INFLUENCE OF NECK DISSECTION AND PREOPERATIVE IRRADIATION ON MICROVASCULAR HEAD AND NECK RECONSTRUCTION—ANALYSIS OF 853 CASES NGIAN CHYE TAN, M.B.B.S., F.R.C.S.ED.,1,2 PAO-YUAN LIN, M.D.,1 YUAN-CHENG CHIANG, M.D.,1 KHONG-YIK CHEW, M.B.B.S., M.R.C.S.ED.,1,3 CHIEN-CHUNG CHEN, M.D.,1 TAKASHI FUJIWARA, M.D.,1 and YUR-REN KUO, M.D., Ph.D., F.A.C.S.1*
Background: Previous neck dissection and irradiation is believed to affect the success of free tissue transfers in head and neck reconstruction, but evidence is scarce and conflicting. This study seeks to evaluate flap success rates in the presence of these two factors. Methods: Over a ten-year period, a total of 853 free flap cases were evaluated. Success rates were compared between a control group with no prior intervention (non-irradiation and neck dissection, NRTND) against three other groups: irradiation only (RT), previous neck dissection only (ND), and both (RTND). The choices of recipient vessel used were also compared. Results: The flap failure rate was 6.3% (4/63) in the RTND group; 4.8% (1/21) in the ND group; 5.2% (6/115) in the RT group; and 2.1% (14/654) in the NRTND group. There was no statistical significance among the four groups (P 5 0.254). Ipsilateral neck vessels (92.7%) were more frequently used in the NRTND group. In contrast, the superficial temporal vessels, contra-lateral neck vessels were more likely to be selected in the groups with irradiation and/or neck dissection. Conclusions: Free tissue transfer in head and neck patients with previous irradiation and neck dissection is feasible and can be safely done. In addition, superficial temporal vessel could be the first choice in patients with previous radioC 2014 Wiley Periodicals, Inc. Microsurgery 34:602–607, 2014. therapy and neck dissection. V
Microsurgical
free tissue transfer has evolved into a mainstay procedure for reconstruction of head and neck defects. Although microvascular surgery is more challenging in patients who had received preoperative radiotherapy, many centers have already proven that this did not have any adverse effect on the success rate of free flaps.1,2 Free flap reconstruction is also made more demanding in patients who had undergone previous neck dissection ipsilateral to the site of defect, reducing the availability of potential recipient neck vessels for free tissue transfers. However, Head et al.3 evaluated this group of patients and concluded that free flap reconstruction of the head and neck is highly successful in patients with a history of neck dissection, despite a relative paucity of potential cervical recipient blood vessels. There have however been limited reports on the feasibility and safety of microvascular free tissue transfer in patients who had undergone both previous neck dissection and radiother1 Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan 2 Department of Surgical Oncology, National Cancer Centre, Singapore 3 KK Women’s and Children’s Hospital, Singapore
Presented at the Annual Meeting of American Society for Reconstructive Microsurgery (ASRM), Jan. 10–13, 2009, Maui, HA, USA Dr. Tan NC and Dr. Lin PY contributed equally to this work and should be considered as co-first authors. *Correspondence to: Yur-Ren Kuo, MD, PhD, FACS, Department of Plastic & Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Rd, Niao-Sung, Kaohsiung 83305, Taiwan. E-mail: [email protected] and [email protected] Received 9 January 2014; Revision accepted 27 March 2014; Accepted 11 April 2014 Published online 22 May 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22270 Ó 2014 Wiley Periodicals, Inc.
