Recipient Vessel Analysis for Microvascular Reconstruction of the Head and Neck

Risk Factors for Free Flap Outcomes: A Retrospective Study of 318 Free Flaps for Head and Neck Defect Reconstruction

ObjectivesThis study was conducted to identify the risk factors for free flap outcomes in head and neck reconstruction.MethodsA retrospective review of 318 free flaps were used for head and neck reconstructions in 317 patients over seven years. The patient characteristics, surgical data, and flap outcomes were recorded. The impact of risk factors related on the outcomes of free flaps were analyzed using single and multivariate analysis.ResultsFor single factor analysis, 295 free flaps for the first reconstruction were included. Hypertension and the type of recipient vein are associated with venous thrombosis (P = .018, P = .047). Hypertension, type of free flap, recipient artery, and recipient vein were associated with the incidence of re-exploration (P = .009, P = .011, P = .017, P = .021). Hypertension had an obvious effect on the flap survival (P = .005). For multivariate analysis, hypertension (odds ratio = .166, 95% confidence interval: .043 - .636; P = .009) was a statistically significant risk factor for flap survival. For types of recipient artery and vein, selecting two venous anastomosis (one of IJVS and one of EJVS) had the minimum incidence of venous thrombosis (2.2%), and selecting facial artery, single vein (one of IJVS), and two veins (one of IJVS and one of EJVS) for anastomosis had lower incidence of re-exploration, which were 4.4%, 2.9%, and 6.0%, respectively (P < .05).ConclusionsRisk factors as hypertension, type of free flap, recipient artery and vein should be paid more attention in the free flaps for head and neck reconstructions. We believe proper measures will lead to better results in head and neck reconstruction.

Microvascular Coupling in Venous Anastomoses for Head and Neck Reconstruction: A Systematic Review and Meta-analysis

OBJECTIVE

We conducted a systematic review and meta-analysis to compare venous couplers and hand-sewn techniques for venous anastomosis in head and neck reconstruction.

DATA SOURCES

PubMed/MEDLINE and Scopus, databases were searched for relevant publications. Additionally, a manual search was performed in Google Scholar and through reference lists.

REVIEW METHODS

Retrospective and prospective cohort studies were included. Odds ratios (ORs) and mean differences (MD) were calculated with their 95% confidence intervals (CIs) for each study comparing the 2 groups (coupler vs hand). The inverse variance method was used to combine the effect sizes from the individual studies.

RESULTS

A total of 14,053 patients undergoing 14,270 head and neck free flap reconstructions were included from 52 studies. A total of 6080 flaps were performed using a coupling device for the venous anastomoses, while 8190 flaps were performed with the hand-sewn technique. No significant difference was found for the venous thrombosis rate (OR: 1.06, 95% CI: 0.65-1.72), and reoperation rate (OR: 0.93, 95% CI: 0.51-1.70), but a significantly lower failure rate was measured for the coupler group (OR = 0.34, 95% CI: 0.20-0.58). A nonsignificant lower operative time was found for venous anastomoses (MD: -20.5, 95% CI: -51.7 to 10.7) and total surgery (MD: -23.7, 95% CI: -344.3 to 296.8) for the coupler group.

CONCLUSION

Despite the slight advantages observed with venous couplers, the overall outcomes of both techniques are excellent, and the choice of anastomotic technique should be guided by surgeon preference.

Jejunal artery and vein positioning in free jejunal transfer: Surgical considerations and clinical implications

BACKGROUND

Previous computed tomography studies have reported that the superior mesenteric artery is often located ventrally to the superior mesenteric vein; however, the precise location of the peripheral jejunal arteriovenous system is unknown. This study investigated the arteriovenous positioning of the free jejunal flaps during reconstructive surgery.

METHODS

This retrospective cohort study included 78 patients who underwent free jejunal flap reconstruction between June 2021 and May 2023. The positions of the jejunal artery and vein were classified into 6 patterns (A-F) based on the photographs taken during the flap harvest. Statistical analysis was performed to examine the location of the artery (ventral vs. dorsal) and its orientation along the oral-anal axis in relation to the vein.

RESULTS

The jejunal arteries were most commonly located on the oral and ventral sides of the vein (type A, 48.6%) when the mesentery of the jejunal flap is positioned toward the front, with the left and right sides corresponding to the oral and anorectal sides, respectively. Notably, 62.1% of the arteries were located on the oral side and 71.6% on the ventral side. The recipient arteries used for vascular anastomosis were predominantly the superior thyroid artery (44.6%) and transverse cervical artery (50.0%), while the internal jugular vein (85.1%) was the most commonly used vein.

CONCLUSION

The position of the jejunal arteriovenous system is important for optimizing anastomotic techniques and ensuring safe surgical outcomes. Understanding vascular anatomy patterns can help prevent vessel misplacement and allow for more reliable and accurate anastomosis procedures.

Effects of Neoadjuvant Radiation and Recipient Vessel Characteristics on Microvascular Complication Rates in Reconstruction of Lower Extremity Soft Tissue Sarcoma Defects

BACKGROUND

 The treatment approach for soft tissue sarcomas (STS) of the lower extremity has shifted toward the use of neoadjuvant radiation combined with limb-sparing surgery (LSS). The resulting defects often require reconstruction with free tissue transfer for adequate outcomes. Data have demonstrated a potentially increased risk of microvascular complications for free flaps performed using irradiated recipient vessels. Similarly, certain anatomic areas of the lower extremity have a high proportion of unnamed perforators that are available as recipient vessels, increasing the technical difficulty. We aimed to determine if the characteristics of recipient vessels that were used for the reconstruction of STS defects influenced rates of microvascular complications in our patients.

METHODS

 A retrospective chart review of all patients who underwent reconstruction of lower extremity STS defects with free tissue transfer from 2009 to 2020 was conducted. Data regarding recipient vessel type (axial vessel vs. unnamed perforator), radiation status of the recipient vessels (irradiated vs. non-irradiated), and microvascular complications were compared across groups.

RESULTS

 A total of 204 free flaps were included. The overall microvascular complication rate was 13.7% (28 cases). Most microvascular complications were detected postoperatively (82.1%) rather than intraoperatively, with the majority involving venous congestion/thrombosis (20 cases, 71.4%). While there was a trend toward increased microvascular complications with the use of irradiated recipient vessels (27 cases, 96.4%), this did not reach statistical significance (OR = 1.98, p = 0.52). The use of perforating branches as recipient vessels did not confer an increased risk of microvascular complications (OR = 0.87, p = 0.75).

CONCLUSION

 The reconstruction of irradiated lower-extremity STS defects represents a particularly challenging issue. This analysis demonstrates that free tissue transfer can be safely performed using irradiated vessels without a significantly increased risk of microvascular complications. Furthermore, unnamed perforating branches can be successfully used for reconstruction in anatomically challenging areas of the lower extremity.

Postoperative Morbidity Outcomes Associated With Superficial Temporal Versus Cervical Vessels as Recipient Vessels in Head and Neck Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

The purpose of this meta-analysis was to compare the surgical outcomes of head and neck reconstruction via free flap surgery, with neck vessels versus superficial temporal vessels as recipient vessels.

