Microvascular free tissue transfer is a standard

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1 ORIGINAL ARTICLE INTERNAL MAMMARY ARTERY AND VEIN: RECIPIENT VESSELS FOR FREE TISSUE TRANSFER TO THE HEAD AND NECK IN THE VESSEL-DEPLETED NECK Mark L. Urken, MD, 1 Kevin M. Higgins, MD, 2 Bryant Lee, MD, 3 Carlin Vickery, MD 4 1 Department of Otolaryngology Head and Neck Surgery, Institute for Head and Neck and Thyroid Cancer, Continuum Cancer Centers of New York, Beth Israel Medical Center, New York, NY. murken@chpnet.org 2 Department of Otolaryngology Head and Neck Surgery, Toronto Sunnybrook Regional Cancer Center, University of Toronto, Toronto, Canada 3 Department of Otolaryngology Head and Neck Surgery, Mount Sinai Medical Center, New York, NY 4 Division of Plastic Surgery, Department of General Surgery, Mount Sinai Medical Center, New York, NY Accepted 8 November 2005 Published online 1 August 2006 in Wiley InterScience ( DOI: /hed Abstract: Background. Microvascular free tissue transfer is a standard reconstructive option for postablative defects of the head and neck. However, the success of this surgery requires suitable recipient vessels in the cervical region. This form of reconstruction can be particularly challenging in the vesseldepleted neck. While the internal mammary artery and vein (IMA/V) have been used extensively in breast reconstruction, there are few reports describing their use in head and neck reconstruction. We report the first case series of the use of the internal mammary vessels for head and neck microvascular reconstruction. Methods. We reviewed 5 cases of free tissue transfers to the head and neck in which extensive prior treatment precluded the use of more traditional recipient vessels in the neck or upper chest. Results. A variety of free flaps were transferred for different reconstructive problems which included: chin/lower lip (n ¼ 2), closure of widely patent tracheoesophageal puncture sites (n ¼ 2), and pharyngoesophageal reconstruction following staged repair of a severe stenosis (n ¼ 1). The radial forearm free flap was transferred in 4 patients and the rectus abdominus free flap in 1 patient. The IMA/V on the right side was prepared in Correspondence to: M. L. Urken VC 2006 Wiley Periodicals, Inc. all cases. All free flaps were successfully revascularized without the need for vein grafts and without the need for any microvascular revision procedures. Conclusion. The internal mammary artery and vein provide reliable, easily accessible recipient vessels for microvascular reconstruction in the vessel-depleted neck. The selection of free flap donor sites with long donor vessels facilitates the microvascular repair. VC 2006 Wiley Periodicals, Inc. Head Neck 28: , 2006 Keywords: internal mammary; free tissue transfer; vesseldepleted neck Microvascular free tissue transfer is a standard reconstructive option for bone and soft tissue defects in the head and neck. However, this type of reconstruction requires suitable recipient vessels in the cervical region. The efficiency, reproducibility, and predictability of free tissue transfer to the head and neck depends upon a number of factors. Early in the senior author s experience in head and neck reconstruction, it became apparent that vessel selection and the geometry of the vascular Internal Mammary Artery and Vein HEAD & NECK DOI /hed September

