The Laryngoscope
C 2014 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Supraclavicular Flap Reconstruction Following Total Laryngectomy
Kevin S. Emerick, MD; Marc A. Herr, MD; Daniel G. Deschler, MD
Objectives/Hypothesis: Report on the successful use of the supraclavicular flap for reconstruction following total laryngectomy and highlight the utility and versatility of the supraclavicular flap for reconstruction after total laryngectomy.
Study Design: Retrospective review of a single institution experience.
Methods: A single institution database was reviewed to identify patients undergoing total laryngectomy and supraclavicular flap reconstruction. The following data were collected: indication for reconstruction, flap viability, flap size, reconstruction site complication, and donor site complication.
Results: Forty-six supraclavicular flaps were identified in the database from July 2011 to September 2013. Fifteen of
these were used following total laryngectomy. Ten flaps were used for patch graft pharyngeal reconstruction, three flaps for
cutaneous defects related to previous tracheotomy, one flap for cutaneous and tracheal reconstruction following resection of
a recurrence in the stoma, and one flap as a pharyngeal interposition graft. Twelve of these cases were performed in the salvage setting after previous radiation. Three cases had significant oropharyngeal resection that required reconstruction. There
was one near complete flap loss. Three patients developed pharyngocutaneous fistula. One patient required an additional surgical procedure to address a complication. Three patients had minor incisional dehiscence. All minor complications resolved
with basic wound care. No significant donor site morbidity was identified.
Conclusions: The supraclavicular flap can be successfully used for multiple purposes following total laryngectomy. This
has been successfully used for reconstruction of limited pharyngeal defects, extensive pharyngeal resection, and skin reconstruction following previous tracheotomy. This flap can be successfully used following previous radiation and with limited
morbidity.
Key Words: Supraclavicular artery island flap, laryngectomy, reconstruction.
Level of Evidence: 4.
Laryngoscope, 124:1777–1782, 2014
INTRODUCTION
In 2003, the Radiation Therapy Oncology Group
(ROTG) published a landmark paper on the treatment of
advanced laryngeal cancer.1 This study followed on the
work of the Department of Veterans Affairs (VA) larynx
trial and led to concurrent chemoradiation becoming the
standard of care for advanced laryngeal cancer.2 This
nonsurgical approach provided equivalent survival and
the potential for organ preservation. However, approximately 30% of patients undergoing chemoradiation will
ultimately require salvage laryngectomy for persistent
or recurrent cancer or due to a dysfunctional larynx.1–5
The vast majority of all laryngectomies are now being
performed in the salvage setting.
Radiation and chemoradiation are well known to compromise soft tissue and lead to a higher risk of postopera-
From the Massachusetts Eye and Ear Infirmary, Head and Neck
Division; Harvard Medical School, Department of Otology and Laryngology, Boston, Massachusetts, U.S.A.
Editor’s Note: This Manuscript was accepted for publication
November 18, 2013.
Accepted for poster presentation at Triological Society Section
Meeting, Miami, Florida, U.S.A., January 10–12 2014.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Kevin Emerick, MD, Massachusetts Eye
and Ear Infirmary, 243 Charles St., Boston, MA 02114. E-mail:
[email protected]
DOI: 10.1002/lary.24530
Laryngoscope 124: August 2014
tive complications. With respect to salvage laryngectomy
following radiation or chemoradiation, pharyngocutaneous
fistula (PCF) is the most common major complication. The
multicenter RTOG study reported a 30% incidence of
PCF for patients undergoing salvage laryngectomy after
concurrent chemoradiation.1 However other studies have
reported dramatically higher incidence of PCF, including
as high as 80%.4,5 Today this remains of significant concern and has become the focus of reconstructive surgeons trying to decrease this complication.
Neck skin closure is another potential challenge in
the salvage setting. This often occurs when a tracheotomy is needed for airway obstruction prior to laryngectomy. This creates a challenging defect that is relatively
small and located near the stoma. Therefore, the ideal
reconstruction could be tailored to this smaller size without compromising the shape and patency of the pharynx
or stoma.
