The Thoracoacromial/Cephalic Vascular System for Microvascular Anastomoses in the Vessel-Depleted Neck

ORIGINAL ARTICLE The Thoracoacromial/Cephalic Vascular System for Microvascular Anastomoses in the Vessel-Depleted Neck

Jeffrey R. Harris, MD; E. Lueg, MD; E. Genden, MD; M. L. Urken, MD

Objective: To review our experience with use of the tem for microvascular anastomoses. thoracoacromial/cephalic (TAC) system in the free flap reconstruction of complicated head and neck defects. Main Outcome Measures: Free flap survival and microvascular thrombosis. Design: Case series. Results: Of 11 patients using TAC anastomoses, all had Setting: Tertiary care referral center. complete survival of free flaps. No complications re- lated to anastomotic failure were identified. Population: A consecutive sample of 11 patients requiring free flap reconstruction of head and neck Conclusions: The TAC system provides a reliable source defects using the TAC system for microvascular anasto- of undisturbed vessels when cervical vessels are unus- moses was identified by medical chart review. able or absent.

Intervention: Free flap reconstruction of complicated defects of the head and neck using the TAC vascular sys- Arch Otolaryngol Head Neck Surg. 2002;128:319-323

REE FLAP reconstruction of de- plicated head and neck defects and found fects of the head and neck has this to be a reliable and invaluable tech- become a commonly used nique. The anatomy and application of this technique. The presence of technique are discussed. adequate blood vessels for anastomosesF is vital to the success of these RESULTS procedures. However, in patients with previous ablative or reconstructive surgery, Patient backgrounds are summarized in extensive trauma, wide surgical excisions, Table 1. Table 2 details previous sur- or irradiated tissues, it may be difficult or gical interventions. Table 3 indicates impossible to find suitable vessels in the the reconstruction method and vascular cervical area. supply used. Of 11 patients using the Sporadic studies in the literature have TAC anastomoses, all had complete sur- looked primarily at techniques to facili- vival of free flaps. No complications re- tate venous anastomoses in the vessel- lated to anastomotic failure were identi- depleted neck. Several articles have looked fied. Two representative patients are at the cephalic vein as an alternative ves- described in greater detail in the follow- sel for venous anastomoses.1-3 There is a ing subsections. From the Department of paucity of literature on techniques for ar- Surgery, University of Alberta, terial anastomoses in the vessel-depleted REPORT OF CASES Edmonton (Dr Harris); Los neck and in particular on the use of the Angeles Medical Center, thoracoacromial system as a reliable arte- Southern California CASE 8 Permanente Medical Group rial source for free flap reconstructions of (Dr Lueg); and the Department the head and neck. This patient originally had cutaneous squa- of Otolaryngology, The Mount We reviewed our experience with use mous cell cancer on the right shoulder and Sinai Hospital, New York, NY of the thoracoacromial/cephalic (TAC) sys- neck. The tumor was excised, and he ex- (Drs Genden and Urken). tem in the free flap reconstruction of com- perienced recurrence approximately 1

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Incision PATIENTS Pectoralis Major Muscle

Eleven patients requiring TAC anastomoses were Deltopectoral Groove identified through review of operative records. These patients’ medical charts were evaluated to identify patient background, indication for surgery, previous surgical or medical interventions, type of resection, type Muscle of reconstruction, use of vein grafts, operative complications, anastomotic difficulties, postopera- tive complications, and free flap survival.

