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

Minimally Invasive Approach to Access Vessels for Microvascular Anastomosis in Head and Neck Reconstruction

OBJECTIVES

To describe our technique, review indications, and evaluate the outcomes of the minimal access approach for recipient vessel identification in microvascular tissue transfer.

METHODS

Retrospective chart review of all patients who underwent microvascular reconstruction using the minimal access technique between 2015 and 2021.

RESULTS

We report 236 cases, comprising 214 patients with a mean age of 60.2 years (3-88). The most common primary defect sites were the mandible (22.6%), cranium (14%), maxilla (13.2%), skull base (12.8%), and nose/nasal cavity (10.6%). Indications for free flap reconstruction included head and neck cancer extirpation (32.2%), osteoradionecrosis (29.7%), acquired deformity (14.0%), chronic wound (11.9%) and oral motor dysfunction (7.2%). Free flap donor sites used were the anterolateral thigh (84.3%), fibula (7.2%), and radial forearm (6.4%). Vessels utilized include superficial temporal (49.8%), facial (38.3%), angular (11.1%), and transverse cervical (0.4%). The overall complication rate was 14% (n = 33), with surgical complications at the recipient site accounting for 67.6% (n = 25). Flap failure occurred in 3.4% of procedures. Prior head and neck surgery and free flaps were associated with an increased risk of major recipient site complications (n = 20, p = 0.0257 and n = 14, p = 0.0117, respectively).

CONCLUSION

Minimal access techniques allow consistent recipient vessel identification for microvascular-free tissue transfer. These approaches may be utilized in reconstructing a broad range of head and neck defects, are low morbidity, and contribute to an overall shorter length of stay.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:2177-2181, 2024.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outcomes and Perioperative Risk Factors after Oncologic Free-Flap Scalp Reconstruction

BACKGROUND

 Little is known about the risk factors associated with complications after free flap scalp reconstruction. The purpose of this study was to identify patient, scalp defect, and flap characteristics associated with increased risk of surgical complications.

METHODS

 A retrospective study was performed of free-flap scalp reconstruction in oncologic patients at Memorial Sloan Kettering Cancer Center from 2002 to 2017. Data collection included patient, defect, flap, and complication characteristics. Complications were classified into major, defined as complications requiring surgical intervention, and minor, defined as complications requiring conservative treatment. Risk factors and outcome variables were compared using chi-square with Fisher's exact test.

RESULTS

 A total of 63 free flaps to the scalp in 58 patients were performed; average follow-up was 3.5 years. Most flaps were muscle-only or musculocutaneous. One-third of patients with free flaps experienced complications (n = 21, 15 major and 6 minor). Examining risk factors for complications, patients with cardiovascular disease were nearly three times more likely to have suffered a major complication than patients without cardiovascular disease (36.7 vs. 12.1%, p = 0.04). This was the only significant risk factor noted. Perioperative radiotherapy, prior scalp surgery, flap type, and recipient vessel selection were found to be nonsignificant risk factors.

CONCLUSION

 Cardiovascular disease may be a significant marker of risk for major complications in patients undergoing free-flap reconstruction of the scalp. This information should be used to help guide perioperative counseling and decision making in this challenging patient population.

The Journey of the Lingual Artery from the Neck to the Oral Cavity: A Cadaveric Study

Study Design

Descriptive cross-sectional.

Objective

The origin of the lingual artery (LA) has been well studied due to its implication in neck dissection, but the course thereafter to the oral cavity is less described. This cadaveric study traced the journey of the LA from the external carotid artery to its terminal branches in the tongue.

Methods

Following bilateral neck dissections in 35 black Kenyan cadavers, the incidence of Beclard's, Lesser's and Pirogoff's triangles, the types of LA origin with its length, relationship to the hyoglossus muscle and anastomosis with other vessels were documented.

Results

Beclard's triangle was found in 64 dissections (91.42%), Lesser's in 46 dissections (65.71%) and Pirogoff's in 39 dissections (55.71%). The LA presented either as a solitary branch (67.15%) or as a branch of either the linguofacial (LFT-24.29%), thyrolingual (TLT-2.72%) or thyrolinguofacial (TLFT-2.86%) trunk. The solitary LA was the longest at 6.93 mm, followed by the TLT branch (6.58 mm), LFT branch (6.12 mm) and TLFT branch (5.65 mm). The majority of solitary LA and LA branches of LFT and TLFT passed through the hyoglossus, while all LA branches of the TLT coursed medial to the muscle. All variants of LA have been found to anastomose with the submental artery (SMA) at frequencies that ranged from 11.10% to 100%.

Conclusions

The LA was found in all cadavers and all Beclards' triangles. There is a significant incidence of LFT and TLFT variants in the Kenyan population. The LA passed either through or medial to the hyoglossus with no lateral relationship being observed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.