To address these challenges, reconstructive surgeons
have used regional pedicled flaps as well as free flaps. To
date, no one has described a significant experience with
the supraclavicular artery island flap (SCAIF) for reconstruction in this setting. The SCAIF is a fasciocutaneous
pedicled flap based on the supraclavicular artery and
vein. These are branches from the transverse cervical
vessels. The anatomy of this flap was initially described
by Toldt in 1903, further described by Kazanjian in
1949,6 and its clinical use was reported by Mathes and
Lamberty in the 1970s.7 However, it was abandoned with
Emerick et al.: Supraclavicular Flap Laryngectomy Defects
1777
TABLE I.
Summary of Demographics, Flap Utilization, Size, and Complications.
Subject
Age
Defect
Size (cm 3 cm)
Previous
Radiation
Recipient Site
Complication
Donor Site
Complication
1
59
ANS
538
2
3
56
64
ANS
ANS
638
8 3 19
yes
none
none
no
yes
incision dehiscence
PCF
none
none
4
69
ANS, stoma
5
6
63
48
PIG
PG
537
yes
none
none
436
638
yes
yes
PCF
none
none
none
7
68
PG
8
9
73
58
PG
PG, BOT, OP
5 3 10
yes
none
none
539
8 3 10
no
yes
none
PCF
none
none
10
50
11
12
55
83
PG
437
yes
none
none
PG, PP
PG
738
8 3 10
no
yes
none
none
none
none
13
62
PG, PP, BOT, OP
14
15
58
74
PG
PG, OP
9 3 12
no
none
none
639
8 3 12
yes
yes
none
PCF
none
none
ANS 5 anterior neck skin; BOT 5 base of tongue; OP 5 oropharynx; PG 5 patch graft; PIG 5 pharyngeal interposition graft; PP 5 partial pharyngectomy.
the introduction of the highly reliable pectoralis major
myocutaneous flap. Pallua et al.’s critical study in the
1990s resulted in the refinement of this flap,8 which dramatically increased its viability and lead to a recent
resurgence in the use of this flap.9
Since 2011, the SCAIF has become a regular part of
our reconstructive toolbox. We have successfully performed 46 SCAIF reconstructions in the head and neck.
Our experience has been very successful overall. Outside
of literature reviews, the otolaryngology literature
remains without significant reporting of the otolaryngology experience with the SCAIF.10 This article is the largest series to date on this topic and aims to describe our
utilization of and experience with the SCAIF following
laryngectomy.
to 9 cm 3 12 cm with an average size of 5.8 cm 3 8.3
cm. All donor sites were closed with adjacent tissue
advancement, and none required a skin graft. No donor
site complications (infection, seroma, dehiscence, scar
widening) were observed in this series of patients
(Fig. 1). Twelve patients previously received radiation or
chemoradiation for treatment of their laryngeal cancer.
MATERIALS AND METHODS
Institutional review board approval from the Massachusetts Eye and Ear Infirmary Human Studies Committee was
obtained. All patients undergoing SAF reconstruction for the
indication of laryngectomy were identified from a prospectively
collected database of SAF reconstructions. Once identified, the
following data points were recorded: indication for reconstruction, flap viability, flap size, reconstruction site complication,
and donor site complication.
RESULTS
Forty-six SCAIF reconstructions were present in
the database. Fifteen reconstructions were identified as
being performed for the indication of salvage laryngectomy. This was further investigated to understand how
the flap was being utilized and the surgical outcomes.
These results are summarized in Table I. One patient
had a near total flap loss and required additional pharyngeal reconstruction. No other flap loss was encountered in this series. Flap size ranged from 4 cm 3 6 cm
Laryngoscope 124: August 2014
1778
Fig. 1. Typical well-healed donor site incision at first postoperative
visit. [Color figure can be viewed in the online issue, which is
available at www.laryngoscope.com.]
Emerick et al.: Supraclavicular Flap Laryngectomy Defects
tract. The second patient with PCF had near total loss
of the flap. One patient who underwent extensive PG,
base of tongue, and tonsillar fossa reconstruction was
observed on fiberoptic exam to have a minor dehiscence
at the base of tongue suture line. The flap appeared fully
viable, and the patient did not develop a PCF or evidence of a collection. The one patient who underwent
PIG reconstruction developed a limited PCF that healed
with limited wound care only.
