Acta Otorrinolaringol Esp.

2018;69(1):8---17

www.elsevier.es/otorrino

ORIGINAL ARTICLE

Utility and Versatility of the Supraclavicular Artery

Island Flap in Head and Neck Reconstruction夽
José A. González-García,∗ Carlos M. Chiesa-Estomba, Jon A. Sistiaga,
Ekhiñe Larruscain, Leire Álvarez, Xabier Altuna

Servicio de Otorrinolaringología y Cirugía de Cabeza y Cuello, Hospital Universitario Donostia-Donostia Unibersitate Ospitalea,
Donostia-San Sebastián, Gipuzkoa, Spain

Received 1 December 2016; accepted 12 March 2017

KEYWORDS Abstract
Surgical flap; Introduction: The supraclavicular island flap is a rotational pedicled flap and may have some
Reconstructive advantages in head and neck reconstruction compared with free-tissue transfer when this kind
surgical procedure; of reconstruction is not affordable or recommended.
Head and neck Material and methods: We present our experience during the year 2016 in the application of
neoplasms; the supraclavicular island flap in five cases as an alternative to microvascular reconstruction in
Parotid neoplasms; several defects after resection of head and neck tumours. In two patients, the flap was used
Island flap; to close the surgical pharyngostoma after total laryngectomy with partial pharyngectomy. In
Pedicled flap one patient, it was used in lateral facial reconstruction after partial resection of the temporal
bone. In one case, it was used to close a skin defect after total laryngectomy with prelaryngeal
tissue extension. And in the last case to close a neck skin defect after primary closure of a
pharyngo-cutaneous fistula. There were no flap complications, and the result was satisfactory
in all cases.
Results: The supraclavicular artery island flap is useful and versatile in head and neck recon-
struction. Operating room time in aged patients or those with comorbidities will be reduced
compared to free flaps. The surgical technique is relatively easy and can be used for skin and
mucosal coverage.
Conclusion: The supraclavicular island flap could be a recommended option in head and neck
reconstruction, its use seems to be increasing and provides a safe and time-saving option to
free flaps in selected patients.
© 2017 Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringologı́a y Cirugı́a de
Cabeza y Cuello. All rights reserved.

夽 Please cite this article as: González-García JA, Chiesa-Estomba CM, Sistiaga JA, Larruscain E, Álvarez L, Altuna X. Utilidad y versatilidad
del colgajo en isla de la arteria supraclavicular en reconstrucción de cabeza y cuello. Acta Otorrinolaringol Esp. 2018;69:8---17.
∗ Corresponding author.

E-mail address: joseangel.gonzalezgarcia@osakidetza.eus (J.A. González-García).

2173-5735/© 2017 Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringologı́a y Cirugı́a de Cabeza y Cuello. All rights reserved.
Utility and Versatility of the Supraclavicular Artery Island Flap 9

PALABRAS CLAVE Utilidad y versatilidad del colgajo en isla de la arteria supraclavicular

Colgajo quirúrgico; en reconstrucción de cabeza y cuello
Procedimiento
Resumen
reconstructivo
Introducción: El colgajo supraclavicular en isla es un colgajo rotacional pediculado que puede
quirúrgico;
presentar ciertas ventajas en reconstrucción de cabeza y cuello en pacientes donde una
Neoplasias de cabeza
reconstrucción microvascularizada no sea factible o aconsejable.
y cuello;
Material y métodos: Presentamos nuestra experiencia durante el año 2016 en 5 casos con la
Neoplasias
aplicación de este colgajo, como alternativa a una reconstrucción microvascularizada tras
parotídeas;
resección de distintos tumores de cabeza y cuello. En 2 casos se utilizó para reconstrucción
Colgajo en isla;
del faringostoma quirúrgico tras laringectomía total con faringectomía parcial. En un caso para
Colgajo pediculado
reconstrucción facial lateral tras resección parcial de temporal. En un caso para reconstruc-
ción de un defecto cutáneo tras laringectomía total ampliada y en otro para cobertura cutánea
tras el cierre primario de una fístula faringocutánea. No hubo complicaciones del colgajo y el
resultado final fue satisfactorio en todos los casos.
Resultados: El colgajo supraclavicular en isla presenta una utilidad y es muy versátil en
reconstrucciones de cabeza y cuello. El tiempo quirúrgico en pacientes de riesgo se reducirá
respecto a colgajos libres microvascularizados. Su técnica quirúrgica es relativamente sencilla
y se adapta perfectamente a reconstrucciones mucosas o cutáneas.
Conclusión: El colgajo supraclavicular en isla es una opción recomendable en reconstrucción de
cabeza y cuello, su uso parece estar incrementándose y supone una alternativa segura y sobre
todo rápida a los colgajos libres microvascularizados en pacientes seleccionados.
© 2017 Elsevier España, S.L.U. y Sociedad Española de Otorrinolaringologı́a y Cirugı́a de Cabeza
y Cuello. Todos los derechos reservados.

