Indications for reconstruction of mucosal defects in oropharyngeal cancer using a supraclavicular island flap

Abstract

The use of the supraclavicular island flap (SCIF) for the reconstruction of facial and neck skin defects is increasing. The value of this fasciocutaneous flap as a reconstructive modality for oropharyngeal defects in cancer patients is unclear. In the present study, a SCIF was used for reconstruction of mucosal defects following resection of the tumour in a group of four patients with T2 squamous cell carcinoma of the oropharynx and a clinical N0 neck. Reconstruction was performed following transoral tumour resection and selective neck dissection at levels I–III in the same session. Intraoperative and postoperative complications were analyzed, and functional and aesthetic results for the neck and shoulder region were evaluated in follow-up examinations. In addition, sensation to the flap was evaluated. No flap failures were observed. Only minor surgical complications were evident, which did not cause any relevant functional or aesthetic impairments. Sensation to the flap was observed in all cases. The SCIF appears to be a good and time-saving alternative to free flaps for oropharyngeal reconstruction following oncological resection in selected patients.

The purpose of oropharyngeal reconstruction is to restore the form and function of the anatomical structures in the oropharynx. While reconstruction of the oropharynx was initially performed to close defects and avoid postoperative complications, functional aspects are now equally relevant. The ability to swallow following surgery and adjuvant or primary radiochemotherapy in patients with oropharyngeal cancer is of high clinical relevance .

Organ preservation protocols in the treatment of squamous cell carcinoma of the oropharynx have been used increasingly in the past few decades, especially with regard to improving functionality. However, radiotherapy can significantly alter the ability to swallow and therefore decrease quality of life . Hence, at early tumour stages, in cases where adjuvant treatment can be spared due to the neck status and tumour characteristics, tumour resection with subsequent reconstructive surgery can lead to even better functionality.

Various surgical techniques for the closure of oropharyngeal defects have been introduced and described in the literature. Microvascular fasciocutaneous flaps such as the radial forearm free flap (RFFF) are used routinely for closure of oropharyngeal defects. The advantage of the RFFF is its reliability and safety in reconstructing oropharyngeal defects using the thin skin of the forearm . However, this procedure requires microvascular anastomoses, which is time-consuming and therefore burdens the often multi-morbid patient with an increased general anaesthesia time. Also, microvascular reconstruction cannot be performed if preoperative evaluation of the vessel status of the forearm shows inadequate supply.

The use of a supraclavicular island flap (SCIF) for reconstruction of facial and neck skin defects is increasing. In recent years, this flap has been used in specialized centres for the reconstruction of mucosal defects in head and neck cancer patients . The few articles available on this subject have mostly described and evaluated the flap healing process. Functional and aesthetic results, as well as indications for the use of this flap in oncology patients, taking into account their neck status, have not been analyzed. Here, we present our initial experience using the SCIF for reconstruction of mucosal defects of the oropharynx in cancer patients.

Patients and methods

Patient characteristics

In the present study, a total of four patients (one female and three males, median age at diagnosis 53.5 years, range 52–67 years) with an oropharyngeal tumour were included retrospectively. All patients had a pT2 squamous cell carcinoma of the oropharynx. In three cases, the tumour was located in the palatine tonsil, and in one case in the base of the tongue. All patients had a clinical N0 neck. Tumour resection was performed transorally using a CO 2 laser in all cases. A selective ipsilateral neck dissection of levels I–III was performed in the same session. The tumour was resected obtaining negative margins in all patients. In one case where a pathological N+ neck was evident, postoperative radiotherapy was performed. All patients had a temporary tracheostomy.

Pharyngeal defect reconstruction

For all patients, the originally planned reconstruction of the mucosal defect using a RFFF could not be performed due to a negative Allen’s test on both sides. Following transoral tumour resection and ipsilateral selective neck dissection, the pharyngeal defect was reconstructed using a SCIF from the ipsilateral side in the same session.

Preoperative diagnostics

A computed tomography (CT) scan of the head and neck was performed preoperatively for all patients. In addition, the neck status was assessed by ultrasound. Preoperative delineation of the supraclavicular artery, which usually had a diameter of 1 mm, was assessed using duplex ultrasound. The origin of the artery was detected approximately 3 cm above the clavicle and around 8.5 cm lateral to the sterno-clavicular joint. The origin of the thyrocervical trunk from the subclavian artery was visualized and then the origin of the transverse cervical artery and ultimately of the supraclavicular artery were identified ( Fig. 1 ).