2 pedicle were critical factors in the success of the free tissue transfer. 1 In patients with prior surgery, and in particular lymph node dissections, the common recipient vessels are often no longer available. In these cases, alternative sites for recipient vessels must be identified if free tissue transfer is to be possible. We have previously described the thoracoacromial cephalic system (TAC) of vessels as a potential option for such cases. 2 The internal mammary artery and vein (IMA/V) are not commonly used as recipient vessels for head and neck free flap reconstruction; however, they have been frequently utilized in free tissue transfer for breast reconstruction. 3,4 In such cases, the IMA/V offer a reliable vascular supply. However, with the exception of reports describing the use of the IMA/V to supercharge a colonic interposition and a transverse rectus abdominis myocutaneous (TRAM) flap, the IMA/V have not been described as a recipient vessel source for microvascular head and neck reconstruction. 5,6 We present the first case series describing the utilization of the internal mammary vessels for revascularization of free tissue transfers used in the head and neck and discuss the advantages and disadvantages of this vascular recipient site. ANATOMICAL DESCRIPTION AND SURGICAL TECHNIQUE The IMA is a branch of the subclavian artery and travels along the undersurface of the upper 6 costal cartilages, approximately 1.0 to 2.3 cm lateral to the sternal margin. Accompanying the artery is the internal mammary vein that feeds into the brachiocephalic system. The thin pleural fascia and transversus thoracis separate the IMV system from the parenchyma of the lung. Caudal to the third rib, the caliber of the vein diminishes significantly and has been estimated as less than 1.5 mm in the majority of patients, rendering a microvascular anastomosis technically challenging. Cadaveric dissections have revealed that the third interspace is the most reliable and consistent area for harvesting the distal vein as it averages 3 mm in more than 70% of patients. There are anatomic differences between the IMA/V on the left and the right sides in a significant percentage of patients. Anatomical studies have revealed that the IMV bifurcates in 80% of patients less than 2 mm distal to the fourth rib on the left side but bifurcates in only 40% of patients at the same level on the right side. At the same level, the IMA averages 2.36 mm in diameter. As a result, it has been our preference to harvest these recipient vessels from the right side. 7 9 The technique for vessel preparation requires dissection and removal of a segment of the medial aspect of the third rib via a subperichondrial dissection and then creating a 2- to 3-cm window in the deep layer of the perichondrium, which is then incised, exposing the underlying vascular bundle. Once the vascular bundle has been identified, they are meticulously dissected from the surrounding tissue. The surgeon must be mindful of the fact that the pleura lies only millimeters deep to this plane of dissection, and careful vessel preparation is required to avoid a violation of the pleural space. The artery and vein are then ligated distally and carefully dissected off of the deep facia. The vessels are then transposed superiorly and prepared for the microvascular anastomoses. The vascular pedicle is typically 2 to 3 cm long and can be lengthened by removing a segment of the cartilage from the second rib. MATERIALS AND METHODS There were 5 patients in this series who underwent free flap transfer to the head and neck in which the internal mammary artery and vein served as the recipient vessels. All patients had undergone extensive prior surgery and radiation. The extent of the surgery varied from patient to patient, but all of the patients in this series had undergone bilateral neck dissections. Each of the 5 patients had undergone salvage surgery for failure of chemoradiation, a second or third primary cancer, or osteoradionecrosis. In addition, 4 of the 5 patients had undergone a minimum of 1 prior free flap transfer to the head and neck, and 2 patients had undergone 3 prior free flap transfers. The pectoralis major flap had been utilized for reconstruction in 4 of the patients, with 2 of the patients having undergone bilateral pectoralis major flaps for a variety of reconstructive problems. REPRESENTATIVE CASE This 54-year-old man underwent a supraglottic laryngectomy and bilateral neck dissections followed by adjuvant radiotherapy. He subsequently developed cervical esophageal obstruction secondary to a severe stricture that could not be resolved by attempted dilation. 798 Internal Mammary Artery and Vein HEAD & NECK DOI /hed September 2006

3 The IMA/V were harvested in the manner described earlier, with removal of the costal cartilage from the second and the third rib (Figure 2). Once the vessels were isolated and all branches meticulously ligated, they were transposed in a cephalad direction for end-to-end anastomosis (Figures 3 and 4). A bilobed rectus abdominus flap was harvested and used to restore both the inner and outer lining (Figures 5 and 6). The patient had an uneventful postoperative course and was able to resume swallowing at 2 weeks following surgery. RESULTS All 5 free flaps were successfully revascularized without a return to the operating room for revision. All anastomoses were performed in an endto-end fashion. There was no need for vein grafts in any case in this series. All patients underwent postoperative chest radiographs, and there was no evidence of a pneumothorax in any case. FIGURE 1. The pharyngoesophageal segment was exteriorized and observed for 3 weeks prior to the second stage closure to ensure patency of the distal lumen. [Color figure can be viewed in the online issue, which is available at A tubed gastroomental free flap was transferred based on the left TAC system of vessels. Attempts to find suitable recipient vessels in the neck were unsuccessful. Although the patency of the esophagus was reestablished, the patient was unable to swallow and experienced chronic aspiration. After a trial of swallowing therapy, the patient elected to undergo a total laryngectomy in order to regain his ability to sustain himself with oral nutrition. A total laryngectomy was performed, but at the time of surgery, a distal narrowing was encountered at the junction of the gastric mucosa with the thoracic esophagus. The pharyngoesophageal segment was formalized and a delayed reconstruction was planned. At the time of the delayed reconstruction, the pharyngostome and esophagostome were widely patent. However, the surrounding cervical skin was severely damaged by prior therapy, and the decision was made to proceed with a rectus abdominus free flap with planned revascularization through the right-sided IMA/V recipient vessels (Figure 1). The decision was made to avoid use of the TAC system on the right side to preserve the pectoralis major donor site for possible future use if needed. DISCUSSION Multiple operations for recurrent head and neck cancer are not uncommon. Those patients that require multiple resections and reconstruction, or augmentation of a prior reconstruction, may represent a challenge with regard to identifying appropriate recipient vessels for microvascular reconstruction. Head et al 10 found that prior surgery and neck dissection was not a contraindication for the use of free flaps. In 39% of their cases, FIGURE 2. A segment of the medial aspect of the third rib was removed with a subperichondrial dissection. The posterior perichondrium was incised to obtain exposure of the IMA/V. The underlying pleura was protected during the dissection to avoid entry into the pleural space. [Color figure can be viewed in the online issue, which is available at Internal Mammary Artery and Vein HEAD & NECK DOI /hed September

