Reliability of internal jugular vein in oral microvascular reconstruction

The Impact of Venous Anastomosis Technique on Outcomes of Free Tissue Transfer to the Head and Neck

Objectives: To evaluate the impact of different techniques of microvascular venous anastomosis on the outcome of free tissue transfer to the head and neck. Methods: Retrospective case series of patients undergoing microvascular free tissue transfer (MFTT) from January 2006 to September 2021. Chi-square tests and t-tests were utilized to identify differences in flap outcomes by technique, and log-binomial regression analyses were utilized to identify differences in flap outcomes by technique. Results: A total of 1055 consecutive MFTTs were analyzed. One hundred four cases required a return to the operating room for any reason, and 19 were attributed to venous compromise (18.0%). Ultimately, there were 22 FTT failures requiring complete revision (2.1%). In total, 1055 MFTTs involved 1352 venous anastomoses, ranging from 1 to 3 anastomoses in each case. End-to-end (ETE) was used 1040 times (76.9%) and end-to-side (ETS) 204 times (15.0%). The calculated risk ratio for venous complication for ETS compared with ETE was 1.17 (0.34-3.98). A microvascular coupler was used in 355 cases (33.6%). The calculated risk ratio for coupler compared with suture anastomoses was 0.92 (0.35-2.39). Conclusions: There were no significant difference in regard to outcomes of MFTT when comparing ETE with ETS, nor when comparing coupler with suture anastomoses.

Safety and reliability of the internal jugular vein for venous anastomoses in head and neck oncological reconstruction: A retrospective study

This study aimed to assess the efficacy of utilizing the internal jugular vein (IJV) as the primary recipient site for venous anastomoses in head and neck oncological reconstruction. Patients who underwent a free flap reconstruction of the head and neck were retrospectively included. Venous anastomoses were preferentially performed less than 1 cm from the IJV, either end-to-side (EtS) on the IJV, or end-to-end (EtE) on the origin of the thyrolingofacial venous (TLF) trunk. When the pedicle length was insufficient to reach the IJV, anastomoses were performed EtE to a size-matched cervical vein. Of the 246 venous anastomoses, 216 (87.8%) were performed less than 1 cm from the IJV, including 150 EtS on the IJV (61.0%), and 66 EtE on the TLF trunk (26.8%). Thirty veins (12.1%) were anastomosed EtE on other cervical veins more than 1 cm from the IJV. Two venous thromboses occurred (0.9%) and were successfully managed after revision surgery. There was no evidence of an increased thrombosis rate in high-risk or pre-irradiated patients. These findings suggest that the internal jugular vein is safe and reliable as a first-choice recipient vessel for free flap transfers in head and neck oncological reconstruction.

Internal jugular vein thrombosis and pulmonary thromboembolism after head and neck reconstructive surgery

BACKGROUND

Free flap failure secondary to internal jugular vein thrombosis (IJVT) is a significant complication after head and neck reconstructive surgery. A consensus has not yet been reached among reconstructive surgeons regarding the treatment of IJVT.

METHODS

We retrospectively evaluated the incidence of IJVT in 118 patients who underwent free flap reconstruction at Hyogo Cancer Center, Akashi, Japan. The occurrence of IJVT-related flap circulation crisis and pulmonary thromboembolism (PTE) was studied. This study was approved by the institutional ethics committee, and written informed consent was obtained from each patient.

RESULTS

From 118 patients who underwent head and neck reconstructive surgery, we included 116 internal jugular veins (IJVs) preserved after neck dissection in the present study. IJVT was confirmed in 25 (21.6%) IJVs from 23 patients. One patient (0.8%) developed venous congestion due to IJVT, which resulted in total flap necrosis. Two patients (1.7%) exhibited PTE associated with IJVT. They were treated with direct oral anticoagulants for 3 months and were discharged without any sequelae.

CONCLUSION

Our results suggest that IJVT after head and neck reconstructive surgery caused not only flap circulation crisis but also PTE. Reconstructive surgeons should be aware of the potential risks due to serious complications associated with IJVT.

Outcomes of Venous End-to-Side Microvascular Anastomoses of the Head and Neck

Objectives/Hypothesis

The literature on outcomes of end‐to‐side (ETS) anastomoses for microvascular reconstruction of the head and neck is limited. This series reviews ETS in free tissue transfer (FTT) across multiple institutions to better understand their usage and associated outcomes.

Study Design

Retrospective review of 2482 consecutive patients across three tertiary institutions.

Methods

Adult patients (> 18) who received a FTT from 2006 to 2019 were included.

