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The Thoracoacromial/Cephalic Vascular System for Microvascular Anastomoses in the Vessel-Depleted Neck
Jeffrey R. Harris, MD;
E. Lueg, MD;
E. Genden, MD;
M. L. Urken, MD
Arch Otolaryngol Head Neck Surg. 2002;128:319-323.
ABSTRACT
Objective To review our experience with use of the thoracoacromial/cephalic (TAC)
system in the free flap reconstruction of complicated head and neck defects.
Design Case series.
Setting Tertiary care referral center.
Population A consecutive sample of 11 patients requiring free flap reconstruction
of head and neck defects using the TAC system for microvascular anastomoses
was identified by medical chart review.
Intervention Free flap reconstruction of complicated defects of the head and neck
using the TAC vascular system for microvascular anastomoses.
Main Outcome Measures Free flap survival and microvascular thrombosis.
Results Of 11 patients using TAC anastomoses, all had complete survival of free
flaps. No complications related to anastomotic failure were identified.
Conclusions The TAC system provides a reliable source of undisturbed vessels when
cervical vessels are unusable or absent.
INTRODUCTION
FREE FLAP reconstruction of defects of the head and neck has become
a commonly used technique. The presence of adequate blood vessels for anastomoses
is vital to the success of these procedures. However, in patients with previous
ablative or reconstructive surgery, extensive trauma, wide surgical excisions,
or irradiated tissues, it may be difficult or impossible to find suitable
vessels in the cervical area.
Sporadic studies in the literature have looked primarily at techniques
to facilitate venous anastomoses in the vessel-depleted neck. Several articles
have looked at the cephalic vein as an alternative vessel for venous anastomoses.1-3 There is a paucity of
literature on techniques for arterial anastomoses in the vessel-depleted neck
and in particular on the use of the thoracoacromial system as a reliable arterial
source for free flap reconstructions of the head and neck.
We reviewed our experience with use of the thoracoacromial/cephalic
(TAC) system in the free flap reconstruction of complicated head and neck
defects and found this to be a reliable and invaluable technique. The anatomy
and application of this technique are discussed.
PATIENTS AND METHODS
PATIENTS
Eleven patients requiring TAC anastomoses were identified through review
of operative records. These patients' medical charts were evaluated to identify
patient background, indication for surgery, previous surgical or medical interventions,
type of resection, type of reconstruction, use of vein grafts, operative complications,
anastomotic difficulties, postoperative complications, and free flap survival.
SURGICAL TECHNIQUE
After the initial portion of the procedure was completed, access was
gained to the TAC system by creating a curved incision over the area of the
deltopectoral groove in such a fashion as to preserve and stage the area of
the deltopectoral flap (Figure 1). Skin and fascia were then elevated as if elevating the deltopectoral flap
until the deltopectoral groove and the lateral aspect of the clavicular head
of the pectoralis major muscle were exposed. Dissection was then taken into
the deltopectoral groove, where the cephalic vein was identified. The vein
was dissected as far into the arm as was necessary to allow transposition
over the clavicle and into the neck for tension-free anastomoses.
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Figure 1. Photograph of the right infraclavicular
area demonstrating the site of incision through the pectoralis major muscle.
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Attention was then turned to dissection of the thoracoacromial system.
A horizontal incision was made across the pectoralis muscle, dividing its
lateral attachment to the clavicle (Figure
1). Careful dissection in the plane deep to the pectoralis major
muscle and superficial to the pectoralis minor muscle was undertaken to identify
the main trunk of the thoracoacromial system and its takeoff from the axillary
artery. Usually, several branches of the thoracoacromial artery can be identified
and preserved for anastomosis. In an effort to preserve the viability of the
pectoralis major muscle flap, the pectoral branch was usually preserved if
an alternative branch was of suitable dimensions.
If a pectoralis major muscle flap had been elevated during previous
surgery, then the pectoral branch of the thoracoacromial artery often could
be identified on the surface of the elevated pectoralis muscle. This branch
was then traced retrograde to its origin at the thoracoacromial artery. The
pectoral branch, thoracoacromial artery, or one of the other identified branches
was then used for anastomoses.
RESULTS
Patient backgrounds are summarized in Table 1. Table 2 details
previous surgical interventions. Table 3 indicates the reconstruction method and vascular supply used. Of
11 patients using the TAC anastomoses, all had complete survival of free flaps.
No complications related to anastomotic failure were identified. Two representative
patients are described in greater detail in the following subsections.
