HEAD
AND
NECK SURGERY
Tracheostoma Reconstruction With the Supraclavicular Artery Island Flap Michael W. Chu, MD,* Joshua M. Levy, MD,Þ Paul L. Friedlander, MD,Þ and Ernest S. Chiu, MD* Abstract: Tracheostoma wounds are complex defects that commonly occur in patients with vessel-depleted necks after cervical lymphadenectomy, who have multiple medical comorbidities, and a history of radiation therapy. The authors report reconstruction of 5 tracheostoma wounds using a pedicled, supraclavicular artery island f lap as a reconstructive alternative. There were no f lap losses, fistulas or leaks, revisions, or other complications. The supraclavicular artery island f lap is a versatile, reliable, and effective option for tracheostoma reconstruction. Key Words: supraclavicular artery flap, SCAIF, supraclavicular artery island flap, tracheostomy reconstruction, tracheostomal reconstruction, peristomal reconstruction (Ann Plast Surg 2015;74: 677Y679)
T
racheostoma defects are complex wounds of the upper aerodigestive tract that can involve the larynx, pharynx, esophagus, and cervical skin. These defects affect the essential functions of respiration, phonation, and swallowing. The supraclavicular artery island f lap (SCAIF) is based on the supraclavicular artery, a branch from the transverse cervical artery that originates from the thyrocervical trunk. Kazanjian and Converse1 first described this f lap in 1949 and named it the acromial f lap, and additional reports have confirmed its use as an effective f lap for head and neck reconstruction.2Y4 Its large arc of rotation and ability to tubularize the f lap make it an excellent option for tracheostomal reconstruction. We present a case series of tracheostoma wound reconstruction using the SCAIF as an effective local f lap option for tracheostoma wounds.
clavicle and 8.6 cm from the sternoclavicular joint2 (Fig. 1). The largest reported f lap was a delayed SCAIF, measuring 12 35 cm3, and the arc of rotation for the supraclavicular f lap has been reported up to 180 degrees.4 An elliptical skin paddle is designed according to the defect, and a suture can be fixated at the pivot point to help design and plan the f lap rotation. The neck is then prepared and draped in the usual sterile fashion and the airway is maintained with a f lexible endotracheal tube, sutured to the chest wall on the contralateral side (Fig. 1A). The dimensions are recommended to not exceed 7 to 8 cm in width or extend more than 3 cm distal to the acromion (Fig. 1B). The skin incision is carried down to a subfascial plane and dissected from distal to proximal to within 2 to 3 cm of the vascular pedicle. Bipolar cautery is used to avoid thermal injury (Fig. 1C). The delicate, small caliber vascular pedicle should not be skeletonized to avoid unnecessary trauma. The supraclavicular artery f lap can be rotated, transposed, or interpolated along a wide arc of rotation as either a tunneled or island f lap. If the f lap is tunneled, care should be taken to prevent kinking or compression of the pedicle (Fig. 1C). The f lap is then carefully inset for watertight closure of the tracheostoma, and also to provide vascular inf low and dead space obliteration to promote wound healing. The supraclavicular f lap usually provides enough soft tissue volume for tracheostoma wound coverage (Fig. 1D). The donor site is undermined and closed primarily for skin paddles up to 8 cm in width. A split-thickness skin graft can be used if there is excessive tension. Drains are not necessary after adequate hemostasis. Avoid tracheostomy ties and pressure around the vascular pedicle and use dry dressings to prevent tracheal secretions from soiling the f lap.
PATIENT AND METHODS A retrospective review of prospectively collected data of all tracheostomal defects reconstructed with a SCAIF was analyzed from 2008 to 2012. Institutional review board approval was obtained, and the clinical histories, operative course, outcomes, and complications were reviewed.
