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460
ab
P. Hever et al.
Fig. 46.9 (a, b) Step 7—The rib is then disarticulated from the ster-
num, it can be removed as a single piece. If remnants of rib are still
present medially; rongeurs can be used to remove rib medially until the
sternum is reached. Care must be taken not to over-resect and iatrogenically remove sternum
ab
Fig. 46.10 (a, b) Step 8—The posterior perichondrium is dissected
free using bipolar cautery from the underlying tissues. A damp swab
can help to gently push and develop a plane between the overlying perichondrium and the vessels underneath. Care must be taken not to avulse
or damage the underlying vessels particularly in cases where the chest
is scarred due to radiotherapy– a nerve hook can help carefully dissect
the perivascular tissues in these cases. To make the space wider, intercostal muscles are resected superiorly and inferiorly down to the second
and fourth rib. The vessels are then dissected clean of perivascular fat
and side branches – such as the anterior intercostal and sternal
branches—cauterised or ligaclipped. Place ligaclips carefully, and
angled appropriately, so they do not interfere with anastomosis
sected clean of perivascular fat and side branches—such
as the anterior intercostal and sternal branches—cauterised or ligaclipped. Place ligaclips carefully and angled
appropriately, so that they do not interfere with
anastomosis.
Alternative Approach: The ‘Rib-Preserving’ Approach
(Fig.46.11) Another approach as is illustrated in this gure is to
go between the ribs by raising an intercostal ap. The space for
anastomosis can be narrow when using this approach, and is not
favoured in cases of Bipedicled DIEP aps, or without experience of the technique.
46 Chest Wall Recipient Vessels Access
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Fig. 46.11 Alternative approach: The rib preserving approach for
internal mammary access—Another approach as is illustrated in this
gure is to go between the ribs by raising an intercostal ap. The space
for anastomosis can be narrow when using this approach, and is not
favoured in cases of Bipedicled DIEP aps, or without experience of
the technique
46.6 Core Surgical Techniques inRecipient
Vessel
We describe dissection of the internal mammary vessels in
the second to third intercostal space following removal of the
third rib, as this is the preferred point of access for the senior
authors.
1. In an immediate reconstruction, the second and third
interspaces are marked before the mastectomy by palpating the ribs starting from the clavicle (Fig.46.3). In a
delayed DIEP, the horizontal mastectomy scar is
reopened down to the pectoralis major muscle, and the
ribs palpated and marked.
2. Pec major is split using monopolar diathermy from its
insertion at the sternum along a length of approximately
4–5cm (Fig.46.4a). Incision length is limited to 5cm to
permit suitable tension for retraction. Any sizeable perforator vessels are preserved for the anastomosis
(Fig.46.4b).
3. A self-retaining Traver’s retractor is inserted to expose
the second and third ribs, and sh hooks used to retract
medial tissues. An alternative to sh hooks involves
suturing 2.0 Vicryl sutures to the medial edge of the
sternum and using these sutures as a retractor
(Fig.46.5).
4. A 3cm line from the sternal edge is marked along the
anterior perichondrium of the lower rib to the begin-
461
ning of the bony rib, and incised with diathermy
(Fig.46.6a, b). {NB: The IM vessels are located within
2–2.5cm of the sternal edge}.
5. A periosteal elevator is then used to strip the anterior
perichondrium from the cartilage to its posterior surface
(Fig.46.7a). A Mitchells trimmer can be used in cases
where there is signicant irradiation of tissues, allowing
for careful elevation of the anterior perichondrium
(Fig.46.7b). A cardiac Doyenne aids posterior dissection with gentle pushing medically once inserted into the
correct plane between the posterior perichondrium
below and the rib above.
6. The rib is then disarticulated from the sternum, with the
aim to remove it as a single piece. If it is not removed as
one piece, it can be removed piecemeal using rongeurs.
Care must be taken here to avoid over resection, and iatrogenic disruption of the sternum.