Results

Two hundred and twenty‐one FTT were identified as requiring at least one ETS anastomosis. These ETS cases had a failure rate of 11.2% in comparison to 3.8% in a cohort of end‐to‐end (ETE) cases (P < .001). ETS cases were significantly more likely to have a prior neck dissection (P < .001), suggesting the ETS method was utilized in select circumstances. A second ETS anastomosis improved survival of the FTT (P = .006), as did utilization of a coupler over suture (P = .002). Failure due to venous thrombosis was significantly more common with one ETS anastomosis instead of two ETS anastomoses (P = .042).

Conclusions

ETS is effective but is often used as a secondary technique when ETE is not feasible; as such, in this series, ETS was associated with higher failure. A second anastomosis and the use of the coupler for completing the anastomoses were associated with lower rates of failure.

Level of Evidence

3 Laryngoscope, 131:1286–1290, 2021

Go for the jugular: a 10-year experience with end-to-side anastomosis to the internal jugular vein in 320 head and neck free flaps

Preferential use of end-to-side anastomosis to the internal jugular vein in head and neck reconstruction offers distinct advantages and has consistently yielded excellent outcomes. Presented is a series of 320 consecutive cases by a single surgeon at 1 institution over 10 years. The most common flaps employed were the rectus (33%), forearm (28%), and fibula (21%) flaps. The most common defects were the mandible +/- floor of mouth (27%), pharyngoesophagus (25%), and tongue or cheek (17% each). Minor wound-healing problems, infection, and hematoma were noted in 5% or less. Partial flap loss was seen in 2%. Total flap loss and arterial or venous thrombosis occurred in less than 1% of patients. The size, constant anatomy, patency, and possibility for multiple anastomoses make use of the internal jugular vein very advantageous. Kinking is not observed when the neck is rotated, and high patency rates can be expected.

Availability of End-to-Side Arterial Anastomosis to the External Carotid Artery Using Short-Thread Double-Needle Microsuture in Free-Flap Transfer for Head and Neck Reconstruction

We seldom have difficulties in the selection of appropriate recipient arteries for microvascular free flap transfer in the head and neck region because many sizable branches (branch artery) of the external carotid artery (ECA) or subclavian artery are available. However, we occasionally encountered the lack of an appropriate recipient artery, especially in secondary reconstruction or reconstruction following the extensive ablation of recurrent cancer. For these challenging cases, we have used end-to-side arterial anastomosis directly to the ECA. Between July 1997 and December 2004, end-to-side anastomosis of the flap artery to the ECA was employed in 16 cases. The reason for its use included the marked size discrepancy between the jejunal artery and branch artery in 4 jejunal transfer cases, the lack of 2 appropriate recipient arteries for double free flap transfers in 1 case, and the lack of an available branch artery as a recipient due to poor regional conditions in 11 cases. Fifteen of 16 flaps underwent an uneventful postoperative course, except 1 whose flap artery was pressed by the submandibular gland and sustained thrombosis 3 days postoperatively. In this case, however, the flap survived perfectly after prompt thrombectomy and reanastomosis. Eventually, all 16 flaps survived completely. We reconfirmed the availability of end-to-side anastomosis to the ECA when a suitable branch artery is not available. Although end-to-side anastomosis to the ECA is laborious compared with end-to-end anastomosis, our newly developed short-thread double-needle microsuture combined with the back-wall-first technique helps to ensure easier anastomosis. Using this device, because all stitches are carried from inside the vessel to outside, the surgeon can place the first stitch at any point on the posterior wall and advance the next suture to the preferred site of the previous suture, and suturing can be performed more safely even in cases where the tunica intima is separated from the tunica media due to arteriosclerosis, previous irradiation, or surgery.

Patency assessment of the internal jugular vein after neck dissection

Twenty-seven patients with oral malignant tumours, who underwent neck dissection with preservation of the internal jugular vein (IJV), were studied retrospectively to evaluate patency of the IJV. Twenty-three patients underwent ablative surgery of the primary lesion with neck dissection and 4 underwent neck dissection alone. Three patients received simple closure and skin grafting of the primary lesion, and 20 received reconstruction surgery (4 platysma flaps, 3 radial forearm flaps, 3 lateral upper arm flaps, 2 pectoralis major myocutaneous flaps and 8 rectus abdominis myocutaneous flaps). The maximum and minimum diameters of the IJV as measured on computed tomographic (CT) scans were used to assess patency. The cross-sectional area of the IJV and the ratio of its long axis to short axis (L/S ratio) were calculated. The relation between the change in IJV status and the type of flap used for reconstruction was also examined. Occlusion of the IJV was present in 3.7% of the patients, and 'narrowing' was present in 63.6%. The size of the flap significantly correlated with 'narrowing' of the IJV, suggesting that 'narrowing' was caused mainly by compression due to the flap.

