Supraclavicular Artery Island Flap in Head and Neck Reconstruction

European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 291–294

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Technical note

Supraclavicular artery island ﬂap in head and neck reconstruction

a b a,c a,∗,c

S. Atallah , A. Guth , F. Chabolle , C.-A. Bach

Service de chirurgie ORL et cervico-faciale, hôpital Foch, 40 rue Worth, 92150 Suresnes, France

Service de radiologie, hôpital Foch, 40, rue Worth, 92150 Suresnes, France

Université de Versailles Saint-Quentin en Yvelines, UFR de médecine Paris Ouest Saint-Quentin-en-Yvelines, 78280 Guyancourt, France

a r t i c l e i n f o

a b s t r a c t

Keywords: Due to the complex anatomy of the head and neck, a wide range of pedicled or free ﬂaps must be available

Supraclavicular artery island ﬂap

to ensure optimal reconstruction of the various defects resulting from cancer surgery. The supraclavi-

Fasciocutaneous ﬂap

cular artery island ﬂap is a fasciocutaneous ﬂap harvested from the supraclavicular and deltoid regions.

Head and neck cancer

The blood supply of this ﬂap is derived from the supraclavicular artery, a direct cutaneous branch of the

Reconstructive surgery

transverse cervical artery in 93% of cases or the supraclavicular artery in 7% of cases. The supraclavicular

artery is located in a triangle delineated by the posterior border of the sternocleidomastoid muscle medi-

ally, the external jugular vein posteriorly, and the median portion of the clavicle anteriorly. This pedicled

ﬂap is thin, malleable, and is easily and rapidly harvested with a reliable pedicle and minimal donor site

morbidity. It can be used for one-step innervated reconstruction of many types of head and neck defects.

It constitutes an alternative to local ﬂaps, while providing equivalent functional results and must be an

integral part of the cancer surgeon’s therapeutic armamentarium.

1. Introduction 2. Anatomical basis

The objective of reconstruction after head and neck cancer The supraclavicular artery island ﬂap is a fasciocutaneous ﬂap

surgery is not limited to closure of the defect, but must allow three- harvested from the supraclavicular and deltoid regions. The blood

dimensional functional and cosmetic rehabilitation with skin of a supply of this ﬂap is derived from the supraclavicular artery,

similar colour and texture to that of the recipient site. The closer a direct cutaneous branch of the transverse cervical artery in

the donor site is situated to the recipient site, the more likely the 93% of cases or the supraclavicular artery in 7% of cases [3].

skin will present a comparable quality. Use of the skin of the shoul- The transverse cervical artery is a branch of the thyrocervical

der, close to that of the face and neck, appears ideal, as it allows trunk, which arises from the third part of the subclavian artery.

reconstruction of a functional anatomical unit with skin equivalent It divides into two main branches: the supraclavicular artery

to the original skin. supplying the skin and a branch supplying the trapezius mus-

Shoulder ﬂaps have been studied sporadically since their ﬁrst cle.

use in 1842 [1] as a random ﬂap. The description of the sup- The constant supraclavicular artery measures 1 to 1.5 mm in

raclavicular artery island ﬂap (SCAI) as an axial pedicle ﬂap by diameter and allows the creation of a 3 to 4 cm pedicle. It is

Lamberty was published in 1979 [2]. A better knowledge of the vas- always located in a triangle delineated by the posterior border

cular anatomy of the shoulder region demonstrated the reliability of the sternocleidomastoid muscle medially, the external jugular

and reproducibility of this ﬂap. The indications for supraclavicular vein posteriorly, and the median portion of the clavicle anteriorly

artery island ﬂap were therefore extended to head and neck recon- (Fig. 1). The artery arises 3 cm above the clavicle at a distance of

struction, particularly in the context of head and neck cancer, in the about 8 cm from the sternoclavicular junction and about 2 cm from

2000s [3]. the sternocleidomastoid muscle. The supraclavicular artery anas-

This article describes the anatomical basis, ﬂap harvesting tech- tomoses distally to branches of the posterior circumﬂex humeral

nique and the main characteristics of the supraclavicular artery artery, allowing the skin paddle to be extended from the supra-

island ﬂap. clavicular region to the lateral surface of the shoulder, beyond the

deltoid muscle insertion.