7. The posterior perichondrium is dissected free using
bipolar cautery from the underlying tissues. A damp
swab cotton bud can help gently push and develop a
plane between the overlying perichondrium and the vessels underneath. Sometimes perforators can guide the
location of the internal mammary vessels. Care must be
taken not to avulse or damage the underlying vessels
particularly in cases where the chest is scarred due to
radiotherapy. A nerve hook can help carefully dissect the
perivascular tissues in these cases. To make the space
wider, intercostal muscles are resected superiorly and
inferiorly down to the second and fourth rib.
8. The perivascular fat of the IM vessels helps with identication once the posterior perichondrium has been dissected free (Fig.46.10a). The vessels can then be cleaned
of perivascular fat either with loupes or under the microscope, and side branches cauterised with bipolar diathermy on a low setting, or ligaclipped in preparation for
the ap (Fig.46.10b). Care must be taken to place ligaclips carefully and angled appropriately, so that they do
not interfere with anastomosis. One can also preserve
the intercostal nerve.
9. One should use the microscope early if there is signicant scarring, or difculty elevating posterior perichondrium off the vessels.
10. The vessels are then marked in their superior longitudinal axis with a series of dots. This helps twisting the
pedicle which can compromise the anastomoses. This is
especially important if using a venous coupler, as this
can help propagate a twist superiorly and may go unnoticed beneath the superior rib.
462
46.7 Pearls andPitfalls 46.8 Selected Readings
P. Hever et al.
Pearls
• The IM vessels, especially the vein, are typically
smaller in caliber on the left than the right side [6,
13].
• When incising the pec major, it is important to
avoid lateral extension of the incision beyond
4–5cm to allow positioning of retractors with suitable tension. The medial extent of muscle split
needs to be continued to the sternal edge to achieve
sufcient exposure.
• In patients with previous chest radiotherapy, it may
be easier to use a standard rib-sacricing approach
due to scarring and immobility of tissues. Often the
segment of the IM vessels below the rib cartilage
tend to be less friable than the segment within the
interspace, suggesting a potential radio-protective
effect of the rib.
• The fourth interspace usually has two venae comitantes, with the IMV most commonly branching at
the level of the third or fourth rib (type I pattern). At
this level, the vessels are of smaller diameter, are a
better match for TUG aps, and can allow double
ap anterograde anastomoses to both venae
comitantes.
• An internal mammary lymph node can frequently
be encountered during dissection of the IM vessels.
Although it may demonstrate inammatory changes
only, the identied node should be sent for histopathology in all patients with a cancer history, as this
can alter stage and inuence future treatment.
Pitfalls
• During perichondrial elevation, care must be taken
in the irradiated chest to avoid puncturing of the
perichondrium due to increased scarring. This
manoeuvre should therefore always be performed
laterally, away from the IM vessels.
• Likewise, extra care must be taken in the dissection
of the IM vessels, as the planes between the vessels
and the perichondrium and pleura are not so easily
separated following radiotherapy.
• When removing the cartilage, it is important to
ensure that the cartilage is removed right to the sternal edge to ensure adequate exposure of the IM
vein—a common mistake is to not remove enough
cartilage medially.
• Arnez ZM, Valdatta L, Tyler MP, et al. Anatomy of the
internal mammary veins and their use in free TRAM ap
breast reconstruction. Br J Plast Surg. 1995;48(8):540–5.
• A leading paper in the popularisation of the TRAM ap for
breast reconstruction, this paper provides the rst reported
anatomical study of the IMV in human cadavers. Sixtyfour internal mammary veins in 34 fresh human cadavers
were studied, with 4 different patterns of venous anatomy
identied. The type 1 pattern, in which the IMV runs
medial and parallel to the IMA to the fourth intercostal
space, where it divided into the medial and lateral IMV,
was the most common pattern, observed in 69% of cases.
• Clark CP, Rohrich RJ, Copit S, etal. An anatomic study of
the internal mammary veins: clinical implications for
free-tissue-transfer breast reconstruction. Plast Reconstr
Surg. 1997;99(2):400–4.
