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Li MM, Miller LE, Old M. State of Head and Neck Microvascular Reconstruction: Current and Future Directions. Surg Oncol Clin N Am 2024; 33:711-721. [PMID: 39244289 DOI: 10.1016/j.soc.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2024]
Abstract
Since its inception, microvascular free tissue transfer has broadened possibilities for oncologic ablation and restoration of form and function. Developments throughout recent decades have resulted in increasing flap success rates and complexity. Advances in technology and knowledge gained from past experiences will continue to improve surgical efficiency, flap success rates, and ultimately, patient outcomes.
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Affiliation(s)
- Michael M Li
- Department of Otolaryngology Head and Neck Surgery, Ohio State University James Cancer Center, 460 West 10th Avenue, Columbus, OH 43210, USA
| | - Lauren E Miller
- Department of Otolaryngology Head and Neck Surgery, Ohio State University James Cancer Center, 460 West 10th Avenue, Columbus, OH 43210, USA
| | - Matthew Old
- Department of Otolaryngology Head and Neck Surgery, Ohio State University James Cancer Center, 460 West 10th Avenue, Columbus, OH 43210, USA.
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Chang CK, Wu CY, Lin YL, Lai CS, Lu CT, Yen JH, Chen IC, Tsai YC. Comparative study of arterial and venous grafting for pedicle lengthening in head and neck microvascular reconstruction. Microsurgery 2024; 44:e31133. [PMID: 37950581 DOI: 10.1002/micr.31133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/12/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND In the field of head and neck microvascular reconstruction, no previous study has compared arterial and venous grafting as methods of anterolateral thigh (ALT) pedicle lengthening. Therefore, we conducted this comparative study to compare the outcomes between the two pedicle lengthening techniques. METHODS We performed comparative effectiveness research by conducting a retrospective chart review from January 2012 to December 2021 to identify patients who underwent head and neck reconstruction with non-descending branch ALT perforator flaps using either the in situ pedicle lengthening (ISPL) technique or the vein graft (VG) technique. A total of 26 patients were analyzed, including 14 who underwent ISPL, and 12 who underwent VG. The collected data, including patient demographics, surgical indications, history of prior free flap, prior neck dissection, radiation therapy, chemotherapy, graft length, and flap outcomes, were analyzed. The flap outcomes were categorized as total flap loss, partial flap loss, flap compromise that required operating room visits, or minor issues, including infection or dehiscence. The flap characteristics and postoperative outcomes were compared between the two groups. RESULTS The VG group had two flap losses, whereas the ISPL group had none. Although the failure rate was higher in the VG group than that in the ISPL group, the difference was not statistically significant (0% vs. 16.7%, p = 0.203). Additionally, there were no significant differences in flap take-back (14.3% vs. 16.7%, p = 1) and minor complications between the two groups (35.7% vs. 33.3%, p = 1). CONCLUSIONS If pedicle lengthening with vessel graft is inevitable in head and neck reconstruction, arterial graft may provide a reliable outcome and may be considered an effective alternative when compared to vein grafts.
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Affiliation(s)
- Chieh-Kai Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
- Department of Nursing, Hungkuang University, Taichung, Taiwan
| | - Cheng-Yeu Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
| | - Yi-Ling Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
- Department of Nursing, Hungkuang University, Taichung, Taiwan
| | - Chih-Shen Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Chen-Te Lu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
| | - Jung-Hsing Yen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
| | - I-Chen Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
| | - Yueh-Chi Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
- Department of Nursing, Hungkuang University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
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Kerai A, Modi P, Shackcloth M, Schache AG, Shaw RJ. Head and neck reconstruction in the vessel depleted neck using robot-assisted harvesting of the internal mammary vessels. Br J Oral Maxillofac Surg 2023; 61:368-372. [PMID: 37246020 DOI: 10.1016/j.bjoms.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/13/2023] [Accepted: 04/20/2023] [Indexed: 05/30/2023]
Abstract
We report a novel technique of robot-assisted harvesting of the internal mammary vessels to provide effective recipient vessels in a patient with bilateral vessel depleted neck (VDN). A 44-year-old with a Notani grade III osteoradionecrosis (ORN) of the anterior mandible underwent robot-assisted (Da Vinci® Surgical System, Intuitive Surgical) harvesting of the left internal mammary vessels (LIMA, LIMV). Reconstruction of the mandibular defect was done with a virtually planned composite fibular free flap and microvascular anastomosis of the peroneal vessels to the LIMA and LIMV. Successful reconstruction of the anterior mandible was achieved with excellent recipient arterial diameter and length, devoid of any significant thoracic morbidities resulting from robot-assisted harvesting of the internal mammary vessels. Robot-assisted harvesting of internal mammary vessels is a viable alternative to an open approach. The advantages in tissue handling, vessel length, and favourable profile of complications may extend the indications for this otherwise 'niche' solution in the VDN.
