Purpose: To describe the use of the cephalic vein as a recipient vessel for venous outflow in head and neck reconstruction. The cephalic vein is used as a vessel in cases where there is a paucity of veins in the neck. This may be due to previous surgery, previous radiation therapy, or advanced cancer. The cephalic vein may also be used to salvage a failing free flap. Methods: It is a retrospective review of 230 free flaps that had been used in head and neck reconstruction performed from July 2014 to July 2018 by a single surgeon. Results: There were 6 patients in whom the cephalic vein was used as a recipient vessel. The cephalic vein was used in 2 cases where a tumor was involved with the internal jugular vein, in 1 case where a previous neck dissection had been done, in 1 case where internal jugular vein had iatrogenic damage, and in 2 cases a salvage procedure was done. In all cases, the cephalic vein was rotated above the clavicle. The cephalic vein easily reached the free flap vein and had a good caliber. There were no failures in any of the patients. Conclusion: The cephalic vein is a good option for venous anastomoses in patients in whom there is a paucity of recipient vessels in the neck

Ahsan, Muhammad Asif

Khan, Muhammad Ubaid

Rahman, Mohammad Fazlur

Shaikh, Safdar Ali

Ullah, Sami

English

eCommons@AKU

eCommons@AKU Department of Surgery Department of Surgery 7-6-2020 Use of cephalic vein for venous anastomosis in head and neck reconstruction: A case series Mohammad Fazlur Rahman Aga Khan University, fazli.rahman@aku.edu Muhammad Asif Ahsan Cancer Foundation Hospital, Karachi, Pakistan Safdar Ali Shaikh Aga Khan University, safdar.shaikh@aku.edu Muhammad Ubaid Khan Aga Khan University Sami Ullah Shaukat Khanum Memorial Cancer Hospital and Research Centre, Peshawar, Pakistan Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg  Part of the Plastic Surgery Commons Recommended Citation Rahman, M. F., Ahsan, M. A., Shaikh, S. A., Khan, M. U., Ullah, S. (2020). Use of cephalic vein for venous anastomosis in head and neck reconstruction: A case series. Eplasty, 20, e9. Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/853 Use of Cephalic Vein for Venous Anastomosis inHead and Neck Reconstruction: A Case SeriesMohammad Fazlur Rahman, MBBS, FCPS,a Muhammad Asif Ahsan, MBBS,MRCPS, FCPS,b Safdar Ali Shaikh, MBBS, FCPS,a Muhammad Ubaid Khan, MBBS,FCPS,a and Sami ullah, MBBS, FCPScaDepartment of Plastic Surgery, Aga Khan University Hospital, Karachi, Pakistan; bDepartment ofPlastic Surgery, Cancer Foundation Hospital, Karachi, Pakistan; and cShaukat Khanum MemorialCancer Hospital and Research Centre, Peshawar, Khyber Pakhtunkhwa, PakistanCorrespondence: Fazli.rahman@aku.eduKeywords: head and neck, free flaps, cephalic vein, recipient, venous anastomosisPublished July 6, 2020Purpose: To describe the use of the cephalic vein as a recipient vessel for venous outflowin head and neck reconstruction. The cephalic vein is used as a vessel in cases wherethere is a paucity of veins in the neck. This may be due to previous surgery, previousradiation therapy, or advanced cancer. The cephalic vein may also be used to salvage afailing free flap. Methods: It is a retrospective review of 230 free flaps that had beenused in head and neck reconstruction performed from July 2014 to July 2018 by asingle surgeon. Results: There were 6 patients in whom the cephalic vein was used asa recipient vessel. The cephalic vein was used in 2 cases where a tumor was involvedwith the internal jugular vein, in 1 case where a previous neck dissection had been done,in 1 case where internal jugular vein had iatrogenic damage, and in 2 cases a salvageprocedure was done. In all cases, the cephalic vein was rotated above the clavicle. Thecephalic vein easily reached the free flap vein and had a good caliber. There were nofailures in any of the patients. Conclusion: The cephalic vein is a good option for venousanastomoses in patients in whom there is a paucity of recipient vessels in the neck.Microvascular free flaps have become increasingly essential for patients requiringhead and neck reconstruction, with success rates greater than 95%.1 As success rates haveincreased, surgeons have started operating on more complex cases. Complexities includeprevious surgeries, previous radiotherapy, more advanced cancer, or a combination ofthese