apy. We are beginning to encounter more and more of such patients due to the presence of metachronous or recurrent cancers and additionally, in patients who are keen for secondary reconstruction after completing cancer treatment. In this article, we investigated patients with previous radiotherapy and ipsilateral neck dissection and analyzed their success of free tissue transfers compared with patients that had undergone either only previous radiotherapy or neck dissection, and patients that had not undergone previous radiotherapy and neck dissection. PATIENTS AND METHODS
A retrospective review was performed on consecutive patients who had undergone free tissue transfer for reconstruction of head and neck defects after cancer resection over a 10-year period at the microsurgical center of Kaohsiung Chang Gung Memorial Hospital. Patients were divided into four groups: those necks which had received preoperative radiation therapy (RT) only, those which had received preoperative ipsilateral neck dissection only (ND), those which had received both preoperative radiotherapy and ipsilateral neck dissection (RTND), and those which had not received any preoperative radiation therapy or neck dissection (NRTND). Total flap failure rates were compared between the four groups. In addition, we analyzed the recipient vessels used for the four different groups. Sequential free flap surgeries performed on the same patient were considered separately. To analyze recipient vessel selection and flap survival rate based on location of the selected vessels, 60 cases with two simultaneous free flaps in one surgery were excluded from this study. A total of 853 free flaps in 782 patients were finally assessed.
Radiotherapy, Neck Dissection, and Microvascular Head and Neck Reconstruction
603
Table 1. Defect Location and Flap type of Reconstruction
Defect location Oral cavity Oropharynx Hypopharynx Flap type Anterolateral thigh Radial forearm Fibular osteocutaneous Jejunum Total flap loss
RT (n 5 178)
NRT (n 5 675)
140 (78.7%) 20 (11.2%) 18 (10.1%)
553 (81.9%) 75 (11.1%) 47 (7.0%)
130 (73.0%) 15 (8.4%) 30 (16.9%) 3 (1.7%) 14 (7.9%)
355 (52.6%) 179 (26.5%) 136 (20.1%) 5 (0.7%) 31 (4.6%)
RT, radiotherapy; NRT, no radiotherapy
Figure 1. The algorithm of recipient vessel choice is depended on the location of the defect and the proximity of the recipient vessels. The number in this figure represents the order of vascular option. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
The algorithm of choice of recipient vessel for head and neck reconstruction was usually made depending on the location of the defect and the proximity of the recipient vessels (Fig. 1). In our institution, the protocol for defects located in the upper or middle third of the head, the first choice recipient vessels were the superficial temporal artery and vein. The second choice was using the ipsilateral neck vessels from the external carotid arterial system and internal/external jugular venous system. Third choice vessels were the ipsilateral transverse cervical vessels with/without vein grafts. For defects located in the lower third of the face or in the neck, ipsilateral neck vessels from external carotid artery and the internal/ external jugular veins or its branches were the first choice of recipient artery and vein. Second choice vessels were the superficial temporal vessels, while the third choice and fourth choice vessels were the ipsilateral transverse cervical vessels and the contralateral neck vessels, respectively. In circumstances in which the flap vessel could not reach the recipient vessel, an interposition vein graft was used. Figure 1 shows our protocol of recipient vessel choice. The surgical procedure of recipient vessel identification and dissection were routinely performed using surgical loupes or a surgical microscope. During the dissection, caliber, quality of the recipient vessel, and location of the anastomosis to prevent compression or kinking were assessed for successful microsurgical anastomosis. If the vessels selected initially were deemed unsuitable, the next choice of vessels was explored in a similar manner. This process continued till appropriate vessels suitable for microvascular anastomosis were identified. A spurt test from the recipient artery was performed to ensure adequate blood flow and venous backflow was also ensured before all microvascular anastomoses.
Bio-statistical analysis was performed. The v2test or Fisher’s exact test were used for binary variables to test statistical significance. The significance level was set to P < 0.05. RESULTS
One hundred seventy patients had received preoperative radiotherapy to the operative site, and 612 patients had not received radiotherapy. The radiation dose for patients who underwent radiotherapy ranged from 50 Gy to 63 Gy. All patients had undergone cancer ablation and reconstructive surgery simultaneously. The defect location and flap type for reconstruction is shown in Table 1. When comparing the free flaps transferred in patients with previous radiotherapy (n 5 178) against flaps transferred in patients without radiotherapy (n 5 675), the flap failure rate was 7.9% versus 4.6%. Although the group with previous radiotherapy revealed higher percentage of failure rate, there was no significant difference in total flap failure rate between the two groups (P 5 0.08). In contrast, the correlation of flap failure rate and the fields of neck irradiation and dissection were re-analyzed and excluded patients using superficial temporal vessels and contralateral vessels as recipient vessels. The result revealed the flaps failure rate in patients with previous radiotherapy (n 5 123) against the patients out of neck irradiation (n 5 730) was 6.5% (8/123) versus 5.2% (38/ 730). There was no statistical difference in flap failure rate between both the groups (P > 0.05). Recipient vessel location is shown in Table 2. Recipient vessels used were stratified into ipsilateral neck vessels (65.2% in the group with previous radiotherapy; 91.9% in the group without previous radiotherapy), ipsilateral superficial temporal vessels (23.0% in the group with previous radiotherapy; 2.8% in the group without previous radiotherapy), contralateral neck vessels (7.3% in the group with previous radiotherapy; 3.1% in the group without previous radiotherapy), and ipsilateral transverse cervical vessel (4.5% in the group with previous radiotherapy; 2.2% in the group without previous Microsurgery DOI 10.1002/micr
604
Tan et al.
