Impact of Flap Size and Comorbidities on Supraclavicular Artery Island Flap Outcomes

Objective

Use of the supraclavicular artery island flap (SCAIF) in head and neck reconstruction has increased in recent years. Limited but improving experience among reconstructive surgeons with the procedure have exposed numerous issues associated with flap success. The objective of this study is to examine the role of flap size on viability.

Study Design

Retrospective case series.

Setting

Tertiary Academic Medical Center.

Methods

Review of patients undergoing SCAIF reconstruction between January 2014 and March 2022 was performed. Flap failure was defined as >50% skin paddle loss. The total flap surface area was examined. Multivariable analysis was performed to evaluate the association of other variables associated with flap failure.

Results

Eighty-nine supraclavicular island flaps were reviewed. Mean patient age was 63.2 ± 11.4 years. Fifty-five (61.2%) were male. Forty-five flaps (50.6%) were used for the reconstruction of defects of the skin of the neck/face. Twenty-nine flaps (32.6%) were utilized for defects of the pharynx/oropharynx, and 15 (16.9%) were utilized for oral cavity defects. Flap success rate was 94% (73/89). Flap site was not associated with flap failure (P = .46). Flaps >25 cm2 were 75% more likely to be successful. Multivariable logistic regression to assess the association of flap size in the context of other co-morbidities indicated flaps >25 cm2 were 3.6 times more likely to succeed regardless of co-morbidities, and patients with chronic obstructive pulmonary disease (COPD) have a 7-fold risk of flap failure (odds ratio: 7.3, 1.72-30.98, P = .007).

Conclusion

An association with improved flap outcomes and larger skin paddles was observed in this series. The applicability of these observations to smaller flaps and larger series with more surgeons requires further study. Co-morbidities, particularly, COPD, continue to impact flap outcomes.

Regional Flap Donor Sites in Head and Neck Reconstruction

Regional flaps are vital to head and neck reconstruction, allowing surgeons to harvest numerous reliable flaps without the need for microvascular anastomosis. These flaps are very useful in cases of vascular depletion and may prove superior to free flaps as a primary option in certain circumstances. Numerous harvest options are available, and the described harvest techniques are safe and straightforward for an experienced reconstructive surgeon to learn. Donor site morbidity is variable depending on flap selection but minimal in many cases. Regional flaps are an excellent option in resource-limited settings or when minimizing reoperation is a high priority.

Experience of using a supraclavicular flap in reconstruction of oral cavity defects

Introduction. In case of cancer of the oral mucosa at the first stage, the standard treatment approach is radical surgical intervention, with the formation of extensive defects leading to aesthetic and functional disorders. Taking into account the characteristics of defects, choosing a flap is a difficult task. Currently, there is a wide selection of regional and microvascular free flaps. However, not all flaps meet the requirements. The supraclavicular fasciocutaneous flap, being a regional flap, has a number of advantages: easy to harvest, reliable due to the constancy of the vascular pedicle, primary closure of the donor site, scarcity of hair, the possibility of closing various defects of the oral cavity.

 Aim. To evaluate the possibility of using a supraclavicular flap in patients with oral cancer to restore the defects after surgical treatment.

Materials and methods. The study included 10 patients with malignant tumors of the oral cavity who underwent surgical intervention with defect replacement using supraclavicular flap at the N. N. Blokhin National Medical Research Center of Oncology between February of 2015 and May of 2021. In 4 cases, buccal mucosa was affected; in 3 cases, the retromolar area; in 1 case, oral floor mucosa; in 1 case, mandibular alveolar ridge; in 1 case, mobile tongue. Flap sizes were 5–10 × 5–8 cm. Three (3) patients had history of radiotherapy, and 1 of them had a radical dose.

Results. In 4 patients without previous radiotherapy, partial flap necrosis was observed. In 1 patient, sutural diastasis in the oral cavity after partial flap necrosis was diagnosed. There were no cases of total flap necrosis and fistula formation. Suture dehiscence in the donor bed was observed in 1 patient only.

Conclusion. Use of supraclavicular flap is an option for oral cavity defect replacement after surgical intervention in patients with malignant tumors of the oral cavity producing satisfactory esthetic and functional results. The advantages of this flap are simple flap dissection, reliability of vascular pedicle, flexibility, possibility of replacing large defects, scant hair coverage.

