Facing a “Vessel Challenged Neck” in Head and Neck Microsurgical Reconstruction: Chang Gung Concepts, Approach, and Systematic Review

Allen Wei-Jiat Wong; Ta-Chun Lin; Fu-Chan Wei

doi:10.1055/s-0045-1811714

Seminars in Plastic Surgery, Table of Contents

Semin Plast Surg
DOI: 10.1055/s-0045-1811714

Review Article

Facing a “Vessel Challenged Neck” in Head and Neck Microsurgical Reconstruction: Chang Gung Concepts, Approach, and Systematic Review

Authors

Allen Wei-Jiat Wong

¹Plastic Reconstructive and Aesthetic Surgery, Sengkang General Hospital, Singapore, Singapore

²Musculoskeletal Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore

³Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan

⁴Medical College, Chang Gung University, Taoyuan, Taiwan
Ta-Chun Lin

³Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan

⁴Medical College, Chang Gung University, Taoyuan, Taiwan
Fu-Chan Wei

³Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan

⁴Medical College, Chang Gung University, Taoyuan, Taiwan

Abstract

Microsurgical free tissue transfer has become the standard for complex head and neck reconstruction. One of the most feared scenarios is the so-called “vessel-depleted neck” (VDN), in which prior surgery, irradiation, or multiple reconstructions are thought to preclude suitable recipient vessels. However, definitions of VDN remain inconsistent, and many patients are not truly “depleted.” A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. PubMed and Web of Science were searched (1980–2025) using terms related to “vessel-depleted neck,” “recipient vessels,” and “head and neck reconstruction.” Eligible studies included case series, cohorts, and case reports describing reconstructive strategies following prior neck dissection, irradiation, or multiple reconstructions. Fifty-six reports met the inclusion criteria. In addition, we contextualized these findings with the Chang Gung Memorial Hospital (CGMH) experience of >10,000 microvascular reconstructions. The review identified a spectrum of recipient vessel options and technical innovations. Common second-tier choices included the transverse cervical vessels, superficial temporal system, and contralateral cervical vessels. Less common strategies involved cephalic vein transposition, internal mammary vessels, thoracoacromial, or subclavian system. Techniques to overcome pedicle length constraints included vein grafts, Corlett loops, vascular bridge flaps (VBFs), and in situ pedicle lengthening. Local and regional flaps, such as the pectoralis major (PM) and supraclavicular flaps, provided salvage options when free flaps were not feasible. At CGMH, even after multiple reconstructions, ipsilateral vessels (transverse cervical, superior thyroid, facial artery) remained usable in most patients, with contralateral or vein graft use required in fewer than 20%. The concept of a “VDN” is often overstated and may serve as a psychological barrier to optimal reconstruction. Most patients retain viable recipient vessels, and free flaps remain achievable with careful planning and surgical expertise. We advocate reframing these cases as “vessel challenged necks,” emphasizing technical demands rather than depletion, to improve decision-making and outcomes.

