Angular vessels may be visualized in the center of the wound.
Note that the scalp and midface-maxilla accounted for most of the microvascular reconstructions.
The fibula and the anterolateral thigh were the most commonly used bone and soft-tissue microvascular transfers, respectively. ALT indicates anterolateral thigh.
Revenaugh PC, Fritz MA, Haffey TM, Seth R, Markey J, Knott PD. Minimizing Morbidity in Microvascular SurgerySmall-Caliber Anastomotic Vessels and Minimal Access Approaches. JAMA Facial Plast Surg. 2015;17(1):44-48. doi:10.1001/jamafacial.2014.875
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Minimizing morbidity when performing free flap reconstruction of the head and neck is important in the overall reconstructive paradigm.
To examine the indications and success rates of free tissue transfer using small-caliber facial recipient vessels and minimal access incisions.
Design, Setting, and Participants
Retrospective medical record review of patients with head and neck defects undergoing free tissue transfer from May 2010 to June 2013 at 2 tertiary care academic medical centers.
Free tissue transfer using small-caliber recipient vessels and minimal access approaches.
Main Outcomes and Measures
Postoperative complications, including flap failure, requirement for revision surgery, and nerve dysfunction.
Eighty-nine flaps in 86 patients met inclusion criteria. Fifty flaps used the facial artery and vein distal to the facial notch, and 33 flaps used the superficial temporal vascular system. Six flaps used the angular artery and vein. A variety of flap donor sites were included. In most cases, free tissue transfer was indicated for the reconstruction of defects secondary to extirpation of malignant neoplasia. Overall success rate was 97.7% with 2 instances of total flap loss and 1 partial loss. One patient had transient nerve weakness (frontal branch), which resolved during a follow-up of 9 months.
Conclusions and Relevance
Free tissue reconstruction of head and neck defects can be safely and reliably accomplished using small-caliber recipient vessels, such as the superficial temporal, distal facial, and angular vessels. Minimal access approaches for microvascular anastomosis may be performed with excellent cosmesis and minimal morbidity.
Level of Evidence
Success rates for microvascular free tissue transfer performed for head and neck reconstruction are currently very high.1- 4 As microvascular techniques improve and patient morbidity decreases, indications for free tissue transfer are expanding. Concomitantly, improved cosmetic outcomes are expected as patient quality-of-life concerns gain importance in the overall reconstructive paradigm. Balancing the need for decreased morbidity and improved cosmesis is particularly difficult in midface, scalp, and cranial base reconstruction, owing to the complex 3-dimensional anatomy, the frequent desire to import both bone and soft-tissue components, as well as the need to prevent potential cerebrospinal fluid leaks.
In many cases, limited pedicle length may preclude use of larger-caliber neck vessels with their established reliability. As recipient vessel diameter decreases, questions of vessel reliability and ease of access are encountered.1,5 Certain reconstructions may not allow adequate pedicle length to reach the neck, and in these situations intervening vein grafts are indicated if anastomosis to the larger-caliber neck vessels is pursued. However, 2 previous large series6,7 have demonstrated an association between the use of vein grafts and an increased risk of flap failure.
The superficial temporal and facial/angular vascular systems are close to the midface. cranial base, and scalp, are superficial, and may be dissected through small, inconspicuous incisions. The facial vessels may be accessed distal to the facial notch, or even through the nasolabial crease. Despite anatomic description and mention of their use, there have been no studies specifically referencing success rates using these vascular subsystems.8
The desire to provide reliable, quick, and minimally morbid vascular access, without the need for vein grafts, for mid- and upper-face reconstruction has led our groups to adopt identification of the distal facial artery at the facial notch and/or the angular artery in the nasolabial fold, and/or the superficial temporal vessels for microvascular anastomosis when indicated. The purpose of this study is to investigate the success of microvascular reconstruction using these 3 small recipient vessel systems.