Is Supraclavicular Artery Island flap (SAI) a viable alternative to Free Tissue Transfer (FTT) in head and neck reconstruction? A systematic review and meta-analysis

PURPOSE

The aim of this study is to compare the outcomes of Supraclavicular Artery Island (SAI) Flap versus Free Tissue Transfer for head and neck reconstruction.

METHODS

We performed a systematic review of MEDLINE (via PubMed), Scopus and Cochrane Library database according to the PRISMA guidelines. Only comparative studies between the two techniques were included. Random-effects model meta-analyses were performed.

RESULTS

Eight studies, reporting a total of 402 patients and same number of flaps, 165 of which underwent reconstruction using supraclavicular artery island flap and 237 reconstructed with free tissue transfer were identified. No statistically significant differences were observed regarding major complications, total flap necrosis, partial flap necrosis, post operative fistula formation, donor site dehiscence, recipient site dehiscence and total flap area.

CONCLUSION

Supraclavicular artery island flap and free tissue transfer seem to be comparable when used in head and neck reconstruction.

Regional pedicled flap salvage options for large head and neck defects: The old, the new, and the forgotten

Objectives

The objective of this article is to review options for regional pedicled reconstruction for large head and neck defects in a salvage setting.

Methods

Relevant regional pedicled flaps were identified and reviewed. Expert opinion and supporting literature were used to summarize and describe the available options.

Results

Specific regional pedicled flap options are presented including the pectoralis major flap, deltopectoral flap, supraclavicular flap, submental flap, latissimus flap, and trapezius flap.

Conclusions

Regional pedicled flaps are useful options in a salvage setting even for large defects and should be in the armamentarium of any reconstructive head and neck surgeon. Each flap option carries specific characteristics and considerations.

Supraclavicular Artery Flap versus Skin Graft: Which Is a Better Reconstructive Tool for Managing Post-Burn Contractures in the Neck

BACKGROUND

Burn in developing countries still has high burden of inadequately managed severe burns. This study compared supraclavicular artery flap and skin graft in managing neck post-burn contractures.

METHODS

In National Institute of Rehabilitation Medicine and Pakistan Institute of Medical Sciences, Islamabad, Pakistan, 30 patients with neck post-burn contractures were enrolled. Half of patients randomly underwent supraclavicular artery flap and half received skin graft. The outcome measures including initial improvement in neck extension, patient’s satisfaction with color-texture-match and recurrent contracture formation rate were assessed.

RESULTS

Among patients, 80% were female and 20% were male. Preoperatively, each group had post-burn contractures of grade II among 26.66% of patients, grade III among 60% and grade III among 13.3%. Postoperatively after three months in the two groups, 86.66% improved to grade I and 13.3% improved to grade II. Patient’s satisfaction with color-texture was 84.66% in supraclavicular artery flap group, whereas it was 42.66% for skin graft group. Complications were hypertrophic scar at donor site (13%) and flap tip necrosis (6.66%) in supraclavicular artery flap group. In skin graft group, partial skin graft loss was noticed among 33% of patients and delayed healing of donor site among 20%. The recurrent contracture formation rate at one year was 73.33% in skin graft group, whereas there was no case of recurrent contracture in supraclavicular artery flap group.

CONCLUSION

Supraclavicular artery flap was superior to skin graft in managing post-burn neck contractures. It provided better color-texture match and was associated with no recurrence of contracture formation.

Application of the Expanded Neck Flap for Face and Ear Reconstruction in Burn Patients: A Report on 2 Cases

Reconstruction of auricular deformities and facial scars after burns is a challenging undertaking for surgeons. Excessive scar tissue, a poor blood supply and the paucity of available skin are all substantial difficulties that should be considered before the operation. Expanded neck flaps provide comparatively larger and thinner flaps for the simultaneous treatment of auricular deformities and facial scars in burn patients. In this article, the authors introduced the use of an expanded neck flap as coverage tissue for ear reconstruction and face resurfacing in 2 burn patients. The operation consisted of 3 stages. In the first stage, the expander was implanted subcutaneously under the skin of the neck to create adequate skin and soft tissue. In the second stage, the expander was removed, and the expanded flap was transferred to cover defects on the auricle and face. The third operation to repair the reconstructed ear and thick flap could be performed according the willingness of the patients and surgeons. Esthetically satisfactory results were achieved in both of the patients. The flaps survived completely, and the skin color, texture, and flexibility were well matched to those of the peripheral tissue. Six months postoperatively, the flaps did not shrink, and subsequent contractures did not recur. Both of the patients experienced high satisfaction, and no adverse effects were detected.