Keywords

vessel-depleted neck - free flap - head and neck

Full Text

References

References
1 Miller KD, Nogueira L, Devasia T. et al. Cancer treatment and survivorship statistics, 2022. CA Cancer J Clin 2022; 72 (05) 409-436
2 Contrera KJ, Zafereo ME, Yaniv D. et al. Outcomes for recurrent oral cavity squamous cell carcinoma. Oral Oncol 2022; 134: 106127
3 Tam S, Araslanova R, Low TH. et al. Estimating survival after salvage surgery for recurrent oral cavity cancer. JAMA Otolaryngol Head Neck Surg 2017; 143 (07) 685-690
4 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) n71
5 Qiao QH, Yin S-C, Shi C. et al. Risk factors for free flap outcomes: A retrospective study of 318 free flaps for head and neck defect reconstruction. Ear Nose Throat J 2025; 104 (05) NP247-NP256
6 Mata Ribeiro L, Tsao CK, Hung YL. et al. Venous size discrepancy is a critical factor when using superficial temporal vessels as recipient vessels for free flaps. J Reconstr Microsurg 2022; 38 (08) 654-663
7 Mattine S, Payne KFB. The evolving role of the superficial temporal vessels as anastomotic recipients in challenging microvascular reconstruction of the upper two-thirds of the face. J Plast Reconstr Aesthet Surg 2022; 75 (09) 3330-3339
8 Lai CS, Chang YT, Shen CH. et al. The role of vein grafts in reconstructive head and neck microsurgery. Braz J Otorhinolaryngol 2022; 88 Suppl 4 (Suppl. 04) S81-S88
9 Lai CS, Shen CH, Chang YT. et al. Recipient vessel selection for multiple free flap transfers in head and neck reconstruction at different periods. Microsurgery 2021; 41 (05) 438-447
10 Choi JW, Kim YC, Jeon DN. et al. Impact of recipient vein selection on venous patency and free flap survival in 652 head and neck reconstructions. J Reconstr Microsurg 2020; 36 (02) 73-81
11 Vamadeva SV, Henry FP, Mace A, Clarke PM, Wood SH, Jallali N. Secondary free tissue transfer in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2019; 72 (07) 1129-1134
12 Ibrahim AE, Adelman DM, Parham C. et al. The external jugular vein used as recipient vessel in head and neck free flap reconstruction: Outcomes compared to the internal jugular vein. J Craniofac Surg 2019; 30 (01) 178-183
13 Di Taranto G, Chen SH, Elia R. et al. Outcomes following head neck free flap reconstruction requiring interposition vein graft or vascular bridge flap. Head Neck 2019; 41 (09) 2914-2920
14 Mahendru S, Singh H, Sarin D. et al. Microvascular free tissue transfer in vessel-compromised neck: Techniques and recommendations. Int Microsurg J 2019; 3: 2
15 Chen YC, Scaglioni MF, Huang EY, Kuo YR. Utility of “open-Y” anastomosis technique in the use of superior thyroid artery as recipient vessel for head and neck reconstruction with free flap. Microsurgery 2016; 36 (05) 391-396
16 Tan NC, Lin PY, Chiang YC. et al. Influence of neck dissection and preoperative irradiation on microvascular head and neck reconstruction-Analysis of 853 cases. Microsurgery 2014; 34 (08) 602-607
17 Hanasono MM, Corbitt CA, Yu P, Skoracki RJ. Success of sequential free flaps in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2014; 67 (09) 1186-1193
18 Shih HS, Hsieh CH, Feng GM, Feng WJ, Jeng SF. An alternative option to overcome difficult venous return in head and neck free flap reconstruction. J Plast Reconstr Aesthet Surg 2013; 66 (09) 1243-1247
19 Schneider DS, McClain L, Robb Jr PK, Rosenthal EL, Wax MK. Use of internal mammary vessels in head and neck microvascular reconstruction. Arch Otolaryngol Head Neck Surg 2012; 138 (02) 172-176
20 Hyodo I, Nakamura R, Okumura S, Kamei Y, Yasuda H, Suzuki H. Feasibility and safety of microvascular anastomoses within previously-dissected neck regions. J UOEH 2022; 44 (04) 331-339
21 Kekatpure VD, Trivedi NP, Manjula BV, Mathan Mohan A, Shetkar G, Kuriakose MA. Pectoralis major flap for head and neck reconstruction in era of free flaps. Int J Oral Maxillofac Implants 2012; 41 (04) 453-457
22 Chia HL, Wong CH, Tan BK, Tan KC, Ong YS. An algorithm for recipient vessel selection in microsurgical head and neck reconstruction. J Reconstr Microsurg 2011; 27 (01) 47-56
23 Shimizu F, Lin MP, Ellabban M, Evans GRD, Cheng MH. Superficial temporal vessels as a reserve recipient site for microvascular head and neck reconstruction in vessel-depleted neck. Ann Plast Surg 2009; 62 (02) 134-138
