The supraclavicular artery flap: a versatile flap for neck and orofacial reconstruction

Supraclavicular Artery Island Flap for Head and Neck Oncologic Reconstruction: 15-year Experience, Past, Present, Future

Head and neck reconstruction poses unique challenges due to the complex structure of the region. Primary goals include soft-tissue coverage, adequate color and texture match, and minimal donor-site morbidity. Local and musculocutaneous regional flaps have largely been replaced with fasciocutaneous free flaps (FFF) over recent years. The supraclavicular artery island flap (SCAIF), a locoregional, fasciocutaneous, axially-based flap, has been shown to produce similar outcomes to FFF. We present our 15-year experience using the SCAIF for head and neck reconstruction, discuss its evolution, and provide case examples for its range of indications.

Methods

Retrospective chart review identified 128 patients who underwent reconstruction of the head and neck with the SCAIF between the years 2006-2021 at Tulane University Medical Center. Patient demographics, lengths of stay, operative times, surgical indications, and complications were recorded.

Results

The cohort mean age was 66.9 years. Mean lengths of stay and follow-up times were 6.9 days and 9.1 months, respectively. The most common indications for SCAIF reconstruction were recurrent radiated neck disease (n=27, 21.1%), pharyngeal wall defects (n=23, 18.0%), and parotidectomy defects (n=21, 16.4%). Overall complication rate was 17.2%. Partial thickness flap loss (5.5%), contained pharyngeal leak (3.2%), and distal tip necrosis (2.4%) were the most common complications. No functional donor site morbidity was encountered.

Conclusions

The SCAIF is a versatile, fasciocutaneous, axially-based flap able to produce similar outcomes to FFF in the reconstruction of the head and neck region while reducing costs, lengths of stay, operative times, and donor site morbidity.

A Comprehensive Review on the Supraclavicular Flap for Head and Neck Reconstruction

ABSTRACT

The supraclavicular artery flap (SCF) is a highly vascularized fasciocutaneous flap overlying the shoulder. The flap was first described in 1979 by Lamberty but did not gain popularity until much later due to lack of a reliable technique. The main advantages of using the SCF include avoiding microsurgical techniques, requiring only a single-stage operation, shorter operative time compared with alternative options, and a wider patient population including those with comorbidities who may be excluded from more extensive operations including free flaps surgeries. The SCF has been successfully performed on individuals with advanced age, poor nutrition, cachexia, obesity, diabetes, tobacco use, severe chronic obstructive pulmonary disease, hypertension, coronary artery disease, peripheral vascular disease, supraventricular tachycardia, atrial fibrillation, heart failure, asthma, and steroid use. The largest disadvantages of the SCF include the possibility of distal tip necrosis, size limitation without pre-expansion, and a moderately visible donor site scar. The following review and meta-analysis of the SCF details its use historically as both an island and a pedicle flap, and its application in head and neck reconstruction.

Revisiting the Cervicodeltopectoral Flap for Reconstruction of Cutaneous Head and Neck Defects: Technique Description and Clinical Presentation Correlates

STUDY DESIGN

Technique Description with clinical presentation Correlates.

PURPOSE

Revisit and discuss the advantages of the cervicodeltopectoral flap (CDP) as an alternative to microvascular reconstruction for head and neck cutaneous defects.

METHODS

Retrospective chart review was performed on 2 patients with prior large cutaneous facial defects after tumor resection followed by cervicodeltopectoral flap reconstruction. These cases were performed at a single institution. The tumor resections, flap reconstructions, and postoperative management were led by the listed senior author (SPK).

RESULTS

A 78-year-old (Clinical presentation 1) and 62-year-old (Clinical presentation 2) were evaluated for large nonmelanoma skin cancers of the face. Due to significant comorbidities, neither patient was an ideal candidate for microsurgical reconstruction. In both cases, lesion resection and CDP flap reconstruction was performed. The reconstruction allowed for successful coverage without significant donor site morbidity for each patient.