A retrospective medical record review identified all patients undergoing head and neck microvascular reconstruction by the 2 senior authors (M.A.F. and P.D.K.) at either Cleveland Clinic Head and Neck Institute or University of California–San Francisco Medical Center from March 2009 to June 2013. This research was approved by the institutional review board at each institution. All patients underwent microvascular reconstruction of head and neck defects using the superficial temporal, facial, or angular arteries and their corresponding venous outflow system. All flap types and indications were included. Patient demographics, flap characteristics, patient comorbidities, intraoperative and postoperative complications, and subsequent flap survival were recorded. A minimum 1-month follow-up was required for study inclusion. Partial or complete flap failure was defined by the occurrence of either of these within the first postoperative month.
The superficial temporal vessels were isolated after palpation just anterior to the tragus. Incisions were planned in a pretragal or posttragal fashion. The corresponding vein was commonly encountered anterior and deep to the superficial temporal artery. These vessels were typically followed into the superior aspect of the parotid gland.
The facial vessels were isolated by making a 2-cm incision through skin and platysma over the palpable facial vessels 1 cm caudal to the inferior mandible margin. It should be noted that this incision is in the proximity of the marginal mandibular branch of the facial nerve, so caution was exercised during dissection. The nerve was frequently encountered just deep to the platysma. Transposition of the nerve in appropriate cases was accomplished using careful dissection and judicious use of bipolar electrocautery.
The angular vessels were approached via an incision in the nasolabial fold. The angular artery was consistently encountered just superficial to the modiolus and the insertion of the zygomaticus major (Figure 1). The angular vein was found immediately deep and lateral to the insertion of the zygomaticus major.
All anastomoses were performed with a 2-headed binocular microscope using 9-0 nylon Sharpoint suture (Surgical Specialties Corp). Venous couplers were not used. Flap monitoring was accomplished using handheld Doppler devices and visual inspection of available skin paddles. No implantable Doppler monitors were used.
Vessel mismatch was an issue routinely encountered during these reconstructions and was one of the primary reasons precluding venous coupler use. The microvascular training programs at both institutions also favor suture anastomosis. The arterial mismatch was usually 2:1 and 6 to 8 interrupted sutures were usually used for the anastomosis. The donor artery was handled and dissected with delicacy, and was usually treated with papaverine immediately following the anastomosis. The venous anastomosis usually had a mismatch from 2:1 to 4:1, and 8 to 10 interrupted sutures were usually used. End-to-end suture anastomosis with compensation for the mismatch was readily accomplished, and anastomotic leaks were rarely encountered.
Vessel mismatch during anastomosis was limited when using the anterolateral thigh (ALT) and/or latissimus dorsi free flaps. Vessel mismatch was usually greatest during fibula free flap reconstruction. The fibula was most commonly used for midface reconstruction following total maxillectomy.9 Pedicle length was extremely limited in these cases and, without using vein grafts, could be accomplished only by accessing the superficial temporal-angular-distal facial vascular systems. Following success early in this series with small-caliber anastomosis, we eschewed the use of vein grafts and access to the larger-caliber neck vessels for the subsequent cases.
Eighty-nine flaps in 86 patients met inclusion criteria. Their mean age was 60.2 years (range, 26-90 years). Thirty-one of the flaps were performed in women.
Reconstruction following extirpation of head and neck malignant neoplasm was the most common indication for free flap reconstruction (60 patients) (Table 1). These included upper aerodigestive tract, cutaneous, and sinonasal tumors. Twenty-five flaps were performed for strictly cosmetic indications or for reconstruction involving benign pathologic diagnoses. When stratified by subsite, the scalp and mid to upper face accounted for most of the flaps (75%) (Figure 2).
Fifty flaps (56%) used the distal facial artery at the level of the facial notch, whereas 33 flaps (38%) used the superficial temporal vessels. Six flaps (7%) used the angular artery system.
A variety of flap donor sites were used (Figure 3). The ALT fasciocutaneous or adipofascial flap (ALTAF) was used in most cases. The mean flap size was 107 cm2 (range, 10-300 cm2).