METHODS

The PubMed, Embase, and Scopus databases were systematically searched via the following keywords: ("superficial temporal" OR "temporal") AND ("free flap" OR "free tissue transfer") AND ("head and neck" OR "face"). The following data were extracted: first author, publication year, flap type, reconstruction region, concordant vein graft, recipient vessel, and postoperative complications, including thrombosis, partial necrosis, and flap failure. The recipient vessels were divided into two groups: the superficial temporal artery (STA)/V group and the neck group.

RESULTS

Six hundred and thirty-five studies that met the inclusion criteria were included and reviewed systematically for a meta-analysis. Compared with the neck vessel group, the STA/V vessel group had a significantly greater risk of flap failure (odds ratio: 2.18; 95% CI: 1.32-3.60; p = 0.002), with low heterogeneity (p = 0.84; I2 = 0%). However, there were no significant differences in the rates of thrombosis or partial necrosis.

CONCLUSIONS

Compared with the use of neck vessels, the use of STA/V vessels as recipient vessels for head and neck reconstruction could increase the risk of total flap necrosis. Considering these findings, surgeons should exercise caution when selecting the STV as the recipient site, and as some authors have suggested, proximal dissection may be necessary during surgery.

Determination of Quality Indicators for Microvascular Grafts in Cranio-Maxillofacial Surgery-A Retrospective Analysis of 251 Free Flaps

BACKGROUND

The use of microvascular grafts is the gold standard in oral and maxillofacial surgery for the reconstruction of soft tissue and bony and combined defects. Graft loss is one of the most serious complications in the field of reconstructive surgery. A comprehensive analysis of factors influencing this is, therefore, essential.

METHODS

This hypothesis-generating study analyzed 251 patient cases of oral and maxillofacial surgery at the University Hospital Düsseldorf from 2016 to 2020 regarding patient- and therapy-specific parameters for their impact on graft survival.

RESULTS

Statistically significant influencing factors were found among the 80 parameters examined: treatment with antiplatelet medication and a BMI ≥ 24.5 at the time of surgery had a positive influence on graft survival, while existing diabetes mellitus, atrial fibrillation, tracheostomy, and a longer operation time had a statistically relevant negative influence.

CONCLUSIONS

This work demonstrates the relevance of patient-specific risk stratification and the need for further research to develop a valid risk profile. Identifying high-risk patients with medium-sized defects, where alternatives to microvascular reconstruction are available, appears to be crucial for the clinical outcome.

Comparisons of Impact of Vein Grafting with Different Indications on Outcomes of Reconstruction with Free Flaps

BACKGROUND

 Prior studies have shown an increased risk of complications and flap loss with the use of vein grafts in microsurgery. We hypothesize that indication for use of a vein graft can affect flap complications and loss rates.

METHODS

 We performed a retrospective review of all patients at our institution from 2010 to 2020 who underwent free flap reconstruction and required use of a vein graft. Indications for vein grafting included: salvage of flap during primary operation after microvascular compromise, augmentation of flow during primary operation, lengthening of the flap pedicle during the primary operation, and salvage of the flap during a secondary salvage operation after microvascular compromise.

RESULTS

 A total of 79 patients met the study inclusion criteria. There were significant differences among the vein graft indication groups and the following: area of reconstruction (p = 0.002), vein graft length (p = 0.018), vessels grafted (p = 0.001), vein graft donor site (p = 0.011), and total flap loss (p = 0.047). Of the four indications for vein grafting, salvage of the flap during secondary salvage operation after microvascular compromise had the highest rate of total flap loss (26.7%). There were no significant associations between other flap complications and vein graft indications.

CONCLUSION

 Vein graft use in the primary reconstructive setting is efficacious, with low risk of thrombosis. Use in secondary procedures, however, is associated with higher rates of total flap loss, likely due to the thrombotic process, which was initiated prior to the use of the graft resulting in the salvage procedure and not secondary to the graft itself.

Flap loss in head and neck reconstruction: Is there a singular cause for failure?

Despite the high success rates reported in head and neck reconstruction, free flap failures continue to persist. Understanding the factors associated with flap loss and improving overall success are paramount. This study aimed to comprehensively assess the factors influencing flap revision and free tissue transfer survival in head and neck reconstruction. The study included 70 patients with defects in the lower two-thirds of the head and neck region and underwent reconstruction using free flaps. Patient age, gender, smoking status, comorbidities and data on the location and aetiology of the defect, the specific type of flap employed, the recipient artery and vein chosen, instances of revision and the overall success of the flap were collected. The investigation aimed to establish correlations between these variables as well as flap success and revision rates. No statistically significant differences were observed in arterial and venous anastomosis revision rates, or flap survival, in relation to variables such as age, gender, flap type, smoking status, comorbidities, recipient artery or vein and the number of vein anastomoses. The malignant tumour group exhibited a lower requirement for arterial revision and a higher flap survival rate compared to the benign tumour group. This study underscores the comparable safety profiles of perforator-based and conventional flaps in head and neck reconstruction. Furthermore, it reveals that patient characteristics are not contraindications for free tissue transfer. Additionally, the quantity of the veins and choice of recipient vessels are flexible and do not significantly impact flap success. The higher rates of flap success in patients with malignant aetiology requires further investigation.

Transverse Cervical Artery for Head and Neck Reconstruction with Free Jejunal Flaps: A Retrospective Study of Computed Tomography Angiography

BACKGROUND

 The transverse cervical artery is less commonly used than other external carotid arteries as a recipient vessel. Therefore, we aimed to compare the utility of the transverse cervical artery as a recipient vessel with that of the external carotid artery system for microvascular head and neck reconstruction by quantitative analysis of dynamic-enhanced computed tomography.

METHODS

 Fifty-one consecutive patients who underwent free jejunum transfer following total pharyngolaryngectomy between January 2017 and December 2020 were retrospectively reviewed. Ninety-four pairs of the diameters of the transverse cervical artery, superior thyroid artery, and lingual artery, measured via computed tomography angiography, were analyzed. Operative outcomes were compared between the following groups based on the recipient artery: transverse cervical artery (n = 27), superior thyroid artery (n = 17), and other artery (n = 7) groups.

RESULTS

 In the analysis of the computed tomography angiography, nine transverse cervical arteries (9.6%) could not be identified. However, the percentage was significantly lower than the percentage of superior thyroid arteries (20.2%) and lingual arteries (18.1%) (p < 0.01). Among the identified vessels, the transverse cervical arteries (2.09 ± 0.41 mm) and the lingual arteries (1.97 ± 0.40 mm) were significantly larger than the superior thyroid arteries (1.70 ± 0.36 mm) in diameter at the commonly used level (p < 0.01). Multivariate analysis revealed that prior radiation therapy was not an independent factor significantly affecting transverse cervical artery diameter (p = 0.17). Intraoperative anastomotic revision was required in only two cases of the superior thyroid artery.

CONCLUSION

 The transverse cervical artery can offer a larger caliber and more reliable candidate than the superior thyroid artery for a recipient artery. More liberal use of the transverse cervical artery may improve the safety of microsurgical head and neck reconstruction.

Anatomical variations of the superior thyroid artery: A systematic review

BACKGROUND

The superior thyroid artery (STA) is one of the main arteries that provide blood supply to the thyroid gland. It has a plethora of anatomical variations, and knowledge of its anatomy is necessary in procedures in this area. The aim of this review is to summarize and describe human studies (cadaveric and angiographic) that investigate the anatomical variations related to the STA.