• Important anatomic study describing the anatomy of the
internal mammary veins. The authors reported that there
were veins of at least 3mm diameter in the second ICS in
100% of cadavers. This was a landmark paper to support
the use of the IM vessels as recipient vessels in free ap
breast reconstruction.
• Parrett B, Caterson SA, Tobias A, Lee BT.The rib-sparing
technique for internal mammary vessel exposure in
microsurgical breast reconstruction. Ann Plast Surg.
2008;60(3):241–3.
• The rst paper to describe the rib-sparing approach for
IM vessel preparation. The authors reported a series of 74
aps in which the rib-sparing technique was performed
over a 3-year period, with no signicant increase in complications, including revision of anastomosis (3%), fat
necrosis (11%), or ap loss (1%), when compared with a
group of 125 aps undergoing rib resection. They demonstrated this approach to allow adequate exposure for safe
and efcient microanastomosis, and to be reliable, bloodless, and reproducible.
• Sasaki Y, Madada-Nyakauru RN, Samaras S.The ideal
intercostal space for internal mammary vessel exposure
during total rib-sparing microvascular breast reconstruction: a critical evaluation. J Plast Reconstr Aesthet Surg.
2019;72:1000–6.
• In this paper, the authors present a series of 296 rib-
preserving free ap breast reconstructions to support the
safety and ease of the rib-preserving technique in microvascular breast reconstruction. They specically looked
at the ideal ICS, providing evidence for the preferential
use of the second ICS.They analysed the vessel exposure
times of different grades of surgeon, demonstrating exposure time to decrease with experience (resident to fellow
to attending), with time taken plateauing off after seven
46 Chest Wall Recipient Vessels Access
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463
cases. They argued the efcacy and safety of the technique, demonstrating a low intraoperative anastamotic
revision rate and free ap failure rate.
• Hardwood N, Teotia S. Five steps to internal mammary
vessel preparation in less than 15minutes. Plast Reconstr
Surg. 2017;140(5):884–6.
• A useful paper describing ve simple steps to efcient and
safe internal mammary vessel preparation, with accompanying technical videos. Breast reconstruction was performed in 415 patients (715 breasts) using autologous
tissue (850 aps) from 2012 to 2016. In 97.6% of these
breast reconstructions, the internal mammary vessels
were used. The preparation of these vessels was routinely
performed using the ve-step technique described, within
an average of approximately 15min (range 7–45min).
Acknowledgements The authors give special thanks to Mr. Georgios
Patanis of Barts Health NHS Trust and Dr. Yumao of Shanghai
People’s Hospital, China, for contributing Fig.46.1a, b.
References
1. Longmire WP Jr, Ravitch MM.A new method for constructing an
articial oesophagus. Ann Surg. 1946;123:819–34.
2. Fujino T, Harashina T, Aoyagi F.Reconstruction for aplasia of the
breast and pectoral region by microvascular transfer of a free ap
from the buttock. Plast Reconstr Surg. 1975;56:335.
3. Shaw WW.Breast reconstruction by superior gluteal microvascular
free aps without silicone implants. J Plast Reconstr Aesthet Surg.
1983;72(4):490–501.
4. Harashina T, Imai T, Nakajima H, et al. Breast reconstruction
with microsurgical free composite tissue transplantation. J Plast
Reconstr Surg. 1980;33(1):30–7.
5. Arnez ZM, Valdatta L, Tyler MP, et al. Anatomy of the internal
mammary veins and their use in free TRAM ap breast reconstruction. Br J Plast Surg. 1995;48(8):540–5.
6. Clark CP, Rohrich RJ, Copit S, et al. An anatomic study of
the internal mammary veins: clinical implications for freetissue-transfer breast reconstruction. Plast Reconstr Surg.
1997;99(2):400–4.