CONCLUSIONS

The authors propose the addition of the CDP flap to the armamentarium of the head and neck reconstructive surgeon as a safe and reliable alternative to microvascular reconstruction.

A 3D visualization layered anatomy for acromial arterial rete and flap design

BACKGROUND

The acromial arterial rete (AAR) is the junction between the skin blood supply of the cervical side and that of the upper arm, and it is the only site crossed by the trans-regional blood supply of the cervico-humeral flap (CHF). The aim of this study was to explore the structures of AAR to optimizing flap design.

METHODS

A body arteriography and spiral CT scan were performed on 33 whole adult corpses. The 3D reconstruction was used to perform continuous digital layered anatomy of the shoulder and upper chest; the acromion and acromioclavicular joint were used as the center to observe the source, route and distribution characteristics of a perforating branch and their anastomosis.

RESULTS

The perforating branches were separated from an acromial branch of the transverse cervical artery (97%), posterior humeral circumflex artery (95%), a deltoid branch of the thoracoacromial artery (95%), and the acromial branch of the thoracoacromial artery (93%). The diameter of the acromial branch of the transverse cervical artery at its initial location was 1.18 ± 0.37 mm; the trunk length was 12.53 ± 3.83 cm, and it was anastomosed with other blood vessels in three forms.

CONCLUSION

Deep fascia should be included in the flap design. Three kinds of pedicled transfer flaps can be designed with the acromial branch of transverse carotid artery as the vascular pedicle. Free flaps can be designed with the acromial branch of thoracoacromial artery as the vascular pedicle.

A twostep supraclavicular flap method in head and neck reconstruction for refractory osteoradionecrosis

Techniques of reconstructive surgery of the head and neck region have existed since Antiquity, with the pedicled forehead flap of Susruta as a reference. These methods are constantly evolving, with the introduction of free flaps in the 1980s, and more recently new technologies such as CAD-CAM. However, the surgical management of patients treated by radiotherapy for upper airway cancers remains a challenge in terms of functional and aesthetic results. Indeed, cervical irradiation, which alters the quality of skin and vascular tissue, jeopardizes good healing after head and neck reconstructive surgery. In this article, the authors proposed to revisit the standard technique of the pedicled supraclavicular flap. Flap design inspired from the known and described technique of the two-stage forehead flap, for the management of a fragile patient with refractory mandibular osteoradionecrosis.

Use of the supraclavicular artery island flap for reconstruction of maxillofacial defects: a case report and literature review

BACKGROUND

Free flaps are widely used in maxillofacial reconstruction; however, this approach was not feasible in the current case. It was not possible because the free flap method requires microvascular anastomosis expertise, which is difficult, time-consuming and costly.

CASE PRESENTATION

An 86-year-old woman suffered squamous cell carcinoma on the right side of her face, which resulted in a large soft-tissue defect. Here, we present a case of facial reconstruction from the inferior margin of the jaw to the top of the head. The size of the defect was 18.5 cm × 7.5 cm, which is rare for a patient of this age in the maxillofacial area. We used the supraclavicular artery island flap (SCAIFP) which measured 19.3 cm × 8.3 cm to repair the defect. After the operation, the flap survived without complications. Then, the patient was followed for 10 months and was satisfied with the aesthetic and functional results at the donor and recipient sites following the tumour resection. The tumour did not recur, and facial nerve function was preserved.

CONCLUSION

Our results provide a new choice for the reconstruction of large defects of the head and face, and expand the potential applications of the SCAIFP.

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.

