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Noothanapati NR, Akali NR, Buggaveeti R, Balasubramanian D, Mathew J, Iyer S, Thankappan K. Reconstruction in Salvage Surgery for Head and Neck Cancers. Craniomaxillofac Trauma Reconstr 2023; 16:211-221. [PMID: 37975025 PMCID: PMC10638975 DOI: 10.1177/19433875221109248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
Introduction Salvage surgery is the treatment option in recurrences and second primary tumors. This paper aimed to study the options and outcomes of reconstruction and the predictors of poor reconstructive outcomes in salvage surgery for head and neck cancers. Study Design This is a retrospective study of all patients who underwent reconstructive flap surgery as part of salvage surgery for head and neck cancers between the years 2004 and 2017. Methods The initial treatment may be single modality radiotherapy or surgery or multimodality with combinations of surgery, radiotherapy, and chemotherapy. Any pathology that required surgical salvage was included. Any procedures done purely as reconstructive surgery were excluded. Predictor variables included demographical, clinical, and treatment factors. The outcome parameter was the occurrence of any flap-related complication or not. The complications and morbidity related to the procedures are reported. Results Ninety-three patients underwent loco-regional flaps (LRF group), and 100 had free flaps (FF group). Pectoralis major flap was the commonest flap used in 68 patients (73.1%). Anterolateral thigh (ALT) flap was the commonest free flap and comprised 41% of the FF group. Any skin-related complication was seen in 35 patients (37.6%) and 41 (41%), respectively, in LRF and FF subsets. Any flap-related complication was seen in 16 patients (17.2%) and 29 patients (29%), respectively, in LRF and FF subsets. A summary measure "any one of the complications" was seen in 46 (49.5%) and 57 (57%), respectively, in LRF and FF subsets. Univariate and multivariate analysis for any flap-related complication identified no statistically significant predictor. Conclusions Soft tissue flaps were preferred in salvage reconstruction, though the defects had a bony component. In the microvascular free flap reconstruction era, pectoralis major flap has shifted its role from a "workhorse flap" to a "salvage flap." About half of the patients develop some complications. Flap-related complications are also common. In salvage surgery, it is important that an appropriate flap is selected, suitable for the setting, according to the indications, neck, and patient conditions.
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Affiliation(s)
- Nageswara R. Noothanapati
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Nisha R. Akali
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Rahul Buggaveeti
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Deepak Balasubramanian
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Jimmy Mathew
- Department of Plastic Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Subramania Iyer
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Krishnakumar Thankappan
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
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2
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Moest T, Kesting MR, Rohde M, Lang W, Meyer A, Weber M, Lutz R. A Treatment Approach for Carotid Blowout Syndrome and Soft Tissue Reconstruction after Radiotherapy in Patients with Oral Cancer: A Report of 2 Cases. J Clin Med 2023; 12:jcm12093221. [PMID: 37176661 PMCID: PMC10179401 DOI: 10.3390/jcm12093221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/17/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND This retrospective case series study aims to demonstrate a salvage technique for the treatment of carotid blow-out syndrome (CBS) in irradiated head and neck cancer patients with a vessel-depleted neck. METHODS Between October 2017 and October 2021, two patients (N = 2) with CBS were treated at our institution in a multidisciplinary approach together with the Department of Vascular Surgery. Patients were characterized based on diagnoses, treatment procedures, and the subsequent postoperative course. RESULTS Surgical emergency intervention was performed in both cases. The transition zone from the common carotid artery (CCA) to the internal carotid artery (ICA) was resected and reconstructed with a xenogic (case 1) or autogenic (case 2) interposition (end-to-end anastomosis). To allow reconstruction of the vascular defect, an additional autologous vein graft was anastomosed to the interposition graft in an end-to-side technique, allowing arterial anastomosis for a free microvascular flap without re-clamping of the ICA. Because of the intraoperative ICA reconstruction, none of the patients suffered a neurological deficit. CONCLUSIONS The techniques presented in the form of two case reports allow for acute bleeding control, cerebral perfusion, and the creation of a vascular anastomosis option in the vessel-depleted neck.
