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Microvascular Reconstruction in the Head and Neck
Microvascular Reconstruction in the Head and Neck
JACK FISHER, M.D., Section of Plastic and Reconstructive Surgery With the advent and refinement of microvascular surgical techniques, the results of reconstruction in the head and neck area have been substantially improved. Free flaps can now be moved in one stage for reconstruction of composite tissue in the head and neck area, whereas multiple procedures were often necessary to accomplish such reconstruc tions in the past. Skin, fat, muscle, bone, and intraoral lining can all be reestablished by using microvascular techniques. Because of the availability of microvascular surgical procedures, defects caused by cancer, congenital anomalies, or acquired disorders can now be reconstructed successfully. This article summarizes the history of microvascular operations and the development of the techniques and equipment; in addition, free tissue transfer reconstruction is compared with traditional techniques. The selection of the appropriate donor tissues and the assessment of patients preoperatively are discussed, and several illustrative case reports are presented.
Defects of the head and neck area have always been a considerable challenge to the reconstruc tive surgeon. These defects may be caused by resection of malignant lesions, congenital anom alies, or acquired disorders such as trauma and hemifacial atrophy. Previously, because of limita tions of local tissue, reconstruction in the head and neck area often necessitated multiple proce dures and frequently yielded less than satisfac tory results. With the advent and subsequent refinement of microvascular surgical procedures during the past 2 decades, tissue may now be transferred from distant anatomic sites in a single procedure.1"5 The type of defect will dictate the type of tissue used for reconstruction. For exam ple, skin, fat and muscle, bone, and lining for the oral cavity and the cervical portion of the esopha gus all are available by use of microvascular free tissue transfer techniques. In the early 1960s, the possibility of anastomos ing small blood vessels with the aid of a micro scope was initially investigated. 6 This study was
Address reprint requests to Dr. Jack Fisher, Section of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN 55905. Mayo Clin Proc 61:451-458,1986
followed by successful replantation of amputated animal digits and ears and repair of the vessels by microsurgical technique. 7,8 The first successful clinical case in which a digit was replanted by microvascular technique was performed by Komatsu and Tamai 9 in J a p a n in 1965; they success fully replanted a thumb that had been completely severed from the hand. Omentum harvested from the abdomen was used to reconstruct a traumatic scalp defect by using microvascular anastomosis in 1972,10 and the first successful free tissue transfer of a groin flap was performed in 1973.11 By the mid-1970s, microvascular surgical proce dures were rapidly gaining acceptance for many aspects of reconstruction. Approximately 70 years earlier (in 1907), Alexis Correl, who won the Nobel Prize for his work in the field of transplantation and vascular surgery, successfully transplanted a segment of small bowel into the neck of a dog and revascularized the segment with the jugular vein and a carotid artery. 12 This procedure was first performed clinically 50 years later by Seidenberg and associates 13 in 1959. By the early 1960s, several published reports had described the use of free bowel transfers and microvascular technique for reconstruction of the cervical portion of the esophagus. 14 " 18
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Although several isolated clinical reports of free tissue transfers were published in the early 1960s, this technique was not widely accepted until a decade later. The primary reason for this delay was the lack of appropriate instrumentation. Otolaryngologists had been using the operating mi croscope since the 1920s;19 however, reliable in struments and suture material appropriate for anastomosing 1-mm vessels were not available until the 1970s.20 Today, 10-0 and 11-0 suture on needles thinner than a human hair are readily available (Fig. 1). Microvascular clamps that can hold 1-mm vessels during suturing and adapted
Fig. 1. Needle with microvascular suture and 10-0 monofilament nylon passing through a human hair.