Four patients underwent anterior skin reconstruction (Fig. 3). The SCAIF was used in three patients with
an existing tracheotomy at the time of laryngectomy.
The presence of a tracheotomy necessitated skin resection, and when combined with limited tissue elasticity
the superior skin flap could not be closed. The fourth
was used to reconstruct lateral neck skin and the lateral
50% of the stoma following resection of a recurrence in
the lateral stoma (Fig. 4). All four of these flaps
remained fully viable. One patient developed a small
incisional dehiscence. This healed well with limited
wound care.
DISCUSSION
The SCAIF can be successfully utilized in multiple
ways for salvage laryngectomy reconstruction. Our experience to date shows that the SCAIF is a potential reconstructive option for patch graft, patch graft reconstruction
with additional oropharynx reconstruction, pharyngeal
interposition graft, and anterior neck skin reconstruction.
Fig. 2. Patch graft reconstruction with one side sutured to the
pharyngeal wall prior to complete closure and anterior pharyngeal
wall reconstruction. [Color figure can be viewed in the online
issue, which is available at www.laryngoscope.com.]
Ten patients in this series underwent patch graft
(PG) reconstruction (Fig. 2). PG reconstruction is defined
as reconstruction of the anterior pharyngeal wall with a
fasciocutaneous or musculocutaneous flap following total
laryngectomy and including possible partial pharyngectomy. Three of the flaps in this series also provided
extensive oropharyngeal reconstruction, including the
base of tongue, tonsillar fossa, and lateral pharyngeal
wall at the level of the oropharynx. One patient had a
pharyngeal interposition graft (PIG) reconstruction performed using a SCAIF. The PIG is an onlay flap of vascularized fascia or muscle after primary closure of the
pharynx.
In terms of complications, the primary reconstruction site complication of interest was PCF. This occurred
in two out of 10 PG patients. One of these PCF occurred
in the delayed setting 4 weeks postoperatively in the setting of rapid recurrence/persistent disease in the fistula
Laryngoscope 124: August 2014
Fig. 3. The anterior neck skin can be reconstructed with the
SCAIF. It provides excellent coverage, color match, and does not
compromise the stoma. [Color figure can be viewed in the online
issue, which is available at www.laryngoscope.com.]
Emerick et al.: Supraclavicular Flap Laryngectomy Defects
1779
Given the current medical, surgical, and logistical challenges in caring for salvage laryngectomy patients, this is
an important reconstructive finding.
The use of SCAIF has been reported to a limited
degree in the plastic surgery literature for head and
neck reconstruction. However, the otolaryngology literature to date is limited to review data.10 This has led
some to question the reliability of this flap. In this
series, one of 15 flaps had a near total loss and no other
partial loss was observed. In our entire series, we had
no total flap loss and we had two major partial flap
losses in 46 patients. The SCAIF has been a very reliable flap. In terms of viability, it compares very well
with all other commonly used reconstructive flaps used
in the head and neck. We have recently published our
very early series, which highlights some technical modifications that we believe are important to the success
and viability of this flap.11
When using the SCAIF for laryngectomy reconstruction, either side can be used given the midline
defect. If one side of the neck is at a higher risk of great
vessel exposure, this side should be chosen for the flap
donor site. The proximal soft tissue pedicle can provide
additional coverage of these vessels. When there are no
contraindications to either side, the nondominant side is
typically chosen. In all cases, the flap was designed as
an island flap.
The first key to the success of this flap is designing
the skin island over the ventral surface of the deltoid.
Islands designed in a more dorsal position over the cap
of the deltoid may not be within the angiosome of the
supraclavicular vessels. Since the distance between the
pharynx and the supraclavicular fossa is relatively
short, the island does not need to be designed beyond
the superior half of the deltoid. However, additional distal tissue can be incorporated to help facilitate closure.
