Evolution and extended indications of the Supraclavicular Island Flap
- A personal 14 years single surgeon´s experience
Norbert Pallua, M.D. Ph.D., Erhan Demir, M.D..
University Hospital RWTH Aachen, Aachen, Germany.
The facial area functioning as a medium for social interaction and communication and the cervical region with it’s functional and anatomical design to achieve a maximum range of motion is of eminent importance. Deformities or scar contractures in the head and neck region represent a challenge with a unique set of problems compared with the rest of the body. Face and neck reconstructions can be performed by reduction or elimination of scars followed by defect coverage with adequate tissue. To achieve satisfactory functional and aesthetic results, the texture, color and thickness of the flap needs to similar to those of the head and neck region.
The Supraclavicular Island Flap (SIF) has been a useful tool for the late phase or primary reconstruction in the head and neck region for 14 years now. Due to the excellent results in the recent years the spectrum of indications was further extended to reconstruct defects following persistent trachecutaneous fistulas and congenital facial deformities. My personal experience in the development and modification of this ultrathin flap in 116 follow-up cases is reported.
In a follow-up study 107 ultrathin SIF flaps in 96 patients have been reviewed. An additional number of nine patients required reconstructions with an osteocutaneous SIF-flap variation following persistent tracheocutaneous fistulas following tracheostomia. The 96 patients suffered from neck contractures or required facial reconstruction following burns (n=68), tumor reconstruction (n=20), trauma (n=4) and others (n=4) such as Rombergs disease. Among these a total number of 20 patients received previously pre-expanded supraclavicular island flaps. Eleven bilateral flaps have been carried out. The maximum flap dimension was 35cm in length and 16 cm in width. The surgical and subjective outcome has been analyzed during follow-up.
Functional and aesthetic requirements in the head and neck region could be fulfilled in all successfully performed flaps. Flap complications occurred in n=8 cases without pre-expansion, including one total flap loss, partial flap loss (n=4) and distal epidermolysis in n=3 cases. We did not notice any flap complications while performing pre-expanded or osteocutaneous SIF-flaps.Donor site morbidity was low (n=9), in cases without pre-expansion; whereas pre-expanded donor regions demonstrated very low (n=1) complication rates - primary closure was always possible. The shoulder area could be easily concealed with everyday clothing.
The supraclavicular island flap is a thin and after pre-expansion ultrathin fasciocutaneous flap, with a nearly perfect facial skin texture match and smooth hairless surface, providing sensitivity. Therefore, the SIF is reliable and safe for immediate or late resurfacing of facial defects and to release cervical contractures following thermal injuries for instance.
In my opinion it is the best choice in full-face reconstructions. Customized flap design with tissue expansion without the need for microsurgery allows extended indications and optimized skin utilization, while good texture and color match is generally difficult to achieve in the head and neck region.