10.14639/0392-100X-N1152
Objective. To describe the surgical technique of the supraclavicular artery fascial flap (SAFF) and outcomes in neopharyngeal covering with overlay technique during salvage total laryngectomy for residual or recurrent carcinoma after chemo/radiation treatment. Methods. Chart review of patients treated between October 2018 and February 2019 at two tertiary care hospitals. Variables extracted from patient records were age, gender, history of chemo/radiation therapy, neck dissection, surgical and postoperative complications. Outcomes measured were surgical time, postoperative complications and flap failure, oral intake start and patient discharge. Results. Ten male patients were included. Median age was 64 years. All patients underwent salvage total laryngectomy and neopharyngeal covering with SAFF. Mean flap harvest time was 25 minutes. No surgical complications or flap failure were recorded. Oral intake was started on a median of post-operative day 10. No cases of pharyngocutaneous fistula were encountered. Conclusions. SAFF is a reliable, easy and quick to harvest flap, which provides a good alternative to other pedicled and free flaps for hypopharyngeal coverage in laryngeal salvage surgery. Donor site morbidity is almost null and postoperative complications are very rare.
text/xml
1827-675X
1152
en
Livio Presutti
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
supraclavicular artery
Supraclavicular artery fascial flap (SAFF): a valuable tool in salvage total laryngectomy and hemipharyngolaryngectomy
Text.Serial.Journal
https://www.actaitalica.it/
41
Head and neck
2021-11-26
2020-10-01
2021-12-22
2021-12-22
523-529
1
Livio Presutti
2021/11/26
10.14639/0392-100X-N1152
523
Department of Otorhinolaryngology Head and Neck Surgery, University Hospital of Modena, Modena, Italy; Department of Otorhinolaryngology Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy; Department of Specialist, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum, Università di Bologna, Bologna, Italy
1827-675X
supraclavicular artery
en
529
Supraclavicular artery fascial flap (SAFF): a valuable tool in salvage total laryngectomy and hemipharyngolaryngectomy
https://www.actaitalica.it/article/download/1152/702
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:523-529; doi: 10.14639/0392-100X-N1152




Head and neck


Supraclavicular artery fascial flap (SAFF):
a valuable tool in salvage total laryngectomy
and hemipharyngolaryngectomy
Lembo peduncolato di fascia sovraclaveare: utile strumento nella laringectomia
ed emifaringolaringectomia totale di salvataggio
Francesco Mattioli1, Matteo Fermi1,2,3, Andrea Martone1, Michael Ghirelli1, Leone Giordano4, Davide Di Santo3,
Mario Bussi4, Livio Presutti1,2,3
1
  Department of Otorhinolaryngology Head and Neck Surgery, University Hospital of Modena, Modena, Italy; 2 Department of
Otorhinolaryngology Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi,
Bologna, Italy; 3 Department of Specialist, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum, Università di
Bologna, Bologna, Italy; 4 Department of Otorhinolaryngology, San Raffaele Scientific Institute, Milan, Italy


SUMMARY
Objective. To describe the surgical technique of the supraclavicular artery fascial flap
(SAFF) and outcomes in neopharyngeal covering with overlay technique during salvage
total laryngectomy for residual or recurrent carcinoma after chemo/radiation treatment.
Methods. Chart review of patients treated between October 2018 and February 2019 at two
tertiary care hospitals. Variables extracted from patient records were age, gender, history of
chemo/radiation therapy, neck dissection, surgical and postoperative complications. Outcomes       Received: October 1, 2020
measured were surgical time, postoperative complications and flap failure, oral intake start and   Accepted: June 26, 2021
patient discharge.                                                                                 Published online: November 26, 2021
Results. Ten male patients were included. Median age was 64 years. All patients underwent
salvage total laryngectomy and neopharyngeal covering with SAFF. Mean flap harvest time was        Correspondence
25 minutes. No surgical complications or flap failure were recorded. Oral intake was started on    Andrea Martone
a median of post-operative day 10. No cases of pharyngocutaneous fistula were encountered.         Department of Otorhinolaryngology, Head & Neck
Conclusions. SAFF is a reliable, easy and quick to harvest flap, which provides a good al-         Surgery, University Hospital of Modena, Italy
ternative to other pedicled and free flaps for hypopharyngeal coverage in laryngeal salvage        Tel. +39 0594 222402. Fax +39 0594 222454
surgery. Donor site morbidity is almost null and postoperative complications are very rare.        E mail: andreamartone@gmail.com

