The vessel-depleted neck in head and neck microvascular reconstruction: extreme solutions for extreme situations

PURPOSE OF REVIEW: The vessel-depleted neck is the ultimate challenge for the head and neck reconstructive surgeon. In patients who have had previous neck dissections or radiotherapy, the arterial and venous options for future reconstruction can be very limited, and it is important for the surgeon to consider alternative options for vessels. RECENT FINDINGS: Appropriate preoperative planning is crucial in these patients with a thorough history including previous operation notes, details of previous treatments, and previously used vessels for reconstruction. Clinical examination and a dual phase CT angiogram/MR angiogram can identify vessels available for reconstruction. Arterial options are discussed including tips on using the common carotid artery and the use of Corlett loops for utilizing contralateral arteries. Venous options are also discussed including cephalic vein transposition and Corlett loops. Novel options, such as use of extracorporeal perfusion of flaps have been shown to be effective when all other options have been depleted. SUMMARY: Creative solutions are needed for these extreme circumstances, and reconstructive surgeons need to be aware of the options available to select the best one in each case. Careful planning and having multiple back-up choices is crucial to successful reconstruction in these cases.