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Affiliation(s)
- Tobias Moest
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstraße 11, 91054 Erlangen, Germany
| | - Marco Rainer Kesting
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstraße 11, 91054 Erlangen, Germany
| | - Maximilian Rohde
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstraße 11, 91054 Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Alexander Meyer
- Department of Vascular Surgery, University Hospital Erlangen, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Manuel Weber
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstraße 11, 91054 Erlangen, Germany
| | - Rainer Lutz
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstraße 11, 91054 Erlangen, Germany
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3
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Pak KY, Anderson SR, Langenfeld TL, Tan K, Slijepcevic A, Wimalawansa S, Ducic Y, Wax MK, Kadakia SP. Analysis of vein grafting versus arteriovenous loop in microvascular head and neck reconstruction: Multicenter series of 36 patients. Head Neck 2023; 45:1237-1243. [PMID: 36891641 DOI: 10.1002/hed.27337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/21/2022] [Accepted: 02/22/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND The utilization of an arteriovenous loop is an underreported technique that affords the creation of reliable vascular options. Understanding the efficacy and impacting variables of microvascular reconstruction with an arteriovenous loop can be critical to its use. METHODS Multi-institutional study of 36 patients who underwent vein grafting or AV loop with free tissue transfer. RESULTS 58.3% of patients received prior radiation and 38.9% prior flap reconstruction. Flap success for vein grafting was 76% and AV loop was 100% (p = 0.16). Success for the radiated cohort was 90.5% and non-radiated 80% (p = 0.63). Flap success for the radiated, vein grafted patient was 83.3% and 100% flap success rate for radiated, AV loop patient (p = 0.49). Overall flap survival was 83.3% versus 97% overall success rate in the United States. CONCLUSION The AV loop is a viable modality for vessel-depleted free tissue reconstruction. Radiation and previous surgery do not significantly impact flap success rates.
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Affiliation(s)
- Kaitlynne Y Pak
- Division of Otolaryngology-Head and Neck Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Spencer R Anderson
- Division of Plastic & Reconstructive Surgery, Wright State University, Dayton, Ohio, USA
| | - Tyler L Langenfeld
- Boonshoft School of Medicine at Wright State University, Dayton, Ohio, USA
| | - Kenneth Tan
- Oregon Health Science University, Portland, Oregon, USA
| | - Allison Slijepcevic
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - Sunishka Wimalawansa
- Division of Plastic & Reconstructive Surgery, Wright State University, Dayton, Ohio, USA
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas, USA
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - Sameep P Kadakia
- Division of Plastic and Reconstructive Surgery, Wright State University, Dayton, Ohio, USA
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4
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Ryan JF, Tanavde VA, Gallia GL, Boahene KDO, London NR, Desai SC. Reconstruction in open anterior skull base surgery: A review and algorithmic approach. Am J Otolaryngol 2023; 44:103700. [PMID: 36473261 DOI: 10.1016/j.amjoto.2022.103700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/25/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Defects resulting from open resection of anterior skull base neoplasms are difficult to reconstruct. Our objective was to review the literature and describe an evidence-based algorithm that can guide surgeons reconstructing anterior skull base defects. METHODS A research librarian designed database search strategies. Two investigators independently reviewed the resulting abstracts and full text articles. Studies on reconstruction after open anterior skull base resection were included. Studies of lateral and posterior skull base reconstruction, endoscopic endonasal surgery, traumatic and congenital reconstruction were excluded. Based on the review, a reconstructive algorithm was proposed. RESULTS The search strategy identified 603 unique abstracts. 53 articles were included. Adjacent subsites resected, defect size, radiotherapy history, and contraindications to free tissue transfer were identified as key factors influencing decision making and were used to develop the algorithm. Discussion of the reconstructive ladder as it applies to skull base reconstruction and consideration of patient specific factors are reviewed. Patients with a prior history of radiotherapy or with simultaneous resection of multiple anatomic subsites adjacent to the anterior skull base will likely benefit from free tissue transfer. CONCLUSIONS Reconstruction of anterior skull base defects requires knowledge of the available reconstructive techniques and consideration of defect-specific and patient-specific factors.
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Affiliation(s)
- John F Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ved A Tanavde
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kofi D O Boahene
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nyall R London
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shaun C Desai
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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5
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Analysis of intraoral microvascular anastomosis in maxillofacial defects reconstruction. J Craniomaxillofac Surg 2023; 51:31-43. [PMID: 36725484 DOI: 10.1016/j.jcms.2023.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
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.
