Original Article

Yonago Acta medica 2016;59:159–162

Recipient Vessel Selection in Head and Neck Reconstruction Based on the Typeof Neck Dissection
Shunjiro Yagi,* Yoshiko Suyama,* Kohei Fukuoka,* Hiromi Takeuchi† and Hiroya Kitano†*Departments of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan and †Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine,
Yonago 683-8503, JapanFree flap transfer is an essential technique in head andneck reconstruction, and the success of free flap transfers depends on the quality of the vascular microanastomoses. Selective neck dissection is often performed
to preserve function and minimize cosmetic deformity
in cases of limited local invasion. Recipient vessel selection in head and neck reconstruction has been thesubject of numerous reports.1–3 However, the recipient
vessel selection based on the type of neck dissection has
yet to be investigated. Tumor resection and flap harvest
are often performed simultaneously, and flap design andpedicle length usually are determined once the shape ofthe defect and recipient vessel availability is known. We
suppose that recipient vessel selection should be part ofpreoperative planning in head and neck reconstruction.
Here, we describe the relationship between the type ofneck dissection and selection of recipient vessel.

ABSTRACT

Recipient vessel selection in head andneck reconstruction using free flap transfers has to bestandardized. However, the recipient vessel selection
based on the type of neck dissection has yet to be investigated. We describe the relationship between the typeof neck dissection and recipient vessel.
Methods Records of 107 consecutive patients who
had undergone head and neck reconstruction using freeflap transfers from 2011 to 2015 were reviewed retrospectively. Ninety-five were men and 12 were women,with a mean age of 65.6 years. Patients were divided
into 5 groups based on the type of neck dissection: noneck dissection (NND, n = 17), upper jugular neck dissection, (UJND, n = 1), supraomohyoid neck dissection(SOND, n = 18), jugular neck dissection (JND, n = 39),and modified radical neck dissection (mRND, n = 32).
We details the number of recipient vessels we selected
for free tissue transfer in head and neck reconstruction
depending on the type of neck dissection.
Results The overall patency rate was 100%. The superficial temporal artery was used most frequently inNND; the superior thyroid artery in SOND; the transverse cervical artery in JND; and the transverse cervical artery in mRND. The superficial temporal vein wasused most frequently in NND; The internal jugular veinin the SOND; and The external jugular vein in mRND.
Conclusion Microsurgeons should remember thatproper recipient vessel selection depending on the typeof neck dissection is important. We believe proper recipient vessel selection should improve results of head andneck reconstruction using free flap transfer.
Background

MATERIALS AND METHODS
Between January 2011 and December 2015, we performed 107 head and neck reconstructions with freeflap transfers. There were 95 men and 12 women with amean age 65.6 years. Thirteen patients (12.1%) had undergone prior neck preoperative radiation therapy withaverage dose of 40.6 Gy, and 59 patients (55.1%) had received preoperative chemotherapy. Tables 1 and 2 present the numbering system used to identify the structures
resected and the type of free flap used for reconstruction.
The range and type of neck dissection were classified into four groups based on Memorial Sloan-Kettering Cancer Center’s (MSKCC) classification system(Fig. 1).4 No neck dissection (NND, n = 17) lymphadenectomy, upper jugular neck dissection (UJND, n =1) including level I lymphadenectomy, supraomohyoidneck dissection (SOND, n = 18) including level I to III
lymphadenectomy, jugular neck dissection (JND, n =39) including level II to IV lymphadenectomy. Modified
radical neck dissection (mRND, n = 32) including level Ito V lymphadenectomy. The external jugular veins wereprepared as a recipient vein whenever possible in allgroups. The number of the type of neck dissection weresummarized for the side where microanastomosis were

Key words free flap; head and neck reconstruction;
microsurgery; neck dissection; recipient vessel

