Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5208_Библиотеки_им_академика_М_И_Перельмана

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 etal. found that one of the ten aps was perfused only about 50% by the supraclavicular artery due to a smaller supraclavicular artery (0.7mm) [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 circumex 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].

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 signicantly shorter operative times, signicantly shorter ICU stays, and signicantly less need for split thickness skin graft [17, 34, 35]. The rate of compli­cations has been found to be signicantly 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].

• Bipolar electrocautery

• Monopolar electrocautery

• Skin hooks

A Doppler probe is used to conrm 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 identied. Subdermal aps are then elevated to the lateral border of the sternocleidomastoid muscle and 3cm 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 etal. in 2013 [12, 19].