Keywords supraclavicular artery island flap - head and neck defects - flap dimensions - complications
Introduction
Head and neck cancer patients after resection and neck dissection require reconstruction
of the defect using local, regional, or free flap. The supraclavicular artery island
flap (SCAIF) provides a versatile and reliable regional flap option for soft tissue
defects in this region. SCAIF can be used to cover defects of buccal mucosa, tongue,
floor of mouth, cheek, parotid, and post-auricular area. It can also be used as a
reconstruction option in cases where patients have undergone multiple neck dissections
or require a salvage procedure due to free flap failure.
This study was undertaken to assess the versatility of SCAIF by measuring the surgical
dimensions of flap, and to evaluate the ease of flap harvest by recording time taken
to harvest. Flap-related complications and their correlation with flap dimensions
were evaluated. This study also provides evidence that SCAIF could be used as a first-line
flap for head and neck reconstruction in selected cases.
Materials and Methods
This prospective study was conducted in our institute for 1 year. A total of 30 patients
were included in the study. Inclusion criteria for the study were patients with head
and neck cancer who were scheduled to undergo wide local excision with or without
neck dissection and required a flap for defect reconstruction. This applied to patients
of all ages, both genders, and those who were willing to participate in the study.
Patients with comorbidity like diabetes mellitus, hypertension, or poor nutrition
were also included in study. Defect size varied from 5 cm × 8 cm to 7 cm × 8 cm. All
defects were low volume, soft tissue only defects, without mandible resection. Those
patients were excluded from the study for whom SCAIF was not found suitable to cover
the expected defect while doing planning in reverse. Thus, patients with large volume
defects or defects higher than lower third of face were excluded. Patients not willing
for a scar at the shoulder were also excluded.
We obtained informed consent from all patients in written form, and our research and
ethics committees have approved this study. Reconstruction was done with supraclavicular
island flap in all patients. Flap surgery was performed by a team of two plastic surgeons
in all patients. During early postoperative period, neck was supported with a sandbag
in opposite side to make sure that the neck was kept in neutral position or flexed
to the side of flap harvest. Patients without any flap-related complications were
discharged after first dressing on postoperative day 5. Examination on follow-up visits
was done on 7th, 14th , and 21st day to assess for any complications. The study variables (location of defect,
length and width of flap, time taken for flap harvest, and complications) were noted
in the working proforma. Flap size and harvest time in patients who developed complications
were compared with those who did not develop complications using independent t -test. p -Value less than 0.05 was considered as statistically significant.
Surgical Technique
The patient was lying in supine position with a sandbag placed under ipsilateral shoulder
and neck turned to opposite side. After cancer resection the defect was measured and
the flap was planned in reverse. The posterior triangle of neck (clavicle, sternocleidomastoid,
and trapezius) was marked. The external jugular vein was marked crossing the posterior
triangle. The supraclavicular vessel was marked based on anatomical landmarks. The
vessel is located behind the belly of omohyoid muscle in the marked triangle. The
vessel runs toward the acromion process, parallel to the clavicle. The upper extent
of the flap was marked by superior margin of the trapezius muscle. The lower extent
was marked as per required flap width, which could be maximum 8 cm. The lateral extent
of flap was marked over the deltoid muscle, as per required pedicle length, to reach
the defect.
After marking the flap was harvested in lateral to medial direction including the
fascia over deltoid muscle. Once the clavicle is reached, then the periosteum was
incised and included in the flap. Further dissection was done carefully avoiding injury
to the flap vessel. No attempt was made to skeletonize the vessel. A width of around
5 cm was maintained for the pedicle while dissecting. Skin over the pedicle was de-epithelialized.
The flap was transferred to the defect through a tunnel. The tunnel was created over
the mandible in subcutaneous space for buccal mucosa defects. However, the tunnel
was created under the mandible in the floor of mouth for defects of tongue. The harvested
flap was then placed into the defect and inset given. A suction drain was placed at
the donor area. The donor wound was closed primarily in proximal part and covered
with a split-thickness skin graft distally ([Figs. 1 ]
[2 ]
[3 ]).