7. Pradas-Irun C, Azzawi K, Malata CM.A plea for recipient vascular pedicle versatility in microvascular breast reconstruction. Plast
Reconstr Surg. 2012;129(2):383e–5e.
8. Tuinder S, Dikmans R, Schipper R, etal. Anatomical evaluation of the internal mammary vessels based on magnetic
resonance imaging (MRI). J Plast Reconstr Aesthet Surg.
2012;65:1363–7.
9. Sasaki Y, Madada-Nyakauru RN, Samaras S. The ideal intercostal space for internal mammary vessel exposure during total ribsparing microvascular breast reconstruction: a critical evaluation. J
Plast Reconstr Aesthet Surg. 2019;72:1000–6.
10. Rosich-Medina A, Bouloumpasis S, Di Candia M.Total ‘rib’-preserving technique of internal mammary vessel exposure for free
ap breast reconstruction: a 5-year prospective cohort study and
instructional video. Ann Med Surg. 2015;4:293–300.
11. Parrett B, Caterson SA, Tobias A, Lee BT. The rib-sparing technique for internal mammary vessel exposure in microsurgical
breast reconstruction. Ann Plast Surg. 2008;60(3):241–3.
12. Jeevaratnam J, Nikkhah D, Dheansa B.The evolution of internal
mammary vessel preparation in microsurgical breast reconstruction: what is the current evidence? J Plast Reconstr Aesthet Surg.
2014;67(9):e226–7.
13. Dupin CL, Allen RJ, Glass CA, Bunch R. The internal mammary artery and vein as a recipient site for free-ap breast reconstruction: a report of 110 consecutive cases. Plast Reconstr Surg.
1996;98(4):685–9.
Head and Neck Recipient Vessels Access
AlexandraO’Neill, JuanEnriqueBerner,
andGeorgiosPatanis
47
47.1 Indications
Head and neck reconstruction poses unique challenges due to
the highly specialised anatomy, and cosmetic importance of the
region. Microvascular free tissue transfer reconstruction has
become the mainstay for large or composite defects and the
guiding principles are to restore integrity, form, and function
while aiming for an acceptable aesthetic outcome. Most reconstructions are performed following oncological surgery, which
for intraoral and aerodigestive malignancies is frequently associated with concurrent neck dissection. However, secondary
management of complications such as stulae or osteoradionecrosis is also common in specialist services. Recipient vessel
selection is inuenced by defect site, indication for concurrent
neck dissection, free ap pedicle length and caliber, and patient
factors including prior surgery or radiotherapy.
47.2 Anatomy
47.2.1 Arterial Anatomy
At the level of the hyoid bone the common carotid artery
(CCA) bifurcates into an internal and external carotid artery
(ICA and ECA). The ICA slopes up in the carotid sheath
beside the pharynx entering the base of skull via the carotid
canal without giving off any branches throughout its course.
The ECA continues anterior to the ICA passing deep to the
posterior belly of digastric and stylohyoid before piercing the
deep lamina of the parotid fascia and dividing into its terminal
branches the maxillary artery and supercial temporal artery.
A. O’Neill (*)
Department Plastic and Reconstructive Surgery, Royal Perth
Hospital, Perth, WA, Australia
J. E. Berner · G. Patanis
London Reconstructive Microsurgery Unit (LRMU), Department
of Plastic Surgery, Emergency Care and Trauma Division, The
Royal London Hospital, Barts Health NHS Trust, London, UK
The non-terminal branches of the ECA include three anterior
branches (superior thyroid, lingual and facial), one medial
branch (ascending pharyngeal), and two posterior branches
(occipital and posterior auricular). The anterior branches of
the ECA are commonly utilised recipient vessels for neck and
lower facial reconstruction due to their favourable orientation.
The arterial anatomy is fairly constant, except for the facial
and lingual arteries that can occasionally arise from a common
trunk, the fascio-lingual trunk. The supercial temporal artery
courses behind the temporomandibular joint anterior to the
mastoid and external ear and crosses the posterior aspect of the
zygomatic arch where it can be palpated in the pre-auricular
region. The supercial temporal vessels are easily accessible
for upper face, temple, and scalp reconstructions.
