INTRODUCTION: Microvascular free tissue transfer is extremely challenging in cases where the neck has had prior surgery and/or preoperative radiation. Dissection of tissues is technically difficult and lack of recipient vessels may limit the ability to perform free tissue transfer.

OBJECTIVES: To evaluate the availability of external carotid artery system and internal/external jugular vein system for microvascular anastomosis as well as alternate recipient vessels in patients with a history of prior neck dissection and/or preoperative radiation therapy. Furthermore, our goal is to evaluate the outcome of free tissue transfer in this patient population.

METHODS: A retrospective review of patients undergoing free tissue transfer reconstruction for oncologic defects of the head and neck between 2004 and 2007 at the University of Texas M. D. Anderson Cancer Center was performed.

RESULTS: 248 microvascular free flaps were performed in 214 consecutive patients for reconstruction after surgical resection of head and neck cancers. Of these, 9 (4%) patients had a history of prior surgery involving the neck, 88 (41%) had a history of preoperative radiation therapy involving the neck, and 25 (12%) had a history of both prior neck surgery and preoperative radiation therapy. The external carotid artery or one of its branches was not available on the side of the defect in 27 (11%) flaps/26 (12%) patients (5 patients with no history of prior neck surgery or radiation treatment, none with history of prior neck surgery, 9 with history of radiation therapy, 12 with history of radiation therapy and prior neck surgery). Strategies for lack of a recipient artery included: use of the transverse cervical artery (13 cases), use of the internal mammary artery (2 cases), arterial anastomosis to another free flap pedicle (7 cases), and vein grafting to the contralateral neck (5 cases). The internal/external jugular vein system was not available on the side of the defect in 32 (13%) flaps/29 (14%) patients (5 patients with no history of prior neck surgery or radiation treatment, none with history of prior neck surgery, 7 with history of radiation therapy, 17 with history of radiation therapy and prior neck surgery). Strategies for lack of a recipient vein included: vein grafting to the contralateral neck (10 cases), cephalic vein transposition (5 cases), venous anastomosis to another free flap pedicle (8 cases), the use of the transverse cervical vein (7 cases), and use of the internal mammary vein (2 cases). Reconstruction of anterior neck skin was required in 27 cases (3 patients with no history of prior neck surgery, no patient with history of prior neck surgery, 11 patients with a history of preoperative radiation therapy, and 13 with a history of prior neck surgery and preoperative radiation therapy). Complications at the operative site occurred in 39 patients (18%), including 14 (15%) in patients who did not have a history of either prior neck surgery or preoperative radiation therapy, none in those with a history of prior neck surgery only, 10 (11%) in those with a history of preoperative radiation therapy, and 11 patients (44%, p<0.05) in those with a history of both prior neck surgery and preoperative radiation therapy. There were 3 (1.2%) free flap losses, all of which occurred in patients with a history of both prior neck surgery and preoperative radiation therapy.

CONCLUSION: In the setting of previously operated and/or irradiated necks, the reconstructive surgeon should be familiar with a variety of techniques to locate recipient vessels adequate for microvascular anastomosis should the external carotid artery system and/or the internal/external jugular vein system not be available. Additional risk for complications must be factored into the surgical plan. The surgeon should be prepared to provide additional cutaneous coverage in select cases as closure of the neck can be difficult or prone to dehiscence in these cases.