Surgical Technique The SCAIF technique has been previously described.5 The course of the supraclavicular artery is marked with a handheld Doppler. Anatomic studies have shown a mean perfused supraclavicular flap skin paddle measuring 24.2 8.7 cm2. The mean diameter of the supraclavicular artery is 1.33 mm and located 3.6 cm above the
Received February 27, 2013, and accepted for publication, after revision, August 18, 2013. From the *Department of Plastic and Reconstructive Surgery, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; and †Department of Otolaryngology-Head and Neck Surgery, Tulane School of Medicine, New Orleans, LA. Conflicts of interest and sources of funding: none declared. Reprints: Ernest S. Chiu, MD, Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, 305 E 33rd St, New York, NY 10016. E-mail: [email protected]. Copyright * 2013 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0677 DOI: 10.1097/SAP.0b013e3182a9e9bd
Annals of Plastic Surgery
& Volume 74, Number 6, June 2015
RESULTS Five consecutive patients (4 men; age range, 62Y73 years) had tracheostomal defects from oncologic procedures reconstructed with SCAIF (Table 1). The etiologies of the tracheostomal defects were resection of 4 stage III recurrent laryngeal squamous cell carcinomas and 1 thyroid carcinoma recurrence. Five patients had a history of radiation therapy and 2 patients also had a history of chemotherapy. Four patients had a positive smoking history, but the thyroid carcinoma was a nonsmoker. The average defect size was 4 6 cm. All f laps were dissected in less than 60 minutes. There were no f lap losses, leaks, or other complications, and shoulder function was normal for all patients. There was 1 case of delayed wound healing in patient 3 that required a pectoralis major myocutaneous f lap (PMCF). The average length of stay was 7 days (6Y9 days), and mean follow-up was 18.2 months (11Y26 months).
DISCUSSION The complex anatomy and essential functions of the upper aerodigestive tract make tracheostoma defect reconstruction difficult. Reconstructive goals of tracheostomal defects should be to (1) provide a patent airway and stable stoma, (2) restore continuity of the alimentary tract, and (3) provide stable soft tissue coverage of the anterior neck. The ideal reconstruction restores both form and function of the defect in a single-stage procedure. The f lap should have www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
677
Annals of Plastic Surgery
Chu et al
& Volume 74, Number 6, June 2015
FIGURE 1. A, Planned extirpation of recurrent peristomal squamous cell carcinoma. B, Design of supraclavicular arterial island f lap. Blue dot represents supraclavicular artery pedicle. C, Harvest of fasciocutaneous f lap from distal to proximal. Blue background shows supraclavicular artery. D, Peristomal defect reconstructed with single-stage, SCAIF, and primary closure of donor site.
similar color and texture, be reliable and easy to perform, and have no donor-site comorbidity. No such f lap exists, but the supraclavicular f lap is a thin, pliable, versatile f lap with a wide arc of rotation that satisfies many criteria of an ideal f lap for tracheostoma defects. Reconstruction options of tracheostomal defects include PMCFs, deltopectoral flaps, skin grafts, trapezius flaps, or microvascular free f laps.6,7 However, PMCF and deltopectoral flaps can be bulky and narrow the airway stoma or hinder speech rehabilitation by obstructing tracheoesophageal prostheses used for esophageal speech. Muscle flaps with skin grafts are susceptible to failure due to sheer and soilage by upper aerodigestive tract secretions. Trapezius flaps require intraoperative repositioning and microvascular free flaps require microsurgical expertise and prolonged operative time. The SCAIF avoids these issues and is an excellent option for tracheostoma wounds. The supraclavicular skin is also a good color match and remains a thin, pliable f lap even in obese patients. The pedicle is a branch of the transverse cervical artery and located behind the clavicles, which is often outside the surgical field of cervical lymphadenectomies and usually spared from radiation damage.