Supraclavicular Artery Island Flap: Critical Appraisal and Comparison to Alternate Reconstruction

OBJECTIVES/HYPOTHESIS

The supraclavicular artery island (SAI) flap may be a good option for selected head and neck reconstruction due to its reliability, ease of harvest, and favorable color match. The objective of this study was to examine the rates of complications for the SAI flap in head and neck oncologic reconstruction, with examination of risk factors and comparisons to alternative flaps often considered the gold-standard soft-tissue flaps for head and neck reconstruction: the pectoralis myocutaneous (PMC), radial forearm free flap (RFFF), and anterolateral thigh (ALT) flaps.

STUDY DESIGN

Retrospective cohort study.

METHODS

Consecutive SAI flaps were compared to PMC, RFFF, and ALT flaps (non-SAI flap group), all performed by the senior author from 2010 to 2018. The non-SAI flaps were included if an SAI flap could have been performed as an alternate flap. The groups were compared based on demographics, flap dimensions, site of reconstruction, operating time, total hospital stay, total hospital costs, and complications.

RESULTS

One hundred seven SAI flaps and 194 non-SAI flaps were identified. SAI flaps were used less commonly than non-SAI flaps for mucosal defects (P < .001). The SAI flap dimensions were narrower but longer than non-SAI flaps (P < .001). SAI flaps had higher rates of total complications, partial flap necrosis, flap dehiscence at the recipient site, fistula, donor site dehiscence, and minor complications compared to non-SAI flaps (all P < .05). SAI flaps had higher rates of total complications, recipient site dehiscence, fistula, and minor complications in both the oral cavity and all mucosal sites compared to non-SAI flaps (all P < .05). SAI flaps for mucosal reconstruction were associated with higher rates of total complications (54% vs. 34%, P = .04), flap dehiscence at the recipient site (32% vs. 14%, P = .03), and major complications (21% vs. 5%, P = .02), compared to cutaneous reconstruction. Complications were equivalent between SAI flaps and non-SAI flaps for cutaneous reconstruction (all P > .05). Multivariate analysis showed that SAI flaps were associated with any postoperative complication (odds ratio [OR]: 3.47, 95% confidence interval [CI]: 1.85-6.54), partial flap necrosis (OR: 5.69, 95% CI: 1.83-17.7), flap dehiscence (OR: 5.36, 95% CI: 2.29-12.5), donor site complications (OR: 11.6, 95% CI: 3.27-41.0), and minor complications (OR: 5.17, 95% CI: 2.42-11.0). Within the SAI flap group, SAI flap length >24 cm was associated with postoperative complications on multivariate analysis (OR: 5.09, 95% CI: 1.02-25.5, P = .048).

CONCLUSIONS

The SAI flap is best suited for cutaneous reconstruction of the face, neck, and parotid/temporal bone regions due to the favorable color match; the thin, pliable nature of the skin; ease of harvest; and equivalent complication rates compared to alternate soft-tissue flaps. However, the SAI flap is associated with more complications for oral cavity and mucosal site reconstruction when compared to RFFF and ALT flaps and should be used in selected cases that do not require complex folding. For all sites, flaps longer than 24 cm should be used with caution.

LEVEL OF EVIDENCE

3 Laryngoscope, 2020.

Supraclavicular flap practice patterns and outcomes: A survey of 221 AHNS surgeons

OBJECTIVES

To describe American Head and Neck Society (AHNS) surgeon supraclavicular flap (SCF) practice patterns and to identify variables associated with SCF complications.

METHODS

The design is a cross-sectional study. An online survey was distributed to 782 AHNS surgeons between November 11, 2016, and December 31, 2016. The primary outcome was frequency of SCF complications. Independent variables included demographics, training, practice patterns, and SCF techniques.

