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Microvascular Reconstruction After Previous Neck Dissection
Christian Head, MD;
Joel A. Sercarz, MD;
Elliot Abemayor, MD, PhD;
Thomas C. Calcaterra, MD;
Jeffrey D. Rawnsley, MD;
Keith E. Blackwell, MD
Arch Otolaryngol Head Neck Surg. 2002;128:328-331.
ABSTRACT
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Background Microvascular reconstruction of defects in the head and neck is more
challenging in patients who have undergone a previous neck dissection, owing
to prior resection of potential cervical recipient blood vessels used for
free flap perfusion.
Objective To evaluate the reliability and safety of free flap reconstruction in
patients with previous neck dissection.
Patients and Methods Sixty free flaps were performed in 59 patients with a medical history
of neck dissection for head and neck cancer. This included patients undergoing
salvage surgery for recurrent cancer as well as patients undergoing secondary
reconstruction of cancer surgery–related defects. Flap selection included
25 radial forearm flaps, 20 fibula flaps, 7 rectus abdominis flaps, 7 subscapular
system flaps, and 1 iliac crest flap.
Results Recipient vessels were used in the field of previous neck dissection
in approximately half the patients with previous selective neck dissection,
while contralateral recipient vessels were always used in patients with a
history of modified radical or radical neck dissection. Vein grafts were not
necessary in any cases. One arterial anastomosis that was created under excessive
tension required urgent reoperation and revision, but there were no cases
of free flap failure.
Conclusions Free flap reconstruction of the head and neck is highly successful in
patients with a history of neck dissection, despite a relative paucity of
potential cervical recipient blood vessels. Heavy reliance on free flaps with
long vascular pedicles obviated the need to perform vein grafts in the present
series, probably contributing to the absence of free flap failure. Previous
neck dissection should not be considered a contraindication to microvascular
reconstruction of the head and neck.
INTRODUCTION
MICROVASCULAR free flaps have proven to be both reliable and functionally
effective for reconstruction of major head and neck defects. The most recent
clinical series of head and neck free flap reconstructions following ablative
cancer surgery have reported flap survival rates in the 98% to 99% range.1-2
Free flap reconstruction is more challenging in patients who have undergone
previous neck dissection ipsilateral to the site of defect reconstruction,
as previous neck dissection reduces the availability of potential recipient
cervical blood vessels for free flap perfusion. The lack of potentially suitable
cervical recipient blood vessels can increase the complexity of achieving
successful free flap perfusion and thereby may increase the risk of free flap
thrombosis and failure. To our knowledge, no previous series have focused
on the impact of previous neck dissection on microvascular head and neck reconstruction.
In this series, we document the reliability and safety of free flap transfer
following previous neck dissection; recommendations for optimizing free flap
survival are also described.
PATIENTS AND METHODS
Fifty-nine patients with a medical history of neck dissection for treatment
of cancer underwent a total of 60 microvascular free flaps (1 patient received
2 simultaneous free flaps) for reconstruction of defects in the head and neck
region. Medical records were reviewed to determine patient age, sex, cancer
histologic characteristics, classification of previous neck dissection, indication
and timing of free flap reconstruction, defect classification and laterality,
and cervical recipient vessel selection. For patients with large recurrent
cancers that crossed the midline, defect laterality was classified according
to the initial site of origin of the tumor or the location of the epicenter
of the defect. Previous neck dissections were classified as radical neck dissections,
modified radical neck dissections (sparing the spinal accessory nerve), or
selective neck dissections (including supraomohyoid, lateral, posterolateral,
or anterior type).3 The internal jugular vein
was preserved in all cases of previous selective neck dissection.
RESULTS
There were 41 men and 18 women with a medical history of neck dissection
for head and neck cancer who underwent microvascular flap reconstruction.
