Anatomic variations in head and neck reconstruction

Trapezius Muscle Flap for Posterior Neck and Shoulder Defects Following Malignant Tumor Resection-A Case Series from a Tertiary Cancer Facility

Reconstructing defects of the shoulder and posterior scalp, arising following tumor resection, requires careful consideration of available options. While free tissue transfers and local advancement flaps have their established roles, the trapezius muscle flap offers a unique set of advantages like proximity, versatility, and reliability as it has a robust blood supply and relatively straightforward surgical technique. In this retrospective analysis, demographic and disease profiles of 10 patients with posterior scalp and shoulder defects following tumor resection, which were reconstructed with a trapezius flap between November 2020 and November 2023, were studied. Complications and functional outcomes were analyzed. Ten patients (9 men and 1 woman) were reconstructed using a trapezius flap. The mean age of the study sample was 45.3 years (30-60 years). Two patients developed donor site seroma and one of them developed wound dehiscence; one patient had partial necrosis of the flap tip, all managed conservatively, and one patient had tumor recurrence. However, the long-term result was good in all patients except the one with recurrence. The post-excision defects in the shoulder and posterior scalp were of mean size 13 ± 2 × 6 ± 2 cm, and the donor site morbidity analyzed by using VAS (visual analog scale) had a mean score of less than 3. This case series provides valuable insights into the successful use of the trapezius muscle flap for shoulder and posterior scalp defects following malignant tumor resection. The documented complications are minimal in comparison to the overall positive outcomes, making the trapezius muscle flap a viable and reliable option for reconstruction in this specific clinical scenario. However, further research is required to improve the design of the flap for different types of defects, refine surgical techniques, and compare outcomes with other reconstruction methods.

"Prompt" for PREEMPT: Dotting the I's and Crossing the T's With Ultrasound

The management of chronic migraine (CM) underwent a significant shift with the introduction of onabotulinumtoxin A (BoNT-A) injections following the landmark PREEMPT trial in 2010. Despite its efficacy, the existing injection protocol lacks precision, prompting a call for revision in light of modern ultrasound (US)-guided techniques. This article highlights the potential of US-guided injections to enhance accuracy, safety, and efficacy in CM treatment. By providing real-time visualization and addressing anatomical variations, US guidance offers a promising avenue for optimizing BoNT-A delivery, minimizing adverse effects, and ensuring therapeutic success.

Standardize routine angiography assessment of leg vasculatures before fibular flap harvest: lessons of congenital and acquired vascular anomalies undetected by color Doppler and physical examinations

BACKGROUND

Fibular flaps have been widely used for mandibular and maxillary reconstructions. On occasion, anatomical variants of fibular arteries (FA) will be encountered.

PURPOSE

Although anatomical variants of FA during fibular harvest have been reported, controversy exists regarding whether simple color Doppler ultrasonography (CDU) and physical examinations (PE) are sufficient for early preoperative detection.

MATERIAL AND METHODS

A 10-year retrospective analysis in our department was performed to find the patients with various FA anomalies confirmed by computed tomography angiography (CTA) or intraoperative findings.

RESULTS

A total number of 19 FA anomalies were found either pre- or intraoperatively in 16 patients, in whom three cases were with bilateral FA variants. Type IIIC variants, also called arteria peronea magna (great peroneal artery), were confirmed in two legs, while the majority (13 legs) had type IIIA hypoplastic/aplastic posterior tibialis arteries (PTA). Four legs had new type IIID (low FA and PTA bifurcations). Preoperative CDU and PE only suspected anomalies in two legs. Six cases proceeded with using the affected fibulas, within whom vascular grafts were used in half of them for lengthening the FA pedicle. Local ischemia, partial soleus muscle necrosis, and claudication were reported in one.

CONCLUSIONS

Routine CTA before every fibular harvest, rather than simple PE and CDU, should be added for screening contraindications and ensuring safety for fibular flap harvest.

Duplicated transverse cervical nerve and external jugular vein

The transverse cervical nerve arises from anterior rami of the second and third cervical spinal nerves via the cervical plexus. We present a case of a left duplicated transverse cervical nerve with a duplicated external jugular vein in a 72-year-old female cadver. The transverse cervical nerve bifurcated into two branches, i.e., superficial and deep branches, lateral to the sternocleidomastoid muscle. The superficial branch ran lateral to the duplicated external jugular vein and gave a cutaneous branch to the area below the great auricular nerve and cutaneous branches to the skin of the neck. The deep branch ran medial to the duplicated external jugular vein, joined the anterior branch of the superficial transverse cervical nerve and cervical branch of the facial nerve, and terminated into the skin. This case adds to the growing data on individual variability that should be considered when operating on the anterolateral neck.