Corresponding author: Shunjiro Yagi, MD, PhD
yagishun@med.tottori-u.ac.jp
Received 2016 March 25
Accepted 2016 April 22
Abbreviations: JND, jugular neck dissection; mRND, modified
radical neck dissection; NND, no neck dissection; SOND, supraomohyoid neck dissection; UJND, upper jugular neck dissection

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performed, and we counted the number of recipient vessels we selected for free tissue transfer in head and neckreconstruction depending on the type of neck dissection.

superficial temporal vein was used most frequently in
NND (10 patients, 55.6%); The internal jugular vein
was the most common recipient vein in the SOND (16patients, 57.1%). and The external jugular vein was themost common recipient vein in mRND (29 patients,69%) while the external jugular vein (18 necks, 45%)and the internal jugular vein (19 patients, 47.5%) have
similar frequency in the JND, (Table 4).

RESULTSThe overall patency rate was 100%. The number of arterial anastomoses by dissection group was as follows:
NND, 17 patients; UJND, 1 patient; SOND, 18 patients;
JND, 39 patients; and mRND, 32 patients. The superficial temporal artery was used most frequently in NND(10 patients, 58.8%); the superior thyroid artery wasused most frequently in SOND (13 patients, 72.2%); thetransverse cervical artery was most common in JND 33patients, 84.6%); and the transverse cervical artery wasmost common in mRND (27 patients, 84.4%) (Table 3).
The number of venous anastomosis was 130 because
2 different recipient veins were used in 23 patients. TheDISCUSSIONFree flap transfer has become indispensable in head andneck reconstruction, with a success rate of over 95 %.2,
5–8
Selection of a suitable recipient vessel is essential for
success, yet the complex vascular anatomy of the headand neck can complicate vessel selection.3 Historically,
the choice of recipient vessel has depended on the personal experience of the surgeon more than on objective

Table1. Regeons requiring reconstruction following
head and neck surgery
Site of reconstruction

Table 2. Flaps used for head and neck reconstruction
Flap

NumberTongue, oral cavity

27

Mesopharynx

15

Hypopharynx

42

Upper 1/3 of the head

7

Middle 1/3 of the head

7Lower 1/3 of the head

9

Total

107

IIV

NumberJejunal flap

44

Rectus abdominis muscurocutaneous flap

29

Anterolateral thigh flap

14

Latissimus dorsi muscurocutaneous flap

8

Forearm flap

6

Fubular flap

4

Omental flap

2

Total

107

IIIIIVUJND : I
SOND: I + II + IIIJND: II + III + IV
mRND: I + II + III + IV + V
160

Fig. 1. A diagram showing levels of cervicallymph nodes. I: submental and submandibular;
II: upper jugular; III: middle jugular; IV: lower jugular; V: posterior triangle. JND, jugularneck dissection; mRND, modified radical neckdissection; NND, no neck dissection; SOND,supraomohyoid neck dissection; UJND, upper
jugular neck dissection.

Recipient vessel selection

data.
Conventional radical neck dissection is very invasivesurgery. In RND, cervical tissue, including accessory
nerve, the internal jugular vein and the sternocleidomastoid muscle are removed. This radical procedure resultsin numerous postoperative complications.9 MRND wasdeveloped to minimize morbidity and mortality.10–12
We arbitrarily divided our cases into four groups basedroughly on MSKCC’s classification system4 because
Japan has no official name or classification system forneck dissection.
Nahabedian et al.3 have discussed the relationshipbetween recipient vessels and the donor site. The superficial temporal artery and vein are used in the upper thirdof the head, the facial and superior thyroid artery andvein for the lower third of the face, and the carotid arteryand jugular vein, along with their various branches, inthe neck. We usually used the facial or superficial temporal vessels in NND because the facial and superficial
temporal artery can be palpated through the skin easily,
and these veins run concomitantly. However, the facialvein sometimes is excessively ramified and remains too