24 Jacobson AS, Eloy JA, Park E, Roman B, Genden EM. Vessel-depleted neck: techniques for achieving microvascular reconstruction. Head Neck 2008; 30 (02) 201-207
25 Yu P. The transverse cervical vessels as recipient vessels for previously treated head and neck cancer patients. Plast Reconstr Surg 2005; 115 (05) 1253-1258
26 Mulholland S, Boyd JB, McCabe S. et al. Recipient vessels in head and neck microsurgery: radiation effect and vessel access. Plast Reconstr Surg 1993; 92 (04) 628-632
27 Chang CK, Wu CY, Lin YL. et al. Comparative study of arterial and venous grafting for pedicle lengthening in head and neck microvascular reconstruction. Microsurgery 2024; 44 (01) e31133
28 Wong AW, Hung SY, Wei FC. Debunking the “vessel depleted neck”-study of 52 patients with more than three reconstructions. Head Neck 2025; 47 (09) 2425-2430
29 Wong AW, Wei FC. Should we view the “vessel-depleted neck” as just a challenging neck?. Plast Reconstr Surg 2024; 154 (03) 628e-629e
30 Moriguchi K, Kurita T, Fujii T, Kawai K, Kubo T. Head and neck reconstruction with 2-stage external pectoralis major myocutaneous flap transfer. Ann Plast Surg 2023; 90 (02) 135-139
31 Anderson SR, Scott BA, Harrison LM, Wimalawansa SM, Kadakia SP. Common carotid-to-internal jugular arteriovenous loop for single-stage microsurgical reconstruction in the radiated vessel-depleted neck. J Craniofac Surg 2021; 32 (02) 711-715
32 Rahman MF, Ahsan MA, Shaikh SA, Khan MU, Ullah S. Use of cephalic vein for venous anastomosis in head and neck reconstruction: A case series. Eplasty 2020; 20: e9
33 Lin KW, Huang TC, Cheng HT. Utilization of anterolateral thigh flap and transverse cervical recipient vessels for head and neck cancer patients with former neck dissection and irradiation: A case series study. Ann Plast Surg 2019; 82 (04) 415-419
34 Javadian R, Bouland C, Rodriguez A, Loeb I, Dequanter D. Head and neck reconstruction: The supraclavicular flap: technical note. Ann Chir Plast Esthet 2019; 64 (04) 374-379
35 Ciudad P, Agko M, Date S. et al. The radial forearm free flap as a “vascular bridge” for secondary microsurgical head and neck reconstruction in a vessel-depleted neck. Microsurgery 2018; 38 (06) 651-658
36 Ooi ASH, Teven CM, Inbal A, Chang DW. The utility of the musculocutaneous anterolateral thigh flap in pharyngolaryngeal reconstruction in the high-risk patient. J Surg Oncol 2017; 115 (07) 842-847
37 Ciudad P, Agko M, Manrique OJ. et al. The retrograde transverse cervical artery as a recipient vessel for free tissue transfer in complex head and neck reconstruction with a vessel-depleted neck. Microsurgery 2017; 37 (08) 902-909
38 Xu ZF, Duan WY, Zhang EJ. et al. Transverse cervical vessels as recipient vessels in oral and maxillofacial microsurgical reconstruction after former operations with or without radiotherapy. World J Surg Oncol 2015; 13: 183
39 Zevallos JP, Urken ML. Reverse-flow scapular osteocutaneous flap for head and neck reconstruction. Head Neck 2013; 35 (06) E171-E174
40 Roche NA, Houtmeyers P, Vermeersch HF, Stillaert FB, Blondeel PN. The role of the internal mammary vessels as recipient vessels in secondary and tertiary head and neck reconstruction. J Plast Reconstr Aesthet Surg 2012; 65 (07) 885-892
41 Quilichini J, Benjoar MD, Hivelin M, Brugel L, Lantieri L. Semi-free radial forearm flap for head and neck reconstruction in vessel-depleted neck after radiotherapy or radical neck dissection. Microsurgery 2012; 32 (04) 269-274
42 Onoda S, Sakuraba M, Asano T. et al. Thoracoacromial vessels as recipients for head and neck reconstruction and cause of vascular complications. Microsurgery 2011; 31 (08) 628-631
43 Yagi S, Kamei Y, Fujimoto Y, Torii S. Use of the internal mammary vessels as recipient vessels for an omental flap in head and neck reconstruction. Ann Plast Surg 2007; 58 (05) 531-535
44 Urken ML, Higgins KM, Lee B, Vickery C. Internal mammary artery and vein: recipient vessels for free tissue transfer to the head and neck in the vessel-depleted neck. Head Neck 2006; 28 (09) 797-801
45 Kim KA, Chandrasekhar BS. Cephalic vein in salvage microsurgical reconstruction in the head and neck. Br J Plast Surg 1998; 51 (01) 2-7