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Affiliation(s)
- Ashwin Kerai
- Liverpool Head & Neck Centre, Aintree University Hospital, Liverpool, UK
| | - Paul Modi
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | | | - Andrew G Schache
- Liverpool Head & Neck Centre, Aintree University Hospital, Liverpool, UK; Department of Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Richard J Shaw
- Liverpool Head & Neck Centre, Aintree University Hospital, Liverpool, UK; Department of Molecular & Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
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Chang K, Akakpo KE, Graboyes EM, Zenga J, Puram SV, Pipkorn P. Free tissue reconstruction in the "vessel-depleted" neck: A multi-institutional cohort study. Microsurgery 2023; 43:205-212. [PMID: 36285983 DOI: 10.1002/micr.30978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 08/16/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Much of the literature on free tissue reconstruction in the "vessel-depleted" neck is focused on identification of vessels outside the pretreated field and data on free flap outcomes when infield microvascular anastomosis is performed remain scarce. We aim to report on free flap outcomes and recipient vessel choice in a large cohort of patients with prior radiation and neck dissection (RTND) to the ipsilateral side of vessel anastomosis. METHODS A retrospective review was performed including patients who received head and neck free tissue transfer following prior RTND to the ipsilateral side of vessel anastomosis. Pretreatment data, free flap type, defect site, and recipient vessel choice were reported. Recipient vessel choice was stratified according to neck dissection level and prior free flap. Primary outcome was free flap survival (total failure, partial failure, success) within 30 days after surgery. RESULTS This study included 72 free flap cases in 68 patients. Free flap success was 94.4%; one case (1.4%) resulted in total flap loss and three cases (4%) had partial flap loss. The facial (35%), external carotid (ECA) (25%), and superior thyroid arteries (16%) were the most common recipient arteries. The external jugular (EJV) (38%), facial (30%), and internal jugular veins (IJV) (15%) were the most common recipient veins. The superior thyroid artery was used less frequently with a prior level 2-3/4 neck dissection compared to a prior level 1-3/4 neck dissection (6% vs. 17%, p = 0.83). The facial artery (7% vs. 67%, p < 0.01) and vein (13% vs. 46%, p = 0.04) were used less frequently when a prior free flap with ipsilateral anastomosis was performed. The superior thyroid, ECA, IJV, and EJV were more commonly used in this subgroup. CONCLUSION Free tissue transfer with infield microvascular anastomosis in a neck with prior RTND can be safely done with comparable outcomes to surgically naïve, non-irradiated necks.