KEY WORDS: salvage laryngectomy, chemoradiation, pedicled flap, pharyngocutaneous                  Funding
fistula, supraclavicular artery                                                                    None.

RIASSUNTO                                                                                          Conflict of interest
Scopo dello studio. Descrivere la tecnica chirurgica del lembo SAFF e le sue applicazioni          The Authors declare no conflict of interest.
e risultati nella ricostruzione faringea durante laringectomia di salvataggio per SCC per-
sistenti dopo trattamento chemio/radioterapico.                                                      How to cite this article: Mattioli F, Fermi M,
Metodi. Analisi retrospettiva di pazienti trattati fra 10/2018 e 02/2019 in due centri ospe-         Martone A, et al. Supraclavicular artery fascial
dalieri di terzo livello. Le variabili analizzate sono età, sesso, precedente chemio/radiote-        flap (SAFF): a valuable tool in salvage total lar-
rapia, svuotamento laterocervicale, complicanze intra e post-operatorie. I risultati valutati        yngectomy and hemipharyngolaryngectomy. Ac-
sono tempo chirurgico, complicanze post-operatorie, fallimento del lembo, tempo d’inizio             ta Otorhinolaryngol Ital 2021;41:523-529. https://
dell’alimentazione per os e durata della degenza.                                                    doi.org/10.14639/0392-100X-N1152
Risultati. Sono stati inclusi 10 pazienti maschi. L’età mediana era 64 anni. Il tempo media-
no di allestimento del lembo è stato di 25 minuti. Non sono state registrate complicanze in-       © Società Italiana di Otorinolaringoiatria
                                                                                                   e Chirurgia Cervico-Facciale
tra o post-operatorie. L’inizio mediano dell’alimentazione per os è stato in decima giornata
post-operatoria. Non sono stati osservati casi di fistolizzazione faringo-cutanea.
                                                                                                                  OPEN ACCESS
Conclusioni. Il SAFF è un lembo affidabile, facile e rapido da allestire, che offre una valida
alternativa ad altri lembi peduncolati e liberi per la copertura ipofaringea nella chirurgia       This is an open access article distributed in accordance with
                                                                                                   the CC-BY-NC-ND (Creative Commons Attribution-Non-
laringea di salvataggio. La morbilità del sito donatore è praticamente nulla e le complican-       Commercial-NoDerivatives 4.0 International) license. The
ze post-operatorie sono molto rare.                                                                article can be used by giving appropriate credit and mentio-
                                                                                                   ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: laringectomia di salvataggio, chemioradioterapia, lembi peduncolati,                only in the original version. For further information: https://
fistola faringocutanea, arteria sovraclaveare                                                      creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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F. Mattioli et al.