Contemporary reconstruction after complex facial trauma

Complex facial trauma requires complex repair and solutions. This process is challenging for the surgeon who seeks to manage the expectations of the patient and family while achieving the best possible result. Historically, the use of pedicled flaps, and then free tissue transfer, were the primary techniques utilized. Advancements in soft-tissue reconstruction, such as perforator flaps and pre-expanded and prefabricated flaps, allow refinement of the soft-tissue reconstruction process to create the best initial soft-tissue coverage. The advent of contemporary technologies, such as virtual surgical planning, stereolithography and customized implants and plates, facilitates a tailored approach to the patient’s reconstructive needs for precise bony reconstruction. When surgical and technological techniques are combined in complementary multistage reconstructions, better reconstructive and aesthetic outcomes are achievable than ever before. In this review, the authors present a summary of the management of complex facial trauma based on the senior author’s broad experience. Initial management and contemporary reconstructive techniques and technology to provide optimal outcomes are reviewed. A case series of complex facial traumas and their reconstructive process is also presented to demonstrate how complementary staged procedures can yield an optimal result. We believe the reconstructive surgeon managing complex facial trauma should strive to incorporate contemporary technologies and techniques into their armamentarium to provide the best patient care.

Subclavicular flap: A valid reconstructive option among anterior chest flaps in oral cancer patients

BACKGROUND

The subclavicular pedicled flap is based on the thoracic branch of the supraclavicular artery, and it represents a versatile reconstructive option for low-middle third face defects. Since its use in head and neck surgical oncology has not been popularized yet, we propose its application for oral cavity reconstruction after cancer resection by showing favorable results.

METHODS

Eighteen subclavicular pedicled flaps were used to treat intraoral defects after oral squamous-cell cancer resection between June 2015 and December 2018. Tumor dissection type, complications, donor and reconstructed area results, and functional and aesthetic outcomes were assessed.

RESULTS

No major complications were observed and all of the flaps survived. Adjuvant therapy was administered without delay when needed, and all of the patients had normal functional outcomes and good aesthetic results.

CONCLUSIONS

The subclavicular flap is an excellent choice for the reconstruction of oral cavity defects. Selection of patients should exclude positive lower-third neck node and include appropriate informed consent for women due to the possibility of deformity of the breast. In our opinion, this flap has the potential for common application given its consistent anatomy and donor site advantages, including long pedicle, high pivot point, and relatively unlimited flap width.

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.

The supraclavicular artery island flap: a salvage option for head and neck reconstruction

Background

Some of head and neck cancer patients are in compromised general condition after ablation surgery and chemoradiation therapy, which makes secondary free tissue transfer quite challenging. Elderly cancer patients also have some risk for microvascular surgery with lengthened general anesthesia. In those cases, the pedicled flap vascularized by supraclavicular artery could be considered as an alternative to free flap. Despite several authors have demonstrated the clinical reliability of supraclavicular artery island flap (SCAIF), to date, SCAIF has not been widely used among reconstructive surgeon. In this article, we clarified vascular flow pattern and introduce simple surgical technique of SCAIF with a literature review.

Case presentation

Three patients who had underwent previous neck surgery and adjuvant therapy received maxillofacial reconstruction using SCAIF. It required only a few landmarks, flap harvesting was carried out, and the elapsed time gradually decreased to 15 min with experiences. There were no remarkable morbidities in both donor and recipient sites.

Conclusion

SCAIF exhibited minimal anatomic variations and short learning curve of surgical techniques, which might be valuable reconstruction modality for beginning surgeon. And it can be beneficial option for the patients with vessel-depleted neck, medically compromised status for lengthened general anesthesia and failed free tissue transfer.

Otolaryngology resident experience with supraclavicular, submental and other regional flaps in the United States

OBJECTIVE

Despite the resurgence in regional flap use, otolaryngology resident regional flap experience has been incompletely studied. We sought to characterize United States (US) otolaryngology resident exposure to, and perceptions of, supraclavicular flaps (SCFs), submental flaps (SMFs), and other regional flaps.

METHODS

An online survey was disseminated every two weeks to 106 US otolaryngology residency program directors for distribution to residents within their programs between August and October 2016. 121 surveys were returned of which 106 were sufficiently completed and eligible for data analysis.