Postoperative complications included bleeding, wound dehiscence, infection, and hematoma (Table 2). Wound dehiscence was the most common complication (8 cases [9%]), and postoperative bleeding was the second most common (4 cases [4.5%]). One patient had transient weakness of the frontal branch of the facial nerve following ipsilateral superficial temporal artery anastomosis, which resolved without further intervention.
The mean follow-up was 9.7 months (range, 1-35 months). The overall microvascular success rate was 97.7%. There were 2 instances of total flap loss, both in ALTAFs. There was 1 instance of partial flap loss in a patient who had ALT fascia lata free flap for nasal lining.
Since the first free tissue transfer was performed, there have been considerable advances in techniques affording exceptional survival rates of microvascular reconstructions. Early dogma held that large vessel anastomoses were more reliable and less prone to microvascular compromise. During extirpation of head and neck malignant neoplasms, a neck dissection is often performed, exposing the great vessels of the neck and their immediate branches. However, neck dissections are not universally indicated, and neck exploration for recipient vessels may introduce unnecessary morbidity. Morbidity aside, free tissue transfer is increasingly being used for secondary reconstructive indications in cases in which a large neck incision is not ideal or aesthetically appealing. In our series, 25 flaps were performed for nonmalignant indications, and 62 were performed for reconstruction of malignant defects in cases in which a formal neck dissection was not indicated.
Perforator flaps are now routinely used in head and neck reconstruction owing to their versatility, ease of harvest, decreased bulk, and muscle-sparing dissection.10 Anterolateral thigh flaps have less predictable vascular anatomy and may have a shorter pedicle length and smaller vessel diameter when compared with other frequently used flaps, such as the radial forearm. Furthermore, as microvascular indications are expanded more aggressively toward scalp, upper face, and midface reconstruction, accessing inflow and outflow vasculature in traditional cervical locations becomes challenging without the use of vein grafts. Descriptions of using distal facial vessels,2,10 superficial temporal vessels,5,11- 14 and angular vessels15 have been published in the literature. However, to our knowledge, there have been no reports on the feasibility and reliability of their use in reconstruction.
Locating each of the commonly used vessel pairs in this study is straightforward and consistent. The facial vessels are easily exposed at the facial notch just below the undersurface of the mandible. Typically, a 2- to 3-cm incision provides adequate exposure for microvascular anastomosis in this area. The angular vessels may be readily accessed through the nasolabial crease, providing adequate exposure and excellent cosmetic results (Figure 1). Similarly, the superficial temporal vessels are reliably dissected in a precise location just anterior to the preauricular crease.
Dissection of the distal facial vessel and angular vessels has been traditionally avoided owing to concerns about transient or permanent facial nerve dysfunction. The marginal mandibular nerve courses in close proximity to the vessels at the facial notch, and the midface branches of the facial nerve innervating the lip elevators and orbicularis oris lie deep to the nasolabial fold. Although careful dissection was used routinely during recipient vessel exposure, the low incidence of even transient paralysis (1.1%) encountered in this study was surprising. Although nerve transposition was commonly performed, the lack of nerve dysfunction is likely attributable to the performance of minimal dissection and redundancy of these small distal nerve branches.
Although anastomoses to small-caliber head and neck vessels are reported, there remains debate as to their reliability, and there is a paucity of literature referable to specific success rates. Shimizu et al14 published a report of a series of 15 patients, wherein the superficial temporal artery and vein were used for reconstructions in otherwise vessel-depleted necks. They had no instances of failure in this small series and 1 instance of venous thrombosis, which was attributed to a kink in the vein that was corrected during reexploration. Beasley et al11 reported a series of forehead and scalp defects in which 22 of 34 flaps were anastomosed to the superficial temporal system. They reported 1 flap failure and 1 instance of operative exploration for ischemic compromise; however, there was no indication as to which vessels were involved in these 2 complications.
