Neck Dissection

Vessel thrombosis rates for head and neck free flaps are lower than for any other anatomic site due to in part to the abundance of accessible recipient vessels.2 However, potential recipient vessels, such as the external and internal jugular veins and their tributaries, may be sacrificed in an extensive neck dissection or may be damaged due to radiation or inflammatory changes. In these cases, local veins of small caliber can be used, but the risk of thrombosis is increased. We prefer to use the undamaged contralateral veins if ipsilateral veins are not available, by using an interpositional vein graft. A cephalic vein can be readily harvested either by itself or in conjunction with the pedicle if a radial forearm flap is being used. A theoretical disadvantage of an interpositional vein graft is the increased risk of thrombosis due to two anastomoses, but we have not found this to be a significant problem. Alternatively, a cephalic vein transposition whereby the vein is harvested as distally as possible and transposed to the head and neck with its proximal origin at the subclavian vessels left intact has been described.44 Although we have not had experience with this technique, there are several reported advantages to this technique: (1) only one anastomosis is needed, (2) the cephalic-subclavian system is a relatively high flow system, (3) the vein is usually outside the surgical and radiation fields, and (4) the pedicle is long enough to reach the midface or contralateral neck without tension.44

Even in cases of modified radical neck dissections (MRND), in which the internal jugular system is spared, the incidence of thrombosis of the internal jugular vein has been reported to range between 15% and 33%.45 The presence of salivary fistula, abscess, or wound dehiscence in the vicinity of the internal jugular can increase the rate of thrombosis of the internal jugular vein to 29.6%.46 Although oncologic considerations are paramount in our therapeutic and prophylactic neck dissection, we advocate surgical techniques that will optimize the patency of the internal jugular system, which include: (1) ligation of side branches far enough from the vein to prevent constriction, (2) avoiding the use of an electrocautery, (3) avoiding desiccation of the vein once it has been dissected, and (4) atraumatic manipulation of the vein.42

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