RESULTS

Among residents with adequate responses, 52 were postgraduate year (PGY) 1-3 (junior) residents and 54 were PGY 4-7 (senior) residents. Senior residents participated in more pectoralis major flaps (mean: 8.1, 95%-CI: 6.5-9.8) compared to SCFs (mean: 1.5, 95%-CI: 1.0-2.0, p < 0.001) and SMFs (mean: 0.7; 95%-CI: 0.4-1.0, p < 0.001). Among senior residents exposed to SCFs, SMFs and pectoralis flaps, more individuals judged pectoralis major flaps as successful or very successful (96.2%, 95%-CI: 91.1-100%), compared to SCFs (64.3%, 95%-CI: 46.5-82.0%; p < 0.001) and SMFs (63.2%, 95%-CI: 41.5-84.8%; p = 0.001).

CONCLUSIONS

Senior otolaryngology residents were exposed to fewer SCFs and SMFs compared to pectoralis major flaps. Resident perception that SCFs and SMFs were not as successful as pectoralis major flaps should be investigated further.

Vascularized dermal autograft for the treatment of irreparable rotator cuff tears

BACKGROUND

Irreparable rotator cuff tears (IRCTs) are a challenging problem with diverse treatment modalities. We propose a technique for the treatment of IRCTs in which a vascularized dermal autograft is transferred to the posterosuperior region of the rotator cuff using the supraclavicular artery (SCA) island flap.

MATERIALS AND METHODS

Dissection of 11 fresh cadavers (19 shoulders) was performed, and the SCA island flap was harvested in all specimens. A full-thickness posterosuperior rotator cuff defect was created, and the flap was tunneled under the acromion and secured into position over the defect using multiple suture anchors. Simulated flap perfusion was then assessed, and flap measurements were recorded.

RESULTS

There were 4 male and 7 female cadavers (19 shoulders). Flap perfusion was assessed in 10 shoulders. On average, the flap thickness was 4.7 mm (range, 3.5-7.1 mm); width, 32.6 mm (range, 25.5-38.0 mm); and length, 169.2 mm (range, 132.0-235.0 mm). The average distance from the flap tip to the Neviaser portal was 76.2 mm (range, 48.0-99.6 mm), and that from the flap tip to the anterolateral acromial edge was 54.1 mm (range, 29.5-75.1 mm). The pedicle-to-footprint distance was 113.7 mm (range, 88.5-147.0 mm). The average flap length exceeded the pedicle-to-footprint distance by 55.5 mm (range, 43.5-88.0 mm), indicating adequate excursion of the flap. All flaps demonstrated adequate simulated perfusion after fixation.

CONCLUSION

The SCA island flap may be an option for a vascularized dermal autograft for IRCTs, as shown in this cadaveric study. This illustrates a possible technique with vascular viability.

Cervicofacial-facial artery myocutaneous flap (C-FAM flap): A novel flap in oral cavity reconstruction

BACKGROUND

Reconstruction is an integral part of the surgical management of oral cancer. Local flaps are one of the options in reconstruction of small to moderate sized defects of oral cavity. Reconstruction is an integral part of the surgical management of oral cancer. Every defect needs to be assessed individually to tailor made the reconstruction because of its multidimensionality and complexity. Varieties of autologous tissues are being used in reconstruction like local, regional, or free flaps which can be simple or complex tissues. There is always a trend to identify the newer flaps/technique to personalize reconstruction. Local flaps are also one of the options in reconstruction of small to moderate sized defects of oral cavity. Local tissue if it is available is in the primary surgeon's purview and the flap can be raised without much technical difficulty and morbidity. We used perforator based tissue from the face and neck which is richly supplied by the facial vessels and named as the Cervicofacial- Facial Artery Myocutaneous flap (C-FAM flap) for reconstruction of oral cavity.

METHODS

We used perforator based local tissue from the face and neck which is supplied by facial vessels and named it as the C-FAM flap for the reconstruction of oral cavity defects.

RESULTS

Twenty-eight patients underwent C-FAM flap reconstruction in different subsites of the oral cavity with acceptable functional rehabilitation. There was no flap loss.