Fig. 1
(A) Right buccal mucosa defect after resection of carcinoma and neck dissection with
markings of supraclavicular artery island (SCAI) flap. (B) SCAI flap elevated. (C) Pedicle area de-epithelialized. (D) Flap inset completed. (E) Distal part of flap donor site covered with split skin graft.
Fig. 2
(A) Left buccal mucosa defect after intraoral resection of carcinoma and neck dissection
with markings of supraclavicular artery island (SCAI) flap. (B) SCAI flap elevated. (C) Pedicle area de-epithelialized. (D) Flap inset completed. (E) Distal part of flap donor site covered with split skin graft.
Fig. 3
(A) Carcinoma in postauricular area. (B) Postauricular defect after resection of carcinoma. (C) Supraclavicular artery island (SCAI) flap elevated. Arrow showing vessel covered
with fat pad on undersurface of flap. (D) Pedicle area de-epithelialized. (E) Flap inset completed and distal part of donor site covered with split skin graft
with tie over dressing. (F) Three-week follow-up showing healthy flap and donor site. Patient is able to extend
his neck comfortably.
Results
A total of 30 patients were included in our study, out of which 21 patients were males
and 9 were females. Age ranged from 28 to 71 years. Most patients were in the age
group 45 to 60 years (63%, n = 19). Location of the lesion was buccal mucosa in 21 (70%) patients, tongue and
floor of mouth in 8 (26.7%) patients, and post-auricular area in 1 (3.3%) patient
([Table 1 ]).
Table 1
Master chart of observations
S. No.
Age
(y)
Gender
Location of defect
Width of flap
(cm)
Flap skin paddle length
(cm)
Flap pedicle length
(cm)
Total length of flap
(cm)
Total flap area
(sq. cm)
Time taken in flap harvest
(min)
Complication
1
71
F
Tongue
8
5
11
16
128
40
Absent
2
45
M
Buccal mucosa
8
5
11
16
128
38
Absent
3
48
M
Buccal mucosa
8
6
11
17
136
40
Absent
4
45
M
Buccal mucosa
8
5
10
15
120
36
Absent
5
56
M
Buccal mucosa
8
6
11
17
136
42
Partial flap necrosis
6
64
F
Buccal mucosa
8
6
11
17
136
44
Neck stiffness
7
58
M
Tongue
8
6
11
17
136
40
Absent
8
54
M
Buccal mucosa
8
6
11
17
136
40
Infection and wound dehiscence and orocutaneous fistula
9
56
M
Buccal mucosa
8
6
11
17
136
38
Distal marginal necrosis
10
53
M
Buccal mucosa
8
5
11
16
128
38
Absent
11
54
M
Post-auricular
8
5
11
16
128
40
Absent
12
28
F
Buccal mucosa
8
5
10
15
120
36
Absent
13
56
F
Buccal mucosa
8
4
11
15
120
36
Absent
14
62
M
Buccal mucosa
8
5
11
16
128
36
Distal margin necrosis
15
58
M
Tongue
8
5
10
15
120
36
Absent
16
62
F
Buccal mucosa
8
5
10
15
120
36
Distal margin necrosis
17
64
F
Tongue
8
5
10
15
120
38
Absent
18
66
M
Buccal mucosa
8
5
10
15
120
36
Absent
19
55
M
Tongue
8
5
10
15
120
36
Absent
20
60
F
Tongue
8
5
11
16
128
38
Neck stiffness
21
48
M
Buccal mucosa
8
5
10
15
120
36
Absent
22
46
F
Buccal mucosa
8
6
11
17
136
38
Absent
23
52
M
Buccal mucosa
8
5
10
15
120
38
Absent
24
60
M
Tongue
8
5
11
16
128
40
Distal margin necrosis
25
56
M
Buccal mucosa
8
5
11
16
128
38
Absent
26
60
M
Buccal mucosa
8
6
11
17
136
38
Absent
27
58
M
Tongue
8
6
10
16
128
40
Absent
28
68
M
Buccal mucosa
8
5
10
15
120
40
Absent
29
58
F
Buccal mucosa
8
6
10
16
128
38
Absent
30
64
M
Buccal mucosa
8
5
10
15
120
36
Absent
Flap dimensions were 15 × 8 (120 sq.cm) in 12 (40.0%) patients, 16 × 8 (128 sq.cm)
in 10 patients (33.3%), and 17 × 8 (136 sq.cm) in 8 patients. The mean flap size was
126.9 sq.cm. Mean time for harvesting flap was 38.20 minutes ([Table 1 ]).
