Understanding the anatomic relationship between facial surface lines and underlying vascular networks is critical for safe dermal filler augmentation. This review presents a systematic taxonomy classifying facial surface changes into 5 categories-line, wrinkle, rhytid, crease, and fold-each with distinct vascular correlates that guide injection strategies. Creases and folds, forming at junctions between adjacent anatomic regions with differing tissue thickness, consistently overlie major arterial trunks that efficiently perfuse both sides. Key examples include the nasolabial, labiomental, preauricular, and corrugator creases, which serve as topographic markers for underlying vessels. Conversely, superficial wrinkles indicate more superficially coursing vessels, requiring deeper injection placement. Region-specific analysis reveals critical vascular landmarks: the supratrochlear and supraorbital arteries along the corrugator crease, the facial artery beneath the nasolabial fold, and the superficial temporal artery deep to the preauricular crease. Important venous structures, including the intercanthal vein at the nasal root and the angular vein traversing the nasojugal groove, pose additional risks due to cavernous sinus connections. This line-guided anatomic approach transforms visible surface features into a dynamic safety roadmap, enabling practitioners to preemptively identify high-risk vascular zones and select appropriate injection depths and techniques to minimize complications in facial aesthetic procedures.

Background. Here we present a diagnostically challenging case of ANCA-associated vasculitis (AAV) that initially presented with clinical features highly suggestive of giant cell arteritis (GCA). Case Report. An 80-year-old woman, with a medical history notable only for prior COVID-19 pneumonitis and a diagnosis of polymyalgia rheumatica (PMR) in 2024, presented to the emergency department in February 2025 with a three-week history of worsening pelvic and scapular girdle pain. Routine laboratory tests revealed elevated inflammatory markers (ESR 76 mm/h, CRP 16.8 mg/dL) and findings consistent with a urinary tract infection (UTI), with preserved renal function (GFR >60 mL/min). A presumptive diagnosis of a PMR flare triggered by the UTI was made, and antibiotic therapy was initiated. Due to the persistence of symptoms, she was referred to the rheumatology unit. A positive history of recent unintentional weight loss and new-onset jaw claudication emerged. Given the high clinical suspicion of giant cell arteritis (GCA), corticosteroid therapy was promptly initiated. Subsequent vascular ultrasound revealed intima-media complex thickening and a positive compression sign in the left frontal artery, along with moderate intima-media thickening of the right facial artery. While suggestive of GCA, these findings were insufficient for a definitive diagnosis. Following an initial symptom remission, corticosteroid tapering led to a relapse of jaw claudication and the new onset of widespread livedo reticularis. Additionally, previously absent signs of acute kidney injury (AKI) emerged, prompting hospital admission for further diagnostic workup. Laboratory testing revealed persistently elevated ESR and CRP levels, significant renal impairment (creatinine 1.67 mg/dL, GFR 29 mL/min), and positive anti-MPO antibodies (37.0 UI/mL). Over the following days, renal function deteriorated rapidly (creatinine rising to 2.2 mg/dL). Given the progressive AKI and ANCA-MPO positivity, a diagnosis of ANCA-associated vasculitis (AAV) with glomerulonephritis was established. Treatment included three intravenous methylprednisolone pulses followed by two 1 g rituximab infusions administered two weeks apart. A PET-CT scan performed shortly after steroid initiation showed no evidence of large vessel involvement. Furthermore, chest X-ray and electromyography revealed no abnormalities suggestive of other organ manifestations of AAV. At one-month follow-up, renal function had sligthly improved (creatinine 1.5 mg/dL, GFR 33 mL/min), while inflammatory markers and anti-MPO titers (5 UI/mL) had significantly decreased. The coexistence or sequential development of GCA and AAV, though rare, has been documented [Tab 1]. In our case, the absence of a temporal artery biopsy prevents the definitive exclusion of GCA and raises the possibility of an overlap syndrome, rather than an atypical manifestation of AAV mimicking cranial vasculitis. Conclusions. This case highlights the importance of considering alternative diagnoses in patients with atypical GCA presentations, particularly when temporal artery biopsy is unavailable.

Post-tonsillectomy hemorrhage (PTH) is a potentially life-threatening complication, often arising from arterial injury. We report a rare case of massive bleeding from the left tonsillar fossa following tonsillectomy in an 18-year-old male, secondary to a pseudo-aneurysm involving the lingual and facial arteries. The patient was successfully managed with endovascular covered graft placement due to the presence of an Aberrant ophthalmic artery, which precluded embolization. This case highlights the importance of early recognition of vascular injuries and individualized endovascular strategies in managing severe oronasal hemorrhage.

