An Algorithm for Recipient Vessel Selection in Microsurgical Head and Neck Reconstruction

ABSTRACT

This article details an algorithm we used for selection of recipient vessels in free tissue transfer to the head and neck. Eighty-eight consecutive free flaps to the head and neck were performed in 85 patients. The superior thyroid was the commonest recipient artery used (61%). The facial artery, used in 14% of our cases, is the choice vessel in instances where neck dissection is not performed. In these cases, we have to access the neck separately for recipient vessels and it can be exposed easily via a short (3-cm) incision. The superficial temporal artery (11%) is our choice vessel for patients with previous neck dissection or radiotherapy as it is well outside the previous operative or irradiated field. Other vessels such as the transverse cervical and end-to-side anastomosis to the carotid artery were also used when appropriate. Recipient vein selection depends primarily on the selected artery. Corresponding veins and large branches of the internal jugular vein (IJV) in the vicinity of the selected artery are preferred. When these are exhausted, the external jugular vein and end-to-side anastomosis to the IJV are considered. We found this algorithm to be reliable in identifying the appropriate vessels in all cases.

KEYWORDS

Recipient vessel - free flap - free tissue transfer - reliable - microsurgery

REFERENCES

• 1 Wong C H, Wei F C. Microsurgical free flap in head and neck reconstruction.  Head Neck. 2010;  32 1236-1245
• 2 Hanasono M M, Barnea Y, Skoracki R J. Microvascular surgery in the previously operated and irradiated neck.  Microsurgery. 2009;  29 1-7
• 3 Head C, Sercarz J A, Abemayor E, Calcaterra T C, Rawnsley J D, Blackwell K E. Microvascular reconstruction after previous neck dissection.  Arch Otolaryngol Head Neck Surg. 2002;  128 328-331
• 4 Jacobson A S, Eloy J A, Park E, Roman B, Genden E M. Vessel-depleted neck: techniques for achieving microvascular reconstruction.  Head Neck. 2008;  30 201-207
• 5 Nahabedian M Y, Singh N, Deune E G, Silverman R, Tufaro A P. Recipient vessel analysis for microvascular reconstruction of the head and neck.  Ann Plast Surg. 2004;  52 148-155 discussion 156-157
• 6 Takamatsu A, Harashina T, Inoue T. Selection of appropriate recipient vessels in difficult, microsurgical head and neck reconstruction.  J Reconstr Microsurg. 1996;  12 499-507 discussion 508-513
• 7 Yazar S. Selection of recipient vessels in microsurgical free tissue reconstruction of head and neck defects.  Microsurgery. 2007;  27 588-594
• 8 Yu P. The transverse cervical vessels as recipient vessels for previously treated head and neck cancer patients.  Plast Reconstr Surg. 2005;  115 1253-1258
• 9 Aycock J K, Stenson K M, Gottlieb L J. The thoracoacromial trunk: alternative recipient vessels in reoperative head and neck reconstructive microsurgery.  Plast Reconstr Surg. 2008;  121 88-94
• 10 Harris J R, Lueg E, Genden E, Urken M L. The thoracoacromial/cephalic vascular system for microvascular anastomoses in the vessel-depleted neck.  Arch Otolaryngol Head Neck Surg. 2002;  128 319-323
• 11 Reid C D, Taylor G I. The vascular territory of the acromiothoracic axis.  Br J Plast Surg. 1984;  37 194-212
• 12 Shima H, von Luedinghausen M, Ohno K, Michi K. Anatomy of microvascular anastomosis in the neck.  Plast Reconstr Surg. 1998;  101 33-41
• 13 Hong P, Taylor S M, Trites J R, Maclean J, Hart R D. Use of the external jugular vein as the sole recipient vein in head and neck free flap reconstruction.  J Otolaryngol. 2006;  35 361-365