MATERIAL AND METHODS

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. A literature search in PubMed, and Embase databases was carried out. Original studies that investigated the origin of the STA and reported data on the variant arterial anatomy were considered, including only cadaveric and angiographic studies.

RESULTS

A total of 34 studies (4048 heminecks in total; heminecks in each study: min: 25-max: 1280) were finally included. All studies provide details about sex [men/women ratio median (IQR): 2(1-5)] but none about age and 10 (29%) about nationality. STA morphological characteristics described in the included studies are origin, length, number of branches, distance from the carotid bifurcation and the vessel's diameter.

CONCLUSIONS

The STA's anatomical features are subject to a non-negligible degree of variability. Our results should improve the awareness of anatomical variations of the STA, and eventually have an impact on the interventions regarding the visceral compartment of the neck in clinical practice.

Head and Neck Reconstruction With 2-Stage External Pectoralis Major Myocutaneous Flap Transfer

BACKGROUND

In head and neck surgery cases where skin is severely scarred or adhered to surrounding tissue, reconstruction can be difficult to perform using microsurgical tissue or conventional pedicled pectoralis major myocutaneous flap (PMMF) transfer given the risks, which include damage to major vessels when manipulating scarred skin. For such cases, we perform a 2-stage external PMMF transfer, whereby the PMMF is directly sutured to the defect over the neck skin (without manipulation the hardened skin), and the flap division is then performed secondarily.

METHODS

A total of 30 patients who had histories of radiotherapy (60-70 Gy) and prior neck dissection received the 2-stage external PMMF transfer procedure. Indications for the flaps included pharyngeal fistula closure in 12 patients, reconstruction for mandibular necrosis after radiotherapy in 8 patients, salvage surgery for partial or total necrosis of the free flap in 4 patients, and simultaneous reconstruction after tumor excision in 6 patients. Two patients underwent a second external PMMF transfer from the contralateral side because of postoperative complications, yielding a total of 32 flap transfers.

RESULTS

Twenty-nine flaps showed complete flap survival, whereas 3 had partial necrosis. Other complications, despite complete flap survival, included large fistulas requiring additional surgery for fistula closure (1 patient) and small fistulas that were closed without requiring reoperation (7 patients).

CONCLUSIONS

External PMMF transfer offers a safe, simple, and effective option in cases where free flap surgery is considered difficult or the risks associated with neck manipulation are high.

Analysis of intraoral microvascular anastomosis in maxillofacial defects reconstruction

This review summarizes the research progress in the field of intraoral microvascular anastomosis techniques (IAT) and attempts to investigate the indications for procedures in which IAT can be applied, the surgical procedure and the difficulties involved, technical assessments, result evaluation and the perspective. Currently, microvascular anastomosis technique is widely used in maxillofacial defects reconstruction from various causes including cutaneous injury or congenital deformity which usually required extensive flap reconstruction and therefore a vascular free flap is routinely used. Conventional microvascular anastomosis reconstruction techniques cannot avoid new incisions, which will affect the postoperative aesthetic situation. Surgeons have therefore attempted to improve this technique to effectively eliminate scars caused by surgery: some patients can be chosen to undergo microvascular anastomosis of the free flap intraorally, thus reducing the extraoral incision caused by the anastomosis located in neck or maxillofacial improving the postoperative appearance of the patients. In addition to preserving the external appearance, intraoral anastomosis technique (IAT) can also solve some other problems of maxillofacial vascular anastomosis, such as insufficient vessel pedicle length and high risk of facial nerve injury.

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.

The Transverse Facial Artery as a Recipient Artery in Neuroplastic Surgery Microvascular Reconstruction

Microvascular reconstruction in the craniofacial region is particularly challenging due to a paucity of adequate recipient vessels. The facial vessels are commonly utilized; however, in neurocranial reconstruction, the distance from the defect to the vessels may require the use of interposition vein grafts. The superficial temporal vessels, which have the benefit of closer proximity, are often compromised or injured in patients with previous neurosurgical procedures or radiation therapy. Here, we describe the use of the transverse facial artery as a recipient for a latissimus dorsi free flap for scalp reconstruction in a 63-year-old man with a compromised scalp from multiple surgeries and radiation therapy for glioblastoma multiforme. The patient had extensive scarring, temporalis muscle wasting, thinning of the overlying scalp, and notable alopecia. On surveillance imaging, he was found to have an area on the brain concerning for tumor recurrence, for which a surgical biopsy was recommended, with a significant risk of postoperative wound healing complications. We present the use of the transverse facial artery in this case as a recipient artery for free flap reconstruction of the scalp.

Evolution and current status of microsurgical tongue reconstruction, part II

Tongue reconstruction remains a major aspect of head and neck reconstructive procedures. Surgeons planning tongue reconstruction should consider several factors to optimize the overall outcomes. Specifically, various technical aspects related to tongue reconstruction have been found to affect the outcomes. Multidisciplinary teams dedicated to oncologic, reconstructive, and rehabilitative approaches play an essential role in the reconstructive process. Moreover, operative planning addressing certain patient-related and defect-related factors is crucial for optimizing functional speech and swallowing, as well as quality of life outcomes. Furthermore, tongue reconstruction is a delicate process, in which overall functional outcomes result from proper flap selection and shaping, recipient vessel preparation and anastomosis, surgical approaches to flap insetting, and postoperative management. The second part of this review summarizes these factors in relation to tongue reconstruction.

Comparison of Current Free Flap Options for Intraoral Lining and Tongue Reconstruction

Free flaps have become the main alternative for intraoral reconstruction in current practice. However, controversy exists on pros and cons of different free flap options for this challenging area. Although there are various studies focusing on different free flap options, comparative studies are very few and there is not a single study comparing all 4 thin free flap options for intraoral reconstruction. Between 2018 and 2021, 30 patients underwent intraoral reconstruction. Four pliable and thin flaps, medial sural artery perforator flap, superficial circumflex iliac artery perforator flap, radial forearm free flap, and superthin anterolateral thigh flap were used for reconstructions and compared per functionality and patients' quality of life. One medial sural artery perforator flap and 1 superficial circumflex iliac artery perforator flap failed because of perfusion problems, and the remaining flaps survived. Harvest time and donor site closure were with significant difference ( P <0.05) between groups. Quality of life results were similar except one of the disease-specific questions. In authors' opinion, anterolateral thigh flap is the best option in normal-weight individuals because of its reliability, pliability, and constant reliable vascular structure. Although other options may be considered in overweighted patients, thinly elevated anterolateral thigh flap still seems to be the most reliable option.