SURGICAL TECHNIQUE Figure 1. Photograph of the right infraclavicular area demonstrating the site of incision through the pectoralis major muscle. After the initial portion of the procedure was com- pleted, access was gained to the TAC system by cre- tion, leaving a large defect (Figure 2). The defect in- ating a curved incision over the area of the deltopec- cluded complete exenteration of the posterior triangle to toral groove in such a fashion as to preserve and the level of the brachial plexus, including removal of all stage the area of the deltopectoral flap (Figure 1). usable posterior triangle vessels. A planned delayed re- Skin and fascia were then elevated as if elevating the construction after final pathology results were obtained deltopectoral flap until the deltopectoral groove was then undertaken using a combined parascapular fas- and the lateral aspect of the clavicular head of the ciocutaneous and latissimus dorsi myocutaneous free flap. pectoralis major muscle were exposed. Dissection was then taken into the deltopectoral groove, where A pedicled flap reconstruction was considered, but the the cephalic vein was identified. The vein was dis- size of the defect required free tissue transfer for ad- sected as far into the arm as was necessary to allow equate coverage. Anastomoses were performed to the tho- transposition over the clavicle and into the neck for racoacromial artery and cephalic vein, which were used tension-free anastomoses. preferentially owing to their proximity to the ablative Attention was then turned to dissection of the defect. The results of this reconstruction are demon- thoracoacromial system. A horizontal incision was strated in Figure 3. made across the pectoralis muscle, dividing its lateral attachment to the clavicle (Figure 1). Careful dis- CASE 10 section in the plane deep to the pectoralis major muscle and superficial to the pectoralis minor muscle was undertaken to identify the main trunk of the tho- This patient was originally treated with an organ preser- racoacromial system and its takeoff from the axil- vation radiation therapy and chemotherapy protocol for lary artery. Usually, several branches of the thora- laryngeal cancer. He subsequently developed evidence coacromial artery can be identified and preserved for of recurrent and persistent laryngeal cancer. He then anastomosis. In an effort to preserve the viability of underwent salvage total laryngectomy and bilateral the pectoralis major muscle flap, the pectoral branch selective neck dissections with placement of a pectoralis was usually preserved if an alternative branch was of major muscle flap over the pharyngeal closure. After suitable dimensions. surgery, the patient developed a pharyngocutaneous fis- If a pectoralis major muscle flap had been tula with wound breakdown and exposure of the elevated during previous surgery, then the pectoral carotid artery. A formal pharyngostome was created branch of the thoracoacromial artery often could be identified on the surface of the elevated pectoralis with cervical skin flaps. This closure subsequently muscle. This branch was then traced retrograde to broke down with exposure of the carotid artery. A supe- its origin at the thoracoacromial artery. The pecto- riorly based trapezius myocutaneous flap was then ral branch, thoracoacromial artery, or one of the brought into the neck for carotid coverage, and the skin other identified branches was then used for from this flap was used to recreate a pharyngostome. anastomoses. This flap pulled away from the posterior pharyngeal wall, again leading to carotid artery exposure. The wound was treated conservatively with packing, and the patient was scheduled for reconstruction of the pharynx using a gastro-omental artery free flap. At the month later and subsequently underwent Mohs sur- time of surgery, extensive exploration of the neck to gery. A recurrence was again experienced approxi- find adequate blood vessels for anastomosis revealed mately 3 months later. At that time, he was referred to that the previous neck dissection, radiation therapy, our institution (The Mount Sinai Hospital). On exami- and salivary leak had left no reliable vasculature in the nation, the patient had a large right neck mass with a fun- ipsilateral or contralateral neck. This procedure was gating appearance. No other abnormalities were noted. performed using the TAC system for vascular supply The patient had an extensive resection with neck dissec- (Figure 4). The patient did well after surgery.

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Patient No./ Sex/Age, y Diagnosis Resection Radiation Therapy Chemotherapy 1/M/77 Osteoradionecrosis of the mandible Segmental mandibulectomy Presurgical No 2/F/52 Pharyngoesophageal stenosis Opening of stenotic segment Presurgical, to neck, Breast cancer therapy axilla, and breast 3/M/49 Contour deformity after radical neck dissection None Presurgical No 4/F/48 Pharyngoesophageal stenosis Opening of stenotic segment Presurgical No 5/M/63 Recurrent cancer of temporal skin and bone Temporal skin and temporal Presurgical Presurgical craniectomy 6/M/68 Pharyngocutaneous fistula after laryngectomy None Presurgical Presurgical 7/F/41 Recurrent cancer at base of tongue Total glossectomy Presurgical Presurgical 8/M/61 Cutaneous squamous cancer involving the Skin of neck, superior shoulder, Postsurgical No shoulder, neck, and deep cervical structures neck dissection 9/F/54 Osteoradionecrosis of the mandible and Segmental mandibulectomy Presurgical No pharyngocutaneous fistula 10/M/57 Pharyngocutaneous fistula None Presurgical No 11/M/80 Recurrent tumor after laryngectomy Pharyngectomy Postsurgical No

Table 2. Previous Surgical Procedures Table 3. Free Flap Donor Site and Anastomoses*

