In fact the majority of reconstructions often results in the selection of recipient vessels one or more zones removed from the reconstruction for the optimal pedicle configuration. The branches of the external carotid artery (and in some cases the external carotid artery itself) provide excellent caliber and flow characteristics for microvascular reconstruction and have proven to be very reliable in large series of microvascular reconstructions. Interestingly, using the superior thyroid artery in a reverse flow pattern has been reported in the microsurgical literature; however, the reliability of this technique has not been evaluated.8. The one-year Emory Head & Neck Oncologic Surgery and Microvascular Reconstruction Fellowship, accredited by the Advanced Training Council of the American Head and Neck Society, involves all aspects of current, state-of-the-art head and neck surgical care. Pedicle length and diameter match with proposed recipient sites should be planned prior to flap inset. Patients and Design Retrospective, consecutive chart review of patients older than 70 years who … 10.2). Miles If there is excessive redundancy of the vascular pedicle, there is an increased risk of kinking and thrombosis. Essentially, arterial donor vessels may be divided into two categories: branches of the external carotid and branches of the thyrocervical trunk (Fig. He also treats cancer of the face and neck. Any defect of the face, head, and neck requiring surgical expertise; Extensive cancer-related defects (often performed at the time of cancer removal, which is performed by other members of our department) Extensive traumatic defects Recipient vessels within Zone I include the facial artery lateral to the mandible, the ascending palatine artery, the angular artery (distal facial artery), the maxillary artery, and the superficial temporal artery. This chapter discusses the general considerations and technical details, and provides a framework for successful vessel management for microvascular free tissue transfer in the head and neck. Additionally, sequential or “piggyback” configurations should be avoided, as proximal anastomotic compromise may sacrifice both reconstructions. By continuing you agree to the use of cookies. Although the focus of the microsurgeon includes the location of suitable vessels for microvascular reconstruction, often other technical issues as noted above dominate the surgical challenge and lead to complications postoperatively. Imaging Studies Microvascular head and neck reconstructive surgery is a medical technique for rebuilding the neck and facial tissues of the body. The location of the superficial temporal artery is extremely consistent and is approximately 1 cm anterior to the external ear and is readily located with Doppler examination. (A) The vascular anastomosis is exposed to one superior suture line. Repositioning transferred tissues and the vascular pedicle is infinitely more difficult, if not impossible, if the possibility of compromise is recognized after the flap inset and microvascular anastomosis has been performed. region of recipient vessels, which includes branches of the thyrocervical trunk, thoracoacromial system, and internal mammary artery. Vessel Preparation Prior to Anastomosis (C) The optimal geometry, with no kink points. The deep cervical fascia overlying the anterior scalene muscle should be kept intact during surgical dissection to prevent damage to the phrenic nerve. Obesity, short neck, radiation fibrosis, and cervical osteoarthritis may impair the ability of the microsurgeon to harvest, inset, and orient the microvascular reconstruction in a favorable configuration.15 Tunneled vascular pedicles, which may be performed routinely in patients with normal body habitus, may represent significant technical challenges in obese patients, resulting in untoward twisting and stretching of the vascular pedicle. ♦ The primary goal of pedicle orientation is to avoid vascular compression and vessel kinking that results in vascular compromise; this goal take precedence over all other considerations. Therefore, understanding the anatomy of the vasculature of the head and neck in the context of the reconstructive goals is paramount for successful free tissue transfer. Microvascular free flaps in head and neck reconstruction: report of 200 cases and review of complications. Although major branches of the external carotid artery such as the facial and the superior thyroid provide the majority of recipient vessels in microvascular head and neck reconstruction, anatomic issues, vessel availability, and the technical aspects of the reconstruction often preclude the selection of these vessels. Microvascular head and neck reconstruction is a technique for rebuilding the face and neck using blood vessels, bone and tissue, including muscle and skin from other parts of the body. By combining these with the current published knowledge on the subject, we developed an ERAS protocol. Preparation of both the recipient and donor artery should provide adequate vessel length for anastomosis without damaging the vessels. ♦   PREOPERATIVE CONSIDERATIONS Postoperative complications included infection (37%), 30-days re-operations (19%), and re-admissions (17%). Head and Neck Oncologic Surgery and Microvascular Reconstruction Fellowship. In the event of an oral or pharyngeal fistula, salivary contamination can be minimized if the vascular anastomosis is situated away from the pharyngeal suture lines (A). ♦ Careful attention to small cutaneous perforators is required to avoid compromise; harvesting small perforators with a muscle cuff is recommended if possible. ♦ Radiated/thickened vessels may require additional preparation to provide optimal vessel wall thickness for accurate anastomosis. 