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Affiliation(s)
- Katherine Chang
- Department of Otolaryngology, Washington University, St. Louis, Missouri, USA
| | - Kenneth E Akakpo
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joseph Zenga
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sidharth V Puram
- Department of Otolaryngology, Washington University, St. Louis, Missouri, USA.,Department of Genetics, Washington University, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology, Washington University, St. Louis, Missouri, USA
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Gur E, Tiftikcioglu YO, Ozturk K. Transferring pectoral muscle flap to depleted neck to create a new recipient source for free flaps in head and neck reconstruction. Microsurgery 2023; 43:245-252. [PMID: 36052868 DOI: 10.1002/micr.30953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/12/2022] [Accepted: 08/19/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The thoracoacromial vessels (TA) are one of the options as recipient for free flaps in head and neck reconstruction when the neck is depleted. However, it has limitations such as need of vein graft or kinking and being under pressure on clavicle. The authors describe a new modification of using pectoral branch of TA as recipient vessel. PATIENTS AND METHODS Between July 2019 and January 2022, 8 patients (1 female, 7 male) underwent head and neck reconstructions with free flaps. Age of patients ranged from 53 to 73 years old. All surgeries were because of SCC. Defects were including 3 total lower lip, 2 pharyngoesophageal defects, 1 cheek, lower and upper lip, 1 mandible, cheek and mount floor and 1 tongue and mount floor. Defects were between 12 × 5 cm and 21 × 9 cm. Pectoral branch of TA was transposed to the depleted neck as pectoral muscle flap to prevent kinking and pressure. Over the clavicle, the proximal root of the pedicle of muscle was found and dissected distally until tensionless anastomoses could be accomplished between the muscle and free flaps. ALT, MSAP, and Radial forearm free flaps were used as free flaps. In one patient the fibula and ALT flaps were used as flow through so the pedicle of ALT flap was anastomosed to pectoral muscle pedicle. Pectoral muscle was rotated 180° on its horizontal axis after finishing anastomoses to guard anastomoses from radiated neck skin. Muscle was fixed to sternocleidomastoid muscle with sutures to maintain its position. All donor sites were closed primarily. RESULTS The diameter of recipient artery was between 1 and 1.6 mm. The veins were approximately same as arteries. All anastomosis were performed end-to-end fashion. Three patients needed skin grafts to closure of tight radiated neck skin. Complications as 1 hematoma and 1 wound dehiscence were salvaged successfully. All flaps survived. Patients were followed up between 2 and 6 months. Our first patient died at post-operative 6th month so long follow-up could not be achieved. The final outcomes such as chewing, oral competence and swallowing were successful for remaining patients. CONCLUSION Transposing TA as pectoral muscle flap to the neck can decrease need of vein graft and prevent kinking or pressure of the pedicle on the clavicle.
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Affiliation(s)
- Ersin Gur
- Department of Plastic Reconstructive and Aesthetic Surgery, Ege University Faculty of Medicine, İzmir, Turkey
| | - Yigit Ozer Tiftikcioglu
- Department of Plastic Reconstructive and Aesthetic Surgery, Ege University Faculty of Medicine, İzmir, Turkey
| | - Kerem Ozturk
- Department of Ear, Nose and Throat, Ege University Faculty of Medicine, İzmir, Turkey
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Qiao QH, Yin SC, Shi C, Wang S, Xu Q, Xu ZF, Feng CJ. Risk Factors for Free Flap Outcomes: A Retrospective Study of 318 Free Flaps for Head and Neck Defect Reconstruction. EAR, NOSE & THROAT JOURNAL 2022:1455613221115143. [PMID: 35830468 DOI: 10.1177/01455613221115143] [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: 11/17/2022] Open
Abstract
OBJECTIVES This study was conducted to identify the risk factors for free flap outcomes in head and neck reconstruction. METHODS A retrospective review of 318 free flaps were used for head and neck reconstructions in 317 patients over seven years. The patient characteristics, surgical data, and flap outcomes were recorded. The impact of risk factors related on the outcomes of free flaps were analyzed using single and multivariate analysis. RESULTS For single factor analysis, 295 free flaps for the first reconstruction were included. Hypertension and the type of recipient vein are associated with venous thrombosis (P = .018, P = .047). Hypertension, type of free flap, recipient artery, and recipient vein were associated with the incidence of re-exploration (P = .009, P = .011, P = .017, P = .021). Hypertension had an obvious effect on the flap survival (P = .005). For multivariate analysis, hypertension (odds ratio = .166, 95% confidence interval: .043 - .636; P = .009) was a statistically significant risk factor for flap survival. For types of recipient artery and vein, selecting two venous anastomosis (one of IJVS and one of EJVS) had the minimum incidence of venous thrombosis (2.2%), and selecting facial artery, single vein (one of IJVS), and two veins (one of IJVS and one of EJVS) for anastomosis had lower incidence of re-exploration, which were 4.4%, 2.9%, and 6.0%, respectively (P < .05). CONCLUSIONS Risk factors as hypertension, type of free flap, recipient artery and vein should be paid more attention in the free flaps for head and neck reconstructions. We believe proper measures will lead to better results in head and neck reconstruction.