RESULTS

Adequate survey responses were obtained from 221 AHNS surgeons. Among these, 54.3% (n = 120) performed supraclavicular flaps (SCFs). Most surgeons used the SCF for cutaneous (n = 85; 78.7%) or parotid-temporal bone (n = 59; 54.6%) defects. Nearly one-third (n = 31; 29.8%) of surgeons experienced more than a "few" SCF complications. Surgeons experienced fewer pectoralis major flap (P < 0.001) and radial forearm free flap (P < 0.001) complications compared to SCF complications. Univariate analysis demonstrated no association between surgeons with "few" SCF complications and Doppler use in SCF design (P = 0.90), harvest location (P = 0.51), and pedicle skeletonization (P = 0.25). Multivariable logistic regression revealed that surgeons performing more than 30 SCFs compared to less than or equal to 30 SCFs had a greater odds of having "few" SCF complications (odds ratio 7.1, 95% confidence interval [1.1-43.9], P = 0.04).

CONCLUSION

A majority of surgeons performing SCFs use the flap to reconstruct cutaneous and parotid-temporal bone defects. The significance of relatively higher SCF complications compared to other routine flaps should be explored further. Surgeon experience with the SCF appears to be significantly associated with SCF success, whereas training characteristics, practice patterns, and technical variations may not be associated with SCF outcomes.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2012-2019, 2019.

Systematic Review of Supraclavicular Artery Island Flap vs Free Flap in Head and Neck Reconstruction

OBJECTIVE

The aim of this systematic review is to compare the surgical outcomes of supraclavicular artery island flap (SCAIF) and free tissue transfer (FTT) in head and neck reconstruction.

DATA SOURCES

PubMed, Web of Science, and EMBASE databases.

REVIEW METHODS

Independent screening and data extraction were performed by 2 authors. Only studies that directly compared SCAIF and FTT were included. Data were pooled with random-effects meta-analysis to determine the standardized mean differences (SMDs), risk differences, and 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistics. The Methodological Index for Non-Randomized Studies tool was used to evaluate extent of bias in studies.

RESULTS

The initial query yielded 661 results, of which 4 comparative studies remained for final analysis. The pooled sample sizes for the SCAIF and FTT cohorts were 100 and 84, respectively. SCAIF was associated with reduction of operative time by a large effect size (SMD, 1.65; 95% confidence interval, 0.78-2.52). The harvested flap areas and perioperative complications, including rates of total flap loss, partial flap necrosis, and recipient/donor site dehiscences, were comparable between the 2 procedures with low to high heterogeneity among studies.

CONCLUSION

SCAIF requires less operative time and has comparable short-term perioperative results to FTT. The findings of this study support the viability of SCAIF as an alternative to FTT and provide evidence for its inclusion in the reconstructive armamentarium of major head and neck ablation and trauma.

Update on the supraclavicular flap

PURPOSE OF REVIEW

The purpose of this study is to describe the supraclavicular flap and its utility in head and neck reconstruction in the context of recent studies.

RECENT FINDINGS

Current literature regarding the supraclavicular flap has described its expanded uses in a variety of head and neck reconstructive settings. Its reliability and limited morbidity have been well demonstrated, and it has been cited as a reasonable alternative to other reconstructive options including, in some situations, free tissue transfer.

SUMMARY

The supraclavicular flap has shown dependability in reconstruction of defects in the head and neck, and it warrants consideration among reconstructive surgeons, especially for circumstances in which free tissue or other pedicled flaps are less than ideal.

Locoregional Flaps for Oral Cavity Reconstruction: A Review of Modern Options

Objective

To review state-of-the-art modifications and advances in soft tissue local and regional flap reconstruction of the oral cavity and to determine the role these techniques play in current practice.

Data Sources

Review of the literature regarding oral cavity reconstruction.

Review Methods

The authors describe advances in locoregional reconstructive options and assimilate data from the literature that compare recent advances to the historic standards.

Conclusions

Modern advances in regional reconstruction of the oral cavity offer outstanding results and demonstrate potential advance over free tissue transfer. These modifications demonstrate the prominent role that regional reconstruction can play in oral cavity reconstruction.

Implications for Practice

With a more complete understanding of these options, the surgeon is better able to tailor the reconstruction to the needs of the patient to provide high-quality cost-effective care.

Pre-expanded Supraclavicular Artery Perforator Flap

The supraclavicular artery perforator (SAP) flap is a versatile flap for the reconstruction of head and neck defects. Recently, the authors have modified the SAP flap by using an anterior branch of the transverse cervical artery. The anterior SAP flap allows the harvest of a tissue island in the deltopectoral fossa, which is even thinner, is more pliable, and shows a superior color match to the face and neck compared with the original SAP flap. Pre-expansion increases flap size considerably, enabling the coverage of extended defects without the need of microsurgery.