Two venae comitantes accompany the supraclavicular artery.

∗ One vein drains into the transverse cervical vein. The second vein

Corresponding author.

drains into the external jugular vein or subclavian vein.

E-mail address: [email protected] (C.-A. Bach).

http://dx.doi.org/10.1016/j.anorl.2015.08.021

292 S. Atallah et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 291–294

Fig. 1. Diagram of the shoulder. The supraclavicular artery is located in a triangle Fig. 2. Intraoperative view of the right shoulder. The ﬂap is harvested in a zone

delineated by the posterior border of the sternocleidomastoid muscle medially, the deﬁned by the edge of the trapezius muscle posteriorly and a parallel line as far as

external jugular vein posteriorly, and the median portion of the clavicle anteriorly. the deltoid muscle anteriorly.

The vascular territory of the supraclavicular artery extends from

The ﬂap is harvested in a zone deﬁned by the edge of the trapez-

the supraclavicular region to the rotator cuff. The area of this angio-

ius muscle posteriorly and a parallel line as far as the deltoid muscle

some is about 10 cm wide by 22 cm long [2,4].

anteriorly (Fig. 2). The size of the paddle can range from 4 to 12 cm

The supraclavicular sensory nerve is composed of 3 to 5

wide and 20 to 30 cm long [4].

branches supplying the skin of the shoulder. They are superﬁcial

Skin, subcutaneous tissue and fascia are incised over the deltoid

cutaneous branches of the cervical plexus derived from C3 or C4,

muscle. Fascia may be sutured to the skin by a 4-0 vicryl suture. Dis-

which then leave the posterior border of the sternocleidomastoid

section is continued in the subfascial plane over the deltoid and the

muscle to travel inferiorly and posteriorly to become superﬁcial

ﬂap is harvested from distal to proximal. Dissection in the subfas-

just above the clavicle and below the sternocleidomastoid muscle.

cial plane over the deltoid muscle allows harvesting of the overlying

One or two branches accompany supraclavicular vessels.

fascia to ensure better vascular protection (perifascial anastomotic

network). Perforating vessels of the deltoid muscle are cauterized

3. Flap harvesting technique during harvesting of the paddle and dissection is easily continued

as far as the supraclavicular fossa.

Duplex ultrasound can be performed before the operation to The pedicle is identiﬁed by transillumination in the middle third

identify the supraclavicular artery and ensure the integrity of the of the ﬂap. The skin and subcutaneous tissue are carefully incised

pedicle. to preserve the pedicle according to the desired dimensions of the

The patient is placed in the supine position, a bolster is placed paddle. The spinal nerve, which crosses the deep portion of the

beneath the shoulder blades to expose the supraclavicular region. posterior triangle of the neck underneath the sternocleidomastoid

The patient’s head is turned towards the opposite side of the ﬂap muscle, is identiﬁed and preserved as far as its point of entry into

donor site. the trapezius muscle.

The origin of the supraclavicular vessels is located in a triangle Depending on the defect to be covered and the required arc of

delineated by the posterior border of the sternocleidomastoid mus- rotation, the vascular pedicle can be cautiously dissected as far as its

cle medially, the external jugular vein posteriorly, and the median origin (Fig. 3a and b). Section of the transverse cervical artery after

portion of the clavicle anteriorly. its division into a supraclavicular cutaneous branch releases the

Fig. 3. Intraoperative view of the right shoulder: a: harvesting of the ﬂap as far as the origin of the pedicle. The skin paddle was de-epithelialized. The adipose connective

tissue surrounding the pedicle was preserved; b: rotation of the ﬂap around its pivot.