CONCLUSION

The C-FAM flap is a robust flap, which is reliable, pliable, and rich in its vascularity. It has to be one of the armamentarium for the oral cavity reconstruction. C-FAM flap: A Novel flap in Oral cavity reconstruction.

Transverse Cervical Artery Perforator Flap: Standardized Surgical Technique and Multiple Reconstructive Opportunity in Head and Neck Surgery

The main purpose of head and neck reconstructive surgery is to provide anatomic restoration of the demolited region and to provide preservation and recovery of function. The anatomical investigations conducted over the years has enabled a detailed knowledge of human body vascularization, giving the opportunity to design and harvest more and more versatile and refined flaps, with increasingly satisfactory results. Even if in the last 2 decades free flaps have been considered a reconstructive criterion standard, they still determine a great physical impact for the patient and require a certain surgical experience. In particular, perforator flaps (based on vessels that, emerging from the main deep axis, supply superficial myofascial cutaneous tissues) represent the new reconstructive frontier, of which a wide variety of types has been described. Our purpose is to illustrate the preparation and harvesting of the transverse cervical artery perforator flap and the variety of its utilization in head and neck reconstruction. From February 2005 to May 2015, 41 reconstructions were performed, and not only for oncologic reasons. Thanks to its anatomical features, reduced donor site morbidity and rapid preparation, this flap is a safe and feasible alternative to most famous free and locoregional flaps. Because our outcomes in functional and aesthetic terms were mostly satisfying, we can assert that the transverse cervical artery perforator flap has an important role in an appropriate reconstructive strategy for head, neck, and oropharyngolaryngeal region.

The pre-expanded subclavicular island flap: A new tool for facial reconstruction

BACKGROUND

The anterior chest is an excellent donor site for cervicofacial reconstruction. Studies of chest flaps began as early as 1988 at our institution. We identified a new branch of the supraclavicular artery that nourishes the anterior chest, and on the basis of this finding, we created a new flap called the subclavicular flap. Unlike the supraclavicular flap, which is pedicled by the deltoid branch, this flap is primarily pedicled by the thoracic branch, and it shares similar vascular territory with the deltopectoral flap. In China, this flap has been widely used for neck reconstruction since our first publications on it in 1993. However, reports of its application are limited. To popularize the use of this flap, we present our experiences with pre-expanded subclavicular island flaps for the repair of facial scars.

METHODS

Fifteen patients with facial scars underwent reconstruction with these flaps. All flaps underwent pre-expansion before being transferred to the face through a subcutaneous tunnel. The pivot point was in the supraclavicular region and allowed the flap to reach the mid-face without compulsive positioning. Donor sites were closed primarily.

RESULTS

Flaps sizes ranged from 4 cm × 5 cm-10 cm × 17 cm. Fourteen flaps survived completely with satisfactory colour and texture. Total flap loss occurred in one patient, who was then treated by harvesting a skin graft from the dying flap. One patient experienced venous congestion, and the flap was successfully salvaged by pure vein anastomosis.

CONCLUSION

Pre-expanded subclavicular island flaps have similar benefits to supraclavicular and deltopectoral flaps, and they may emerge as one of the best choices for cervicofacial reconstruction globally.

The use of supraclavicular free flap with vascularized lymph node transfer for treatment of lymphedema: A prospective study of 100 consecutive cases

BACKGROUND AND OBJECTIVES

Vascularized lymph node transfer (VLNT) is gaining popularity for treatment of lymphedema. The purpose of this study was to evaluate the flap and the donor site morbidity of the supraclavicular (SC) VLNT.

METHODS

A review of a prospective database was performed for patients who had undergone SC VLNT to treat upper or lower extremity lymphedema. Flap and donor site complications were registered for each patient. A detailed technical surgical approach is explained.