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.

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.

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.

Recipient Vessel Selection in Head and Neck Reconstruction

Objective: Recipient vessel caliber may be the single most important variable for flow to free tissue transfer. We performed cadaveric dissection of the external carotid artery and its branches to analyze average diameter in order to determine an algorithm for recipient vessel selection in head and neck reconstruction. Methods: The external carotid artery and branches were exposed on 3 lightly embalmed male human cadavers, aged 82 to 85 years. Each vessel was dissected, and luminal diameters were recorded with calipers. Results: The proximal ECA had the greatest average diameter (4 ± 0.6 mm) and potential flow; followed by distal ECA (2.85 ± 0.4 mm) facial (2.0 ± 0.6 mm), lingual (1.65 ± 0.6 mm), superior thyroid (1 ± 0.3  mm), and superficial temporal (0.85 ± 0.4 mm). There was a trend towards size variation between sides of the same cadaver. Conclusion: The external carotid artery has the greatest internal diameter and potential blood flow. It should be considered, when feasible, especially for defects of the upper third of the head. For defects of the lower third, the facial artery and the lingual artery should be utilized before the smaller diameter superior thyroid artery. Vessel selection is more challenging in the setting of radiation therapy, complex trauma, and prior neck surgery. In these settings, it is useful to have knowledge of the vascular anatomy and an objective algorithm for recipient vessel selection.

The maxillary artery as a recipient vessel option for complex midface and anterior skull base microsurgical repair: A cadaveric study

INTRODUCTION

Variations in the operative situation for complex head and neck defect reconstructions resulting from mechanisms such as trauma, oncologic resection, and prior radiation exposure can result in situations of a vessel-depleted neck. This requires an awareness of alternate, innovative options for use in reconstructive repairs. The purpose of this study was to provide characterization of the third segment of the maxillary artery necessary to consider its use as a recipient vessel in free flap repair of complex midface defects.

MATERIALS AND METHODS

Seventeen cadaver hemifaces were used for anatomic demonstration of the maxillary artery third segment by a transmaxillary approach to obtain descriptive measures for statistical analysis.

RESULTS

The average artery intraluminal cross-section diameter was obtained for the sphenopalatine (1.39 ± 0.12 mm) descending palatine (0.94 ± 0.10 mm), and terminal maxillary (1.68 ± 0.17 mm) arterial vessels. The mean transmaxillary depth with was (43 ± 1.2 mm). Mean mobilizable lengths for sphenopalatine, descending palatine, and terminal maxillary arteries were (30 ± 2 mm), (29 ± 2 mm), and (20 ± 2 mm), accordingly. Vessel patterns were characterized using Morton and Kahn classification for sphenopalatine-descending palatine bifurcation as well as the Kwak classification for maxillary artery third segment morphology.

CONCLUSIONS

In situations where primary recipient vessel sites are unavailable, the maxillary artery represents an innovative option to be considered with suitable recipient artery characteristics.

Stepwise training for reconstructive microsurgery: the journey to becoming a confident microsurgeon in singapore

Microsurgery training in Singapore began in 1980 with the opening of the Experimental Surgical Unit. Since then, the unit has continued to grow and have held microsurgical training courses biannually. The road to becoming a full-fledged reconstructive surgeon requires the mastering of both microvascular as well as flap raising techniques and requires time, patience and good training facilities. In Singapore, over the past 2 decades, we have had the opportunity to develop good training facilities and to refine our surgical education programmes in reconstructive microsurgery. In this article, we share our experience with training in reconstructive microsurgery.

Origin of the dorsal scapular artery and its relation to the brachial plexus in Thais

We investigated the variations of the origin of the dorsal scapular artery (DSA) and its relation to the brachial plexus in 252 sides of the posterior cervical triangles of Thais. The origin of this artery on each part of the subclavian artery or other arterial branches was examined with special reference to their course in relation to the brachial plexus. The results show that the DSA originated from three sites; most commonly from the transverse cervical artery (69%) followed by the direct branching from the second (2.8%) or the third part (28.2%) of the subclavian artery. When the DSA was branched from the transverse cervical artery, its course was always posterior or above the brachial plexus. When the DSA arose from the second or the third part of the subclavian artery, it always ran in the branches of the brachial plexus in various sites. The most frequent course was to pass between the upper and middle trunks of the brachial plexus (63.2%). Other courses were far less frequent and found to pass between the anterior division of the upper trunk and the middle trunk of brachial plexus or between the roots of C8 and T1 with the frequency of 1.3 and 2.6%, respectively.