Versatility of the Supraclavicular Flap in Head and Neck Reconstruction

F. Martins de Carvalho, MD; Bernardo Correia, MD; Álvaro Silva, MD; Joana Costa, MD

Disclosures

ePlasty. 2020;20(e7) 

In This Article

Results

Medical History and Surgical Indications

Between July 2016 and December 2017, we performed 9 SAP flap reconstructions. Surgical indications were 3 pharyngocutaneous fistulas, 2 tracheoesophageal fistulas, 2 cutaneous defects, 1 immediate pharyngoesophageal reconstruction, and 1 cutaneous and intraoral defect (Table 1).

Surgical Technique

SAP flaps were designed with an axis drawn from the center of a triangle formed by the dorsal edge of the sternocleidomastoid muscle, the external jugular vein, and the medial part of the clavicle, toward the acromioclavicular joint and the ventral surface of the deltoid muscle. In this axis, the supraclavicular artery was consistently found using Dopper flowmetry before surgery and confirmed intraoperatively with a sterile probe. The flap was elevated from distal to proximal in a subfascial plane. The pedicle was never skeletonized and always included the superficial fascial system and the related platysma for approximately the width of the flap. The maximal length from the center of the described triangle was 20 cm. Flap widths longer than 7 cm required skin grafting for donor site closure. All flaps were harvested in about 45 minutes. They were then tunneled to the defect and the intervening tissue deepithelialized.

Selected cases

Patient 2: Immediate Pharyngoesophageal Reconstruction. A 49-year-old woman with T3N0 laryngeal carcinoma underwent total laryngectomy along with lateral pharyngeal wall resection and bilateral nodal dissection levels II-IV. Only a narrow strip of about 7 cm in length of the posterior pharyngoesophageal wall remained. A tubularized SAP flap of 15 × 7 cm was raised for reconstruction. The postoperative period was uneventful. The patient started oral feeding on postoperative day 12, and no fistula occurred. Both the neck and donor sites were closed primarily. At 21-month follow-up and 17 months after completion of radiotherapy, there is no evidence of dysphagia, fistula, or stricture (Figures 1a-1d).

Figure 1.

Case 2. (a) Posterior pharyngoesophageal wall with the nasogastric tube (blue arrow). (b) SAP flap raised. (c) SAP flap partially sutured to the posterior pharyngoesophageal wall. (d) Postoperative result at 16 months.

Patient 4: Tracheoesophageal Fistula. A 68-year-old man with a history of total laryngectomy 6 years before presented with a pharyngocutaneous fistula at the level of the tracheostoma. He underwent reconstruction with an SAP flap with 2 skin paddles, one for the anterior esophageal wall and the other for the posterior tracheal wall, achieving a 2-layer closure. The donor site was closed primarily. Besides a donor site hematoma managed conservatively, the postoperative period was uneventful. The patient started oral feeding on postoperative day 14, and no fistula occurred. At 12-month follow-up, there is no evidence of dysphagia, fistula, or stricture (Figures 2a-2d).

Figure 2.

Case 4. (a) Tracheoesophageal fistula at the level of the tracheostoma (blue circle). (b) Anterior esophageal wall isolated. (c) SAP flap raised with 2 skin paddles. (d) Final aspect with the peristomal paddle visible (blue arrow).

Patient 6: Cutaneous and Intraoral Defect. A 49-year-old man with osteoradionecrosis of the mandible with plate exposure and intraoral fistulization underwent segmental mandibulectomy and reconstruction with an SAP flap with 2 skin paddles and a reconstruction plate. The donor site was closed primarily. In the immediate postoperative period, the patient showed cellulitis and small dehiscence of the external paddle that healed with conservative measures. One month after discharge, the patient exhibited an ulceration and plate exposure through the SAP flap and underwent reconstruction with a pectoralis major flap. At 8-month follow-up, there is no evidence of tissue instability (Figures 3a-3d).

Figure 3.

Case 6. (a) Osteoradionecrosis of the mandible with plate exposure. (b) Reconstruction with segmental mandibulectomy, reconstruction plate, and an SAP flap. (c) Exposure of the reconstruction plate through the SAP flap. (d) Coverage with a pectoralis major flap.

Complications and Outcomes

All flaps survived completely. Patients 3 and 5 had persistent leaking. Patient 3 required initiation of negative pressure wound therapy with fistula closure, and patient 5 was managed conservatively. Patient 6 had reexposure of the plate and required a second flap (see previously). Patients 1, 5, and 7 died at 16-, 5-, and 1-month follow-up, respectively, due to the underlying pathology.

Color match for cutaneous defects was very good. No donor site complications were found beyond hematoma managed conservatively and slight scar enlargement. No functional shoulder morbidity was reported.

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