2026 Proffered Presentations
S214: THE USE OF INTERPOSITION VEIN GRAFTS FOR MICROVASCULAR RECONSTRUCTION OF THE SKULL BASE, SCALP AND SKULL - PRINCIPLES AND EXPERIENCE
Mark D DeLacure, MD; The Cleveland Clinic
The microvascular reconstruction of defects of the vertex or occipital scalp and calvarium represents one of the most challenging technical contemporary surgical feats Even in cases where superficial temporal vessels are avaialble as recipients, few defects will allow direct anatomosis to flap donor vessels - usually ALT or latissimus flaps. While length / reach is the principal limitation, caliber match and suitability (friable thin-walled vein) may exclude one of the vessel pairs and necessitate reach into the neck for a satisfactory recipient vessel (usually external jugular vein, or facial vessels). While the occasional attempt under less-than-optimal conditions will be successful, many are not, resulting in additional hours, frustration and morbidity.
The neuroreconstructive surgeon should be well-versed and facile with interposition vein grafting, and quick to use this solution, to achieve optimal length requirements, caliber match, and unrestricted flap insetting. The construction of acute A-V loops for vessel interposition, and of split anastomoses (one donor vessel to superifical temporal, the other to neck vessel target) are key. There is some lack of clarity to the dogma of "reversed" polarity grafting and it has been the author's experience over several deades of use, that prograde (anatomic flow) is more often the preferable polatiry in practice. The physiologic importance of the valvular system of the conduit is variable and in the event of an unfavorable flow geometry, the obstruction to flow becomes immediately appraent. In other cases, flow failure may become evident and be amenable to corrective maneuvers such as Fogarty catheter embolectomy and/or TPA thrombolytic therapy. When all else has failed, reversal of polarity of the interposed segment, has salvaged the effort. This phenomenen has been observed even several days after intermitent flow insufficiency, and rectified by revision of polarity. In short, there appears to be no absolute approach to the polarity observation. Valvulotomes have not been used by the author on the basis of theoretical intimal damage and percieved effect and risk in the microvascular context.
The pedicle course to the neck is usually, but not always, preauricular and closure itself must avoid adding resistance to flow. Here skin-only is most often the closure. A quarter inch penrose, or test tube micro drain, should be added here. The long pedicle runs are also susceptible to compression by hematomas from poorly clipped branch vessels (hand tie recommended) or on long, tuneled passages. The pedicle may be directly skin grafted (nonmeshed) here, where necessary. Fortunately, head movement does not add another potential length variable, unlike the head & neck region (e.g. kinking). For occipital reconstructions, the liberal use of headframes may be necessary for flap protection, to optimize flap safety.
The perioperative care of these high-altitude grafted patients must be meticulous and completely avoid extrinsic compression by over-the-ear eyeglass temples, or O2 cannulae. Progressive reintroduction of pressure from glasses and head wear follow over the months after surgery.
This presentation will cover all aspects of this architecture in the hands of a single surgeon over 3 decades of microsurgical practice in this area.