RESULTS

One hundred consecutive patients with lower or upper extremity lymphedema underwent SC VLNT (84% from the right side) with a mean of 11-months follow-up (range 3-19 months). There were no flap loss but three flaps (3%) required re-exploration due to venous congestion of the skin paddle. Two patients had local infection and three patients developed chyle leak (3%) at the donor site but resolved spontaneously. No donor site secondary lymphedema was noted.

CONCLUSIONS

This is the largest prospective series of SC free flap VLNT for treatment of lymphedema. Low flap and donor site morbidity makes this flap an appealing source of lymph node transfer for lymphedema treatment. J. Surg. Oncol. 2017;115:68-71. © 2016 Wiley Periodicals, Inc.

Anterolateral thigh adipofascial flap in mucosal reconstruction

IMPORTANCE

This study describes a reliable technique for mucosal reconstruction of large defects using components of a common free flap technique.

OBJECTIVE

To review the harvest technique and the varied scenarios in which the anterolateral thigh adipofascial flap (ALTAF) can be used for mucosal restoration in oral cavity and nasal reconstruction.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of the medical records of 51 consecutive patients was conducted. The patients had undergone ALTAF head and neck reconstruction between January 2009 and June 2013. Each case was reviewed, and flap survival and goal-oriented results were evaluated.

RESULTS

Thirty patients met the inclusion criteria and were included in the analysis. The mean patient age was 60.6 years. Reconstruction sites included the tongue, palate, gingiva, floor of the mouth, and nasal mucosa. All mucosal reconstructions maintained function and form of replaced and preserved tissues. One patient (3%) experienced flap failure that was reconstructed with a contralateral adipofascial flap with excellent outcome. Three patients (10%) required minor flap revisions. There were no other complications.

CONCLUSIONS AND RELEVANCE

The ALTAF is a versatile flap easily harvested for use in several types of mucosal reconstructions.

Pre-expanded cervico-acromial fasciocutaneous flap based on the supraclavicular artery for resurfacing post-burn neck scar contractures

OBJECTIVE

Post-burn cicatricle contractures of neck pose a challenge for plastic and reconstructive surgeons. To improve functional and cosmetic results, and to minimize the donor-site morbidity, we use pre-expanded cervico-acromial fasciocutaneous flap based on the supraclavicular artery as a feasible choice for resurfacing large skin defects of the neck.

METHODS

In this series, from 2008 to 2012, 18 patients with ages ranging between 11 and 42 years (20 flaps with 2 patients in bilateral fashion) suffering from post-burn scar contractures of the neck were treated. In the first stage, an expander was implanted on the deep fascia layer of the cervico-acromial region; 600 to 800 mL of saline was then injected during a 10- to 16-week period. In the second stage after expansion, sufficient skin and tissue was obtained to resurface the defects of the neck after releasing the contractures and excision of post-burn scars.

RESULT

All 20 flaps healed primarily with good functional and cosmetic results. The maximum size was 23×16 cm, whereas the minimum was 20×8 cm. After an average follow-up time of 12 months, significant improvement in range of motion with good esthetic outcomes were achieved, and the scars in donor sites seemed acceptable. There ware no significant complications.

CONCLUSIONS

The pre-expanded cervico-acromial fasciocutaneous flap based on the supraclavicular artery can provide a large amount of thin tissue with both good color and texture, and without the need for microsurgery, and avoid the disadvantages of donor-site morbidity. This flap is reliable and safe for resurfacing large skin defects of the neck.

Safety of the supraclavicular artery island flap in the setting of neck dissection and radiation therapy

BACKGROUND

The supraclavicular artery island flap (SAIF) has recently been repopularized as a versatile and reliable option for reconstruction of oncological head and neck defects. Prior ipsilateral neck dissection or irradiation is considered a relative contraindication to its use. The aim of this study was to describe the safety and utility of the SAIF for head and neck reconstruction in the setting of neck dissection and radiation.

METHODS

A retrospective chart review was performed of consecutive SAIF reconstructions at two institutions between May 2011 and 2014. In addition to demographic data, comorbidities, indications, surgical characteristics, data about radiation treatment, and neck dissection were specifically recorded. Donor and recipient site complications were noted. Fisher exact test was performed to analyze if neck dissection or radiation were associated with complications.

