Cephalic vein: Saviour in the microsurgical reconstruction of breast and head and neck cancers

Abstract

Background:

Reconstruction with microvascular free flaps is considered the reconstructive option of choice in cancer of the head and neck regions and breast. Rarely, there is paucity of vessels, especially the veins, at the recipient site. The cephalic vein with its good caliber and constant anatomy is a reliable recipient vein available in such situations.

Materials and Methods:

It is a retrospective study from January 2010 to July 2012 and includes 26 patients in whom cephalic vein was used for free-flap reconstruction in head and neck (3 cases) and breast cancers (23 cases).

Results:

All flaps in which cephalic vein was used survived completely.

Conclusion:

Cephalic vein can be considered as a reliable source of venous drainage when there is a non-availability/unusable of veins during free-flap reconstruction in the head and neck region and breast and also when additional source of venous drainage is required in these cases.

INTRODUCTION

The improvement in microsurgical techniques and the better understanding of anatomy has favoured the use of free tissue transfer as the most common reconstruction in breast and head and neck cancer patients. Problems with the microanastomosis patency are the most common cause of failure of free flaps. Venous problems are more common than their arterial counterpart. The cephalic vein has been used either primarily to prevent to augment or substitute venous drainage or during re-exploration to salvage such venous problems. The position, size, and the relatively constant anatomy of the cephalic vein, serves as an alternate route for venous drainage in these regions. The article highlights the usage of cephalic vein in head and neck and breast reconstruction where cephalic vein is uncommonly used.

MATERIALS AND METHODS

We retrospectively analysed the cases of free tissue transfers in head and neck and breast reconstruction where cephalic was used for anastomosis. The study period was between January 2010 and July 2012. There were total of 26 patients in which cephalic vein was used, 23 for breast reconstruction and 3 patients in head and neck reconstruction. The age of the patients was between 23 and 56. In head and neck cancers, the cephalic vein was used in two patients primarily and one patient during re-exploration. In breast cancer patients, the number of patients who underwent primary and secondary reconstruction was 19 and 4, respectively. Among the 23 patients of breast reconstruction, the cephalic vein was used primarily in 20 patients and in 3 patients for salvage during re-exploration. During the same period, the total number breast reconstruction with Deep Inferior Epigastric artery Perforator flap or Muscle Sparing Transverse Rectus Abdominus (DIEP)/flap was 60. There were no anatomical variations noted during the dissection of the cephalic vein and all flaps in which the cephalic vein was used survived completely.

Surgical technique

In head and neck reconstruction

The required length of the vein is measured and planning in reverse is done to identify the distal extent of dissection. The cephalic vein is identified in the Delto Pectoral (DP) groove and traced proximally in the arm. We make an open lazy ‘S’ incision for a better exposure and to clip all the tributaries. A straight line ink marking is done over the vein to identify and prevent any twisting during transposition.

In breast reconstruction

During harvest of DIEP, we always identify and dissect the superficial inferior epigastric vein (SIEV) or the superficial external pudendal vein (SEPV) (if present) on both the sides [Figure 1a–c]. These superficial veins lie in the plane superficial to scarpa's fascia. We prefer to anastomose the Deep Inferior Epigastric Artery and Vein (DIEA and DIEV) to the internal mammary artery (IMA) and internal mammary vein (IMV), respectively. We choose the deep inferior epigastric vessels on the same side of the breast reconstruction and rotate the flap 180° before inset, so that the vessels have a suitable lie to anastomose with the internal mammary vessels. If the IMV is not suitable or venous drainage is inadequate then the alternate options are the cephalic vein and the acromiothoracic vein. The acromiothoracic vein is usually of small caliber, thin walled and sometimes could have been excised with the specimen. Hence, an anastomosis to the cephalic vein is preferred.

Figure 1a.

Dissection of superficial inferior epigastric vein (SIEV)

Figure 1c.

Harvested MSTRAM flap with superficial inferior epigastric vein (SIEV) on both sides and SEPV on right side

Figure 1b.

TRAM flap harvested showing the superficial inferior epigastric vein (SIEV) on both sides

The SIEV/SEPV of the suitable side is anastomosed to the cephalic vein depending upon the need. The cephalic vein is usually identified and dissected through the same surgical wound [Figure 2]. Occasionally a short vertical incision is made for adequate exposure. The length of cephalic vein required in cases of free DIEP/MSTRAM is short and hence dissection up to the anterior axillary fold might me sufficient. The vein is identified and dissected till the desired length before inset of the flap. The vein is divided just before the anastomosis [Figure 3a]. This is to ensure that the vein is divided only if required and the anastomosis done [Figure 3b and c].

Figure 2.

Cephalic vein in DP groove

Figure 3a.

Cephalic vein (CV) and superficial inferior epigastric vein (SIEV) before anastomosis

Figure 3b.

After completion of anastomosis

Figure 3c.

After release of clamp

Here, we mention few cases and discuss the need where cephalic vein was used.

