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. Similarly, it is important to avoid a kink or twist in the vascular pedicle during flap positioning. Additional vessel preparation may be required in special circumstances such as vein grafting, application of monitoring devices, or for certain vessel configurations. Essentially, arterial donor vessels may be divided into two categories: branches of the external carotid and branches of the thyrocervical trunk (Fig. 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. 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. Perhaps less obvious is the avoidance of placing the microvascular anastomosis in positions of possible peril. Recipient/donor veins are similarly prepared, although careful examination of the internal anatomy is required to avoid adjacent branches or valves, which may dispose the anastomosis to thrombosis. 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). 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. Fig. ♦ Radiated/thickened vessels may require additional preparation to provide optimal vessel wall thickness for accurate anastomosis. ♦ Prepare sufficient vessel length to avoid adventitial interference and provide sufficient nontraumatized vessel length to facilitate microsurgery. 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 Fellowship in Advanced Head & Neck Surgical Oncology and Microvascular Reconstruction within the Department of Otolaryngology at Washington University is a longstanding feature of the educational curriculum offered within this academic medical center. 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. 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. 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. (C) The optimal geometry, with no kink points. 10.2 Vessel geometry is exceptionally important. 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 most obvious are related to vascular compromise of the flap. Zone I 10.2 Vessel geometry is exceptionally important. It is in situations such as these that confusion or poor vessel selection and orientation may occur, resulting in a failed reconstruction. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. Postoperative complications are common, which often leads to prolonged hospital stay. The experienced microsurgeon makes every effort to recognize the potential factors leading to vascular compromise prior to performing microvascular anastomosis. 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. Pedicle length and diameter match with proposed recipient sites should be planned prior to flap inset. Recipient/donor veins are similarly prepared, although careful examination of the internal anatomy is required to avoid adjacent branches or valves, which may dispose the anastomosis to thrombosis. 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. The preoperative assessment of patients who are to undergo microvascular free tissue transfer is important to successful surgical outcomes. Education. ♦ Microvascular anastomosis should be performed to the highest flow vessels available that do not compromise pedicle geometry. There are several objectives that should be recognized by the microsurgeon for successful pedicle orientation. ♦ Heparinized saline (100 U/mL) is used for irrigation and visualization and prevention of thrombosis during microsurgery. The region of the planned reconstruction may or may not coincide with the Zone of recipient vessel selection. (C) This is the least desirable orientation, exposing the vascular anastomosis to three suture lines. Recipient vessels located within Zone II are the most commonly utilized vessels for microvascular reconstruction of the head and neck. These vessels have been extensively utilized in situations in which Zone II vessels are unavailable or are in an unfavorable location related to the reconstruction. Heiligers, Ludi E. Smeele The favoured method of reconstruction for large head and neck defects after resection for cancer is microvascular free flaps. 10.3 The position of the vascular anastomosis relative to the oral or pharyngeal suture line should be considered. Microvascular reconstruction of the head and neck continues to challenge surgeons worldwide despite significant technical advances. ♦ Prior to performing microsurgical anastomosis, the microsurgeon verifies the position of the reconstructive tissue to optimize pedicle orientation and geometry. These vessels have been extensively utilized in situations in which Zone II vessels are unavailable or are in an unfavorable location related to the reconstruction. Surgical Technique and Considerations Careful attention to avoiding manipulation of the internal lumen and vessel intima to prevent damage to the endothelium is paramount to prevent arterial thrombosis. 10.1 The donor vessels may be divided into two categories: branches of the external carotid and branches of the thyrocervical trunk. The reconstructive surgeon must verify adequate flow from the selected vessel prior to arterial anastomosis. © 2020 The Authors. Excellent arterial length may be obtained by tracing the artery inferiorly until several branches supplying the thyroid gland are encountered and vessel diameter is compromised. Although the routine use of preoperative imaging in the surgical planning for ablative surgery is widely accepted, preoperative imaging obtained specifically for microvascular surgery is often unnecessary. Access to deeper systems, such as the ascending palatine or maxillary artery, generally requires an ablative procedure that exposes these vessels, and they are infrequently utilized due to their anatomic location. The region of the planned reconstruction may or may not coincide with the Zone of recipient vessel selection. 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. Microvascular reconstruction/free flap: also known as “free tissue transfer,” this special technique entails the skin, muscle, and or bones that are “harvested” from throughout the body and implanted under a microscope to correct the defect in the face, head, and neck. unnecessary destruction of recipient vessels during tumor ablations is critical for successful reconstruction in these situations. Geometry of the vascular pedicle in free tissue transfers to the head and neck. ♦ Careful attention to small cutaneous perforators is required to avoid compromise; harvesting small perforators with a muscle cuff is recommended if possible. The thyrocervical system represents the ideal arterial system for microvascular surgeon in the vessel-depleted neck. Microvascular Reconstruction Surgery. ♦ Radiated/thickened vessels may require additional preparation to provide optimal vessel wall thickness for accurate anastomosis. 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. 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. ♦ The order of microvascular anastomosis (arterial versus venous) may vary depending on the pedicle geometry to facilitate microsurgery. 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. Success rates in excess of 95% can be achieved in major centers. ♦ The external cutaneous paddle for monitoring should not be employed at the expense of appropriate pedicle geometry. 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. Recipient vessels located within Zone II are the most commonly utilized vessels for microvascular reconstruction of the head and neck. Enhanced recovery after surgery (ERAS) is a peri- and postoperative care concept with the aim of achieving pain- and risk-free surgery. 10.2). 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. By combining these with the current published knowledge on the subject, we developed an ERAS protocol. ♦ Microvascular anastomosis should be performed to the highest flow vessels available that do not compromise pedicle geometry. 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. 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. Fig. Caution should be exercised when selecting these vessels for microvascular reconstruction if the region has received radiation.5. 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. 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. 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. : Microvascular reconstructions after head and neck cancer are among the most complicated procedures in plastic surgery. 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. ♦ Avoid placing the anastomosis in positions of peril. 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