BackgroundIn recent years, the use of facial soft tissue fillers via cosmetic injections has steadily increased, along with the incidence of adverse events caused by injection vascular occlusion. We aimed to three-dimensionally visualize the anastomosis between facial soft tissue and the vascular system to enhance the safety and effectiveness of facial injections. A cadaver model was used to visualize facial anatomy. A red gelatin–lead oxide contrast agent was perfused to visualize the blood vessels, while 3.75% iodine-potassium iodide was used to stain the soft tissues. Micro-computed tomography scanning was then performed to capture detailed imaging results.ResultsWe successfully visualized both facial soft tissues and blood vessels simultaneously, including the two-dimensional distribution of vascular tissues and the three-dimensional hierarchical structure of the soft tissue. This allowed accurate assessment of the vascular flow and interconnections in the facial region.ConclusionsThis study provides a detailed three-dimensional representation of the facial vascular anatomy, particularly in the periocular area. By clarifying facial vascular anastomoses, this technique offers a valuable reference for promoting safer and more effective filler injections and reducing the risk of injection-related complications. Providing an interactive, high-resolution vascular dataset of a specific developmental stage. Promoting safe and effective injection of fillers provides a more reliable reference for reducing complications caused by injections.Supplementary InformationThe online version contains supplementary material available at 10.1186/s40902-025-00492-7.

As the popularity of non-hyaluronic acid (HA) injectables such as biostimulators rise in medical aesthetics, so have the rates of complications related to these injectables, including that of iatrogenic visual loss from vascular occlusion. The authors conducted a systematic review of the available literature on visual loss related to the most widely used biostimulator injectables including calcium hydroxylapatite (CaHA), polycaprolactone (PCL), poly-L-lactic acid (PLLA), and poly-D,L-lactic acid (PDLLA) to provide a report on the incidence of such events, as well as evidence-based management protocols. CaHA has at least 11 published cases of vascular occlusion causing visual impairment, most involving the nasal dorsum. PLLA has two confirmed reports of visual loss, one from injection to periorbital/nasal region, and another from injection to the temple. PDLLA- carboxy-methylcellulose (CMC) has two reported cases of visual loss, one from injection to the forehead, another from injection to glabella region. PDLLA-HA has one reported case of visual loss from posterior ischemic optic neuropathy (PION). PCL has no published cases of blindness but one case of facial artery embolism. An evidence-based management protocol includes a sound knowledge of anatomy and injectable characteristics, timely recognition of symptoms, immediate actions such as starting intraocular lowering agents and sending to the ophthalmologist, as well as supportive therapy such as hyperbaric oxygen, anti-inflammatory and anti-coagulation therapy. Our review and proposed management protocol is timely in guiding physicians of the recognition and management of vascular occlusion causing visual loss by biostimulator injectables, especially in a time of rising popularity of these injectables in medical aesthetics. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reconstruction of central facial regions, particularly the lower eyelid and lateral nasal areas, continues to pose significant challenges for plastic surgeons. These regions encompass multiple esthetic subunits, necessitating meticulous consideration of texture compatibility and tension-free closure within each unit. Although various perforator flaps-such as those based on the facial artery or supraorbital artery-have been employed for mid-cheek reconstruction, achieving optimal contour and esthetic integration of the periorbital and nasal subunits remains difficult. In this study, we investigate the application of an infraorbital artery (IOA) perforator flap for the reconstruction of the lower eyelid and lateral nasal region, aiming to improve postoperative esthetic outcomes. This study provides an anatomical description and its clinical applications. In a cadaveric study, eight hemifaces were used to illustrate the precise location of the IOA, and the flap and artery pedicle were dissected to confirm surgical feasibility. Between August 2022 and May 2024, four patients underwent surgery with IOA perforator flaps to repair their lower eyelid or nose. Anatomical Study: In anatomical dissections, the mean distance between the infraorbital artery (IOA) and the infraorbital rim was 10.12 ± 1.10mm, while the mean diameter of the IOA at its origin from the infraorbital foramen measured 1.50 ± 1.09mm. During the dissection of the IOAP and its accompanying nerves, the mean diameter of the perforating vessels was approximately 0.5mm. The length of the vascular pedicle that could be mobilized ranged from 2 to 4cm. In the clinical series, four patients underwent reconstruction with an IOA perforator flap. All flaps survived without signs of necrosis or vascular compromise, indicating excellent flap viability and reliable perfusion. According to the FACE-Q assessment scale, patients showed significant improvements in both esthetic appearance and functional outcomes. The infraorbital artery perforator flap represents a feasible and effective option for the reconstruction of defects involving the nose and lower eyelid, offering superior contour restoration of the periorbital and nasal regions compared to alternative techniques. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The transverse facial artery (TFA) is a key vascular structure supplying the lateral region of the face. Due to its central location, the artery is vulnerable to transection during lateral facial rejuvenation and other invasive facial procedures. This study aimed to determine the location of the TFA origin relative to two palpable bony landmarks: the head of the mandible and the upper border of the zygomatic arch. Thirty hemifaces from fifteen embalmed cadaveric heads were examined. Two palpable landmarks-the upper border of the zygomatic arch and the tip of the mandibular head-were marked using pins. After intra-arterial injection of a mixture of liquid latex and red acrylic paint, a vertical skin incision was made anterior to the tragus to expose the TFA origin. Vertical distances from the TFA origin to each landmark were then measured. In all specimens, the TFA originated from the superficial temporal artery. The mean vertical distance from the origin of the TFA to the upper border of the zygomatic arch was 26.6 ± 8.2 mm, and to the tip of the mandibular head was 17 ± 6.87 mm. The small diameter and deep anatomical location of the TFA complicate its visualization on radiologic imaging. However, its origin can be reliably approximated using palpable landmarks. Preoperative identification of these landmarks may reduce the risk of iatrogenic vascular injury and improve the safety of lateral facial interventions.