Superficial Temporal Recipient Vessels for Craniofacial Microvascular Free-Flaps

The selection of recipient vessels for microvascular free-flaps is critical in craniofacial reconstruction. Especially the suitability of the superficial temporal vessels is questioned conflictingly in the literature. The aim of this study was to share our experience with microvascular craniofacial free-flap reconstruction and to evaluate a set of factors that are related to the recipient vessels and to determine how these factors influence flap survival. We conducted a retrospective analysis of 39 free-flaps for craniofacial reconstruction that were performed from 2006 until 2020 and evaluated the indication for microvascular reconstruction, recipient vessels, various factors related to the recipient vessels and complications. The most utilized recipient artery was the facial artery, selected in 20 patients followed by the superficial temporal artery selected in 12 patients. The most commonly used recipient vein was the facial vein used in 16 patients, followed by the superficial temporal vein selected in 10 patients and the external jugular vein in 6 patients. Total flap necrosis occurred in one patient. There was no statistically significant association between the selected recipient vessels and patient comorbidities, major and minor complications, revision of anastomosis or flap loss. The results of our study have demonstrated that the superficial temporal artery and vein show similar results when used for face and scalp reconstruction. Considering their technical and aesthetic advantages they may be the first choice recipient vessels in established free-flap treatment algorithms for craniofacial reconstruction.

Optimization of Vascular Supply in Free Flaps for Head and Neck Reconstruction: Analysis of a Young Team’s Experience

Background

For head and neck reconstructive procedures, free flap survival depends on microsurgical and anatomical choices besides multimodal clinical management. The aim of the present study is to identify relevant variables for flap survival in our initial consecutive series.

Methods

A single-center, novel reconstructive team consecutive surgical series was revised. The outcome was analyzed in terms of flap survival observing variables considered more relevant: flap type, recipient artery, vein(s), and graft interposition were discussed for facial thirds to be reconstructed. Statistical analysis was performed with Chi-square, Mann–Whitney, and Odds ratio.

Results

A total of 118 free flaps were performed in 115 microsurgical procedures (93.9% for malignancies) on 109 patients, with a flap survival rate of 91.5%. For reconstruction of the middle and lower third of the face, the facial artery was privileged, because it was already transected during lymph node dissection in order to save the superior thyroid artery for further microsurgical needs. Flap failure was 50% venous. Double vein anastomosis was not related to flap survival. Deep venous drainage (as the internal jugular vein system) required fewer revisions. Half of the re-explorations saved the flap. Grafts were a risk for flap survival. Bony flaps were more critical.

Conclusion

At comparable reconstructive quality, flap choice should avoid a vascular graft. The facial artery is a preferable recipient vessel, since it saves other arteries both in the case of an arterial revision and in the case of recurrence, for further free flap reconstruction. For venous anastomosis, a deep venous recipient is safer, since it offers the possibility to choose the level of anastomosis optimizing the vascular pedicle geometry. A close postsurgical flap monitoring is advisable up to 7 days postoperatively to allow for timely flap salvage.

Vein Grafts in Free Flap Reconstruction: Review of Indications and Institutional Pearls

SUMMARY

Vein grafts enable soft-tissue reconstruction in cases of insufficient pedicle length, a lack of nearby recipient vessels, and a wide zone of injury caused by trauma or radiation therapy. The purpose of this article is to provide a comprehensive review of vein grafts in free flap reconstruction focusing on the timing of arteriovenous loops, complications, and surgical technique. Vein graft indications, types of vein grafts, and location-specific considerations are also reviewed. Three reconstructive microsurgeons at high-volume centers were asked to offer institutional pearls on the order of anastomosis, selection of donor veins, and timing of arteriovenous loops. In terms of gap length, vessel gaps less than 10 cm may be reconstructed with an interposition or transposition vein graft. For longer gaps, surgeons should consider the use of arteriovenous loops, transposition arteriovenous loops, or flow-through flaps. Both one and two-stage arteriovenous loops are used, depending on patient comorbidities, potential exposure of critical structures, and surgeon preference. Although one-stage arteriovenous loops expedite the reconstructive process, two-stage arteriovenous loops require shorter operations and help identify patients at risk of flap failure. Although whether the use of vein grafts increases flap failure rates is controversial, complications are highest in lower extremity reconstruction, cases of a prolonged interval between stages in two-stage arteriovenous loops, and unplanned vein grafts.

Venous Size Discrepancy Is a Critical Factor When Using Superficial Temporal Vessels as Recipient Vessels for Free Flaps

BACKGROUND

 Superficial temporal vessels have been used successfully as recipient vessels for head and neck reconstruction. This study evaluates the impact of several treatment variables on flap failure and take-back rate when using these recipient vessels.

METHODS

 We conducted a retrospective study of all microsurgical reconstructions using superficial temporal vessels as recipient vessels in a period of 10 years. Variables collected included previous treatments (radiotherapy, chemotherapy, neck dissection, free flap reconstruction), type of flaps used (soft tissue, osteocutaneous), and vessel size discrepancy between donor and recipient vessels.

RESULTS

 A total of 132 patients were included in the study. The flap success rate was 98.5%. The take-back rate was 10.6%. The most frequent reason for take-back was venous congestion secondary to thrombosis. None of the studied variables was associated with flap failure. Reconstructions using osteocutaneous flaps and vein diameter discrepancy (ratio ≥ 2:1) had significantly higher take-back rates.

CONCLUSION

 Flaps with a significant size discrepancy between donor and recipient veins (ratio ≥ 2:1) and fibula flaps (compared with soft tissue flaps) were associated with a higher risk of take-back. It is crucial to minimize venous engorgement during flap harvest and anastomosis, and limit vein redundancy during flap in-setting.

Effect of preoperative radiation on free flap outcomes for head and neck reconstruction: An updated systematic review and meta-analysis

BACKGROUND

There is an ongoing debate about whether neoadjuvant radiation therapy is associated with higher rates of postoperative complications after head and neck reconstruction. Herle et al. conducted a systematic review in 2014 of 24 studies, finding higher complication rates in irradiated fields. We sought to perform an exhaustive updated systematic review and meta-analysis.

METHODS

We conducted an updated systematic review of the literature, as outlined in our protocol, which was registered on PROSPERO. Databases included Medline, Embase, Cochrane Central, and Web of Science. There were no limits placed on the date range, place of publication, or origin. Exclusion criteria included patients less than 18 years of age, studies with less than 20 participants (n < 20), case studies, skull base reconstructions, and local tissue rearrangements. The combined results of the studies and relative risks (RR) were calculated.

RESULTS

53 studies were included for analysis, including 5,086 free flaps in an irradiated field, and 9,110 free flaps in a non-irradiated field. Of the 53 studies, 21 studies overlapped with those discussed in Herle et al.'s study, with a total of 32 additional studies. Neoadjuvant radiation was found to be a statistically significant risk factor for postoperative complications (RR 1.579, P < 0.001), total flap failure (RR, 1.565; P < 0.001), and fistula (RR, 1.810; P < 0.001). Our work reaffirmed the findings of the Herle et al.

STUDY

CONCLUSION

Preoperative radiation was associated with a statistically significant increase in the risk of total flap failure, fistula, and total complications but not partial flap failure. These high-morbidity complications must be taken into consideration when determining which patients should receive neoadjuvant radiation therapy.