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jeweler and ophthalmologic instruments were ma jor contributions that advanced the use of micro vascular surgical techniques. ADVANTAGES OF FREE FLAP RECONSTRUCTION OVER TRADITIONAL METHODS Traditional pedicle flaps are limited to those tissues within reach of the head and neck area, such as the deltopectoral or forehead axial flaps or the pectoralis major or trapezius myocutaneous flaps. Before the development of microvascular surgical procedures, tissue from distant sites was moved to the site of reconstruction in stages as tubed pedicles or jump flaps, and multiple proce dures and intervals of many months were neces sary. Free flaps transferred by microvascular technique, however, offer a wider choice of donor tissues that can be transplanted in a single proce dure. Depending on the nature of the defect, various combinations of skin, muscle, bone, or mucosal lining can be transferred to provide an optimal reconstruction. Also, the position of a free flap is less restricted because the vascular pedicle is reanastomosed, usually in a more favorable position than is possible with a traditional pedicle flap. A free tissue transfer is particularly helpful in reconstructing irradiated wounds because of the use of tissue not previously in the field of irradiation, which has a rich independent blood supply. Another important consideration in intraoral, pharyngeal, or cervical esophageal reconstruction is that a free tissue transfer avoids the controlled salivary fistula traditionally necessary in the early stages of a pedicle flap reconstruction. Fi nally, a free tissue transfer from a distant site avoids the obvious donor site defect of a local head or neck flap. SELECTION OF DONOR TISSUE The selection of the donor tissue depends on the requirements for the specific defect and its loca tion. When a thin flap is needed, an axial-pattern donor flap, such as a groin, deltoid, lateral arm, or dorsalis pedis flap, is appropriate. Each of these axial-pattern flaps has a known anatomic vascu lar pedicle that is harvested with the skin and subcutaneous tissue for the microvascular anasto mosis in the recipient area. These flaps are use ful in intraoral reconstruction, especially when
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tissue is needed to drape over bony ridges and prominences. When greater soft tissue bulk is necessary, a muscle or musculocutaneous flap is appropriate for free tissue transfer. For head and neck recon struction, the latissimus dorsi and the rectus abdominis musculocutaneous flaps are most com monly used. The latissimus dorsi is harvested with its vascular pedicle (the thoracodorsal ves sels), and the rectus abdominis is harvested with the inferior epigastric vessels. Either of these flaps can be adjusted to provide the appropriate amounts of skin, fat, and muscle to optimize reconstruction. The latissimus dorsi unit is used for large defects, whereas the rectus abdominis muscle is preferred for smaller defects. More than 35 musculocutaneous units have been defined anatomically, many of which could also be used in microvascular head and neck reconstruction. 21 Another tissue that can provide bulk in head and neck reconstruction is the omentum. The omentum is harvested through a laparotomy inci sion, and the right gastroepiploic vessels are isolated with the omentum for the microvascular anastomoses. The omentum provides an abun dance of tissue that can be readily contoured to fit the defect. It either is placed under intact skin (when available) or is covered with a skin graft. Reconstruction in the head and neck region frequently involves bony defects of the mandible, maxilla, and orbits. The primary source of vascularized bone for microvascular tissue transfer is the iliac crest along with the deep circumflex iliac vessels. 22 During the past 5 years, this flap has become the main source of vascularized bone in head and neck reconstruction. It provides enough bone for a complete mandibular reconstruction and can be harvested with skin, muscle, or both. This flap enables the surgeon to reconstruct bone and soft tissue defects concurrently. It is particu larly useful in patients who have received radio therapy, in whom conventional bone grafts have a high failure rate. By using microvascular tech niques to transfer bone in these patients, the results are dramatically improved because the blood supply of the bone is maintained. Vascular ized rib has also been used in head and neck reconstruction. 23 Pharyngeal and cervical esophageal recon struction can be accomplished by transferring a segment of jejunum, as originally done experi mentally by Alexis Correl in a dog.12 Trans
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plantation of a jejunal segment is primarily performed in patients undergoing esophagolaryngectomy for cancer. The jejunum is har vested from the abdomen together with a segment of mesentery and its jejunal artery and vein. The bowel is harvested while a concomitant extirpa tive operation is performed in the neck. After completion of the esophagolaryngectomy, the jeju num is sutured into the esophageal defect and revascularized by microsurgical techniques usu ally with use of the internal jugular vein and external carotid artery as the recipient vessels. This reconstruction can be done in a single stage, avoids a temporary controlled fistula, and main tains peristaltic activity. This method of recon struction of the cervical portion of the esophagus has also been used in patients with traumatic esophageal injuries, caustic burns, and failed colon interposition. 24 PREOPERATIVE ASSESSMENT OF PATIENTS In patients who are candidates for microvascular head and neck reconstruction, the potential recipi ent vessels must be assessed preoperatively. In those patients who have undergone radical neck dissections previously, usually the ipsilateral in ternal jugular vein and occasionally also the external carotid artery or its branches have been removed. Therefore, in such a situation the con tralateral vessels are prepared for the microvascu lar anastomoses. In patients who have received radiotherapy or who have traumatic injuries, a specific evaluation to determine the most appro priate recipient vessels may be necessary before performing a free tissue transfer. In this group of patients, preoperative evaluation at the Mayo Clinic has been based primarily on Doppler as sessment, oculoplethysmography, and physical examination, and the use of arteriography has been limited. In those patients in whom oculople thysmography showed more than 60 mm Hg flow during ipsilateral carotid artery compression, we have occasionally used the common carotid artery as the recipient artery when no other branches were available. We have used the common carotid artery as the recipient vessel without complica tions in 9 of 60 patients (15%) who underwent microvascular reconstruction. The free flap artery is anastomosed in an end-to-side fashion to the common carotid artery, which is temporarily cross-clamped. For the recipient vein, the inter-
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nal jugular has been used in most of our free tis sue transfers, although branches of the external jugular vein or transverse cervical vein have been used as well. R E P O R T O F CASES
Case 1.—A 63-year-old w o m a n u n d e r w e n t a n esophagolaryngectomy a n d left radical neck dissection for a p r i m a r y s q u a m o u s cell c a r c i n o m a of the posterior p a r t of the p h a r y n x a n d left pyriform sinus (Fig. 2). Concur r e n t with the extirpative surgical procedure, a 12-cm s e g m e n t of jejunum w a s h a r v e s t e d from the a b d o m e n (Fig. 3). T h e jejunum w a s sutured into the e s o p h a g e a l defect in a n isoperistaltic fashion, a n d with the use of a microscope, the jejunal artery w a s a n a s t o m o s e d to t h e external carotid artery a n d the jejunal vein to the i n t e r n a l j u g u l a r vein (Fig. 4 a n d 5). Postoperatively, the
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p a t i e n t did well; on the 10th postoperative day, a c o n t r a s t study (Gastrografin swallow) showed good flow t h r o u g h t h e reconstructed a r e a without evidence of a leak (Fig. 6). A liquid diet w a s begun a n d then rapidly progressed, until by the 13th postoperative day the p a t i e n t w a s tolerating a regular diet a n d w a s dismissed from the hospital. At 3-year follow-up, she was free of disease a n d c o n s u m i n g a n o r m a l diet.