CASE REPORTS

Case 1

This is a 40-year-old male with cancer patient with recurrent rhabdomyosarcoma of right side maxilla [Figure 4a]. The initial treatment was a wide local excision followed by chemotherapy and radiotherapy. The patient underwent right total maxillectomy with orbital exentration and radical neck dissection on right side [Figure 4b]. The defect was planned to cover with free Antero Lateral Thigh (ALT) flap. After the flap inset the flap artery was planned to anastomose to the facial artery. There were no veins in the ipsilateral side of the neck and the Internal Jugular Vein (IJV) was ligated at the lower part of the neck [Figure 4b], not suitable for anastomosis. The flap vein was not reaching the opposite side of neck. We harvested the cephalic vein from the right arm, transposed, and an end-to-end anastomosis done [Figure 4c and d]. The flap settled uneventfully [Figure 4e] except for the extra-scar at the cephalic vein harvest donor site [Figure 4f].

Figure 4a.

Pre-operative: Tumour of maxilla

Figure 4b.

Intra-operative – Defect, IJV excised

Figure 4c.

Cephalic vein dissected

Figure 4d.

Completion of anastomosis

Figure 4e.

Post-operative

Figure 4f.

Cephalic vein donor site

Case 2

A 56-year-old male patient was diagnosed with recurrent cancer of lower alveolus on the right side. The first surgery was done 4 years back during which the patient underwent segmental mandibulectomy and reconstructed with free vascularised fibula flap followed by post-operative radiotherapy. The patient was now planned for a wide local excision along with part of the previously reconstructed fibula [Figure 5a and b] and reconstruction with free fibula from the other leg. The flap artery was anastomosed to the superior thyroid artery and the flap vein was anastomosed to the right IJV in an end-side fashion. The patient developed venous problem on post-operative day 3. On exploration, the anastomotic site was thrombosed [Figure 5c]. Because of previous surgery and RT, the IJV was densely adhered to surrounding tissue and had thin wall, not suitable for a second anastomosis. The cephalic vein was transposed and the venous anastomosis was done [Figure 5d and e] and the flap settled.

Figure 5a.

Intra-operative defect

Figure 5b.

Excised specimen showing previous plate

Figure 5c.

Re-exploration showing venous thrombosis

Figure 5d.

Cephalic vein dissected

Figure 5e.

Revised venous anastomosis with cephalic vein

Case 3

A 38-year-old female underwent left side nipple preserving mastectomy for breast cancer. The whole breast reconstruction was done with free MSTRAM flap. There were nodes along the internal mammary chain and both the IMA and IMV were not suitable for anastomosis. Hence, the DIEA was anastomosed to the acromiothoracic artery and the DIEV was anastomosed to the cephalic vein [Figure 6a–d]. The venous drainage was adequate and the flap settled well.

Figure 6a.

Intra-operative showing defect on left side

Figure 6d.

Post-operative

Figure 6b.

Flap partial inset and lie of the vessels

Figure 6c.

Anastomosis A - DIEA to thoracoacromial artery, V - DIEV to cephalic vein

Case 4

A 34-year-old female underwent modified radical mastectomy and primary reconstruction with free MSTRAM flap. On exposing the internal mammary vessel, there were enlarged lymph nodes over the vessels [Figure 7]. Hence, the DIEA and one of the venae comitantes were anastomosed to the acromiothoracic artery and vein, respectively. The acromiothoracic vein was preserved and was of good caliber in this patient. Though the venous drainage was found to be adequate initially; there was diffuse congestion of the flap after 6 h post-surgery. On re-exploration, both the anastomosis was found to be patent with normal flow across the anastomosis. The other venae comitantes was distended and tense compared with the superficial veins. Hence, it was diagnosed that the venous drainage is insufficient and the other venae comitantes was anastomosed to the cephalic vein. The venous congestion was relieved and the flap settled well.

Figure 7.

Intra operative: Internal Mammary node

Case 5

A 44-year-old female patient had cancer of the left breast and underwent modified radical mastectomy. The patient had a lower abdominal midline vertical scar [Figure 8a] and hence only a right hemi-TRAM was planned. The DIEV had 2 venae comitantes and one was very small compared with the other. The IMV was also very small on the right side. Hence, the small venae comitantes was anastomosed to the IMV and the larger one was anastomosed to the cephalic vein [Figure 8b and c]. Though the SIEV was harvested, it was not distended and both the venous anastomosis done was adequate for drainage. The patient also had an incisional hernia for which a mesh repair was done.

Figure 8a.

DIEP flap donor site with vertical midline scar

Figure 8b.

Anastomosis details A1 - DIEA to IMA; V1 - DIEV1 to IMV; V2 - DIEV2 to CV

Figure 8c.

