return to: Reconstructive Procedures Protocols

GENERAL CONSIDERATIONS

1. Indications
   1. The supraclavicular flap is a thin, axial, fasciocutaneous flap that may be used for reconstruction of tracheal-stomal, mandible, intra-oral, parotid, neck (eg. exposed carotid arteries), pharyngeal wall, skull base, and cutaneous facial defects
   2. Advantages of a supraclavicular flap include its minimal donor site morbidity (typically closed primarily); reliability of pedicle; pliability; and ease of harvest (less than 1 hour; verbal report of a minimum of 8 minutes achieved by experts with significant experience with this flap); texture and color match
      1. Does not require microvascular expertise or prolonged operative time of a free flap
   3. The width of the flap is determined by the laxity of the neck skin allowing primary closure, and can be as large as 24cm x 8cm. 
2. Contraindications
   1. Caution and consideration for pre-operative imaging of patients with prior level V neck dissections, or use of contralateral shoulder in the setting of prior radiation.
3. Pertinent anatomy
   1. Arterial anatomy
      1. Transverse cervical artery
         1. Branches off the thyrocervical trunk in most cases; rarely may branch from the first part of the subclavian artery
         2. Courses posteriorly in the neck and travels deep to the inferior belly of the omohyoid muscle
      2. Supraclavicular artery
         1. ​Generally originates from the transverse cervical artery, however may infrequently arise from the suprascapular artery
            1. ​Branch point on the transverse cervical artery occurs about 3-5 cm off the thyrocervical trunk
         2. After branching, the supraclavicular artery will pierce the deep fascia of the deltoid muscle after 2-4.5 cm (Kim et al).
         3. Anatomical dissection studies have found the supraclavicular artery to have a mean diameter from 1.1 to 1.5 mm, its pedicle length ranged from 1 to 7 cm, and it was present 80 percent of the time (Abe et al). Studies based on CT angiography demonstrated mean vessel diameter of 1.5mm (range, 0.8-2.1 mm) with mean length of 38 mm (range, 24-67 mm) (Adams et al)
         4. Skin landmarks
            1. ​The supraclavicular artery is located in a triangle bounded inferior by the clavicle, medially by the posterior border of the SCM, and laterally by the external jugular vein
            2. In general, the artery will be 2.5-4 cm superior to the clavicle, and 2 cm posterior to the SCM
   2. Venous anatomy
      1. Two venae comitantes, which most commonly drain via the transverse cervical vein; less commonly it is from the external jugular vein
   3. Nerve anatomy
      1. ​The 3rd and 4th cervical nerves merge to form supraclavicular nerves, which provide sensation to the region of the flap over the shoulder as well as lateral neck and upper chest
      2. Some patients have noted sensation referred to the shoulder after this flap. Additional studies are investigating the possibility of neurotized flap.

PREOPERATIVE PREPARATIONS

1. Evaluation
   1. Doppler (pencil Doppler) verification of the artery is done during pre-operative evaluation
      1. CT angiography may be performed (eg. prior level V neck dissection and concern for prior disruption of the transverse cervical artery or supraclavicular artery)
2. Consent for Surgery
   1. Potential complications 
      1. Major
         1. Flap loss with inadvertent pedicle division. Distal-to-proximal dissection reduces this risk.
      2. Minor
         1. Distal tip necrosis - minimized with use of scalpel and bipolar cautery in raising the flap, rather than monopolar
            1. Generally, the insertion of the deltoid muscle marks the longest the flap can be without tip necrosis
         2. Donor site wound dehiscence and cellulitis - typically managed with local wound care
      3. No functional donor site morbidity has been reported

NURSING CONSIDERATIONS

1. Room Setup
   1. See Basic Soft Tissue Room Setup 
2. Instrumentation and Equipment
   1. Standard
      1. Major Instrument Tray 1
      2. Major Instrument Tray 2
      3. Bipolar Forceps Tray
   2. Special
      1. Doppler probe and control unit
3. Medications (specific to nursing)
   1. 1% lidocaine with 1:1000 epinephrine
   2. Antibiotic ointment to incision
4. Prep and Drape
   1. Shoulder roll to improve exposure
   2. Standard prep, 10% providone iodine
   3. Drape
      1. Head drape
      2. Towels to square off operative site
      3. Split sheet
   4. Drains and Dressings
      1. 7 mm or 10 mm flat drain (optional)

ANESTHESIA CONSIDERATIONS

1. General
   1. The patient is positioned and, in most cases, the bed will be turned 180° from the anesthesiologist.
   2. In the vast majority of cases, the surgery is done under general anesthesia. 

OPERATIVE PROCEDURE

1. The flap is designed on the patient's shoulder extending anteriorly to the clavicle, posteriorly to the trapezius muscle, and laterally to the deltoid muscle. 
2. Pencil doppler is used to identify the supraclavicular vessel, and the flap is designed with a fusiform shape, up to 24cm x 8cm to allow for primary closure
   1. A "pinch test" before incision can help determine the width of the flap that will still allow closure
3. The flap is incised and raised in a suprafascial or subfascial plane from distal to proximal until the supraclavicular vascular pedicle is identified. At the clavicle, slow the dissection and transition to subfascial plane to improve arch of rotation. Full skeletonization of the vascular pedicle to its origin from the transverse cervical artery may improve flap rotation, but is generally not necessary. 
   1. Trim the distal tip of the flap if necessary until healthy bleeding is seen. 
4. Flap inset with connection to the neck scar rather than tunneling is recommended to avoid constriction of the pedicle
   1. Proximal flap may be de-epithelialized if necessary
5. Donor site is closed after wide undermining anteriorly and posteriorly. Drain may not be necessary as closure typically obliterates dead space.

POSTOPERATIVE CARE

1. No compressive ties around the neck
2. Keep the patient's head in neutral position without pillows for the initial post-op days

REFERENCES

Chiu ES, Liu PH, Friedlander PL. Supraclavicular artery island flap for head and neck oncologic reconstruction: indications, complications, and outcomes. Plast Reconstr Surg. 2009 Jul;124(1):115-23.

Kim RJ, Izzard ME, Patel RS. Supraclavicular artery island flap for reconstructing defects in the head and neck region.  Curr Opin Otolaryngol Head Neck Surg. 2011 Aug;19(4):248-50.

Abe M, Murakami G, Abe S, Sakakura I, Yajima I. Supraclavicular artery in Japanese: An anatomical basis for the flap using a pedicle containing a cervical, non-perforating cutaneous branch of the superficial cervical artery. Okajimas Polia Anat Jpn. 2000;77:149--154.

Adams AS, Wright MJ, Johnston S, Tandon R, Gupta N, Ward K, Hanemann C, Palacios E, Friedlander PL, Chiu ES. The Use of Multislice CT Angiography Preoperative Study for Supraclavicular Artery Island Flap Harvesting.  Ann Plast Surg. 2011 Aug 5  (Epub ahead of print)