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6
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Gréant E, Haesendonck GV, Faris C. A Buccal Space Approach for Midface Free Flap Reconstruction. Facial Plast Surg 2022; 38:214-217. [PMID: 35114712 DOI: 10.1055/s-0041-1742133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
This article describes a transbuccal approach to reach the facial vessels. The anatomy of this intraoral approach is predictable, minimizing the risk of facial nerve dysfunction. This technique provides the possibility of free flap midface reconstruction with short pedicles and avoids the need to use vein grafts. Moreover, it is esthetically preferable. Through cadaver dissection and anatomical drawings, we describe extensively the different surgical steps. Using the combination of the previous knowledge and recent anatomical understandings, we can provide a reliable step-by-step approach to find the facial artery and vein through a transbuccal approach for microvascular midface free flap repair.
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Affiliation(s)
- Elisabeth Gréant
- Department of Otorhinolaryngology & Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Gilles Van Haesendonck
- Department of Otorhinolaryngology & Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Callum Faris
- Department of Otorhinolaryngology & Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
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7
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Potential Complications With Cryopreserved Cadaveric Veins in Arteriovenous Loop Formation for Head and Neck Microvascular Reconstruction. J Craniofac Surg 2021; 32:1874-1876. [PMID: 33427784 DOI: 10.1097/scs.0000000000007413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Vessel depletion in the head and neck from radiation or previous surgical intervention adds to the operative complexity by limiting reconstructive options. Arteriovenous (AV) loop vascular grafts provide a conduit to bypass these nonviable local vessels to provide adequate blood flow. In certain situations, autologous donor vascular options are deficient or not readily available for creation of the AV loop. Cadaveric vein grafts provide an alternative option in these circumstances, but the efficacy and safety has not yet been delineated. In this study we discuss our experience utilizing cryopreserved cadaveric vein grafts for AV loop creation in head and neck reconstruction. In our initial cohort we aim to elucidate potential challenges and complications associated with the use of cadaveric vein grafts.
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8
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Common Carotid-to-Internal Jugular Arteriovenous Loop for Single-Stage Microsurgical Reconstruction in the Radiated Vessel-Depleted Neck. J Craniofac Surg 2021; 32:711-715. [PMID: 33705016 DOI: 10.1097/scs.0000000000006953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Management of head and neck defects in a radiated field can be quite challenging owing to the dearth of vasculature and significant degree of post-radiation fibrosis. In this setting, arteriovenous (AV) loop vascular grafts can bypass nonviable local vessels to provide viable and reliable inflow and outflow vessels for free tissue transfer in an otherwise hostile environment. Prior reports of the Corlett loop utilizing a cephalic vein transposition has been described however a common carotid-to-internal jugular AV loop has not been recently reported. Three patients underwent carotid artery to internal jugular vein AV loop creation to facilitate free-flap reconstruction secondary to radiation-induced vessel depletion. The specific technique described utilizes the saphenous vein as a donor and spares the cephalic vein for the possibility of flap complication. All three cases resulted in successful reconstruction, maintaining healthy tissue, vascular flow, and flap viability at all follow-up intervals. In our experience, vascular augmentation via AV loop formation provides reliable vascular inflow and outflow in the vessel-depleted neck to facilitate microvascular reconstruction. Sparing the cephalic vein yields an additional salvage mechanism in the event of venous congestion.
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9
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Honeyman C, Eschete M, Patel V, Martin D, McGurk M. Re: Use of the subclavian vessels for microvascular reconstruction in the vessel-depleted neck. A historical solution to a modern problem - the reverse flow, pedicled radial forearm flap as a back-up option in head and neck reconstruction. Br J Oral Maxillofac Surg 2021; 59:1106-1107. [PMID: 34266700 DOI: 10.1016/j.bjoms.2021.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 11/18/2022]
Affiliation(s)
- C Honeyman
- Department of Plastic and Reconstructive Surgery, Ninewells Hospital, Dundee, Scotland, United Kingdom.
