Subclavicular flap: A valid reconstructive option among anterior chest flaps in oral cancer patients

Abstract

Background: The subclavicular pedicled flap is based on the thoracic branch of the supraclavicular artery, and it represents a versatile reconstructive option for lowmiddle third face defects. Since its use in head and neck surgical oncology has not been popularized yet, we propose its application for oral cavity reconstruction after cancer resection by showing favorable results.Methods: Eighteen subclavicular pedicled flaps were used to treat intraoral defects after oral squamous-cell cancer resection between June 2015 and December 2018.Tumor dissection type, complications, donor and reconstructed area results, and functional and aesthetic outcomes were assessed. Results: No major complications were observed and all of the flaps survived. Adjuvant therapy was administered without delay when needed, and all of the patients had normal functional outcomes and good aesthetic results. Conclusions: The subclavicular flap is an excellent choice for the reconstruction of oral cavity defects. Selection of patients should exclude positive lower-third neck node and include appropriate informed consent for women due to the possibility of deformity of the breast. In our opinion, this flap has the potential for common application given its consistent anatomy and donor site advantages, including long pedicle, high pivot point, and relatively unlimited flap width. K E Y W O R D S oral cancer, pedicled flap, reconstruction, thoracic branch of supraclavicular artery 1 | INTRODUCTION Deformed appearance and impaired function in the oral cavity due to tumor resection necessitate appropriate and high-quality reconstructive tissue. Among multiple reconstructive options, microsurgical techniques might be time-consuming and costly, and the results are not always satisfactory, even though free flaps remain the first choice for vessel-depleted neck and osseous reconstruction, as well as for through-and-through defects. 1 Consequently, the adjacent pedicled local flaps (eg pectoralis major, submental island, and deltopectoral flaps) are excellent alternative reconstructive options due to their fair color and contour, even though they are usually bulky. In this setting, the chest region seems to be an ideal donor site, with abundant vessel networks that can guarantee a high reconstructive success rate 2-4 and where, depending on the skin paddle design, differing skin thicknesses are available. In many people, the skin is not hair-bearing and the color match is ideal for cervicofacial skin. Various flaps have been explored, 5 including muscle-sparing thoracoacromial artery perforator flaps, 6 propeller flaps, 7 and supraclavicular flaps, 8 but the short length of the pedicle, the long distance Meeting: This paper was presented as oral presentation at the 24th Congress of the European Association for Cranio Maxillo Facial Surgery, 18 to 21 September 2018, in Munich, Germany.

A Comprehensive Review on the Supraclavicular Flap for Head and Neck Reconstruction

“…52 In comparison with the new infraclavicular flap/TBSA, the SCF provides less width without pre-expansion. 30 Pallua and Wolter 33 state that the length of the TBSA flap can be up to 35 cm, which is the same as the maximum length quoted for the SCF. Xie et al 51 stated that the TBSA flap is not suitable for defects above the middle zygoma laterally or the upper lip centrally, similar to the SCF.…”

“…In comparison with the new infraclavicular flap/TBSA, the SCF provides less width without pre-expansion 30 . Pallua and Wolter 33 state that the length of the TBSA flap can be up to 35 cm, which is the same as the maximum length quoted for the SCF.…”

“…Similar to pre-expansion, this does require more OR time and resources. One further option is the combination SCF, using both the DBSA and the infraclavicular flap from the TBSA, which can be harvested together to create a much larger intermediate flap 30,36,53 …”

“…7 If female patients are able to accept the idea of their breasts having conspicuous scars, and appropriate counseling/informed consent is obtained, anterior chest flaps such as the TBSA are acceptable. 30 Chen et al 58 reported a series that included 3 female patients receiving anterior chest wall flaps for cica-contracture of the face and neck. One had complaints about resultant bilateral breast scars and required "persuasion" to accept the deformities.…”

“…It anastomoses with perforators from the internal mammary arteries. 30 An anatomic study by Ma et al 37 found that the TBSA only exists in 60% of patients; thus, preoperative imaging is required with this infraclavicular rendition of the original SCF. A study using contrast-enhanced ultrasound (CEUS) in a series of 26 flaps was able to identify the TBSA in 20/26 or 78% of cases (2 of these were insufficient for flap creation).…”