46 Horng SY, Chen MT. Reversed cephalic vein: a lifeboat in head and neck free-flap reconstruction. Plast Reconstr Surg 1993; 92 (04) 752-753
47 Kerai A, Modi P, Shackcloth M, Schache AG, Shaw RJ. Head and neck reconstruction in the vessel depleted neck using robot-assisted harvesting of the internal mammary vessels. Br J Oral Maxillofac Surg 2023; 61 (05) 368-372
48 Delay A, Carlier A, Varazzani A. et al. Head and neck reconstruction in vessel-depleted necks: Case report of a labio-mental and mandibular reconstruction using an arteriovenous loop. J Stomatol Oral Maxillofac Surg 2023; 124 (6 suppl 2): 101649
49 Fardizza F, Hediyati Reksodiputro M, Hermani B. et al. Promising perioperative outcomes of supraclavicular flap in the reconstruction of head and neck complex defects: An evidence-based case report. Acta Otolaryngol Case Rep 2022; 7: 68-73
50 Benbassat B, Cros F, Dupret-Bories A, Meresse T. Cephalic vein transposition in head-and-neck reconstruction. Eur Ann Otorhinolaryngol Head Neck Dis 2022; 139 (06) 361-363
51 Scaglioni MF, Meroni M, Fritsche E, Rajan G. Internal mammary artery perforators as recipient vessels for free tissue transfer in head and neck reconstruction: A case report and literature review. Microsurgery 2021; 41 (04) 355-360
52 Broderick D, Vassiliou L, Kyzas P. Use of the subclavian vessels for microvascular reconstruction in the vessel-depleted neck. Br J Oral Maxillofac Surg 2021; 59 (01) 114-116
53 Alotaibi AS, Shah Mardan QNM, Almarghoub MA, Mahabbat NA, Almarshad FA, Hashem FK. The pedicled lateral forehead flap in reconstructing oral floor defect - The last resort; case report. Int J Surg Case Rep 2021; 89: 106521
54 Kuba R, Shimizu Y, Kitabata R, Yamazaki S. Posterior external jugular vein: a useful alternative recipient vessel in head and neck free flap reconstructions. Eur J Plast Surg 2020; 43: 661-664
55 Ibrahim ASG, Kakarala K, Bur AM. Lateral thoracic artery as recipient vessel for head and neck free flap reconstruction in the vessel depleted neck: A case report. Microsurgery 2019; 39 (08) 748-752
56 Miyamoto S, Fukunaga Y, Shinozaki T, Yasunaga Y, Hayashi R, Sakuraba M. T-shaped pectoralis major musculocutaneous flap for reconstruction of an extensive circumferential pharyngeal defect. Plast Reconstr Surg Glob Open 2014; 2 (04) e129
57 Baj A, Bolzoni A, Torretta S, Pignataro L. Arterial microanastomoses on the reverse flow of the internal carotid artery reverse flow: An extreme solution in free-flap revascularisation. How we do it. Acta Otorhinolaryngol Ital 2014; 34 (05) 368-371
58 Salgarello M, Snider F, Finocchi V, Bussu F, Paludetti G, Almadori G. The Pruitt-Inahara carotid shunt as an assisting tool to anastomose the arterial free flap pedicle to the internal carotid artery in the vessel-depleted neck. Microsurgery 2011; 31 (03) 234-236
59 Depprich RA, Naujoks CD, Meyer U, Kübler NR, Handschel JG. Ateriovenous subclavia-shunt for head and neck reconstruction. Head Face Med 2008; 4: 27
60 Ethunandan M, Cole R, Flood TR. Corlett loop for microvascular reconstruction in a neck depleted of vessels. Br J Oral Maxillofac Surg 2007; 45 (06) 493-495
61 Gschossmann JD, Balk M, Rupp R. et al. Results of contralateral anastomosis of microvascular free flaps in head and neck reconstruction. Ear Nose Throat J 2025; 104 (05) NP237-NP246
62 Ooms M, Puladi B, Winnand P. et al. Perfusion of microvascular free flaps in head and neck reconstruction after prior neck dissection and irradiation. Int J Oral Maxillofac Implants 2023; 52 (06) 640-647
63 Wu CY, Lai CS, Wang YP. et al. In situ pedicle lengthening and perforator shifting technique for overcoming the perforator variation of the anterolateral thigh free flap during head and neck reconstruction. Microsurgery 2021; 41 (08) 743-752
64 Sato T, Deek NAL, Sandars J, Wei FC. Teaching surgery through immediate preoperative small-group discussions. Hand Clin 2025; 41 (02) 181-187
65 Wei FC, Demirkan F, Chen HC. et al. The outcome of failed free flaps in head and neck and extremity reconstruction: what is next in the reconstructive ladder?. Plast Reconstr Surg 2001; 108 (05) 1154-1160 , discussion 1161–1162
66 Ridha H, Morritt AN, Wood SH. Spatulated end-to-end microvascular anastomosis: a useful technique for overcoming vessel size discrepancy. J Plast Reconstr Aesthet Surg 2014; 67 (10) e254-e255