KEY WORDS: Chest and upper arm reconstructions - second-line recipient vessels - transverse cervical
vessels
INTRODUCTION
For a successful microvascular reconstruction, selection of appropriate recipient
vessels in the near vicinity is one of the key decisions. In situations where the
local vascular access is not available on account of scarring of different aetiology
or non-availability of the vessels, remote vascular access would be required.[[1 ]
[2 ]
[3 ]]
Transverse cervical pedicle found at the base of the neck is one such option for head-and-neck
reconstructions. Since the location is the junction area for the thorax and the upper
arm, transverse cervical vessels can be considered for microvascular reconstruction
of these regions. We discuss our experience with transverse cervical vessels as a
second-line recipient pedicle for proximal chest and upper arm reconstructions in
addition to the head-and-neck reconstructions.
MATERIALS AND METHODS
During the years 2010–2017, 14 transverse cervical vessels were explored for microvascular
reconstructions involving head and neck, proximal chest and upper arm defects. Scarring
consequent to previous surgery, radiation, trauma or burns precluded the choice of
usual vessels.
Before the neck exploration, the course of the external jugular vein (EJV) was noted
and marked. A sandbag under the shoulder permitted exposure of the posterior triangle
of the neck. Exploratory incision was given along the lower third of lateral border
of sternocleidomastoid then extending laterally in the supraclavicular area, about
one inch above the upper border of the clavicle. Initially, the EJV was dissected
and preserved. The omohyoid muscle running across the posterior triangle was the marker
for the location of the transverse cervical vessels, which were explored in the underlying
fat planes, above the omohyoid [[Figure 1 ]]. Proximal dissection of the artery stopped 1 cm lateral to the phrenic nerve; both
the artery and venae commitantes were identified and checked for the adequacy of size
and flow before proceeding with the reconstruction.
Figure 1: Anatomical landmarks for transverse cervical vessels – STM: Sternomastoid, OH: Omohyoid,
TCa: Transverse cervical artery, EJV: External jugular vein
Pedicle was realigned for the chest and upper arm reconstructions according to the
site of the defect. It was pivoted down in a smooth arc, for not >90°. If the pedicle
needed >90° adjustment, donor pedicle is pivoted to maintain a smooth arc to avoid
kink at the anastomosis. Available length of the recipient pedicle after the distal
transection [[Figure 2 ]], vessel diameter and mismatch were noted.
Figure 2: Transverse cervical arteries, on an average 3.4 cm of artery could be dissected
About 12 reconstructions were performed. Risk of pedicle kink or redundancy, need
for re-exploration, flap salvage, complications and ultimate flap outcome were analysed.
RESULTS
A total of 14 transverse cervical vessels were explored as second-line recipient vessels.
Age group ranged from 14 to 67 years, eight patients were male and six patients were
female. Eight right side and six left side transverse cervical vessels were explored.
Details of the indications, reconstructions and type of the flap used have been tabulated
in [[Table 1 ]].