| | - M Eschete
- Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - V Patel
- Oral Surgery Department, Guys Dental Institute, Guys & St Thomas NHS Foundation Trust, London, England, United Kingdom
| | - D Martin
- Private Practice, 35 Avenue des Pins 13013, Marseille
| | - M McGurk
- Department of Head and Neck Surgery, University College London Hospital, London, United Kingdom
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10
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Prince ADP, Broderick MT, Neal MEH, Spector ME. Head and Neck Reconstruction in the Vessel Depleted Neck. FRONTIERS OF ORAL AND MAXILLOFACIAL MEDICINE 2020; 2. [PMID: 33236000 DOI: 10.21037/fomm-20-38] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
| | | | - Molly E Heft Neal
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan
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11
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The vessel-depleted neck in head and neck microvascular reconstruction: extreme solutions for extreme situations. Curr Opin Otolaryngol Head Neck Surg 2020; 28:129-135. [DOI: 10.1097/moo.0000000000000611] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Patel SY, Meram AT, Kim DD. Soft Tissue Reconstruction for Head and Neck Ablative Defects. Oral Maxillofac Surg Clin North Am 2019; 31:39-68. [PMID: 30449526 DOI: 10.1016/j.coms.2018.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Soft tissue reconstruction of head and neck ablative defects is a broad, challenging, and subjective topic. The authors outline goals to keep in mind when deciding on a primary reconstructive option for defects created by oncologic resection. Factors considered in local, regional, and distant flap selection are discussed. Based on the goals of reconstruction and factors involved in flap selection, a defect-based reconstructive algorithm is developed to help choose the ideal reconstructive option. The authors also discuss indications, pearls, pitfalls, and challenges in the harvest and inset of commonly used soft tissue flaps for head and neck reconstructive surgery.
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Affiliation(s)
- Stavan Y Patel
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA.
| | - Andrew T Meram
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA
| | - Dongsoo D Kim
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA
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13
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Frohwitter G, Rau A, Kesting MR, Fichter A. Microvascular reconstruction in the vessel depleted neck – A systematic review. J Craniomaxillofac Surg 2018; 46:1652-1658. [DOI: 10.1016/j.jcms.2018.05.051] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/25/2018] [Accepted: 05/29/2018] [Indexed: 11/24/2022] Open
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14
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Morel F, Crampon F, Adnot J, Litzler PY, Duparc F, Trost O. Rerouting the internal thoracic pedicle: a novel solution for maxillofacial reconstruction in vessel-depleted situations? A preliminary anatomic study. Surg Radiol Anat 2018; 40:911-916. [PMID: 29289988 DOI: 10.1007/s00276-017-1965-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/20/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Microsurgical reconstruction in a vessel-depleted neck is a challenge due to the lack of reliable vessels in or nearby the host site. The use of the internal thoracic pedicle (ITP) by rib section or sparring is a limited option due to the small length of the pedicle of some flaps. However, in cardiac surgery, the internal thoracic artery (ITA) is widely used for myocardial revascularization, providing a long and versatile pedicle. We aimed at determining precise anatomical bases for the use of the ITP, approached by sternotomy and rerouted in the neck, as recipient vessels for free-flap facial reconstructions. METHODS We performed a descriptive single centre anatomical study on 20 formalin-embalmed cadavers. The ITP was harvested on both sides from the emergence of the artery under the brachiocephalic vein to its terminal division. The level reached by the ITP in the cervicofacial area was described. Distal arterial and venous diameters, pedicle length and other parameters were measured. RESULTS In at least 85% of the cases, the ITP reached the mandibular angle. The mean diameter at the distal extremity for the ITA was 2.36 ± 0.15, and 2.48 ± 0.19 mm for the committing vein. The mean length of the ITP was 177.3 mm. CONCLUSION Rerouting the ITP towards the cervicofacial area could provide a reliable pedicle for free-flap reconstructions in patients with a vessel-depleted neck but it should be limited to selected patients. This novel solution for situations where current techniques are unfeasible warrants further clinical research.
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Affiliation(s)
- François Morel
- Department of Oral and Maxillofacial Surgery, Rouen University Hospital, Rouen, France
| | - Frédéric Crampon
- Laboratory of Anatomy, Rouen Faculty of Medicine, 22, Boulevard Léon-Gambetta, 76000, Rouen, France
| | - Jérôme Adnot
- Department of Oral and Maxillofacial Surgery, Rouen University Hospital, Rouen, France
| | - Pierre-Yves Litzler
- Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital, Rouen, France.,French National Institute for Health (INSERM), U-1096, Rouen, France
| | - Fabrice Duparc
- Laboratory of Anatomy, Rouen Faculty of Medicine, 22, Boulevard Léon-Gambetta, 76000, Rouen, France
| | - Olivier Trost
- Department of Oral and Maxillofacial Surgery, Rouen University Hospital, Rouen, France. .,Laboratory of Anatomy, Rouen Faculty of Medicine, 22, Boulevard Léon-Gambetta, 76000, Rouen, France. .,French National Institute for Health (INSERM), LIMICS UMR-1142, Rouen, France.