Fig. 4 (case 1). Completion of reconstruction of cervical portion of esophagus with vascularized jejunum. Jejunal artery has been anastomosed to external carotid artery and jejunal vein to internal jugular vein.
Fig. 2 (case 1). Appearance of defect after completion of esophagolaryngectomy and left radical neck dissection for squamous cell carcinoma.
Fig. 3 (case 1). Segment of jejunum harvested for free tissue transfer to esophageal area; silk suture (upper left) orients bowel segment in isoperistaltic fashion.
Fig. 5. Diagrammatic representation of patient after resection of cervical portion of esophagus (A), harvesting of jejunal segment with isolation of vascular pedicle (B), and completion of reconstruction with revascularization of bowel segment in neck (C).
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reconstruct the anterior hairline (Fig. 10). At 2-year follow-up, the patient continued to have stable scalp coverage with an anterior hairline (Fig. 11). Case 3.—A 29-year-old woman had had the onset of right-sided hemifacial atrophy as a teenager. She had undergone multiple previous reconstructive procedures elsewhere. Previous nonvascularized soft tissue grafts placed in the right side of the facial defect had reabsorbed (Fig. 12).
Fig. 7 (case 2). Appearance of patient's scalp 10 years after an avulsion injury. Note exposed cranium and nonhealing wounds.
Fig. 6 (case 1). Contrast study 10 days after esophageal reconstruction, showing flow through transplanted jejunal segment.
Case 2.—A 53-year-old woman had been examined initially at our institution in 1973 after sustaining an avulsion scalp injury in a power takeoff device. She was initially treated with split-thickness skin grafts of the cranial bone. These grafts failed to heal, and she had chronic drainage from the nonhealing wounds. When the patient was reexamined in 1983, the defect involved the entire top of the scalp, and bone was exposed in numerous areas (Fig. 7). In May 1983, she underwent reconstruction of the scalp with a latissimus dorsi free muscle transfer (Fig. 8). The thoracodorsal vessels of the latissimus dorsi muscle were anasto mosed to the right superficial temporal vessels, and the muscle was covered with a split-thickness skin graft. The muscle and split-thickness skin graft healed un eventfully and provided stable coverage of the scalp (Fig. 9). Six months after the free tissue transfer, a visor bipedicle flap from the posterior scalp area was raised to
Fig. 8. Entire right latissimus dorsi muscle with attached thoracodorsal artery and vein (arrow).
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In February 1983, the patient underwent reconstruc tion of the right side of the face with a rectus abdominis musculocutaneous free flap (Fig. 13). The flap consisted of a small segment of muscle and a large ellipse of overlying fat and skin. The flap was contoured to provide adequate correction of the facial deformity. The inferior epigastric vessels were anastomosed to the external carotid artery and the internal jugular vein. At 1 year after the reconstruction, the vascularized tissue had maintained its bulk and provided adequate correc tion of the facial deformity (Fig. 14).
Fig. 9 (case 2). Appearance of patient's scalp 3 months after undergoing reconstruction with latissimus dorsi free flap and skin graft.
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SUMMARY T h e development a n d refinement of microvascular surgical techniques h a v e dramatically im proved reconstruction in t h e h e a d a n d neck area.
Fig. 10 (case 2). Elevation of a posterior bipedicle flap for creation of an anterior hairline.
Fig. 11 (case 2). A and B, Appearance of patient 2 years after undergoing scalp reconstruction with a latissimus dorsi free flap.
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MICROVASCULAR RECONSTRUCTION IN THE HEAD AND NECK
Fig. 12 (case 3). Appearance of patient with hemifacial atrophy before microvascular free tissue transfer.
Fig. 13. Rectus abdominis musculocutaneous free flap, consist ing of muscle and overlying fat and skin. Arrow = inferior epigastric vascular pedicle.