Table 1
Various defects, indications, vessels and flaps used
Region
Indication
Reconstruction/flap
Flap
Vessels
Reason
RT: Radiotherapy, TCA: Transverse cervical artery, TCv: Transverse cervical vein,
EJV: External jugular vein, RAFA: Radial artery forearm flap, ALT: Anterolateral thigh
flap, TFL: Tensor fascia lata flap, RND: Radical neck dissection, STA: Superior thyroid
artery
Thoracic
Failed colon transposition for post-corrosive stricture
Thoracic oesophageal reconstruction
Tubed ALT
TCA, EJV
Post-surgery
Ewing's sarcoma sternum and right anterior chest wall
Sternal reconstruction
Fibula osteocutaneous flap
TCA, TCv, EJV
Surgical sacrifice
Post-trauma defect of left axilla and lateral chest wall with multiple rib fractures
Cover for left axillary structures and lateral chest wall
TFL flap
TCA, TCv, EJV
Zone of trauma and injured vessels
Upper arm
Post-traumatic pan brachial plexus injury with infraclavicular scar
Free functioning muscle transfer for elbow flexion
Gracilis
TCA, EJV
Traumatic scar infraclavicular area
Post-resection and post-RT for Ewing's sarcoma right humerus
Head and proximal shaft humerus reconstruction
Fibula osteocutaneous flap
TCA, EJV
Post-RT
Head and neck
Post-RND and post-fibula reconstruction of maxilla with contour deformity right side
of the neck
Post-RND contour correction right side of neck
Partially deepithelialised ALT
TCA, TCv
Post-surgery previous flap
Post-fibula reconstruction for mandible with deficient lower lip hight
Lower lip reconstruction
RAFA flap with Palmaris longus
TCA, EJV
Previous free flap
Post-radionecrosis and osteomyelitis of right mastoid with trismus
Cover for exposed dura and transverse sinus
Rectus femoris flap
TCA, TCv
Post-RT
Fibrosarcoma neck right side
Cover for neck defect (right)
Free ALT flap
TCA, EJV
Surgical sacrifice
Post-RT left alveolar carcinoma
Mandibular reconstruction
Fibula osteocutaneous flap
TCA, EJV
Post-RT
Post-electrical burn reconstruction of left cheek with osteonecrosis of both alveoli
with infection and trismus
Full-thickness cheek reconstruction
Free TFL flap
TCA, EJV
PEB scarring n infection
Post-resection, post-RT Ewing's sarcoma left temple region with TMJ ankylosis and
contour deformity
Release of left TMJ ankylosis and vascularised fascia interposition arthroplasty
Free ALT flap
TCA, EJV
Post-RT
Failed fat grafting for right hemifacial atrophy
Contour correction
De epithelialised ALT flap
TCA - STA, TCv, Cephalic vein
Proximal neck involvement, EJV hypoplastic
Right hemifacial atrophy
Contour correction
De epitheliaised ALT flap
Facial A, TCV smaller in size
Proximal neck involvement
Indications included prior surgery and/or radiotherapy (RT) in five cases, post-traumatic
scarring in two, post-electrical burn scarring in one case, previous microvascular
reconstructions in two and sacrifice of vessel during the surgical clearance in two
cases.
In two cases of hemifacial atrophy involving the proximal neck, there was a concern
that the facial artery would be hypoplastic.
Different free flaps with variable donor vessel diameter were used for reconstructions,
four anterolateral thigh (ALT), three fibulas, two tensor fascia lata (TFL) flaps,
one radial forearm flap, one gracilis and one rectus femoris flap.
Transverse cervical vessels could be found in all the 14 explorations (100%). An average
of 3.4 cm usable length and a diameter of >2 mm was available for arterial anastomosis
(13/14 cases). In one case, vessels were smaller and could not be used.
There was not much of vessel mismatch with the donor vessels of ALT, TFL, rectus femoris
and gracilis. There was about 1.5 times mismatch with the donor vessels of fibula
and radial artery forearm flap which was acceptable for micro anastomosis.
About 12 successful reconstructions were performed using the transverse cervical artery,
involving the head and neck (7), proximal chest (3) and upper arm defects (2).
Transverse cervical artery was not used in two cases of hemifacial atrophy involving
the proximal neck, and the anastomosis was shifted to an alternative artery.
In one of these cases, repeated arterial thrombosis occurred on table, with the thrombus
extending proximally (probably clamp induced intimal damage). Superior thyroid artery
was used as an alternative artery [[Figure 4 ]]. In the other case, the transverse cervical vessels were smaller in size, and facial
artery and EJV were used thus 12 transverse cervical arteries (TCa) were used for
arterial anastomsis.
Figure 4: Anastomotic details in a case of hemifacial atrophy, Repeated arterial thrombosis
occurred in transverse cervical artery, STA: Superior thyroid artery, CV: Cephalic
vein and TCv: Transverse cervical vein were used
In all the explorations, accompanying veins were available. Of the 12 reconstructions
using TCa, EJV alone was used for venous drainage in eight cases (8/12); transverse
cervical veins alone were used in two cases and both accompanying vein and EJV were
used in other two cases.