Introduction 2 venasa comitans which are anastomosed to the external

Head and neck reconstructions in oncology surgery often
require the use of local, regional or free flaps to cover
mucosal or cutaneous surfaces and for restoration of
anatomical structure, for a certain function or aesthet-
ics. Although reconstruction through vascularised free tissue
flaps has led to a leap in quality in oncology surgery, its
use requires the patient to be in good physical condition,
considerable reconstructive experience, long periods in the
operating theatre and maximum postoperative monitoring.
As a result, pedicled flaps continue to play an important
role in reconstructive head and neck surgery, particularly
in patients with advanced comorbidities or who are of
advanced ages.
The supraclavicular island skin flap was described by
Lamberty1 in 1979 and derives from the studies on
‘‘shoulder’’ flaps by Mütter2 in 1842 and their redefini-
tion by Kirschbaum3 in 1958, which he called the acromial
‘‘epaulet’’ flap as a reference to the ornamental fabric
on the shoulders of military uniforms. Both the Mütter and
Kirschbaum flaps have random vascularisation but Lamberty
describes the supraclavicular island artery flap as an axial
flap based on the supraclavicular artery and describes the
origin of this artery in the transverse cervical artery. More-
over, he describes the origin of the transverse cervical artery
preferably in the thyrocervical arterial trunk (60% of the thy-
rocervical trunk, 30% of the distal subclavian artery, 6.6% of
the proximal subclavian artery and 3.3% of the subclavian
artery in midregion).1 Vein drainage occurs thanks to the
jugular vein or the transverse cervical vein.
In 1997 Pallua et al.4 published a modification of the flap
and defined it as the ‘‘supraclavicular island flap’’, with Pal-
lua et al.5 publishing the technique for its tunnelisation in
head and neck reconstructions again in 2000 and creating
considerable drive for its use worldwide.
One of its advantages is that the supraclavicular island
flap is highly foldable, small in volume and its length
allows sutures to be made without tension in the facial,
cervical, auricular, oropharyhgeal and parotid regions and
also in the reconstruction of pharyngostomas after total
laryngectomy. The almost constant possibility of a pri-
mary closure in the donor site after good elevation of the
remaining epithelial edges, low morbidity in the shoulder
region and rapidity of its elevation makes this flap viable
if a microsurgical flap is not going to be used due to
patient, hospital or tumour circumstances.6 A summary of
the supraclavicular island flap advantages are displayed in
Table 1.
Its limitations are the need for a wide rotation arc, the
need for a flap with a muscular component for the fill-in
or coverage of cavities, distal vascularisation which is com-
promised in patients who are smokers or the need to cover
defects which go as far as or overpass the oropharynx.7
Since this is a flap from the cervical region, proximity of
the anatomical area to reconstruct impedes working in 2
teams, which means in the majority of cases the raising of
the flap and the removal of the tumour cannot be performed
simultaneously.
10
Table 1 Advantages of the supraclavicular artery island
flap.
Easy of elevation
Speed of dissection
Versatility for use in different anatomical areas of head and
neck
Does not normally require dissection of its vascular pedicle
Primary closure in the great majority of reconstructions
Flap with constant and safe vascularisation
Possibility of following the vascular pathway through
Doppler
Minimum morbidity of donor area
Possibility of use in elderly patients or those with
comorbidites
Its length allows for a double-sided design for cheek or
large fistulas
Possibility of previous skin expansion in non tumour
pathology
Material and Methods
The head and neck tumour cases which, for diverse reasons,
required reconstruction with a pedicled supraclavicular
island flap in 2016 were reviewed by our service. A search of
the literature was also conducted with regard to the history,
anatomy and possible applications of the supraclavicular
island flap in head and neck reconstructions.
During the January to December period 2016 we per-
formed 5 cases of supraclavicular island flaps. The most
relevant medical record data may be observed in Table 2.
A descriptive analysis of the cases was performed which
included patient age and gender, defect size, total time
in surgery and reconstructive time, postoperative hospi-
tal stay, skin flap paddle size, postoperative and flap
complications and functional outcome.
The operating room schedule and surgical notes on the
