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End-to-side anastomosis to the external jugular vein: preservation of external jugular vein blood flow
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British Journal of Oral and Maxillofacial Surgery 50 (2012) e31–e32
Technical note
End-to-side anastomosis to the external jugular vein: preservation of external jugular vein blood flow Tetsuji Nagata ∗ , Kazuma Masumoto, Yoshiko Watanabe, Fuminori Katou Department of Oral and Maxillofacial Surgery, Hamamatsu University School of Medicine, 1-20-1 Handa-yama, Higashi-ku, Hamamatsu City, Shizuoka 431-3125, Japan Accepted 12 July 2011 Available online 25 August 2011
Keywords: End-to-side anastomosis; External jugular vein; Microsurgery; Reconstruction
The external jugular vein provides a long, free vessel that facilitates microsurgical anastomosis in free tissue transfers of the head and neck. However, it is liable to kink because of its length, which increases the risk of venous thrombosis.1,2 Early in a conventional neck dissection the vein is identified and ligated near the inferior pole of the parotid gland. When a microvascular free flap is to be used for reconstruction, the entire external jugular vein is dissected and preserved with a suture-ligation at the upper end. Because of the prolonged duration of ischaemia before revascularisation, clots can form in its lumen and may be found at the time of anastomosis. Even after revascularisation using an end-toend anastomosis, the decreased venous flow may accelerate venous thrombosis.3 We describe an end-to-side anastomosis to the external jugular vein that preserves blood flow by avoiding ligation and decreases the likelihood of thrombosis.
vein, a deeper dissection to the subclavian vein is made to provide the most favourable vessel geometry (Fig. 1). After the anastomosis of the artery, the vein of the donor flap is anastomosed to the external jugular vein. The anastomosis is
Surgical technique Early during the neck dissection, the external jugular vein is identified near the inferior pole of the parotid gland in the neck and preserved carefully without ligation. The vein is dissected from the sternocleidomastoid muscle and the supraclavicular fatty tissues to permit end-to-side anastomosis. If the vessel of the donor flap is a long distance from the external jugular
∗
Corresponding author. Tel.: +81 53 435 2349; fax: +81 53 435 2349. E-mail address: [email protected] (T. Nagata).
Fig. 1. After the flap has been transferred to the oral cavity after the neck dissection, the external jugular vein is dissected from the sternocleidomastoid muscle without ligation at the inferior pole of the parotid gland and shifted forward for end-to-side anastomosis.
0266-4356/$ – see front matter © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2011.07.024
e32
T. Nagata et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) e31–e32
Discussion Whether the external jugular vein can be preserved depends on the clinical state of the tumour, as the external jugular vein is located in a superficial layer of deep cervical fascia. The superficial cervical lymph nodes in the area of the external jugular vein as it emerges from beneath the parotid gland have, as their afferents, the cutaneous lymphatics of the auricular and parotid regions of the face, the efferents of the retromandibular and parotid nodes, and the occasional occipital nodes.4 Unless the tumour is near the parotid gland or the external jugular vein, the preservation of the vein is not associated with lymphatic drainage from oral cancer and will not undermine the benefits of the neck dissection. The method reported here is a useful technique for use in reconstructive microsurgery of the head and neck.
Conflict of interest Fig. 2. A forearm flap is transferred to the tongue and its pedicle pulled down to the submandibular space. One of the venae comitantes is anastomosed to the external jugular vein. A stay suture is added to stabilise the vessel.
None declared.
References end-to-side in principle, but an end-to-end anastomosis to a branch of the external jugular vein is used if the anastomosis is a long way away from the target vessels (Fig. 2). During the operation, blood flow through the external jugular vein was only partly blocked using a C-shaped clamp within the area of the anastomosis, which prevented venous thrombosis being caused by complete block to the blood flow as a result of ligature and clamping.
1. Fukuiwa T, Nishimoto K, Hayashi T, Kurono Y. Venous thrombosis after microvascular free-tissue transfer in head and neck cancer reconstruction. Auris Nasus Larynx 2008;35:390–6. 2. Chalian AA, Anderson TD, Weinstein GS, Weber RS. Internal jugular vein versus external jugular vein anastomosis: implications for successful free tissue transfer. Head Neck 2001;23:475–8. 3. Kerstein M. Thrombophlebitis. Angiology 1977;28:228–34. 4. Hollingshead WH. Anatomy for surgeons. Vol. I: The head and neck. 2nd ed. New York: Harper & Row; 1968.