Post-operative

DISCUSSION

Primary free microvascular reconstruction has better quality of life in head and neck cancer patients.[1,2] Tributaries of internal jugular vein, external jugular vein, and the internal jugular veins are the most commonly used recipient veins for anastomosis of free flaps in head and neck reconstruction.[3] Rarely there is paucity/lack of good vessels at the recipient site. This is more common with veins than arteries. This may be due to scarring from previous surgery, Irradiation, injury during surgery, and removal of vessels in radical excision. Sometimes the vessel will be present but may not be of good quality. In post-radiotherapy scenario, there is a higher possibility of venous thrombosis and the arterial patency is not altered as shown in the rabbit model[4] and also demonstrated by Watson.[5] The alternatives in such cases are to look for vessels on the opposite side of the neck or using vein grafts to anastomose at a relatively virgin area. Anastomosis on the opposite side of neck requires a longer pedicle which is not always available. The use of vein graft increases the number of anastomosis thereby increasing the chances of occlusion. In such cases, the cephalic vein serves as alternate venous outflow channel from an uninvolved site, and also requires only a single anastomosis. The anatomical course and location of the cephalic vein allow good patency and straightforward harvesting.

The cephalic vein has been used as a source of vein graft[6] in microsurgery. Nakayama et al.[7] and Bhathena and Kavarana[8] used radial forearm flap with dissecting the cephalic vein up to the clavicle. Hence, only the arterial anastomosis has to be done. Patients undergoing total laryngopharyngectomy usually receive pre-operative chemotherapy and radiotherapy. Hence, when free intestinal transfer is planned for such cases, Vasilakis et al.[9] has demonstrated that cephalic vein transposition serve as a suitable source of venous drainage.

Free autologous tissue reconstruction is considered the optimal method for the patients undergoing breast resection.[10,11] In breast reconstructions with DIEP flap, the cephalic vein can be used to drain either the superficial or the deep system. The IMV wall is usually thin and practically is more fragile after neo-adjuvant chemotherapy. The IMV, particularly the left, is unsuitable for microsurgical transfer in approximately 20% of patients.[12,13] This figure is likely higher due to fibrosis and scarring in patients who have previously undergone mastectomy and radiation therapy of the internal mammary lymph node basin. Moreover, the presence of nodes along the internal mammary chain causes surrounding inflammation or may involve the vessel which precludes from using that vessel. In physiological conditions, the SIEV is the dominant venous drainage for the lower abdominal panniculus.[14] Hence, the venous drainage through the DIEV depends upon the communication between the superficial and the perforator veins. The clinical guidelines to do a second venous anastomosis of the superficial venous system are perforator vein size <1 mm,[15] SIEV >1.5 mm at waist crease level[16] and diffuses congestion of the flap after anastomosis of the deep system.[17] Blondeel et al.[17] found a lack of midline crossover by the SIEV in 36% of specimens. Hence, in these scenarios, to overcome the venous congestion, another anastomosis of the superficial vein is needed. The cephalic vein with a good caliber, being away from the irradiated field, with an appropriate lie and the anatomical location acts as a suitable alternative or additional venous drainage channel in such cases. Though the total number breast reconstruction with DIEP/MSTRAM flap was 60, only 23 cases (38%) required cephalic vein for different reasons as mentioned.

Barnett et al.[18] was the first one to describe the report of the use of cephalic vein in free microvascular breast reconstruction. Mehrara et al.[19] reported a large series of using external jugular vein and the cephalic vein as alternate venous outflow vessels in breast reconstruction. The disadvantage of using the external jugular vein is that it needs an additional access incision for dissecting the vein. The other sources of recipient vessel are thorocodorsal vessels[20] and acromiothoracic vessels. We do not prefer using the thorocodorsal vessels as the major bulk of the flap shifts laterally and the lattismus dorsi pedicle serves as a life boat, if the free flap fails. The acromiothoracic vein is small and thin walled as compared with the cephalic vein. Moreover, the pectoralis major muscle might also be removed in certain cases for tumour margins.

The cephalic vein has a relatively constant anatomy. Loukas et al.,[21] in a large study of the cephalic vein anatomy in the deltopectoral triangle has found that the cephalic vein could be absent in 5% of cases. The vein was superficial in the DP groove in 80% of patients and was deep in the remaining 20%. The cephalic vein had an average diameter of 0.8 ± 0.1 cm. In our series, we could easily identify the cephalic vein in the DP groove in all the patients and there was no anatomical variation.

Kim and Chandrasekhar[22] has described the salvage of free flaps in head and neck reconstruction using cephalic vein and enumerated the advantages of using cephalic vein transposition: (1) It requires only one venous anastomosis; (2) a long pedicle can be obtained to reach the mid-face or contralateral neck without undue tension; (3) the cephalic-subclavian system is a high flow low pressure system which can accommodate a high venous outflow from the head and neck; (4) this vein is usually located outside ablative surgical field, radiated tissue, and zone of injury; and (5) the size of vein is suitable for microsurgical anastomosis even when dissected as distal to antecubital fossa.

Hence, the cephalic vein can be considered a reliable and constant venous outflow channel in cases of head and neck reconstructions with free tissue transfer especially in previously operated and post-radiotherapy patients. Similarly, in breast reconstruction the cephalic vein with its appropriate lie, easy harvest and good caliber, can be used to drain the superficial or the deep venous system of the DIEP flap depending upon the requirement.