Reconstructive options in the vessel-depleted neck: Past, present and future strategies

Repetitive ablative surgery, neck dissection and radiation therapy lead to a gradual depletion of cervical vessels. About 7% of oral cancer patients end up with a neck devoid of all potential donor vessels, a so-called frozen or vessel-depleted neck, rendering all future reconstruction endeavours extremely challenging. Due to the complexity of the deformity, treatment of affected patients requires experience with the whole repertoire of reconstructive options. For most reconstructive problems, microvascular transfer remains the most reliable option. Alternative recipient vessels can be found in the distant neck or thorax region but require flaps with extra-long pedicles or interpositional vein grafts. Pedicled musculo-and fasciocutaneous flaps are an important safety net if all microsurgical attempts fail. Based on the concept of ischemic conditioning, the 'carrier flap technique' uses the radial artery as a wrist carrier to provide temporary blood supply to a flap until revascularization in the recipient wound bed has occurred. Based on the same principle, extracorporeal flap perfusion using membrane oxygenation is an experimental procedure reserved for desolate cases. An algorithm is provided to serve as a guideline for the treatment of these challenging cases. Due to the complexity of the deformity, however, the final decision on how to treat the patient has to be made in each individual case. Since present concepts like free flaps may not be suitable in the most severe cases, the knowledge of past concepts is just as important as continuous ongoing scientific effort in finding new ways for treating this situation.