Abstract Partial glossectomy defects can be managed by different methods, ranging from primary closure to pedicled or free flaps. The facial artery musculomucosal (FAMM) flap provides an excellent match to lingual tissue and provides an inconspicuous donor site. This study aims to compare functional outcomes, especially speech, of patients with partial glossectomy defects (≤1/3rd of tongue) reconstructed by FAMM flap with those of similar defects closed primarily or healed by secondary intention. It also offers to resolve the question of whether defects of this size should be reconstructed at all. A total of 25 patients with T1 or T2 oral tongue cancer undergoing resection and reconstruction with islanded FAMM Flap were included in the prospective limb of the study. Retrospective comparison was done with patients of similar defects who had primary closure (25 patients) or were allowed healing by secondary intention (25 patients). Their peri-operative parameters and functional outcomes were compared. The FAMM flap group required longer duration of nasogastric feeds and overall hospital stay. Speech intelligibility, as assessed by a speech therapist after 3 months, was satisfactory in all the groups of patients. Results of subjective assessment of speech-related problems did not demonstrate any advantage to the flap group. Patients with small tongue defects, irrespective of method of repair, have good speech outcomes. There was no significant difference between flap and non-flap groups in objective speech intelligibility outcomes. The benefit of reconstructing defects less than or equal to one-third of the tongue is questionable.

Energy-based vessel sealing is a trusted technique in modern surgery. However, the application of mechanical clips over a thermally sealed vessel can paradoxically disrupt the integrity of the seal. A 55-year-old male underwent radical surgery for a retromolar trigone malignancy. The facial artery was sealed with LigaSure and secondarily clipped. On postoperative day four, torrential bleeding from the stump led to a cardiac arrest. Re-exploration revealed that the clip had transected the energy-sealed segment. Reinforcement clipping over energy-sealed stumps may compromise vessel integrity. If additional control is needed, clips should be applied before sealing, not after. This case highlights the need for adherence to energy device principles and avoidance of reinforcement clipping over thermally sealed vessels.

