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

Versatility of the supraclavicular artery island flap for head and neck reconstruction

Objective

To present our experience using the supraclavicular artery island flap (SCAIF) for head and neck reconstruction.

Methods

We performed a retrospective chart review to identify patients who underwent head and neck reconstruction with SCAIF at our institution. The following data were collected: age, sex, surgical indications, flap harvest time, flap dimensions, length of hospital stay, complications, and clinical outcomes.

Results

Thirty-three patients underwent SCAIF reconstruction, of whom four underwent pectoralis major myocutaneous flap reconstruction simultaneously. Twenty flaps were used to repair pharyngeal or esophageal defects following resection for tonsillar, hypopharyngeal, laryngeal, and cervical esophageal cancers. Five flaps were used for tracheal reconstruction following resection for tracheal or thyroid gland cancer. Seven flaps were used for reconstruction of cervical skin defects or fistulas related to a previous treatment. One flap for tracheal stenosis following tracheotomy. The mean age of the patients was 60.69 ± 11.47 years. The mean flap harvest time was 32.00 ± 4.44 min. The mean flap size was 10.16 ± 3.91 × 5.78 ± 0.68 cm. The mean length of hospital stay is 24.84 ± 13.78 days. Three patients had partial necrosis of the distal portion of the flap, which resolved with anti-infection therapy and local wound care. One patient developed a fistula that was resolved with wound care and further surgical intervention. Complete flap loss or major complications were not observed. No donor site complication or compromised shoulder function was observed.

Conclusion

The SCAIF can be successfully used to reconstruct head and neck defects with good outcomes and limited morbidity.

Level of Evidence

4.

Effect of Preoperative Neck Radiotherapy on the Reconstruction of Head and Neck Defects With the Supraclavicular Artery Island Flap

Purpose: The supraclavicular artery island (SAI) flap is commonly used in the reconstruction of head and neck defects. However, the safety of SAI flaps for neck irradiated patient needs to be verified. To investigate the safety of using the SAI flap for patients who have undergone neck radiotherapy, as well as the risk factors for flap complications. Materials and Methods: Sixty-one patients (16 irradiated and 45 nonirradiated) with SAI flap-reconstructed head and neck defects were included, and relevant data were collected retrospectively. The gender, age, body mass index, presence of diabetes mellitus, preoperative albumin level, and flap size between irradiated and nonirradiated patients had no significant difference. Results: No significant difference was observed in the incidence of complications (total, mild, or severe) between the radiotherapy and nonradiotherapy groups. In univariate analysis, preoperative radiotherapy was not associated with postoperative complications of the SAI flap procedure (P = 1.00), while a low preoperative albumin level was a significant risk factor for postoperative complications (P < .05). Conclusions: Our data suggest that preoperative radiotherapy does not increase the risk of SAI flap postoperative complications compared with surgical reconstruction alone.

Application of supraclavicular island flap in oral and maxillofacial reconstruction

Several surgical modalities are available for maxillofacial reconstruction as locoregional or microvascular free flaps.

PURPOSE

(a) Evaluate the reliability of the supraclavicular flap in cervico-orofacial region; (b) investigate the role of computed tomography angiography (CTA) in predicting the post-operative viability of the flap; (c) assess the speech, feeding, and esthetics after reconstruction using this flap.

METHODS

Eleven patients included in this study underwent either conventional or delayed harvesting of the supraclavicular flap (SCF). All the patients had diagnostic computed tomography angiography (CTA) of the supraclavicular flap before the surgery.

RESULTS

The mean harvesting time of the flap was 45.45 ± 4.16 min. The average length of the flap was 22.64 ± 1.12 cm, whereas the mean width of the flap was 6.14 ± 1.14 cm. The flap survived in 9 patients, while two patients had complete flap loss. After the surgery, three patients complained of speech difficulties. Two patients had swallowing problems. After the surgery, three patients complained of speech difficulties. Two patients had swallowing problems. Only two patients complained of weakness in the donor site. None of the patients reported that the weakness or pain at the donor site affected their daily activities or quality of life.

CONCLUSION

The pedicled SCF represents a safe and feasible option that can be used to reconstruct a wide array of maxillofacial oncologic defects. However, a study with a larger sample size is recommended to achieve more reliable clinical results for the modified delayed technique modification in terms of their effect on the survival of the supraclavicular flap.