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15
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Knackstedt R, Aliotta R, Gatherwright J, Djohan R, Gastman B, Schwarz G, Hendrickson M, Gurunluoglu R. Single-stage versus two-stage arteriovenous loop microsurgical reconstruction: A meta-analysis of the literature. Microsurgery 2017; 38:706-717. [DOI: 10.1002/micr.30204] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/05/2017] [Accepted: 06/30/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Rebecca Knackstedt
- Department of Plastic & Reconstructive Surgery; Cleveland Clinic; Cleveland Ohio
| | - Rachel Aliotta
- Department of Plastic & Reconstructive Surgery; Cleveland Clinic; Cleveland Ohio
| | - James Gatherwright
- Department of Plastic & Reconstructive Surgery; Cleveland Clinic; Cleveland Ohio
| | - Risal Djohan
- Department of Plastic & Reconstructive Surgery; Cleveland Clinic; Cleveland Ohio
| | - Brian Gastman
- Department of Plastic & Reconstructive Surgery; Cleveland Clinic; Cleveland Ohio
| | - Graham Schwarz
- Department of Plastic & Reconstructive Surgery; Cleveland Clinic; Cleveland Ohio
| | - Mark Hendrickson
- Department of Plastic & Reconstructive Surgery; Cleveland Clinic; Cleveland Ohio
| | - Raffi Gurunluoglu
- Department of Plastic & Reconstructive Surgery; Cleveland Clinic; Cleveland Ohio
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16
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New aspects in free flap surgery: Mini-perforator flaps and extracorporeal flap perfusion. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2017. [PMID: 28642191 DOI: 10.1016/j.jormas.2017.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND The scope of microvascular tissue transfer in the Head and Neck reaches from coverage of simple soft tissue defects to complex 3-D reconstructions using multiple or chimeric flaps. This paper summarises the presentation given at the Congress of the French Society of Oral and Maxillofacial Surgery in Marseille 2017. It was the aim of our work to add further elements to this wide spectrum of reconstructive possibilities. METHODS For patients with small intraoral soft tissue defects in whom the use of a radial forearm flap would not be justified because of its donor site morbidity, but who nevertheless would take a benefit from a small free flap, we used mini-perforator flaps from the lower leg. These flaps were raised with negligible morbidity. Moreover, for patients necessarily needing a free flap, but having vessel depleted, irradiated necks, we have developed a first idea of extracorporeal flap perfusion to make microvascular anastomoses unnecessary. RESULTS Using donor sites from the lower leg, mini-soleus and medial sural perforator flaps were raised to cover defects of 2×3 to 2×4cm at the anterior floor of the mouth or lateral tongue. The success rate was 91%, and despite their small size, the flaps helped to maintain the mobility of the tongue. The donor site morbidity was minimal. After extensive experimental work on small animals and human tissue, four flaps could successfully be transferred so far by means of extracorporeal perfusion. In these patients, autonomisation took place between 5 and 12 days. CONCLUSIONS Although microvascular tissue transfer already allows for reconstruction in almost any possible defect constellation, mini-perforator flaps and machine-perfused transplants seem to represent new aspects of free flap surgery, being useful extensions of the reconstructive surgeon's armament.