Salvage operations of free tissue transfer following internal jugular venous thrombosis: a review of 4 cases

The internal jugular vein (IJV) is used as the optimal recipient for free-tissue transfer in reconstruction following modified radical neck dissection. Some reports documented rare cases of flap compromise following IJV thrombosis, but large sample studies are few. We present cases of emergent exploration and an analysis of factors to improve salvage rates of compromise due to IJV thrombosis. From a survey of 756 patients, four developed congestion due to IJV thrombosis and returned to the operating room. A restrospective analysis was made from the case records. This represents a rate of 0.5% for the entire series. Three flaps survived,and one failed. Detection of compromise ranged from 7-25 h postoperatively. All four IJVs recovered to provide adequate drainage after thrombectomy. While flap compromise following IJV thrombosis is rare, careful observation and early exploration are crucial for salvage, as in other microvascular venous crises.

Management of flaps with compromised venous outflow in head and neck microsurgical reconstruction

Microvascular tissue transfer has become an indispensable procedure for head and neck reconstruction. Although remarkable progress has been made technically, anastomosed vessel occlusion is still a serious complication. Even with technically skilled microsurgeons, anastomosed vessel occlusion occurs because the technique is not the sole prophylaxis against thrombosis in microsurgery. Therefore, to minimize the possibility of an unfavorable result in microsurgery, microsurgeons must be familiar with management options for a vascular compromised flap. Most investigators have agreed that venous obstruction occurs more often than arterial obstruction. Here, we reviewed the published literature on the salvage of venous compromised flaps from the viewpoints of surgical correction, including reanastomosis and catheter thrombectomy, and nonsurgical procedures, such as a medicinal leech, hyperbaric oxygen, and thrombolytic therapy.

Internal jugular vein occlusion in head and neck microsurgical reconstruction

The internal jugular vein has been the preferred recipient vein in head and neck microsurgical reconstruction. However, recent reports have demonstrated internal jugular vein occlusion after functional neck dissection. The purpose of this article is to demonstrate and discuss the possibility of recipient internal jugular vein occlusion after free tissue transfer. Of 58 patients who received an end-to-side venous anastomosis with the internal jugular vein, four cases of recipient internal jugular vein occlusion were detected during the early postoperative period. Although the success rate of end-to-side anastomosis with the internal jugular vein may be high, microsurgeons should be aware of the possibility of internal jugular vein occlusion.

Comparison of reliability between the modified groin flap and the forearm flap in oral reconstruction

OBJECTIVE

The groin flap has the advantage of minimum donor-site morbidity, while having the disadvantage of short vascular pedicle of small caliber. Modification of the groin flap has improved the former disadvantage, but the latter one remains. The purpose of this study was to compare the reliability of the modified groin flap with the forearm flap.

STUDY DESIGN

Eleven modified groin flaps and 40 forearm flaps consecutively performed by a single surgeon in a hospital for patients with oral cancer were retrospectively reviewed.

RESULTS

The rate of total flap loss in the modified groin flap group (8.3%) was higher than that in the forearm flap group (2.5%). The rates of partial flap loss in both flaps were similar to those of total flap loss. The failures of the modified groin flap and the forearm flap were due to arterial and venous complications, respectively.

CONCLUSION

The modified groin flap appears to be a little less reliable than is forearm flap; nevertheless, it could be a good option for patients who desire less conspicuous postoperative scars.

The effect of head rotation on the diameter of the internal jugular vein: implications for free tissue transfer

PURPOSE

To determine the effects of medial (inwards) and lateral (outwards) rotation of the head on the transverse diameter of the internal jugular vein.

MATERIAL

The original study sample included 26 patients. Duplex ultrasound was used to measure the transverse diameter of the internal jugular vein at a fixed point on either side of the neck. Measurements were taken with the head central (neutral position), rotated laterally and medially.

RESULTS

Using Student's t-test we found that lateral rotation of the head produced a reduction in the mean of the transverse diameters of the left and right ipsilateral vein from 6.9 mm to 5.4 mm (p < 0.03) and 5.9 mm to 5.0 mm (p = 0.2173) respectively. One patient excluded from the study because of previous neck surgery showed complete occlusion of the ipsilateral internal jugular vein on lateral rotation of the head.