The transverse cervical artery (TCA), a branch of the thyrocervical trunk, is usually spared in most neck dissections
and radiotherapy eld for intraoral and aerodigestive tract
malignancies. It passes across the lower aspect of the posterior triangle just superior to the clavicle and anterior to scalenus anterior. It is usually the vessel of choice in hostile and
vessel-depleted necks (Fig.47.1).
47.2.2 Venous Anatomy
The external jugular vein (EJV), formed by the posterior
branch of the retromandibular vein and the posterior auricular vein, courses down in the subcutaneous tissue over sternocleidomastoid, piercing the investing layer of the deep
cervical fascia approximately 1cm above the midpoint of the
clavicle to empty into the subclavian vein. The anterior
branch of the retromandibular vein joins the facial vein emptying into the continuation of the sigmoid sinus to form the
internal jugular vein (IJV) which typically receives the superior thyroid vein and the vena commitantes of the hypoglossal nerve. The IJV lies posterior to the ICA within the loose
lateral aspect of the carotid sheath receiving numerous tributaries along its course.
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_47
465
466
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A. O’Neill et al.
Superficial
temporal a.
Maxillary a.
Facial a.
Lingual a.
Superior
Thyroid a.
Transverse
cervical a.
Occipital a.
Posterior
auricular a.
Ascending
pharyngeal a.
Internal
carotid a.
Common
carotid a.
Subclavian a.
Fig. 47.1 Commonly used vessels in head and neck reconstruction
47.3 Pre-operative Investigation
Head and neck cancer patients tend to be older, smokers, and
with comorbidities and require thorough pre-operative work
up, including nutritional arrangements for the peri-operative
period. Patients undergoing immediate reconstruction
following tumour excision typically undergo pre-operative
staging scans to assess the primary tumour, the nodal basin
and investigate for metastatic disease with a combination of
computed topography (CT) of the head and neck, magnetic
resonance imaging (MRI), and positron emission tomography (PET) for selected cases. Specic imaging to assess
recipient vessels is not routinely performed in head and neck
reconstruction; however, CT-angiography can be considered
for high-risk patients that have undergone prior surgery or
radiotherapy.
47.4 Recipient Vessel Access
A variety of skin incisions have been described for performing neck dissections. The aim of these is to allow generous
exposure to sub-platysma neck structures while raising
robust skin aps. Incision selection may change depending
on which lymphatic levels and adjacent structures need to be
addressed (for example: Conley, Schobinger, Macfee, Ariyan
skin incisions). If no oncological neck dissection is indicated, an access neck dissection can be performed to prepare
recipient vessels. This incision is placed preferably on skin
crease 3cm inferior to the border of the mandible. The incision continues through subcutaneous tissues and the platysma muscle. This approach allows identication and
protection of the marginal mandibular nerve while exposing
the investing layer of the deep cervical fascia (Fig.47.2).
47 Head and Neck Recipient Vessels Access
Fig. 47.2 Examples of
described incisions for
performing a neck dissection
467
Conley
Schobinger
47.5 Recipient Vessel Dissection:
AStep- by- Step Guide
Recipient vessel selection is of paramount importance in head
and neck microsurgical reconstruction. The decision will be
inuenced by the location of the reconstruction, the pedicle
length of the chosen free ap, and the availability of vessels in
the region. For defects in the upper third ofthe face and scalp, the
supercial temporal vessels tend to be ideally positioned, however, for defects of the lower two-thirds the facial artery offers
easier access. For aerodigestive tract or neck resurfacing, the
superior thyroid vessels are usually preferred. The transverse cervical vessels offer a lifeboat alternative in vessel- depleted necks,
as it is spared in selective anterolateral neck dissections and
radiotherapy elds. This algorithm should only be a guide, the
ideal vessels for a given location may not be available, necessitating exploration of nearby alternatives. In this scenario having a
long ap pedicle is preferred, with vein grafts being a last resort.