Supraclavicular Artery Island Flap for Treatment of Cervical Wound Defects and Persistent Cerebrospinal Fluid Leaks: A Technical Note and Systematic Review of the Literature

BACKGROUND

Soft tissue defects and persistent cerebrospinal fluid (CSF) leaks can create complications after cervical spinal surgery. The supraclavicular artery island (SAI) flap is useful in closing tissue defects, particularly in these complex surgeries and multiple reinterventions. However, technical reports in this context are scarce. We describe application of the SAI flap technique to control persistent CSF leak in the first documented instance (to our knowledge) of a low-grade fibromyxoid sarcoma (LGFMS) in the cervical epidural space. Additionally, we conducted a comprehensive review of PubMed, Embase, and Google Scholar from their earliest records through December 17, 2023 using combined terms, "supraclavicular artery island flap AND spine" and "supraclavicular AND flap AND spine".

TECHNICAL NOTE

A 56-year-old woman with arm pain and weakness presented with a cervical epidural mass extending from C4-C6 and associated spinal cord compression. She underwent a 3-level corpectomy and tumor resection. Primary dural closure was impossible due to the dural invasion, and reintervention with an SAI flap and definitive lumboperitoneal shunting were required to control and seal the CSF leak.

SYSTEMATIC LITERATURE REVIEW

Seven case reports describing SAI flap for spinal surgery complications were identified. The indications in those cases were correcting esophageal and hypopharyngeal perforations after cervical fusion and discectomy and persistent soft tissue coverage after cervical instrumentation.

CONCLUSIONS

The SAI flap technique provided wound defect coverage in this case and is suitable for addressing issues such as persistent CSF leaks or soft tissue coverage after cervical spine surgery.

The Supraclavicular Artery Island Flap for Pharynx Reconstruction

The supraclavicular artery island flap (SCAIF) is a reliable, easy-to-harvest and versatile fasciocutaneous flap that can be used for pharynx reconstruction. Instead of free flaps, it requires no microsurgical technique, reduced operating time and postoperative care, making it an ideal option, especially during the COVID-19 pandemic. The primary aim of our study was to present two cases of a total laryngectomy and reconstruction with the SCAIF during the pandemic. The secondary aim was to review the literature concerning surgical techniques, complications and contradictions of the SCAIF for pharynx reconstruction. A literature search was performed using the PubMed, ScienceDirect, Wiley Online Library, Google Scholar, Scopus and Cochrane Library databases, using MeSH terms: larynx AND reconstruction AND flap. Ten full-text articles comprising 92 patients with 93 supraclavicular flaps were included. The patch graft, pharyngeal interposition graft, tubularization or "U"-shaped SCAIF were the main surgical techniques. Pharyngocutaneous fistula was the most frequent postoperative complication, especially in patients with previous radiotherapy, but just 19% of patients required secondary intervention. The lack of donor-site morbidity, low flap loss rates and stenosis rates favored this reconstructive option. This review underlined that the SCAIF has comparable results with other reconstructive options, consolidating this flap in the workhorse of pharynx reconstruction.

Reconstruction of Soft Tissue Defects on the Face, Neck, and Chest by Expanded Cervico-Acromial Flap

BACKGROUND

Repairing the defects of face and neck remains a big challenge for plastic surgeons. Here we present a case series of pre-expanded cervico-acromial flaps in the repair of soft tissue defects.

METHOD

This is a retrospective study that a total of 126 patients between 2001 and 2019 were included. One patient was excluded since he did not complete the treatment. All patients were followed for at least 0.5 years (range: 0.5-4 years, mean 2.50 years) after surgery.

RESULTS

All patients are satisfied with the appearance. The color and texture of expanded flaps were similar to surroundings. One patient (0.8%) had complete necrosis and received skin grafts. The size of cervico-acromial was 26-10 × 14-6 cm (mean, 15.389 ± 2.701× 8.341 ± 1.075 cm). The time of operation during stage 1 was 59.254 ± 9.895 minutes, 96.912 ± 18.936 minutes during stage 2, and 38.146 ± 9.478 minutes during stage 3. Surgical complication rate was 14.3%, given that 18 patients had complications following the surgery.

CONCLUSIONS

The cercico-acromial flap is a reliable and multifunctional method for face, neck, and chest reconstruction.

Regional Salvage Flap Options in Head and Neck Reconstruction

Microvascular free tissue transfer is the standard in the complex head and neck reconstruction with success rates greater than 95%. Free tissue transfer allows for more versatility in reconstructing complex defects with better tissue match. Failures, however, do occur and subsequent free tissue transfer might not be an option due to either the patients' health or in a vessel depleted neck. In these challenging salvage scenarios, the head and neck reconstructive surgeon must turn to regional flaps for reconstruction. Here, we review multiple regional flap options for salvage head and neck reconstruction.