patients made by anaesthiology and nursing staff were
reviewed electronically so as to obtain the total time in
surgery, which was measured from the initial incision to
closure. The time employed to raise and finally locate the
supraclavicular island flap on the defect was also measured.
To begin to measure reconstructive time, the start time was
regarded to be when the surgical specimen reflected in the
nursing care sheet was sent to the Pathological Anatomy
Service.
Surgical Technique
The supraclavicular artery, which is a branch of the trans-
verse cervical artery, is located as emerging towards the
antero-superior surface of the shoulder in the triangle
formed by the posterior edge of the sternocleidomastoid
muscle, the collar bone and the external jugular vein. Its
pathway begins in the fatty tissues of region V (Fig. 1).
The skin paddle of the upper region of the shoulder is
constantly and richly vascularised from its point of origin
towards the acromion clavicular joint, where the behaviour
pattern of its branches is somewhat more randomised. The
flap is designed with an island of elliptic or square shaped
J.A. González-García et al.
skin which lies along the distal supraclavicular region with
its most distal part being where shoulder and arm meet,
although it could be extended to the superior lateral region
of the arm or exceed the distal deltoid insertion in the
humerus if necessary.
The pathway of the artery is marked in accordance with
the before-mentioned anatomical references or may be
identified using a one-direction acoustic Doppler device or
a colour Doppler device.
The width of the flap must not be greater than 8 cm if
a primary closure of the defect is to be made without skin
grafts.
Although it has been reported that the ideal position for
its performance would be lateral decubitus, in our experi-
ence, elevation time is easy, viable and fast in the standard
surgical position in head and neck which is the supine posi-
tion.
The skin paddle should not be cut until there is precise
certainty of the defect to be reconstructed, of the pivotal
point (the origin of the supraclavicular artery at the base
of the neck) and the maximum reach of the flap in accor-
dance with the rotation arc. The skin paddle design may be
obtained in several ways. One would be to measure the sur-
gical specimen, which is rather more imprecise due to the
changes it may suffer once ressected. Another is to make a
model of the defect to be reconstructed in plastic coated
paper which could be taken to the supraclavicular region.
This is the method we usually use for skin reconstructions.
A third would be to calculate the mucous defect using mil-
limetre or centimetre rulers which are positioned over the
nasogastric probe and the Montgomery salivary stunt and
which enable the width of the reconstructable defect in a
postoperative pharyngostoma to be calculated. The length
from the base of the tongue to the oesophageal region is
much more easily measurable using a manual ruler.
Dissection starts at the distal margin of the flap in the del-
toid region, and involves skin, subcutaneous tissues and the
fascia of the deltoid muscle, raising the flap along the sub-
fascial surface, from the region which is distal to the flap
up to the proximal end (from lateral to medial). We may
observe the vascular pedicle by transillumination approx-
imately from the mid-clavicular region. Once sufficiently
raised, the skin dissection around the point of emergence of
the supraclavicular artery at the base of neck is completed
up to the skin island, dissecting the anterior and posterior
margins of the flap until there is sufficient detachment for a
rotation arc to take the flap to the recipient region. Metic-
ulous dissection or the individualisation of the pedicle are,
in the main, unnecessary thus leading to one of the greatest
advantages, the speed of obtaining the flap.
De-epithelisation of the region proximal to the flap in
head and neck reconstruction is highly standard (Fig. 2)
and means the pedicle may be tunnelled below the inferior
or superior dermoplatismal flap or in a pharyngeal tunnel
or the bottom of the mouth for oral cavity or oropharynx
reconstructions. De-epithelisation may be performed at the
beginning of dissection if we are precisely aware of the size
of the defect or at the end of elevation, thus adapting it to
changes in the area of reconstruction.
The donor site will be closed first in the majority of
cases, with the help of resection of a distal skin triangle, to
avoid over raising of the scar and a broad dissection of the
Utility and Versatility of the Supraclavicular Artery Island Flap 11