47.5.1 Facial Artery (FA)
• Step 1: The facial artery is palpated against the mandible
and marked (Fig.47.3).
• Step 2: Skin and subcutaneous tissues are incised; pla-
tysma is then divided. Flaps are raised on the sub- platysma
Macfee
Ariyan
Fig. 47.3 Incision for accessing facial vessels
plane, allowing identication of the marginal mandibular
nerve (Fig.47.4).
• Step 3: Protecting the nerve, the deep investing fascial
layer of the neck can be incised and reected superiorly.
This exposes the facial artery (Fig.47.5), which can be
dissected proximally and distally.
• Step 4: Removal of the submandibular gland and transpos-
ing the facial artery stump below the posterior body of digastric allows mobilisation of this recipient vessel (Fig.47.6).
468
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Fig. 47.4 Subplatysmal dissection
A. O’Neill et al.
47.5.2 Superior Thyroid Artery (STA)
• Step 1: The superior thyroid artery is usually accessed in
the context of an anterolateral neck dissection.
• Step 2: The artery is identied as it arises from the exter-
nal carotid artery and travels caudally to the thyroid gland
within the carotid sheath.
• Step 3: The vessels are prepared carefully as they have a
smaller calibre than the facial artery, providing a good
match for SCIP or lateral arm aps (Fig.47.7).
• Step 4: The artery can be mobilised cranially to facilitate
anastomosis.
47.5.3 Supercial Temporal Artery (SuTA)
• Step 1: A pre-auricular incision can be continued superi-
orly, or a hemi-coronal incision can be utilised to access
the supercial temporal fascia in the temple region.
Fig. 47.5 Facial vessels are identied, while protecting marginal mandibular branch of facial nerve
Fig. 47.6 Facial artery can be traced superiorly to augment the length
of recipient vessels
Fig. 47.7 Superior thyroid vessels are ideally positioned for microsurgical pharyngeal reconstruction
47 Head and Neck Recipient Vessels Access
• Step 2: The supercial temporal vessels are identied
under the supercial temporal fascia. Approximately
2–4cm superior to the zygomatic arch the SuTA divides
into its terminal branches.
• Step 3: The supercial temporal vessels are dissected and
prepared. If small, they can be dissected inferiorly into the
parotid gland, where their calibre increases.
47.5.4 Transverse Cervical Artery (TCA)
• Step 1: The transverse cervical vessels are located at the
base of the posterior triangle of the neck, and are usually
accessed in the context of a neck dissection.
• Step 2: The vessels can be identied as they pass laterally
from their origin, the thyrocervical artery, across the posterior triangle on scalenus anterior, just above the
clavicle.
• Step 3: The vessels are ligated just prior to their division
into supercial and deep branches, facilitating superior
transposition of the vessel to make it reach the level of the
hyoid. Vessel length ranges from 4 to 7cm and has mean
diameter of 2.65mm [1] (Fig.47.8).
469
Fig. 47.9 The EJV can be mobilised to achieve an end-to-end anastomosis, using a coupler device for this case
47.5.5 Venous Recipients
The EJV can be marked pre-operatively in slim patients; however, this is rarely required. Commonly, the EJV is divided
during the neck dissection, where it is ligated as high as feasible and dissected a few centimetres proximally in its subcutaneous course to facilitate unrestricted mobility. Good
communication between the reconstructive team and resecting
teams is imperative to optimise EJV preservation during the
nodal dissection. The EJV provides a reliable, easily accessible choice for end-to-end venous anastomosis (Fig.47.9).
The IJV is exposed through its entire cervical course dur-
ing a neck dissection and its many tributaries ligated, thereby
providing multiple viable recipient vessels (Fig. 47.10).