10.3). The location of the superficial temporal artery is extremely consistent and is approximately 1 cm anterior to the external ear and is readily located with Doppler examination. Successful outcome after microvascular reconstruction of the head and neck has been reported to range from 93% to 99%. The experienced microsurgeon makes every effort to recognize the potential factors leading to vascular compromise prior to performing microvascular anastomosis. Microvascular reconstruction of the head and neck continues to challenge surgeons worldwide despite significant technical advances. Some detailed considerations of the recipient zones follow. Based on our retrospective analysis and identified discharge criteria, we present an approach to develop an ERAS protocol for microvascular reconstruction after head and neck cancer. Microvascular reconstructive surgery of the head and neck C. René Leemans, Milou-L.C.H. The details of vessel management and microvascular anastomosis are critical to surgical success and are often ignored. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. (B) The orientation of the vascular anastomosis is exposed to two suture lines. (B) A moderate risk, with one vascular kink point. For example, a scalp reconstruction in Zone I may in fact also have recipient vessels in Zone I (i.e., superficial temporal artery/vein); however, a fibular reconstruction of the mandible (zone I) is likely to have recipient vessels selected within Zone II or III. Dissection should proceed immediately subcutaneously in this area until the superficial temporal vein is identified to avoid damaging the vein. Procedures such as neck dissections, thyroidectomy, submandibular gland surgery, tracheostomy, carotid endarterectomy, and previous cervical spine surgery via an anterior approach may not preclude the availability of a microvascular vessel but will undoubtedly have some level of impact on operative findings when performing free tissue transfer. ♦ Careful planning for double free tissue transfers will avoid unnecessary technical difficulties during microsurgery. Recipient vessels located within Zone II are the most commonly utilized vessels for microvascular reconstruction of the head and neck. Additionally, operative details may offer insight into the difficulties that may be encountered when additional procedures are performed. Microvascular reconstruction in head and neck surgery is increasing in the elderly because of prolonged life expectancy. mhanasono@mdanderson.org Microvascular reconstruction of head and neck defects can be extremely challenging in patients with a history of prior neck … The most obvious are related to vascular compromise of the flap. Objectives To evaluate the complications of head and neck reconstruction using microvascular free tissue transfers (MFTTs) performed in an elderly population and to determine whether these complications are more common than in a younger population.. The region of the planned reconstruction may or may not coincide with the Zone of recipient vessel selection. Perhaps the most obvious indication for preoperative imaging is the assessment of peripheral vessels in fibular surgery in patients with longstanding peripheral vascular disease. Repositioning transferred tissues and the vascular pedicle is infinitely more difficult, if not impossible, if the possibility of compromise is recognized after the flap inset and microvascular anastomosis has been performed. ♦ Prepare the vessels adequately for anastomosis, and avoid aggressive vessel manipulation and manipulation of the internal lumen. Similarly, it is important to avoid a kink or twist in the vascular pedicle during flap positioning. 1989;115:954-960. Review of previous operative reports can yield information related to the vasculature available for microvascular anastomosis. Dental implants: this restoration of teeth technique starts with a metal screw that acts as a tooth anchor; a crown is then fitted over the implant. Paramount to successful microvascular reconstructive surgery is appropriate management of the microvascular anastomosis and vascular pedicle. Education. Essentially, arterial donor vessels may be divided into two categories: branches of the external carotid and branches of the thyrocervical trunk (Fig. Author information: (1)Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA. Skin, blood vessels, and other bodily tissues are extracted from other areas of the body and transplanted to the face or neck to replace lost or excised tissue. Zone I represents the superiormost region, including vessels available from the facial artery as it passes lateral to the mandible and superior to this level. Cadaveric investigations have reported the outer diameter of the superior thyroid artery to be approximately 3.5 mm. Distally, the angular/nasolabial branch of the facial artery may be reliably located within the nasolabial fold and has been used successfully for microvascular reconstruction.1 Cadaveric investigation revealed that the average length of the artery was 28 mm and the mean diameter of the respective artery and vein (1.5 and 2.5 mm) was suitable for microvascular anastomosis in 85% of the sides investigated.2 Successful intraoral preparation and microvascular anastomosis has been reported as well and represents an option for intraoral reconstructions when extraoral incisions may be avoided.3 Postoperative care concept with the aim of achieving pain- and risk-free surgery piggyback ” configurations should be that. Often leads to prolonged hospital stays intima to prevent damage to the flow. Adverse features overlying the anterior scalene muscle should be carefully reviewed surgeons have multiple donor. 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