Patient Patient No. Donor Site Vein Grafts No. Previous Procedures 1 Iliac crest/internal oblique muscle Arterial and venous 1 Base of tongue resection, bilateral neck dissections 2 Radial forearm No 2 Total laryngopharyngectomy, bilateral neck dissections, radial 3 Scapular fascia No forearm free flap, mastectomy, axillary node dissection 4 Radial forearm No 3 Tonsil resection, radical neck dissection 5 Anterolateral thigh Arterial 4 Partial laryngectomy, bilateral neck dissections 6 Gastro-omental arteries No 5 Oral cavity resection, maxillectomy, skull base resection, neck 7 Gastro-omental arteries Arterial dissection, rectus abdominus muscle free flap 8 Parascapular/latissimus No 6 Laryngectomy, bilateral neck dissections, pectoralis major 9 Scapula/latissimus Arterial and venous muscle flap, bilateral superior trapezius muscle flaps 10 Gastro-omental arteries No 7 Partial pharyngectomy, total laryngopharyngectomy, 11 Anterolateral thigh No pharyngoesophageal stenosis repair, bilateral neck dissections, bilateral radial forearm flaps, bilateral *Flap survival was complete for all patients. The artery used for all pectoralis major muscle flaps, island deltopectoral patients was the thoracoacromial; the vein used for all patients was the 8 Mohs resection of cutaneous malignancy on neck and cephalic, except for patients 7 and 9 for which the thoracoacromial vein was shoulder used. 9 Not available 10 Total laryngectomy, bilateral neck dissections, pectoralis major muscle flap, superior trapezius muscle flap was used preferentially because of its simple dissection 11 Total laryngectomy, bilateral neck dissections and the length of the vessel that allows for transposition over the clavicle to reach virtually any area of the ipsilateral neck. COMMENT The anatomy of the cephalic vein has been described in detail elsewhere.3 The radial continuation of Reconstruction of the head and neck in the presence of the dorsal venous arch forms the origin of the cephalic a vessel-depleted neck is becoming a common problem vein. The cephalic vein then crosses the tendon of the with the increased use of free flaps. The cephalic vein extensor pollicis longus and ascends across the radial bor- has recently been described as a “lifeboat” for head and der of the wrist. The cephalic vein next turns anteriorly neck reconstruction.1 Horng and Chen1 reported their to parallel the anterior border of the brachioradialis experience with 3 patients requiring free flap recon- muscle and the radial artery and its venae commitantes. struction. The cephalic vein was the recipient vein in 2 In the antecubital fossa, the median cubital vein ob- cases and was used in continuity with a radial forearm liquely ascends as a major branch to connect with the flap in a third case. A later study2 presented 11 cases of basilic vein and the deep venous system. This anasto- cephalic vein transposition for head and neck recon- motic network provides the various options for venous struction with excellent results. The advantages of the outflow for the radial forearm flap. The cephalic vein transposed cephalic vein technique include the ability next follows the lateral bicipital groove to enter the del- to span long distances in the head and neck, thereby topectoral groove between the respective muscles. The eliminating the need for vein grafts and anastomosing cephalic vein usually accompanies the deltoid arterial to a vessel outside an irradiated field.4 In addition, the branch of the thoracoacromial axis, where it pierces the cephalic vein is often an excellent size match for micro- brachial fascia to leave the subcutaneous level. Deep in vascular anastomoses. In our series, the cephalic vein the deltopectoral triangle, the cephalic vein perforates

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CL SCM TA GDP

LS CV

Figure 2. Postablation defect in patient 8. SCM indicates Figure 4. Thoracoacromial artery (TA) and cephalic vein (CV) transposed sternocleidomastoid muscle; LS, levator scapulae muscle. over the clavicle (CL) and anastomosed to the gastroduodenal pedicle (GDP) in patient 10.