small even for a microanasotmosis. In such cases, theincision is extended inferiorly and the external jugularvein is used. The external jugular vein is easily traced
by compressing the lower neck. In SOND, only arteries
within the submandibular triangle and the carotid triangle are exposed, and the facial artery and the lingularartery are sometimes ligated, so the superior thyroid artery is the first choice for the recipient artery.
In mRND, the transverse cervical artery is the firstchoice. The transverse cervical artery always passes
behind the omohyoid and anterior scalene muscle and islong enough to reach the flap pedicle in head and neckreconstruction.13 However the path of the transverse cervical vein is more variable,13, 14 so the external jugularvein is a better choice. In JND, the superior thyroid andtransverse cervical artery are useful because they areprepared easily after neck dissection. The external jugular vein is the first choice for recipient vein; however,
the internal jugular vein is exposed for its full cervicallength, so the internal jugular vein is a viable alternative.
Selecting the external jugular vein for the recipient vein offers several advantages. First, the head andTable 3. Recipient artery as a type of neck dissection group
NND
Superficial temporal artery

UJND

SONDmRND

10 (58.8%)

Lingual artery

1 (5.6%)

Superior thyroid artery

1 (5.9%)

Facial artery

6 (35.3%)

13 (72.2%)
1 (100%)4 (22.2%)

Transverse cervical artery
TotalJND

171184 (10.3%)

3 (9.4%)2 (5.1%)2 (6.3%)33 (84.6%)

27 (84.4%)3932(n = 107)
JND, jugular neck dissection; mRND, modified radical neck dissection; NND, no neck dissection; SOND, supraomohyoid neck dissection; UJND, upper jugular neck dissection.

Table 4. Recipient vein as a type of neck dissection group
NND
Superficial temporal vein

10 (55.6%)

Facial vein

5 (27.8%)

UJND

1 (50%)

Superior thyroid vein
External jugular vein

SOND

2 (7.1 %)

JND

2 (5%)

2 (7.1%)3 (16.7%)

1 (50%)

8 (28.6%)

Transverse cervical vein

18 (45%)29 (69%)1 (2.5%)2 (4.8%)Posterior cevical vein

2 (4.8%)Internal jugular vein
Total

mRND

18216 (57.1%)

19 (47.5%)

9 (21.4%)

2840

42(n = 130)
JND, jugular neck dissection; mRND, modified radical neck dissection; NND, no neck dissection; SOND, supraomohyoid neck dissection; UJND, upper jugular neck dissection.

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neck surgeon generally prepares the external jugularvein during neck dissection, so this vessel is usuallyavailable. Second, color-flow doppler and computed tomography studies have shown a 14 to 26.4% incidence
of internal jugular vein thrombosis within 1 week after
functional and selective cervical lymph- node dissection.15, 16 Third, we use a coupling device frequently forthe venous anastomosis and these devices are unsuitablefor end-to-side anastomosis, as Ahn reported.17 Use ofa coupling device saves time and reduces the surgeon’sload. Finally the external jugular vein is long and mobile
making it quite adaptable.
Despite these advantages in using the external jugular vein as a recipient vessel, we use the internal jugularvein most frequently in SOND. We suppose one of thereasons for postoperative thrombosis in internal jugularvein is twist of the vein. The risk of venous twist is small
because lower part of the internal jugular vein is notdissected in SOND. And venous blood flow of internal
jugular vein is reliable. So, both the internal jugular andexternal jugular veins were selected as recipient vein atthe same time in SOND.
Neck dissection is standardized to a great extent andtherefore which recipient vessels to use for microanastomoses can to some extent be determined preoperatively.
The choice will depend most strongly on the donor site
for the free flap and the length of the vascular pedicle.
We believe proper positioning depends only on the relation between the vascular pedicle and the recipient
vessels. Microsurgeons should remember that proper
recipient vessel selection depending on the type of neckdissection is important and this leads to improve resultsof head and neck reconstruction using free flap transfer.

