Keywords
surgical flaps - reconstructive surgical procedures - operative time
Introduction
Major surgical defects after ear, nose, and throat (ENT) oncological surgery have,
for a long time, presented challenges for surgeons.[1] Over the last few decades, the use of microvascular free flaps has provided a vast
range of reconstructive solutions for wound healing and covering techniques following
surgical defects in the head and neck area.[2]
[3]
However, the feasibility of reconstructive surgery with free flaps is affected by
local factors related to the surgical site (such as the suitability of the vessels
for anastomoses and vasculopathies) and by the condition of the patient (age, a complex
history of present illness or past medical history). In some instances, these factors
may mean that prolonged intraoperative anesthesiology, often required for reconstructive
surgery with free flaps, may not be achievable.[4]
In the present study, we report the cases of 11 patients in whom supraclavicular artery
flap (SCAF) was used for surgical reconstruction after oncological surgery between
January 2018 and January 2019 in our Otolaryngology Department.[5]
[6]
Methods
The medical charts of 11 patients in whom a supraclavicular flap was used for surgical
reconstruction after oncological surgery between January 2018 and January 2019 in
the Otolaryngology Department of our Hospital were retrospectively reviewed. A supraclavicular
flap was used for the reconstruction of large combined defects of the oral cavity
in four cases, of the larynx in four cases, and of the skin of the face in three cases.
Male or female patients diagnosed with locally advanced squamous cell carcinoma that
required enlarged surgical excision were included in the present study. Patients who
had a prior clinical history of other local and laterocervical surgeries or who had
undergone any major trauma that could have created defects in the vascular circuit
of the SCAF were excluded from the present study. Additionally, any subject who had
a history of recreational drug abuse within 6 months prior to the surgery was also
excluded.
In one patient, the SCAF was used for the treatment of pharyngocutaneous fistula after
a total laryngectomy. In another case, the defect created during the first surgery
(pull-through) was repaired with a pelviglossoplasty using a paramedian infrahyoid
flap, which in the following days exhibited signs of deterioration. A Thiersch graft
obtained at the donor site of the flap was used for reconstruction in 8 patients.
The demographic and oncological characteristics of the patients are summarized in
[Table 1].
Table 1
Demographic and oncological characteristics of patients
|
Patients
|
Age (years old)
|
Comorbidities
|
Oncological disease
|
Surgery
|
|
1
|
48
|
Psychiatric problems
Chronic obstructive pulmonary disease
Alveolitis
Arthrosis
|
Laryngeal cancer
pT4aN0M0
|
Total laryngectomy
|
|
2
|
55
|
Hypertension
Thrombocytosis
|
Laryngeal cancer
pT4aN2M0
|
Total laryngectomy
|
|
3
|
70
|
Acute myocardial infarction (percutaneous transluminal coronary angioplasty)
Hypertension
Diabetes
Chronic obstructive pulmonary disease
Vasculopathy
|
Laryngeal cancer
pT4a N0M0
|
Pharyngoplasty following total laryngectomy
|
|
4
|
60
|
Meniscectomy
|
Oral cavity cancer
pT2N0M0
|
Revision of pelviglossectomy
|
|
5
|
79
|
Pulmonary edema
Hemicolectomy (colon cancer)
|
Oral cavity cancer
pT4aN0M0
|
Mandibulectomy
|
|
6
|
55
|
—
|
Oral cavity cancer
pT2N0M0
|
Mandibulectomy (jawbone interruption)
|
|
7
|
70
|
Cirrhosis of the liver
Erosive gastropathy
Hypertension
|
Oral cavity cancer
pT3N2M0
|
Pull-through mandibulectomy
|
|
8
|
89
|
Hypertension
Acute myocardial infarction
Knee prosthesis
Chronic venous insufficiency
Varicose veins in the lower limb
|
Skin cancer
pT3N0M0
|
Radical parotidectomy extended to the preparotid skin and the auricle
|
|
9
|
80
|
Acute myocardial infarction
Hypertension
Carotid atheroma
Cerebral hemorrhage
Acute pulmonary edema
Deep vein thrombosis
Acute myocardial infarction
Renal cell carcinoma
|
Skin cancer
pT3N0M0
|
Auricular parotidectomy, preservation facial n. extended to the pre-parotid skin,
to the auricle (
|
|
10
|
81
|
Hypertension
Diabetes
Aortic valve prosthesis
Dyslipidemia
|
Alveolar ridge cancer
pT4aN0M0
|
Pelvectomy with mandibulectomy
|
|
11
|
69
|
Acute myocardial infarction (percutaneous transluminal coronary angioplasty)
|
Laryngeal cancer
pT3N2bM0
|
Salvage total laryngectomy after CTRT failure
|
Abbreviations: CTRT, chemiotherapy and radiotherapy.
