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Supraclavicular Flap
12
AryaNamin andMasoudSaman
Introduction
The supraclavicular ap is a pedicled fasciocutaneous ap based off the supraclavicular artery that was originally described in the late 1970s. While various descriptions of shoulder aps were present in the literature, Lamberty described the vascular
anatomy of the supraclavicular ap in 1979 [1]. The cervicohumeral ap was
described as a ap based off the transverse cervical artery and centered over the
acromioclavicular joint with the option of extending the ap distally over the lateral
arm [2]. The anatomic study by Lamberty included 30 cadaveric sides that described
a supercial branch of the supercial transverse cervical artery that was present in
28 out of 30 cadaveric sides [1]. The course of the supercial branch of the supercial transverse cervical artery is described as originating from the supercial transverse cervical artery and then passing laterally toward the acromioclavicular joint
and then sending branches laterally onto the lateral aspect of the upper arm [1].
Lamberty later went on to clarify that the cervicohumeral ap was a musculocutaneous ap with random extensions, explaining the higher failure rate in certain studies
[3]. The use of the supraclavicular ap did not become widespread during the 1980s
and 1990s likely because of the rise of free tissue transfer and lack of a clear understanding of the angiosome and therefore design of the supraclavicular artery ap.
The vascular anatomy, angiosome, ap design, and reliability were more robustly
described by a series of studies in the late 1990s [4, 5]. In the 2000s, multiple studies were published supporting the utility of the supraclavicular ap in reconstructing a variety of cutaneous and aerodigestive tract defects [6–9]. Subsequently during
A. Namin
Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, TX, USA
M. Saman (*)
DallasFaceDoc, PLLC, Dallas, TX, USA
e-mail: drsaman@dallasfacedoc.com
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_12
159
160
A. Namin and M. Saman
the 2010s, the supraclavicular ap gained widespread use across many centers for
the reconstruction of defects, including cutaneous defects of the head and neck,
lateral skull base, parotidectomy, and aerodigestive tract [10–17]. Head and neck
defects often have multiple reconstructive options that would result in acceptable
form and function with minimal morbidity. The benets of the supraclavicular ap
include avoidance of distant donor site morbidity, microvascular anastomosis,
rapidity of harvest, and thinness and pliability of the ap matching cutaneous
defects of the head and neck.
Anatomy
The supraclavicular ap is a pedicled fasciocutaneous ap based off the supraclavicular artery, which is most commonly a branch of the transverse cervical artery [4,
8]. The supraclavicular artery can be less commonly found as a branch of the supra-
scapular artery [8]. However, there is discrepancy in the published literature regarding the anatomy of the supraclavicular artery. In an anatomical study of 19 fresh
cadavers, the supraclavicular artery arose 3–4cm from the origin of the transverse
cervical artery in 100% of the specimens [4]. Multiple anatomical studies have demonstrated the supraclavicular artery branching from the transverse cervical artery
3.0–3.6 cm above the clavicle, 8.2–8.6 cm from the sternoclavicular joint, and
2.1cm dorsal to the sternocleidomastoid muscle with a mean diameter of 1.0–1.5mm
[4, 18]. Importantly, this study of 19 fresh cadavers dened the angiosome of the
supraclavicular artery as the skin over the ventral surface of the deltoid extending
from the supraclavicular region to the should cap, which was an important clarication of the early studies describing the cervicohumeral ap that centered the skin
paddle over the acromioclavicular joint and extending distally over the lateral arm
[2, 4]. Understanding this anatomy and typical course of the supraclavicular artery
is important when designing the ap over the ventral surface of the deltoid muscle
(Fig.12.1). The area of the angiosome ranged from 10×22cm2 to 16×30cm2 [4].
More recently, Pallua etal. have described the anterior supraclavicular artery, which
is also a branch of the transverse cervical artery, but branches more proximally
above the clavicle directly lateral to the sternocleidomastoid muscle before passing
through the platysma crossing the clavicle in the medial third and then running in
the deltopectoral groove [19]. In the experience of Pallua etal., both the supraclavicular artery and the anterior supraclavicular artery are reliably present [19].
