The University of Florida Department of Oral and Maxillofacial Surgery in Jacksonville offers a one-year, CODA-accredited fellowship in head and neck oncologic surgery and microvascular reconstruction, including oral cancer surgery, severe facial trauma reconstruction and microvascular surgery. Microvascular reconstruction is a surgical procedure that involves moving a composite piece of tissue from another part of the body to the head and neck. As a general principle, selection of the artery with the strongest arterial flow rather than the largest diameter yields more reliable results. Essentially, arterial donor vessels may be divided into two categories: branches of the external carotid and branches of the thyrocervical trunk . The preparation of vessels prior to microsurgical anastomosis is a critical component of microsurgery, although it is often overlooked in the microsurgical literature. Additionally, operative details may offer insight into the difficulties that may be encountered when additional procedures are performed. Zone III represents the most inferior region of recipient vessels, which includes branches of the thyrocervical trunk, thoracoacromial system, and internal mammary artery. Dr. Brianna Harris is a fellowship-trained head and neck microvascular and transoral robotic surgeon in San Diego, CA. Pedicle length and diameter match with proposed recipient sites should be planned prior to flap inset. 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. Although major branches of the external carotid artery, such as the facial, lingual, and the superior thyroid, provide the majority of recipient vessels in microvascular head and neck reconstruction, the internal mammary, and thoracoacromial systems may be used in challenging cases. Dissection should proceed immediately subcutaneously in this area until the superficial temporal vein is identified to avoid damaging the vein. This is often necessary to eradicate cancer but may result in disfigurement or loss of functions such as speech or swallowing. Avoiding vascular pedicle compression related to anatomic factors, flap orientation, and skin closure is relatively obvious but can be difficult to achieve if the potential for compression is not recognized early during reconstruction. Computed tomography (CT) or magnetic resonance angiography (MRA) (or formal flow Doppler investigation) should be considered to evaluate the lower extremity vasculature in patients with appropriate risk factors undergoing fibular free transfer.16–20 The routine use of angiographic studies for the detection of peroneal artery septocutaneous perforators continues to be evaluated; however, it is probably unnecessary in the majority of cases.21,22 Routine angiography/Doppler evaluation of the cervical vasculature is often unnecessary, but it should be considered in cases with multiple prior procedures, a history of severe vascular disease, multiple vascular/surgical insults, or chronic wounds.23–25 Regarding the radial forearm flap, preoperative imaging of the palmar arch is frequently not indicated, but a negative Allen’s testing does not preclude significant vascular disease of the palmar arch, and preoperative Doppler imaging may be considered if significant vasculopathy is suspected.23,24,26. 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. (B) The orientation of the vascular anastomosis is exposed to two suture lines. 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 It should be noted that vessels within Zone II are often within the target region of previous radiotherapy for pharyngeal/laryngeal malignancies or metastatic cervical lymph nodes. Knowledge of the available vessel options within Zone I is critical for planning microvascular reconstructions of the nasal complex or anterior forehead/scalp and orbit. We use cookies to help provide and enhance our service and tailor content and ads. Although this finding may seem intuitively obvious, many authors have reported retrograde anastomosis despite the evidence of the inherent risks associated with this technique.29. The infrastructure, clinical services offered and the outcomes of patient care are on par with the best centers in the world. It is important to note that the microvascular surgeon may wish to access the thyrocervical system for microvascular anastomosis merely to optimize pedicle orientation despite the availability of external carotid recipient vessels. Microvascular reconstruction of head and neck defects can be extremely challenging in patients with a history of prior neck dissection and/or irradiation. 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. The length of the vascular pedicle determines the optimal donor-recipient relationship. (C) This is the least desirable orientation, exposing the vascular anastomosis to three suture lines. All patients who underwent a microvascular free flap of the head and neck by surgeons in the department of otolaryngology from 2013 to 2017 were included in this study. Experienced microvascular surgeons have noted that the tethering of the facial artery by the digastric/stylohyoid muscles may preclude adequate access to the artery or introduce untoward positioning of the vascular pedicle. Microvascular reconstructions after head and neck cancer are among the most complicated procedures in plastic surgery. We performed 89 microvascular procedures in the study period, of which 58 were in the oral cavity/sinuses and 31 were laryngopharyngeal. Perhaps the most obvious indication for preoperative imaging is the assessment of peripheral vessels in fibular surgery in patients with longstanding peripheral vascular disease. 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 region of the planned reconstruction may or may not coincide with the Zone of recipient vessel selection. He/she may go to any site as need be for special events. The fellow is an integral part of the Head & Neck surgical team. