels in reoperative head and neck reconstructive microsurgery

BACKGROUND

Reoperative free tissue transfer in head and neck cancer patients is often a challenging endeavor. Finding adequate recipient vessels for microvascular anastomosis can be difficult, as scar is present from previous surgery and irradiation, and the usual recipient vessels may have been damaged or sacrificed.

METHODS

Seventeen consecutive cases of head and neck reconstruction with free tissue transfer using the thoracoacromial vessels as the recipient pedicle were reviewed. Clinical data were analyzed, including indication for surgery, preoperative radiation dose, previous pectoralis major myofascial flap, free flap design, operative technique, perioperative complications, and follow-up.

RESULTS

Of the 17 cases of free tissue transfer using thoracoacromial vessels for anastomosis, 13 flaps were performed in 12 patients who had received double irradiation. Twelve thoracoacromial trunks used as recipient vessels were in patients with transferred pectoral myofascial flaps. Anastomotic patency was achieved in all flaps.

CONCLUSIONS

The thoracoacromial trunk is a good alternative for recipient vessels in reoperative reconstructive microsurgery of the head and neck when first-line vessels are not available. This choice of vessels is feasible whether or not a pectoralis myofascial flap has previously been used.

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.

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 stress analysis

PURPOSE OF THE STUDY

To develop a finite element model (FEM) to study the effect of the stress and strain, in microvascular anastomoses that result from the geometrical mismatch of anastomosed vessels.

MATERIAL AND METHODS

FEMs of end-to-end and end-to-side anastomoses were constructed. Simulations were made using finite element software (NISA). We investigated the angle of inset in the end-to-side anastomosis and the discrepancy in the size of the opening in the vessel between the host and recipient vessels. The FEMs were used to predict principal and shear stress and strain at the position of each node.

RESULTS

Two types of vascular deformation were predicted during different simulations: longitudinal distortion, and rotational distortion. Stress values ranged from 151.1 to 282.4MPa for the maximum principal stress, from -122.9 to -432.2MPa for the minimum principal stress, and from 122.1 to 333.1MPa for the maximum shear stress. The highest values were recorded when there was a 50% mismatch in the diameter of the vessels at the site of the end-to-end anastomosis.

CONCLUSION

The effect of the vessel's size discrepancy on the blood flow and deformation was remarkable in the end-to-end anastomosis. End-to-side anastomosis was superior to end-to-end anastomosis. FEM is a powerful tool to study vascular deformation, as it predicts deformation and biomechanical processes at sites where physical measurements are likely to remain impossible in living humans.

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.

Scalp and Forehead Reconstruction

The reconstruction of defects that involve the scalp and forehead presents unique aesthetic and functional challenges. This article reviews the surgical anatomy of these regions and presents an algorithm for decision making in reconstructive surgery. Nonmicrosurgical techniques are briefly reviewed. The microsurgical reconstruction of scalp and forehead defects differs from the more common oropharyngeal reconstructions in several ways, including flap choices, choices for recipient vessels, and the opportunity to use conventional and microsurgical techniques simultaneously to improve outcomes. Each of these considerations is reviewed and the authors' preferred techniques presented.

Success of Multiple, Sequential, Free Tissue Transfers to the Head and Neck

INTRODUCTION

Free tissue transfer has become the primary reconstructive modality for significant ablative defects in the head and neck. The overall success rate is high, approaching 95% in most centers. The success rate of multiple sequential free flaps has been thought to be lower, based on the absence of optimal vessel availability and the presence of significant scar tissue in the previously operated patient. We evaluated a series of patients who underwent multiple free flaps at different time points to determine the overall success rate and to identify pitfalls encountered in this population.

METHODS

Retrospective review, tertiary care medical center.

RESULTS

From 1995 to 2002, 377 free flaps were performed by our reconstructive service. Of this group, 36 underwent multiple free flaps at different time points. Thirty-two had two flaps, and four had three flaps. Reasons for performing sequential free flap procedures were as follows: recurrent disease/new primary (18), need for further augmentation (10), failed previous flap (6), delayed mandibular reconstruction after plate fracture (2), mandibular osteoradionecrosis (3), and delayed pharyngoesophageal stenosis (1). The overall failure rate on the second and third flap was 2 of 32 and 0 of 4, respectively, with an overall success rate of 94%.

CONCLUSION

Multiple, sequential, free tissue transfer for reconstruction of head and neck defects is a safe and reliable procedure with success rates equal to that in patients undergoing initial free flap reconstruction. Careful preoperative planning can result in optimal outcomes even in this difficult patient population.

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.