• 14 Steele S R, Martin M J, Mullenix P S, Crawford J V, Cuadrado D S, Andersen C A. Focused high-risk population screening for carotid arterial stenosis after radiation therapy for head and neck cancer.  Am J Surg. 2004;  187 594-598
• 15 Anderson J E. Grant's Atlas of Anatomy. Baltimore: Williams & Wilkins Company; 1978
• 16 Gray H. Anatomy of the Human Body. Philadelphia: Lea & Febiger; 1985
• 17 Netter F H, Oppenheimer E. The CIBA Collection of Medical Illustrations. Part 1, Upper Digestive Tract. Summit: CIBA; 1966: 24
• 18 Strauch B, Yu H L, Chen Z W, Liebling R. Head and Neck. Atlas of Microvascular Surgery. New York: Thieme Medical Publishers; 1993: 526-554
• 19 Hansen S L, Foster R D, Dosanjh A S, Mathes S J, Hoffman W Y, Leon P. Superficial temporal artery and vein as recipient vessels for facial and scalp microsurgical reconstruction.  Plast Reconstr Surg. 2007;  120 1879-1884
• 20 Furnas H, Lineaweaver W C, Alpert B S, Buncke H J. Scalp reconstruction by microvascular free tissue transfer.  Ann Plast Surg. 1990;  24 431-444
• 21 Sakai S, Soeda S, Ishii Y. Avulsion of the scalp: which one is the best artery for anastomosis?.  Ann Plast Surg. 1990;  24 350-353
• 22 Wei F C, Demirkan F, Chen H C et al.. The outcome of failed free flaps in head and neck and extremity reconstruction: what is next in the reconstructive ladder?.  Plast Reconstr Surg. 2001;  108 1154-1160 discussion 1161-1162
• 23 Siebert J W, Anson G, Longaker M T. Microsurgical correction of facial asymmetry in 60 consecutive cases.  Plast Reconstr Surg. 1996;  97 354-363
• 24 Wei F C, Yazar S, Lin C H, Cheng M H, Tsao C K, Chiang Y C. Double free flaps in head and neck reconstruction.  Clin Plast Surg. 2005;  32 303-308, v
• 25 Shimizu F, Lin M P, Ellabban M, Evans G R, Cheng M H. Superficial temporal vessels as a reserve recipient site for microvascular head and neck reconstruction in vessel-depleted neck.  Ann Plast Surg. 2009;  62 134-138
• 26 Urken M L, Vickery C, Weinberg H, Buchbinder D, Biller H F. Geometry of the vascular pedicle in free tissue transfers to the head and neck.  Arch Otolaryngol Head Neck Surg. 1989;  115 954-960
• 27 Chen H C, Coskunfirat O K, Ozkan O et al.. Guidelines for the optimization of microsurgery in atherosclerotic patients.  Microsurgery. 2006;  26 356-362
• 28 Francis D O, Stern R E, Zeitler D, Izzard M, Futran N D. Analysis of free flap viability based on recipient vein selection.  Head Neck. 2009;  31 1354-1359
• 29 Halvorson E G, Cordeiro P G. 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.  Ann Plast Surg. 2007;  59 31-35 discussion 35
• 30 Ueda K, Harii K, Nakatsuka T, Asato H, Yamada A. Comparison of end-to-end and end-to-side venous anastomosis in free-tissue transfer following resection of head and neck tumors.  Microsurgery. 1996;  17 146-149
• 31 Yamamoto Y, Nohira K, Kuwahara H, Sekido M, Furukawa H, Sugihara T. Superiority of end-to-side anastomosis with the internal jugular vein: the experience of 80 cases in head and neck microsurgical reconstruction.  Br J Plast Surg. 1999;  52 88-91
• 32 Jones N F, Johnson J T, Shestak K C, Myers E N, Swartz W M. Microsurgical reconstruction of the head and neck: interdisciplinary collaboration between head and neck surgeons and plastic surgeons in 305 cases.  Ann Plast Surg. 1996;  36 37-43
• 33 Khouri R K, Cooley B C, Kunselman A R et al.. A prospective study of microvascular free-flap surgery and outcome.  Plast Reconstr Surg. 1998;  102 711-721
• 34 Singh B, Cordeiro P G, Santamaria E, Shaha A R, Pfister D G, Shah J P. Factors associated with complications in microvascular reconstruction of head and neck defects.  Plast Reconstr Surg. 1999;  103 403-411
• 35 Urken M L, Weinberg H, Buchbinder D et al.. Microvascular free flaps in head and neck reconstruction. Report of 200 cases and review of complications.  Arch Otolaryngol Head Neck Surg. 1994;  120 633-640