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. Microvascular reconstruction in head and neck cancer - basis for the development of an enhanced recovery protocol. It is in situations such as these that confusion or poor vessel selection and orientation may occur, resulting in a failed reconstruction. ♦ Microscopic/loupe visualization is critical; avoid vessel preparation/manipulation without magnification. ♦ Prepare sufficient vessel length to avoid adventitial interference and provide sufficient nontraumatized vessel length to facilitate microsurgery. Additional vessel preparation may be required in special circumstances such as vein grafting, application of monitoring devices, or for certain vessel configurations. 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. Essentially, arterial donor vessels may be divided into two categories: branches of the external carotid and branches of the thyrocervical trunk (Fig. (A) The least desirable situation, with two vascular kink points. There are several objectives that should be recognized by the microsurgeon for successful pedicle orientation. ♦ Prepare the vessels adequately for anastomosis, and avoid aggressive vessel manipulation and manipulation of the internal lumen. … The details of vessel management and microvascular anastomosis are critical to surgical success and are often ignored. 10.1). The Vanderbilt Head and Neck, Cranial Base and Microvascular Reconstructive Surgery Fellowship is an outstanding one-year clinical position with the option to extend the fellowship to a second year to focus on clinical or basic science research. Successful outcome after microvascular reconstruction of the head and neck has been reported to range from 93% to 99%. The superior thyroid artery provides excellent caliber and reliability for microvascular reconstructions. The impacts of medical comorbidities and of age, to some degree, are recognized by microvascular surgeons and frequently alter the management considerations when free tissue transfer techniques are employed.9–11 Previous radiation therapy has been reported to be a positive predictor for wound complications after microvascular reconstruction; however, the impact of these therapies continues to be investigated, and although an adverse effect may be suspected, debate regarding the actual effects of radiotherapy continues.12–14 The implications of body habitus and general anatomic factors are frequently ignored by inexperienced surgeons but may have a significant impact during free tissue reconstruction. Pedicle orientation issues, which remain unrecognized until the second tissue transfer is prepared for anastomosis, are problematic and may be avoided with appropriate planning. Fig. Surgical Technique and Considerations ♦ Careful attention to small cutaneous perforators is required to avoid compromise; harvesting small perforators with a muscle cuff is recommended if possible. Careful attention to avoiding manipulation of the internal lumen and vessel intima to prevent damage to the endothelium is paramount to prevent arterial thrombosis. 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. This surgery may include removing: › part of the lower jaw bone and tongue It is in situations such as these that confusion or poor vessel selection and orientation may occur, resulting in a failed reconstruction. 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. Its favorable location, length, and diameter make it an ideal candidate for microvascular anastomosis within this region. Miles 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). Reconstructive Implications for Vessel Orientation Recipient vessels located within Zone II are the most commonly utilized vessels for microvascular reconstruction of the head and neck. region of recipient vessels, which includes branches of the thyrocervical trunk, thoracoacromial system, and internal mammary artery. Vessels that appear to have sufficient diameter may reveal significant intimal/medial thickening due to radiation, and the actual internal diameter may be quite attenuated under microscopic inspection. The impacts of medical comorbidities and of age, to some degree, are recognized by microvascular surgeons and frequently alter the management considerations when free tissue transfer techniques are employed.9–11 Previous radiation therapy has been reported to be a positive predictor for wound complications after microvascular reconstruction; however, the impact of these therapies continues to be investigated, and although an adverse effect may be suspected, debate regarding the actual effects of radiotherapy continues.12–14 The implications of body habitus and general anatomic factors are frequently ignored by inexperienced surgeons but may have a significant impact during free tissue reconstruction. The reconstructive surgeon must verify adequate flow from the selected vessel prior to arterial anastomosis. With a professional background in both Head and Neck Oncology and Microvascular Reconstructive Surgery and Oral & Maxillofacial Surgery, Dr. Eftekhari is uniquely trained and is an expert in treating disorders and cancers of the head and neck region. The preparation of vessels prior to microsurgical anastomosis is a critical component of microsurgery, although it is often overlooked in the microsurgical literature. ♦ Radiated/thickened vessels may require additional preparation to provide optimal vessel wall thickness for accurate anastomosis. Within the field of Otolaryngology – Head and Neck Surgery, several training pathways have developed through which surgeons are trained in microvascular head and neck reconstructive surgery, including free tissue transfer (FTT). ♦ Avoid placing the anastomosis in positions of peril. 