CONCLUSION

There is a possibility that patency of the vein could be compromised if the head is turned laterally. This situation may arise immediately after surgery in the ventilated and paralysed patient when the head may be unsupported. It could be of particular importance if the vein has been used as a recipient vein for free tissue transfer.

Macrophage-derived chemokine (MDC/CCL22) and CCR4 are involved in the formation of T lymphocyte-dendritic cell clusters in human inflamed skin and secondary lymphoid tissue

Our previous study demonstrated formation of T cell-dendritic cell (DC) clusters in inflamed dermis of intraorally autotransplanted skin flaps. Such T cell-DC clusters are supposed to be important for close interactions between T cells and DCs including the specific antigen presentation. Here we show the involvement of the macrophage-derived chemokine (MDC/CCL22) and its specific receptor CC chemokine receptor 4 (CCR4) in the formation of T cell-DC clusters. Reverse transcriptase-polymerase chain reaction analysis revealed high levels of mRNA expression for MDC and CCR4 in inflamed skin and neck lymph nodes (LNs), but not in normal skin. Immunohistochemically, MDC(+) cells and CCR4(+) cells were mainly located within the T cell-DC clusters both in the dermis of inflamed skin and the T cell area of LNs. MDC(+) cells were identified to be DCs both in inflamed skin and LNs. The majority of CCR4(+) cells were CD4(+) T cells, accounting for approximately one-third of total CD4(+) T cells in the inflamed skin. Our data suggest that the MDC-CCR4 system plays an important role in the formation of T cell-DC clusters both in inflamed skin and LNs.

Internal jugular vein versus external jugular vein anastamosis: Implications for successful free tissue transfer

BACKGROUND

Microvascular free flaps are becoming the reconstructive option of choice for many head and neck defects. Many previous studies have examined factors predicting free flap survival. No study has compared differences in free flap survival when anastomosed to the internal or external jugular systems.

METHODS

Retrospective review of all free flaps performed at an academic medical center by a single head and neck microvascular surgeon during the period July 1995 to December 1999. Flaps were closely monitored postoperatively and taken back to the operating room urgently for arterial insufficiency or venous congestion.

RESULTS

On hundred fifty-six free flaps were performed during this time period. Sixty-five free flaps were anastomosed to the external jugular (EJ) vein and 86 to the IJ system (62 to the proximal common facial vein, 17 end-side on the IJ, and 7 to other branches). Five had either two venous anastomoses or were anastomosed to other veins and were excluded from statistical analysis. Six (4%) vascular thromboses occurred; 5 were venous and 1 arterial. Success by group was 99% for IJ anastomosis (1 arterial thrombosis) and 92% for EJ anastomosis (5 venous thromboses, p =.03). Urgent anastomotic revision and reperfusion salvaged 5 of the 6 flaps (overall success 99%).

CONCLUSIONS

Although the overall success rate (96% success with 99% success with salvage) is comparable to other large series, microvascular free flaps anastomosed to the external jugular vein failed at a significantly higher rate than those anastomosed to the IJ system. This suggests that the IJ system should be used as a recipient vessel when feasible.

Immunological activation of dermal Langerhans cells in contact with lymphocytes in a model of human inflamed skin

Langerhans cells play an important role in the skin's immune system. Little is known, however, about the antigen-presenting capacity of Langerhans cells in the context of skin inflammation. By immunohistochemistry we investigated the phenotypic characteristics of epidermal and dermal Langerhans cells and their spatial relationship with infiltrating lymphocytes. We studied skin flaps autotransplanted to the oral cavity to fill a defect after maxillofacial cancer surgery. In 15 of 21 cases sampled for the present study, the skin flaps were severely inflamed by Candida albicans infection. In contrast to the normal skin, such inflamed skin showed a marked increase in CD1a(+) dermal Langerhans cells. Double immunohistochemistry revealed that dermal Langerhans cells abundantly expressed B7-2 (CD86), a representative costimulatory molecule, and CD83, a marker of mature dendritic cells. Furthermore, these dermal Langerhans cells were in close contact with CD4(+)/CD45RO(+) lymphocytes. This cell-to-cell contact was further visualized by immunoelectron microscopy. Langerhans cells were also observed within lymphatic vessels that were identified by the expression of vascular endothelial growth factor receptor-3. Ki-67 labeling indices were 4.2% in CD4(+) T cells and 0.8% in CD8(+) T cells within the dermis. Factor XIIIa(+) dermal dendrocytes were distributed outside the clusters of lymphocytes and were not in contact with them. Our observations indicate that dermal Langerhans cells in the inflamed skin are activated to express common phenotypes to mature dendritic cells so that they could stimulate neighboring memory CD4(+) T cells.