Vascularized Clavicular Bone With Supraclavicular Artery Island Flap for Oromandibular Reconstruction

Anatomical research of the clavicular pedicled flap for mandibular reconstruction: vascularization and harvesting technique

PURPOSE

Mandibular reconstruction remains a challenging procedure despite the availability of various flaps and grafts. The ultimate objective is to restore oral functioning and attain acceptable morphological outcomes while considering donor site morbidity. This study describes the vascular supply and harvesting technique of a pedicled clavicular bone. The proximity of the clavicle is conducive to a mandibular replacement and allows the use of vascularized bone with a single surgical field.

METHODS

The osteoperiosteal clavicular pedicled flap was harvested on the right side of ten fresh cadaver specimens. The cervical transverse artery was injected with colored latex in some cases and methylene blue in others.

RESULTS

The vascular periosteal supply of the clavicular flap was highlighted. The clavicular bone was linked to its pedicle which was composed of vascular and adipose-fascial tissues, without any overlying skin paddle. Its vasculature was supplied by a reverse flow from the ascending cervical artery. The pedicled clavicular bone readily reached the mandible in all dissections.

CONCLUSION

The osteoperiosteal vasculature of the clavicular flap is based on the transverse cervical artery which receives a reverse blood supply from the ascending cervical artery. This vascular pattern is reliable because of the existence of the sub-occipital microvascular network named the "Bosniak node." This pedicled clavicular flap seems to be a robust perspective in both mandibular and facial bone reconstruction. We do not claim that it will replace the existing approaches, but it will expand the surgical panel of mandibular reconstruction. Its clinical realisation will judge its functionality.

Description of the Pedicled Osteo-Muscular Flap of Split Temporal Muscle

Background

Reconstruction of the head and neck is dominated by free flaps, and for bone reconstruction by fibula and scapula flaps. However, this choice is sometimes difficult to make in patients who cannot tolerate an extensive and lengthy surgical procedure. In addition, vascular micro-anastomoses are sometimes complicated in patients who have been previously irradiated. Pedicle flaps remain an option and can sometimes be considered as first choice for head and neck reconstruction.

Purpose

In this study, we describe the feasibility of a split temporal muscle pedicled flap with coronal harvesting for a reconstruction that can reach the midline.

Study design sample covariates

Ten fresh-frozen human cadaver heads were dissected, and the length of the split flap was noted, followed by the length of the non-split flap.

Results

The mean length was 155.7 mm (± 20.0) for the split flap, from the point of rotation to the tip of the coronoid process. These results coincide with the tragus-midline distance, which makes it possible to consider reconstruction of the midline, especially the maxilla and the mandible, which has not yet been described in the literature.

Conclusions and relevance

This technique would then allow a supply of pedicled vascularized bone for loco-regional reconstruction.

Clinical Analysis of Supraclavicular Flaps for the Repair of the Pharyngeal Fistula

Objectives: We explored the value of supraclavicular flaps in repairing pharyngeal fistula. Methods: Patients treated with supraclavicular flaps were included. Data on preoperative radiotherapy, surgical modality, flap size, postoperative healing, and other clinical outcomes were collected. Techniques, indications, and postoperative complications after repairing with supraclavicular flaps were described. A total of 16 male patients aged 58 to 79 years were involved, including 10 cases of postoperative pharyngeal fistula after hypopharyngeal cancer, 5 cases of postoperative pharyngeal fistula after laryngeal cancer, and 1 case of postoperative pharyngeal fistula after laryngeal and esophageal cancer. In 12 patients, the pharyngeal fistula was repaired by double island folding of the supraclavicular flap; in the remaining 4 patients, the pharyngeal fistula was repaired by the supraclavicular flaps combined with the pectoralis major flaps. The supraclavicular flap was 6 to 8 cm in width and 6 to 15 cm in length. Results: One patient developed partial necrosis at the distal end of the flap, which was successfully treated with debridement and dressing. The flaps grew well in the remaining 15 patients. Among them, a patient with a postoperative pharyngeal fistula after hypopharyngeal carcinoma was implanted with radioactive particles for tumor recurrence at the esophageal entrance, and died in the 11th month after surgery. Conclusions: The supraclavicular flap can achieve excellent results in the repair of pharyngeal fistula.

Resurgence of regional flaps for head and neck reconstruction

PURPOSE OF REVIEW

The strain on healthcare resources in light of the COVID-19 pandemic has forced many head and neck surgeons to explore reconstructive options that may decrease length of stay. Here, we review three common and versatile regional flaps used in head and neck reconstruction that are comparable alternatives to free tissue transfer.

RECENT FINDINGS

Initial anatomic descriptions of the facial artery musculocutaneous (FAMM) flap, the supraclavicular artery island flap and the submental artery island flap were published decades ago. Since then, many have proposed modifications to these descriptions to improve technical ease and patient outcomes. Benefits of regional flaps include ease of harvest, comparable outcomes to free tissue microvascular flaps, shorter operative time and hospital length of stay. Drawbacks to regional flaps include limitations to size and reach, partial necrosis, wound dehiscence and surgeon experience. The integrity of the vascular pedicle is also contingent upon vessel preservation during the cancer ablation.

SUMMARY

Although a resurgence of regional flaps began well before the COVID-19 pandemic, many institutions began looking for alternatives to free flap reconstruction to conserve healthcare resources and minimize patient hospitalization time in the past year. There has been a revival of regional flaps such as the FAMM, supraclavicular and submental flaps that are valuable reconstructive options for many defects of the head and neck.