The radial forearm free flap as a "vascular bridge" for secondary microsurgical head and neck reconstruction in a vessel-depleted neck.

In a vessel-depleted neck, distant recipient sites may be the only option for secondary free flap reconstruction. While interposition vein grafts and arteriovenous loops can bridge the gap between the recipient and donor pedicle, they are not without risks. In these scenarios, we examinate the reliablity of a radial forearm free flap (RFFF) as an alternative vascular conduit. A retrospective review of cases between March 2005 and May 2016 was performed. Demographic data, prior surgical history, intraoperative details and outcomes were recorded. A total of ten patients, eight male and two female, with a mean age of 54.2 years (range, 39-74) were identified. The RFFF was initially anastomosed to either the thoracoacromial (n = 6) or internal mammary vessels (n = 4) and subsequently served as the recipient pedicle for the second "main" flap, an anterolateral thigh (n = 4), jejunum (n = 3) or fibula flap (n = 3). The average RFFF dimensions were 13.8 cm by 5.8 cm. All twenty flaps, ten RFFF and ten "main' flaps survived completely with only one case of minimal epidermal loss. One patient with esophageal reconstruction with jejunum developed a fistula that required closure with a local falp. At a mean follow-up of 18.4 months (range 8-29), the reconstructive goals had been achieved in all cases. The RFFF serves as a reliable "vascular bridge" that extends the reach of distant recipient sites to free flaps in secondary head and neck reconstruction.

Ciudad P ，Agko M ，Date S ，Chang WL ，Manrique OJ ，Huang TCT ，Lo Torto F ，Trignano E ，Chen HC ... -  《-》

The role of the internal mammary vessels as recipient vessels in secondary and tertiary head and neck reconstruction.

Successful microsurgical free tissue transfer for head and neck reconstruction highly depends on the quality of the recipient vessels. In most cases, vessels near the site of resection are available; however, when the bilateral vascular network in the neck is compromised or inaccessible due to prior surgery and/or irradiation, alternatives have to be sought. Secondary or tertiary head and neck reconstruction was performed using the internal mammary vessels (IMVs) as recipient vessels in seven patients who had undergone previous neck dissection and radiation therapy. Indications were: tracheal-oesophageal fistula or stenosis (n = 4), oesophageal-cutaneous fistula (n = 1), saliva fistula (n = 1) and oral cancer (n = 1). Free flaps used for reconstruction were radial forearm flap (FRFF) (n = 5), anterolateral thigh flap (ALT) (n = 3) and transverse rectus abdominis myocutaneous flap (TRAM) (n = 1). Within two patients an additional ALT flap was necessary for soft-tissue coverage and resurfacing of the neck. The IMVs were separately exposed in a standard fashion over the second or third rib. The pedicle of the flap was anastomosed anterograde and end-to-end to the recipient vessels in all cases. Mean pedicle length was 14.3 cm (11-20 cm), with a mean distance of 9.8 cm (7-13 cm) between the resection and recipient vessel site. All patients were tumour free at time of re-operation and no sign of radiation injury was observed in the recipient vessels. All flaps survived and all patients healed without major complications. Mean follow-up time was 18 months. Four patients died of local recurrence or distant metastases during follow-up. In the vessel-depleted neck, the IMVs are a reliable and easy accessible recipient area for microsurgical reconstruction of the head and neck. Surgical management and technique refinements for dissection of the vessels are discussed. In combination with free flaps with a long pedicle, especially perforator flaps, vein grafts are unnecessary and microsurgery can safely be performed outside the zone of injury.

Roche NA ，Houtmeyers P ，Vermeersch HF ，Stillaert FB ，Blondeel PN ... -  《-》

An alternative option to overcome difficult venous return in head and neck free flap reconstruction.

The frozen neck secondary to prior neck irradiation and surgery is not uncommon in head and neck surgery. Identifying the optimal and alternative recipient vein in patients with difficult necks is one of most important steps in preceding a free flap for head and neck reconstruction. This is a retrospective study. From January 2006 to October 2011, the authors performed 544 cases of free flap reconstruction for head and neck cancer. The indications for choosing the retrograde limb of the superficial temporal vein as recipient vein were: (1) the flap pedicle contained only one vein 'and' (2) the patient had frozen neck or vessel-depleted neck from surgery. Amongst them, 10 patients with difficult neck where the retrograde limb of the superficial temporal vein was used as the only recipient vein for outflow were collected for the study. The mean age was 51.7 years. The types of flaps included the anterolateral thigh (ALT) flap (n = 6), anteromedial thigh (AMT) flap (n = 1), medial sural perforator flap (n = 1) and trapezius perforator flap (n = 1). One flap needed take-back due to haematoma compression of the pedicle. All nine flaps survived completely. The retrograde limb of the superficial temporal vein used as the only recipient vein served as an alternative option for venous return to precede a successful free flap reconstruction in difficult neck cases. The presence of valves in the vein system in the head and neck does not seem to preclude the use of retrograde flow anastomosis in patients with frozen neck.