Differences in free flaps’ reconstructions with and without coupling device for venous anastomosis

<br><b>Introduction:</b> Introduction of the coupler devices for anastomoses of neck vessels changes planning and performance of the surgical procedures. The Rigid ring of the coupling devices keeps a vein open and less prone to occlusion. Therefore, this should improve the flap survival rate and surgery duration.</br> <br><b>Aim:</b> The aim of the study was to point out the differences in surgery planning between couplers and sutures for venous microsurgical anastomoses.</br> <br><b>Methods:</b> The medical records of 209 patients who underwent 212 microvascular free flap reconstructions from January 2011 till December 2017 were retrospectively analyzed; 103 received radial forearm free flap (RFFF); 43 – anterolateral thigh flap (ALTF); 51 – fibula free flap (FFF); 15 – iliac crest free flap (ICFF). In 189 cases, reconstruction was performed simultaneously with tumor resection and in 23 cases, reconstruction was secondary, after previous oncological treatment. Among 443 anastomoses, suturing was used for 212 arteries and 127 venous anastomoses, while coupling was used for 104 venous anastomoses.</br> <br><b>Results:</b> The mean surgery duration for suturing was 452.82 min vs 358.88 min for coupling (P<0.05). Differences in flap survival and partial necrosis rates between coupling and suturing groups were not statistically significant (P>0.05). Donor vessel distribution in the neck was significantly different in both groups. Estimated costs of the surgical procedures performed with and without coupler devices were not equal.</br> <br><b>Conclusions:</b> The use of couplers for venous anastomosis in free flap head and neck reconstructions impacts the surgery process by shortening surgery duration which leads to cost reduction.</br>

The impact of a double vein anastomoses on doppler's loss of signal rates

BACKGROUND

Impact on blood flow by double vein anastomosis in head and neck free flaps is unclear. We aimed to assess venous doppler loss of signal (LOS) rates of double vein system compared with a single vein system.

METHODS

Consecutive free flaps with implanted venous flow couplers between 2015-2017 were included. LOS rates were compared between groups and with regard to flap type, defect site and recipient vein within double vein group.

RESULTS

92 double-vein (184 veins) and 48 single-vein flaps were included. LOS was similar in single- and double-vein flaps (11/48 (25%) versus 46/184 (25%), p = 0.765). Double veins had fewer flap takebacks compared with single vein (4.3% vs. 12.5%, p = 0.075). Common facial vein (CFV) anastomosis showed superior LOS rates compared with external jugular and CFV branches (p = 0.026).

CONCLUSIONS

Double vein anastomosis does not impact LOS rates, results in fewer flap takebacks, yet LOS rates depend on selected recipient vein.

The Effect of Smoking on the Postoperative Course After Head and Neck Reconstruction With a Vascularized Free Flap: A Retrospective Study

OBJECTIVES

The objective of the present study is to determine the impact of smoking on hospital and intensive care unit stay, need for surgical reintervention, Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity, and surgical complications after head and neck reconstructions.

METHODS

All 153 patients who underwent head and neck reconstructions with free tissue transfer at the department of oral and maxillofacial surgery at the University Hospitals of Leuven between January 1, 2015 and December 31, 2018 were enrolled in this retrospective cohort study. Data from medical charts were extracted. Univariate and multiple regression analyses were performed. A level of significance of P < 0.05 (α = 0.05) was used.

RESULTS

Smoking was not associated with Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity, hospital or ICU stay, the incidence of postoperative complications in both flap and donor site, or surgical reintervention.

CONCLUSIONS

Regarding the outcomes included in this study, smoking status should not be considered as a critical factor in patient selection for head and neck reconstructions with a vascularized free flap.

Extending the Indication of the Superior Thyroid Artery as a Recipient Vessel for Complex Upper Body Defects

BACKGROUND

Reconstruction of complex chest and upper back defects can pose a challenge to microsurgeons, especially when prior surgery, scarring, tumor resection, or radiotherapy, have caused a shortage of recipient vessels. Although already being a standard approach for head and neck reconstructions, we investigated whether the indication of the superior thyroid artery (STA) as a safe and universal recipient vessel could be extended for reconstruction in aforementioned regions.

METHODS

Seventeen patients received free myocutaneous vastus lateralis (MVL) muscle flaps for reconstruction of upper body defects (chest n = 11; upper back n = 6). In all cases, the STA was used for microvascular anastomosis because of a lack of standard recipient vessels. A retrospective chart review was performed and the data was screened for patients' demographics, intraoperative and perioperative details, flap survival, surgical complications, and overall long-term outcomes. Patients had a minimum follow-up of 6 months.

RESULTS

Defects resulted from infections after cardiac surgery (n = 10), infections after spinal neurosurgery (n = 2) or tumor resection (n = 5). Average defect size measured 144.6 (range, 40-286 cm2; ±67.9 cm2), with a mean size of the MVL free flaps of 266.8 (range, 160-384 cm2; ±69.5 cm2). The flap success rate was 100%, with minor complications in 4 patients. No major complications were observed in any of the patients.

CONCLUSIONS

The STA is a viable and safe alternative as a recipient vessel for reconstruction of upper body defects, especially when other vessels in proximity to the defect are deprived.

Meta-analysis of arterial anastomosis techniques in head and neck free tissue transfer

The present meta-analysis aimed to investigate the differences in the incidence of thrombosis and vascular compromise in arterial anastomosis between microvascular anastomotic devices and hand-sewn techniques during free tissue transfer in the head and neck. We searched for articles in PubMed/Medline, CNKI, WANFANG DATA, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science, from January 1, 1962 till April 1, 2020 that reported data of microvascular anastomosis during free tissue transfer in the head and neck. The incidence of arterial thrombosis or vascular compromise, or both was the primary outcome. The secondary outcome was anastomotic time. We also assessed the sensitivity and the risk of bias. This meta-analysis included 583 arterial anastomoses from six studies. The group using microvascular anastomotic devices tended to have an increased incidence of arterial thrombosis and vascular compromise (risk ratio (RR), 3.42; P = 0.38; 95% confidence interval (CI), 0.91–12.77). The hand-sewn technique took significantly longer to perform the anastomosis compared with that of the microvascular anastomotic devices (weighted mean difference, 15.26 min; P<0.01; 95% CI, 14.65–15.87). Microvascular anastomotic devices might increase the risk of arterial thrombosis and vascular compromise compared with the hand-sewn technique; however, further randomized controlled trials are needed to provide a more accurate estimate. The application of microvascular anastomotic devices will help to reduce anastomotic surgery time and achieve acceptable vessel opening, benefiting from the developments of arterial couplers and microsurgical techniques.

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.

Head and Neck Reconstruction in the Vessel Depleted Neck

Microvascular free tissue transfer has revolutionized reconstruction and subsequently functional outcomes in the head and neck, but requires suitable recipient vessels for successful results. Recipient vessels can be significantly compromised by prior surgery, radiation therapy, or existing and/or underlying vascular disease in the neck. When further microvascular reconstruction is required in the vessel-depleted neck, identification of appropriate vessels for anastomosis can be difficult and can present complex decisions for the surgeon as well as the patient. In this article, we review the available literature on the vessel depleted neck and the possible vessel options. We present critical strategies for preoperative treatment planning and vessel selection in these patients. We also discuss the benefits and limitations of arterial and venous options while commenting on our unique institution's experiences. The external carotid branches as well as the available subclavian artery branches are presented in detail. The venous anatomy is also described, with particular focus on the accompanying veins and cephalic vein. We provide guidance on the selection and modification of free flaps to achieve the greatest function and cosmetic outcomes in the vessel depleted neck. Our collection of advanced management techniques will provide surgeons with more options to manage the complexity of the vessel depleted neck, and to further help patients understand the risk and benefits of these selections.