Fig. 47.10 End-to-side anastomosis to IJV
Anastomoses can be performed end to end onto one of its
tributaries or end to side on to the IJV itself. If a side branch
is to be used, standard microvascular clamps can be applied
to the vessel base. For end-to-side anastomoses a paediatric
Satinsky clamp can be applied to the IJV to facilitate anastomosis, this should be applied after the venotomy site is
marked, as the vessel collapse can obscure the ideal site and
size required.
47.6 Core Surgical Techniques inRecipient
Vessel Harvesting
Fig. 47.8 Transverse cervical vessels can be found in the posterior tri-
angle of the neck during a comprehensive or radical neck dissection
Recipient vessel selection and preparation is largely determined by whether a neck dissection is indicated at the time
of reconstruction and the type of dissection planned including what structures are anticipated to be sacriced [2].
470
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A. O’Neill et al.
Subplatysmal aps are raised via the surgeon’s preferred
neck dissection incision and the EJV is dissected and ligated
as a potential recipient vein. The sternocleidomastoid muscle
is retracted laterally with a conventional or self-retaining
retractor or, alternatively, a nylon tape, to expose the underlying carotid sheath and its contents. The IJV is dissected
cranial with preservation of tributary stumps, provided its
sacrice is not planned with the oncologic resection. The
external carotid artery is dissected, and particular attention
paid to the anterior branches, notably the facial and superior
thyroid arteries which are conveniently positioned to facilitate microvascular anastomosis. Recipient vessels should be
mobilised 1–2cm where possible to provide adequate length
and reduce the risk of kinking. Patency and pulsatile ow are
conrmed, and a microvascular clamp is applied in anticipation for ap transfer (Table47.1).
Table 47.1 Proposed algorithm for recipient vein selection in head
and neck reconstruction
Algorithm for recipient vein selection in
Head and Neck free tissue transfer
1º:
Venous comitant vein of
the selected recipient artery
2º:
Branches of the Internal Jugular Vein (IJV) in
proximity to the selected recipient artery
3º:
External Jugular Vein (EJV)
4º:
Internal Jugular Vein (IJV) in an
end-to-side configuration
5º:
Long Vein grafting to the contralateral neck
veins (IJV branches or contralateral EJV)
6º:
Cephalic vein transposition
47.6.1 Microvascular Anastomosis
Once the flap is transferred to the recipient site, the pedicle is checked to ensure no twist has occurred during
transfer (Fig.47.10). The decision in terms of sequence
for venous and arterial anastomoses should consider the
position of the recipient vessels and the difficulty of
access. Reconstruction of head and neck defects often
requires partial flap inset prior to microvascular anastomoses, and this should be factored into the surgical planning. An algorithm for recipient arteries is displayed in
Table47.2.
47.7 Pearls andPitfalls
Pearls
• The decision to perform end-to-end or end-toside arterial and venous anastomoses is best
decided on a case by case basis with consideration of the conguration of recipient and pedicle
vessels, vessel calibre, and potential size mismatch rather than a dogmatic approach that has
been traditionally taught [3–5].
• Consider the transverse cervical vessels or the contralateral neck in irradiated elds and patients with
prior neck dissections. The TCA is less affected by
atherosclerosis than the carotid system [1, 6, 7].
• Two venous anastomoses are better than one where
possible [8]. Studies have demonstrated IJV thrombosis rated between 0 and 26% at 1week post free
ap reconstruction [9, 10].
Pitfalls
• Where two free aps are required to reconstruct
large or composite defects and recipient vessels are
limited, the rst ap can be used as a recipient vessel to the second ap. In this situation, the second
ap can be vascularised by either a proximal muscle branch off the ap pedicle (a pseudo-chimeric
ap) or by distal run off from the rst ap (owthrough style ap [11]). This technique does carry a
high rate of partial and total ap failure but can provide a bailout in the vessel- deplete neck.
• The contralateral neck, internal mammary vessels
and the cephalic vein are alternatives for vesseldepleted necks for which the transverse cervical
vessels are not available. The pectoralis major is
still a robust regional ap option when no recipient
vessels are available for soft tissue transfer.
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