Therefore, it is important for the reconstructive microsurgeon to have mastery of the anatomic considerations and a wide variety of reconstructive options available to address the multitude of challenges that may arise during surgery. The deep cervical fascia overlying the anterior scalene muscle should be kept intact during surgical dissection to prevent damage to the phrenic nerve. Although external cutaneous monitors may be helpful in select cases, flap orientation complexity increases with their use and may compromise the geometry of the reconstruction. Caring for patients with head and neck cancer diagnoses can be emotionally tough, so Dr. Harris stays centered by spending time outdoors, exercising and snowboarding. Pharynx, Cervical Esophagus, and Hypopharynx Reconstruction. As a general principle, selection of the artery with the strongest arterial flow rather than the largest diameter yields more reliable results. These tumours may be cancerous. ♦ Prepare the vessels adequately for anastomosis, and avoid aggressive vessel manipulation and manipulation of the internal lumen. Perhaps the most obvious indication for preoperative imaging is the assessment of peripheral vessels in fibular surgery in patients with longstanding peripheral vascular disease. Fig. ♦ Microscopic/loupe visualization is critical; avoid vessel preparation/manipulation without magnification. Paramount to successful microvascular reconstructive surgery is appropriate management of the microvascular anastomosis and vascular pedicle. Preparation of both the recipient and donor artery should provide adequate vessel length for anastomosis without damaging the vessels. Pedicle orientation issues, which remain unrecognized until the second tissue transfer is prepared for anastomosis, are problematic and may be avoided with appropriate planning. Brett A. Avoiding unnecessary destruction of recipient vessels during tumor ablations is critical for successful reconstruction in these situations. Caution should be exercised when selecting these vessels for microvascular reconstruction if the region has received radiation.5 Miles Nevertheless, microvascular surgeons have multiple vascular donor options within the head and neck for microvascular surgery. The superficial temporal vein is relatively thin, and careful dissection and avoiding excessive manipulation or kinking during microvascular anastomosis are required. It should be noted that vessels within Zone II are often within the target region of previous radiotherapy for pharyngeal/laryngeal malignancies or metastatic cervical lymph nodes. Avoiding vascular pedicle compression related to anatomic factors, flap orientation, and skin closure is relatively obvious but can be difficult to achieve if the potential for compression is not recognized early during reconstruction. Cadaveric investigations have reported the outer diameter of the superior thyroid artery to be approximately 3.5 mm. Advantages of this recipient site include avoiding previously radiated areas, good anatomic reliability, and the avoidance of vein grafting for reconstructions of this region. Adventitia may interfere with knot tying and, of greater concern, be trapped within the lumen of the anastomosis in situations of inadequate vessel preparation. Urken ML, Weinberg H, Buchbinder D, et al. Although this finding may seem intuitively obvious, many authors have reported retrograde anastomosis despite the evidence of the inherent risks associated with this technique.29 This is often necessary to eradicate cancer but may result in disfigurement or loss of functions such as speech or swallowing. 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. ♦ Prepare sufficient vessel length to avoid adventitial interference and provide sufficient nontraumatized vessel length to facilitate microsurgery. The thyrocervical system represents the ideal arterial system for microvascular surgeon in the vessel-depleted neck. Fellows are encouraged to align their experience with their specific interests. It should also be noted that the reported location of the artery in relation to the carotid bifurcation is somewhat variable.7 The superior thyroid artery offers an additional advantage of having an inferior orientation relative to the superior orientation of all other branches of the external carotid. (B) A moderate risk, with one vascular kink point. The vascular anatomy of the neck is well described, and a complete review of the anatomy is beyond the scope of this chapter. The experienced microsurgeon makes every effort to recognize the potential factors leading to vascular compromise prior to performing microvascular anastomosis. The superior thyroid artery provides excellent caliber and reliability for microvascular reconstructions. flow pattern has been reported in the microsurgical literature; however, the reliability of this technique has not been evaluated. 10.1). 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. The thyrocervical system represents the ideal arterial system for microvascular surgeon in the vessel-depleted neck. Procedures such as neck dissections, thyroidectomy, submandibular gland surgery, tracheostomy, carotid endarterectomy, and previous cervical spine surgery via an anterior approach may not preclude the availability of a microvascular vessel but will undoubtedly have some level of impact on operative findings when performing free tissue transfer. Microvascular reconstruction is a surgical procedure that involves moving a composite piece of tissue from another part of the body to the head and neck. The superior thyroid artery provides excellent caliber and reliability for microvascular reconstructions. 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. Although the routine use of preoperative imaging in the surgical planning for ablative surgery is widely accepted, preoperative imaging obtained specifically for microvascular surgery is often unnecessary. The experienced microsurgeon makes every effort to recognize the potential factors leading to vascular compromise prior to performing microvascular anastomosis. Patients and Design Retrospective, consecutive chart review of patients older than 70 years who … If there is excessive redundancy of the vascular pedicle, there is an increased risk of kinking and thrombosis. 10.2). Class II—involves more than one subsite, no adverse features. The reconstructive surgeon must verify adequate flow from the selected vessel prior to arterial anastomosis. 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