Head and neck reconstruction in the vessel depleted neck

Abstract

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 (VDN) 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 VDN. Our collection of advanced management techniques will provide surgeons with more options to manage the complexity of the VDN, and to further help patients understand the risk and benefits of these selections.

Transferring pectoral muscle flap to depleted neck to create a new recipient source for free flaps in head and neck reconstruction

“…Transvers cervical artery (TCA) is one of the options used for this rare condition when compared to standard cases. There are successful studies about the use of this vessel system in the literature (Schettini et al, 2021; Tessler et al, 2017; Yu, 2005) but; variable anatomy, need of vein grafts, risk of thoracic duct injury are some drawbacks about this approach (Jacobson et al, 2008; Prince et al, 2020; Tessler et al, 2017; Yu, 2005). Superficial temporal artery (STA) and vein are another commonly used options.…”

“…So, familiarity and experience with this flap have made TA vascular network an alternative recipient vessel for depleted necks when free flaps are required (Di Taranto et al, 2019; Harris et al, 2002; Numajiri et al, 2009; Onoda et al, 2011). However, this vascular system has also some disadvantages and one of the drawbacks in the literature is need of vein graft because of its caudal location (Harris et al, 2002; Prince et al, 2020; Wong et al, 2010).…”

“…The limitation of using TA as recipient vessel is the fact that the pectoral myocutaneous flap cannot be used in the future, if necessary (Prince et al, 2020). The deltopectoral flap also will share the same fate due to incision.…”

Free tissue reconstruction in the “vessel‐depleted” neck: A multi‐institutional cohort study

“…When both modalities are combined, it is thought that there is a synergistic effect on vessel damage (Kushida‐Contreras et al, 2021). The term “vessel‐depleted neck” (VDN) is often used to describe these scenarios due to a lack of suitable recipient vessels for microvascular anastomosis when a patient's neck has received prior radiation and neck dissection (RTND) (Jacobson et al, 2008; Kushida‐Contreras et al, 2021; Martinez et al, 2020; Prince et al, 2020).…”

“…Use of cervical vessels ipsilateral to the site of reconstruction is preferred in head and neck surgery, but often avoided in a neck with prior RTND (Kushida‐Contreras et al, 2021). Most of the reconstructive literature on this topic focuses on identifying alternative vessels outside the field of prior radiation or surgery, such as the contralateral neck or extracervical regions (Kushida‐Contreras et al, 2021; Martinez et al, 2020; Prince et al, 2020; Rosko et al, 2017). However, this poses additional challenges, namely increased distance of recipient vessels from the area of reconstruction, which may result in unfavorable geometry, kinking, need for a vein graft, or tension on the pedicle.…”