The revival of the supraclavicular artery island flap (SCAIF) during the COVID-19 pandemic

1. Introduction

The outbreak of the COVID-19 pandemic has dramatically affected the health-care system organization. The hospital resources were reallocated in order to face the big Coronavirus disease challenge. According to the pandemic related guidelines, the surgical and anesthesiologic staff, the operating rooms and the ICU availability were drastically minimized [1]. Of course, the Head and Neck cancer lanes were inevitably impacted by the pandemic's healthcare priority. When dealing with head and neck cancer, the surgery usually represents the first treatment choice. Most of the patients require complex reconstructive surgery to avoid comorbidities resulting from the ablative process. During the last years, the use of free flaps has represented the gold standard in HNC reconstruction. However, free flaps require a large hospital resources commitment, such as the personnel, ward and ICU beds and even diagnostics services use. During the COVID era, the locoregional flaps have taken over as reconstructive techniques as they are less demanding in terms of the deployment of human, financial and facilities resources [2]. In particular, the supraclavicular artery island flap (SCAIF) is slowly becoming a mainstream flap in head and neck reconstruction. It is a fasciocutaneous pedunculated flap based on the supraclavicular artery, a branch of the transverse cervical artery and it is characterized by a rotation angle of up to 180 ° [3], that makes it quite easy to manipulate. It is quick and easy to set up and thanks to its versatility it can be used in most of the head and neck areas.

The aim of this paper is to investigate if the SCAIF can be considered as a valid alternative technique to free flaps when dealing with a resource restricted setting.

2. Materials and methods

From April 2021 to January 2022, a series of 11 patients (47–84 years old, 7 males and 4 females) underwent head and neck reconstruction with SCAIF after tumor resection in the Italian Maxillo-facial Unit of the Azienda Ospedaliera Universitaria Luigi Vanvitelli of Naples.

All the patients were affected by locally advanced head and neck malignancies, recurrent cancers or experienced the failure of the previous reconstruction. All patients underwent an extensive resection of the lesions with at least 1.0-cm safe margins of soft tissue. All the patients who underwent head and neck reconstruction by SCAIF were included in the study, despite age, sex, race and tumor size. The patients with more than one comorbidity were included in the study (Table 1 ).

Table 1.

Patients characteristics.

N°	Patient	Age	Sex (M/F)	Tumor site	Staging	Comorbidities
1	BF	51	M	Parotid	pT4 N1 M0	HBP, T2DM
2	GV	47	F	Buccal mucosa	pT3 N1 M0	O, HBD, T2DM
3	IF	56	M	Mouth floor	pT4a N0 M0	AF
4	MG	84	M	Salivary Duct	pT3 N0 M0	MI
5	FA	67	M	Parotid	pT4 N2 M0	TIA
6	LE	61	F	Tongue	pT3 N0 M0	CAD, O
7	PR	77	F	Buccal mucosa	pT4a N0 M0	PAD
8	SC	58	M	Salivary Duct	pT4 N0 M0	CHF, T2DM
9	TG	63	M	Parotid	pT3 N0 M0	HBD

2.1. Preoperative planning

SCAI flaps were designed with an axis drawn from the center of a triangle formed by the posterior edge of the sternocleidomastoid muscle, the external jugular vein, and the medial part of the clavicle, toward the acromioclavicular joint and the ventral surface of the deltoid muscle. The supraclavicular artery arises from the transverse cervical artery, a branch of the subclavian artery that may arise from the thyrocervical trunk or, in a minority of cases, from the subclavian artery directly.

It is mandatory to demonstrate the presence of the artery and to locate it preoperatively.

If the patient previously underwent a neck dissection, an angio-CT scan was preferred to demonstrate the artery, otherwise the artery was located and marked with a pencil Doppler probe.

The pedicle of the flap is drawn according to the distance of the site of reconstruction and the size of the flap according to the extension of the defect.

2.2. Surgical technique

Flap rising was conducted from distal to proximal, dissecting it in a subfascial plane.