tently arises as a branch off the second part of the axillary artery. It classically divides into 4 named branches: the pectoral, deltoid, clavicular, and acromial arteries. The thoracoacromial venous system generally mirrors the arterial branching, although more variability has been reported. Through cadaver studies,9 the diameters of the branches of the thoracoacromial arterial system have been found to range from 1.2 to 2.4 mm; the diameter of the thoracoacromial arterial trunk was found to have a diameter of 2.5 to 7.0 mm. In our series, the branches of the thoracoacromial arterial system could be dissected distally to achieve enough length to transpose the artery over the clavicle into the neck while maintain- ing an adequate lumen for anastomosis. The pectoral branch of the thoracoacromial artery is the main vascular pedicle on which the pectoralis major muscle flap is based. This becomes a consideration when using the TAC system for 2 reasons. First, when a pectoralis muscle flap has not been elevated during a previous procedure, thought must be given to the possibil- ity of requiring a pectoralis muscle flap in the future. Us- ing another branch of the thoracoacromial artery for anastomosis can preserve the vascular pedicle to the pectoralis major muscle flap. We successfully preserved the Figure 3. Result of combined parascapular and latissimus dorsi free flap pectoral branch and later used the pectoralis muscle in closure 6 months after surgery in patient 8. 1 patient. Second, when the patient has had a pectoralis major muscle flap elevated at a previous procedure, there the costocoracoid membrane at the upper border of the may be distortion of the usual anatomy of the TAC sys- pectoralis minor muscle to empty finally into the axil- tem. Three of 10 patients in our study were in this cat- lary vein. The cephalic vein has been reported to cross egory. In each situation, the TAC system could be dis- anterior to the clavicle to penetrate to cervical fascia sected and used. In some respects, dissection was actually and end in the external jugular vein.3 facilitated in this situation as the pectoral branch of the To our knowledge, there have been no previous thoracoacromial artery was readily exposed due to its lo- reports of the thoracoacromial system being used as an cation on the previously elevated pectoralis muscle flap. arterial source for free flap reconstruction of the head This branch was then easily traced to the main trunk of and neck. Seikaly et al5 recently detailed the thoracoac- the TAC system. romial axis as a vascular supply for the clavipectoral In conclusion, we report our experience using the osteomyocutaneous free flap. Other articles6-8 have com- TAC system for microvascular anastomoses in 11 pa- mented on the thoracoacromial axis as a recipient vas- tients requiring free flaps for head and neck reconstruc- cular supply for reconstruction of other areas, including tion in the presence of a vessel-depleted neck. The TAC the breast and thoracic esophagus. system provides a reliable source of undisturbed vessels The anatomy of the thoracoacromial system has when cervical vessels are unusable or absent. The sub- been well described.9 The thoracoacromial artery consis- stantial drawback of this technique is the potential loss

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 of the major vascular pedicle to the pectoralis major REFERENCES muscle myocutaneous flap, thereby preventing its future use, if required. However, with selective dissection of other branches of the thoracoacromial artery, the pec- 1. Horng SY, Chen MT. Reversed cephalic vein: a lifeboat in head and neck free- flap reconstruction. Plast Reconstr Surg. 1993;92:752-753. toral branch can be preserved. If a pectoralis major muscle 2. Kim KA, Chandrasekhar BS. Cephalic vein in salvage microsurgical reconstruc- flap has been elevated during a previous procedure, it is tion in the head and neck. Br J Plast Surg. 1998;51:2-7. still possible to use the TAC system provided that ad- 3. Hallock GG. The cephalic vein in microsurgery. Microsurgery. 1993;14:482- equate time has passed for neovascularization to occur. 486. Exposure of the TAC system is not technically compli- 4. Mulholland S, Boyd JB, McCabe S, et al. Recipient vessels in head and neck microsurgery: radiation effect and vessel access. Plast Reconstr Surg. 1993;92: cated and should be included in the armamentarium of 628-632. any surgeon performing complicated head and neck re- 5. Seikaly H, Calhoun K, Rassekh CH, Slaughter D. The clavipectoral osteo- constructions. myocutaneous free flap. Otolaryngol Head Neck Surg. 1997;117:547-554. 6. Barnett GR, Carlisle IR, Gianoutos MP. The cephalic vein: an aid in free TRAM flap breast reconstruction: report of 12 cases. Plast Reconstr Surg. 1996;97:71- Accepted for publication November 27, 2001. 76. This study was presented at the annual meeting of the 7. Serletti JM, Moran SL, Orlando GS, Fox I. Thoracodorsal vessels as recipient ves- American Head and Neck Society, Palm Desert, Calif, May sels for the free TRAM flap in delayed breast reconstruction. Plast Reconstr Surg. 14, 2001. 1999;104:1649-1655. Corresponding author and reprints: Jeffrey R. Harris, 8. Fujita H, Inoue Y, Kakegawa T, et al. Esophageal reconstruction using microvascular anastomosis to the thoracoacromial artery and cephalic vein. Jpn J Surg. MD, Department of Surgery, 2D, University of Alberta, WC 1991;21:512-516. Mackenzie Centre, 8440112 St, Edmonton, Alberta, Canada 9. Reid CD, Taylor GI. The vascular territory of the acromiothoracic axis. Br J Plast T6G 2B7 (e-mail: [email protected]). Surg. 1984;37:194-212.

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