S. Atallah et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 291–294 293

reported for ﬂaps longer than 22 cm [8]. These “extreme” ﬂaps

should be reserved for young patients with a perfect vascular status.

Level V neck dissection can damage the supraclavicular artery

pedicle, but this dissection is rarely performed and, when it is nec-

essary, the surgeon can usually preserve the vascular pedicle. A

history of level V neck dissection or radical dissection does not con-

stitute a contraindication to the use of this ﬂap. Duplex ultrasound

examination can be performed before harvesting the ﬂap to ensure

the presence and integrity of the vascular pedicle.

The supraclavicular artery island ﬂap can be an alternative to the

myocutaneous ﬂap or pectoralis major muscle ﬂap. With time, the

pectoralis major muscle atrophies and forms an adhesion responsi-

ble for decreased range of neck ﬂexion and extension. The absence

Fig. 4. Satisfactory appearance of the scar of the right shoulder at the sixth postop-

of the pectoralis major muscle in the shoulder results in a reduction

erative month. Good integration of the ﬂap in the superior part of the tracheostomy.

of the range of external and internal rotation and adduction. These

sequelae limit the patient’s activity. Harvesting of a supraclavicu-

pedicle and increases the arc of rotation of the flap. Identification lar artery island flap preserves the muscles and motor nerves of the

of the nerve pedicle at this level allows its section or its preservation shoulder and therefore preserves the normal range of motion of the

to obtain a sensory innervated ﬂap. shoulder [9].

The ﬂap is tunnelled under the skin of the neck to reach the Donor site complications such as scar dehiscence or seroma

defect to be repaired, by avoiding torsion of the pedicle. have been reported in 0 to 15% of cases [9] and can be treated

The generally self-closing donor site is sutured over a suction by local wound care. The donor site is self-closing for ﬂaps up to

drain. Harvesting of a very large ﬂap (>22 cm) may require skin graft 16 cm wide [3]. Local ﬂaps or skin graft have also been proposed to

to the donor site. The long-term appearance of the scar is usually ensure closure of the donor site. The long-term appearance of the

satisfactory (Fig. 4). scar is satisfactory, although widening of the scar may be observed.

Patients report mild-to-moderate rapidly resolving shoulder pain

4. Discussion after ﬂap harvesting. Contact with the ﬂap in the reconstructed site

is experienced in the shoulder by 20% of patients [10]. Identiﬁcation

Reconstruction of the soft tissues of the head and neck after can- of the nerve pedicle during ﬂap dissection allows nerve section to

cer resection is often complex and requires the use of local, regional avoid postoperative dysaesthesia.

or free ﬂaps to ensure anatomical, functional and cosmetic rehabili- The donor site surgical morbidity is low, associated with a short

tation. The type of ﬂap must be chosen carefully in order to preserve hospital stay and the functional results are equivalent to those

the donor site. A thin, malleable ﬂap with a texture and colour sim- of other techniques. This ﬂap constitutes an excellent option for

ilar to those of the recipient site is ideal for repair of head and patients with vascular disease preventing microsurgery, multiop-

neck defects. Local ﬂaps would be ideally adapted, but their use is erated patient or patients with advanced cancer.

often compromised by previous surgery or radiotherapy. Very large

regional myocutaneous ﬂaps are difﬁcult to position in certain sites

5. Conclusion

(e.g. oropharynx). Sacriﬁce of a muscle at the donor site is associated

with morbidity and sequelae. Microanastomosed fasciocutaneous

The supraclavicular artery island ﬂap is a thin, malleable fascio-

flaps (forearm flap, anterolateral thigh flap) provide thin, flexible,

cutaneous ﬂap that is easily and rapidly harvested, with a reliable

well vascularized tissue to cover large defects. However, not all

pedicle and minimal donor site morbidity. It can be used for one-

patients are eligible for this long surgery, which requires an expe-

step innervated reconstructions of many types of head and neck

rienced multidisciplinary team. In these difﬁcult cases, regional

defects. It constitutes an alternative to local ﬂaps, while providing

ﬂaps remain the reference technique and the supraclavicular artery

equivalent functional results, and must be an integral part of the

island ﬂap is an ideal solution for these patients, as it is a reliable

head and neck cancer surgeon’s therapeutic armamentarium.