More than 60 microvascular reconstructive proce dures of the head and neck area have been per-
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Fig. 14 (case 3). Appearance of patient 1 year after facial reconstruction, showing correction and maintenance of soft tissue contour.
formed at the Mayo Clinic. Half of these proce dures involved the pharynx and cervical portion of the esophagus. The microvascular free bowel transfers have primarily been performed in pa tients with cancer who have undergone esophagolaryngectomy; however, patients with benign caustic and traumatic esophageal injuries, as well as those in whom colon interpositions have failed, have also undergone reconstruction with this technique. Microvascular reconstructive procedures have been performed for resection of tumors or for traumatic injuries of the scalp. Microvascular facial reconstruction has been done for extensive tumor resections, congenital anomalies, and acquired defects from trauma or hemifacial atro phy. Bone reconstructions have been accom plished in patients who have undergone hemimandibulectomy for cancer or resection of an orbital tumor.
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In our series of patients, we had a 93% success rate for free tissue transfers. The failures were due to arterial thrombosis. In one patient with a free jejunal transfer, thrombosis of the jejunal artery occurred 2% weeks postoperatively. In other pa tients with unsuccessful results, thrombosis of the arterial anastomosis of a vascularized iliac crest and of a rectus abdominis free flap occurred within 24 hours after the procedure. The patients in our group ranged in age from 4 to 70 years (mean age, 43 years). The most common recipient vessels used in the microvascular reconstructions were the external carotid artery or its branches and the internal jugular vein. Other vessels avail able for the arterial anastomosis include the com mon carotid and transverse cervical arteries. The external jugular and transverse cervical veins were also used for recipient venous anastomoses. A free tissue transfer in head and neck recon struction can be performed as a one-stage proce dure that provides well-vascularized tissue with out creating an obvious donor defect in the head and neck area. It also is of benefit in patients who have received heavy irradiation or who have scars, in whom the local tissue has a poor blood supply. The overall results in the management of patients with lesions of the head and neck region have dramatically improved with the develop ment of microsurgical reconstruction.
REFERENCES 1. Tabah RJ, Flynn MB, Acland RD, Banis JC Jr: Microvas cular free tissue transfer in head and neck and esophageal surgery. Am J Surg 148:498-504,1984 2. Zuker RM, Rosen IB, Palmer JA, Sutton FR, McKee NH, Manktelow RT: Microvascular free flaps in head and neck reconstruction. Can J Surg 23:157-162, 1980 3. Zuker RM, Manktelow RT, Palmer JA, Rosen IB: Head and neck reconstruction following resection of carcinoma, using microvascular free flaps. Surgery 88:461-466,1980 4. Barrow DL, Nahai F, Fleischer AS: Use of free latissimus dorsi musculocutaneous flaps in various neurosurgical disorders. J Neurosurg 58:252-258,1983 5. Maxwell GP, Stueber K, Hoopes JE: A free latissimus dorsi myocutaneous flap: case report. Plast Reconstr Surg 62:462-466,1978
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6. Jacobson JH II, Suarez EL: Microsurgery in anastomosis of small vessels. Surg Forum 11:243-245, 1960 7. Buncke HJ Jr, Schulz WP: Experimental digital amputa tion and reimplantation. Plast Reconstr Surg 36:62-70, 1965 8. Buncke HJ Jr, Schulz WP: Total ear reimplantation in the rabbit utilising microminiature vascular anastomoses. Br J Plast Surg 19:15-22, 1966 9. Komatsu S, Tamai S: Successful replantation of a com pletely cut-off thumb: case report. Plast Reconstr Surg 42:374-377,1968 10. McLean DH, Buncke HJ Jr: Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg 49:268-274, 1972 11. Daniel RK, Taylor GI: Distant transfer of an island flap by microvascular anastomoses: a clinical technique. Plast Reconstr Surg 52:111-117, 1973 12. Correl A: The surgery of blood vessels. Bull Johns Hop kins Hosp 18:25,1907 13. Seidenberg B, Rosenak SS, Hurwitt ES, Som ML: Immedi ate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg 149:162-171, 1959 14. Roberts RE, Douglass FM: Replacement of the cervical esophagus and hypopharynx by a revascularized free jejunal autograft: report of a case successfully treated. N Engl J Med 264:342-344, 1961 15. Hiebert CA, Cummings GO Jr: Successful replacement of the cervical esophagus by transplantation and revascularization of a free graft of gastric antrum. Ann Surg 154:103-106, 1961 16. Jurkiewicz MJ: Vascularized intestinal graft for recon struction of the cervical esophagus and pharynx. Plast Reconstr Surg 36:509-517, 1965 17. Nakayama K, Yamamoto K, Tamiya T, Makino H, Odaka M, Ohwada M, Takahashi H: Experience with free autografts of the bowel with a new venous anastomosis apparatus. Surgery 55:796-802, 1964 18. McKee DM, Peters CR: Reconstruction of the hypophar ynx and cervical esophagus with microvascular jejunal transplant. Clin Plast Surg 5:305-312, 1978 19. Nylen C-O: The otomicroscope and microsurgery: 19211971. Acta Otolaryngol (Stockh) 73:453-454,1972 20. Acland RD: Instrumentation for microsurgery. Orthop Clin North Am 8:281-294, 1977 21. Mathes SJ, Nahai F: Clinical Applications for Muscle and Musculocutaneous Flaps. St. Louis, CV Mosby Company, 1982 22. Taylor GI, Townsend P, Corlett R: Superiority of the deep circumflex iliac vessels as the supply for free groin flaps: clinical work. Plast Reconstr Surg 64:745-759, 1979 23. Serafin D, Villarreal-Rios A, Georgiade NG: A ribcontaining free flap to reconstruct mandibular defects. Br J Plast Surg 30:263-266, 1977 24. Fisher J, Payne WS, Irons GB Jr: Salvage of a failed colon interposition in the esophagus with a free jejunal graft. Mayo Clin Proc 59:197-201,1984
JACK FISHER, M.D., Section of Plastic and Reconstructive Surgery With the advent and refinement of microvascular surgical techniques, the results of reconstruction in the head and neck area have been substantially improved. Free flaps can now be moved in one stage for reconstruction of composite tissue in the head and neck area, whereas multiple procedures were often necessary to accomplish such reconstruc tions in the past. Skin, fat, muscle, bone, and intraoral lining can all be reestablished by using microvascular techniques. Because of the availability of microvascular surgical procedures, defects caused by cancer, congenital anomalies, or acquired disorders can now be reconstructed successfully. This article summarizes the history of microvascular operations and the development of the techniques and equipment; in addition, free tissue transfer reconstruction is compared with traditional techniques. The selection of the appropriate donor tissues and the assessment of patients preoperatively are discussed, and several illustrative case reports are presented.