Potential complications of the SCAIF include distal tip ischemia, injury to the pedicle during f lap harvest, fistulas, pharyngeal leaks, rare cases anomalous referred shoulder sensation during swallowing because innervated skin paddles may be stimulated by the passage of food, and minor donor-site wound dehiscence or scarring.5 In our small series, there were no complications and all reconstructions were successful. The relative contraindications for the supraclavicular f lap are prior history of neck dissection and neck irradiation because the supraclavicular artery or its source vessels may not be patent. These patients should have vascular studies, such as computed tomography or magnetic resonance angiography, to confirm f low of the thyrocervical trunk and supraclavicular artery before proceeding with a supraclavicular artery f lap.8
CONCLUSIONS Tracheostomal wounds are complex defects that commonly occur in patients with multiple medical comorbidities, often with a history of radiation therapy and neck dissections. The supraclavicular is a thin,
TABLE 1. Patient Demographics of Tracheostomal Reconstruction With SCAIF Pt
Age, y/Sex
1 2 3 4 5
66M 68M 72M 62M 73F
Etiology
Stage
Tobacco Use
Alcohol Use
Prior Therapies
Recurrent SCC Recurrent SCC Recurrent SCC Recurrent SCC Recurrent thyroid carcinoma
T4N2bM0 T4N2bM0 T4N2bM0 T4N2cM0 T4aN1aM0
40 PYH 45 PYH 60 PYH 45 PYH None
Yes Yes Yes Yes No
Chemo/XRT XRT XRT Chemo/XRT XRT
Defect, cm 5 4 4 6 5
6 5 6 6 5
Flap Size, cm
Complications
Additional Procedures
Length of Stay, d
Followup, mo
6 20 7 10 7 20 7 16 6 13
None None None None None
None None Pec flap None None
7 6 6 9 7
11 17 26 13 24
Chemo indicates chemotherapy; F, female; M, male; pec f lap, pectoralis myocutaneous f lap; Pt, patient; PYH, pack-year history; SSC, squamous cell carcinoma; XRT, radiation therapy.
678
www.annalsplasticsurgery.com
* 2013 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 74, Number 6, June 2015
pliable, rotational flap, and is a reliable option for reconstructing tracheostomal defects. It is not too bulky and does not require microsurgical expertise. We report a case series of 5 patients who underwent a supraclavicular artery flap as a safe and effective reconstruction option for tracheostomal defects. REFERENCES 1. Kazanjian VH, Converse JM. The Surgical Treatment of Facial Injuries. Baltimore, Md: Williams & Wilkins; 1949. 2. Pallua N, Maches HG, Rennekampff O, et al. The fasciocutaneous supraclavicular artery island flap for releasing postburn mentosternal contractures. Plast Reconstr Surg. 1997;99:1978Y1884. 3. Di Benedetto G, Aquinati A, Pierangeli M, et al. From the ‘‘charretera’’ to the supraclavicular fascial island flap: revisitation and further evolution of a
* 2013 Wolters Kluwer Health, Inc. All rights reserved.
Tracheostoma Reconstruction with Supraclavicular Flap
controversial flap. Plast Reconstr Surg. 2005;115:70Y76. 4. Vinh VQ, Van Anh T, Ogawa R, et al. Anatomical and clinical studies of the supraclavicular flap: analysis of 103 flaps used to reconstruct neck scar contractures. Plast Reconstr Surg. 2009;123:1471Y1480. 5. Chiu ES, Liu PH, Friedlander PL. Supraclavicular artery island flap for head and neck oncologic reconstruction: indications, complications, and outcomes. Plast Reconstr Surg. 2009;124:115Y123. 6. Yu P. One-stage reconstruction of complex pharyngoesophageal, tracheal, and anterior neck defects. Plast Reconstr Surg. 2005;116:949Y956. 7. Cordeiro PG, Mastorakos DP, Shaha AR. The radial forearm fasciocutaneous free-tissue transfer for tracheostomy reconstruction. Plast Reconstr Surg. 1996; 98:354Y357. 8. Adams AS, Wright MJ, Johnston S, et al. The use of multislice CT angiography preoperative study for supraclavicular artery island flap harvesting. Ann Plast Surg. 2012;69:312Y315.