3 Nahabedian MY, Singh N, Deune EG, Silverman R,Tufaro AP. Recipient vessel analysis for microvascular reconstruction of the head and neck. Ann Plast Surg. 2004;52:14855. PMID: 14745264.
4 Shah JP, Strong E, Spiro RH, Vikram B. Surgical grandrounds. Neck dissection: current status and future possibilities.
Clin Bull. 1981;11:25-33. PMID: 6791863.
5 Khouri RK, Coolley BC, Kunselman AR, Landis JR,
Yeramian P, Ingram D, et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg.
1998;102:711-21. PMID: 9727436.
6 Wei FC, Demirkan F, Chen HC, Chuang DC, Chen SH,Lin CH, et al. The outcome of failed free flap in head andneck and extremity reconstruction: What is next in the reconstructive ladder? Plast Reconstr Surg. 2001;108:1154-60.
PMID: 11604621.
7 Wei FC, Celik N, Chen HC, Cheng MH, Huang WC. Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite
mandibular defects. Plast Reconstr Surg. 2002;109:45-52.
PMID: 11786790.
8 Yagi S, Kamei Y, Torii S. Donor side selection in mandibular
reconstruction using a free fibular osteocutaneous flap. Ann
Plast Surg 2006;56:622-7. PMID: 16721074.
9 Genden EM, Felio A, Shaha AR, Talmi YP, Robbins KT,
Rhys-Evans Ph, et al. Complication of neck dissection. Acta
Otolaryngol. 2003;123:795-801. PMID: 14575393.
10 Chu W and Strawits JG. Results in suprahyoid, modified radical and standard radical neck dissections for metastatic squamous cell carcinoma: Recurrence and survival. Am J Surg.
1978;136:512-5. PMID: 707733.
11 Jesse RH, Ballantyne AJ and Larson D. Radical or modified neck dissection: a therapeutic dilemma. Am J Surg.
1978;136:516-9. PMID: 707734.
12 Bocca E, Pignataro O, Oldoni C, Calla C. Functional neckdissection: an evaluation and review of 843 cases. Laryngoscope. 1984;94:942-5. PMID: 6738274.
13 Yu P. The transverse cervical vessels as recipient vessels forpreviously treated head and neck cancer patients. Plast Reconstr Surg. 2005;115:1253-9. PMID: 15809582.
14 Goodwin WJ Jr and Resenberg GJ. Venous drainage of thelateral trapezius musculocutaneous island flap. Arch Otolaryngol. 1982;108:411-3. PMID: 7092682.
15 Quraishi HA, Wax MK, Granke K, Rodmam SM. Internal
jugular vein thrombosis after functional and selective neckdissection. Arch Otolaryngol Head Neck Surg. 1997; 123:969973. PMID: 9305248.
16 Brown DH, Mulholland S, Yoo JH, Gullane PJ, Irish JC,Neligan P, et al. Internal jugular vein thrombosis following
modified neck dissection: Implications for head and neck flap
reconstruction. Head Neck. 1998;20:169-74. PMID: 9484949.
17 Ahn CY, Shaw WW, Berns S, Markowitz BL. Clinical experience with the 3M microvascular coupling anastomotic devicein 100 free-tissue transfers. Plast Reconstr Surg. 1994;93:14814. PMID: 8208815.

Acknowledgments: The authors thank Bin Nakayama M.D., Ph.D.,
for his surgical support.
The authors declare no conflict of interest.

REFERENCES
1 Chia HL, Wong CH, Tan BK, Tan KC, Ong YS. An algorithm
for recipet vessel selection in microsurgical head and neckreconstruction. J Reconstr Microsurg. 2011;27:47-56. PMID:20976669.
2 Mulholland S, Boyd JB, McCabe S, Gullane P, Rotstein L,Brown D, et al. Recipient vessels in head and neck microsurgery: Radiation effect and vessel access. Plast Reconstr Surg.
1993;92:628-32. PMID: 8356125.

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