Defects of the head and neck area have always been a considerable challenge to the reconstruc tive surgeon. These defects may be caused by resection of malignant lesions, congenital anom alies, or acquired disorders such as trauma and hemifacial atrophy. Previously, because of limita tions of local tissue, reconstruction in the head and neck area often necessitated multiple proce dures and frequently yielded less than satisfac tory results. With the advent and subsequent refinement of microvascular surgical procedures during the past 2 decades, tissue may now be transferred from distant anatomic sites in a single procedure.1"5 The type of defect will dictate the type of tissue used for reconstruction. For exam ple, skin, fat and muscle, bone, and lining for the oral cavity and the cervical portion of the esopha gus all are available by use of microvascular free tissue transfer techniques. In the early 1960s, the possibility of anastomos ing small blood vessels with the aid of a micro scope was initially investigated. 6 This study was
Address reprint requests to Dr. Jack Fisher, Section of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN 55905. Mayo Clin Proc 61:451-458,1986
followed by successful replantation of amputated animal digits and ears and repair of the vessels by microsurgical technique. 7,8 The first successful clinical case in which a digit was replanted by microvascular technique was performed by Komatsu and Tamai 9 in J a p a n in 1965; they success fully replanted a thumb that had been completely severed from the hand. Omentum harvested from the abdomen was used to reconstruct a traumatic scalp defect by using microvascular anastomosis in 1972,10 and the first successful free tissue transfer of a groin flap was performed in 1973.11 By the mid-1970s, microvascular surgical proce dures were rapidly gaining acceptance for many aspects of reconstruction. Approximately 70 years earlier (in 1907), Alexis Correl, who won the Nobel Prize for his work in the field of transplantation and vascular surgery, successfully transplanted a segment of small bowel into the neck of a dog and revascularized the segment with the jugular vein and a carotid artery. 12 This procedure was first performed clinically 50 years later by Seidenberg and associates 13 in 1959. By the early 1960s, several published reports had described the use of free bowel transfers and microvascular technique for reconstruction of the cervical portion of the esophagus. 14 " 18
451
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Although several isolated clinical reports of free tissue transfers were published in the early 1960s, this technique was not widely accepted until a decade later. The primary reason for this delay was the lack of appropriate instrumentation. Otolaryngologists had been using the operating mi croscope since the 1920s;19 however, reliable in struments and suture material appropriate for anastomosing 1-mm vessels were not available until the 1970s.20 Today, 10-0 and 11-0 suture on needles thinner than a human hair are readily available (Fig. 1). Microvascular clamps that can hold 1-mm vessels during suturing and adapted
Fig. 1. Needle with microvascular suture and 10-0 monofilament nylon passing through a human hair.