Multiple radiographic studies of cadaveric supraclavicular aps have examined
the angiosome of the supraclavicular artery [18, 20, 21]. A cadaveric study has been
described where postcontrast CT scans were obtained after supraclavicular aps
were elevated, including the deltoid muscle in some of the aps [21]. The course of
the supraclavicular artery and the dimension of the vessel were in concordance with
previously published studies [4, 21]. The supraclavicular artery was noted to cross
the clavicle in the middle to lateral thirds in the suprafascial plane [21]. The skin
supercial to the deltoid muscle was noted to have perfusion through musculocutaneous perforators originating from the anterior and posterior circumex humeral
12 Supraclavicular Flap
Fig. 12.1 Supraclavicular
ap design. The
supraclavicular artery is
identied with Doppler
ultrasonography in the
triangle formed by the
posterior border of the
sternocleidomastoid, the
clavicle, and the external
jugular vein. The skin
paddle is designed over the
ventral surface of the
deltoid, not extending
distal to the deltoid’s
insertion point into the
humerus. (Courtesy of
Masoud Saman, MD)
161
arteries [21]. The study concluded that it was anastomosis between the supraclavicular artery and the musculocutaneous perforators through the deltoid muscle that
allow for a reliable ap design up to the insertion of the deltoid muscle, which is
consistent with clinical ndings [8, 12, 21]. A similar study of ten cadaveric supraclavicular aps demonstrated concordant ndings that the supraclavicular artery
perfused the distal portions of the ap overlying the deltoid muscle through an interperforator ow from direct linking vessels and recurrent ow through the subdermal
plexus [18]. Chan etal. found that one of the ten aps was perfused only about 50%
by the supraclavicular artery due to a smaller supraclavicular artery (0.7mm) [18].
The venous drainage of the supraclavicular ap typically drains via the venae comitantes that subsequently drain into the transverse cervical veins and a second vein
draining into the external jugular vein [4, 18, 21]. Prior to ap elevation, the skin
overlying the distal aspect of the ap has venous drainage into the cephalic vein and
circumex humeral vein via the musculocutaneous branches through the deltoid
muscle, which likely increases venous pressure within the distal portion of the ap
after elevation [18, 21]. While the supraclavicular ap has been described as a free
ap, the diameter of the veins requiring anastomosis and number of excellent low
morbidity donor site alternatives has led to its infrequent use as a free ap [20].
162
A. Namin and M. Saman
Indications
The indications for the supraclavicular ap have been widely expanded over the
past two decades to include postburn neck scar contractures, noma orofacial defects,
progressive hemifacial atrophy asymmetry, tracheal reconstruction, parotidectomy
contour defects, cutaneous defects of the head and neck, lateral skull base defects,
auriculectomy defects, and aerodigestive tract defects.
The supraclavicular ap initially gained more widespread use after its application in reconstructing postburn neck scar contractures [5, 22]. With pre-expansion
of the supraclavicular ap, entire facial resurfacing of burn scars with the supraclavicular ap proved feasible [23]. Noma, a rapidly progressive, multifactorial, gangrenous condition of the mouth and face that is predominantly found in malnourished
patients within the sub-Saharan region, is a challenging disease to treat with exceptionally high morbidity and mortality [24]. While management of the early stages of
disease involves medical and nutritional support, late stage management involves
reconstructing complex orofacial defects for which the supraclavicular ap has
been utilized [24–26]. Progressive hemifacial atrophy is a rare disorder of unknown
etiology that typically develops during the rst or second decade of life that is characterized by slowly progressive unilateral atrophy of the skin, soft tissue, muscle,
and bony skeleton [7, 27]. Soft tissue augmentation in the form of a scapular free
tissue transfer has been found to correct the facial asymmetry and halt the progression of the disease [27]. The supraclavicular ap has also been described as an
alternative to free tissue transfer in correcting the facial asymmetry in progressive
hemifacial atrophy. [7]
The supraclavicular ap has been successfully applied to reconstruct auriculectomy and temporal bone defects [10, 28]. In order to obtain adequate pedicle length,
a soft tissue back cut can be made superiorly over the posterior border of the sternocleidomastoid muscle, and the pedicle can also be elevated over the clavicle in a
subperiosteal plane [10]. In cases where the lateral skull base defect is too large for
free fat grafts or in cases where vascularized soft tissue coverage is needed, the
supraclavicular ap is an option. The supraclavicular ap is not ideal in lateral skull
base defects greater than 10–15cm in width and deep defects that require substantial vascularized soft tissue bulk [10].
