An alternative option to overcome difficult venous return in head and neck free flap reconstruction

Coverage of radial forearm free flap donor site defect using another free flap

BACKGROUND

Donor site defects following the radial forearm flap (RFF) harvest have been usually covered with skin grafting, which often lead to suboptimal outcomes and donor morbidities, including delayed healing and scar contractures. The present report aimed to evaluate the outcomes of using another free flap, the domino flap, for coverage of donor site defects following RFFF harvest.

METHODS

Five patients (two males and three females) who underwent coverage of donor defects of RFFF using another free flap between 2019 and 2021 were reviewed. Their mean age was 74 years and the mean dimension of the defect of the RFF donor site was 8.7 × 5.6 cm. Four patients used an anterolateral thigh flap and one used a superficial circumflex iliac artery perforator flap.

RESULTS

The mean size of the domino flaps were 12.2 × 5.8 cm. Distal stumps of radial vessels adopting retrograde flow were used as recipients in four cases, and proximal ones adopting anterograde in one. The donor site of the domino flaps was primarily closed. All patients recovered well without any postoperative complications. Aesthetically pleasing outcomes with no functional impairment related to scar contractures were observed in the donor site of RFF during the mean follow-up of 15.7 months.

CONCLUSIONS

Use of another free flap for coverage of RFFF donor defects may provide rapid wound healing and satisfactory outcomes, and may be considered an alternative option in cases with large-sized defects that are expected to take a long time to achieve complete healing with skin grafting.

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

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

Potential of the common facial vein as a recipient vein in free flap reconstruction

Recipient vessel selection for free flap reconstruction depends on numerous factors and may be limited due to previous treatment. Currently, little evidence is available regarding the anatomy and reconstructive potential of the common facial vein (CFV), a tributary of the internal jugular vein (IJV). The aim of this project was to determine the diameter of the CFV at various points along its course and identify suitable landmarks to locate the CFV, to consider the vessel as a potential recipient vein in free flap reconstruction. A cadaveric study was conducted by dissecting 17 embalmed neck hemi-sections in the Keele University Medical School Anatomy Suite. Our intent was to describe the gross anatomy of the CFV in terms of diameter and relation to surrounding structures. We found the mean diameter of the CFV to be 5.9 (± 1.8) mm at its termination into the IJV. We also found the mean distance of the CFV termination into the IJV from the level of the hyoid bone was 8.0 (± 4.0) mm. The diameter of the CFV could accommodate for end-to-end anastomoses to be formed with the IJV system. The diameter also suggests the vein to be appropriate for microvascular anastomosis with commonly used free flaps. The results propose that the CFV can be found within 12 mm of the level of the hyoid bone, knowledge of which could reduce operative time and site morbidity. These findings support the CFV as a potential recipient vein in free flap reconstruction of the head and neck.

Reliability of Temporal Vascular Anastomosis and Techniques for Better Outcomes

BACKGROUND

 Although there are several potential recipient vessels in the neck, those in the temporal region are limited. In skull base reconstruction, there are difficulties associated with the anastomosing recipient vessels in the neck region since long nutrient vessels are needed in the flap. We evaluated the reliability of temporal vascular anastomosis by comparing surgical outcomes between reconstructive methods and examined which surgical procedures may achieve better results.

METHODS

 We examined the medical records of free tissue transfer cases between April 2007 and March 2018. Seventy-three surgeries were performed in the temporal region, including skull base reconstruction in 48, head and neck reconstruction (without skull base) in 16, and secondary surgery for head deformities in nine cases. In total, 445 neck surgeries were performed. Postoperative complications were retrospectively analyzed.

RESULTS

 The postoperative complication rates were 8.2 and 2.7% for all temporal and neck surgeries, respectively. There were no arterial complications in the temporal region and all of the six postoperative anastomotic complications were due to venous thrombosis. In contrast, there were 12 cases of vascular anastomotic complications, with six cases each of arterial and venous thrombosis in the neck. In the temporal region, the complication rate was 2.1% for skull base reconstruction, 11% for secondary revision, and 25% in head and neck reconstruction. The corresponding values for middle temporal vein (MTV) usage rates were 54, 22, and 25%. In skull base reconstruction, a coronal incision was made in all cases. A more frequent use of the MTV was associated with a reduced complication rate.

CONCLUSION

 The low complication rate in the temporal region was attributed to the wide surgical field and low tension of anastomotic vessels. Multiple venous anastomoses, including those of the MTV, are recommended to prevent complications.

Secondary Cervicofacial Soft Tissue Reconstruction With Upper Trapezius Myocutaneous Flap in "Frozen Neck" With Bone Flap and Reconstructive Plate Exposure

ABSTRACT

A frozen neck is a scarred neck with severe fibrosis with a loss of tissue planes secondary to prior irradiation with or without surgery. The purpose of this study was to evaluate the outcomes of cervicofacial reconstruction in patients with soft tissue defects and bone flap and reconstruction plate exposure with the upper trapezius myocutaneous flap. Fifteen oncologic patients with prior surgery and radiotherapy developed soft tissue dehiscence with bone and osteosynthesis material exposure. All patients had either a frozen neck or a vessel-depleted neck. The soft tissue defects were reconstructed, the osteosynthesis material was removed and the bone flap exposure was covered in all patients. One patient developed a seroma and 1 patient reported wound dehiscence. In terms of esthetic results, 6 patients referred a good esthetic result, whereas 8 patients referred a fair result and 1 patient a poor result. Two patients with prior radical neck dissection reported a poor functional result in the ipsilateral shoulder, previously to secondary reconstruction. Functional neck dissection was performed in 10 patients, 8 patients referred a good functional outcome and 2 patients reported a fair result. The upper trapezius flap is an extremely reliable source for secondary cervicofacial soft tissue reconstruction in "frozen neck." In comparison with other locoregional flaps, the upper trapezius flap fulfills all aesthetic and functional criteria for secondary cervicofacial soft tissue reconstruction.