Risk factors for surgical site infection after supraclavicular flap reconstruction in patients undergoing major head and neck surgery

BACKGROUND

Surgical site infections can adversely affect flaps in head and neck reconstruction. The purpose of this study was to evaluate the risk factors of surgical site infections in supraclavicular artery island flap reconstructions.

METHODS

Records of patients undergoing head and neck surgery from 2011 to 2014 with supraclavicular artery island flap reconstruction at a single specialty hospital were reviewed; surgical site infections ≤30 days postoperatively were noted.

RESULTS

Of 64 patients, 86% underwent resection for malignancy, 55% previously received radiation. Sixty-three percent of surgeries were clean-contaminated. Seven patients (11%) developed recipient site surgical site infections, all in patients who underwent clean-contaminated surgery for malignancy. There was no complete flap loss. No significant differences in demographics or perioperative factors were noted. Oral cavity and laryngeal reconstructions (p = .014) and clean-contaminated surgery (p = .04) were factors associated with increased surgical site infection risk on univariate but not multivariate analysis. Patients with surgical site infections had longer hospitalizations (p = .003).

CONCLUSION

The supraclavicular artery island flap can be used for head and neck reconstruction with a low rate of surgical site infection. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Comparison of Perioperative Outcomes between the Supraclavicular Artery Island Flap and Fasciocutaneous Free Flap

Objective

Outcomes of the supraclavicular artery island flap (SCAIF) have not been extensively studied in comparison with free tissue transfer (FTT) flaps for head and neck reconstruction. We hypothesize that the pedicled SCAIF has decreased operating room time, length of stay, time to wound healing of recipient site, complications, and hospital charges as compared with FTT.

Study Design

Case series with chart review.

Setting

Tertiary care teaching hospital.

Subjects and Methods

Medical records were reviewed for patients who underwent SCAIF (n = 45) or FTT (n = 28) reconstruction between 2011 and 2013.

Results

Total operating room time was significantly lower for the SCAIF group vs the FTT group (6.7 vs 8.1 hours, P = .002). Procedural time was 5.7 hours for the SCAIF group, as compared with 7.2 hours for FTT group ( P = .0015). Mean area for SCAIF donor site was 63.89 cm2 vs 81.8 cm2 for the radial forearm free flap group ( P = .015). There was no significant difference in mean length of stay between SCAIF (8.8 days) and FTT (11 days, P = .12). Mean length of time to wound healing of the recipient site was similar in the SCAIF group vs the FTT group (17.3 vs 22.1 days, P = .071). Ratio of total hospital charges for SCAIF were 32% lower than that of FTT ( P = .0001).

Conclusion

This is among the first studies to compare SCAIF with FTT in a large cohort analysis. We find decreased operating room times for SCAIF vs FTT, with similar length of stay and wound healing. Other outcomes between SCAIF and FTT were also comparable.

Shoulder function following reconstruction with the supraclavicular artery island flap

OBJECTIVES/HYPOTHESIS

The supraclavicular artery island flap (SCAIF) is a pedicled fasciocutaneous flap used for head and neck reconstruction. In recent years, its use has significantly increased as a result of several advantageous characteristics, including pliability, an excellent color and texture match, ability to reconstruct a variety of skin and aerodigestive tract defects, and short harvest times. Clinical experience suggests that donor site complications are relatively infrequent and typically self-limiting, and there have been no documented cases of prolonged or permanent shoulder dysfunction. However, formal studies have not been performed to assess this outcome. The goal of this study was to evaluate the effects of SCAIF flap harvest on postoperative shoulder strength and flexibility.

STUDY DESIGN

Prospective cohort pilot study.

METHODS

Data was gathered prospectively during routine follow-up and surveillance. The Penn Shoulder Score and Constant Shoulder Scale were used to measure subjective and objective outcomes. Physical therapists performed testing for strength and flexibility.

RESULTS

Ten patients were evaluated from January to July, 2013. Subjective self-reporting of shoulder function and satisfaction was good to excellent in most patients. The majority of patients demonstrated limitations in range of motion for one or more shoulder movements. Muscle strength was preserved postoperatively.

CONCLUSION

Harvest of the SCAIF appears to have limited postoperative morbidity. Postoperative shoulder strength and function appears to be very good; however, some limitation of range of motion was observed.

LEVEL OF EVIDENCE

4