radiotherapy). There was statistically significant difference between the two groups in the frequency of using the ipsilateral neck vessels (P < 0.01), superficial temporal vessels (P < 0.01), and contralateral neck vessels (P < 0.05) (Table 2). Further analysis revealed sixty-three flaps were done in necks that had received preoperative radiotherapy and previous neck dissection to the operative site (RTND group), and 654 flaps were transferred to necks that had not received any previous radiotherapy or neck dissection (NRTND group). One hundred fifteen flaps were done in necks that received only previous radiotherapy but no neck dissection (RT group), while 21 flaps were done in necks that had previous neck dissection with no radiotherapy (ND group). Total flap failure was 6.3% in the RTND group (4 of 63), 0% in the ND group (0 of 21), 8.7% (10/115) in the RT group, and 4.7% (31/654) in the NRTND group. There was no significant difference in total flap failure rates between all four groups (P 5 0.254). When the flap failure rates regarding the locations of recipient vessels between RT and NRT group were compared, flap failure rates were still insigTable 2. Comparison of Recipient Vessel Selection Recipient vessel ECA branch and I/ EJV system Superficial temporal Contralateral neck Transverse cervical Total
RT
NRT
P value
116 (65.2%)
620 (91.9%)
P < 0.01
41 (23.0%) 13 (7.3%) 8 (4.5%) 178
19 (2.8%) 21 (3.1%) 15 (2.2%) 675
P < 0.01 P
Background: Previous neck dissection and irradiation is believed to affect the success of free tissue transfers in head and neck reconstruction, but evidence is scarce and conflicting. This study seeks to evaluate flap success rates in the presence of these two factors. Methods: Over a ten-year period, a total of 853 free flap cases were evaluated. Success rates were compared between a control group with no prior intervention (non-irradiation and neck dissection, NRTND) against three other groups: irradiation only (RT), previous neck dissection only (ND), and both (RTND). The choices of recipient vessel used were also compared. Results: The flap failure rate was 6.3% (4/63) in the RTND group; 4.8% (1/21) in the ND group; 5.2% (6/115) in the RT group; and 2.1% (14/654) in the NRTND group. There was no statistical significance among the four groups (P 5 0.254). Ipsilateral neck vessels (92.7%) were more frequently used in the NRTND group. In contrast, the superficial temporal vessels, contra-lateral neck vessels were more likely to be selected in the groups with irradiation and/or neck dissection. Conclusions: Free tissue transfer in head and neck patients with previous irradiation and neck dissection is feasible and can be safely done. In addition, superficial temporal vessel could be the first choice in patients with previous radioC 2014 Wiley Periodicals, Inc. Microsurgery 34:602–607, 2014. therapy and neck dissection. V
Microsurgical
free tissue transfer has evolved into a mainstay procedure for reconstruction of head and neck defects. Although microvascular surgery is more challenging in patients who had received preoperative radiotherapy, many centers have already proven that this did not have any adverse effect on the success rate of free flaps.1,2 Free flap reconstruction is also made more demanding in patients who had undergone previous neck dissection ipsilateral to the site of defect, reducing the availability of potential recipient neck vessels for free tissue transfers. However, Head et al.3 evaluated this group of patients and concluded that free flap reconstruction of the head and neck is highly successful in patients with a history of neck dissection, despite a relative paucity of potential cervical recipient blood vessels. There have however been limited reports on the feasibility and safety of microvascular free tissue transfer in patients who had undergone both previous neck dissection and radiother1 Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan 2 Department of Surgical Oncology, National Cancer Centre, Singapore 3 KK Women’s and Children’s Hospital, Singapore
Presented at the Annual Meeting of American Society for Reconstructive Microsurgery (ASRM), Jan. 10–13, 2009, Maui, HA, USA Dr. Tan NC and Dr. Lin PY contributed equally to this work and should be considered as co-first authors. *Correspondence to: Yur-Ren Kuo, MD, PhD, FACS, Department of Plastic & Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta-Pei Rd, Niao-Sung, Kaohsiung 83305, Taiwan. E-mail: [email protected] and [email protected] Received 9 January 2014; Revision accepted 27 March 2014; Accepted 11 April 2014 Published online 22 May 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22270 Ó 2014 Wiley Periodicals, Inc.
