Vessel Selection in the Difficult Neck

The lack of a suitable recipient vessel may jeopardize successful free tissue transfer. Common problems include inadequate pedicle length, a lack of suitable veins, arterial mismatch, poor-quality vessels, or a total lack of a suitable artery or vein. Inadequate pedicle length can be remedied through the use of reversed vein grafts. Vein grafts are most commonly obtained from the cephalic vein, external jugular veins, or from various leg veins. Vein grafts are reversed so that the valves are non functional. Notably, the use of vein grafts is not associated with an increased incidence of flap loss or thrombosis. If a vein is not available for anastomosis within the head and neck, the cephalic vein can be divided distally and turned into the head and neck based on the axillary vein. The cephalic vein is of large caliber and is not typically within prior surgical or radiation fields.

Arterial mismatch is a common problem when the donor artery is small (1-1.5 mm). The majority of the named vessels from the external carotid artery -g and thyrocervical trunk are much larger with a single exception: the ascending phar- |

yngeal artery. The ascending pharyngeal artery is often neglected because of its posterior location. It originates posteriorly just beyond the carotid bulb and is not easily seen. The great advantage of this artery is that its diameter is much smaller than the d other primary branches of the external carotid, yet its flow is very brisk. It is an ideal recipient artery for flaps with smaller donor arteries. |

Finally, in some cases, there are no vessels in the neck that are useable. If a flap is to be transferred an artery and vein must be brought into the field. Thoracodorsal vessel transposition provides a practical solution to this problem (52). The thoraco-

Figure 26 Thoracodorsal transposition to supply virgin large-caliber vessels to the neck to act as recipient vessels for a microvascular free flap. [From Ref. (52).]

dorsal vascular pedicle provides both arterial and venous components of large caliber (3-4 mm for the artery and vein) without manipulation of the carotid system that may be encased in scar (Fig. 26). This technique possesses several advantages: the vessels are not in the typical radiation field for head and neck cancer; they are of sufficient length to reach the lower neck easily; and the necessity for additional anastomoses is eliminated, thus reducing operating time.

The characteristics and relative qualities of each flap are presented in Table 1. A star is placed under each characteristic that is considered a favorable quality of the flap.

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How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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