Table 2 Clinical Data.

Supraclavicular artery island flap in head and neck reconstruction. Clinical data

Sex Age, in years Pathology Intervention Comorbidity

1 Male 82 Recurrent parotid Partial resection of the Ischaemic cardiopathy
carcinoma temporal bone with total
auriculectomy and unilateral
cervical emptying
2 Male 74 Pharyngeal cutaneous Primary closure of the Ischaemic cardiopathy
fistula after total pharyngostoma and skin defect
laryngectomy coverage
3 Male 71 Laryngeal carcinoma Partial pharyngectomy with Cachexia
total laryngectomy and
bilateral cervical
emptying + phonatory
prosthesis
4 Male 68 Laryngeal carcinoma Partial pharyngectomy with Severe chronic
total laryngectomy + bilateral obstructive pulmonary
cervical emptying + phonatory disease
prosthesis
5 Male 76 Laryngeal carcinoma Total laryngectomy extended Cardiac arrest and aortic
to cervical skin + bilateral wall thrombus
cervical emptying + phonatry
prosthesis

Figure 1 Anatomical references for identification of the pedi-

cle in the supraclavicular artery island flap. Collarbone: star.
External jugular vein: arrowhead. Posterior edge of the stern-
ocleidomastoid muscle: arrow.
remaining tissues in front and behind the paddle for suitable
approximation without tension.
Results
The most relevant results may be consulted in Table 3. All
patients were over 65. Mean age of reconstruction in our
service with a supraclavicular island flap during 2016 was
74.2 years (range between 68 and 82).
In one case a lateral facial reconstruction was made after
resection of a relapsed parotid adenocarcinoma with partial
resection of the temporal bone (Fig. 3). We also performed
an anterior cervical skin reconstruction after total laryn-
gectomy extended to prelaryngeal tissues (Fig. 4) and after
a postsurgical pharyngocutaneous fistula. In 2 cases there
Figure 2 Elevation of the supraclavicular artery island flap.
Note the clavicular deperiostisation, the subfascial dissection
with exposure of muscle fibres of the deltoid muscle and the
medial de-epithelialisaion for tunnelling the flap.
was reconstruction of the surgical pharyngostoma after total
laryngectomy with partial pharyngectomy. One patient had
previously received radiotherapy treatment, prior to the
presented intervention due to a glottic carcinoma 8 years
previously (Fig. 5).
Characteristics of the Supraclavicular Artery Island
Flap
Due to the versatility of the supraclavicular artery island
flap the defects to be reconstructed were varying in size and
location but could be divided into groups under the consid-
eration as to whether it was necessary to cover a skin defect
 12
Table 3 Postoperative Outcomes.
Supraclavicular island flap in head and neck reconstruction. Outcomes

Sex Age in years Reconstruction Defect size Time in surgery Postoperative stay Vitality of flap Complications
(reconstructive time)
1 Male 82 Skin 10 × 6 cm 4 h 45 min (120 min) 11 days 100% No
2 Male 74 Skin 12 × 5 cm 2 h 10 min (100 min) 13 days 100% Recurrent fistula 5
months after termination
of chemo and
radiotherapy treatment
3 Male 71 Surgical 7 × 6 cm 5 h 45 min (70 min) 10 days 100% No
pharyngostoma
4 Male 68 Surgical 8 × 7 cm 7 h (120 min) 14 days 100% Febrile neutropenia---
pharyngostoma pneumonia 3 days after
termination of chemo
and radiotherapy. Death
5 Male 76 Skin defect from 9 × 7 cm 5 h 50 min (55 min) 10 days 100% No
extended
laryngectomy

J.A. González-García et al.

Utility and Versatility of the Supraclavicular Artery Island Flap 13

Figure 3 Use of the supraclavicular artery island flap for post-auriculectomy defect. (A) Design of the planned resection with
intention of preserving part of the scapha and helix. (B) Surgical site after supraomohyoid emptying, partial resection of temporal
bone and total auriculectomy with elevation of temporal muscle flap and supraclavicular island flap. (C) Supraclavicular island flap
elevated and in position. (D) Appearance of reconstruction 6 months after termination of adjuvant radiotherapy.

Figure 4 Use of the supraclavicular artery island flap for cervical skin defect. (A) Design of the skin extension to tissues and
peritrachostomal skin. (B) Skin defect after pharyngostoma closure. (C) Supraclavicular island flap elevated and in position (D)
Appearance of the flap and donor area three months after surgery.