www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
679
AND
NECK SURGERY
Tracheostoma Reconstruction With the Supraclavicular Artery Island Flap Michael W. Chu, MD,* Joshua M. Levy, MD,Þ Paul L. Friedlander, MD,Þ and Ernest S. Chiu, MD* Abstract: Tracheostoma wounds are complex defects that commonly occur in patients with vessel-depleted necks after cervical lymphadenectomy, who have multiple medical comorbidities, and a history of radiation therapy. The authors report reconstruction of 5 tracheostoma wounds using a pedicled, supraclavicular artery island f lap as a reconstructive alternative. There were no f lap losses, fistulas or leaks, revisions, or other complications. The supraclavicular artery island f lap is a versatile, reliable, and effective option for tracheostoma reconstruction. Key Words: supraclavicular artery flap, SCAIF, supraclavicular artery island flap, tracheostomy reconstruction, tracheostomal reconstruction, peristomal reconstruction (Ann Plast Surg 2015;74: 677Y679)
T
racheostoma defects are complex wounds of the upper aerodigestive tract that can involve the larynx, pharynx, esophagus, and cervical skin. These defects affect the essential functions of respiration, phonation, and swallowing. The supraclavicular artery island f lap (SCAIF) is based on the supraclavicular artery, a branch from the transverse cervical artery that originates from the thyrocervical trunk. Kazanjian and Converse1 first described this f lap in 1949 and named it the acromial f lap, and additional reports have confirmed its use as an effective f lap for head and neck reconstruction.2Y4 Its large arc of rotation and ability to tubularize the f lap make it an excellent option for tracheostomal reconstruction. We present a case series of tracheostoma wound reconstruction using the SCAIF as an effective local f lap option for tracheostoma wounds.
clavicle and 8.6 cm from the sternoclavicular joint2 (Fig. 1). The largest reported f lap was a delayed SCAIF, measuring 12 35 cm3, and the arc of rotation for the supraclavicular f lap has been reported up to 180 degrees.4 An elliptical skin paddle is designed according to the defect, and a suture can be fixated at the pivot point to help design and plan the f lap rotation. The neck is then prepared and draped in the usual sterile fashion and the airway is maintained with a f lexible endotracheal tube, sutured to the chest wall on the contralateral side (Fig. 1A). The dimensions are recommended to not exceed 7 to 8 cm in width or extend more than 3 cm distal to the acromion (Fig. 1B). The skin incision is carried down to a subfascial plane and dissected from distal to proximal to within 2 to 3 cm of the vascular pedicle. Bipolar cautery is used to avoid thermal injury (Fig. 1C). The delicate, small caliber vascular pedicle should not be skeletonized to avoid unnecessary trauma. The supraclavicular artery f lap can be rotated, transposed, or interpolated along a wide arc of rotation as either a tunneled or island f lap. If the f lap is tunneled, care should be taken to prevent kinking or compression of the pedicle (Fig. 1C). The f lap is then carefully inset for watertight closure of the tracheostoma, and also to provide vascular inf low and dead space obliteration to promote wound healing. The supraclavicular f lap usually provides enough soft tissue volume for tracheostoma wound coverage (Fig. 1D). The donor site is undermined and closed primarily for skin paddles up to 8 cm in width. A split-thickness skin graft can be used if there is excessive tension. Drains are not necessary after adequate hemostasis. Avoid tracheostomy ties and pressure around the vascular pedicle and use dry dressings to prevent tracheal secretions from soiling the f lap.
PATIENT AND METHODS A retrospective review of prospectively collected data of all tracheostomal defects reconstructed with a SCAIF was analyzed from 2008 to 2012. Institutional review board approval was obtained, and the clinical histories, operative course, outcomes, and complications were reviewed.
