Department of Plastic and Reconstructive Surgery, University Hospital, De Pintelaan 185, 9000 Gent, Belgium.
J Plast Reconstr Aesthet Surg. 2012 Jul;65(7):885-92. doi: 10.1016/j.bjps.2012.01.006. Epub 2012 Jan 27.
Successful microsurgical free tissue transfer for head and neck reconstruction highly depends on the quality of the recipient vessels. In most cases, vessels near the site of resection are available; however, when the bilateral vascular network in the neck is compromised or inaccessible due to prior surgery and/or irradiation, alternatives have to be sought.
Secondary or tertiary head and neck reconstruction was performed using the internal mammary vessels (IMVs) as recipient vessels in seven patients who had undergone previous neck dissection and radiation therapy. Indications were: tracheal-oesophageal fistula or stenosis (n = 4), oesophageal-cutaneous fistula (n = 1), saliva fistula (n = 1) and oral cancer (n = 1). Free flaps used for reconstruction were radial forearm flap (FRFF) (n = 5), anterolateral thigh flap (ALT) (n = 3) and transverse rectus abdominis myocutaneous flap (TRAM) (n = 1). Within two patients an additional ALT flap was necessary for soft-tissue coverage and resurfacing of the neck. The IMVs were separately exposed in a standard fashion over the second or third rib. The pedicle of the flap was anastomosed anterograde and end-to-end to the recipient vessels in all cases. Mean pedicle length was 14.3 cm (11-20 cm), with a mean distance of 9.8 cm (7-13 cm) between the resection and recipient vessel site.
All patients were tumour free at time of re-operation and no sign of radiation injury was observed in the recipient vessels. All flaps survived and all patients healed without major complications. Mean follow-up time was 18 months. Four patients died of local recurrence or distant metastases during follow-up.
In the vessel-depleted neck, the IMVs are a reliable and easy accessible recipient area for microsurgical reconstruction of the head and neck. Surgical management and technique refinements for dissection of the vessels are discussed. In combination with free flaps with a long pedicle, especially perforator flaps, vein grafts are unnecessary and microsurgery can safely be performed outside the zone of injury.
头颈部重建的显微外科游离组织移植的成功高度依赖于受区血管的质量。在大多数情况下，可利用切除部位附近的血管；但是，当由于先前的手术和/或放疗导致颈部双侧血管网络受损或无法接近时，就需要寻找替代方法。
7 例先前接受过颈部解剖和放疗的患者，采用内乳血管（IMV）作为受区血管进行二次或三次头颈部重建。适应证为：气管食管瘘或狭窄（n=4）、食管皮瘘（n=1）、唾液瘘（n=1）和口腔癌（n=1）。用于重建的游离皮瓣为桡侧前臂皮瓣（FRFF）（n=5）、股前外侧皮瓣（ALT）（n=3）和横行腹直肌肌皮瓣（TRAM）（n=1）。在 2 例患者中，还需要额外的 ALT 皮瓣进行颈部软组织覆盖和表面修复。以标准方式分别暴露第二或第三肋骨上方的 IMV。在所有病例中，均将皮瓣的蒂顺行端端吻合至受区血管。皮瓣蒂的平均长度为 14.3cm（11-20cm），切除部位与受区血管之间的平均距离为 9.8cm（7-13cm）。
所有患者在再次手术时均无肿瘤，且受区血管无放射损伤迹象。所有皮瓣均存活，所有患者均愈合良好，无重大并发症。平均随访时间为 18 个月。4 例患者在随访期间死于局部复发或远处转移。
在血管耗竭的颈部，IMV 是头颈部显微重建的可靠且易于接近的受区。讨论了血管解剖的手术管理和技术改进。结合长蒂游离皮瓣，特别是穿支皮瓣，无需静脉移植，可在损伤区外安全进行显微手术。