4 FIGURE 3. The internal mammary artery and vein were circumferentially dissected and ligated distally. The ends of the vessels were transposed in a cephalad direction for end to end anastomosis to the donor vessels. [Color figure can be viewed in the online issue, which is available at FIGURE 5. A bilobed rectus abdominus flap was harvested to provide both inner and outer lining. [Color figure can be viewed in the online issue, which is available at com.] suitable vessels were identified in the ipsilateral neck. However, if a radical or modified radical neck dissection had been previously performed, this number dropped to 0%. In over 60% of the cases, exploration of the unoperated neck was required to identify suitable recipient vessels. While the authors recommended reconstructing patients with prior neck dissection with long pedicled flaps to obviate the need for vein grafting, they did not address the issue of extensive prior surgery in both necks. 10 In patients with prior surgery, we first search for branches of the external carotid artery. However, scar tissue, radiation, or prior ligation of the branches often makes this search unproductive. Radiation therapy causes an intimal fibrosis that that may predispose a vessel to intimal injury and thrombosis. 11 When branches of the external carotid are not available, the transverse cervical artery is often intact despite prior neck dissection. Alternatively, careful dissection in the viscerovertebral angle may uncover a preserved inferior thyroid artery. The TAC system of vessels provides a useful and highly reliable source of recipient vessels in the vessel-depleted neck. The TAC vessel caliber is usually of sufficient size for microvascular anastomosis at the level of the clavicle but prevents the use of the ipsilateral pectoralis major flap. 2 The cephalic vein can be dissected caudally in the arm FIGURE 4. Following revascularization, the recipient vessels (double arrow) are turned over the proximal costal cartilage and the donor vessels (single arrow) lie just deep to the upper chest skin. [Color figure can be viewed in the online issue, which is available at FIGURE 6. Following revascularization the tracheostoma was formed and the reconstruction completed. [Color figure can be viewed in the online issue, which is available at wiley.com.] 800 Internal Mammary Artery and Vein HEAD & NECK DOI /hed September 2006

5 and then transposed into the upper neck to reestablish venous outflow without the need for vein grafts. Moran et al 12 compared the internal mammary and the TAC vascular systems for microvascular breast reconstruction and found that while in the majority of cases both sites provided an acceptable set of recipient vessels, the anatomic consistency of the internal mammary vessels led them to conclude that they were more reliable than the TAC system. CONCLUSION The IMA/V represent an alternative source for recipient vessels for a microvascular anastomosis in a vessel-depleted neck. While the distance of the vessels from the neck can present a problem, the vascular anatomy is consistent and the diameter of both the artery and the vein offer an excellent source of recipient vessels. While complications related to IMA/V harvest are rare, the patient should be aware of the risks, including pneumothorax, intercostal neuralgia, chest wall herniation, and a sternal contour defect. 4 REFERENCES 1. Urken ML, Vickery C, Weinberg H, Buchbinder D. Geometry of the vascular pedicle in free tissue transfers to the head and neck. Arch Otolaryngol Head Neck Surg 1989;115: Harris JR, Lueg E, Genden E, Urken ML. The thoracoacromial/cephalic vascular system for microvascular anastomoses in the vessel-depleted neck. Arch Otolaryngol Head Neck Surg 2002;128: Maillard GF. Breast reconstruction with the internal mammary artery pedicled fasciocutaneous island flap: description of a new flap. Plast Reconstr Surg 2002;109: 1203, Majumder S, Batchelor AG. Internal mammary vessels as recipients for free TRAM breast reconstruction: aesthetic and functional considerations. Br J Plast Surg 1999; 52: Kaddoura IL, Hashim H, Kayle D, Shabb B. Intercostal thorascopic harvesting of the internal mammary artery for supercharging a pedicled rectus abdominis flap. Ann Plast Surg 1998;40: Sung SC, Chung IY, Jun HJ, Choi PJ, Woo JS, Ahn HC. Revascularization of the ischemic colon transplant using the internal mammary vessels. Ann Thorac Surg 1994;58: Feng LJ. Recipient vessels in free-flap breast reconstruction: a study of the internal mammary and thoracodorsal vessels. Plast Reconstr Surg 1997;99: Clark CP III, Rohrich RJ, Copit S, Pittman CE, Robinson J. An anatomic study of the internal mammary veins: clinical implications for free-tissue-transfer breast reconstruction. Plast Reconstr Surg 1997;99: Kavouni A, Shibu M. Problems associated with the use of internal mammary vessels as recipients for free flap breast reconstruction. Br J Plast Surg 1999;52: Head C, Sercarz JA, Abemayor E, Calcaterra TC, Rawnsley JD, Blackwell KE. Microvascular reconstruction after previous neck dissection. Arch Otolaryngol Head Neck Surg 2002;128: Kirkpatrick JB. Pathogenesis of foam cell lesions in irradiated arteries. Am J Pathol 1967;50: Moran SL, Nava G, Behnam AB, Serletti JM. An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients. Plast Reconstr Surg 2003;111: Internal Mammary Artery and Vein HEAD & NECK DOI /hed September