Tapia et al. originally described a flap from the superior part of the SMAS for malar enhancement during face-lifting procedures. The flap remained attached at its base (random type vascularization) and was folded to the malar area. We present a modification of this technique, raising the flap as an island, irrigated by the perforator of the transverse facial artery (which is consistently present at the infero-lateral border of the zygoma). The flap is completely isolated as an island and it is rotated 180° as a propeller to be placed in the pre-zygomatic space. The donor area is closed directly by advancement of the subcutaneous-SMAS, during the face lifting procedure. Immediate postoperative period was uneventful in all patients. Flap viability was proved intraoperatively by ICG - indocyanine-. A series of 42 patients underwent this procedure from 2022 to 2024. Long term results - evaluated clinically and with ultrasonography at one month and one year postoperatively- revealed that the volume remained permanent without reabsorption. Patient satisfaction was evaluated with a satisfaction scale resulted in high rate of excellent results. An anatomical study was performed in 14 fresh cadaveric specimens (28 hemifaces). The cutaneous branches of the transverse facial artery were dissected from its origin. They were consistently present in all the specimen giving branches to the subcutaneous - SMAS system. This modification of the original Tapia's flap reassures its vascularization. It allows a better flap in-setting and a longer medial reach in the tear trough area. Complete flap survival and long- term volume preservation was observed. The purpose of this manuscript is to describe the surgical technique of this modification of the Tapia's flap for malar volume enhancement, to mention the results of an anatomical study of the transverse facial artery, and to present the results of a retrospective analysis of 42 clinical cases who received this flap as part of their facelift procedure.

Buccinator myomucosal flaps (BMFs) have been proposed as a reconstructive solution for defects of the tongue and oral floor; however, their harvest requires preservation of the facial artery and vein. This study aimed to evaluate the oncologic safety of this approach compared with free fasciocutaneous flaps (FFF). A retrospective multicenter case-control study including cT1-T3 cN0 tongue/oral floor squamous cell carcinoma was performed. Cases received BMFs while controls received FFFs. The primary endpoint was progression-free survival (PFS) tested for non-inferiority. Secondary endpoints were overall survival (OS), disease-specific survival (DSS), and cumulative incidence of local, regional, and distant recurrence using competing-risk methods. A total of 615 patients (BMF n = 390; FFF n = 225) with comparable baselines were included. Five-year PFS was 69.8% (BMF) versus 66.2% (FFF); adjusted HR (FFF vs. BMF) 0.87 (95% CI: 0.43-1.78), meeting non-inferiority. Five-year OS was 77.9% versus 73.5%. Cumulative incidence of recurrence was similar: local 7.5% versus 8.3%, regional 6.3% versus 6.1%, and distant 2.1% versus 1.7%. Preservation of the facial artery and vein during selective neck dissection did not compromise oncologic outcomes. Facial-vessel-based BMFs are a valid option for small-to-medium tongue/oral floor defects in appropriately selected cN0 patients when meticulous level I clearance is performed and a pull-through resection is not required.

Nasolabial folds (NLFs) are a hallmark of facial ageing, and precise correction requires detailed anatomical and vascular mapping. High-resolution ultrasound offers real-time visualisation of soft-tissue layers, filler distribution, and vascular anatomy, enabling safer and more targeted injection. This study integrates ultrasound into the aetiologic classification and treatment algorithm for NLF correction in Korean patients, whose facial artery course and subcutaneous fat distribution differ subtly from Western populations. Fresh cadaver dissections were correlated with ultrasound imaging in 45 Korean patients presenting for NLF correction. NLFs were categorised into three aetiologic types-(1) volume deficiency, (2) tissue laxity, and (3) muscular tethering-based on both clinical and ultrasound assessment. Volume-deficient folds were treated with biphasic hyaluronic acid filler using a deep-then-superficial layering approach under ultrasound guidance, with real-time confirmation of injection depth and avoidance of vascular structures. Injection techniques included needle and cannula methods (Fern-leaf, Duck-walk)and hyaluronic acid filler (Lorient No 6 and 4, Joonghun Pharmaceutical) has been used. Global Aesthetic Improvement Scale (GAIS) scores and adverse events were recorded over 12weeks. Ultrasound allowed precise differentiation of superficial and deep fat loss patterns and identified individual variations in facial artery course in 38% of patients. Of the 45 patients, 20 (44%) had volume-deficient NLFs and underwent ultrasound-guided filler placement. GAIS improved from baseline "no change" (0) to a median "much improved" (2) at 12weeks, with no vascular compromise or filler malposition observed. Ultrasound also detected early filler integration and confirmed even distribution in targeted planes. Patients with laxity- or muscle-dominant folds, identified by ultrasound, benefitted from adjunct thread lifting or low-dose botulinum toxin. Ultrasound-guided, anatomy-based filler injection offers enhanced safety, precise plane targeting, and real-time monitoring of filler distribution in NLF correction. Integrating ultrasound into aetiologic classification improves treatment planning and reduces complications, particularly in populations with variable vascular anatomy. Larger controlled trials are recommended to validate long-term outcomes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Most studies of the ascending pharyngeal artery (APA) observed its different possibilities of origin. No evidence had been previously presented of either double or partly duplicated APAs. The anatomic variants reported here were found during the retrospective review of archived angioCT imaging data from two adult males, both aged 65years. In the first case, a double APA was found on the right side. The inferior APA and a linguofacial trunk had infrahyoid origins from the external carotid artery (ECA) and coursed over the greater horn of the hyoid. The superior APA had a suprahyoid origin from the ECA. On the left side, the APA, lingual, and facial arteries had infrahyoid origins and ascended on the inner side of the greater hyoid horn. In Case #2, there were two roots of the left APA, leaving the ECA above the greater hyoid horn. An anastomotic branch united the APA and the ascending palatine artery. A superiorly looped long sternocleidomastoid branch left the ECA proximally to the origin of the lingual artery. We brought here the first convincing evidence of double and, respectively, two-rooted (partly duplicated) APAs. These possibilities warrant caution during open-field surgeries. Care should be taken to the arteries expected to originate from the ECA at a distance from the greater hyoid horn because they can have infrahyoid origins and may course over or under this surgical landmark.