Recipient vessel selection for head and neck reconstruction: A 30-year experience in a single institution

Background

The advance in microsurgical technique has facilitated a proper approach for reconstruction of extensive head and neck defects. For the success of free tissue reconstruction, selection of the recipient vessel is one of the most important factors. However, the vascular anatomy of this region is very complex, and a clear guideline about this subject is still lacking. In this study, we present our 30 years of experiences of free tissue reconstruction for head and neck defects.

Methods

In this retrospective study, we analyzed a total of 138 flaps in 127 patients who underwent head and neck reconstruction using free tissue transfer following tumor resection between October 1986 to August 2019. Patients who underwent facial palsy reconstruction were excluded. Medical records including patient’s demographics, detailed operation notes, follow-up records, and photographs were collected and analyzed.

Results

Among a total of 127 patients, 10 patients underwent a secondary operation due to cancer recurrence. The most commonly used type of flap was radial forearm flap (n= 107), followed by the anterolateral thigh flap (n= 18) and fibula flap (n= 10). With regard to recipient vessels, superior thyroid artery was most commonly used in arterial anastomosis (58.7%), and internal jugular vein (51.3%) was the first choice for venous anastomosis. The flap survival rate was 100%. Four cases of venous thrombosis were resolved with thrombectomy and re-anastomosis.

Conclusion

Superior thyroid artery and internal jugular vein were reliable choices as recipient vessels. Proper recipient vessel selection could improve the result of head and neck reconstruction.

[Anatomical characteristics of the superficial temporal venous system and implications in microsurgery]

INTRODUCTION

The superficial temporal vessels remain underused in microsurgery, the superficial temporal vein (STV) being reported as inconstant. The aim of this study was to precise the anatomical characteristics of the superficial temporal venous system by means of a cadaveric anatomical study and a doppler-ultrasound study on healthy subjects.

MATERIALS AND METHODS

In order to study the anatomical variations of the STV and its different branches in the temporo-parietal area, 10 hemifaces of bodies donated to science were injected with latex and dissected. A doppler-ultrasound study of the superficial temporal venous system was also performed on 10 healthy subjects in order to assess the median diameter of the STV.

RESULTS

A common temporo-parietal trunk was found on all the bodies dissected, with a mean number of 1,6 [1-3] venous affluents. The STV preceded systematically the superficial temporal artery (STA) in the pre-auricular area. The arterio-venous relationships were in contrast highly variable above that area. The diameter of the STV presented major interindividual variations, with a median diameter of 1,3mm [0,5-2].

CONCLUSION

The superficial temporal vessels can be easily identified in the pre-auricular area. With a mean harvestable length of 6,5cm and a mean diameter of 1,3mm, the parietal branch of the STV presents a caliber sufficient for the realization of the anastomoses.

Flap demise reversed after central venous access device removal: A case report

Patients undergoing head and neck free flap reconstruction should be evaluated for radiation-induced venous stenosis and presence of central venous port as a potential risk for flap failure.

Anatomy, Exposure, and Preparation of Recipient Vessels in Microsurgical Head and Neck Reconstruction

Successful microvascular reconstruction of head and neck defects requires the ability to safely identify, isolate, and utilize recipient vessels. To date, however, a comprehensive review of the anatomy and techniques relevant to the available anatomic regions has not been undertaken. This review covers the relevant clinical anatomy of the anterior triangle, posterior triangle, submandibular region, intraoral region, preauricular region, chest, and arm, taking particular care to highlight the structures that are crucial to identify while performing each dissection. Finally, a step-by-step technique for safely dissecting the recipient vessels at each site is provided.

Microvascular reconstruction for maxillofacial defects: a retrospective analysis of outcomes and complications in 121 consecutive cases

Background

Microvascular reconstruction is the treatment of choice after oral cancer ablation surgery. There are few published studies of free flap survival among Korean populations. This study aimed to determine the survival rate after 121 consecutive cases of maxillofacial microvascular reconstruction and to analyze the complications associated with microsurgery.

Methods

This study included consecutive patients who underwent microsurgical reconstruction with free flaps, from January 2006 through September 2019, performed by a single surgeon at the oral and maxillofacial surgery department of a tertiary medical center. A total of 121 cases were reviewed retrospectively. The flap survival rate, flap type, radiotherapy history, complications, and treatment results were analyzed.

Results

Four different flap types were used for microvascular reconstruction: radial forearm (n = 65), fibula (n = 34), latissimus dorsi (n = 21), and serratus anterior muscle with rib bone free flap (n = 1). Total necrosis of the flap was found in four cases (two latissimus dorsi flaps and two fibular flaps). The free flap survival rate was 97.5%. Nineteen patients received radiotherapy before surgery, and none of them experienced flap failure. The mean operation time was 334 ± 83.1 min, and the mean ischemic time was 48.9 ± 12.7 min.

Conclusions

The success rate was reliable and comparable with previous studies. The success rate was not affected by radiation therapy. Free flaps can be safely used even after radiation treatment.

Two-stage Reconstruction of the Scalp with Facial AV Loop

We present the case of a 65-year-old woman with extensive osteoradionecrosis of the scalp and calvaria after external beam radiation therapy for follicular lymphoma. Due to the compromise of her adjacent vasculature including the superficial temporal vessels, she underwent two-stage reconstruction with the creation of an AVL (arteriovenous loop) graft utilizing her great saphenous vein. This was anastomosed to her right facial artery and vein, which was then matured. She underwent resection of the necrotic portions of calvaria and soft tissue of approximately 180 cm2, and a vascularized free latissimus dorsi muscle flap was harvested and anastomosed to her new conduit. This free muscle flap was then covered with a split-thickness skin graft harvested from her thigh. She achieved satisfactory functional and cosmetic results with minimal morbidity and without complication despite her age, multiple co-morbidities, and extensive and complex disease process.

The impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap: a systematic review and meta-analysis

Reconstructive surgery with a free vascularised tissue flap is indicated in large defects in the head and neck region, which arise mostly because of head and neck cancer. Tobacco smoking is a major risk factor for head and neck cancer, and many patients undergoing reconstructive surgery in the head and neck have a history of smoking. The objective of this meta-analysis was to determine the impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap. A systematic review was undertaken for articles reporting and comparing the incidence of overall surgical complications after reconstructive surgery with a free vascularised tissue flap between smokers and nonsmokers. Relevant articles were searched using PubMed, Cochrane, and Embase databases, and screened for eligibility according to the PRISMA guidelines. The risk of bias analysis was conducted using the Newcastle-Ottawa quality assessment scale. A meta-analysis was performed to quantitatively compare the incidence rate of overall surgical complications, flap failure, surgical site infection, fistula, and haematoma between smokers and nonsmokers using OpenMetaAnalyst (open source) software. Only qualitative analysis was performed for wound dehiscence, bleeding, nerve injury, and impaired wound healing. Forty-six articles were screened for eligibility; 30 full texts were reviewed, and 19 studies were included in the quantitative meta-analysis. From the 19 studies, 18 were retrospective and 1 was a prospective study. In total, 2155 smokers and 3124 nonsmokers were included in the meta-analysis. Smoking was associated with a significantly increased risk of 19.12% for haematoma (95% Confidence Interval (CI): 4.75-33.49; p<0.01), and of 4.57% for overall surgical complications (95% CI: 1.97-7.15; p<0.01). No significant difference in risk was found for flap failure (95% CI: -4.33-9.90; p=0.44), surgical site infection (95% CI: -0.88-2.60; p=0.33) and fistula formation (95% CI: -3.81-3.71; p=0.98) between smokers and nonsmokers. Only for flap failure was a significant heterogeneity found (I²=63.02%; p=0.03). Smoking tobacco was significantly associated with an increased risk of overall surgical complications and haematoma, but did not seem to affect other postoperative complications. Encouraging smoking cessation in patients who need reconstructive head and neck surgery remains important, but delaying surgery to create a non-smoking interval is not needed to prevent the investigated complications. More high-quality retrospective or prospective studies with a standardised protocol are needed to allow for definitive conclusions.