A total of 22 patients did not have any complication of surgery. However, flap-related
early complications were observed in 6 (20%) patients. Distal margin necrosis was
observed in four patients and partial (distal third) flap loss was observed in one
patient. These five flaps were managed with local wound care and healed by secondary
intention. In one patient, there was wound infection, pus discharge, and development
of orocutaneous fistula. This fistula was closed using tongue flap. Stiffness in neck
and shoulder movements (late complication) was noted in two patients, which was relieved
with physical therapy.
Among patients who developed complications, the mean size was 131.0 sq.cm when compared
with 125.4 sq.cm among those who did not develop complications. The difference between
the mean flap sizes in both groups was found to be statistically significant using
an independent sample t -test (p -value = 0.04; [Table 2 ]).
Table 2
Comparison of mean size of flap with development of complications
Complications
N
Mean size of flap
SD
t -Statistic
p- Value
No
22
125.45
6.23
2.226
0.04
Yes
8
131.00
5.95
Abbreviation: SD, standard deviation.
Among patients who developed complications, the mean flap length was 16.38 cm when
compared with 15.68 cm among those who did not develop complications. The difference
between the mean flap lengths of both groups was statistically significant using the
independent sample t -test (p -value 0.019; [Table 3 ]).
Table 3
Comparison of mean length of flap with development of complications
Complications
N
Mean flap length
SD
t- Statistic
p- Value
No
22
15.68
0.78
2.177
0.019
Yes
8
16.38
0.74
Abbreviation: SD, standard deviation.
Flap width was kept 8 cm in all patients. Donor site was closed primarily in its proximal
part and split skin graft was applied in the distal part of donor site in all patients.
No donor site complication was observed in all patients.
Among patients who developed complications, the mean time was 39.25 minutes when compared
with 37.82 minutes among those who did not develop complications. The difference between
the mean duration of harvesting in both groups was found to be statistically insignificant
using an independent sample t -test (p -value 0.208; [Table 4 ]).
Table 4
Comparison of mean time to harvest flap with development of complications
Complications
N
Mean duration of harvesting
SD
t- Statistic
p- Value
No
22
37.82
1.662
1.356
0.208
Yes
8
39.25
2.816
Abbreviation: SD, standard deviation.
Discussion
Lamberty named the supraclavicular flap in 1983.[1 ] The supraclavicular artery is a branch of transverse cervical artery that originates
from the thyrocervical trunk. The supraclavicular artery generally arises 3 to 5 cm
from the origin of the transverse cervical artery within the triangle formed by the
clavicle, sternocleidomastoid muscle, and external jugular vein.[2 ]
[3 ]
[4 ]
[5 ]
[6 ]
[7 ]
[8 ]
[9 ]
[10 ]
[11 ] The supraclavicular artery's origin is located 6 to 8.5 cm away from the sternoclavicular
joint. The starting location of the supraclavicular artery and the point of deep fascia
penetration are separated by 2 to 4.5 cm.[4 ] Cadaver study has demonstrated that the normal arterial diameter ranges from 1.1
to 1.5 mm.[4 ]
Computed tomographic angiography of fresh cadaver tissue has established that the
supraclavicular artery is the flap's primary source of perfusion and that the flap's
distal portion depends on inter-perforator flow from the direct connecting arteries
and recurrent flow through the subdermal plexus.[12 ] These vascular studies also recommend flap dimensions, with a mean length of 24.2 cm
(Western population) and a mean width of 8.7 cm, as a guide to the size of the flap
based on perfusion.[12 ] The study performed by Kokot et al documented the average dimensions of the flap,
which were 6.1 cm in width and 21.4 cm in length.[6 ]
Our study shows that a flap length of 15 to 17 cm is adequate to reach most defects
of buccal mucosa, tongue, parotid, and postauricular area. We have observed increased
rate of complications with flap length more than 16 cm (area 128 sq.cm). In our experience,
the lateral limit of flap is lower third of deltoid muscle, which is less than 17 cm
from the flap axis in our patient population. The safe length can be increased by
tissue expansion or flap delay as suggested by Telang et al.[13 ] Telang et al suggest a safe length up to 20 cm even with the use of tissue expansion.[13 ] Other Indian studies also suggest that the distal limit of flap is up to deltoid
insertion, and the average flap length is less than 17 cm in all these studies.[14 ]
[15 ]
[16 ]
[17 ]
[18 ] This variation in safe flap length may be due to anthropological difference between
Indian and Western population. Further studies are needed to confirm this observation.