Oh et al15 reported a series of 6 patients who underwent midface reconstruction with recipient angular vessels. The indications for reconstruction in 5 of these patients were nasal defects, whereas the sixth patient underwent orbitotemporal reconstruction. The authors describe a similar dissection to locate the recipient vessels. They reported zero flap failures with a mean follow-up of 5.8 years.
In the present series, there were 2 instances of complete flap loss and 1 instance of partial flap loss. One loss occurred with an ALTAF flap anastomosed to the superficial temporal system for auricular reconstruction for an extensive basal cell carcinoma. The patient had a viable flap on the 1-week postoperative visit but then independently started wearing an occlusive dressing, leading to flap failure. The second loss occurred in a patient undergoing ALTAF for coverage of mandibular osteoradionecrosis with a distal facial anastomosis. She had experienced late failure with a healthy flap noted 1 week postoperatively and a nonviable flap at 2 weeks postoperatively. She subsequently underwent a contralateral ALTAF anastomosed to the superficial temporal vessels without complications. The etiology of this failure was not clear, although perhaps the overall small size of the flap and use of vessels within the heavily irradiated field may have contributed to the failure. The partial flap loss involved a nasal lining reconstruction with an ALTAF anastomosed to the distal facial vessels at the facial notch. This was noted 1 week postoperatively, and the etiology was thought to be related to twisting of the distal perforator during inset. The compromised portion of the flap was debrided, and the remainder of the flap mucosalized with some distortion of the nasal reconstruction. To date, this patient has not proceeded with revision surgery.
This series suggests that smaller vessels can be routinely used for reconstructions of the scalp, skull base, and midface, provided careful attention is dedicated to vessel exposure and pedicle geometry, because only 1 flap in our series may have failed owing to anastomotic compromise. Certainly, flap take-back and potential for microvascular revision and salvage are compromised by pedicle reach and minimal access incisions, and potentially by vessel caliber. As a result, these minimally invasive techniques, while reliable, may have slightly lower overall success rates.
Considerations of marginally lower success rates must be counterbalanced by additional patient benefits using these approaches. Based on our experience, many patients in this series only require a short hospital stay since surgical dissections are limited. In cases of short hospital stays, patient education is critical for acceptable outcomes. In addition, because vessel diameter is minimal, we do agree that clinical judgment should be used in cases in which the potential donor vessel is located directly within a postradiated field.
Reconstruction of defects in the central and upper third of the face can be reliably accomplished using smaller-caliber vessels, such as the superficial temporal, distal facial, and angular vessels. Minimal access incisions permit microvascular anastomosis with improved cosmesis and minimal nerve dysfunction. The use of superficial temporal, distal facial, and angular arteries should be considered in facial reconstructions in which pedicle length is limited and in cases in which neck dissections are not performed.
Corresponding Author: P. Daniel Knott, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, UCSF Medical Center, 2233 Post St, Third Floor, San Francisco, CA 94115 (email@example.com).
Accepted for Publication: July 8, 2014.
Published Online: November 13, 2014. doi:10.1001/jamafacial.2014.875.
Author Contributions: Dr Revenaugh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Fritz,Knott.
Acquisition, analysis, or interpretation of data: Revenaugh, Haffey, Seth, Markey, Knott.
Drafting of the manuscript: Revenaugh, Markey, Knott.
Critical revision of the manuscript for important intellectual content: Revenaugh, Fritz,Haffey, Seth, Markey.
Statistical analysis: Revenaugh, Seth, Markey.
Administrative, technical, or material support: Fritz,Seth, Knott.
Study supervision: Revenaugh, Fritz,Haffey, Knott.
Conflict of Interest Disclosures: Dr Knott has been a member of the Basal Cell Carcinoma Surgical Advisory Board, Genentech Corp. No other disclosures are reported.
Previous Presentation: This study was a poster presentation at the American Academy of Facial Plastic and Reconstructive Surgery Fall Meeting; September 8-11, 2011; San Francisco, California.