Age at the time of therapy ranged from 32 to 85 years. All defects arose as
a result of treatment of head and neck cancer, with the specific pathologies
consisting of squamous cell carcinoma (55 cases), epimyoepithelial carcinoma
(1 case), adenoid cystic carcinoma (1 case), and metastatic renal cell carcinoma
(1 case). Forty-seven reconstructions were carried out in conjunction with
resection of recurrent cancers or secondary primary cancers, while 10 cases
entailed secondary reconstruction of cancer therapy–related defects
among patients in remission. Two additional reconstructions were done in conjunction
with segmental mandibulectomy for treatment of advanced osteoradionecrosis
of the mandible. The wounds undergoing reconstruction were classified as oral-oropharyngeal
(48 cases), pharyngoesophageal (8 cases), or skull base–midface defects
(3 cases).
All patients had a medical history of previous neck dissection. In 50
(85%) of 59 cases, a previous neck dissection had been performed ipsilateral
to the site of the defect. Of the 9 patients (15%) who had previous neck dissections
performed contralateral to the site of the defect, 2 had functional neck dissections
and 7 had selective neck dissections. Overall, there were 29 cases of previous
unilateral radical or modified radical neck dissection and 24 cases of previous
unilateral selective neck dissection. In addition, 3 patients had a history
of ipsilateral radical neck dissection combined with contralateral selective
neck dissection. Three additional patients had a history of bilateral selective
neck dissection, resulting in a total of 33 previous selective neck dissections
among the 59 cases in this series. Forty-two cases (71%) had preoperative
radiation therapy.
Flap selection included 25 radial forearm flaps, 20 fibula flaps, 7
rectus abdominis flaps, 7 subscapular system flaps, and 1 iliac crest flap.
Recipient vessel selection is summarized in Table 1. The number of recipient arteries and veins used for free
flap perfusion exceeds the number of reconstructions performed because dual
venous drainage was used in select cases of radial forearm flap and fibula
flap reconstruction, and there was 1 case of simultaneous transfer of 2 free
flaps. Overall, cervical recipient vessels located on the side of the neck
that was contralateral to the defect site were used in 36 (61%) of 59 cases
of microvascular reconstruction. The contralateral facial artery was the most
common recipient artery, while the most common recipient vein was divided
relatively evenly between the contralateral internal and external jugular
veins (Table 1). Cervical recipient
vessels for free flap perfusion were located in the field of previous selective
neck dissection much more frequently than in the field of previous radical
or modified radical neck dissection. Recipient blood vessels for free flap
perfusion were located in the field of 17 (52%) of 33 previous selective neck
dissections, compared with no instances where cervical recipient vessels were
in the field of previous radical or modified radical neck dissection (0 of
29 cases). It was not necessary to use vein grafts to lengthen the vascular
pedicles that supplied the free flaps in any cases.
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Recipient Artery and Vein Selection
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One case required urgent reexploration 3 days postoperatively for disruption
of a microarterial anastomosis that was created under excessive tension. In
this case, the patient had previously undergone a right radical neck dissection
that was ipsilateral to the defect site. A through-and-through defect of the
tongue, mandible, and skin of the chin and neck was reconstructed using simultaneous
transfer of a fibula free flap and a radial forearm free flap. Both flaps
were perfused using recipient vessels in the contralateral left neck. The
microarterial anastomosis created between the peroneal artery of the fibula
flap to the left lingual artery ruptured 3 days postoperatively when the patient
turned his head position to the extreme right. This anastomosis was urgently
revised and the fibula flap was successfully salvaged. There were no cases
of free flap failure, resulting in a success rate of 100%. Preoperative radiotherapy
had no impact on free flap viability.