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Kasai S, Nagasao T, Sakamoto Y, Shimizu Y, Imanishi N, Kishi K. An anatomical study on the availability of contralateral recipient vessels in hemi-mandibular reconstruction with vascularised free fibula transfer. J Plast Surg Hand Surg 2017; 51:358-361. [DOI: 10.1080/2000656x.2017.1281820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Shogo Kasai
- Department of Plastic and Reconstructive Surgery, Keio University, Tokyo, Japan
| | - Tomohisa Nagasao
- Department of Plastic, Reconstructive and Aesthetic Surgery, Kagawa University, School of Medicine, Takamatsu, Japan
| | - Yoshiaki Sakamoto
- Department of Plastic and Reconstructive Surgery, Keio University, Tokyo, Japan
| | - Yusuke Shimizu
- Department of Plastic and Reconstructive Surgery, Ryukyu University Hospital, Naha, Japan
| | | | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University, Tokyo, Japan
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Wolff KD, Mücke T, von Bomhard A, Ritschl LM, Schneider J, Humbs M, Fichter AM. Free flap transplantation using an extracorporeal perfusion device: First three cases. J Craniomaxillofac Surg 2016; 44:148-54. [DOI: 10.1016/j.jcms.2015.11.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 11/10/2015] [Indexed: 11/29/2022] Open
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Brandtner C, Bürger H, Hachleitner J, Gaggl A. The intraoral anastomosing technique in reconstructive surgery of the face – A consecutive case series of 70 patients. J Craniomaxillofac Surg 2015; 43:1763-8. [DOI: 10.1016/j.jcms.2015.07.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 07/17/2015] [Accepted: 07/20/2015] [Indexed: 11/16/2022] Open
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Moubayed SP, Giot JP, Odobescu A, Guertin L, Harris PG, Danino MA. Arteriovenous fistulas for microvascular head and neck reconstruction. Plast Surg (Oakv) 2015; 23:167-70. [PMID: 26361623 DOI: 10.4172/plastic-surgery.1000925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In head and neck cancer patients, multiple surgeries and radiation can leave the neck depleted of recipient vessels appropriate for microvascular reconstruction. The creation of temporary arteriovenous fistulas using venous interposition for subsequent microvascular reconstruction has rarely been reported in the head and neck. The authors report the largest series of temporary arteriovenous loops for head and neck reconstruction in vessel-depleted necks. METHODS The authors performed a case series of major head and neck reconstructions using temporary arteriovenous fistulas with a saphenous vein graft. A subclavian surgical approach was used. All reconstructions were performed at least two weeks after the creation of the initial fistula. RESULTS The authors have performed nine reconstructive cases for malignancy using five different free flaps. The subclavian and transerve cervical arteries were used, and the subclavian, internal jugular and cephalic veins were used for microanastomosis. Two cases of flap hematoma and one case of venous pedicle compression were recorded. No cases of flap failure were reported. CONCLUSIONS Reconstruction using temporary arteriovenous fistulas is a reliable technique that can be used in the vessel-depleted neck, with excellent outcomes in experienced hands.
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Affiliation(s)
- Sami P Moubayed
- Otolaryngology-Head and Neck Surgery Service, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
| | - Jean-Philippe Giot
- Plastic Surgery Service, Department of Surgery, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
| | - Andrei Odobescu
- Plastic Surgery Service, Department of Surgery, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
| | - Louis Guertin
- Otolaryngology-Head and Neck Surgery Service, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
| | - Patrick G Harris
- Plastic Surgery Service, Department of Surgery, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
| | - Michel Alain Danino
- Plastic Surgery Service, Department of Surgery, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
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Moubayed SP, Giot JP, Odobescu A, Guertin L, Harris PG, Danino MA. Arteriovenous fistulas for microvascular head and neck reconstruction. Plast Surg (Oakv) 2015. [DOI: 10.1177/229255031502300302] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background In head and neck cancer patients, multiple surgeries and radiation can leave the neck depleted of recipient vessels appropriate for microvascular reconstruction. The creation of temporary arteriovenous fistulas using venous interposition for subsequent microvascular reconstruction has rarely been reported in the head and neck. The authors report the largest series of temporary arteriovenous loops for head and neck reconstruction in vessel-depleted necks. Methods The authors performed a case series of major head and neck reconstructions using temporary arteriovenous fistulas with a saphenous vein graft. A subclavian surgical approach was used. All reconstructions were performed at least two weeks after the creation of the initial fistula. Results The authors have performed nine reconstructive cases for malignancy using five different free flaps. The subclavian and transerve cervical arteries were used, and the subclavian, internal jugular and cephalic veins were used for microanastomosis. Two cases of flap hematoma and one case of venous pedicle compression were recorded. No cases of flap failure were reported. Conclusions Reconstruction using temporary arteriovenous fistulas is a reliable technique that can be used in the vessel-depleted neck, with excellent outcomes in experienced hands.