The Value of Facial Artery and Vein Preservation During Submandibular Sialo- Adenectomy

Transarterial chemoembolization (TACE) has recently emerged as a new alternative and palliative treatment option for head and neck cancers in human medicine, with a few case reports in veterinary medicine also showing good outcomes for canine oronasal tumors. Therefore, this study aimed to analyze the anatomical structures of canine head arteries using computed tomography angiography (CTA), focusing on the feeding arteries of oronasal tumors, as this information is essential for interventional procedures. This retrospective multicenter study used triple-phase CTA images of nasal tumors (n=30), oral tumors (n=31) (including one case of a caudal mandibular tumor with two tumors), and a control group (n=51). Among the 100 feeding arteries identified in the 61 oronasal tumors, the descending palatine artery (27/45; 60%) had the highest prevalence in nasal tumors. In rostral maxillary tumors, the infraorbital artery (10/24; 41.7%) was identified as the major feeding artery, whereas in mandibular tumors, the facial artery was the most prevalent feeder in both the rostral (4/4; 100%) and caudal (6/7; 85.7%) locations. Of the 222 head arteries observed on CTA, all lingual and facial arteries originated separately. The mean diameters of the major head arteries in different groups were significantly and positively correlated with body weight. However, when comparing the diameters of the head arteries normalized to body weight between the tumor feeder group and the control group, no significant difference was observed. This study provided comprehensive information on canine head arteries, including the feeding arteries of oronasal tumors, which is important for preprocedural planning.

Several preclinical animal models of face transplantation have been described in the literature with variable broad descriptions of surgical technique, but none with accompanying video with granular details of surgical dissection. In particular, the rodent hemifacial transplantation model has many advantages compared with other larger animals for its analogous anatomy to humans, vessel sizes appropriateness for anastomosis, cost, operation time, and ease of animal care. In this study, the authors describe a step-by-step surgical technique with video demonstration of face transplantation in a rodent model, allowing for high reproducibility of the procedure. Hemifacial transplantation procedures were performed on rodents. The vascular pedicle was based on the facial and superficial temporal arteries and the external jugular vein. End-to-side anastomosis of the common carotid arteries and end-to-end anastomosis of the external jugular veins between donor and recipient animals were performed. Animals did well postoperatively with adequate resuscitation and pain control regimen. Operative time can widely vary based on the surgeon's microsurgical skills and mostly based on the comfort level with the procedure. Taken together, this study describes a step-by-step surgical technique with video demonstration of face transplantation in a rodent model. This method is reproducible to anyone with microsurgical skills.

Complex facial defects resulting from trauma, cancer, or congenital genital disorders present significant challenges for reconstructive surgery. Traditional methods, such as local flaps and grafts, often yield suboptimal aesthetic and functional outcomes. Facial vascularized composite allotransplantation (fVCA) has become a valid option for extensive facial defects. The isolated transplantation of facial subunits, however, potentially allowing for a targeted restoration of smaller defects of individual subunits, is currently not implemented in clinical practice. This narrative review synthesizes findings from animal models, human cadaver studies, and clinical experiences to assess the feasibility, anatomical requirements, and immunosuppressive demands of facial subunit transplantation. We examined preclinical studies on vascular supply dynamics and rejection in transplanted tissues, particularly in animal models like nonhuman primates and rats, and cadaver studies focusing on vascularization strategies for facial subunits. Our results indicate that subunit transplantation is anatomically feasible, with established pedicle options for specific regions. Immunosuppression protocols similar to full-face transplantation are required, with preclinical models showing a critical need for optimized immunosuppressive management to prolong graft survival. Cadaver studies reveal that adequate vascularization can be achieved in subunits with the facial artery as the main pedicle. Facial subunit transplantation offers the potential for improved outcomes in selective facial reconstruction, particularly in functional and aesthetic-critical subunits. However, further advancements in immunosuppression and vascular planning are necessary for clinical application. Addressing these challenges could position subunit transplantation as a less invasive alternative for specific patient populations with tailored benefits regarding localized facial defects.