COMMENT
Over the past decade, the use of microvascular free flaps has greatly
enhanced the armamentarium of methods available to achieve surgical reconstruction
of defects in the head and neck. Microvascular free flaps allow single-stage
reconstruction at the time of surgical resection. Although the first microscope-assisted
transfer of a free flap was reported in 1973,4
prior to the 1990s there was limited enthusiasm in the United States to apply
free flaps for reconstruction of head and neck defects.5
This reluctance arose from several perceived shortcomings of microvascular
tissue transfer. Such concerns included questions regarding the reliability
of a technique that was dependent on small vessel vascular anastomoses for
a successful outcome and the potential for an adverse impact on the costs
and complications of therapy.
As surgeons became more experienced with microvascular free flap techniques,
the reliability of free flaps has improved steadily. An early survey revealed
that the rate of successful free flap transfer was 89% during the first decade
of clinical experience with microvascular surgery6
By the mid-l990s, several large series reported successful head and neck reconstruction
using free flaps in 91% to 95% of cases.7-11
In l999, Blackwell1 described a success rate
of 99% in 119 cases of microvascular head and neck reconstruction, while Singh
et al2 reported success in 98% of 200 cases.
Improved free flap reliability has been due to improved microvascular techniques,
increased reliance on free flaps with long vascular pedicles that contain
large-caliber blood vessels, and greater experience by individual surgeons.
The most common cause of free flap failure is thrombosis of the vascular
pedicle in the region of the microvascular anastomosis.12
Microvascular reconstruction in the head and neck is more challenging in patients
who have undergone previous neck dissection, owing to prior resection of potential
recipient blood vessels. It is conceivable that a paucity of potential cervical
recipient blood vessels might result in increased risk of free flap failure
in patients with a history of previous neck dissection.
The present series details 59 patients who underwent free flap reconstruction
following previous neck dissection, achieving a success rate of 100%. About
15% of the neck dissections were contralateral to the defect site. Prior radiation
therapy does not appear to have a negative impact on flap survival since 71%
of our patients had preoperative radiation therapy. The study therefore does
not identify previous neck dissection as a risk factor associated with an
increased rate of free flap failure. The data indicate that free flaps need
not be avoided when there is a history of previous neck dissection. Although
the flaps proved reliable, 61% of patients required use of cervical recipient
blood vessels in the contralateral neck, reflecting an increased complexity
of reconstruction. Use of contralateral cervical recipient blood vessels is
rarely necessary in the absence of previous neck surgery.
The extent of the previous neck dissection had an impact on the need
to rely on contralateral vessels. In approximately half the cases of previous
selective neck dissection, cervical recipient blood vessels were successfully
located in the field of the previous neck dissection. By contrast, all patients
with a history of modified radical or radical neck dissection required use
of cervical recipient blood vessels in the opposite side of the neck. This
is likely a reflection of the unavailability of suitable cervical recipient
veins in the field of previous modified radical or radical neck dissection.
The facial and superior thyroid arteries are commonly ligated during cases
of selective, modified radical, and radical neck dissection. However, the
external carotid artery and medial branches of the external carotid artery
such as the lingual artery are commonly preserved during neck dissection and
may be available to use as cervical recipient blood vessels during subsequent
cases of microvascular flap reconstruction. This may explain why the external
carotid artery and lingual artery were used frequently within the ipsilateral
neck (52% of ipsilateral recipient arteries) compared with the contralateral
neck (11% of contralateral arteries) in the present series. However, the external
and internal jugular veins are routinely sacrificed during a modified radical
or radical neck dissection. This makes isolation of a recipient vein within
the field of previous modified radical or radical neck dissection more difficult
compared with after previous selective neck dissection, where the external
or internal jugular veins are more commonly preserved.
Another approach when there is not a suitable recipient vein relies
upon cephalic vein transposition.13 In cases
of previous modified radical or radical neck dissection, the cephalic vein
can be transposed from the ipsilateral arm to the neck to serve as a recipient
vein for free flap perfusion. Advantages of this technique include the fact
that only one microvenous anastomosis is required, and the high-flow, low-pressure
cephalic-subclavian system may be resistant to stasis and thrombosis. The
primary disadvantage of this technique arises from the increased potential
of kinking or extrinsic compression of the venous pedicle within its long
subcutaneous course, particularly where the cephalic vein crosses over the
clavicle.