Fig. 1
The origin of the supraclavicular artery is located in the supraclavicular fossa between the clavicle, external jugular vein, and dorsum of the sternocleidomastoid muscle (A and B). The supraclavicular artery (1) originates from the thyrocervical trunk (2), which is the common origin of the three arteries: inferior thyroid artery (3), ascending cervical artery (4), and the transverse cervical artery (5) (C and D); the omohyoid muscle is resected in D. The supraclavicular artery originates from the thyrocervical trunk approximately 3 cm after the origin of the transverse cervical artery. The vascular pedicle contains the supraclavicular artery and the transverse cervical vein (E and F). The angiosome covered by the supraclavicular artery extends to the deltoid region.

Surgical method

After elevation of the shoulder, the size of the transplant, which usually measured 10–13 cm in length and 5–7 cm in width, was marked on the skin. Two further cervical marks were added for a McFee incision of the neck. Neck dissection and opening of the pharynx were performed through the upper incision. The caudal incision was necessary for preparation of the vascular pedicle in the supraclavicular fossa, and also its mobilization into the upper neck area. For improved wound closure, two triangle-like skin areas were excised. Relevant landmarks such as the expected location of the origin of the vascular pedicle and the cervical incision line were also marked ( Fig. 2 A and B ).

Fig. 2
Marking the location of the transplant on the skin (A and B). To allow a more sufficient preparation of the vascular pedicle, the incision is extended cranially. Two further marks are added for a McFee incision of the neck. To improve subsequent wound closure, two triangle-shaped skin areas are excised. The skin is raised to expose the subcutaneous fatty tissue and the fascia of the deltoid muscle, and this is followed by subcutaneous preparation of the vascular pedicle and mobilization of the flap to reach the oropharynx (C and D).

Prior to harvesting the flap, tumour resection and neck dissection of ipsilateral levels I–III was performed. The subsequent harvesting of the flap was performed from distal to proximal, starting in the mid-deltoid region. A subfascial preparation was first performed. The skin, subcutaneous fatty tissue, and the fascia of the deltoid muscle were elevated en bloc. The fascia of the deltoid muscle was fixed onto the transplant with sutures. Further proximally, subcutaneous preparation of the vascular pedicle up to its origin in the supraclavicular fossa was performed. To avoid damage to the vascular pedicle, it was not skeletonized.

Subsequently, after mobilization of the vascular pedicle and further subcutaneous preparation, the flap was rotated around its vascular pedicle and tunnelled in the subplatysmal plane following a respective incision, to reach the oropharynx ( Fig. 2 C and D). After raising the flap, the skin of the shoulder was mobilized allowing an uncomplicated primary wound closure. Two drainages were placed distally and proximally.

Postoperative care and follow-up

All patients received antibiotic prophylaxis (cephalosporin) for 7 days after surgery. Nutrition was provided via a nasogastric tube for 7 days postoperatively. Surgical and clinical outcomes were evaluated based on the last follow-up visit and patient symptoms. In addition, possible intraoperative and postoperative complications were reviewed. The postoperative follow-up time was at least 6 months for all patients.

Postoperative functional and aesthetic evaluation

Possible injury to the internal jugular vein, the carotid artery, the thoracic duct, and the major neural structures, and the occurrence of significant bleeding were evaluated. Abnormal wound healing, secondary haemorrhage, and neural function (laryngeal nerve, hypoglossal nerve, and the sympathetic trunk) were assessed by clinical inspection and endoscopy in all patients. Postoperative pain in the head, neck, and shoulder was assessed subjectively using a visual rating scale from 0 to 10 (0 no pain, 10 maximum pain). Cosmetic results for the operation scar on the neck and shoulder were evaluated according to the patient’s assessment. Semi-quantitative grading into five levels – excellent, very good, good, fair, and poor – was applied for this purpose. Functional impairment of head, neck, and shoulder mobility was analyzed semi-quantitatively by the patient’s subjective assessment (grading into none, slight, moderate, and intense impairment) and also by clinical measurements. Active arm abduction as well as head rotation and lateral head inclination were measured using a goniometer assessing the range of motion. In all patients, the postoperative ability to swallow and tendency to aspirate were evaluated. In addition, sensation to the flap area was evaluated in comparison to the adjacent normal mucosa of the oropharynx using a tongue blade. Further, the patients were questioned as to whether they could sense food on the reconstructed part of the oropharynx after mastication.

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Jan 19, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Indications for reconstruction of mucosal defects in oropharyngeal cancer using a supraclavicular island flap
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