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Affiliation(s)
- Qi-Hui Qiao
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, Shenyang, China
| | - Shou-Cheng Yin
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, Shenyang, China
| | - Chao Shi
- Department of Day Surgery Ward, The First Clinical School of Harbin Medical University, Harbin, China
| | - Shuai Wang
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qiang Xu
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, Shenyang, China
| | - Zhong-Fei Xu
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, Shenyang, China
| | - Cui-Juan Feng
- Department of Orthodontics, School and Hospital of Stomatology, China Medical University, Shenyang, China
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Gschossmann JD, Balk M, Rupp R, Müller SK, Allner M, Sievert M, Mantsopoulos K, Koch M, Iro H, Gostian AO. Results of contralateral anastomosis of microvascular free flaps in head and neck reconstruction. EAR, NOSE & THROAT JOURNAL 2022:1455613221112338. [PMID: 35786046 DOI: 10.1177/01455613221112338] [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: 11/15/2022] Open
Abstract
OBJECTIVES Despite various solutions to the issue of ipsilateral vessel-depleted neck in microvascular head and neck reconstruction, concrete data on its safety and implementation are scarce. This paper focuses on the feasibility and success rates of contralateral anastomosis in free flap reconstruction in the head and neck region. METHODS This single-center retrospective study at a tertiary referral center includes all patients who underwent free flap reconstruction of the head and neck with contralateral anastomosis between January 1st, 2007 and February 28th, 2021. Primary objectives were frequency, success, and flap-associated complication rates. Secondary objectives were recipient vessels and flap type. RESULTS Of 318 patients who underwent microvascular reconstruction, anastomosis was performed on the contralateral side of the neck in 32 patients (10.0%). Recipient vessels involved mainly the superior thyroid artery (74.2%; n = 23) and the facial vein (51.1%; n = 23). Thirty patients (93.8%) received a radial forearm free flap. Flap-associated complications occurred in 12.5% of included cases (n = 4): one partial flap necrosis (3.1%), one anastomotic insufficiency (3.1%), one venous thrombosis of the microvascular pedicle (3.1%), and one wound dehiscence (3.1%). All of these complications were resolved without complete flap loss. CONCLUSION This study demonstrates that contralateral anastomosis is a successful and safe option in microvascular head and neck reconstruction, especially using a radial forearm free flap. Thus, anastomosing to the contralateral side of the neck can be advocated as a valuable option in the ipsilateral vessel-depleted neck.
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Affiliation(s)
- Juliane D Gschossmann
- Department of Otorhinolaryngology, Head and Neck, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Matthias Balk
- Department of Otorhinolaryngology, Head and Neck, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Robin Rupp
- Department of Otorhinolaryngology, Head and Neck, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sarina K Müller
- Department of Otorhinolaryngology, Head and Neck, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Moritz Allner
- Department of Otorhinolaryngology, Head and Neck, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Matti Sievert
- Department of Otorhinolaryngology, Head and Neck, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Konstantinos Mantsopoulos
- Department of Otorhinolaryngology, Head and Neck, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Michael Koch
- Department of Otorhinolaryngology, Head and Neck, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Heinrich Iro
- Department of Otorhinolaryngology, Head and Neck, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Antoniu O Gostian
- Department of Otorhinolaryngology, Head and Neck, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
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Abdel Razek AAK, Saleh GA, Denever AT, Mukherji SK. Preimaging and Postimaging of Graft and Flap in Head and Neck Reconstruction. Magn Reson Imaging Clin N Am 2021; 30:121-133. [PMID: 34802575 DOI: 10.1016/j.mric.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Head and neck reconstructive surgical techniques are complex; now the microvascular free tissue transfer is the most frequently used. The postreconstruction imaging interpretation is challenging due to the altered anatomy and flap variability. We aim to improve radiologists' knowledge with diverse methods of flap reconstruction for an accurate appreciation of their expected cross-sectional imaging appearance and early detection of tumor recurrence and other complication.
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Affiliation(s)
| | - Gehad A Saleh
- Faculty of Medicine, Department of Diagnostic Radiology, Mansoura University, Elgomhoria Street, Mansoura 35512, Egypt
| | - Adel T Denever
- Faculty of Medicine, Department of Surgery, Mansoura University, Elgomhoria Street, Mansoura 35512, Egypt
| | - Suresh K Mukherji
- Marian University, Head and Neck Radiology, ProScan Imaging, Carmel, IN, USA.
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