Introduction                                                       verse cervical artery before piercing the deep fascia of the
                                                                   deltoid muscle. The supraclavicular artery can be identi-
Most laryngectomies are performed in the salvage set-
                                                                   fied in a triangular area bounded inferiorly by the clavicle,
ting due to organ preservation protocols with concurrent
                                                                   medially by the posterior border of the sternocleidomastoid
chemoradiation (CRT) 1. Radiation and chemoradiation are
                                                                   muscle and laterally by the external jugular vein. These an-
known for their adverse effects on soft tissue which leads to
                                                                   atomical landmarks can be marked pre-operatively (Fig. 1).
a significantly higher risk of postoperative complications,
                                                                   A rectilinear incision including skin and subcutaneous tis-
especially pharyngocutaneous fistula (PCF). This adverse
                                                                   sue is made from the point of origin of the vascular pedicle
outcome remains of significant concern and has become the
                                                                   to 1 cm lateral to the acromion. Alternatively, the classic
focus of reconstructive surgeons. The main goal is to trans-
                                                                   shape of the fascio-cutaneous flap is drawn and only the
fer healthy vascularised tissue from outside the radiation
                                                                   anterior portion is incised (Fig. 2).
field, thus enhancing the healing process and reducing the
incidence of wound complications. The choices of donor             The incision can also be made along the main axis of the
tissues are usually among pedicled or microvascular free           flap to elevate two shorter flaps (superior and inferior), thus
flaps. Moreover, surgeons have adopted two different tech-         reducing the risk of distal loss in case of wide flaps.
niques when using vascularised tissue following salvage            The fascial plane is identified distally at the level of the del-
total laryngectomy (STL): vascularised tissue to increase          toid muscle. Once this plane has been highlighted, it is ex-
the pharyngeal circumference by a patch graft and vascu-           posed anteriorly and posteriorly to cover the entire length
larised tissue to reinforce the pharyngeal repair 2.               of the flap. It is useful to maintain a layer of subcutaneous
Herein, we describe a new reconstructive option in neopha-         adipose tissue above the fascial plane.
ryngeal covering during STL based on supraclavicular ves-          The flap is dissected in a distal-to-proximal manner along
sels: the supraclavicular artery fascial flap (SAFF).              a subfascial plane over the deltoid muscle. The fascia of
                                                                   the deltoid muscle is incised and detached according to the
                                                                   classical form of the supraclavicular flap. Normally, a 6-7
Methods
A descriptive retrospective study was conducted on pa-
tients subjected to STL and SAFF reconstruction after ra-
diation or CRT between October 2018 and February 2019
at two tertiary care hospitals. Patient eligibility criteria for
SAFF reconstruction were laryngeal cancer, with or with-
out extension to pyriform sinus, after previous radiation or
CRT. Exclusion criteria were cancer involving the posterior
hypopharyngeal wall or both pyriform sinuses. All patients
underwent a pre-operative Doppler evaluation to demon-
strate the presence of the vascular pedicle.
Variables extracted from patient records were age, gender,
history of chemoradiation or radiation therapy prior to SAFF
reconstruction, neck dissection prior or during reconstructive
surgery, surgical and postoperative complications. Adverse
events were defined as any deviation from normal postop-
erative course. Descriptive statistical analysis was conducted
with IBM SPSS Statistics Version 19.0 (IBM Corp, Armonk,
NY, USA). Results are presented as median (range) for con-
tinuous variables and as frequencies for categorical variables.
Ethics committee approval: University Hospital of Modena
and San Raffaele Scientific Institute’s ethics committees do
not require approval for anonymised retrospective chart re-
views.

Surgical technique
The supraclavicular artery usually has a diameter of 1-1.5         Figure 1. Surgical landmarks. SCM: sternocleidomastoid muscle; C: clavicle;
mm and travels for 30 mm perpendicularly from the trans-           EGV: external jugular vein.



524
                                                                                                           Supraclavicular artery fascial flap




Figure 2. Skin and subcutaneous tissue incision.                Figure 3. Right supraclavicular artery fascial flap isolation and elevation.
                                                                Dotted line highlights the SAFF. D, deltoid muscle. VP, vascular pedicle. SCM,
                                                                sternocleidomastoid muscle.

cm (antero-posterior) by 20-26 cm (lateromedial) flap is
obtained. The flap’s length usually allows for neopharyn-
geal coverage without further need to skeletonise the vas-
cular axis, thus avoiding its accidental injury. A subfascial
plane must be followed while elevating the flap, except for
the clavicular region where a subperiosteal plane must be
followed (Fig. 3).
Once the pedicle is isolated, the flap is rotated over the
pharyngeal reconstruction (Fig. 4).
An incision of the anterior portion of the SCM muscle can
be performed to facilitate the positioning of the flap. Oth-
erwise, the flap can be placed under the muscle after iden-
tification and preservation of the spinal nerve. Final steps
consist in placing a suction drain and suturing the skin with
non-absorbable separate threads.