British Journal of Oral and Maxillofacial Surgery 50 (2012) e31–e32
Technical note
End-to-side anastomosis to the external jugular vein: preservation of external jugular vein blood flow Tetsuji Nagata ∗ , Kazuma Masumoto, Yoshiko Watanabe, Fuminori Katou Department of Oral and Maxillofacial Surgery, Hamamatsu University School of Medicine, 1-20-1 Handa-yama, Higashi-ku, Hamamatsu City, Shizuoka 431-3125, Japan Accepted 12 July 2011 Available online 25 August 2011
Keywords: End-to-side anastomosis; External jugular vein; Microsurgery; Reconstruction
The external jugular vein provides a long, free vessel that facilitates microsurgical anastomosis in free tissue transfers of the head and neck. However, it is liable to kink because of its length, which increases the risk of venous thrombosis.1,2 Early in a conventional neck dissection the vein is identified and ligated near the inferior pole of the parotid gland. When a microvascular free flap is to be used for reconstruction, the entire external jugular vein is dissected and preserved with a suture-ligation at the upper end. Because of the prolonged duration of ischaemia before revascularisation, clots can form in its lumen and may be found at the time of anastomosis. Even after revascularisation using an end-toend anastomosis, the decreased venous flow may accelerate venous thrombosis.3 We describe an end-to-side anastomosis to the external jugular vein that preserves blood flow by avoiding ligation and decreases the likelihood of thrombosis.
vein, a deeper dissection to the subclavian vein is made to provide the most favourable vessel geometry (Fig. 1). After the anastomosis of the artery, the vein of the donor flap is anastomosed to the external jugular vein. The anastomosis is
Surgical technique Early during the neck dissection, the external jugular vein is identified near the inferior pole of the parotid gland in the neck and preserved carefully without ligation. The vein is dissected from the sternocleidomastoid muscle and the supraclavicular fatty tissues to permit end-to-side anastomosis. If the vessel of the donor flap is a long distance from the external jugular
∗
Corresponding author. Tel.: +81 53 435 2349; fax: +81 53 435 2349. E-mail address: [email protected] (T. Nagata).
Fig. 1. After the flap has been transferred to the oral cavity after the neck dissection, the external jugular vein is dissected from the sternocleidomastoid muscle without ligation at the inferior pole of the parotid gland and shifted forward for end-to-side anastomosis.
0266-4356/$ – see front matter © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2011.07.024
e32
T. Nagata et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) e31–e32
Discussion Whether the external jugular vein can be preserved depends on the clinical state of the tumour, as the external jugular vein is located in a superficial layer of deep cervical fascia. The superficial cervical lymph nodes in the area of the external jugular vein as it emerges from beneath the parotid gland have, as their afferents, the cutaneous lymphatics of the auricular and parotid regions of the face, the efferents of the retromandibular and parotid nodes, and the occasional occipital nodes.4 Unless the tumour is near the parotid gland or the external jugular vein, the preservation of the vein is not associated with lymphatic drainage from oral cancer and will not undermine the benefits of the neck dissection. The method reported here is a useful technique for use in reconstructive microsurgery of the head and neck.
Conflict of interest Fig. 2. A forearm flap is transferred to the tongue and its pedicle pulled down to the submandibular space. One of the venae comitantes is anastomosed to the external jugular vein. A stay suture is added to stabilise the vessel.
None declared.
References end-to-side in principle, but an end-to-end anastomosis to a branch of the external jugular vein is used if the anastomosis is a long way away from the target vessels (Fig. 2). During the operation, blood flow through the external jugular vein was only partly blocked using a C-shaped clamp within the area of the anastomosis, which prevented venous thrombosis being caused by complete block to the blood flow as a result of ligature and clamping.
1. Fukuiwa T, Nishimoto K, Hayashi T, Kurono Y. Venous thrombosis after microvascular free-tissue transfer in head and neck cancer reconstruction. Auris Nasus Larynx 2008;35:390–6. 2. Chalian AA, Anderson TD, Weinstein GS, Weber RS. Internal jugular vein versus external jugular vein anastomosis: implications for successful free tissue transfer. Head Neck 2001;23:475–8. 3. Kerstein M. Thrombophlebitis. Angiology 1977;28:228–34. 4. Hollingshead WH. Anatomy for surgeons. Vol. I: The head and neck. 2nd ed. New York: Harper & Row; 1968.