In one case of hemifacial atrophy with hypoplastic EJV, one transverse cervical vein
and rerouted cephalic vein were used for venous drainage [[Figure 4 ]]. Thus, only five venae commitantes were used in 14 explorations.
About seven head-and-neck reconstructions were performed [[Table 1 ]] involving the lower third face and neck in four cases, middle and upper thirds
in other three cases. Flaps with long donor pedicles (RAFA, Fibula) were tunnelled
subcutaneously to reach the transverse cervical pedicle; the flaps with short pedicle
length and the flaps (TFL, Rectus femoris) intended to reach upper third face were
brought down to the recipient vessels by laying open the lateral neck to avoid traction
on the pedicle [[Figure 3 ]]. Excess skin flap that traversed along the neck was excised subsequently after
3 months and neck wound was closed primarily. Since the natural lie of the transverse
cervical vessels is vertical, there was no need for realignment of the pedicle and
the risk of acute kink and redundancy was minimal.
Figure 3: (a) Extra-articular left temporomandibular join ankylosis. (b) Contour deformity
left temple. (c) X-ray postresection and radiotherapy for Ewing's sarcoma left temple
region. (d) Condylectomy. (e) Free anterolateral thigh flap a - vascularised fascia,
b – post-condylectomy defect. (f) Follow-up before skin paddle correction
All the upper limb and chest reconstructions needed a realignment of the recipient
pedicle by carefully pivoting down the vessels for not >90°.
If the required angulation was more and adequate donor pedicle length was available
the donor pedicle was pivoted in a smooth arc.
All the transverse cervical vessels sustained the realignment of vessels very well
without any problem of acute kinking or redundancy.
Case details of the proximal chest and upper arm reconstructions
Two-stage thoracic oesophageal reconstruction was done in a case of corrosive stricture,
following a failed colon conduit. Cervical oesophageal fistula was situated on the
left side of the neck; hence, the right-sided transverse cervical vessels were chosen
as the choice of recipient pedicle. Free ALT flap of size 30 cm × 10 cm was tubed
on its cutaneous surface and tunnelled under the subcutaneous plane to the left side
of the neck; donor pedicle was tunnelled across the lower neck on to the right side.
TCa was pivoted down laterally about 60° and donor vessels about 30° upward with a
gentle curve for microanastomosis. Proximal oesophageal anastomosis was done on the
left side of the neck. Distal end of the tube was left as a cutaneous fistula at the
xiphisternum. Second-stage restoration of distal bowel continuity was performed after
3 months [[Figure 5 ]]
Sternal reconstruction was performed for a case of Ewing's sarcoma. Defect involved
total loss of sternum from the sternoclavicular joints on both the sides along with
the right anterior chest wall extending up to the 5th rib. During resection, the right internal mammary artery had been sacrificed. Free
osteocutaneous fibula was used in a ‘reverse 7’ shape (3 cm and 7 cm segments), stabilised
at both the sternoclavicular joints and across the right first and left 3rd ribs using titanium plates. Donor (peroneal) vessels were taken up into the neck
and then pivoted down about 60°; the left TCa pivoted 20° medially to make a smooth
arc for the anastomosis [[Figure 6 ]]
Post-traumatic defect of the axilla and lateral chest wall with loss of latissimus
dorsi, pectoralis major and multiple rib fractures extending from 2nd rib and axillary artery repair, was reconstructed using free TFL flap. The left TCa
was used after pivoting the artery about 45° downwards laterally
Proximal humerus reconstruction was performed for a case of Ewing's sarcoma involving
the head and proximal shaft, following resection and RT. Free osteocutaneous fibula
flap of 13 cm length was used to stabilise the functioning forearm. The right transverse
cervical artery was pivoted down about 40° laterally and used as the recipient vessel
[[Figure 7 ]]
One patient with pan brachial plexus injury underwent functioning muscle transfer
using gracilis to restore the elbow function on account of infraclavicular scar, using
the right TCa above the level of clavicle after pivoting the vessel down about 50°
laterally.