Shih HS ，Hsieh CH ，Feng GM ，Feng WJ ，Jeng SF ... -  《-》

Use of the pedicle of previously harvested pectoral myocutaneous flap as a recipient for free flaps in head and neck reconstruction.

The pectoral myocutaneous flap (PMF) is a workhorse regional reconstructive option for head and neck defects. It is commonly used for primary reconstructions due to its advantages or as a life-boat flap in the salvage of failed reconstructions of free flaps. However, it also has intrinsic drawbacks, such as perfusion problems and partial or complete flap loss. Although there are many studies about the advantages and use of PMF in the literature, the number of studies about salvage of this workhorse flap is inadequate. We aimed to present the use of the pedicle of previously performed PMF as a recipient for free flaps in head and neck reconstruction. Between January 2022 and August 2023, 10 free flaps were used in nine patients (three females and six males) who had previously undergone head and neck reconstruction with PMF. The age of the patients ranged from 54 to 74 years. Seven out of the nine PMFs were previously performed by different surgical teams. Squamous cell carcinoma (SCC) was the reason for primary surgeries in all patients and the PMFs were used for right lower lip and right submandibular defect, left lower lip and mentum defect, lower lip defect, right lower lip and right submandibular defect, right retromolar trigone defect, right buccal defect, left anterolateral esophageal defect, right retromolar trigone defect and left anterolateral pharyngoesophageal defect reconstructions. The problems were partial skin island necrosis and wound dehiscence in six patients and total skin necrosis in three patients. The partial skin island necroses already showed that the pedicles were unproblematic. For patients with total skin island necrosis the muscle stalks so the pedicles were also unproblematic which were confirmed by physical examination and Doppler device. After complications, the finally defects were located in the lower lip, left lower lip and mentum, right lower lip and right submandibular area, left anterolateral esophageal area and left neck, right buccal area, right retromolar trigon, left anterolateral pharyngoesophageal fistula and left neck. The sizes of the defects were between 3 × 4 cm and 11 × 17 cm. For all patients, the pedicle of the previously harvested PMF was used as a recipient for free flaps. Since the PMF was flipped over the clavicula for the reconstruction previously, the pedicle was so close to skin or skin graft which was used for coverage of the muscle stalk. The Doppler device was used first over the clavicle where the PMF was flipped for vessel identification. After marking the vessels, a vertical zigzag incision was made on the skin or skin graft. The perivascular fatty tissue and the pedicle were encountered with minimal dissection by the guidance of Doppler. After meticulous microscopic dissection, the pedicle of PMF was prepared for anastomoses as usual. Six radial forearm free flap (RFFF) and four anterolateral thigh flap (ALT) flaps were used in the head and neck reconstructions for the nine patients. The sizes of the flaps were between 4 × 5 cm and 12 × 17 cm. The diameters of the recipient arteries were between 0.9 and 1.2 mm. Recipient veins were approximately the same diameter as the arteries. In one patient, two vein grafts were used for lengthening both the artery and vein to reach recipient vessels. End-to-end anastomoses without vein grafts were performed in the remaining patients. One arterial thrombosis that manifested on the first postoperative day was salvaged successfully. Hematoma was seen in two patients and wound dehiscence was seen in three patients. There was no partial or total flap necrosis and all flaps survived. The follow-up period ranged from 2 to 12 months. Despite successful reconstructions, two patients died during the follow-up period due to unrelated conditions. Functional results were acceptable in the remaining patients. The pedicle of previously used pectoral myocutaneous flaps may be a useful alternative option as the recipient for free flaps in head and neck reconstruction.

Gur E ，Tiftikcioglu YO ，Kuybulu TF ，Durukan K ，Bekir HH ，Ozturk K ... -  《-》

Transverse cervical vessels as recipient vessels in oral and maxillofacial microsurgical reconstruction after former operations with or without radiotherapy.

Xu ZF ，Duan WY ，Zhang EJ ，Bai S ，Tian Y ，Tan XX ，Liu FY ，Sun CF ... -  《World Journal of Surgical Oncology》