Application of the Supraclavicular Artery Island Flap for Fistulas in Patients With Laryngopharyngeal Cancer With Prior Radiotherapy

OBJECTIVE

To evaluate the effect of the supraclavicular artery island flap (SAIF) in reconstructing pharyngocutaneous fistula in patients with laryngopharyngeal cancer with prior radiotherapy.

METHODS

Six patients with laryngopharyngeal cancer with pharyngocutaneous fistula due to previous radiotherapy and surgery during 2016 to 2019 were retrospectively analyzed. Initially, the fistula was treated conservatively. The SAIF was applied with double folding technique to reconstruct fistula in the patients who failed to heal after conservative treatment.

RESULTS

The fistulae closed in 4 patients after conservative treatment. After SAIF operation, fistula closure was achieved in the other 2 patients who received highest dose of radiation and had largest fistulae size. The flaps grew well and there were no donor-site complications in these 2 patients. All patients achieved oral feeding without any complications.

CONCLUSION

The SAIF is an effective and safe approach to reconstruct the pharyngocutaneous fistula after laryngopharyngeal surgery in patients with laryngopharyngeal cancer with previous radiotherapy, especially for those who have received high-dose radiation and have large fistula.

Versatility of the Supraclavicular Flap in Head and Neck Reconstruction

Objective: Head and neck oncologic resections often leave intricate defects whose reconstruction remains a challenge. The pedicled supraclavicular artery perforator flap is an emerging option, and its applicability in head and neck reconstruction is gaining popularity. Methods: A retrospective analysis of patients regarding medical history, surgical indication, surgical technique, postoperative complications, and outcomes was carried out on all patients admitted to undergo pedicled supraclavicular artery perforator flap reconstruction within our institution. Results: Nine pedicled supraclavicular artery perforator flap reconstructions were performed. Surgical indications were 3 pharyngocutaneous fistulas, 2 tracheoesophageal fistulas, 2 cutaneous defects, 1 immediate pharyngoesophageal reconstruction, and 1 cutaneous and intraoral defect. All flaps survived completely. Excluding one patient who required a second flap due to plate reexposure, the remaining functional and esthetic outcomes were good. Conclusions: The pedicled supraclavicular artery perforator flap is reliable, is quick to harvest, and entails minimal donor site morbidity. Also, it is thin, is pliable, and has a wide arc of rotation, making it extremely versatile. It is an option that should be added to the spectrum of solutions of any head and neck reconstructive surgeon.

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 Artery Island Flap in Head and Neck Reconstruction: A Case Series and Literature Review

INTRODUCTION

Supraclavicular artery island flap (SCAIF) is emerging as an efficient and reliable flap for various complex head and neck defects after tumor extirpation.

OBJECTIVE

To examine a series of cases using a SCAIF for head and reconstruction at our institution.

METHODS

We performed a retrospective review of 8 patients who underwent SCAIF reconstruction of various head and neck defects from 2015 to 2018 at our institution. We also reviewed the English-language literature of reports of a SCAIF used for head and neck defects.

RESULTS

Eight patients underwent SCAIF reconstruction of head and neck defects. Various anatomic sites were reconstructed including the neck (n = 4), oral cavity (n = 1), and parotid/lateral skull base (n = 3). Two patients had partial flap necrosis, requiring débridement and wound care. There was no total loss of the flap or donor-site complication.

CONCLUSION

SCAIF is an excellent choice for reconstructing various head and neck defects, with low complication rates and donor-site morbidity. The outcomes of our SCAIF reconstruction are comparable to previously published outcomes.

[Research progress of pedicled flaps for defect repair and reconstruction after head and neck tumor resection]

Objective

To summarize the current status of pedicled flaps for defect repair and reconstruction after head and neck tumor resection, and to present its application prospects.

Methods

Related literature was reviewed, and the role evolution of pedicled flaps in the reconstruction of head and neck defects were discussed. The advance, anatomical basis, indications, advantages, disadvantages, and modification of several frequently used pedicled flaps were summarized.

Results

The evolution of pedicled flaps application showed a resurgence trend in recent years. Some new pedicled flaps, e.g., submental artery island flap, supraclavicular artery island flap, submandibular gland flap, and facial artery musculomucosal flap, can acquire equivalent or even superior outcome to free flaps in certain cases. Technological modification of some traditional pedicled flaps, e.g., nasolabial flap, pectoralis major myocutaneous flap, latissimus dorsi musculocutaneous flap, temporalis myofascial flap, and temporoparietal fascial flap, can further broaden their indications. These traditional flaps still occupy an irreplaceable role, especially in patients with poor condition and institution with immature microsurgical techniques.

