Debunking the “Vessel Depleted Neck”—Study of 52 Patients With More Than Three Reconstructions

Background: Recurrences, complications, or unfavorable results in head and neck cancer can be treated surgically, including major flap reconstruction. The “vessel depleted neck” may lead to unnecessarily heroic solutions and even prevent surgeons from attempting free flaps. Method: Prospectively collected cases performed by the senior surgeon between 2015 and 2023 were analyzed. They included patients with three or more major flap reconstruction attempts in the head and neck region with a follow-up of at least 6 months. Results: A total of 52 patients were included; 143 flaps (76.9%) were used for reconstructions after malignant cancers, and 43 (23.1%) for non-malignant. A total of 186 flaps, with 178 and 8 respectively for free and pedicle flaps, were performed, with an average of 3.58 (±0.871) flaps per patient. Overall flap survival was at 96.1%, with seven failures (3.9%). Partial flap necrosis occurred in 2 flaps (1%). The average length of the flap pedicle was 8.72 cm (5-18 cm). Eighty-eight flaps (47.3%) were performed after radiotherapy, and vein grafts were only used in 7 out of 178 free flaps (3.9%), with three vein grafts to the contralateral neck. In 35 out of 178 free flaps (19.7%), the recipient vessels were from the contralateral neck. A prior history of radiotherapy is associated with an increased use of contralateral recipient vessels (Odds ratio 4.3, p = 0.001). Conclusion: The concept of a “vessel depleted neck” remains ambiguous, as viable recipient vessels can often still be identified. Rather than assuming vessel depletion, a more precise assessment of available options is warranted to guide reconstructive planning and optimize surgical outcomes.