Results
Ten male patients were included in the present study. Medi-
an age was 64 years (range 54-82). All patients underwent
salvage total laryngectomy and neopharyngeal covering
with SAFF. Eight patients underwent salvage total laryn-
gectomy, and two were subjected to salvage total hemi-          Figure 4. Positioning of the SAFF over the pharyngeal reconstruction.
pharyngolaryngectomy (Tab. I). Four were staged as T3N0
according to TNM Classification of Malignant Tumors,
                                                                on GM because of a second primary posterior commissure
Eight Edition 3. EZ and CA were selected T3N0 amenable
                                                                cancer 120 months after radiation therapy. STL was per-
to larynx preserving surgery, thus performed only RT and
not CRT. FP could not undergo CT for vascular and renal         formed on MF because of disease recurrence 16 months
co-pathologies, while FC was not deemed fit due to age. MF      after the end of RT.
and GM were subjected to prior surgical treatment (OPHL         Mean flap harvest time was 25 minutes (range 23-28). Bilat-
IIa and type IV cordectomy respectively) that resulted in       eral selective neck dissection (SND) was performed in five
R1 margins, after which they underwent adjuvant therapy         patients (50%), ipsilateral SND in one patient (10%) and
(RT and CRT). Salvage total laryngectomy was performed          no neck dissection was performed in two patients (20%).


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F. Mattioli et al.




Table I. Patient characteristics, oncological history and treatment (continues on page 527).
        Patient          Sex        Age        Comorbidities          BMI       Disease site      Disease            cTNM*       Previous       Surgical
                                                                                                  subsite           (before      surgery        margins
                                                                                                                    primary
                                                                                                                  treatment)
 1         F.C.                  M          60    High blood pressure,    18.3   Hypopharynx    Right pyriform    T4aN2bM0          No             -
                                                      valvular heart                                sinus
                                                     disease, COPD
 2         G.M.                  M          55            None            27.2     Glottis       Right vocal       T2N0M0      Yes (type IV       R1
                                                                                                    fold                       cordectomy)

 3         F.P.                  M          58        COPD, CKD,          24.7     Glottis       Right false       T3N0M0           No             -
                                                   peripheral arterial                           vocal fold
                                                         disease
 4         M.F.                  M          71    High blood pressure,    29.0     Glottis       Right vocal      T2N2bM0      Yes (OPHL IIa)     R1
                                                   ischaemic stroke,                                fold
                                                   previous colorectal
                                                         cancer
 5         R.O.                  M          60    High blood pressure,    22.5   Supraglottis    Ariepiglottic    T2N2cM0           No             -
                                                      CAD, COPD                                    fold left,
                                                                                                  epiglottis
 6         C.A.                  M          64      Alcoholism, HCV       20.2     Glottis      Left vocal fold    T3N0M0           No             -
                                                        infection
 7         L.G.                  M          73         Alcoholism         24.2   Hypopharynx    Left pyriform     T3N2bM0           No             -
                                                                                                    sinus

 8         A.E.                  M          70      Alcoholism, high      28.4     Glottis      Right and left     T2N0M0           No             -
                                                     blood pressure,                              vocal fold
                                                    diabetes mellitus
 9         F.C.                  M          80      Alcoholism, HCV       22.3     Glottis      Left vocal fold    T3N0M0           No             -
                                                  infection, high blood
                                                        pressure
 10        E.Z.                  M          54            None            20.8     Glottis        Anterior         T3N0M0           No             -
                                                                                                commissure
* TNM Eighth Edition 3; ** pyr: pyriform sinus.