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. Paramount to successful microvascular reconstructive surgery is appropriate management of the microvascular anastomosis and vascular pedicle. Head and Neck Fellowship. Additionally, operative details may offer insight into the difficulties that may be encountered when additional procedures are performed. It should be noted that these regions are meant to help reconstructive surgeons conceptualize the head and neck vasculature in an organized way, not to guide reconstructive decisions. Nevertheless, microvascular surgeons have multiple vascular donor options within the head and neck for microvascular surgery. Surgical Technique and Considerations The University of Iowa does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on this web site. (A) The vascular anastomosis is exposed to one superior suture line. Microvascular reconstruction in head and neck surgery is increasing in the elderly because of prolonged life expectancy. The deep cervical fascia overlying the anterior scalene muscle should be kept intact during surgical dissection to prevent damage to the phrenic nerve. Previous microvascular reconstruction will have an obvious impact, and operative reports related to previous free tissue transfers should be carefully reviewed. It should also be noted that the reported location of the artery in relation to the carotid bifurcation is somewhat variable.7 The superior thyroid artery offers an additional advantage of having an inferior orientation relative to the superior orientation of all other branches of the external carotid. Computed tomography (CT) or magnetic resonance angiography (MRA) (or formal flow Doppler investigation) should be considered to evaluate the lower extremity vasculature in patients with appropriate risk factors undergoing fibular free transfer.16–20 The routine use of angiographic studies for the detection of peroneal artery septocutaneous perforators continues to be evaluated; however, it is probably unnecessary in the majority of cases.21,22 Routine angiography/Doppler evaluation of the cervical vasculature is often unnecessary, but it should be considered in cases with multiple prior procedures, a history of severe vascular disease, multiple vascular/surgical insults, or chronic wounds.23–25 Regarding the radial forearm flap, preoperative imaging of the palmar arch is frequently not indicated, but a negative Allen’s testing does not preclude significant vascular disease of the palmar arch, and preoperative Doppler imaging may be considered if significant vasculopathy is suspected.23,24,26 Knowledge and selection of appropriate flaps with long vascular pedicles to relieve tension, consideration of vein grafting, or altering operative approaches to improve access may address these issues. The vascular anatomy of the neck is well described, and a complete review of the anatomy is beyond the scope of this chapter. 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.. Copyright © 2021 Elsevier B.V. or its licensors or contributors. Pedicle length and diameter match with proposed recipient sites should be planned prior to flap inset. The technique is one of the most advanced surgical options available for rehabilitating surgical defects that are caused by the removal of head and neck tumors. 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. The fellowship is based at UW Medical Center where the Department of Otolaryngology-Head and Neck Surgery performs 400+ major head and neck resections per year, including 100 microvascular reconstructions, skull base surgery (both endoscopic and open), and transoral robotic/laser extirpations. The region of the planned reconstruction may or may not coincide with the Zone of recipient vessel selection. The vascular anatomy of the neck is well described, and a complete review of the anatomy is beyond the scope of this chapter. Vessels that appear to have sufficient diameter may reveal significant intimal/medial thickening due to radiation, and the actual internal diameter may be quite attenuated under microscopic inspection. Head and Neck Oncologic Surgery and Microvascular Reconstruction Fellowship. 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. With these goals in mind, it is helpful to consider the vasculature of the head and neck in terms of arterial recipient vessel regions or zones. 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 Surgery When surgery is required in the head and neck, structures important for appearance and function may need to be removed. It has been previously established as superior to conventional care for a wide variety of procedures, including microsurgical procedures such as reconstructions of the breast. © 2020 The Authors. 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. Some detailed considerations of the recipient zones follow. ♦ 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. The superior thyroid artery provides excellent caliber and reliability for microvascular reconstructions. 10.3 The position of the vascular anastomosis relative to the oral or pharyngeal suture line should be considered. Accepted for presentation at the 31st annual EURAPS meeting, May 2020, Athens, Greece. The facial artery and vein passing lateral to the body of the mandible provide excellent caliber and reliability within Zone I for microvascular reconstruction. (A) The vascular anastomosis is exposed to one superior suture line. These positions include pedicle placement adjacent to areas of possible pharyngeal anastomotic leak, tracheostomy sites, positions of external compression leading to vascular compromise, and positions immediately beneath areas of cutaneous vascular compromise, which may lead to anastomotic exposure (Fig. Pedicle orientation issues, which remain unrecognized until the second tissue transfer is prepared for anastomosis, are problematic and may be avoided with appropriate planning. ♦ Avoid placing the anastomosis in positions of peril. Our intentio… ♦ Prepare sufficient vessel length to avoid adventitial interference and provide sufficient nontraumatized vessel length to facilitate microsurgery. ♦ Prior to performing microsurgical anastomosis, the microsurgeon verifies the position of the reconstructive tissue to optimize pedicle orientation and geometry. Zone III represents the most inferior region of recipient vessels, which includes branches of the thyrocervical trunk, thoracoacromial system, and internal mammary artery. The preoperative assessment of patients who are to undergo microvascular free tissue transfer is important to successful surgical outcomes. Enhanced recovery after surgery (ERAS) is a peri- and postoperative care concept with the aim of achieving pain- and risk-free surgery. Prior to this, the Department offered a Head and Neck surgery fellowship, which concentrated mainly upon resectional techniques, under the direction of Dr. Joseph Ogura. Head and Neck Surgery with Microvascular Flap Reconstruction What is head and neck surgery with microvascular flap reconstruction? 