Anatomical Landmarks
The supraclavicular artery island flap is a fasciocutaneous flap harvested from the
supraclavicular and deltoid regions.[7] This flap can be pivoted and transferred to cover many of the postsurgery head and
neck defects due to the angle of its rotation and its length.[8] Furthermore, thanks to the skin palette, it offers the opportunity to carry out
plastic reconstructive surgery as well as internal reconstructions, including in extensive
external areas.[9] The main afferent branch of the supraclavicular flap arises from the transverse
cervical artery; the SCAF, specifically, is pedunculated on the supraclavicular artery.[10] The transverse cervical artery can originate from the branches of the thyrocervical
trunk or from the first portion of the subclavicular artery. The transverse cervical
artery runs posteriorly in the neck and goes deeper than the posterior belly of the
omohyoid muscle. Regarding the supraclavicular artery, it originates from the transverse
cervical artery, although it can, less frequently, also originate from the suprascapular
artery. The supraclavicular artery then perforates the deep fascia of the deltoid
muscle after 2 to 4 cm.[11] Anatomical dissection studies have found that, on average, the diameter of the supraclavicular
artery is between 1.1 and 1.5 mm and that its pedicle varies in length between 1 and
7 cm and is present in 80% of cases. Studies based on angiography have shown that
the average caliber values are ∼ 1.5 mm, with a length of 38 mm.[12]
Regarding skin markers, the supraclavicular artery is located in an ideal triangle
consisting of the clavicle at the inferior side, of the posterior margin of the sternocleidomastoid
muscle (SCM) medially, and of the jugular vein laterally. Typically, the artery is
between 2.5 and 4 cm above the collarbone and 2 cm behind the SCM ([Fig. 1]). Venous drainage is provided by two “venae comitantes”, which most frequently are
tributaries to the transverse cervical vein and, sometimes, drain into the external
jugular vein. The tactile sensation of an oral cavity reconstructed with the SCAF
recovers to a detectable, though not normal, level within a couple of years. In patients
who have already undergone laterocervical neck dissection or other types of local
surgery, an ultrasound Doppler or computed tomography (CT) angiography should be performed
preoperatively to demonstrate the presence of the vascular peduncle.
Fig. 1 Preoperative skin markers for the supraclavicular artery flap.
Operative Techniques
The dissection technique was originally described by Lamberty in 1979, was later taken
up again and clarified by other authors and standardized by Kokot et al.[13] and, particularly, by Pallua et al.[14]
[15]
[16] The most recent review in the literature is by Chiu et al.:[17] the pedicle is located within a triangular area bounded by the posterior margin
of the SCM and by the external jugular vein from the clavicle. The size of the flap
is determined by the distance from the “reception” site to be reconstructed and the
size of the defect. In addition to an accurate preoperative drawing with a dermographic
pen, we suggest a “template” with gauze to simulate the radius of rotation by moving
the gauze around the supraclavicular area. Furthermore, the adequacy of the size necessary
to cover the defect should also be verified. The dissection of the flap starts at
the distal portion and cautiously moves to the proximal level, where the supraclavicular
artery is located. The pedicle is usually covered with fascia and connective tissue.
Surgical positioning for SCAF preparation does not usually involve large movements
of the patient. To facilitate dissection, the patient is placed in the supine position,
with the shoulder donor site preferably elevated by a pilet. As already mentioned,
a preoperative drawing is created (which can be revised during the surgical phases
when the resection is well-delineated, to have the actual size): a fusiform-oval island
with the proximal portion at the base of the neck, ipsilateral to the defect.
Special care must be taken with the collarbone to not remove the periosteum during
the harvesting of the SCAF.
To speed up the procedure, the distal portion can only be dissected with an electric
scalpel, while the proximal dissection must be performed exclusively with a cold blade
and with careful hemostatic control through delicate use of the bipolar forceps on
the perimeter of the flap. Once the pedicle has been skeletonized and the flap has
been sculpted, it is not difficult to rotate the flap by 180 degrees.
In internal reconstructions,[18] that is, those that require a portion of the flap to penetrate a tunnel, surgical
time must be dedicated to the de-epithelialization of the area, which will then be
placed internally, replacing the mucosa. This procedure makes possible to obtain free
skin graft (exactly as a Thiersch graft), which can be used to cover the supraclavicular
donor site when closure is not possible due to the size of the harvested flap. It
is recommended to use a cold blade scalpel. ([Fig. 2]) All surgical procedures have been conducted by otolaryngologists.
Fig. 2 Free skin flaps (Tiersch flap) used to cover the supraclavicular donor site.
Results
The technique has shown highly satisfactory results without the need for further intervention.
In particular, in surgical revision, the use of SCAF for closure was essential.