modalities.2 Radiotherapy leads to intimal fibrosis and arteriosclerosis of the vessels.Previous surgery and extensive disease may lead to compromised vessel. Reconstructingfree flaps in such cases is always a challenge as there is vessel depletion/unsuitability,particularly of veins. Commonly used veins that include ipsilateral external jugular vein58RAHMAN ET AL(EJV) and internal jugular vein (IJV) are usually unavailable, thrombosed, or unsuitable foranastomosis.3 In such cases, the surgeon is forced to look for other options. These includecontralateral neck veins, use of a vein graft, or an alternate recipient vein.4Figure 1. Ligated internal jugular vein.Figure 2. Harvesting of the anterolateral thigh flap.A good option for alternate recipient vein is the cephalic vein. Use of the cephalic veinin microsurgery was first described by Hallock.5 Horng and Chen6 called it the lifeboat forhead and neck reconstruction. The first series was published by Kim and Chandrasekhar.7Here, we report our experience with using the cephalic vein as a recipient vein in cases ofhead and neck cancer reconstruction.ANATOMY AND SURGICAL TECHNIQUEThe cephalic vein is present in the forearm fascia and ascends along the radial border ofthe radius from the forearm.8 In the arm, it ascends along the lateral bicipital groove on59ePlasty VOLUME 20the lateral side of biceps muscle. It then enters the deltopectoral groove to lie between thepectoralis major and deltoid muscle.9 In the upper part, the thracoacromial artery and itsbranches lie in close proximity to the cephalic vein. It pierces the costocoracoid fascia anddrains into the axillary vein. The place where the cephalic vein enters the costocoracoidfascia is the pivot point of the flap.10Figure 3. Cephalic vein harvested.An open technique is used to harvest the cephalic vein. This is done to prevent anypostoperative compression on the vessel. The groove between the pectoralis major and thedeltoid muscle is palpated below the acromion. Incision is made over the deltopectoralgroove. Once deep fascia is opened, the vein can be visualized between the pectoralis majorand deltoid muscle. Branches of the thoracoacromial artery may be present here and needto be saved. Retrograde dissection is then done, and the vein is followed into the upper armand mobilized. Measurements are made from the free flap vessel to the point of rotation ofthe vein. The vein is dissected distally for 2 to 3 cm more than the required length from thepoint of rotation. Once enough length of the vein is obtained, the proximal end of the veinin the arm near the elbow is ligated. The vein is rotated upward in the semicircular fashionabove the clavicle. This is done to prevent kinking of the vein.60RAHMAN ET ALFigure 4. Postoperative day 4.MATERIALS AND METHODSData were collected retrospectively from the medical record of the patients. Patients’confidentiality was maintained by not including the name and address of the patients inthe performa, and the patients were addressed by their serial numbers. There were a totalof 230 free flaps done from July 2014 to July 2018 by a single surgeon. Of these, therewere 6 cases that required use of the cephalic vein (Table 1). All the patients requiring thecephalic vein were male. Their age range was from 30 to 56 years (mean = 46 years). Allpatients had squamous cell carcinoma. Four patients required soft-tissue reconstructionsand 2 required bony reconstruction with soft tissue. Of the soft-tissue reconstructions, 3patients had reconstruction with anterolateral thigh flap and 1 patient had reconstructionwith lateral arm free flap. Both bony reconstructions were done by free fibular flap. Arterialanastomosis was done with lingual artery in 4 cases and with superior thyroid artery in 2cases. The cephalic vein was used for anastomoses primarily in 3 cases as the sole vessel,as there were no other vessels suitable. In one case, it was used for a second anastomosis inthe primary surgery to enhance venous outflow as the flap was large. In 2 cases, the cephalicvein was used to salvage flaps after venous congestion. In the first case, initial anastomosiswas end to side into the IJV. Thrombosis occurred 2 hours after surgery, and revision wasdone using the cephalic vein. In the second case, 2 anastomoses were done, one to theEJV and second to the IJV. After 18 hours, venous congestion