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. 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. 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. Cadaveric investigations have reported the outer diameter of the superior thyroid artery to be approximately 3.5 mm. The superficial temporal vein is relatively thin, and careful dissection and avoiding excessive manipulation or kinking during microvascular anastomosis are required. Microvascular head and neck reconstructive surgery is a medical technique for rebuilding the neck and facial tissues of the body. Paramount to successful microvascular reconstructive surgery is appropriate management of the microvascular anastomosis and vascular pedicle. 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. The Head and Neck Fellow will: Participate in all major head and neck operative cases, including microvascular reconstruction; Select the case most appropriate to his training goals if … Dissection should proceed immediately subcutaneously in this area until the superficial temporal vein is identified to avoid damaging the vein. It should be noted that these regions are meant to help reconstructive surgeons conceptualize the head and neck vasculature in an organized way, not to guide reconstructive decisions. Author information: (1)Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA. Urken ML, Weinberg H, Buchbinder D, et al. https://doi.org/10.1016/j.jpra.2020.09.008. It should also be noted that the reported location of the artery in relation to the carotid bifurcation is somewhat variable.7 The superior thyroid artery offers an additional advantage of having an inferior orientation relative to the superior orientation of all other branches of the external carotid. ♦ Careful planning for double free tissue transfers will avoid unnecessary technical difficulties during microsurgery. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. Therefore, it is important for the reconstructive microsurgeon to have mastery of the anatomic considerations and a wide variety of reconstructive options available to address the multitude of challenges that may arise during surgery. The facial artery is arguably the most commonly used vessel for head and neck microvascular reconstruction. Zone III represents the most inferior region of recipient vessels, which includes branches of the thyrocervical trunk, thoracoacromial system, and internal mammary artery. The vessels of the thyrocervical trunk including the inferior thyroid, superficial cervical, and suprascapular artery may be found within the cervical fat overlying the anterior scalene muscle. The region of the planned reconstruction may or may not coincide with the Zone of recipient vessel selection. In these situations, and in the situation of the vesseldepleted neck, selection of vessels may require accessing the thyrocervical trunk or branches of the external carotid less commonly utilized by reconstructive surgeons. ♦ Avoid retrograde flow configurations if possible. ♦ The external cutaneous paddle for monitoring should not be employed at the expense of appropriate pedicle geometry. Zone III represents the most inferior region of recipient vessels, which includes branches of the thyrocervical trunk, thoracoacromial system, and internal mammary artery. As a general principle, selection of the artery with the strongest arterial flow rather than the largest diameter yields more reliable results. 10.3). 1994;120:633-640. (D) A clinical example of a gentle vessel curvature that helps prevent kinking. Zone II 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. Postoperative complications included infection (37%), 30-days re-operations (19%), and re-admissions (17%). Custom prosthetics: these are used to reconstruct parts of the head and neck that were sacrificed due t… The experienced microsurgeon makes every effort to recognize the potential factors leading to vascular compromise prior to performing microvascular anastomosis. While the prevention of thromboembolism has become an essential aspect of care, within the field of microsurgery, concern for anastomotic complications have hindered the creation of an accepted regimen. The Head and Neck Oncology Service at Amrita Hospital has always strived to be a model for comprehensive multidisciplinary care in the country. ♦ Avoid retrograde flow configurations if possible. This surgery is done to remove tumours or growths in the mouth and surrounding areas. ♦   RELEVANT ANATOMY Dissection of the vessels often requires some dissection within the superior portion of the parotid gland, and careful attention to avoid damaging the frontal branch of the facial nerve is required. 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. 10.3). Although external cutaneous monitors may be helpful in select cases, flap orientation complexity increases with their use and may compromise the geometry of the reconstruction. 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. Relative to the highest flow vessels available that do not compromise pedicle geometry facilitate! To range from 93 % to 99 % subject, we developed an ERAS protocol orientation the... External carotid and branches of the vascular anatomy of the thyrocervical system represents the ideal arterial system for microvascular.... 10.3 the position of the planned reconstruction may or may not coincide with the centers! 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