Contour irregularities and Frey’s syndrome are common postoperative sequelae
after parotidectomy. Fat grafts, supercial musculoaponeurotic system aps, and
buried free aps have all been utilized to minimize the incidence of Frey’s syndrome and contour abnormalities [29–31]. The supraclavicular ap has also been
described as an excellent option for reconstructing parotidectomy contour defects
[10, 13]. The supraclavicular ap provides an adequate volume of vascularized tissue for most parotidectomy contour defects while also avoiding the need for microvascular surgery and distant donor site morbidity. Typically, the supraclavicular ap
is deepithelialized for contour defect reconstruction. However, if a cutaneous defect
is present, the supraclavicular ap is an ideal regional reconstruction option
(Figs.12.2 and 12.3). The morbidity of a shoulder scar from the supraclavicular ap
must be considered and discussed with the patient.
12 Supraclavicular Flap
Fig. 12.2 Preauricular
defect amenable to
supraclavicular ap
reconstruction. (Courtesy
of Masoud Saman, MD)
163
As experience has been gained with the supraclavicular ap in reconstructing
cutaneous and soft defects, aerodigestive tract reconstruction with the supraclavicular ap has been demonstrated as a feasible option. A prefabricated supraclavicular
ap with auricular cartilage has been described in reconstructing high-risk tracheal
stenosis with eight out of eight patients being successfully decannulated [15]. In a
series of ten patients who underwent patch graft reconstruction, a reconstruction of
the anterior pharyngeal wall, of total laryngectomy defects with a supraclavicular
ap two out of ten patients developed a pharyngocutaneous stula with one of those
patients having near total loss of the ap [11]. The circumferential pharyngoesophageal defect following salvage laryngectomy is a complex defect with high risk for
complications [32]. While free tissue transfer is usually the preferred method of
reconstructing circumferential pharyngoesophageal defects after salvage laryngectomy, the supraclavicular ap has been successfully utilized for this challenging
problem [9]. Primary tracheoesophageal puncture with intraoperative prosthesis
placement has been found to be safe and effective in patients undergoing reconstruction with the supraclavicular ap [33]. The supraclavicular ap provides a
regional source of vascularized soft tissue that can be employed in reconstructing
esophageal perforations after anterior cervical spine surgery [14].
164
Fig. 12.3 Supraclavicular
ap inset into preauricular
defect. Donor site
successfully closed
primarily. (Courtesy of
Masoud Saman, MD)
A. Namin and M. Saman
As can be seen in the above discussion, the supraclavicular ap has been successfully applied to many reconstructive challenges. However, most defects often have
many acceptable reconstructive options. As the supraclavicular ap has gained popularity, studies identifying limitations and comparing outcomes of the supraclavicular ap with free aps have been published. In a retrospective series of 32 patients
in whom all patients were candidates for either a free fasciocutaneous ap or a
supraclavicular ap, the 16 patients who underwent supraclavicular ap reconstruction had signicantly shorter operative times, signicantly shorter ICU stays, and
signicantly less need for split thickness skin graft [17, 34, 35]. The rate of complications has been found to be signicantly higher in patients undergoing mucosal
reconstruction with the supraclavicular ap compared to patients undergoing cutaneous reconstruction with the supraclavicular ap [16, 36]. The supraclavicular ap
can be utilized to reconstruct oral cavity defects in addition to pharyngeal defects
(Fig.12.4). While the supraclavicular ap has been successfully utilized in patients
with prior radiation therapy to the neck and prior neck dissection, the presence and
size of the supraclavicular artery should be more intensively scrutinized [9, 37]. The
presence of an ipsilateral pacemaker or ports adds risk of contamination of these
devices, particularly in clean contaminated surgery; however, the supraclavicular
ap has been successfully utilized in patients with these devices [38].