occurred. Anastomosis was61ePlasty VOLUME 20revised to the EJV and as an adjunct the second vein was anastomosed to the cephalic veinto ensure survival of the flap.Figure 5. Cephalic vein.Figure 6. Cephalic vein rotated for anastomoses.62RAHMAN ET ALTable 1. Demographics and vascular anastomosis∗Sex Age Defect area Flap ArterialanastomosisVenousanastomosisReason forchoosing thecephalic vein1 Male 38 Cheek, lips, andneckALTF 29 × 10 cm,2 perforatorsLingual artery Cephalic vein IJV ligated abovethe clavicle becauseof tumorinvolvement2 Male 50 Mandible defect Fibula with lining 6× 4 cmSuperior thyroidarteryTwo veins done,one to the EJV andsecond to the IJV.Anastomosisrevision, one veinto the EJV andsecond to thecephalic veinAfter 18 h, the flapbecame congested.The patient wastaken back to theOR; vein to the IJVthrombosed and tothe EJV partiallythrombosed3 Male 30 Cheek lining andcoverALTF 14 × 7 cm Lingual artery Cephalic vein The IJV haddecreased flow dueto tumorinvolvement4 Male 55 Palate and innerliningALTF 15 × 6 cm Lingual artery Cephalic vein Previous neckdissection 10 yback. No suitableveins in the neck5 Male 48 Mandible defectwith both internallining and externalcover requiredFibula lining andcover 20 × 10 cmflapSuperior thyroidarteryTwo venousanastomoses: thefirst vein to the EJVand the second veinto the cephalic veinIatrogenic injury tothe IJV. Two venousanastomoses doneas the flap was large6 Male 56 Palate, maxilla, andliningLateral arm 15 × 6cmLingual artery Vein done to theIJV. Venouscongestion after 2h, anastomosesrevised with thecephalic veinIatrogenic injury tothe IJV∗ALTF indicates anterolateral thigh flap; IJV, internal jugular vein; EJV, external jugular vein; OR, operating roomCASE 1A 38-year-old man underwent excision of squamous cell carcinoma of the cheek and neckand reconstruction with a free right anterolateral thigh flap. The tumor was large and the IJVwas ligated at the base of neck (Fig. 1). A large 29 × 10 cm anterolateral flap was harvested(Fig 2). The artery was anastomosed to the lingual artery. For venous anastomosis, thecephalic vein was harvested and anastomosis done to the flap vein (Fig 3). The patient didwell postoperatively (Fig 4).CASE 2A 50-year-old man underwent resection of squamous cell carcinoma of the mandible. Afree fibular flap was done with arterial anastomosis to the lingual artery and 2 venousanastomoses (one end to end to the EJV and second end to side to the IJV). After 18hours, the flap started getting congested. On reexplanation, the vein anastomosed to theIJV was thrombosed while the vein anastomosed to the EJV was partially thrombosed.Venous anastomosis to the EJV was revised. To ensure flap survival, it was decided that asecond anastomosis should be done. The cephalic vein was then harvested and end-to-endanastomosis was done between the cephalic vein and the second vein (Figs 5 and 6). Theflap survived and recovery was uneventful.63ePlasty VOLUME 20DISCUSSIONThe IJV, its branches, and the EJV are the most commonly used recipient vessels inhead and neck free flaps. These veins have good caliber and are reliable.11 In patientswith advanced diseases, recurrences, or needing salvage procedure, these vessels may becompromised and an alternate vessel may be required for venous outflow. The cephalic veinis a good alternative for such cases. The cephalic vein has many advantages, which havebeen previously published.7,10,12 The vessel has a long pedicle that can easily reach theneck. It is easily dissectible and has a large diameter suitable for microvascular anastomosis.It also requires only one anastomosis. It is also present outside the zone of previous surgeryand radiation therapy. All these make the cephalic vein suitable for anastomosis. Differenttechniques have been used to harvest the cephalic vein including the modified “stepwise”technique.13 We prefer the open technique, as the vessel is easy to handle and any chanceof injury to the vein while harvesting it is minimum. To prevent vessel kinking, we turnthe vessel in a semicircular fashion. Compression of the vein over the clavicle has beennoted.12 To prevent compression postoperatively, a small groove is made on the clavicleto place the vessel and skin closed in a single layer. Hanasono et al14 reported loss of theEJV and IJV in 16% of patients after radiation therapy or surgery. Herle et al15 