The Rolling Fingers Test

The superficial temporal vessels are crucial and reliable recipient vessels in head and neck reconstruction.[1] [2] They are especially useful in vessel-depleted necks but have to be tunneled to reach.[3] As such, these vessels are often susceptible to external compression, twisting, or stretching forces. Compression of these small calibre vessels is a common cause of free flap failures and can occur up to one week postoperatively.[1] [4] To avoid any vascular compression, creating a wide tunnel that can accommodate the flap pedicle is mandatory.

Unfortunately, there is no fail-safe way of performing this procedure using conventional techniques described in the literature. Some surgeons advocate a two-finger width tunnel.[5] [6] However, assessing the subcutaneous width using this method is not reliable, especially in the midpoint between the preauricular area and the oral cavity. Postoperative inflammation, edema, or swelling may easily compress the pedicle, resulting in vascular compromise. These risks are further increased with extensive dissection in previously operated or irradiated patients.

We describe a novel technique that reliably increases the safety of pedicle tunneling during flap inset. This technique, apart from being used for blunt dissection of the subcutaneous tunnel, also provides the crucial tactile feedback required to eliminate any compression points within the tunnel. This is an important step in eliminating a potential cause for pedicle compression and vascular compromise.

We use facelift scissors to perform the initial dissection in the chosen subcutaneous plane. We then place a finger side-to-side within the tunnel to stretch the subcutaneous tissues while performing blunt dissection. The fingers are then rolled upon each other within the tunnel in a circular motion. This allows for a 360 degree feel for the tunnel width while evaluating the soft tissue stiffness and the laxity of the skin at the same time. Multiple septae from the superficial muscular aponeurotic system to the superficial skin are present within the face and can form constricting bands within the tunnel.[7] If constriction bands are encountered, blunt dissection can be performed to ensure adequate release. We provide an endoscopic view demonstrating this technique, with particular focus on the improved width of the tunnel ([Fig. 1]). The ease in performing the rolling maneuver of fingers demonstrates the adequate release of constricting bands within the tunnel ([Fig. 2]).

Fig. 1 Counter-clock rolling of both fingers inside the tunnel after digital dissection.

Fig. 2 Before and after further digital dissection around 360 degrees of the tunnel walls to ensure adequate release of subcutaneous septae.

This technique provides tactile feedback, which is a key difference from other techniques described in the literature. It allows the surgeon to assess the tunnel for any potential compression points thoroughly, which is not possible with instruments alone. A direct path to the superficial temporal vessels is also created which may not be possible with a single digit or instruments alone. This will ensure the pedicle does not kink within the tunnel. It also facilitates soft tissue dissection, allowing for safer tunneling of flap pedicles.

• References

• 1 Hansen SL, Foster RD, Dosanjh AS, Mathes SJ, Hoffman WY, Leon P. Superficial temporal artery and vein as recipient vessels for facial and scalp microsurgical reconstruction. Plast Reconstr Surg 2007; 120 (7) 1879-1884
• 2 Doscher M, Charafeddine AH, Schiff BA , et al. Superficial temporal artery and vein as recipient vessels for scalp and facial reconstruction: radiographic support for underused vessels. J Reconstr Microsurg 2015; 31 (4) 249-253
• 3 Shimizu F, Lin MP, Ellabban M, Evans GRD, Cheng M-H. Superficial temporal vessels as a reserve recipient site for microvascular head and neck reconstruction in vessel-depleted neck. Ann Plast Surg 2009; 62 (2) 134-138
• 4 Revenaugh PC, Fritz MA, Haffey TM, Seth R, Markey J, Knott PD. Minimizing morbidity in microvascular surgery: small-caliber anastomotic vessels and minimal access approaches. JAMA Facial Plast Surg 2015; 17 (1) 44-48
• 5 Hao S-P, Cheng MH. Cancer of the buccal mucosa and retromolar trigone. Oper Tech Otolaryngol Head Neck Surg 2004; 15 (4) 239-251
• 6 Futran ND, Wadsworth JT, Villaret D, Farwell DG. Midface reconstruction with the fibula free flap. Arch Otolaryngol Head Neck Surg 2002; 128 (2) 161-166
• 7 Sandoval SE, Cox JA, Koshy JC, Hatef DA, Hollier LH. Facial fat compartments: a guide to filler placement. Semin Plast Surg 2009; 23 (4) 283-287