Figure 5: First-stage reconstruction of thoracic oesophagus for corrosive poisoning using tubed
anterolateral thigh. (a) Left-sided oesophageal fistula – EF, ST - subcutaneous tunnel,
(b and c) Tubing of anterolateral thigh, in its anatomical location, (d) Anastomosis
after pivoting down the vessels with a smooth arc, (e) Anterolateral thigh and oesophageal
anastomosis, (f) distal fistula
Figure 6: Sternal reconstruction using Fibula in ‘Reverse 7’ shape, (a) Computed tomography
scan showing the sterna involvement, (b) Free osteocutaneous fibula reconstruction,
oblique segment highlighted, (c) Recon plate across 4th Rib covered by bilateral pectoralis major -PM, (d) 6 months follow-up, (e and f)
three-dimensional computed tomography of the chest
Figure 7: Proximal humerus reconstruction using free fibula osteocutaneous flap. (a) Post-resection
and radiotherapy for Ewing's sarcoma involving head and proximal shaft humerus, (b)
X-ray showing the bone loss, (c and d) Intraoperative stabilisation of fibula with
the humerus, (e and f) follow-up pictures
In 12 of 14 cases where the transverse cervical artery was used, there were no re-explorations.
There were only two partial flap necroses; due to tight suturing in one case, needed
excision and split skin grafting. In the other case, the distal, most part of the
fibula skin paddle, was necrosed; excision and primary closure were done before discharging
the patient.
DISCUSSION
Selection of the recipient pedicle for a microvascular reconstruction is mainly based
on the location of the defect and the proximity of recipient vessels. Factors such
as quality of the vessels, the zone of injury, matching diameters of donor and recipient
vessels, ease and safety of dissection and distance from the defect intended to be
repaired (to avoid vein grafting)[[4 ]] will also influence the selection the vessels.
Atherosclerosis and local factors such as prior radiation[[1 ]
[5 ]
[6 ]
[7 ]
[8 ]] and prior operative procedures influence the quality of the vessels and subsequent
outcome of the procedure;[[3 ]
[9 ]
[10 ]
[11 ]] the length of the vascular pedicle[[12 ]
[13 ]
[14 ]
[15 ]] is also an important consideration.
Even when multiple recipient vessels are available for a given defect, usually one
vessel will offer the most straightforward and safe option. However, in circumstances
where the usual local vessels are not available, remote vascular access would be required.[[1 ]
[2 ]
[3 ]]
Options for primary recipient vessels varies region wise. Fortunately, multiple primary
recipient vessels are available in head-and-neck region including (from cephalic to
caudal) superficial temporal vessels, facial, lingual, superior thyroid and the transverse
cervical.[[16 ]] The 1st four vessels are used much of the time depending on the location of the defect.[[4 ]
[16 ]
[17 ]]
If these primary vessels are not available for a safe anastomosis, alternative options
include end-to-side anastomosis to the external carotid artery (ECA) or use of vessels
from the contralateral neck directly or by using vein grafts. Even arteries outside
of the neck such as internal mammary vessels and reverse flow thoraco dorsal scapular
artery.[[2 ]
[4 ]
[13 ]
[16 ]] also have been described. This makes the reconstruction complex and increases the
risks incurred by using vein grafts.[[4 ]
[7 ]
[8 ]
[14 ]
[18 ]
[19 ]]
Transverse cervical vessels in the posterior triangle of the neck have been described
as second-line recipient vessels for head-and-neck reconstructions as they are spared
during previous neck dissections and less likely to be affected by standard irradiation
protocols.[[20 ]] These vessels are reliable and robust and can reduce the need for vein grafts.
It has a comparable diameter and blood flow, as the other branches of the ECA[[21 ]] and less affected by atherosclerosis than the carotid system.[[17 ]]
Due to its location, these vessels can also be used to advantage for the upper arm
and the proximal thoracic reconstructions if the native first choice vessels are not
available.
The concern with the transverse cervical vessels seems to be the size of the vessels,
venae commitantes and positioning the pedicle especially for proximal chest and upper
arm reconstructions. These concerns can be attended as follows.
For reconstructions at the lateral chest or the upper limb, the orientation of the
vessels is more or less in line with the area of reconstruction; hence, minor realignment
of the of pedicle is sufficient (30–45°);
Reconstruction of the medial chest needs more angulations of the pedicle, up to 90°
or more. Pedicle can be pivoted up to 90° where the donor pedicle length is limited.