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Table 1. Patient Backgrounds
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Table 2. Previous Surgical Procedures
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Table 3. Free Flap Donor Site and Anastomoses*
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REPORT OF CASES
CASE 8
This patient originally had cutaneous squamous cell cancer on the right
shoulder and neck. The tumor was excised, and he experienced recurrence approximately
1 month later and subsequently underwent Mohs surgery. A recurrence was again
experienced approximately 3 months later. At that time, he was referred to
our institution (The Mount Sinai Hospital). On examination, the patient had
a large right neck mass with a fungating appearance. No other abnormalities
were noted. The patient had an extensive resection with neck dissection, leaving
a large defect (Figure 2). The defect
included complete exenteration of the posterior triangle to the level of the
brachial plexus, including removal of all usable posterior triangle vessels.
A planned delayed reconstruction after final pathology results were obtained
was then undertaken using a combined parascapular fasciocutaneous and latissimus
dorsi myocutaneous free flap. A pedicled flap reconstruction was considered,
but the size of the defect required free tissue transfer for adequate coverage.
Anastomoses were performed to the thoracoacromial artery and cephalic vein,
which were used preferentially owing to their proximity to the ablative defect.
The results of this reconstruction are demonstrated in Figure 3.
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Figure 2. Postablation defect in patient
8. SCM indicates sternocleidomastoid muscle; LS, levator scapulae muscle.
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Figure 3. Result of combined parascapular
and latissimus dorsi free flap closure 6 months after surgery in patient 8.
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CASE 10
This patient was originally treated with an organ preservation radiation
therapy and chemotherapy protocol for laryngeal cancer. He subsequently developed
evidence of recurrent and persistent laryngeal cancer. He then underwent salvage
total laryngectomy and bilateral selective neck dissections with placement
of a pectoralis major muscle flap over the pharyngeal closure. After surgery,
the patient developed a pharyngocutaneous fistula with wound breakdown and
exposure of the carotid artery. A formal pharyngostome was created with cervical
skin flaps. This closure subsequently broke down with exposure of the carotid
artery. A superiorly based trapezius myocutaneous flap was then brought into
the neck for carotid coverage, and the skin from this flap was used to recreate
a pharyngostome. This flap pulled away from the posterior pharyngeal wall,
again leading to carotid artery exposure. The wound was treated conservatively
with packing, and the patient was scheduled for reconstruction of the pharynx
using a gastro-omental artery free flap. At the time of surgery, extensive
exploration of the neck to find adequate blood vessels for anastomosis revealed
that the previous neck dissection, radiation therapy, and salivary leak had
left no reliable vasculature in the ipsilateral or contralateral neck. This
procedure was performed using the TAC system for vascular supply (Figure 4). The patient did well after surgery.
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Figure 4. Thoracoacromial artery (TA) and
cephalic vein (CV) transposed over the clavicle (CL) and anastomosed to the
gastroduodenal pedicle (GDP) in patient 10.
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COMMENT
Reconstruction of the head and neck in the presence of a vessel-depleted
neck is becoming a common problem with the increased use of free flaps. The
cephalic vein has recently been described as a "lifeboat" for head and neck
reconstruction.1 Horng and Chen1
reported their experience with 3 patients requiring free flap reconstruction.
The cephalic vein was the recipient vein in 2 cases and was used in continuity
with a radial forearm flap in a third case. A later study2
presented 11 cases of cephalic vein transposition for head and neck reconstruction
with excellent results. The advantages of the transposed cephalic vein technique
include the ability to span long distances in the head and neck, thereby eliminating
the need for vein grafts and anastomosing to a vessel outside an irradiated
field.4 In addition, the cephalic vein is often
an excellent size match for microvascular anastomoses. In our series, the
cephalic vein was used preferentially because of its simple dissection and
the length of the vessel that allows for transposition over the clavicle to
reach virtually any area of the ipsilateral neck.
The anatomy of the cephalic vein has been described in detail elsewhere.3 The radial continuation of the dorsal venous arch
forms the origin of the cephalic vein. The cephalic vein then crosses the
tendon of the extensor pollicis longus and ascends across the radial border
of the wrist. The cephalic vein next turns anteriorly to parallel the anterior
border of the brachioradialis muscle and the radial artery and its venae commitantes.
In the antecubital fossa, the median cubital vein obliquely ascends as a major
branch to connect with the basilic vein and the deep venous system. This anastomotic
network provides the various options for venous outflow for the radial forearm
flap. The cephalic vein next follows the lateral bicipital groove to enter
the deltopectoral groove between the respective muscles. The cephalic vein
usually accompanies the deltoid arterial branch of the thoracoacromial axis,
where it pierces the brachial fascia to leave the subcutaneous level. Deep
in the deltopectoral triangle, the cephalic vein perforates the costocoracoid
membrane at the upper border of the pectoralis minor muscle to empty finally
into the axillary vein. The cephalic vein has been reported to cross anterior
to the clavicle to penetrate to cervical fascia and end in the external jugular
vein.3
To our knowledge, there have been no previous reports of the thoracoacromial
system being used as an arterial source for free flap reconstruction of the
head and neck. Seikaly et al5 recently detailed
the thoracoacromial axis as a vascular supply for the clavipectoral osteomyocutaneous
free flap. Other articles6-8
have commented on the thoracoacromial axis as a recipient vascular supply
for reconstruction of other areas, including the breast and thoracic esophagus.
