Cadaveric investigations have reported the outer diameter of the superior thyroid artery to be approximately 3.5 mm. Careful attention to avoiding manipulation of the internal lumen and vessel intima to prevent damage to the endothelium is paramount to prevent arterial thrombosis. This type of procedure is often referred to as microvascular reconstruction surgery (also known as "free flap" or "free tissue transfer" surgery). Additionally, sequential or “piggyback” configurations should be avoided, as proximal anastomotic compromise may sacrifice both reconstructions.27,28 Similarly, configurations resulting in retrograde flow, although possible in the first vascular territory, are not generally recommended due to decreased vascularity and flap survival. 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. Pedicle orientation issues, which remain unrecognized until the second tissue transfer is prepared for anastomosis, are problematic and may be avoided with appropriate planning. 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 region of the planned reconstruction may or may not coincide with the Zone of recipient vessel selection. Additional vessel preparation may be required in special circumstances such as vein grafting, application of monitoring devices, or for certain vessel configurations. Microvascular reconstructions after head and neck cancer are among the most complicated procedures in plastic surgery. Postoperative complications are common, which often leads to prolonged hospital stay. 10.1). 10.1). 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. 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. Surgical Technique and Considerations It is in situations such as these that confusion or poor vessel selection and orientation may occur, resulting in a failed reconstruction. 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). It should be noted that the previously radiated or operated neck does not preclude the use of recipient vessels from that side. Review of previous operative reports can yield information related to the vasculature available for microvascular anastomosis. 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. This success rate is dependent on 3 basic components that include the preoperative evaluation of the patient, technical aspect of the operation, and postoperative management.11 Surgical Technique and Considerations 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. 10 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. Zone III Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Microvascular Reconstruction of the Head and Neck. 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. ♦ 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. 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. He/she may go to any site as need be for special events. The purpose of this study was to evaluate the impact of age on outcomes after microvascular reconstruction. The details of vessel management and microvascular anastomosis are critical to surgical success and are often ignored. 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. 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. 10.2 Vessel geometry is exceptionally important. ♦ Microscopic/loupe visualization is critical; avoid vessel preparation/manipulation without magnification. In some situations, tissue from a patient’s own body outside of the head and neck region is "transplanted" to reconstruct areas of the face, mouth, throat or neck. The experienced microsurgeon makes every effort to recognize the potential factors leading to vascular compromise prior to performing microvascular anastomosis. Planning for double free tissue transfers requires further attention by the microsurgeon to avoid technical difficulties related to pedicle geometry and vessel availability. ♦ 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. Fig. The details of vessel management and microvascular anastomosis are critical to surgical success and are often ignored. 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. 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. More importantly, the microsurgeon must recognize the inherent factors present in each individual patient to allow for adequate preoperative planning and maximize success. Microvascular reconstruction of the head and neck continues to challenge surgeons worldwide despite significant technical advances. The most obvious are related to vascular compromise of the flap. Overview of the Program The University of Pittsburgh Department of Otolaryngology offers fellowship training in advanced head and neck oncologic and microvascular reconstructive surgery as a one-year or two-year commitment, designed to prepare you for a career as a comprehensive head and neck … 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. Location of these vessels is readily achieved by palpation of the mandibular notch and careful dissection to identify the vessels for vascular access as well as to identify and protect the marginal branch of the facial nerve, which overlies the facial vein in this region. (D) A clinical example of a gentle vessel curvature that helps prevent kinking. 10.2). This surgery is done to remove tumours or growths in the mouth and surrounding areas. Favorable pedicle geometry implies gentle pedicle curvature with alignment of the microvascular anastomosis (Fig. Adventitia may interfere with knot tying and, of greater concern, be trapped within the lumen of the anastomosis in situations of inadequate vessel preparation. 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. 10.3 The position of the vascular anastomosis relative to the oral or pharyngeal suture line should be considered. 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. Head and Neck Oncologic Surgery and Microvascular Reconstruction Fellowship. There are, however, several situations in which imaging is indicated prior to reconstruction. 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. ♦ Avoid placing the anastomosis in positions of peril. Fig. Advantages of this recipient site include avoiding previously radiated areas, good anatomic reliability, and the avoidance of vein grafting for reconstructions of this region. ♦ Microscopic/loupe visualization is critical; avoid vessel preparation/manipulation without magnification. Class III—only one subsite, adverse features. 10.1 The donor vessels may be divided into two categories: branches of the external carotid and branches of the thyrocervical trunk. ♦ Careful attention to small cutaneous perforators is required to avoid compromise; harvesting small perforators with a muscle cuff is recommended if possible. Pedicle length and diameter match with proposed recipient sites should be planned prior to flap inset. ♦ Prior to performing microsurgical anastomosis, the microsurgeon verifies the position of the reconstructive tissue to optimize pedicle orientation and geometry. 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