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jeweler and ophthalmologic instruments were ma jor contributions that advanced the use of micro vascular surgical techniques. ADVANTAGES OF FREE FLAP RECONSTRUCTION OVER TRADITIONAL METHODS Traditional pedicle flaps are limited to those tissues within reach of the head and neck area, such as the deltopectoral or forehead axial flaps or the pectoralis major or trapezius myocutaneous flaps. Before the development of microvascular surgical procedures, tissue from distant sites was moved to the site of reconstruction in stages as tubed pedicles or jump flaps, and multiple proce dures and intervals of many months were neces sary. Free flaps transferred by microvascular technique, however, offer a wider choice of donor tissues that can be transplanted in a single proce dure. Depending on the nature of the defect, various combinations of skin, muscle, bone, or mucosal lining can be transferred to provide an optimal reconstruction. Also, the position of a free flap is less restricted because the vascular pedicle is reanastomosed, usually in a more favorable position than is possible with a traditional pedicle flap. A free tissue transfer is particularly helpful in reconstructing irradiated wounds because of the use of tissue not previously in the field of irradiation, which has a rich independent blood supply. Another important consideration in intraoral, pharyngeal, or cervical esophageal reconstruction is that a free tissue transfer avoids the controlled salivary fistula traditionally necessary in the early stages of a pedicle flap reconstruction. Fi nally, a free tissue transfer from a distant site avoids the obvious donor site defect of a local head or neck flap. SELECTION OF DONOR TISSUE The selection of the donor tissue depends on the requirements for the specific defect and its loca tion. When a thin flap is needed, an axial-pattern donor flap, such as a groin, deltoid, lateral arm, or dorsalis pedis flap, is appropriate. Each of these axial-pattern flaps has a known anatomic vascu lar pedicle that is harvested with the skin and subcutaneous tissue for the microvascular anasto mosis in the recipient area. These flaps are use ful in intraoral reconstruction, especially when
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tissue is needed to drape over bony ridges and prominences. When greater soft tissue bulk is necessary, a muscle or musculocutaneous flap is appropriate for free tissue transfer. For head and neck recon struction, the latissimus dorsi and the rectus abdominis musculocutaneous flaps are most com monly used. The latissimus dorsi is harvested with its vascular pedicle (the thoracodorsal ves sels), and the rectus abdominis is harvested with the inferior epigastric vessels. Either of these flaps can be adjusted to provide the appropriate amounts of skin, fat, and muscle to optimize reconstruction. The latissimus dorsi unit is used for large defects, whereas the rectus abdominis muscle is preferred for smaller defects. More than 35 musculocutaneous units have been defined anatomically, many of which could also be used in microvascular head and neck reconstruction. 21 Another tissue that can provide bulk in head and neck reconstruction is the omentum. The omentum is harvested through a laparotomy inci sion, and the right gastroepiploic vessels are isolated with the omentum for the microvascular anastomoses. The omentum provides an abun dance of tissue that can be readily contoured to fit the defect. It either is placed under intact skin (when available) or is covered with a skin graft. Reconstruction in the head and neck region frequently involves bony defects of the mandible, maxilla, and orbits. The primary source of vascularized bone for microvascular tissue transfer is the iliac crest along with the deep circumflex iliac vessels. 22 During the past 5 years, this flap has become the main source of vascularized bone in head and neck reconstruction. It provides enough bone for a complete mandibular reconstruction and can be harvested with skin, muscle, or both. This flap enables the surgeon to reconstruct bone and soft tissue defects concurrently. It is particu larly useful in patients who have received radio therapy, in whom conventional bone grafts have a high failure rate. By using microvascular tech niques to transfer bone in these patients, the results are dramatically improved because the blood supply of the bone is maintained. Vascular ized rib has also been used in head and neck reconstruction. 23 Pharyngeal and cervical esophageal recon struction can be accomplished by transferring a segment of jejunum, as originally done experi mentally by Alexis Correl in a dog.12 Trans
453
plantation of a jejunal segment is primarily performed in patients undergoing esophagolaryngectomy for cancer. The jejunum is har vested from the abdomen together with a segment of mesentery and its jejunal artery and vein. The bowel is harvested while a concomitant extirpa tive operation is performed in the neck. After completion of the esophagolaryngectomy, the jeju num is sutured into the esophageal defect and revascularized by microsurgical techniques usu ally with use of the internal jugular vein and external carotid artery as the recipient vessels. This reconstruction can be done in a single stage, avoids a temporary controlled fistula, and main tains peristaltic activity. This method of recon struction of the cervical portion of the esophagus has also been used in patients with traumatic esophageal injuries, caustic burns, and failed colon interposition. 24 PREOPERATIVE ASSESSMENT OF PATIENTS In patients who are candidates for microvascular head and neck reconstruction, the potential recipi ent vessels must be assessed preoperatively. In those patients who have undergone radical neck dissections previously, usually the ipsilateral in ternal jugular vein and occasionally also the external carotid artery or its branches have been removed. Therefore, in such a situation the con tralateral vessels are prepared for the microvascu lar anastomoses. In patients who have received radiotherapy or who have traumatic injuries, a specific evaluation to determine the most appro priate recipient vessels may be necessary before performing a free tissue transfer. In this group of patients, preoperative evaluation at the Mayo Clinic has been based primarily on Doppler as sessment, oculoplethysmography, and physical examination, and the use of arteriography has been limited. In those patients in whom oculople thysmography showed more than 60 mm Hg flow during ipsilateral carotid artery compression, we have occasionally used the common carotid artery as the recipient artery when no other branches were available. We have used the common carotid artery as the recipient vessel without complica tions in 9 of 60 patients (15%) who underwent microvascular reconstruction. The free flap artery is anastomosed in an end-to-side fashion to the common carotid artery, which is temporarily cross-clamped. For the recipient vein, the inter-
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nal jugular has been used in most of our free tis sue transfers, although branches of the external jugular vein or transverse cervical vein have been used as well. R E P O R T O F CASES
Case 1.—A 63-year-old w o m a n u n d e r w e n t a n esophagolaryngectomy a n d left radical neck dissection for a p r i m a r y s q u a m o u s cell c a r c i n o m a of the posterior p a r t of the p h a r y n x a n d left pyriform sinus (Fig. 2). Concur r e n t with the extirpative surgical procedure, a 12-cm s e g m e n t of jejunum w a s h a r v e s t e d from the a b d o m e n (Fig. 3). T h e jejunum w a s sutured into the e s o p h a g e a l defect in a n isoperistaltic fashion, a n d with the use of a microscope, the jejunal artery w a s a n a s t o m o s e d to t h e external carotid artery a n d the jejunal vein to the i n t e r n a l j u g u l a r vein (Fig. 4 a n d 5). Postoperatively, the
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p a t i e n t did well; on the 10th postoperative day, a c o n t r a s t study (Gastrografin swallow) showed good flow t h r o u g h t h e reconstructed a r e a without evidence of a leak (Fig. 6). A liquid diet w a s begun a n d then rapidly progressed, until by the 13th postoperative day the p a t i e n t w a s tolerating a regular diet a n d w a s dismissed from the hospital. At 3-year follow-up, she was free of disease a n d c o n s u m i n g a n o r m a l diet.