No surgical complications nor flap failure were recorded.                           delays return to oral feeding and vocal rehabilitation. Several
Patients received enteral feeding through a nasogastric                             authors have reported 15%-30% rates of PCF for patients
tube. None of the patients underwent percutaneous endo-                             undergoing salvage total laryngectomy (STL) after radia-
scopic gastrostomy placement. Oral feeding was delayed                              tion or CRT with an approximate 2.28-fold increased risk 2.
until a negative salivary fistula blue dye test, which was                          CRT damage to surrounding tissue translates in an increased
performed in median post-operative day 9 (range 8-10). No                           risk of complications within the first year after treatment 4.
cases of PCF were encountered. Patients were dismissed                              Hence, different surgical techniques have been developed to
in median post-operative day 14 (range 13-15). No post-                             reduce PCFs 5.
operative complications were recorded.                                              Surgeons have adopted two different techniques when us-
                                                                                    ing vascularised tissue following STL: vascularised tissue
                                                                                    to augment pharyngeal circumference by a patch graft and
Discussion
                                                                                    vascularised tissue to reinforce pharyngeal repair. Pecto-
Pharyngocutaneous fistula (PCF) has been a challenge for                            ralis major myofascial flap (PMMF) and pectoralis major
head and neck surgeons for the treatment of advanced phar-                          myocutaneous flap (PMMC) have been the most common-
yngolaryngeal cancer 1. PCFs extend hospitalisation time                            ly used pedicled flaps for this purpose 2. However, the bulky
due to increased necessity of wound care, and may lead to                           nature of the pectoralis major muscle may prevent closure
major vascular injuries such as carotid or jugular vein rup-                        of the overlying skin and the morbidity of the donor site is
ture. PCFs may also require revision surgery which further                          significant, especially for female patients where incisions



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Table I. Patient characteristics, oncological history and treatment (follows from page 526).
        Patient Previous RT Dose Previous                     Reason for         Time to     Treatment       Neck            ypTNM*             Present
                      RT           (Gy)         CT       salvage treatment relapse                        dissection                             status
                                                                                (months)

 1         F.C.             Yes            66     Yes      Recurrence             9       Salvage total    Right II-IV      T4aN0M0               NED
                                                                                         laryngectomy         SND
                                                                                          + right pyr**
 2         G.M.             Yes            66     No     Second primary         120       Salvage total   Bilateral II-IV   T2N0M0                NED
                                                           T (posterior                  laryngectomy          SND
                                                          commissure)
 3         F.P.             Yes            64     No       Recurrence            21       Salvage total   Bilateral II-IV   T3N2bM0               NED
                                                                                         laryngectomy          SND

 4         M.F.             Yes            60     Yes      Recurrence            16       Salvage total   Bilateral II-IV   T4aN2bM0        NED on primary
                                                                                         laryngectomy          SND                         T. In treatment for
                                                                                                                                            primary prostate
                                                                                                                                                  cancer
 5         R.O.             Yes            64     Yes      Recurrence            14       Salvage total   Bilateral II-V    T3N2bM0                NED
                                                                                         laryngectomy         SND

 6         C.A.             Yes            60     No       Recurrence            28       Salvage total   Bilateral II-IV   T3N2cM0               NED
                                                                                         laryngectomy          SND
 7         L.G.             Yes            70     Yes      Recurrence            12       Salvage total   Bilateral II-IV   T4aN2bM0              NED
                                                                                         laryngectomy          SND
                                                                                           + left pyr
 8         A.E.             Yes            66     No       Recurrence            15       Salvage total   Bilateral II-V    T3N0M0                NED
                                                                                         laryngectomy         SND

 9         F.C.             Yes            66     No       Recurrence            13       Salvage total   Bilateral II-V    T3N2aM0               NED
                                                                                         laryngectomy         SND

 10        E.Z.             Yes            66     No       Recurrence            14       Salvage total   Bilateral II-IV   T3N2aM0               NED
                                                                                         laryngectomy          SND
* TNM Eighth Edition 3; ** pyr: pyriform sinus.