Two patients who underwent surgery for total laryngectomy had complications due to
local fistula. In both cases, a revision of the surgical field revealed voluminous
pharyngostomas that were completely repaired with SCAF. No further complications were
identified. In three cases, however, immediate closure, following a pelvimandibulectomy
with SCAF, had already been considered during the planning stage. In these patients,
the flap proved to be reliable and did not cause complications, except in one case
in which, a few days after surgery, the superficial layer of the flap exhibited some
superficial epidermal necrosis, which did not affect the final result. The two cases
of skin defects involved extensive epithelial tumors of the face, which involved the
surgical excision of large areas of facial skin, as well as parotidectomy and functional
neck dissection. ([Figures 3],[4],[5],[6]).
Fig. 3 Patients with gland metastasis of epithelial skin cancer after total parotidectomy.
Fig. 4 Patients with gland metastasis of epithelial skin cancer 10 days after surgery.
Fig. 5 Patients with gland metastasis of epithelial skin cancer 2 months after surgery.
Fig. 6 Patient with extensive epithelial tumors of the right auricle before surgery.
In most of these cases, in which the patients were elderly and had significant comorbidities,
surgery did not cause complications. However, in one case, the resection involved
the auricle entirely and a small area of perimeatal bone exposure occurred, which
then healed by secondary intention ([Fig. 7]).
Fig. 7 Postoperative complication.
Dicussion
In our practice, as reported in the literature,[19] preoperative Doppler was not used to preventively verify the presence of an effective
vascular pedicle for the flap. In our experience, the SCAF required an average 40
to 50 minutes of harvesting time, which decreased progressively with practice. Given
a net increase in the overall length of the surgery, it was not feasible to create
free flaps for patients with comorbidities, and especially for the elderly. In these
instances, the SCAF would require different preparation and implementation times.
The only part that was a little more challenging, although it was not difficult to
perform, was the removal of the skin layer to expose the area of the flap that provides
for its internal location. This procedure should always be performed with a cold blade
scalpel, as de-epithelialization with an electric scalpel, although apparently faster,
inevitably creates damage to the flap itself due to the heat generated by this tool.
From our experience, we suggest using the partial-thickness skin graft obtained after
de-epithelialization (Thiersch graft) to cover the defect of the supraclavicular donor
site where the surgical defect (sometimes even measuring 8 × 7 cm) did not allow,
even after mobilizing the surrounding tissues, a first intention closure. The SCAF
is extremely effective in treating extensive skin defects, which is in line with the
data found in the literature,. The presence of the dermal layer has also been found
to be useful for the creation of neopharynx following laryngectomies and for the closure
of fistulous passages: the dermal layer increases resistance to erosive salivary phenomena,
thus reducing the likelihood of developing postsurgical fistulas.
In oral cavity defects, the capacity and reliability of the flap also proved to be
very satisfactory in all cases treated; among these, however, we report only one case
in which, as already mentioned, there was an ischemic area of the distal portion of
the flap, which was resolved with local dressings and removal of the necrotic area
without the need for further surgery.[20] This data, however, correlates with what is reported in the literature. In fact,
other authors have reported the possibility of distal partial necrosis, especially
in large SCAFs.[21] Compared with, for example, the performance of the pectoral muscle flap, which in
some cases has, in our experience, presented partial detachments from the graft site
due to its weight, the SCAF did not exhibit this problem.
Almost all patients could feel some kind of tactile sensations in their SCAF flap
after surgery. Sometimes, patients have reported a paradoxical hot-cold sensation
in the area of the shoulder during meals for a few months after surgery. This is due
to normal sensory innervation by the third and fourth cervical nerves originating
from the supraclavicular nerve.[22]
Using the SCAF to treat head and neck postoperative defects is an effective choice
and offers various advantages. In our experience, it has proved to be reliable and
versatile, both in terms of range and applicability. The preparation of the flap itself,
both in terms of ease and timing, without demanding a lengthy “learning curve”, deserves
a special mention.
In our hands, therefore, and in line with the data in the literature, preparation
times have quickly been reduced from > 1 hour to ∼ 50 minutes (hence the term in the
literature of the “50-minute flap”).
The introduction of the use of the skin graft we obtained after de-epithelialization
of the supraclavicular donor site as a Thiersch graft for healing the donor site is
recommended to decrease the recovery time and hospitalization. This is also why, in
order not to damage the Thiersch graft, it is mandatory to use a cold blade scalpel
and not an electric one.
Conclusion
We conclude that the SCAF is an extremely versatile flap for head and neck surgery
and should be considered especially for fragile and vulnerable patients who cannot
undergo prolonged surgery. Due to its ease of implementation, the SCAF could also
be very useful in hospitals that do not have any plastic surgeons available.
The SCAF significantly shortens the time required for surgery compared with microvascular
flaps.