The anatomy of the thoracoacromial system has been well described.9 The thoracoacromial artery consistently arises as
a branch off the second part of the axillary artery. It classically divides
into 4 named branches: the pectoral, deltoid, clavicular, and acromial arteries.
The thoracoacromial venous system generally mirrors the arterial branching,
although more variability has been reported. Through cadaver studies,9 the diameters of the branches of the thoracoacromial
arterial system have been found to range from 1.2 to 2.4 mm; the diameter
of the thoracoacromial arterial trunk was found to have a diameter of 2.5
to 7.0 mm. In our series, the branches of the thoracoacromial arterial system
could be dissected distally to achieve enough length to transpose the artery
over the clavicle into the neck while maintaining an adequate lumen for anastomosis.
The pectoral branch of the thoracoacromial artery is the main vascular
pedicle on which the pectoralis major muscle flap is based. This becomes a
consideration when using the TAC system for 2 reasons. First, when a pectoralis
muscle flap has not been elevated during a previous procedure, thought must
be given to the possibility of requiring a pectoralis muscle flap in the future.
Using another branch of the thoracoacromial artery for anastomosis can preserve
the vascular pedicle to the pectoralis major muscle flap. We successfully
preserved the pectoral branch and later used the pectoralis muscle in 1 patient.
Second, when the patient has had a pectoralis major muscle flap elevated at
a previous procedure, there may be distortion of the usual anatomy of the
TAC system. Three of 10 patients in our study were in this category. In each
situation, the TAC system could be dissected and used. In some respects, dissection
was actually facilitated in this situation as the pectoral branch of the thoracoacromial
artery was readily exposed due to its location on the previously elevated
pectoralis muscle flap. This branch was then easily traced to the main trunk
of the TAC system.
In conclusion, we report our experience using the TAC system for microvascular
anastomoses in 11 patients requiring free flaps for head and neck reconstruction
in the presence of a vessel-depleted neck. The TAC system provides a reliable
source of undisturbed vessels when cervical vessels are unusable or absent.
The substantial drawback of this technique is the potential loss of the major
vascular pedicle to the pectoralis major muscle myocutaneous flap, thereby
preventing its future use, if required. However, with selective dissection
of other branches of the thoracoacromial artery, the pectoral branch can be
preserved. If a pectoralis major muscle flap has been elevated during a previous
procedure, it is still possible to use the TAC system provided that adequate
time has passed for neovascularization to occur. Exposure of the TAC system
is not technically complicated and should be included in the armamentarium
of any surgeon performing complicated head and neck reconstructions.
AUTHOR INFORMATION
Accepted for publication November 27, 2001.
This study was presented at the annual meeting of the American Head
and Neck Society, Palm Desert, Calif, May 14, 2001.
Corresponding author and reprints: Jeffrey R. Harris, MD, Department
of Surgery, 2D, University of Alberta, WC Mackenzie Centre, 8440 112 St, Edmonton,
Alberta, Canada T6G 2B7 (e-mail: jharris{at}powersurfr.com).
From the Department of Surgery, University of Alberta, Edmonton (Dr
Harris); Los Angeles Medical Center, Southern California Permanente Medical
Group (Dr Lueg); and the Department of Otolaryngology, The Mount Sinai Hospital,
New York, NY (Drs Genden and Urken).
REFERENCES
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1. Horng SY, Chen MT. Reversed cephalic vein: a lifeboat in head and neck free-flap reconstruction. Plast Reconstr Surg. 1993;92:752-753.
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neck. Br J Plast Surg. 1998;51:2-7.
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3. Hallock GG. The cephalic vein in microsurgery. Microsurgery. 1993;14:482-486.
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vessel access. Plast Reconstr Surg. 1993;92:628-632.
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5. Seikaly H, Calhoun K, Rassekh CH, Slaughter D. The clavipectoral osteomyocutaneous free flap. Otolaryngol Head Neck Surg. 1997;117:547-554.
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6. Barnett GR, Carlisle IR, Gianoutos MP. The cephalic vein: an aid in free TRAM flap breast reconstruction:
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8. Fujita H, Inoue Y, Kakegawa T, et al. Esophageal reconstruction using microvascular anastomosis to the thoracoacromial
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