Analysis of Selection of Recipient Vein, Number of Outflows, Style and Technique in Head and Neck Venous Anastomosis and a Proposed Algorithm

Surgeons have preferential ways of performing venous anastomosis in head and neck microsurgery. However, controversies exist regarding the superiority of each method. This study aims to determine the effects of these variables on the rates of thrombosis and flap failure, and propose an algorithm to be used as a facilitator in the decision-making process. A total of 208 microsurgical reconstructions on 199 patients from a single surgeon's data were evaluated. Selection of recipient vein (superficial vs. deep), style of anastomosis (end-to-end vs. end-to-side), number of outflows (one vs. two) and technique of anastomosis (hand-sewn vs. coupler) were compared. Selection was done according to the pre- and intraoperative plan, as well as, surgeon's clinical judgement. Outcomes were determined as rates of venous thrombosis and flap failure. Five patients (2.4%) had venous problems, leading to two partial and three total flap failures. Selection of the recipient vein, style and number of outflows did not affect the outcomes, whereas coupler use decreased the rates of venous thrombosis and flap failure (p=0.008). Although it is difficult to set dogmatic criteria to achieve consistent outcomes, coupler use in this study prevented flap failure. An algorithmic approach was proposed with the results of the data and literature to increase the success in microsurgical anastomosis. Surgeons should use algorithms and sound judgement with adherence to microsurgical principles to obtain the best results for each patient.

Utilization of microvascular couplers in salvage arterial anastomosis in head and neck free flap surgery: Case series and literature review

BACKGROUND

In microvascular reconstruction of ablative oncologic defects, coupler devices have traditionally been used for venous anastomosis, whereas the arterial anastomosis is hand-sewn. In the setting of repeated intraoperative arterial anastomotic thrombosis, a coupler device may be of use in reducing the risk of rethrombosis.

METHODS

Two patients were seen with advanced stage head and neck cancer and underwent oncologic resection. During microvascular reconstruction, a clot at the arterial anastomosis was encountered in both cases.

RESULTS

After starting therapeutic anticoagulation and attempting unsuccessful suture reanastomosis, coupler devices were used for arterial anastomosis, resulting in viable free-tissue transfer.

CONCLUSIONS

Although traditionally used for venous anastomosis, coupler devices may serve a purpose in the salvage setting when facing repeated intraoperative arterial thrombosis.

The impacts of intra-arterial chemotherapy on head and neck microvascular reconstruction

BACKGROUND

For locally advanced head and neck cancers, intra-arterial (IA) chemotherapy is utilized for locoregional control with favorable results. The study aimed to evaluate the surgical outcomes of microsurgical reconstruction in head and neck cancer patients with IA chemotherapy METHODS: This cohort study retrospectively reviewed patients who underwent head and neck microsurgical reconstruction from January 2014 to August 2018. Patients with prior history of chemotherapy were included and categorized into two groups according to history of IA chemotherapy (IA group)/intravenous chemotherapy (IV group). Flap survival was evaluated along with microsurgical revision rates and complications. Recipient vessel specimens were analyzed by histological examination. A 1:1 propensity score matched analysis was performed.

RESULTS

The study cohort included 45 patients with IA chemotherapy and 201 patients with IV chemotherapy. After propensity score matching, the difference in total flap loss and microsurgical revision rates were nonsignificant between two groups. However, the IA group had significantly higher rates of arterial thrombosis (Odds ratio [OR] 4.98; 95%CI, 1.28-19.38; p = 0.021), wound-related complications (OR 3.30; 95%CI, 1.21-9.02; p = 0.02) and revision surgery within one month (OR 3.73; 95%CI, 1.10-12.64; p = 0.035). Based on histology, IA group vessels showed a higher intima/media ratio than the IV group (0.45 ± 0.06 versus 0.23 ± 0.03, p = 0.02) CONCLUSION: Despite treating local advanced head and neck cancers with good results, IA chemotherapy may cause subsequent deleterious effects on local tissue due to the high concentration of cytotoxic chemotherapeutic agents. Surgeons should be cautious in selection of recipient vessels when performing microvascular reconstruction.

Comparison of Internal Jugular Vein System Anastomosis and External Jugular Vein System Anastomosis in Free Flaps for Head and Neck Reconstruction: A Meta-Analysis

PURPOSE

The purpose of the present study was to investigate the differences in postoperative thrombosis and flap failure between internal jugular vein (IJV) system anastomosis and external jugular vein (EJV) system anastomosis in free flaps for the reconstruction of head and neck defects.

MATERIALS AND METHODS

We searched PubMed, Web of Science, EMBASE, Chinese BioMedical Literature Database, and other databases until March 2019 for studies that had reported data for anastomosis for the 2 different venous systems in the microvascular free-flap reconstruction of head and neck defects. We assessed thrombosis and flap failure in patients undergoing anastomosis of the IJV system and patients undergoing anastomosis of the EJV system.

RESULTS

Nine studies with a total of 2051 patients with venous anastomosis were included in the present meta-analysis. IJV system anastomosis showed a significantly lower incidence of venous thrombosis than did the EJV system (relative risk [RR], 0.55; 95% confidence interval [CI], 0.37 to 0.82). Eight studies were included in the analysis of the flap failure rate, which showed a lower failure rate for the IJV system anastomosis than for the EJV system (RR, 0.59; 95% CI, 0.35 to 1.00).

CONCLUSIONS

The incidence of thrombosis and flap failure after venous anastomosis in the IJV system was lower than that in the EJV system. The results from the present study have shown that the IJV system should be the first choice for venous anastomosis in the reconstruction of free flaps.

[Use of coupler for venous anastomoses in cervico-facial reconstruction. Retrospective study on 51 free flaps]

OBJECTIVE

The aim of our study was to evaluate the interest of the mechanical anastomosic coupling device for venous anastomoses in a series of cervico-facial reconstructions after carcinologic excision.

PATIENTS AND METHODS

Between January 2010 and December 2017, 46 patients underwent free flap cervico-facial reconstruction. We performed 54 venous anastomoses for 51 free flaps. Mechanical venous anastomoses were performed with a coupler (Coupler®). Thrombotic complications and choice of recipient vessels were assessed for the entire series.