Fig. 4 (case 1). Completion of reconstruction of cervical portion of esophagus with vascularized jejunum. Jejunal artery has been anastomosed to external carotid artery and jejunal vein to internal jugular vein.
Fig. 2 (case 1). Appearance of defect after completion of esophagolaryngectomy and left radical neck dissection for squamous cell carcinoma.
Fig. 3 (case 1). Segment of jejunum harvested for free tissue transfer to esophageal area; silk suture (upper left) orients bowel segment in isoperistaltic fashion.
Fig. 5. Diagrammatic representation of patient after resection of cervical portion of esophagus (A), harvesting of jejunal segment with isolation of vascular pedicle (B), and completion of reconstruction with revascularization of bowel segment in neck (C).
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reconstruct the anterior hairline (Fig. 10). At 2-year follow-up, the patient continued to have stable scalp coverage with an anterior hairline (Fig. 11). Case 3.—A 29-year-old woman had had the onset of right-sided hemifacial atrophy as a teenager. She had undergone multiple previous reconstructive procedures elsewhere. Previous nonvascularized soft tissue grafts placed in the right side of the facial defect had reabsorbed (Fig. 12).
Fig. 7 (case 2). Appearance of patient's scalp 10 years after an avulsion injury. Note exposed cranium and nonhealing wounds.
Fig. 6 (case 1). Contrast study 10 days after esophageal reconstruction, showing flow through transplanted jejunal segment.
Case 2.—A 53-year-old woman had been examined initially at our institution in 1973 after sustaining an avulsion scalp injury in a power takeoff device. She was initially treated with split-thickness skin grafts of the cranial bone. These grafts failed to heal, and she had chronic drainage from the nonhealing wounds. When the patient was reexamined in 1983, the defect involved the entire top of the scalp, and bone was exposed in numerous areas (Fig. 7). In May 1983, she underwent reconstruction of the scalp with a latissimus dorsi free muscle transfer (Fig. 8). The thoracodorsal vessels of the latissimus dorsi muscle were anasto mosed to the right superficial temporal vessels, and the muscle was covered with a split-thickness skin graft. The muscle and split-thickness skin graft healed un eventfully and provided stable coverage of the scalp (Fig. 9). Six months after the free tissue transfer, a visor bipedicle flap from the posterior scalp area was raised to
Fig. 8. Entire right latissimus dorsi muscle with attached thoracodorsal artery and vein (arrow).
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In February 1983, the patient underwent reconstruc tion of the right side of the face with a rectus abdominis musculocutaneous free flap (Fig. 13). The flap consisted of a small segment of muscle and a large ellipse of overlying fat and skin. The flap was contoured to provide adequate correction of the facial deformity. The inferior epigastric vessels were anastomosed to the external carotid artery and the internal jugular vein. At 1 year after the reconstruction, the vascularized tissue had maintained its bulk and provided adequate correc tion of the facial deformity (Fig. 14).
Fig. 9 (case 2). Appearance of patient's scalp 3 months after undergoing reconstruction with latissimus dorsi free flap and skin graft.
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SUMMARY T h e development a n d refinement of microvascular surgical techniques h a v e dramatically im proved reconstruction in t h e h e a d a n d neck area.
Fig. 10 (case 2). Elevation of a posterior bipedicle flap for creation of an anterior hairline.
Fig. 11 (case 2). A and B, Appearance of patient 2 years after undergoing scalp reconstruction with a latissimus dorsi free flap.
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Fig. 12 (case 3). Appearance of patient with hemifacial atrophy before microvascular free tissue transfer.
Fig. 13. Rectus abdominis musculocutaneous free flap, consist ing of muscle and overlying fat and skin. Arrow = inferior epigastric vascular pedicle.
