Objective

Head and neck soft tissue oncologic resections often result in complex reconstructive problems that require a dependable and vascular local, regional, or free flap to restore both form and function. With recent advances in microsurgical free-tissue transfers, the reconstructive bar has been raised. Significant donor site morbidity is neither acceptable nor necessary.  Local flaps are often of inadequate size while regional muscle flaps (pectoralis major, deltopectoral, trapezius) are not only bulky, but are often associated with significant donor site morbidity. Microsurgical free flaps (forearm, anterolateral thigh, parascapular, abdominal) are ideal but require technical expertise and increased operative time.  For patients who are poor free flap candidates, the pedicled supraclavicular artery flap offers a local-regional flap alternative with comparable functional reconstructive results and minimal donor site morbidity.  Initially described for skin resurfacing after burn/trauma scar contracture release, this flap is a versatile, thin, fasciocutaneous flap that can be harvested easily and quickly.  We demonstrate its utility and durability in a variety of neck and lower face reconstructive problems.

Methods

Over a six month period, tumor ablation defects of the neck and lower face were reconstructed using a pedicled supraclavicular artery rotation flap. All pedicle vessels were pre-operatively mapped using a handheld Doppler probe.  Flap design was based upon the dopplered vascular anatomy and harvested on the non-radiated side when possible.  The traditional distal to proximal as well as an alternate anterior to posterior subfascial flap harvest techniques were utilized.  Complications and functional outcomes were assessed.

Results

A pedicled supraclavicular artery flap was used to reconstruct partial and circumferential pharyngeal, tracheal-stomal, mandible, oral cavity, and neck contour defects.  All flaps (n=10) were harvested in under one hour.  All patients had uneventful postoperative recoveries. All ablative wounds and donor sites were closed primarily and did not require additional surgery.  One patient, after undergoing a hemi-circumferential pharyngeal reconstruction with a normal swallowing study 1 week postoperatively, developed a small controlled leak that subsequently resolved. This patient had received preoperative radiation and likely disrupted the suture line repair with overly eager oral intake following the swallowing study. Another radiated patient, after undergoing mandibular fibular free flap and soft tissue reconstruction, developed distal supraclavicular flap necrosis secondary to tight skin closure over the flap.  None of the patients reported any functional donor site morbidity.  One patient noted referred sensation to the shoulder in the immediate postoperative period.

Conclusions

This is the first reported series describing the use of a pedicled supraclavicular artery flap for reconstructing a variety of head and neck oncologic defects that would otherwise have required a regional muscle flap or free tissue transfer. We demonstrate its utility in a variety of head and neck reconstructions beyond skin resurfacing, potentially making free forearm and anterolateral thigh flaps a secondary reconstructive option. The supraclavicular artery flap is an excellent flap option for poor microvascular surgical candidates as well as individuals with either high recurrence risk or advanced disease.  This thin flap is easy and quick to harvest, has a reliable pedicle, and has minimal donor site morbidity. It is a versatile under-utilized flap that should be in every head and neck reconstructive surgeon’s armamentarium.