RESULTS

Venous anastomoses were performed using a coupler in 33.3% of the flaps (n=18). Mean operative time was lower for reconstructions with mechanical coupler anastomoses, and significantly for fibula flaps. Of eight thromboses, six were venous, two of which after the coupler anastomosis. The thrombosed veins were the branches of the internal jugular vein and the anterior jugular veins. The diameter of the couplers used was respectively 2.5mm and 2mm.

CONCLUSION

The use of the microvascular coupling system for venous anastomoeis would help reduce the occurrence of venous thrombosis, but larger and prospective studies should be conducted. This coupling system, relatively easy to use, would overcome the lack of congruence of anastomosing veins and reduce the risk of intimal injury. Regarding the recipient vessels, the anterior jugular vein should not be used as first line because the risk of vascular complications seems more important.

Superficial temporal vessels, both anterograde and retrograde limbs, are viable recipient vessels for recurrent head and neck reconstruction in patients with frozen neck

BACKGROUND

Reconstruction of recurrent head and neck malignancy especially in the presence of a frozen neck is challenging. The superficial temporal vessels would be ideal as recipient vessels because they lie out of the previous surgical and radiation field.

METHODS

We conducted a retrospective case-control study based on our database between January 2013 and June 2016. A total of 581 primary cases were selected as controls. The 60 test group patients had (a) recurrent head and neck reconstruction, (b) previous surgery and irradiation, (c) frozen neck, and (d) superficial temporal vessels as recipients.

RESULTS

There was no significant difference between vascular compromise rates of superficial temporal vessels (anterograde and retrograde limbs) and controls (P > .05). Flap success rate of the test and control group is comparable, 95% vs 98% respectively.

CONCLUSION

Superficial temporal vessels, both anterograde and retrograde, should be the first consideration for recurrent intraoral, facial, and scalp reconstruction with frozen necks.

Shift in the timing of microvascular free tissue transfer failures in head and neck reconstruction

OBJECTIVE

Analyze the cause and significance of a shift in the timing of free flap failures in head and neck reconstruction.

STUDY DESIGN

Retrospective multi-institutional review of prospectively collected databases at tertiary care centers.

METHODS

Included consecutive patients undergoing free flap reconstructions of head and neck defects between 2007 and 2017. Selected variables: demographics, defect location, donor site, free flap failure cause, social and radiation therapy history.

RESULTS

Overall free flap failure rate was 4.6% (n = 133). Distribution of donor tissue by flap failure: radial forearm (32%, n = 43), osteocutaneous radial forearm (6%, n = 8), anterior lateral thigh (23%, n = 31), fibula (23%, n = 30), rectus abdominis (4%, n = 5), latissimus (11%, n = 14), scapula (1.5%, n = 2). Forty percent of flap failures occurred in the initial 72 hours following reconstruction (n = 53). The mean postoperative day for flap failure attributed to venous congestion was 4.7 days (95% confidence interval [CI], 2.6-6.7) versus 6.8 days (CI 5.3-8.3) for arterial insufficiency and 16.6 days (CI 11.7-21.5) for infection (P < .001). The majority of flap failures were attributed to compromise of the arterial or venous system (84%, n = 112). Factors found to affect the timing of free flap failure included surgical indication (P = .032), defect location (P = .006), cause of the flap failure (P < .001), and use of an osteocutaneous flap (P = .002).

CONCLUSION

This study is the largest to date on late free flap failures with findings suggesting a paradigm shift in the timing of flap failures. Surgical indication, defect site, cause of flap failure, and use of osteocutaneous free flap were found to impact timing of free flap failures.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:347-353, 2020.

Challenges in Microsurgical Reconstruction for Craniofacial Osteomyelitis With Resultant Osteonecrosis

INTRODUCTION

Chronic osteomyelitis is characterized by compromised blood supply and eventual osteonecrosis. Definitive treatment requires aggressive resection of affected bone. The resultant defect poses a unique challenge to reconstructive surgeons. Much of the literature on craniofacial osteomyelitis focuses on infection eradication, rather than subsequent reconstruction. This article reports representative cases from our experience with free flap reconstruction for defects secondary to chronic osteomyelitis of the craniofacial skeleton.

METHODS/RESULTS

The authors selected 5 of the most difficult reconstructive cases of craniofacial osteomyelitis from our experience in a single tertiary referral institution with a follow-up of at least 6 months. Three of the 5 cases arose in the setting of previous head and neck cancer treated with resection and radiation therapy. One case had a previous surgical craniotomy complicated by osteomyelitis and multiple failed alloplastic reconstructions. The final case was due to multiple gunshots to the head, with subsequent cerebral and cranial abscess (>1000cc). In each case, the defect was successfully treated with free tissue transfer. Two cases required creation of recipient vessels with an arteriovenous loop.

CONCLUSIONS

Free tissue transfer provides a versatile and effective tool in the reconstruction of extensive craniofacial osteomyelitis defects. Furthermore, the addition of vascularized tissue can protect against further episodes of osteomyelitis. Finally, arteriovenous loops can be employed successfully when prior radiation and infection of the wound bed precludes the use of local recipient target vessels.

Review of Cross-Leg Flaps in Reconstruction of Posttraumatic Lower Extremity Wounds in a Microsurgical Unit

Since the advent of microsurgery, and expanding expertise in the field, extensive traumatic wounds of leg have been managed successfully with free tissue transfer. Various patient-related factors may preclude the use of free flaps even in units with available expertise and infrastructure. It is in such situations that the "cross-leg flap" comes into play. In these cases, instead of attempting complicated anastomotic techniques or anastomosis in the zone of trauma, it is better to perform the simpler and more reliable cross-leg flap. In this study, we try to show the utility of a cross-leg flap based on a retrospective study of 198 patients who underwent cross-leg flap in our institute over a period of 15 years extending from November 2003 to March 2018.

MATERIALS AND METHODS

Case sheets of all patients who underwent cross-leg flap from November 2003 to March 2018 were reviewed. The location of defect in the leg, the indication for cross-leg flap, the pattern of cross-leg flap, and perioperative complications were noted.

RESULTS

A total of 198 patients underwent cross-leg flap for traumatic soft tissue injury of leg during this period. The most common reason for performing cross-leg flap was poor pulsatility of the recipient artery as seen intraoperatively, followed by the economics of the procedure wherein the initial cost of free flap was found significantly higher compared with cross-leg flap. All flaps survived with partial necrosis occurring in 23 patients. All flaps settled well by 2 years' time. Bony union/fracture healing evaluation was not a part of this study.

CONCLUSION

Cross-leg flap is still a useful tool for leg wound coverage even in microsurgical unit in situations precluding free flap coverage.

Perioperative Care of Free Flap Patients

Microvascular free tissue transfer is an indispensable reconstructive option in head and neck reconstruction. Flap failure is relatively rare, but it is nonetheless very morbid and psychologically devastating to patients when it does occur. Further, complications after free tissue transfer to the head and neck remain common. There are numerous ongoing debates about various facets of preoperative, intraoperative, and postoperative care of patients undergoing free flap reconstruction of the head and neck, all ultimately searching for the optimal treatment algorithm to further improve flap success, minimize complications, and maximize patient outcomes. Herein, the authors review current literature surrounding optimal preoperative nutritional support, intraoperative vasopressor use, perioperative fluid management, use of antithrombotic agents, antibiotic use, and other facets of the care of head and neck free flap patients to provide a guide to surgeons.