Vein Grafting in Free Flap Surgery for Head and Neck Oncology: Necessity, Innovation, or Complication?

Vein grafting may provide a valuable option in microvascular free flap reconstruction for head and neck cancer when direct anastomosis is not feasible. This study assesses indications and outcomes, reappraises prevailing assumptions, and delineates clinical contexts in which the technique could enhance reconstructive reliability and success.

This retrospective study evaluates the use of vein grafts in microvascular free flap reconstruction for head and neck malignancies. Among 51 consecutive patients treated at S. Marco Hospital, University of Catania (2021-2024), 11 underwent vein grafting. In 4 cases, grafting was adopted as a secondary measure following anastomotic failure or excessive vessel distance that precluded direct anastomosis; in 7, it was planned from the outset due to anticipated vessel misalignment or insufficient pedicle length. The external jugular vein served as the graft conduit in all cases.

Among 11 patients, 5 underwent radial forearm flap, 2 fibular flap, 2 anterolateral thigh (ALT), and 2 latissimus dorsi flap. Four patients underwent radiotherapy, whereas 2 are still awaiting evaluation. Only 1 case resulted in flap necrosis, requiring surgical revision. Complications were minimal, with 1 case of wound dehiscence. No cases of venous thrombosis, arterial insufficiency, or total flap loss occurred beyond the single necrosis case. The overall flap survival rate was 91%.

Vein grafting is a safe, effective adjunct for head and neck free flap reconstruction, particularly when pedicle-recipient mismatch or thrombosis precludes direct anastomosis, and can improve outcomes in complex cases.