Surgical Technique The SCAIF technique has been previously described.5 The course of the supraclavicular artery is marked with a handheld Doppler. Anatomic studies have shown a mean perfused supraclavicular flap skin paddle measuring 24.2 8.7 cm2. The mean diameter of the supraclavicular artery is 1.33 mm and located 3.6 cm above the
Received February 27, 2013, and accepted for publication, after revision, August 18, 2013. From the *Department of Plastic and Reconstructive Surgery, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; and †Department of Otolaryngology-Head and Neck Surgery, Tulane School of Medicine, New Orleans, LA. Conflicts of interest and sources of funding: none declared. Reprints: Ernest S. Chiu, MD, Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, 305 E 33rd St, New York, NY 10016. E-mail: [email protected]. Copyright * 2013 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7406-0677 DOI: 10.1097/SAP.0b013e3182a9e9bd
Annals of Plastic Surgery
& Volume 74, Number 6, June 2015
RESULTS Five consecutive patients (4 men; age range, 62Y73 years) had tracheostomal defects from oncologic procedures reconstructed with SCAIF (Table 1). The etiologies of the tracheostomal defects were resection of 4 stage III recurrent laryngeal squamous cell carcinomas and 1 thyroid carcinoma recurrence. Five patients had a history of radiation therapy and 2 patients also had a history of chemotherapy. Four patients had a positive smoking history, but the thyroid carcinoma was a nonsmoker. The average defect size was 4 6 cm. All f laps were dissected in less than 60 minutes. There were no f lap losses, leaks, or other complications, and shoulder function was normal for all patients. There was 1 case of delayed wound healing in patient 3 that required a pectoralis major myocutaneous f lap (PMCF). The average length of stay was 7 days (6Y9 days), and mean follow-up was 18.2 months (11Y26 months).
DISCUSSION The complex anatomy and essential functions of the upper aerodigestive tract make tracheostoma defect reconstruction difficult. Reconstructive goals of tracheostomal defects should be to (1) provide a patent airway and stable stoma, (2) restore continuity of the alimentary tract, and (3) provide stable soft tissue coverage of the anterior neck. The ideal reconstruction restores both form and function of the defect in a single-stage procedure. The f lap should have www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
677
Annals of Plastic Surgery
Chu et al
& Volume 74, Number 6, June 2015
FIGURE 1. A, Planned extirpation of recurrent peristomal squamous cell carcinoma. B, Design of supraclavicular arterial island f lap. Blue dot represents supraclavicular artery pedicle. C, Harvest of fasciocutaneous f lap from distal to proximal. Blue background shows supraclavicular artery. D, Peristomal defect reconstructed with single-stage, SCAIF, and primary closure of donor site.
similar color and texture, be reliable and easy to perform, and have no donor-site comorbidity. No such f lap exists, but the supraclavicular f lap is a thin, pliable, versatile f lap with a wide arc of rotation that satisfies many criteria of an ideal f lap for tracheostoma defects. Reconstruction options of tracheostomal defects include PMCFs, deltopectoral flaps, skin grafts, trapezius flaps, or microvascular free f laps.6,7 However, PMCF and deltopectoral flaps can be bulky and narrow the airway stoma or hinder speech rehabilitation by obstructing tracheoesophageal prostheses used for esophageal speech. Muscle flaps with skin grafts are susceptible to failure due to sheer and soilage by upper aerodigestive tract secretions. Trapezius flaps require intraoperative repositioning and microvascular free flaps require microsurgical expertise and prolonged operative time. The SCAIF avoids these issues and is an excellent option for tracheostoma wounds. The supraclavicular skin is also a good color match and remains a thin, pliable f lap even in obese patients. The pedicle is a branch of the transverse cervical artery and located behind the clavicles, which is often outside the surgical field of cervical lymphadenectomies and usually spared from radiation damage.