The flap is dissected until its most proximal portion, where the supraclavicular artery arises from the transverse cervical artery.

Since the pedicle is surrounded by the fascia and the connective tissues in this region, it can be dissected without the need to expose the supraclavicular artery. No particular effort was made to locate and preserve the nervous pedicle of the flap.

After harvesting was completed, the flap was rotated to reach the site of reconstruction and, in most cases, the proximal portion of the flap was de-epithelialised and the flap was tunnelled under the cervical skin to reach mouth defects.

For facial and cervical skin reconstruction, the flap can be simply rotated to cover the defect (Table 2 ) (Fig. 1, Fig. 2 ).

Table 2.

Surgery details.

N°	Patient	Hospitalization time (days)	Length of reconstruction (hh:mm)	Lymphadenectomy	ICU (hours)	Tracheostomy	NGT	Flap size (cm)	Tunneling	Donor site closure	Donor site morbidity	Recipient site morbidity
1	BF	4	1h 5min	Yes	No	No	No	5 x 8,5	No	Direct	None	None
2	GV	13	1h 35min	Yes	18h	No	Yes	5,5 x 8	Yes	Direct	None	Partial Flap Necrosis
3	IF	3	1h 20min	No	26h	No	Yes	4,2 x 5,8	Yes	Direct	None	None
4	MG	4	1h 10min	No	No	No	Yes	6 x 12	No	Direct	Seroma	None
5	FA	4	1h 10min	Yes	No	No	No	7 x 11	No	Direct	Seroma	None
6	LE	5	1h 25min	No	21h	Yes	Yes	7 x 10	Yes	Direct	None	1,5cm Distal tip
7	PR	5	1h 30min	No	14h	No	Yes	4 x 8,5	Yes	Direct	None	None
8	SC	4	1h 10min	Yes	No	No	Yes	6,5 x 10	No	Direct	Hypertrophic scarring	None
9	TG	3	1h 5min	No	No	No	No	6 x 9	No	Direct	None	None
10	MM	5	1h 10min	No	No	No	No	5 x 8	Yes	Direct	None	None
11	PG	6	1h 25min	Yes	20h	No	Yes	7 x 10	Yes	Direct	Small incision dehiscence	Partial Skin Loss
N°	Patient	Age	Sex (M/F)	Tumor site	Staging	Comorbidities
1	BF	51	M	Parotid	pT4 N1 M0	HBP, T2DM

Fig. 1.

SCAIF inset after tongue cancer ablation.

Fig. 2.

SCAIF inset after total parotidectomy without skin sparing.

3. Results

A total of 11 patients were included in this study, 4 (36,37%) females and 7 (63,64%) males. Mean age of all the patients was 62.45 ± 11.46 (51 to 84) years. 6 (54,54%) patients were affected by oral cavity tumors, such as tongue, floor of the mouth and buccal mucosa tumors, while 4 (36,37%) patients had a diagnosis of parotid or salivary duct tumors. Tumor size ranged from pT2 to pT4a, only 3 (27,27%) patients presented with lymph node involvement (stage N1-N2). None of the patients had distant metastases at the time of presentation. All the patients were affected by comorbidities. Two of them suffered of type II diabetes (18,18%) and one of them of COPD (9,09%), while most of the patients had a diagnosis of cardiovascular diseases, such as atrial fibrillation, myocardial infarction, peripheral arterial disease (Table 1). The mean hospitalization time was 5.09 ± 2.77 days (3 to 13 days) and only 5 (45,45%) patients required an ICU stay that lasted 19 h 30 min ± 4.38 on average (14 h–26 h). The total time required for the reconstruction, that comprises flap harvesting and inset, was overall 1 h and 16 min ± 10 min (1 h 5 min to 1 h to 25 min). Five patients (45,45%) underwent lymphadenectomy. Only 1 patient (9,09%) needed a tracheostomy, all the other patients received a nasotracheal intubation. The mean flap size was 53.8964 ± 17.96 cm3 (23.36 to 77 cm3). Flap tunneling was required in all the patients who received SCAIF for the reconstruction of oral cavity tumor resection (54,54%). In every patient, the donor site closure was direct and it did not require a reconstruction. Regarding post-operative complications, 2 patients (9,09%) developed seromas, 1 patient (9,09%) a hypertrophic scar and 1 patient (9,09%) a small incision dehiscence. With regard to the recipient site morbidity, only 3 patients (27,27%) had complications: 1 patient experienced partial flap necrosis, 1 patient a distal 1,5 cm tip necrosis and 1 patient suffered of partial skin loss. All these patients were affected by oral cavity tumors (Table 2).