ﬂap with a constant neurovascular pedicle. In a series of 349 supra-

clavicular artery island ﬂaps, the complete necrosis rate was 1.4%

Disclosure of interest

and the partial necrosis rate was 6.9% [5].

Flap harvesting is easy and rapid, taking only 40 min to 60 min

The authors declare that they have no conﬂicts of interest con-

depending on the surgeon’s experience [6]. Due to its rapid harvest-

cerning this article.

ing and the site of the ﬂap in a usually neutral region (not operated,

not irradiated), use of this ﬂap can be considered in multioperated

References

patients or patients with major comorbidities.

The supraclavicular artery island ﬂap is thin, hairless, with a

[1] Ross RJ, Baillieu CE, Shayan R, Leung M, Ashton MW. The anatomical basis for

colour and texture similar to those of the face. The thin dermis and

improving the reliability of the supraclavicular ﬂap. J Plast Reconstr Aesthet

the absence of body hair facilitate use of this ﬂap in the oral cavity Surg 2014;67(2):198–204.

[2] Lamberty BG. The supra-clavicular axial patterned ﬂap. Br J Plast Surg

and oropharynx. This malleable, well-vascularized tissue can be de-

1979;32(3):207–12.

epithelialized and then buried in the neck or mediastinum to close

[3] Pallua N, Magnus Noah E. The tunneled supraclavicular island ﬂap: an opti-

tracheoesophageal ﬁstulas [7]. Supraclavicular innervation can be mized technique for head and neck reconstruction. Plast Reconstr Surg

2000;105(3):842–51.

preserved during ﬂap dissection, allowing sensory reconstructions,

[4] Pallua N, Machens HG, Rennekampff O, Becker M, Berger A. The fasciocuta-

for example in a neopharynx.

neous supraclavicular artery island ﬂap for releasing postburn mentosternal

Vascular island harvesting, which offers an arc of rotation of contractures. Plast Reconstr Surg 1997;99(7):1878–84.

◦

[5] Nthumba PM. The supraclavicular artery ﬂap: a versatile ﬂap for neck and

180 of the ﬂap, allows the closure of defects ranging from the

orofacial reconstruction. J Oral Maxillofac Surg 2012;70(8):1997–2004.

middle third of the face to the mediastinum.

[6] Alves HR, Ishida LC, Ishida LH, Besteiro JM, Gemperli R, Faria JC, et al. A clinical

Large skin paddles, measuring up to 30 cm long, can be har- experience of the supraclavicular ﬂap used to reconstruct head and neck defects

in late-stage cancer patients. J Plast Reconstr Aesthet Surg 2012;65(10):1350–6.

vested, although distal ischaemia of the skin paddle has been

294 S. Atallah et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 291–294

[7] Bach CA, Wagner I, Darmon S, Denoux Y, Chabolle F. Versatility of the supra- [9] Herr MW, Bonanno A, Montalbano LA, Deschler DG, Emerick KS. Shoulder

clavicular artery island flap for post-radiation tracheoesophageal fistula. Head function following reconstruction with the supraclavicular artery island flap.

Neck Oncol 2015. Laryngoscope 2014;124(11):2478–83.

[8] Kokot N, Mazhar K, Reder LS, Peng GL, Sinha UK. The supraclavicular artery [10] Sands TT, Martin JB, Simms E, Henderson MM, Friedlander PL, Chiu ES. Sup-

island ﬂap in head and neck reconstruction: applications and limitations. JAMA raclavicular artery island ﬂap innervation: anatomical studies and clinical

Otolaryngol Head Neck Surg 2013;139(11):1247–55. implications. J Plast Reconstr Aesthet Surg 2012;65(1):68–71.