The supraclavicular flap for reconstruction of post-burn mentosternal contractures

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 Flap for Severe Post-burn Neck Contracture in Children

The neck is essential and vital for all head movements and performing daily functional activities. The second-degree deep dermal and full-thickness burns causing anterior neck contracture restricts movement and if untreated develop deformities, in the oral cavity, eyes, posture, and chin growth and development, especially in children. Neck contracture results in kyphoscoliosis, lower lip seal resulting in impaired vision, balance, swallowing, feeding, and speech as well as social stigma, depression, and embarrassment. The treatment for post-burn anterior neck contractures is contracture release and reconstruction with skin grafts (split and full-thickness), axial pattern flaps, perforator propeller flaps, microvascular free flaps, tissue expansion, prefabrications, and skin substitutes. In addition to functional and esthetic recovery, post-surgery social and vocational rehabilitation is essential for children. We report a ten-year-old boy with severe anterior neck post-burn contracture managed with unilateral supraclavicular flap and residual areas with a split-thickness skin graft.

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.

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.

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 perforator flap in management of post-burn neck reconstruction: clinical experience

Anterior cervical contractures of the neck represent a great challenge for plastic and reconstructive surgeons. Necks can be reconstructed with a wide range of surgical techniques, including chimeric flaps, supercharged flap, pre-expanded flaps, "superthin" flaps and perforator flaps. The supraclavicular flap is easy to harvest without the need for free tissue transfer. It provides a relatively large flap for neck resurfacing with tissue very similar to that of the neck. Between January 2013 and March 2015, 20 patients suffering from postburn neck contracture underwent reconstruction with 20 unilateral supraclavicular artery perforator flaps. Nineteen patients had post-burn neck contractures (9 cases type Іc, 10 cases type Пc) while only one had post-burn granulation tissue in the neck. We harvested fifteen flaps from the right side and five from the left. Size of the reconstructed defect ranged from 23x10 to14x6, and flap size varied from 25/11 to 16/7cm. Period of follow up ranged from 27-2months (average 12.3). Nineteen flaps survived well (95% survival rate): only one was lost due to iatrogenic extensive dissection over the pedicle. Five cases showed distal superficial epidermolysis, and 2 cases showed 2 cm complete distal necrosis. All patients were managed conservatively. Our results coincide with other literature results confirming the efficacy and rich vascularity of this flap. In all cases with distal partial necrosis, flaps were 23 cm or more. We recommend that supraclavicular flaps of more than 22 cm in length are not harvested immediately and that flaps are expanded before harvesting. Expanding the supraclavicular flap increases its surface area and decreases donor site morbidity.

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.