In cases where ipsilateral cervical recipient blood vessels are unavailable,
vein grafts can be used to lengthen vascular pedicle to reach remote recipient
vessels. In the present series, the need to use vein grafts was eliminated
by careful preoperative planning and heavy reliance on free flaps that contain
long vascular pedicles. Two previous large series of microvascular head and
neck reconstruction have correlated the use of vein grafts with an increased
risk of free flap failure, so they are best avoided whenever feasible.10-11 In the present series, radial forearm
flaps, fibula flaps, rectus abdominis flaps, and subscapular system flaps
accounted for the 98% of the donor sites selected. All of these flaps contain
long vascular pedicles that usually can reach cervical recipient blood vessels
in the contralateral neck without requiring the use of vein grafts.
Based on our experience with the patients in this series, we propose
the following algorithm for microvascular flap reconstruction in patients
with a history of neck dissection as related to factors that affect recipient
vessel selection. The status of potential recipient veins within the field
of previous neck dissection is usually the most critical factor in determining
the selection of cervical recipient vessels for flap perfusion. Some length
of the external carotid artery is usually preserved during most neck dissections,
and an end-to-side arterial anastomosis to the external carotid artery can
usually be performed even when all external carotid branches have been previously
ligated.
In patients with a history of radical neck dissection or modified radical
neck dissection, plans should be made for use of recipient vessels in the
unoperated-on neck, as it has been our experience that recipient veins are
seldom available owing to prior resection of the internal and external jugular
venous systems in patients with previous radical neck dissection or modified
radical neck dissection. In cases where the unoperated-on neck is contralateral
to the defect site, selection of a free flap that offers a long vascular pedicle
usually obviates the need to perform vein grafting, although all patients
with previous neck dissection are routinely informed of and consented for
the possibility to perform vein grafting if necessary.
In patients with a history of a selective neck dissection that is ipsilateral
to the defect site, careful review of the previous operative report to determine
the status of the internal jugular vein is recommended. In cases where the
internal jugular vein was preserved during previous neck dissection, we have
found that recipient vessels are usually available within the field of the
prior neck dissection in approximately half the cases. In the other half of
cases, it is necessary to use recipient vessels within the contralateral neck,
owing to difficulty in isolating and preparing suitable recipient veins within
the field of previous selective neck dissection, due to periadventitial scarring
or perioperative thrombosis of an internal jugular vein that had been preserved
during a prior selective neck dissection. Even in these cases, selection of
flaps that offer long vascular pedicles and planning for possible vein grafting
is desirable, as use of contralateral recipient vessels will be necessary
in approximately 50% of cases.
CONCLUSIONS
Free flap reconstruction of the head and neck is highly successful in
patients with a history of neck dissection, despite a relative paucity of
potential cervical recipient blood vessels. Recipient vessels can be identified
in the field of previous selective neck dissection in approximately half of
such cases, while recipient vessels are rarely available in the field of a
previous radical neck dissection. In most cases of microvascular reconstruction
after previous neck dissection, it is necessary to use recipient vessels in
the neck that is contralateral to the side of the defect. Heavy reliance on
free flaps with long vascular pedicles eliminated the need to perform vein
grafts in the present series, probably contributing to the absence of free
flap failure. Previous neck dissection should not be considered a contraindication
to microvascular reconstruction of the head and neck.
AUTHOR INFORMATION
Accepted for publication December 6, 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: Keith E. Blackwell, MD, Department
of Surgery, Box 951624, UCLA School of Medicine, Los Angeles, CA 90095-1624
(e-mail: kblackwe{at}ucla.edu).
From the Department of Surgery, Division of Head and Neck Surgery,
the University of California Los Angeles School of Medicine, Los Angeles.
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