title: The role of the internal mammary vessels as recipient vessels in secondary and tertiary head and neck reconstruction.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Plastic and Reconstructive Surgery, University Hospital, De Pintelaan 185, 9000 Gent, Belgium. nathalie.roche@ugent.be
authors.forename: N A
authors.initials: NA
authors.lastname: Roche
authors.forename: P
authors.initials: P
authors.lastname: Houtmeyers
authors.forename: H F
authors.initials: HF
authors.lastname: Vermeersch
authors.forename: F B
authors.initials: FB
authors.lastname: Stillaert
authors.forename: Ph N
authors.initials: PN
authors.lastname: Blondeel
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D005260:Female; D005542:Forearm / Q000601:surgery; D058752:Free Tissue Flaps / Q000098:blood supply*; D006258:Head and Neck Neoplasms / Q000532:radiotherapy / Q000601:surgery*; D006801:Humans; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D009333:Neck / Q000098:blood supply; D037981:Neck Dissection; D019651:Plastic Surgery Procedures / Q000379:methods*; D017568:Rectus Abdominis / Q000637:transplantation; D012086:Reoperation; D013848:Thigh / Q000601:surgery; D016896:Treatment Outcome