The width of flap should be kept up to 8 cm to prevent donor-site complications. Few
previous studies suggest that the donor site of SCAIF up to 10 cm can be closed primarily.[3 ]
[5 ]
[6 ]
[7 ] We have kept the flap width of 8 cm in all our cases and the split thickness skin
graft was needed in the distal portion of donor site in all cases. None of our patient
had any complication related to donor site. In our experience, primary closure is
under tension at the distal portion of donor site even if the width is kept 8 cm.
However, the present study does not have any observation to comment on the width of
donor site to be able to achieve primary closure without complications.
Supraclavicular vessels lie in the lower part of posterior triangle (level Vc of cervical
lymph nodes). This vessel is usually spared in neck dissection up to level V. Studies
have shown that the supraclavicular vessel is fairly reliable despite prior radiation
or neck dissection.[11 ]
[19 ]
[20 ] Thus, SCAIF can be safely used in cases of cancer recurrence or flap failure. However,
our study does not include any such patient.
The SCAIF can be raised within 40 minutes, which is comparable to other regional flaps.
It has a shorter total operative time compared with microvascular flaps.[21 ]
[22 ]
[23 ] Flap harvest time increases with increasing size of the flap; however, it does not
have significant correlation with development of complications. Being a pedicle flap,
SCAIF has advantage of less need for close monitoring and lower overall expenditure
compared with a free flap.[21 ]
[22 ]
[23 ] Free flap is not preferred in patients with advanced age, poor nutrition, or multiple
comorbidities.[5 ] Also, the microvascular free flaps need higher expertise and resources compared
with pedicled flap.
The SCAIF should not be considered superior to other regional flaps, but rather a
complementary alternative reconstruction option. Regional muscle flaps (pectoralis
major, deltopectoral, trapezius, and latissimus flaps) are bulky.[5 ] Pectoralis major myocutaneous (PMMC) flap is suitable to fill large volume defects,
while the SCAIF is suitable for limited volume defects. Muscle in the PMMC flap gets
atrophied, leading to a decreased range of neck movements.[7 ] The range of internal rotation and adduction of the shoulder is reduced after PMMC
flap harvest.[5 ]
[7 ] SCAIF preserves the muscle and has less impact on neck movements. Another fasciocutaneous
regional flap option for defects in this region is submental flap. SCAIF provides
non-hair-bearing skin and larger tissue volume compared with submental flap.[9 ] The deltopectoral flap has a disadvantage of limited arc of rotation because of
its broad base and it cannot reliably reach oral cavity or mastoid defects; however,
SCAIF can reliably reconstruct these defects.[9 ]
Limitations of SCAIF include its limited reach up to the neck and lower third of the
face and potential donor-site morbidity due to scarring.[9 ] Donor-site scar may be visible while wearing clothes with exposed shoulder.[13 ] It may cause pain or irritation due to brasserie strap in females.[23 ]
Conclusion
The SCAIF enables one-stage reconstruction of head and neck defects with a low learning
curve. It yields low cost, less time consuming, cosmetic option with manageable less
severe complications that too have low chance to occur. SCAIF provides a skin paddle
which is hairless, thin, pliable, and color-matched with the recipient site in the
head and neck region. However, its limited reach and smaller volume should be kept
in mind while planning reconstruction. Safe length of SCAI flap is 16 to 17 cm (up
to lower third of deltoid muscle), which makes it a suitable choice for defect of
lower third of head and neck region. A reconstruction surgeon should keep SCAIF as
an option in his armamentarium.