Conclusion

The pedicled flaps still plays an important role in head and neck reconstruction after tumor resection. In certain cases, they demonstrate some advantages over free flaps, e.g., more convenient harvest, more rapid recovery, less expenditure, and better functional and aesthetic effect.

Usefulness of supraclavicular flap in reconstruction following resection of oral cancer

Objective

To evaluate the usefulness of supraclavicular artery flap in reconstruction of defects following resection of buccal mucosa cancer.

Methods

Twenty-five patients who presented to R.L Jalappa Hospital and Research centre and diagnosed as squamous cell carcinoma of buccal mucosa staged T₂ and above were included in our study. All patients underwent wide excision of tumour and neck dissection. Six patients underwent hemi-mandibulectomy while 4 patients underwent marginal mandibulectomy depending on extent of the tumour along with neck dissection. The defect following surgery was reconstructed using the supraclavicular artery flap and were followed up for minimum 6 months during which they were assessed for the functional and aesthetic outcome using a scoring system. The details of the scoring system comprised of 7 attributes. Each attribute was given a score of 10 if the patients experienced that attribute, while a score of 0 was given if the patient did not experience that particular attribute.

Results

Seven (28%) patients had complete necrosis of the flap. One patient had a local recurrence 2 months following surgery and was lost to follow up. The remaining 17 patients were followed up for a minimum of 6 months and a scoring system was adopted to evaluate the functional and aesthetic outcome of the supraclavicular flap. We observed that 14 patients had an excellent outcome score (58%), 3 patients had a good outcome score (13%), while 7 patients (28%) had flap necrosis.

Conclusions

We find the supraclavicular flap to be safe, technically simple, sensate, thin, pliable and reliable regional fasciocutaneous flap in reconstructing intra oral defects. Preserving the external jugular vein and sacrificing supraclavicular nerves give good outcome.

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.

Utility and versatility of the supraclavicular artery island flap in head and neck reconstruction

INTRODUCTION

The supraclavicular island flap is a rotational pedicled flap and may have some advantages in head and neck reconstruction compared with free-tissue transfer when this kind of reconstruction is not affordable or recommended.

MATERIAL AND METHODS

We present our experience during the year 2016 in the application of the supraclavicular island flap in five cases as an alternative to microvascular reconstruction in several defects after resection of head and neck tumours. In two patients, the flap was used to close the surgical pharyngostoma after total laryngectomy with partial pharyngectomy. In one patient, it was used in lateral facial reconstruction after partial resection of the temporal bone. In one case, it was used to close a skin defect after total laryngectomy with prelaryngeal tissue extension. And in the last case to close a neck skin defect after primary closure of a pharyngo-cutaneous fistula. There were no flap complications, and the result was satisfactory in all cases.

RESULTS

The supraclavicular artery island flap is useful and versatile in head and neck reconstruction. Operating room time in aged patients or those with comorbidities will be reduced compared to free flaps. The surgical technique is relatively easy and can be used for skin and mucosal coverage.

CONCLUSION

The supraclavicular island flap could be a recommended option in head and neck reconstruction, its use seems to be increasing and provides a safe and time-saving option to free flaps in selected patients.

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.

Supraclavicular artery island flap (SCAIF): a rising opportunity for head and neck reconstruction

Over the last 20 years, free flaps have represented the gold standard for moderate to large head and neck reconstruction. However, regional flaps continue to evolve and still play an important role in a reconstructive surgeon's armamentarium, especially for the more delicate patients who would certainly benefit from simpler surgical procedures. The supraclavicular artery island flap (SCAIF) is a pedicled flap that has recently gained great popularity for reconstruction of most head and neck sites, because of its unusual versatility and wide arc of rotation. SCAIF is a fasciocutaneous flap that is very reliable and both easy and quick to harvest. It is pedicled on the supraclavicular artery, which is a branch of the transverse cervical artery. Between October 2012 and July 2015, at Ospedale San Raffaele (Milan, Italy) and Policlinico San Matteo (Pavia, Italy), we used the SCAIF procedure on 14 patients with cervical and facial skin, oral cavity, oropharyngeal, and hypopharyngeal defects after oncologic surgery or as revision surgery after free-flap failure. The presence of the supraclavicular artery was demonstrated preoperatively by computed tomography angiography. Harvesting time never exceeded 50 min. Functional outcomes were excellent, and the donor site was always closed. We reported only one case of tip desquamation, which was treated conservatively, and two cases of partial flap necrosis, which required revision surgery. In our opinion, SCAIF should be considered to be a valid alternative to free-flap reconstruction, especially for facial and cervical skin, floor-of-mouth, and hypopharyngeal defects; oropharyngeal defects may be harder to reconstruct.

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.