Abstract This case series presents four uncommon vascular anomalies of the carotid arterial system identified during routine cadaveric dissections. We describe atypical spatial arrangements between the internal carotid artery (ICA) and external carotid artery (ECA), including instances where the ICA is positioned medially relative to the ECA, and pronounced ECA curvature forming a 6.2 cm S-shaped loop. In addition, two rare branching configurations were noted: a linguofacial-laryngeal trunk giving rise to the lingual, facial, and superior laryngeal arteries, and an ascending pharyngeal-occipital trunk. These findings were observed in cadavers aged 65–72 years. The observed vascular irregularities have significant implications for head-and-neck surgeries, such as thyroidectomy, laryngectomy, and carotid endarterectomy, as well as for radiological assessments and interventional techniques. We explore the developmental origins of these anomalies, likely stemming from irregular vascular migration during embryogenesis. This series emphasizes the importance of clinicians recognizing potential carotid artery deviations to prevent procedural complications and optimize patient outcomes. By thoroughly documenting these cases, we contribute to the expanding knowledge base on vascular anomalies and their clinical significance.

Summary:This review presents a comprehensive analysis of nasolabial fold classification and correction using thread-lifting techniques. Three distinct types of nasolabial folds are identified: those caused by paranasal volume deficiency, differential tissue laxity, and muscular insertions. The study emphasized the importance of Lore fascia as a key anatomical landmark and optimal adhesion point for thread placement, offering advantages over the traditional temporal approach. The technique uses a combination of bidirectional threads (Sihler Bi Lift) for tissue repositioning and volumizing threads (Sihler Volume) for fine line correction. Special consideration is given to the anatomical course of the facial artery and its branches, particularly in Asian populations, where more than 70% of people demonstrate medial crossing of the nasolabial fold. This comprehensive approach enables effective correction while minimizing complications.

Abstract Microsurgical free tissue transfer has become the standard for complex head and neck reconstruction. One of the most feared scenarios is the so-called “vessel-depleted neck” (VDN), in which prior surgery, irradiation, or multiple reconstructions are thought to preclude suitable recipient vessels. However, definitions of VDN remain inconsistent, and many patients are not truly “depleted.” A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. PubMed and Web of Science were searched (1980–2025) using terms related to “vessel-depleted neck,” “recipient vessels,” and “head and neck reconstruction.” Eligible studies included case series, cohorts, and case reports describing reconstructive strategies following prior neck dissection, irradiation, or multiple reconstructions. Fifty-six reports met the inclusion criteria. In addition, we contextualized these findings with the Chang Gung Memorial Hospital (CGMH) experience of >10,000 microvascular reconstructions. The review identified a spectrum of recipient vessel options and technical innovations. Common second-tier choices included the transverse cervical vessels, superficial temporal system, and contralateral cervical vessels. Less common strategies involved cephalic vein transposition, internal mammary vessels, thoracoacromial, or subclavian system. Techniques to overcome pedicle length constraints included vein grafts, Corlett loops, vascular bridge flaps (VBFs), and in situ pedicle lengthening. Local and regional flaps, such as the pectoralis major (PM) and supraclavicular flaps, provided salvage options when free flaps were not feasible. At CGMH, even after multiple reconstructions, ipsilateral vessels (transverse cervical, superior thyroid, facial artery) remained usable in most patients, with contralateral or vein graft use required in fewer than 20%. The concept of a “VDN” is often overstated and may serve as a psychological barrier to optimal reconstruction. Most patients retain viable recipient vessels, and free flaps remain achievable with careful planning and surgical expertise. We advocate reframing these cases as “vessel challenged necks,” emphasizing technical demands rather than depletion, to improve decision-making and outcomes.