(3/5) or mucous defect (2/5). It was also important to con-
sider whether it was a defect with a similar wide-length
(3/5) or a more ‘‘rectangular’’ type defect with a latero-
medial length above the anteroposterior one (2/5), as were
necessary for the reconstruction after pharyngeal-cutaneous
fistulas or the defect after partial resection of the temporal
bone.
In our case, 3 of the flaps were elevated trust-
ing solely in the anatomical references. The other 2
cases, where reconstruction was made of the postsurgi-
cal pharyngostoma after partial pharyngectomy and total
laryngectomy, an acoustic one direction Doppler device
was used to mark the pathway of the supraclavicular
artery.
14
Figure 5 Use of the supraclavicular artery island flap for hypopharyngeal defect after partial pharyngectomy, total laryngectomy,
bilateral emptying. (A) Hypopharyngeal defect with remainder insufficient for primary closure. (B) Elevation of the supraclavicular
flap and tunnelling below the cervical skin (cranial view). (C) Immediate postoperative appearance after reconstruction (caudal
view).
Time in Surgery
Mean time in surgery was 306 min (5 h and 16 min) with a
range of between 130 and 420 min.
It should be taken into consideration that in one of the
cases only a minimum skin elevation and closure of a minor
pharyngocutaneous fistula was performed with a reconstruc-
tion time to perform a skin coverage after primary closure.
Total time in surgery was 130 min.
Mean time for reconstruction was 93 min, with a range of
between 55 and 120 min.
De-Epithelialisation
In 4 of the 5 cases de-epitheliaslisation proximal to the flap
was necessary for tunnelling below the dermoplatismal skin
flap, at a distance from the pivot point where the supracla-
vicular artery emerged cervically.
In the case of the skin cover after primary closure of
a pharyngocutaneous fistula following total laryngectomy,
de-epithelialisation was not necessary and the flap was
designed to be somewhat narrower so it could be rotated
towards the superior and lateral region of the tracheal stoma
without the need for de-epithelialisation.
Primary Closure
Primary closure of the donor area was achieved in the 5
patients using resection of the remaining skin in the distal
area of the triangular shape and/or dissection of the skin
plane around the defect which enabled simple advancement
of the remaining flaps and a closure in 2 planes without the
need for skin graphs or rotating flaps. We did not record any
wound dehiscence in the donor region.
J.A. González-García et al.
Functional Complications of Donor Site
No postoperative complications were detected in the donor
area as a result of flap elevation and the clinical character-
istics and bilaterism of the discomfort and functional failure
which one of the patients experienced were attributable to
a lesion caused by the traction of both peripheral spinal cord
nerves.
Postoperative Period
Mean postoperative period was 11.8 days, with a range
between 10 and 14 days.
Postoperative Complications
In our case study there were 3 complications, 2 of which
could be considered major.
One patient died as a consequence of a febrile neu-
tropenia complicated by pneumonia once month after
finalising chemotherapy and radiotherapy treatment. There
was also one recurrence of cutaneous pharyngeal fistula
4 months after finalising chemotherapy and radiotherapy,
which externalised along the intact cervical skin approxi-
mately 3 cm from the distal edge of the flap, but without
the flap being affected. Reconstruction was performed with
a miocutaneous flap from the pectoralis major to include
muscle separation tissue due to the recent irradiation.
Discussion
Oncology surgery of the head and neck has experienced a
major development in the last 20 years since the appear-
ance of free microvascular flaps, which have been associated
Utility and Versatility of the Supraclavicular Artery Island Flap
with better functional, aesthetic results and a better qual-
ity of life with a success rate close to 95%.8 However, free
microvascular flaps will require great training in microvascu-
lar surgery and a series of specific resources in the hospital
where they are to be performed. Furthermore, not all the
patients who we are going to operate on for a tumour in the
head and neck area will be candidates for reconstruction
with free microvascular flaps due to comorbidities which
would place their viability at risk. It will be in these cases
where pedicled regional flaps will offer an additional pos-
sibility for reconstructing the defect without running the
risk of failure of the microvascular suture or the morbidity
associated with very long operations in patients with prior
comorbidities or who are advanced in age.
In this article we present the results of a small group
of patients who underwent complex nonmicrovascularised
reconstruction with the use of the supraclavicular island
artery flap. We present this review to demonstrate the
safety and versatility of this flap in reconstruction after head
and neck oncology surgery, and also the advantages that this
type of reconstruction offers in cases where a reconstruction