apy. We are beginning to encounter more and more of such patients due to the presence of metachronous or recurrent cancers and additionally, in patients who are keen for secondary reconstruction after completing cancer treatment. In this article, we investigated patients with previous radiotherapy and ipsilateral neck dissection and analyzed their success of free tissue transfers compared with patients that had undergone either only previous radiotherapy or neck dissection, and patients that had not undergone previous radiotherapy and neck dissection. PATIENTS AND METHODS
A retrospective review was performed on consecutive patients who had undergone free tissue transfer for reconstruction of head and neck defects after cancer resection over a 10-year period at the microsurgical center of Kaohsiung Chang Gung Memorial Hospital. Patients were divided into four groups: those necks which had received preoperative radiation therapy (RT) only, those which had received preoperative ipsilateral neck dissection only (ND), those which had received both preoperative radiotherapy and ipsilateral neck dissection (RTND), and those which had not received any preoperative radiation therapy or neck dissection (NRTND). Total flap failure rates were compared between the four groups. In addition, we analyzed the recipient vessels used for the four different groups. Sequential free flap surgeries performed on the same patient were considered separately. To analyze recipient vessel selection and flap survival rate based on location of the selected vessels, 60 cases with two simultaneous free flaps in one surgery were excluded from this study. A total of 853 free flaps in 782 patients were finally assessed.
Radiotherapy, Neck Dissection, and Microvascular Head and Neck Reconstruction
603
Table 1. Defect Location and Flap type of Reconstruction
Defect location Oral cavity Oropharynx Hypopharynx Flap type Anterolateral thigh Radial forearm Fibular osteocutaneous Jejunum Total flap loss
RT (n 5 178)
NRT (n 5 675)
140 (78.7%) 20 (11.2%) 18 (10.1%)
553 (81.9%) 75 (11.1%) 47 (7.0%)
130 (73.0%) 15 (8.4%) 30 (16.9%) 3 (1.7%) 14 (7.9%)
355 (52.6%) 179 (26.5%) 136 (20.1%) 5 (0.7%) 31 (4.6%)
RT, radiotherapy; NRT, no radiotherapy
Figure 1. The algorithm of recipient vessel choice is depended on the location of the defect and the proximity of the recipient vessels. The number in this figure represents the order of vascular option. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
The algorithm of choice of recipient vessel for head and neck reconstruction was usually made depending on the location of the defect and the proximity of the recipient vessels (Fig. 1). In our institution, the protocol for defects located in the upper or middle third of the head, the first choice recipient vessels were the superficial temporal artery and vein. The second choice was using the ipsilateral neck vessels from the external carotid arterial system and internal/external jugular venous system. Third choice vessels were the ipsilateral transverse cervical vessels with/without vein grafts. For defects located in the lower third of the face or in the neck, ipsilateral neck vessels from external carotid artery and the internal/ external jugular veins or its branches were the first choice of recipient artery and vein. Second choice vessels were the superficial temporal vessels, while the third choice and fourth choice vessels were the ipsilateral transverse cervical vessels and the contralateral neck vessels, respectively. In circumstances in which the flap vessel could not reach the recipient vessel, an interposition vein graft was used. Figure 1 shows our protocol of recipient vessel choice. The surgical procedure of recipient vessel identification and dissection were routinely performed using surgical loupes or a surgical microscope. During the dissection, caliber, quality of the recipient vessel, and location of the anastomosis to prevent compression or kinking were assessed for successful microsurgical anastomosis. If the vessels selected initially were deemed unsuitable, the next choice of vessels was explored in a similar manner. This process continued till appropriate vessels suitable for microvascular anastomosis were identified. A spurt test from the recipient artery was performed to ensure adequate blood flow and venous backflow was also ensured before all microvascular anastomoses.