Potential complications of the SCAIF include distal tip ischemia, injury to the pedicle during f lap harvest, fistulas, pharyngeal leaks, rare cases anomalous referred shoulder sensation during swallowing because innervated skin paddles may be stimulated by the passage of food, and minor donor-site wound dehiscence or scarring.5 In our small series, there were no complications and all reconstructions were successful. The relative contraindications for the supraclavicular f lap are prior history of neck dissection and neck irradiation because the supraclavicular artery or its source vessels may not be patent. These patients should have vascular studies, such as computed tomography or magnetic resonance angiography, to confirm f low of the thyrocervical trunk and supraclavicular artery before proceeding with a supraclavicular artery f lap.8
CONCLUSIONS Tracheostomal wounds are complex defects that commonly occur in patients with multiple medical comorbidities, often with a history of radiation therapy and neck dissections. The supraclavicular is a thin,
TABLE 1. Patient Demographics of Tracheostomal Reconstruction With SCAIF Pt
Age, y/Sex
1 2 3 4 5
66M 68M 72M 62M 73F
Etiology
Stage
Tobacco Use
Alcohol Use
Prior Therapies
Recurrent SCC Recurrent SCC Recurrent SCC Recurrent SCC Recurrent thyroid carcinoma
T4N2bM0 T4N2bM0 T4N2bM0 T4N2cM0 T4aN1aM0
40 PYH 45 PYH 60 PYH 45 PYH None
Yes Yes Yes Yes No
Chemo/XRT XRT XRT Chemo/XRT XRT
Defect, cm 5 4 4 6 5
6 5 6 6 5
Flap Size, cm
Complications
Additional Procedures
Length of Stay, d
Followup, mo
6 20 7 10 7 20 7 16 6 13
None None None None None
None None Pec flap None None
7 6 6 9 7
11 17 26 13 24
Chemo indicates chemotherapy; F, female; M, male; pec f lap, pectoralis myocutaneous f lap; Pt, patient; PYH, pack-year history; SSC, squamous cell carcinoma; XRT, radiation therapy.
678
www.annalsplasticsurgery.com
* 2013 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 74, Number 6, June 2015
pliable, rotational flap, and is a reliable option for reconstructing tracheostomal defects. It is not too bulky and does not require microsurgical expertise. We report a case series of 5 patients who underwent a supraclavicular artery flap as a safe and effective reconstruction option for tracheostomal defects. REFERENCES 1. Kazanjian VH, Converse JM. The Surgical Treatment of Facial Injuries. Baltimore, Md: Williams & Wilkins; 1949. 2. Pallua N, Maches HG, Rennekampff O, et al. The fasciocutaneous supraclavicular artery island flap for releasing postburn mentosternal contractures. Plast Reconstr Surg. 1997;99:1978Y1884. 3. Di Benedetto G, Aquinati A, Pierangeli M, et al. From the ‘‘charretera’’ to the supraclavicular fascial island flap: revisitation and further evolution of a
* 2013 Wolters Kluwer Health, Inc. All rights reserved.
Tracheostoma Reconstruction with Supraclavicular Flap
controversial flap. Plast Reconstr Surg. 2005;115:70Y76. 4. Vinh VQ, Van Anh T, Ogawa R, et al. Anatomical and clinical studies of the supraclavicular flap: analysis of 103 flaps used to reconstruct neck scar contractures. Plast Reconstr Surg. 2009;123:1471Y1480. 5. Chiu ES, Liu PH, Friedlander PL. Supraclavicular artery island flap for head and neck oncologic reconstruction: indications, complications, and outcomes. Plast Reconstr Surg. 2009;124:115Y123. 6. Yu P. One-stage reconstruction of complex pharyngoesophageal, tracheal, and anterior neck defects. Plast Reconstr Surg. 2005;116:949Y956. 7. Cordeiro PG, Mastorakos DP, Shaha AR. The radial forearm fasciocutaneous free-tissue transfer for tracheostomy reconstruction. Plast Reconstr Surg. 1996; 98:354Y357. 8. Adams AS, Wright MJ, Johnston S, et al. The use of multislice CT angiography preoperative study for supraclavicular artery island flap harvesting. Ann Plast Surg. 2012;69:312Y315.
www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
679