using microvascularised free flaps is not recommended due
to patient characteristics or health centre characteristics
where the treatment is to take place.
The skin in the supraclavicular area is ideal for head and
neck surgery reconstruction and facial surgery due to its sim-
ilarity in texture, thickness and colour to the recipient area.
This skin moves well, has an extensive rotation arc to reach
the parotid-auricular region, the neck and the lower third
of the face, as well as the oral cavity and the oropharynx.
Coverage of the middle third of the face or the upper pharyn-
geal region is much more complex. The skin paddle is slim,
quite foldable and highly vascularised by the axial pedicle
flap dependent on the supraclavicular artery.
Numerous indications have been described for the sup-
raclavicular artery island flap, among which are those
described in this article: reconstruction of the auricu-
lotemporal area,9,10 reconstruction of the postoperative
pharyngostoma after total laryngectomy11 and skin cover
for extensive defects after total laryngectomy.12 It has also
been indicated for reconstructions after multiple oncologi-
cal surgeries, when the neck is lacking in receptor vessels or
there is fibrosis after multiple treatments make microvascu-
larised reconstruction insecure.13
Other indications include complex reconstructions after
resections of the parotid gland, the lateral base of the cra-
nium, and the auricular and temporal region, including the
reconstruction of the posterior and lateral cranium,14 the
reconstruction of a circular pharyngeal defect after cir-
cular pharyngectomy with total laryngectomy,15 skin cover
after resection of post-burn scars in the cervical and lower
facial region,4 mucous cover after surgical treatment of
mandibular osteorradionecrosis,16 the closure of orocuta-
neous fistulas after complicated oral cavity surgery,17 and
the reconstruction of the oropharynx after preferably tran-
soral surgery.18
The usefulness of this supraclavicular artery island flap
has also been demonstrated for the reconstruction of
the suprasternal bone and the closure of long term tra-
cheostomies, even with a small, flat bony fragment of
the distal clavicular.19 A use which is more aesthetic than
functional is the filling in of the lateral facial defect
15
after parotidectomies, which has been successful using the
application of the supraclavicular artery island flap in its
adiposfascial format, i.e. completely de-epithelialised.20
The use of the supraclavicular artery island flap does not
affect the primary fistuloplastia function when used for the
mucous reconstruction of the defect,21 since in 2 of the
patients presented in this review the phonatory prosthesis
could be easily inserted and the functioning of the pul-
monary voice of the phontory prosthesis after reconstruction
was confirmed.
As previously described, the technique for obtaining the
supraclavicular flap is simple, easy to learn and consists of
designing an appropriate skin paddle and in preserving the
vascular pedicle. The references for locating the origin of
the pedicle are consistent and lead to the identification of
the origin of the axial artery without the need for vascular
topographical techniques. Vascularisation is highly constant
up to the acromioclavicular joint and depends on axial vas-
cularisation, although its extension to the supero-lateral
region of the arm whose vascularisation depends on some-
what more random artery branches continues to be viable
and safe, and may be as long as 30 cm.22
When the use of the supraclavicular artery island flap
is compared to the use of free flaps it has been demon-
strated that the microvascularised flaps require significantly
greater time in surgery and lead to higher costs.23 Even with
a 2-team approach, time in surgery was considerably lower
with the supraclavicular artery island flap, with significantly
longer supraclavicular artery island flaps being raised, with
less time in the intensive care unit and a lower use of free
skin grafts for the donor site.24 In the study by Zhang et al.,25
when comparing reconstructions after hemiglosectomy with
a free radial antebrachial island flap of the supraclavicular
artery, it was demonstrated that there was a lower hospital
stay and lower incidence of complications in the donor area,
with similar functional outcome in swallowing and language
expression.
Morbidity in the donor area is minimal and does not
require a new incision in the cervical region, since its tun-
nelling below the inferior dermoplatismal flap is possible. As
shown by the Herr et al.26 study, the function of the shoulder
girdle and the shoulder after reconstructions with the sup-
raclavicular artery island flap, analysed by objective means,
neither alters strength or range of movement and the ele-
vation of the supraclavicular artery island flap does not lead
to any significant changes in daily activities or in quality of
life.
Despite the fact that age is not a contraindication for
undertaking microsurgical reconstruction,27 in certain cen-
tres there is preference to undertaken pedicled flaps in