The flap is then inset beginning inferiorly such that the
more distal tissue can be excised if not needed, or it can
be overlaid for reinforcement. We recommend creating
the tunnel from the supraclavicular fossa to the neck
early in the harvest. This keeps the vascular pedicle and
perforators attached deeply to help decrease the risk of
inadvertent injury. A subdermal plane is developed
superficial to the platysma until a point over the sternocleidomastoid is reached. At this point, the platysma can
be safely incised to create a tunnel between the neck
and supraclavicular fossa without concern for vascular
injury.
Another technical aspect to improve reliability is
the creation of a soft tissue pedicle around the vascular
pedicle. We design the soft tissue pedicle to be the width
of the skin island. Proximal to our skin island, subdermal skin elevation is performed anteriorly and posteriorly. This provides exposure to create the soft tissue
pedicle. This soft tissue pedicle should be incised along
the inferior/anterior aspect inferior to the clavicle all the
way to the clavicular head. At this point, a back cut can
be safely performed to provide greater rotation and
reach for the flap. The last consideration is the flap elevation over the clavicle. The flap should be elevated in a
subperiosteal plane. At the medial aspect of the clavicle,
tunnels are created in the fascia in the direction of the
pedicle. The see-through fascia can then be safely
incised, providing additional flap rotation and reach
while keeping the vascular pedicle safe.
Pharyngocutaneous fistula has been the dominant
postoperative complication and challenge for head and
neck surgeons since the transition to primary chemoradiation for the treatment of advanced laryngeal cancer.
Estimates for the incidence of this complication in the
salvage setting range from 30% to 80%.1–5 PCF is important for several reasons: It leads to longer hospital stays;
requires additional and prolonged wound care—often
lasting several weeks; requires prolonged visiting nursing or rehabilitation-level care; may lead to catastrophic
complications such as carotid/jugular bleeding; may
require additional surgical procedures; delays the return
to eating, usually requiring a gastronomy-tube placement; and delays voice restoration. Therefore, over the
last decade surgeons have investigated different techniques with the specific aim of decreasing fistula rates.
Early experience utilized the pectoralis major muscle flap, which is still used in some institutions today.12
This commonly is employed as a muscle-only PIG and as
a myocutaneous PG. In some series, this has been shown
to decrease fistula rates.12,13 However, the bulky nature
may prevent closure of the overlying superior skin flap
and distort the stoma, compromising voice restoration
while creating significant donor site morbidity. The University of Michigan group described using a free fascia
flap from the forearm or thigh as a PIG.14 This technique reduced the need for wound care, hospital stay,
incidence of major complications such as bleeding, and
the need for additional surgery. However, it did not
reduce PCF rates compared to the control group of primary closure. This led to the use of free flaps as a PG.
The initial work and publication by Withrow et al. is
important as they showed a decrease in fistula rate to
17% compared to a control of 34% undergoing primary
Laryngoscope 124: August 2014
Emerick et al.: Supraclavicular Flap Laryngectomy Defects
Fig. 4. This reconstruction following resection of a stoma recurrence highlights the versatility of the flap. Despite previous neck
dissection, free flap reconstruction, and chemoradiation, there is
excellent vascularity, and it can be appropriately contoured to the
unique defect. [Color figure can be viewed in the online issue,
which is available at www.laryngoscope.com.]
1780
closure in patients who have previously received chemoradiation.15 This question has been further studied in a
recent multicenter study. The study compared pectoralis
muscle PIG to free tissue PG. They report PCF rates of
34% for primary closure, 25% for free tissue PG, and
15% for pectoralis PIG.16
Our initial experience, although still relatively
small, compares favorably with the reported outcome for
fasciocutaneous free-flap PG reconstruction. Two of 10
patients who underwent patch reconstruction developed
a PCF. When considering that one of these patients had
persistent disease likely contributing to the PCF, only
one of nine (11%) patients developed a PCF. This suggests that the technique compares favorably to reported
large series of free fasciocutaneous PG (17–25%).15,16
Additional experience with a larger cohort from multiple
institutions is needed to confirm this finding.