4. Discussion

The SCAIF has been known since the early 19th century and it was quickly abandoned probably due to the high number of complications [4]. In the 1990s, Pallua et al., recovered this flap for the reconstructions after burns or cervical scar contractures [5] and in 2009 Chiu et al. has been the first to propose SCAIF for reconstruction of oncological defects after the head and neck surgery. The SCAIF is becoming more and more prevalent as head and neck reconstructive technique. Its similarity in color and texture to facial and neck skin structure makes it suitable for the reconstruction of these areas. As a matter of fact, it has been shown to be suitable for defects of the buccal mucosa, tongue, oral floor, palate, oropharynx, lower gum parotid, and neck [6].

During the COVID-19 pandemics, the SCAIF has become a potential alternative to the free flaps, thanks to several characteristics that makes it a valid option when surgical resources are limited. Preoperative imaging is cheap and easy: although Adams et al. demonstrated that CT angiography allowed accurate identification of the vascular pedicle [7], the use of the Doppler is usually sufficient for the identification of the supraclavicular artery [8], thereby preserving diagnostics services. The SCAIF can be set up by a single surgeon, thereby minimizing the use of the medical and nursing staff in the operating room [9]. When a free flap reconstruction is performed, two concurrent teams are required. In all the patient a nasotracheal intubation was performed, only one patient required a tracheostomy. The total time required for reconstruction, including flap harvesting and inset, that accounts to 1 h and 16 min on average, is dramatically reduced if compared to microvascular free tissue transfer. The concern of high dependency is significantly reduced [10]. The hospital stay was decreased if compared to free flaps (5 days on average) and most of the patients did not require ICU stay. Compared to free flaps, the donor site closure was direct and did not require a reconstruction, which represents one of the most common complication in the radial free forearm flap (RFFF) [11], that is the one of the most used free flap in this area. Regarding post-operative complications, the most common were minor complications that were easily managed as outpatient procedure, such as seromas, hypertrophic scars or dehiscence. Three patients experienced partial flap necrosis, that was again treated as outpatient by surgical debridement. To avoid this kind of problem, many authors suggested to prevent scaling of the tip, the distal extension should not exceed 5 cm. Di Benedetto et al. in the 2005 recommended to leave a fascial lining around the vascular pedicle and to skeletonize the pedicle only in case to increase the length or the arc of rotation of the flap [9].

Furthermore, this flap can also be considered in patients undergoing previous radiotherapy treatments of the head and neck and in patients affected by more than one comorbidity [12,13].

Overall, the SCAIF can be considered a valid alternative to the free flaps in terms of health-care resources saving. Functional and aesthetic outcomes were also satisfactory [14,15] (Fig. 3 ) thereby the supraclavicular flap can be considered superimposable to the free flap when required.

Fig. 3.

Patient follow-up: 6 months after surgery.

5. Conclusion

The supraclavicular artery island flap (SCAIF) is a reliable alternative to the free tissue flaps. Its characteristics make it a good choice when hospital resources are limited or strained, such as during the COVID-19 pandemics. The SCAIF allows for immediate soft tissue reconstruction, with reduced surgical time, staff components, hospital and ICU stay.

Consent for publication

The consent to participate and the consent for publication were obtained.

Disclosures

None.

Funding

None.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.