reporteda higher risk of free flap failure after radiation therapy. In our study, there was no case inwhich the cephalic vein was used in free flaps after radiation therapy. The reason being insuch cases, we always prefer the contralateral side of the neck. We did use the cephalic veinin one case where neck dissection had been done previously, but patient had not undergoneradiotherapy. We used the cephalic vein for anastomosis in 2 cases where the tumor wasextensive. In one of the cases, the tumor was abutting the vessel and the venous flow wasdecreased. In the other case, the IJV was clamped at the base of the neck just above theclavicle. Using a vein graft here would have required 2 anastomoses, so we preferred touse the cephalic vein. In 2 cases, the cephalic vein was used as a salvage procedure aftervenous congestion. In one of the cases, only the cephalic vein was used for venous outflowbut in the second case the cephalic vein was used as a second vein to ensure flap survival.Drawbacks of using the cephalic vein include additional surgical incision,16 additional scar,and thin wall of the cephalic vein. Reid and Taylor17 found the absence of the vein in 2 of50 cases, and Jacobson et al12 reported small size of the vein in one of 10 cases.CONCLUSIONThe cephalic vein is a viable option as a recipient vein in free flaps being used in vessel-depleted necks during head and neck reconstruction. It should certainly be considered anoption as opposed to the contralateral IJV in cases where there is a high likelihood ofrecurrence of the carcinoma, so as not to complicate future prognosis and treatment.REFERENCES1. Corbitt C, Skoracki RJ, Yu P, Hanasono MM. Free flap failure in head and neck reconstruction. Head Neck.2014;36:1440-5.2. Bras J, de Jonge HK, van Merkesteyn JP. Osteoradionecrosis of the mandible: pathogenesis. Am J Oto-laryngol. 1990;11:244-50.64RAHMAN ET AL3. Ross GL, Ang ES, Golger A, et al. Which venous system to choose for anastomosis in head and neckreconstructions? Ann Plast Surg. 2008;61:396-8.4. Wong KK, Higgins KM, Enepekides DJ. Microvascular reconstruction in the vessel-depleted neck. CurrOpin Otolaryngol Head Neck Surg. 2010;18:223-6.5. Hallock GG. Venous outflow simplified by the cephalic vein loop. Ann Plast Surg. 1988;21:427-9.6. Horng SY, Chen MT. Reversed cephalic vein: a lifeboat in head and neck free-flap reconstruction. PlastReconstr Surg. 1993;92:752-3.7. Kim KA, Chandrasekhar BS. Cephalic vein in salvage microsurgical reconstruction in the head and neck.Br J Plast Surg. 1998;51:2-7.8. Hallock GG. The cephalic vein in microsurgery. Microsurgery. 1993;14:482-6.9. Thoma A, Archibald S, Jackson S, Young JE. Surgical patterns of venous drainage of the free forearm flapin head and neck reconstruction. Plast Reconstr Surg. 1994;93:54-9.10. Vasilaks V, Patel HDL, Chen HC. Head and neck reconstruction using cephalic vein transposition in thevessel-depleted neck. Microsurgery. 2009;29:598-602.11. Ad-El DD, Sichel JE. Reversed-flow external jugular vein: an optional recipient vessel in microsurgicalhead and neck reconstruction. Plast Reconstr Surg. 2004;113:1873-5.12. Jacobson AS, Eloy JA, Park E, Roman B, Genden EM. Vessel depleted neck: techniques for achievingmicrovascular reconstruction. Head Neck. 2008;30:201-7.13. Agostini T, Agostini V. Cephalic vein transposition in head and neck microsurgery: advantages of amodified step-wise (closed) technique. J Plast Reconstr Aesthet Surg. 2009;62:625.14. Hanasono MM, Barnea Y, Skoracki RJ. Microvascular surgery in the previously operated and irradiatedneck. Microsurgery. 2009;29:1-7.15. Herle P, Shukla L, Morrison WA, Shayan E. Preoperative radiation and free flap outcomes for head andneck reconstruction: a systematic review and meta-analysis. ANZ J Surg. 2015;85:121-7.16. Kadota H, Fukushima J, Yoshida S, et al. Microsurgical free flap transfer in previously irradiated andoperated necks: Feasibility and safety. Auris Nasus Larynx. 2012;39(5):496-501.17. Reid CD, Taylor GI. The vascular territory of the acromiothoracic axis. Br J Plast Surg. 1984;37:194-212.65

Use of cephalic vein for venous anastomosis in head and neck reconstruction: A case series

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Use of cephalic vein for venous anastomosis in head and neck reconstruction: A case series

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