Discussion
The SCAIF has good color and texture match to the skin of the neck. With
its proximity, thin skin paddle and arc of rotation, it has become a
reliable and versatile source in complex head and neck reconstruction.
The SCAIF was first described by Lamberty[1] in
1979, but it got many criticisms because of its high incidence of distal
flap necrosis. In 1997, Pallua[2] performed
detailed anatomical studies examining the vascularity of the SCAIF,
which popularized its use for reconstruction. DiBenedetto further
demonstrated its utility in reconstructing a variety of chest and facial
defects[3, 4]. In 2009, Chiu were the first to
describe the use of the SCAIF in head and neck oncologic
reconstruction[5]. Subsequently, multiple studies
highlighted the use of the flap for a variety of head and neck oncologic
ablative defects, including partial and total pharyngectomy defects,
posterolateral skull base defects, oropharyngeal defects, defects in
mandible or parotid gland, neck skin defects or fistula after radiation,
tracheal-stomal junction, and the establishment of digestive tract
continuity, and so on[6-9].
The SCAIF is based on the suprascapular artery, a branch of the
transverse cervical artery in 93% of patients and the suprascapular
artery in the remaining cases[1]. The venous
drainage is usually via the accompanying transverse cervical vein or
subclavian vein. It is demonstrated that the vascular territory of the
SCAIF ranges from 10 to 18 cm in width by 20 to 30 cm in
length[10, 11] , which extends from the
supraclavicular region to the shoulder cap. In our study all flaps were
designed within the dimensions of the angiosome and showed excellent
viability. Computed tomography angiography or vascular ultrasound was
routinely performed preoperatively in our cases, so that we can
determine whether the suprascapular artery is present or has been
injured previously.
The most common complications of SCAIF were partial flap necrosis, donor
site dehiscence, recipient site dehiscence, fistula, infection, and
esophageal stenosis, etc[12]. Minor complications
occurred in two cases and were resolved with local wound care. No
further surgical intervention was needed. The results were very
acceptable for us. According to our review, the author thought that the
necrosis of distal part of the flap and the development of fistula were
possibly related to previous radical
radiotherapy[13], transverse cervical vessels
injury and design of the skin paddle beyond the inferior aspect of the
angiosome. Kokot[14, 15] demonstrated that a flap
length greater than 22-24 cm was significantly associated with flap
necrosis. But other studies have demonstrated survival in flap lengths
up to 41 cm[16]. Therefore, for patients who had
received radical radiotherapy or functional neck dissection (level IV or
V lymph node) should be carefully evaluated preoperatively. During flap
harvest, the vascular pedicle should be carefully protected. The
creation of a soft tissue pedicle around the vascular pedicle may be
extremely useful. Which can protect the flap vasculature by preventing
kinking, partial compression, and undue
tension[3].
Unfavorable complications were not observed in our study. In this small
series, only one patient developed neck tightness sensation after
surgery, which was resolved by physical rehabilitation. All other
patients were satisfied with their functional and aesthetic outcomes.
In our series, all the donor sites were primary closed with adjacent
tissue advancement. But it is suggested that skin grafting should be
performed when the defect is wider than 8 cm[5]. A
shoulder drain may be not necessary because the dead space is closed
thoroughly. No compromised shoulder function was observed in our study.
Some investigators also use the Penn Shoulder Score and Constant
Shoulder Scale to measure the postoperative shoulder strength and
flexibility[17].
Due to the elimination of microvascular anastomosis, the majority flap
harvest time was usually less than 1 hour. This may extremely decrease
perioperative morbidity and reduce overall cost of care.