We have also found that the SCAIF can be used for
extensive defects. We were able to use the flap as a PG,
as well as extend into the oropharynx for base of tongue
and even the superior aspect of the tonsillar fossa. In
this series, we used one flap as large as 9 cm 3 12 cm
and routinely harvest flaps 6 to 8 cm 3 8 to 10 cm in
size. In our broader experience with the SCAIF for other
defect site reconstruction, we have used flaps up to 15
cm in length and 12 cm in width. Chiu et al. described a
case of circumferential total laryngopharyngectomy
defect reconstruction with a tubed SAF.17
There are additional benefits of the SCAIF to consider. When considering the need for reconstruction in
the salvage setting, one must also consider the overall
complexity of the patient and medical environment.
Most of these patients have multiple comorbidities and
functional limitations. The ideal reconstructive option
would decrease the complexity of the reconstruction,
limit donor site morbidity and additional high-level postoperative monitoring, and decrease prolonged donor site
wound care. By eliminating the microvascular component, the reconstruction has been simplified. The SCAIF
meets these criteria and can be quickly harvested in 30
to 60 minutes. To date there are no reports of donor site
weakness, decreased range of motion, or pain in the literature. No patients in this series reported significant
limitation or pain. Although a recent publication
described use of the anterior branch of the SCAIF as a
free flap, for the purpose of laryngectomy reconstruction
a pedicled flap is preferred given the benefits described
above—and when the nature of the defect does not
require the freedom of geometry provided by free flaps.18
The SCAIF was initially described in the plastic
surgery literature for its use in the reconstruction and
release of burn contractures involving the anterior neck
skin.19 It is a natural extension for the SCAIF to be
used for reconstruction of the anterior neck skin in the
salvage laryngectomy setting. After chemoradiation, it is
not uncommon for patients with recurrent laryngeal cancer to develop airway compromise requiring tracheotomy
prior to salvage laryngectomy. At the time of laryngectomy, the skin resection around the tracheotomy site,
combined with the decreased elasticity of the neck skin
after chemoradiation, can make skin flap closure imposLaryngoscope 124: August 2014
sible. There are a few options for closure in this setting,
including the pectoralis myocutaneous flap, deltopectoral
flap, or free flap reconstruction. All have significant limitations. The SCAIF provides the correct thickness and
geometry for reconstruction without compromising the
stoma. Last, as mentioned above, the SCAIF can be
quickly harvested without adding complexity. It also
does not require additional preoperative planning. This
can be important if the surgeon unexpectedly encounters
the need for skin reconstruction. The SCAIF can be used
without acquiring additional instrumentation, a second
surgeon, or changing the postoperative plan for bed location and monitoring.
In addition to this specific laryngectomy experience
with SCAIF, our broader experience has been a positive
one. Although our PG experience still is relatively small,
it is the largest reported to date; and over time we
expect to confirm its equivalence to free flaps in this setting. However, this is not to say that our positive experience suggests that the SCAIF is superior in all settings
to free flap reconstruction options. There are contraindications to the SCAIF, including comprehensive neck dissections that ligate the transverse cervical vessels,
previous shoulder surgery (i.e., rotator cuff surgery), and
skin cancer on the ventral deltoid. Additionally, certain
body habitus features may make one donor site preferred over another. Last, not all surgeons have reported
as successful of an experience with SCAIF viability.
Regardless of how the SCAIF is utilized, surgeons ultimately must become skilled in this technique to make it
reliable.
CONCLUSION
The SCAIF can be used for multiple types of reconstruction following laryngectomy. To date, we have used
the SCAIF as a PG, PG with oropharyngeal extension,
PIG, and anterior neck skin reconstruction. In this series,
we had only one significant flap loss and no donor site
morbidity. In comparison to the commonly used fasciocutaneous free flap for PG reconstruction, the SCAIF
appears to have a similar PCF incidence. Last, the SCAIF
offers the potential for decreasing overall complexity in
the operating room and postoperatively.
BIBLIOGRAPHY
1. Wolf G, Hong K, Fisher S, et al. Induction chemotherapy plus radiation
compared with surgery plus radiation in patients with advanced laryngeal cancer: the Department of Veterans Affairs Laryngeal Cancer
Study Group. N Engl J Med 1991;324:1685–1690.