If >90° angulation is needed, donor pedicle was arced up to prevent any kink at the
site of the anastomiosis.
All these reconstructions sustained the realignment well without any risk of kink.
Well-supported anastomoses over the underlying muscular bed (unlike the facial vessels
in submandibular region), and the excellent blood flow thrusting on the vessel wall
probably would have helped in maintaining the smooth arc avoiding the risk of kink.
Post-operatively, immobilisation with the neck in extension and chin turned to the
opposite side may prevent compression of the venous anastomosis.
Prior dissection of the EJV ensures safe drainage even in case of variable venous
anatomy of TCvTransverse cervical vein.
Although the origin of the TCa may vary (77% from the thyrocervical trunk; 21% directly
from the subclavian artery or from the internal mammary artery 2%[[22 ]]), the TCa was seen in all 14 cases. Out of 13, 12 times the transverse cervical
artery used for the anastomosis was deemed a success at the end of the surgery; in
one case, the anastomosis had to be redone to the superior thyroid artery on table,
and one TCa could not be used at all.
The transverse cervical vein might have a variable course, running deep (75%), or
superficial (25%) to the omohyoid. It could drain into the EJV or the subclavian vein.[[23 ]] Five venae commitantes were used in this series. In only 2 of 12 cases, we relied
on the venae commitantes alone. The EJV was always present. However, in one case of
hemifacial hypoplasia, EJV was hypoplastic and rerouted cephalic vein was used.
Although the dissection of the transverse cervical artery is fairly straightforward,
it is not devoid of risk. The phrenic nerve lies in the region of the transverse cervical
artery branching from the thyrocervical trunk; on the left, the thoracic duct courses
anterior to the transverse cervical artery near its branching point from the thyrocervical
trunk.[[21 ]] Neither of these structures (Phrenic nerve or Thoracic duct) suffered any injury
in the present series.
Favourable factors to choose the TCV as second-line recipient vessels
Constant location of the vessels in an untouched and unirradiated area
Easily accessible, dissectible in the superficial fat planes, in a short time of about
20–30 min
Arterial diameter is >2 mm for a safe anastomosis without much mismatch
Usable length of 2–4 cm allows for an adequate realignment of the pedicle if needed,
for a comfortable anastomosis
Favourable orientation of vessels over an even bed of scalene muscles for head-and-neck
reconstructions. Reliable realignment of the pedicle for the upper limb and trunk
reconstructions Further, donor pedicle can be tunnelled subcutaneously without opening
up the neck skin for flaps with adequate pedicle lenth[[24 ]]
Advantageous location in the lower neck away from the mandible and clavicle allows
easy positioning of the microscope thus a comfortable anastomosis
In the absence of appropriate sized veins, EJV is the best alternate choice available
in the vicinity for venous drainage.
All these factors with few simple careful measures helped us in locating the anastomosis
at a favourable depth away from the potentially diseased or injured recipient sites
and avoiding a compromised anastomosis or a difficult end-to-side anastomosis to axial
vessels in a deeper plane thus aiding a favourable outcome of these unusual reconstructions
in difficult situations.
Thus, we consider the transverse cervical vessels as a safe second-line choice for
the extended use in the upper arm and trunk reconstructions in addition to head-and-neck
reconstructions.
CONCLUSIONS
Transverse cervical vascular pedicle is a safe option as a second-line recipient vessel
in difficult head-and-neck reconstructions; in addition, they are useful as the recipient
vessel in thoracic and proximal upper limb reconstructions. Preserving the EJV during
dissection ensures safe venous drainage, even when the accompanying vein is of small
calibre. Care needs to be exercised regarding choosing the transverse cervical vessels
in the presence of severe hemifacial atrophy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form, the patient has given her consent for her images and other clinical information
to be reported in the journal. The patient understand that names and initials will
not be published and due efforts will be made to conceal identity, but anonymity cannot
be guaranteed.
Financial support and sponsorship
Nil.