Bio-statistical analysis was performed. The v2test or Fisher’s exact test were used for binary variables to test statistical significance. The significance level was set to P < 0.05. RESULTS
One hundred seventy patients had received preoperative radiotherapy to the operative site, and 612 patients had not received radiotherapy. The radiation dose for patients who underwent radiotherapy ranged from 50 Gy to 63 Gy. All patients had undergone cancer ablation and reconstructive surgery simultaneously. The defect location and flap type for reconstruction is shown in Table 1. When comparing the free flaps transferred in patients with previous radiotherapy (n 5 178) against flaps transferred in patients without radiotherapy (n 5 675), the flap failure rate was 7.9% versus 4.6%. Although the group with previous radiotherapy revealed higher percentage of failure rate, there was no significant difference in total flap failure rate between the two groups (P 5 0.08). In contrast, the correlation of flap failure rate and the fields of neck irradiation and dissection were re-analyzed and excluded patients using superficial temporal vessels and contralateral vessels as recipient vessels. The result revealed the flaps failure rate in patients with previous radiotherapy (n 5 123) against the patients out of neck irradiation (n 5 730) was 6.5% (8/123) versus 5.2% (38/ 730). There was no statistical difference in flap failure rate between both the groups (P > 0.05). Recipient vessel location is shown in Table 2. Recipient vessels used were stratified into ipsilateral neck vessels (65.2% in the group with previous radiotherapy; 91.9% in the group without previous radiotherapy), ipsilateral superficial temporal vessels (23.0% in the group with previous radiotherapy; 2.8% in the group without previous radiotherapy), contralateral neck vessels (7.3% in the group with previous radiotherapy; 3.1% in the group without previous radiotherapy), and ipsilateral transverse cervical vessel (4.5% in the group with previous radiotherapy; 2.2% in the group without previous Microsurgery DOI 10.1002/micr
604
Tan et al.
radiotherapy). There was statistically significant difference between the two groups in the frequency of using the ipsilateral neck vessels (P < 0.01), superficial temporal vessels (P < 0.01), and contralateral neck vessels (P < 0.05) (Table 2). Further analysis revealed sixty-three flaps were done in necks that had received preoperative radiotherapy and previous neck dissection to the operative site (RTND group), and 654 flaps were transferred to necks that had not received any previous radiotherapy or neck dissection (NRTND group). One hundred fifteen flaps were done in necks that received only previous radiotherapy but no neck dissection (RT group), while 21 flaps were done in necks that had previous neck dissection with no radiotherapy (ND group). Total flap failure was 6.3% in the RTND group (4 of 63), 0% in the ND group (0 of 21), 8.7% (10/115) in the RT group, and 4.7% (31/654) in the NRTND group. There was no significant difference in total flap failure rates between all four groups (P 5 0.254). When the flap failure rates regarding the locations of recipient vessels between RT and NRT group were compared, flap failure rates were still insigTable 2. Comparison of Recipient Vessel Selection Recipient vessel ECA branch and I/ EJV system Superficial temporal Contralateral neck Transverse cervical Total
RT
NRT
P value
116 (65.2%)
620 (91.9%)
P < 0.01
41 (23.0%) 13 (7.3%) 8 (4.5%) 178
19 (2.8%) 21 (3.1%) 15 (2.2%) 675
P < 0.01 P
![[Stereotactic irradiation in head and neck cancers].](/assets/img/hold.png)