More than 60 microvascular reconstructive proce dures of the head and neck area have been per-
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Fig. 14 (case 3). Appearance of patient 1 year after facial reconstruction, showing correction and maintenance of soft tissue contour.
formed at the Mayo Clinic. Half of these proce dures involved the pharynx and cervical portion of the esophagus. The microvascular free bowel transfers have primarily been performed in pa tients with cancer who have undergone esophagolaryngectomy; however, patients with benign caustic and traumatic esophageal injuries, as well as those in whom colon interpositions have failed, have also undergone reconstruction with this technique. Microvascular reconstructive procedures have been performed for resection of tumors or for traumatic injuries of the scalp. Microvascular facial reconstruction has been done for extensive tumor resections, congenital anomalies, and acquired defects from trauma or hemifacial atro phy. Bone reconstructions have been accom plished in patients who have undergone hemimandibulectomy for cancer or resection of an orbital tumor.
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In our series of patients, we had a 93% success rate for free tissue transfers. The failures were due to arterial thrombosis. In one patient with a free jejunal transfer, thrombosis of the jejunal artery occurred 2% weeks postoperatively. In other pa tients with unsuccessful results, thrombosis of the arterial anastomosis of a vascularized iliac crest and of a rectus abdominis free flap occurred within 24 hours after the procedure. The patients in our group ranged in age from 4 to 70 years (mean age, 43 years). The most common recipient vessels used in the microvascular reconstructions were the external carotid artery or its branches and the internal jugular vein. Other vessels avail able for the arterial anastomosis include the com mon carotid and transverse cervical arteries. The external jugular and transverse cervical veins were also used for recipient venous anastomoses. A free tissue transfer in head and neck recon struction can be performed as a one-stage proce dure that provides well-vascularized tissue with out creating an obvious donor defect in the head and neck area. It also is of benefit in patients who have received heavy irradiation or who have scars, in whom the local tissue has a poor blood supply. The overall results in the management of patients with lesions of the head and neck region have dramatically improved with the develop ment of microsurgical reconstruction.
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6. Jacobson JH II, Suarez EL: Microsurgery in anastomosis of small vessels. Surg Forum 11:243-245, 1960 7. Buncke HJ Jr, Schulz WP: Experimental digital amputa tion and reimplantation. Plast Reconstr Surg 36:62-70, 1965 8. Buncke HJ Jr, Schulz WP: Total ear reimplantation in the rabbit utilising microminiature vascular anastomoses. Br J Plast Surg 19:15-22, 1966 9. Komatsu S, Tamai S: Successful replantation of a com pletely cut-off thumb: case report. Plast Reconstr Surg 42:374-377,1968 10. McLean DH, Buncke HJ Jr: Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg 49:268-274, 1972 11. Daniel RK, Taylor GI: Distant transfer of an island flap by microvascular anastomoses: a clinical technique. Plast Reconstr Surg 52:111-117, 1973 12. Correl A: The surgery of blood vessels. Bull Johns Hop kins Hosp 18:25,1907 13. Seidenberg B, Rosenak SS, Hurwitt ES, Som ML: Immedi ate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg 149:162-171, 1959 14. Roberts RE, Douglass FM: Replacement of the cervical esophagus and hypopharynx by a revascularized free jejunal autograft: report of a case successfully treated. N Engl J Med 264:342-344, 1961 15. Hiebert CA, Cummings GO Jr: Successful replacement of the cervical esophagus by transplantation and revascularization of a free graft of gastric antrum. Ann Surg 154:103-106, 1961 16. Jurkiewicz MJ: Vascularized intestinal graft for recon struction of the cervical esophagus and pharynx. Plast Reconstr Surg 36:509-517, 1965 17. Nakayama K, Yamamoto K, Tamiya T, Makino H, Odaka M, Ohwada M, Takahashi H: Experience with free autografts of the bowel with a new venous anastomosis apparatus. Surgery 55:796-802, 1964 18. McKee DM, Peters CR: Reconstruction of the hypophar ynx and cervical esophagus with microvascular jejunal transplant. Clin Plast Surg 5:305-312, 1978 19. Nylen C-O: The otomicroscope and microsurgery: 19211971. Acta Otolaryngol (Stockh) 73:453-454,1972 20. Acland RD: Instrumentation for microsurgery. Orthop Clin North Am 8:281-294, 1977 21. Mathes SJ, Nahai F: Clinical Applications for Muscle and Musculocutaneous Flaps. St. Louis, CV Mosby Company, 1982 22. Taylor GI, Townsend P, Corlett R: Superiority of the deep circumflex iliac vessels as the supply for free groin flaps: clinical work. Plast Reconstr Surg 64:745-759, 1979 23. Serafin D, Villarreal-Rios A, Georgiade NG: A ribcontaining free flap to reconstruct mandibular defects. Br J Plast Surg 30:263-266, 1977 24. Fisher J, Payne WS, Irons GB Jr: Salvage of a failed colon interposition in the esophagus with a free jejunal graft. Mayo Clin Proc 59:197-201,1984