Surgical Techniques for Head and Neck Reconstruction in the Vessel-Depleted Neck

Abstract

The vessel-depleted neck presents a unique and challenging scenario for reconstructive surgery of the head and neck. Prior surgery and radiation often result in significant scarring and damage to the neck vasculature, making identification of suitable recipient vessels for microvascular free tissue transfer exceedingly difficult. Therefore, alternative reconstructive techniques and/or vessel options must be considered to obtain a successful reconstructive outcome for a patient. In this article, we discuss our experience and approach to the management of the vessel-depleted neck, emphasizing the importance of preoperative planning and having multiple backup options prior to surgery. The various preoperative imaging modalities and available options for recipient arteries and veins are presented in detail. Additionally, we discuss modifications of select free flaps to maximize their utility in successful reconstruction. Together with thoughtful preoperative planning, these techniques can help aid the reconstructive surgeon in addressing the complex decisions associated with the vessel-depleted neck.

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

“…A neck with prior RTND is often avoided by microsurgeons due to the lack of suitable vessels and theoretically increased risk of free flap demise. Much of the literature on the VDN neck is focused on use of contralateral or extracervical vessels outside the field of prior RTND (Chia et al, 2011; Frohwitter et al, 2018; Jacobson et al, 2008; Kushida‐Contreras et al, 2021; Lin et al, 2019; Martinez et al, 2020; Prince et al, 2020; Reddy et al, 2020; Rosko et al, 2017; Schneider et al, 2012; Sudirman et al, 2019; Tessler et al, 2017). In a recent review, the superficial temporal vessels were used most frequently for free tissue transfer in this setting (Kushida‐Contreras et al, 2021; Shimizu et al, 2009; Sudirman et al, 2019; Tan et al, 2014).…”

“…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.…”

“…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).…”

Reconstructive methods to resolve intractable fistulas that develop after radiation therapy in patients with head and neck cancer

“…Recipient vessel selection is limited in previously irradiated neck region. In these cases, the use of distant flaps such as PMMC flaps may be a suitable option for reconstructive surgery [ 17 ]. These flaps use multiple skin paddles and harvest muscle layers to reduce damage to the perforators, secure vascularity, and provide barriers to the fistulas.…”