RESULTS

A total of 22 patients underwent SAIF reconstruction for an array of head and neck defects. Donor site infection was noted in one patient. Recipient site complications included, wound dehiscence (n = 2), orocutaneous fistula (n = 1), carotid blowout (n = 1), and total flap loss (n = 1). There was no association between prior neck dissection or radiation treatment and flap loss (p = 1.00).

CONCLUSION

The SAIF is safe for use in patients who have had an ipsilateral neck dissection involving level IV or V lymph nodes and/or radiation treatment to the neck. It can be used alone or in combination with other flaps for closure of a variety of head and neck defects.

Palliative reconstructive surgery: contextualizing palliation in resource-poor settings

Introduction. Palliative care in Kenya and the larger Sub-Saharan Africa is considered a preserve of hospices, where these exist. Surgical training does not arm the surgeon with the skills needed to deal with the care of palliative patients. Resource constraints demand that the surgeon be multidiscipline trained so as to be able to adequately address the needs of a growing population of patients that could benefit from surgical palliation. Patients and Methods. The author describes his experience in the management of a series of 31 palliative care patients, aged 8 to 82 years. There were a total of nine known or presumed mortalities in the first year following surgery; 17 patients experienced an improved quality of life for at least 6 months after surgery. Fourteen of these were disease-free at 6 months. Conclusion. Palliative reconstructive surgery is indicated in a select number of patients. Although cure is not the primary intent of palliative surgery, the potential benefits of an improved quality of life and the possibility of cure should encourage a more proactive role for the surgeon. The need for palliative care can be expected to increase significantly in Africa, with the estimated fourfold increase of cancer patients over the next 50 years.

The supraclavicular artery flap for lateral skull and scalp defects: effective and efficient alternative to free tissue transfer

Objectives Describe the use of the supraclavicular artery flap for reconstruction of lateral skull and scalp defects. Discuss advantages and potential limitations of the supraclavicular artery flap.

Design Case series.

Setting Tertiary care academic medical center.

Participants Patients undergoing lateral scalp and skull base resections.

Main Outcome Measures Effectiveness in reconstructing lateral skull base defects and complications.

Results All three patients reconstructed with the supraclavicular artery flap had excellent reconstructive outcomes. There were no flap losses, either complete or partial. There were no major complications, but one patient had a significant donor site dehiscence requiring local wound care. Referred sensation to the shoulder was alleviated by division of the sensory innervations into the flap.

Conclusions The supraclavicular artery flap is an excellent option for lateral skull and scalp defects, and donor site morbidity is limited. It should be considered as an alternative to free tissue transfer.

The supraclavicular artery island flap (SCAIF) for head and neck reconstruction: surgical technique and refinements

OBJECTIVE

We have found the supraclavicular artery island flap (SCAIF) to be a reliable, first-line tool for the reconstruction of complex head and neck defects. Here, we review our technique of flap elevation and summarize the current literature citing important contributions in the evolution of this flap.

DATA SOURCES

Medline literature review of supraclavicular artery island flap or shoulder flap in head and neck reconstruction with particular emphasis on developments within the past 5 years.

REVIEW METHODS

Literature review of technique, indications, anatomy, modification, and outcomes of the supraclavicular artery island flap.

CONCLUSION

The supraclavicular artery island flap is an important and reliable option in head and neck reconstruction. We use the flap routinely in our practice as a first-line technique when fasciocutaneous soft-tissue reconstruction is required, and we provide a detailed summary of the flap elevation and inset.

IMPLICATIONS FOR PRACTICE

The supraclavicular artery island flap is a safe, reliable, technically simple, sensate, thin, pliable fasciocutaneous regional flap option that has low morbidity. It provides sensate, single-stage reconstruction for a variety of head and neck defects and should be considered as a first-line option in head and neck reconstruction.