12 Supraclavicular Flap
Fig. 12.4 Supraclavicular
ap inset into partial
glossectomy defect. Many
reconstructive options lend
themselves to partial
glossectomy
reconstruction. Pedicle
length of the
supraclavicular ap does
allow for utilization in oral
cavity defects. (Courtesy
of Masoud Saman, MD)
165
Preoperative Planning
Preoperative conrmation of the presence of a supraclavicular artery should be performed either with a Doppler identifying the supraclavicular artery within the triangular fossa (sternocleidomastoid muscle, clavicle, and external jugular vein) or
computed tomography angiography (CTA) [12, 39]. The neck should be examined
for any prior scars. If the patient has had a prior neck dissection and/or radiation, the
presence of a supraclavicular artery should be more thoroughly investigated.
Preoperative discussion with the ablative surgeon should be had regarding plans for
incorporating level 5b and 4, as the transverse cervical artery and supraclavicular
artery will be at risk. The benets of CTA allow the surgical team to have strong
clinical data regarding the presence, location, diameter, and length of the pedicle
[39]. If the surgical team has a donor side preference, the contrast bolus should be
given contralaterally to minimize bolus artifacts, and the arms should be kept at the
patients’ side during the study [39].
166
A. Namin and M. Saman
Instrumentation
• Bipolar electrocautery
• Monopolar electrocautery
• Skin hooks
• Suction drains
• Fine tip dissecting scissors
• Dissolvable and permanent sutures
• Doppler probe
Surgical Technique
A Doppler probe is used to conrm the presence and location of the supraclavicular
artery in the triangle bordered by the posterior border of the sternocleidomastoid
muscle, the clavicle, and the external jugular vein. A fusiform skin paddle is then
designed over the ventral aspect of the deltoid muscle. The neck and arm are then
prepped and draped circumferentially down to the elbow. An incision is then made
from the medial aspect of the skin paddle to triangle where the supraclavicular
artery was identied. Subdermal aps are then elevated to the lateral border of the
sternocleidomastoid muscle and 3cm lateral to the point where the supraclavicular
artery crosses over the clavicle. Designing the soft tissue pedicle to include a wide
base of soft tissue protects the pedicle, minimizes risk of kinking the pedicle, and
also likely incorporates the anterior supraclavicular artery described by Pallua etal.
in 2013 [12, 19].
The supraclavicular ap is then elevated in the subfascial plane from distal to
proximal. As the clavicle is encountered, the pedicle is dissected over the clavicle in
a subperiosteal plane. In the plane supercial to the pedicle, dissection is carried
forth in the subdermal pane in order to protect the pedicle. Dissection continues in
the subdermal plane supercially until a point over the sternocleidomastoid muscle
is reached at which point the plane of dissection is transition to the subplatysmal
plane and therefore allowing tunneling of the ap into the anterior neck, face, and
aerodigestive tract [4, 11, 12].
Postoperative Management
Standard postoperative care is undertaken. Suction drains are managed. The area is
closely followed for signs of infection. Evidence of partial or complete ap loss are
monitored for in cases where the ap is visible on examination. Signs of stula are
closely looked for in cases of mucosal reconstruction. The donor site is assessed for
any evidence of dehiscence.
12 Supraclavicular Flap
167
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A. Namin and M. Saman