Three salvage strategies in microvascular fibula osteocutaneous flap for mandible reconstruction with vascular compromise and establishment of an algorithm

BACKGROUND

Fibula osteocutaneous flap is associated with a higher rate of reexploration in mandible reconstruction due to limited space for the fixation of various tissue components on multiple segments of the fibula flap. To maintain optimal circulation to the flap and to prevent negative outcomes because of partial or total flap loss, we shared our experiences on salvaging the free fibula flap with vascular compromise in the first reexploration and we developed an algorithm.

METHODS

From 1992 to 2018, 12 patients between the ages of 48 to 63 (mean: 52.5) who had presented with oral squamous cell carcinoma (n = 10) followed by osteoradionecrosis of the mandible (n = 2) were explored. The operative findings were; (1) occlusions of vein (3 cases); (2) occlusions of artery (4 cases); and (3) occlusions of both artery and vein (5 cases). After correcting the kinking or evacuating the hematoma, the arterial inflow was initially reestablished by anterograde flow. If this was nonfunctional, retrograde flow from the distal end of the peroneal artery was provided. For the vein, anterograde venous drainage was reestablished. If the thrombus extended deep into the peroneal vein, regular venous return was blocked on the anterograde side, and the flap remained congested therefore retrograde venous drainage was performed regardless of the valves in the vein. However, the two ends of the peroneal artery were anastomosed to prevent thrombosis of the artery.

RESULTS

The success rate of revised cases was 75% (9/12). All failed cases had presented with both artery and vein occlusion (three cases). Pectoralis major musculocutaneous flap and anterolateral thigh flap were needed for the external surface in two cases. Skin graft was required for seven cases to restore intraoral lining. Six patients underwent dental rehabilitation with prosthetic implants.

CONCLUSION

Immediate reexploration is mandatory to salvage the flap.

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.

Comparison of the surgical outcomes of free flap reconstruction for primary and recurrent head and neck cancers: a case-controlled propensity score-matched study of 1,791 free flap reconstructions

This study was designed to compare the outcome and analyze the operation-related risk factors in free flap reconstruction for patients with primary and recurrent head and neck cancers. A 1:1 propensity score-matched analysis of the microsurgery registry database of the hospital. The primary outcome of the free flap reconstruction had a higher failure rate in the recurrent group than the primary group (5.1% vs. 3.1%, p = 0.037). Among the 345 pairs in the matched study population, there were no significant differences between the primary and recurrent groups regarding the rate of total flap loss (3.5% vs. 5.5%, p = 0.27) and secondary outcomes. This study revealed that free flap reconstruction had a higher failure rate in the recurrent group than the primary group, but such a difference may be attributed by the different patient characteristics.

Reverse blood flow in cervicofacial veins after venous ligations: Potential implications in microsurgery

INTRODUCTION

The consequences on the cervicofacial venous circulation of major cervicofacial vein ligations are poorly known. We aimed to highlight by using Doppler Ultrasound flow differences in the cervicofacial venous network in the case of unilateral or bilateral ligation of main venous collector trunks (external jugular vein [EJV] and internal jugular vein [IJV]) METHODS: A Doppler ultrasound was performed on 10 healthy volunteers, 8 patients with previous bilateral ligation of the EJV, 8 with a unilateral ligation of the EJV, and 8 with a unilateral ligation of the EJV and IJV, after modified radical neck dissection. The diameter, the flow direction and the peak systolic velocity (PSV) of the superficial temporal vein, the facial vein (FV) and the IJV were measured.

RESULTS

Healthy patients had a similar right and left PSV for all the veins studied, with always antegrade flows. Patients with previous ligations had some significant right/left differences and retrograde flows.

CONCLUSION

A redistribution of venous blood flow on the contralateral side of the face and neck seems to take place in the case of unilateral ligation of the EJV and/or IJV. Retrograde flows are sometimes observed in the case of previous ligation of the EJV and/or IJV and might compromise the success of venous microanastomoses.

[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.

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.

Soft Tissue Reconstruction for Head and Neck Ablative Defects

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.

Double-island anterolateral thigh free flap used in reconstruction for salvage surgery for locally recurrent head and neck carcinoma

Salvage surgery is usually the only treatment for recurrent head and neck tumors but often poses a challenge to surgeons due to post-resected defects at 2 or more sites. Here we present the outcomes and rationale for reconstruction by a double-island anterolateral thigh (ALT) free flap following the salvage surgery.Patients treated with double-island ALT free flaps in salvage surgery between September 2012 and January 2017 at West China Hospital, Sichuan University were retrospectively viewed.A total of 18 patients (15 males) underwent reconstruction with double-island ALT free flaps (range from 40 to 77 years old). All patients had recurrent tumors after surgery and/or chemoradiotherapy and were selected for salvage surgery by a multidisciplinary team. The flaps were initially harvested as 7 cm × 7 cm to 16 cm × 10 cm single blocks and then divided into double-island flaps with each individual paddle ranging from5 cm × 3 cm to 10 cm × 8 cm. The average flap thickness was 3.5 cm (range from 2 to 6 cm), and the average pedicle length was 8 cm (range from 6 to 10 cm). A total of 18 arteries and 32 veins were anastomosed. Three patients developed fistula, 1 developed flap failure due to thrombosis and was re-operated with a pedicle flap. One patient died of pulmonary infection 6 months after the operation.Flap reconstruction for complex head and neck defects after salvage surgery remains challenging, but double-island ALT free flap reconstruction conducted by a multidisciplinary team and experienced surgeons would have a role in this setting.