2. Forastiere AA, Goepfert H, Maor M, et al. Concurrent chemotherapy and
radiotherapy for organ preservation in advanced laryngeal cancer.
N Engl J Med 2003;349:2091–2098.
3. Weber RS, Berkey BA, Farastiere A, et al. Outcome of salvage total laryngectomy following organ preservation therapy: The Radiation Therapy
Oncology Group Trial 91–11. Arch Otolaryngol Head Neck Surg 2003;
129:44–49.
4. Johansen L, Overgaard J, Elbrond O. Pharyngo-cutaneous fistulae after
laryngectomy: influence of previous radiotherapy and prophylactic metronidazole. Cancer 1988;61:673–678.
5. Sassler AM, Esclamado RM, Wolf GT. Surgery after organ preservation
therapy: analysis of wound complications. Arch Otolaryngol Head Neck
Surg 1995;121:162–165.
6. Di Benedetto G, Aquinati A, Pierangeli M, Scalise A, Bertani A. From the
“cherretera” to the supraclavicular fascial island flap: revisitation and further evolution of a controversial flap. Plast Reconstr Surg 2005;115:70–76.
7. Mathes SJ, Vasconez LO. The cervicohumeral flap. Plast Reconstr Surg
1978;61:7–12.
Emerick et al.: Supraclavicular Flap Laryngectomy Defects
1781
8. Pallua N, Machens HG, Rennekampff O, Becker M, Berger A. The fasciocutaneous supraclavicular artery island flap for releasing postburn mentosternal contractures. Plast Reconstr Surg 1997;99:1878–1884.
9. Pallua N, Magnus Noah E. The tunneled supraclavicular island flap: an
optimized technique for head and neck reconstruction. Plast Reconstr
Surg 2000;105:842–851.
10. Granzow JW, Suliman A, Roostaeian J, Perry A, Boyd JB. The supraclavicular artery island flap (SCAIF) for head and neck reconstruction: surgical
technique and refinements. Otolaryngol Head Neck Surg 2013;148:933–940.
11. Herr M, Emerick K, Deschler D. Supraclavicular artery flap: incorporating
a reconstructive alternative into a high-volume head & neck practice.
JAMA Facial Plast Surg 2013. In press.
12. Sakai A, Okami K, Sugimoto R, et al. Prevention of wound complications
in salvage pharyngolaryngectomy by the use of well-vascularized flaps.
Acta Otolaryngol 2012;132:778–782.
13. Gil Z, Gupta A, Kummer B, et al. The role of pectoralis major muscle flap
in salvage total laryngectomy. Arch Otolaryngol Head Neck Surg 2009;
135:1019–1023.
Laryngoscope 124: August 2014
1782
14. Fung K, Teknos TN, Vandenberg CD, et al. Prevention of wound complications following salvage laryngectomy using free vascularized tissue.
Head Neck 2007;29:425–430.
15. Withrow KP, Rosenthal EL, Gourin CG, et al. Free tissue transfer to manage salvage laryngectomy defects after organ preservation failure.
Laryngoscope 2007;117:781–784.
16. Patel UA, Moore BA, Wax M, et al. Impact of pharyngeal closure technique on fistula after salvage laryngectomy. JAMA Otolaryngol Head
Neck Surg 2013;10:1–6.
17. Henderson MM, Chiu ES, Jaffer AS. A simple approach of tubularizing
the supraclavicular flap for circumferential pharyngoesophageal defects.
Plast Reconstr Surg 2010;126:28–29.
18. Pallua N, Wolter TP. Moving forwards: the anterior supraclavicular artery
perforator (a-SAP) flap: a new pedicled or free perforator flap based on
the anterior supraclavicular vessels. J Plast Reconstr Aesthet Surg
2013;66:489–496.
19. Pallua N. Reconstruction of neck scar contractures using supraclavicular
flaps. Plast Reconstr Surg 2007;120:2114.
Emerick et al.: Supraclavicular Flap Laryngectomy Defects