encompass the mammary region. Additionally, shoulder                              A growing interest in the use of tissue harvested from the
dysfunction, difficulties with vocal rehabilitation and de-                       cervicohumeral area has been reported recently 9-12. Su et
creased chest wall compliance have been reported 6. Sev-                          al. showed several advantages from using the SCAIF over
eral authors use pedicled flaps as a second-line option when                      distant free flaps in head and neck reconstruction 13, espe-
free flap reconstruction is not feasible 7. The radial forearm                    cially after RT or revision surgery. Granzow and coworkers
free flap (RFFF), the anterolateral thigh flap (ALTF) and                         compared the SCAIF with the RFFF concluding that the
the temporoparietal fascia free flap (TPFF) are the most                          former should be considered a first-choice reconstructive
used in STL reconstructive setting. The ALTF is virtually                         option for head and neck defects 8. The main disadvantage
free from donor site morbidity, but its added bulk might be                       of this flap is the size of the skin paddle, limited by the
troublesome for optimal reconstruction. Nonetheless, free                         need for primary closure, and a shorter vascular pedicle.
flaps are characterized by increased operative times, exten-                      Furthermore, several authors advise against the use of this
sive postoperative monitoring and microvascular surgery                           flap in cases of ipsilateral neck metastasis and following
expertise 8.                                                                      neck radiation 14.
Moreover, in the reconstruction of head and neck cancer                           Herein, we describe a novel and valuable reconstructive tech-
patients who have undergone previous neck dissections or                          nique based on supraclavicular vessels: the supraclavicular
radiotherapy, the paucity of good calibre and quality ves-                        artery fascial flap (SAFF). The fascia of the deltoid region
sels for microvascular anastomosis constitute a real chal-                        can provide thin, pliable and vascularised tissue that can
lenge for microvascular surgeons.                                                 help in resurfacing reconstructions in the head and neck dis-



                                                                                                                                                           527
F. Mattioli et al.




trict 15. Complications to the donor site are not frequent, as
the shoulder and supraclavicular fossa skin is left in place. In
fact, no wound complications were reported in present case
series. Based on our results a good aesthetic outcome of the
donor site can be achieved after SAFF reconstruction (Fig.
5). Several patients reported tightness in the shoulder and
minor widening of the donor-site scar was common. Wound
dehiscence and widened scarring are more frequent when
tension at closure site increases, especially in patients with
comorbidities and following CRT or radiation therapy. Care
should be taken, especially while suturing the skin overlying
the acromion in order to avoid excessive tension which might
hinder optimal healing as it is the point of maximal move-
ment 16. There is no need for pedicle section since the flap
is positioned in the subcutaneous tissue. Thus, second stage
surgery can be avoided.
In our opinion, SAFF represents an effective and safe option
to prevent postoperative fistula in patients who undergo STL
after CRT or radiation for laryngeal cancer. In our experience,
SAFF reconstruction is a valuable option when pharyngeal
resurfacing is required to prevent PCF. It can be easily and
rapidly harvested to reinforce pharyngeal suture line, provid-
ing healthy and vascularised tissue to a critical surgical area
without compromising primary closure of the donor site. This
is especially of use in patients with previous radiation treat-
ment or in case of free flap contraindication, where pedicled
flaps can become a first-choice treatment 8. This pilot multi-     Figure 5. Aesthetic outcome 1 month after surgery.
institutional experience with SAFF in STL setting has dem-
onstrated its safety and low complication rates. Even though
the number of patients is limited, no complications were en-       of complications make the SAFF a valuable option when
countered. For these reasons, we deem the results encourag-        pharyngeal resurfacing is required to prevent PCF. This flap
ing for patients who must undergo STL after neck irradiation.      might gain popularity over the coming years, becoming a
The main contraindications to SAFF are previous neck dis-          strong point for head and neck reconstructive surgeons.
section with absence of transverse cervical vessel, previ-
ous shoulder surgery and skin cancer of the deltoid region.        References
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