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Affiliation(s)
- Sami P Moubayed
- Otolaryngology-Head and Neck Surgery Service, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
| | - Jean-Philippe Giot
- Plastic Surgery Service, Department of Surgery, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
| | - Andrei Odobescu
- Plastic Surgery Service, Department of Surgery, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
| | - Louis Guertin
- Otolaryngology-Head and Neck Surgery Service, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
| | - Patrick G Harris
- Plastic Surgery Service, Department of Surgery, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
| | - Michel Alain Danino
- Plastic Surgery Service, Department of Surgery, Université de Montréal Hospital Center (CHUM), Montreal, Quebec
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Zaoui K, Federspil P, Plinkert PK, Simon C. [Grafts with microvascular anastomosis. Their use in the head and neck region following radiotherapy and vessel depletion]. HNO 2013; 61:573-9. [PMID: 23532515 DOI: 10.1007/s00106-013-2673-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Surgical tumor removal is often the treatment of choice in patients with head and neck squamous cell carcinoma. Depending on the extent of tumor resection, large defects are often produced in the individual head and neck regions, necessitating reconstructive surgery to avoid further functional impairment. In principle, this decision depends on the size and location of the defect, the aesthetic importance of the region and the functional significance of the area to be replaced. Reconstructive free flap procedures in patients who have undergone radiotherapy or exhibit vessel depletion in the neck due to multiple previous surgical interventions are particularly challenging. In order to ensure the best possible outcomes of surgical oncology therapies under difficult circumstances, this paper discusses the important factors and variables that can increase the success rate of microvascular grafts in irradiated or multiply resected patients.
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Affiliation(s)
- K Zaoui
- Hals-Nasen-Ohrenklinik, Universitätsklinikum Heidelberg.
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Su T, Pirgousis P, Fernandes R. Versatility of Supraclavicular Artery Island Flap in Head and Neck Reconstruction of Vessel-Depleted and Difficult Necks. J Oral Maxillofac Surg 2013; 71:622-7. [DOI: 10.1016/j.joms.2012.07.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 07/05/2012] [Accepted: 07/05/2012] [Indexed: 11/24/2022]
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Karle WE, Anand SM, Clain JB, Scherl S, Buchbinder D, Smith ML, Urken ML. Use of a combined latissimus dorsi scapular free flap revascularized with vein grafting to the internal mammary artery in a vessel-depleted and previously irradiated neck. Head Neck 2012; 35:E328-32. [PMID: 23152141 DOI: 10.1002/hed.23194] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2012] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND For patients who have extensive prior treatment, use of the internal mammary artery/vein (IMA/IMV) or cephalic vein has been shown to be a reliable option. Additionally, for those patients who require vascularized bone and extensive soft tissue reconstruction, the combined latissimus dorsi scapular free flap (mega-flap) is an excellent option. METHODS We reviewed 3 cases in which extensive prior surgery and radiation precluded the use of traditional recipient vessels in the neck. RESULTS Three patients with major jaw deformities were reconstructed using a mega-flap. In all cases, saphenous vein grafting succeeded in achieving arterial inflow from the IMA to the subscapular artery. Venous egress was achieved using a vein graft to the IMV in 1 patient and a transposed cephalic vein in the remaining 2 patients. CONCLUSIONS This approach of restoring large oral cavity defects for patients with extensive prior therapy and comorbid conditions has proven to be reliable and reproducible.
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Affiliation(s)
- William E Karle
- Albert Einstein College of Medicine, New York, New York; Thyroid Head and Neck Cancer Foundation, New York, New York
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Nagasao T, Shimizu Y, Kasai S, Hatano A, Ding W, Jiang H, Kishi K, Imanishi N. Extension of the jejunum in the reconstruction of cervical oesophagus with free jejunum transfer using the thoracoacrominal vessels as recipients. J Plast Reconstr Aesthet Surg 2012; 65:156-62. [DOI: 10.1016/j.bjps.2011.08.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 08/16/2011] [Accepted: 08/21/2011] [Indexed: 11/29/2022]
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Brennan P, Shekar K, McLeod N, Puxeddu R, Cascarini L. A synopsis of oncology and oncology-related papers published in the British Journal of Oral and Maxillofacial Surgery 2007–2008. Br J Oral Maxillofac Surg 2009; 47:515-20. [DOI: 10.1016/j.bjoms.2009.06.227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2009] [Indexed: 11/28/2022]
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Vasilakis V, Patel HDL, Chen HC. Head and neck reconstruction using cephalic vein transposition in the vessel-depleted neck. Microsurgery 2009; 29:598-602. [DOI: 10.1002/micr.20680] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Bibliography. Current world literature. Head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 2008; 16:394-7. [PMID: 18626261 DOI: 10.1097/moo.0b013e32830c1edc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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