• 36 Wax M K, Quraishi H, Rodman S, Granke K. Internal jugular vein patency in patients undergoing microvascular reconstruction.  Laryngoscope. 1997;  107 1245-1248
• 37 Amato M M, Rodriguez L R, Lineaweaver W C. Survival of free tissue transfer following internal jugular venous thrombosis.  Plast Reconstr Surg. 1999;  104 1406-1408
• 38 Brown D H, Mulholland S, Yoo J H et al.. Internal jugular vein thrombosis following modified neck dissection: implications for head and neck flap reconstruction.  Head Neck. 1998;  20 169-174
• 39 Fisher C B, Mattox D E, Zinreich J S. Patency of the internal jugular vein after functional neck dissection.  Laryngoscope. 1988;  98 923-927
• 40 Leontsinis T G, Currie A R, Mannell A. Internal jugular vein thrombosis following functional neck dissection.  Laryngoscope. 1995;  105 169-174
• 41 Tan B K, Wong C H, Chew W, Hong S W. Use of the slit arteriotomy for end-to-side arterial anastomosis in free-tissue transfers to the extremities.  J Plast Reconstr Aesthet Surg. 2009;  62 1519-1523
• 42 Futran N D, Stack Jr B CJ. Single versus dual venous drainage of the radial forearm free flap.  Am J Otolaryngol. 1996;  17 112-117
• 43 Alam D S, Khariwala S S. Technical considerations in patients requiring a second microvascular free flap in the head and neck.  Arch Otolaryngol Head Neck Surg. 2009;  135 268-273
• 44 Wong C H, Lin J Y, Wei F C. The bottom-up approach to the suprafascial harvest of the radial forearm flap.  Am J Surg. 2008;  196 e60-e64
• 45 Wong C H, Wei F C. Anterolateral thigh flap.  Head Neck. 2010;  32 529-540
• 46 Horng S Y, Chen M T. Reversed cephalic vein: a lifeboat in head and neck free-flap reconstruction.  Plast Reconstr Surg. 1993;  92 752-753
• 47 Kim K A, Chandrasekhar B S. Cephalic vein in salvage microsurgical reconstruction in the head and neck.  Br J Plast Surg. 1998;  51 2-7
• 48 Mulholland S, Boyd J B, McCabe S et al.. Recipient vessels in head and neck microsurgery: radiation effect and vessel access.  Plast Reconstr Surg. 1993;  92 628-632
• 49 Safak T, Akyürek M. Cephalic vein-pedicled arterialized anteromedial arm venous flap for head and neck reconstruction.  Ann Plast Surg. 2001;  47 446-449
• 50 Dolan R, Gooey J, Cho Y J, Fuleihan N. Microvascular access in the multiply operated neck: thoracodorsal transposition.  Laryngoscope. 1996;  106 1436-1437
• 51 Urban V, Fritsche E. Internal thoracic vessels as recipient vessels for free flap reconstruction in head and neck surgery.  J Plast Reconstr Aesthet Surg. 2006;  59 1348-1349
• 52 Urken M L, Higgins K M, Lee B, Vickery C. Internal mammary artery and vein: recipient vessels for free tissue transfer to the head and neck in the vessel-depleted neck.  Head Neck. 2006;  28 797-801
• 53 Yagi S, Nakayama B, Kamei Y, Takahashi M, Torii S. Posterolateral cervical vein as a recipient vein in reconstructive microvascular surgery of the head and neck.  J Reconstr Microsurg. 2007;  23 19-23
• 54 Lin P Y, Kuo Y R, Chien C Y, Jeng S F. Reconstruction of head and neck cancer with double flaps: comparison of single and double recipient vessels.  J Reconstr Microsurg. 2009;  25 191-195
• 55 Wells M D, Luce E A, Edwards A L, Vasconez H C, Sadove R C, Bouzaglou S. Sequentially linked free flaps in head and neck reconstruction.  Clin Plast Surg. 1994;  21 59-67
• 56 Huang S H, Wu S H, Wang W H et al.. Reversed-flow superior thyroid artery: an alternative recipient vessel in head and neck reconstruction.  Kaohsiung J Med Sci. 2008;  24 598-601
• 57 Neligan P C, She-Yue H, Gullane P J. Reverse flow as an option in microvascular recipient anastomoses.  Plast Reconstr Surg. 1997;  100 1780-1785 discussion 1786-1787