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.