patients of advanced ages, where surgical risk is high or who
have tumours which are at high risk of recurring. The aim
is to reduce time in surgery and the aggressiveness of that
surgery.28
In our case only one patient had received radiotherapy
prior to intervention and another patient had previously
had a prior cervical emptying (cervical emptying in the
patient with the persistent pharyngocutaneous fistula). In
the other cases a previous ipsolateral cervical emptying on
the donor side was performed during the same operation as
the flap elevation. Neither of these 2 conditions presented
any contraindications for the use of this flap in head and
16
neck reconstructions, since its safety was demonstrated in
patients undergoing radiation and in those undergoing cer-
vical dissection, provided that the vascular structures are
respected.29 Alves et al.28 performed 9 cases of supraclavi-
cular artery island flaps in patients in which an emptying of
the ipsolateral area V had taken place, without any associ-
ation of a higher rate of vascular complications for the flap
as a result of respecting its vascular anatomy.
With regard to functional outcome, the 2 cases of mucous
reconstruction after partial pharyngectomy with total laryn-
gectomy achieved appropriate swallowing of solid and liquid
foods before being discharged from hospital without any
signs of salivary fistulisation, also achieving vocal rehabil-
itation with the use of the inserted phonatory prosthesis. In
the 20-patient study by Chiu et al.15 they reported 30% of
fistulas in circular pharyngeal reconstruction, 10% of steno-
sis of reconstruction treated with pneumatic dilation, and
100% usage of phonatory prostheses.
Our series is obviously too small to show general relevant
conclusions on the use of the supraclavicular artery island
flap, although we did not experience any complications
relating to surgery itself or to reconstruction. However, we
present 2 complications, relating in one case to adjuvant
treatment and in the other to a recurrence of the pathology
treated using a supraclavicular artery island flap (recurrence
of the pharyngocutaneous fistula after 5 months from the
end of the adjuvant treatment). This enables us to conclude
that they are operations where, regardless of the reduction
of the aggressiveness of the free flap surgical procedure,
may lead to high morbidity and mortality on treating onco-
logical patients with serious pathologies.
Sensitivity in the flap may be maintained. In fact the
patient with the reconstruction after partial resection of
the temporal bone had almost normal sensitivity in the flap
and when the stitches were removed and the wound handled
the sensations referred to the shoulder. One of the patients
with reconstruction of the postsurgical pharyngostoma after
laryngectomy referred to a sensation of wetting the shoul-
der when they swallowed liquids. This sensitivity could be
of major use in intraoral reconstructions if suitable neural
plasticity is demonstrated and the sensation could be iden-
tified as lingual rather than referring to the shoulder. This
has yet to be demonstrated.
In our experience, with the use of the supraclavicular
artery island flap we found there were neither operative
differences nor greater intraoperative safety using the one-
direction acoustic Doppler. This is due to the fact that one
of the greatest advantages of this flap is that it has made
meticulous dissection and isolation of the vascular pedicled
flap unnecessary and merely requires anatomical respect for
vascularisation without identifying, isolating, meticulously
dissecting or excessively handling the axial vessels.
Conclusions
The supraclavicular artery island flap is highly versatile and
may therefore be included as a technique to consider in
reconstructive surgery of the head and neck when microvas-
cularised reconstruction has been ruled out. The technique
for its elevation is fast and relatively simple, with a low
operational morbidity and this means that primary closure
J.A. González-García et al.
may take place with a highly constant anatomy. The island
flap skin is thin and easily folds, and its rotation arc means
it can reach the whole neck and the lower and side facial
regions. Since publication the technique has been refined
and indications broadened, making it adaptable to very dif-
ferent reconstructions and anatomical regions. We therefore
consider this technique useful for head and neck surgeons
to learn.
Conflict of Interests
The authors have no conflict of interests to declare.
References
1. Lamberty BG. The supra-clavicular axial pattered flap. Br J Plast
Surg. 1979;32:207---12.
2. Mütter TD. Case of deformity from burns relieved by operation.
Am J Med Sci. 1842;4:66.
3. Kirschbaum S. Mentosternal contracture: preferred treatment
by acromial (in charretera) flap. Plast Reconstr Surg Transplant
Bull. 1958;21:131---8.
4. Pallua N, Machens HG, Rennekampff O, Becker M, Berger A. The
fasciocutaneous supraclavicular artery island flap for releas-
ing postburn mentosternal contractures. Plast Reconstr Surg.
1997;99:1878---86.
5. Pallua N, Magnus N. The tunneled supraclavicular island flap:
an optimized technique for head and neck reconstruction. Plast
Reconstr Surg. 2000;105:842---51.
6. Teymoortash A, Mandapathil M, Hoch S. Indications for recon-
struction of mucosal defects in oropharyngeal cancer using
a supraclavicular island flap. Int J Oral Maxillofac Surg.
2014;43:1054---8.
7. Kokot N, Mazhar K, Reder LS, Peng GL, Sinha UK. The supra-
clavicular artery island flap in head and neck reconstruction:
applications and limitations. JAMA Otolaryngol Head Neck Surg.
2013;139:1247---55.
8. Gusenoff JA, Vega SJ, Jiang S, Behnam AB, Sbitany H, Herrera
HR, et al. Free tissue transfer: comparison of outcomes between
university hospitals and community hospitals. Plast Reconstr
Surg. 2006;118:671---5.
9. Levy JM, Eko FN, Hilaire HS, Friedlander PL, Melgar MA, Chiu
ES. Posterolateral skull base reconstruction using the supracla-
vicular artery island flap. J Craniofac Surg. 2011;22:1751---4.
10. Pointer DT, Friedlander PL, Amedee RG, Liu PH, Chiu ES.
Infratemporal fossa reconstruction following total auriculec-
tomy: an alternative flap option. J Plast Reconstr Aesthet Surg.
2010;63:615---8.
11. Emerick KS, Herr MA, Deschler DG. Supraclavicular flap
reconstruction following total laryngectomy. Laryngoscope.
2014;124:1777---82.
12. Chiu ES, Liu PH, Friedlander PL. Supraclavicular artery island
flap for head and neck oncologic reconstruction: indica-
tions, complications, and outcomes. Plast Reconstr Surg.
2009;124:115---23.
13. Su T, Pirgousis P, Fernandes R. Versatility of supraclavicu-
lar artery island flap in head and neck reconstruction of
vessel-depleted and difficult necks. J Oral Maxillofac Surg.
2013;71:622---7.
14. Emerick KS, Herr MW, Lin DT, Santos F, Deschler DG. Sup-
raclavicular artery island flap for reconstruction of complex
parotidectomy, lateral skull base, and total auriculectomy
defects. JAMA Otolaryngol Head Neck Surg. 2014;140:861---6.
15. Chiu ES, Liu PH, Baratelli R, Lee MY, Chaffin AE, Friedlan-
der PL. Circumferential pharyngoesophageal reconstruction
Utility and Versatility of the Supraclavicular Artery Island Flap
with a supraclavicular artery island flap. Plast Reconstr Surg.
2010;125:161---6.
16. Kalantar-Hormozi A, Khorvash B. Repair of skin covering
osteoradionecrosis of the mandible with the fasciocutaneous
supraclavicular artery island flap: case report. J Craniomaxillo-
fac Surg. 2006;34:440---2.
17. You YH, Chen WL, Zhang DM. Closure of large oropharyn-
gocutaneous fistulas using a folded extensive supraclavicular
fasciocutaneous island flap. J Oral Maxillofac Surg Med Pathol.
2013;25:310---3.
18. Anand AG, Tran EJ, Hasney CP, Friedlander PL, Chiu ES.
Oropharyngeal reconstruction using the supraclavicular artery
island flap: a new flap alternative. Plast Reconstr Surg.
2012;129:438---41.
19. Pallua N, Wolter TP. Defect classification and reconstruction
algorithm for patients with tracheostomy using the tunneled
supraclavicular artery island flap. Langenbecks Arch Surg.
2010;395:1115---9.
20. Epps MT, Cannon CL, Wright MJ, Chaffin AE, Newsome RE, Fried-
lander PL, et al. Aesthetic restoration of parotidectomy contour
deformity using the supraclavicular artery island flap. Plast
Reconstr Surg. 2011;127:1925---31.
21. Sethi RK, Kozin ED, Lam AC, Emerick KS, Deschler DG. Pri-
mary tracheoesophageal puncture with supraclavicular artery
island flap after total laryngectomy or laryngopharyngectomy.
Otolaryngol Head Neck Surg. 2014;151:421---3.
22. Fang SL, Zhang DM, Chen WL, Wang YY, Fan S. Reconstruction of
full-thickness cheek defects with a folded extended supraclavi-
17
cular fasciocutaneous island flap following ablation of advanced
oral cancer. J Cancer Res Ther. 2016;12:888---91.
23. Kozin ED, Sethi RK, Herr M, Shrime MG, Rocco JW, Lin D,
et al. Comparison of perioperative outcomes between the sup-
raclavicular artery island flap and fasciocutaneous free flap.
Otolaryngol Head Neck Surg. 2016;154:66---72.
24. Granzow JW, Suliman A, Roostaeian J, Perry A, Boyd JB. Sup-
raclavicular artery island flap (SCAIF) vs free fasciocutaneous
flaps for head and neck reconstruction. Otolaryngol Head Neck
Surg. 2013;148:941---8.
25. Zhang S, Chen W, Cao G, Dong Z. Pedicled supraclavicular
artery island flap versus free radial forearm flap for tongue
reconstruction following hemiglossectomy. J Craniofac Surg.
2015;26:527---30.
26. Herr MW, Bonanno A, Montalbano LA, Deschler DG, Emerick KS.
Shoulder function following reconstruction with the supraclavi-
cular artery island flap. Laryngoscope. 2014;124:2478---83.
27. Sierakowski A, Nawar A, Parker M, Mathur B. Free flap surgery
in the elderly: experience with 110 cases aged ≥ 70 years. J
Plast Reconstr Aesthet Surg. 2017;70:189---95.
28. Alves HR, Ishida LC, Ishida LH, Besteiro JM, Gemperli R, Faria
JC, et al. A clinical experience of the supraclavicular flap
used to reconstruct head and neck defects in late-stage cancer
patients. J Plast Reconstr Aesthet Surg. 2012;65:1350---6.
29. Razdan SN, Albornoz CR, Ro T, Cordeiro PG, Disa JJ, McCarthy
CM, et al. Safety of the supraclavicular artery island flap in
the setting of neck dissection and radiation therapy. J Reconstr
Microsurg. 2015;31:378---83.