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Page 4 of 8 Hussaini et al. Plast Aesthet Res 2022;9:30 https://dx.doi.org/10.20517/2347-9264.2021.132

lymphatic packet of level IA, there remains a concern that occult disease may inadvertently be transposed
into an oncologically “clean” defect. For this reason, we generally feel that any clinical or radiographic
evidence of deeply invasive tumor or level IA locoregional disease should be a firm contraindication for
proceeding with a SIPF. Sporadic level IB disease is considered a relative contraindication but can be safely
dissected away from the vascular pedicle. Retrospective studies have otherwise demonstrated a high degree
[15]
of oncologic safety when these factors are accounted for .
Another disadvantage in male patients is the persistence of hair-bearing skin in the recipient bed, which can
be both mechanically irritating and aesthetically unfavorable. The use of Nd:YAG laser therapy has shown
to be > 90% efficacious in the treatment of intraoral hair secondary to flaps from hairy donor sites and may
[16]
be an excellent mode of therapy . Furthermore, radiation-induced alopecia from patients undergoing
[17]
adjuvant treatment may also be a welcomed adverse effect in the post-surgical period .

SUPRACLAVICULAR ARTERY ISLAND FLAP
History
[18]
The concept of cutaneous flaps from the shoulder dates back to 1842, as described by Mütter , who made
use of random supply flaps for burn reconstructions. In 1903, the Austrian anatomist, Carl Toldt described
a preserved vessel originating from the thyrocervical trunk exiting between the sternocleidomastoid and
trapezius muscles and named it arteria cervicalis superficialis. From this initial work, the so-called “in
[19]
charretera” flap was developed by Kirschbaum , which provided a viable option for the reconstruction of
chest and neck defects. Later, the flap technique was slightly modified and became known as the
cervicohumeral flap, as popularized by Mathes and Vasconez in the 1970s. Over the next decade, the
[20]
reliability of the flap was challenged, as evidenced by nearly a 40% incidence of distal flap loss, and
investigations were undertaken to better understand the vascular anatomy of the region . In 1979,
[21]
Lamberty described the supraclavicular artery as a distinct, preserved branch of the transverse cervical
[22]
trunk and proposed an axial flap taken from the area superior to the clavicle. Despite his meticulous
descriptions, interest in the flap waned until it was revisited by Pallua et al. , Pallua and Magnus Noah in
[24]
[23]
the 1990s, who formally named it the supraclavicular island flap and described a method for tunneling the
pedicle which reduced the length of the donor site scar and improved distal skin reliability. Following this
body of work, there was renewed interest in the flap, and the first report of it as a method for reconstruction
of head & neck oncologic defects was proposed by Chiu et al. in 2009. For the past decade, the
[25]
supraclavicular artery island flap (SCAIF) has remained a popular option for defects of the lower face, neck,
pharynx, and oral cavity.

Surgical technique and pearls
Adequate perfusion of the supraclavicular artery is paramount to the success of the SCAIF. If there is any
question regarding the integrity of this artery, CT angiography or duplex studies may be performed
preoperatively. Intraoperatively, the location of the supraclavicular artery is routinely found in the triangle
formed anteriorly by the clavicle, medially by the posterior border of the sternocleidomastoid muscle, and
laterally by the external jugular vein. In most cases, the artery will be identified at the middle third of the
clavicle and a doppler ultrasound probe can be used to confirm flow through the vessel. In addition, a
doppler may be used to trace the artery as it courses laterally towards the acromion, where the signal will
fade as it pierces the deep fascia of the deltoid muscle. The skin paddle is then designed with usually a
6-7 cm width and a total length around 20-22 cm from the fulcrum point at the origin of the pedicle.
Additional skin distal to the acromion may be incorporated; however, the deltoid tuberosity is usually
considered the maximum limit of the flap to avoid distal necrosis. The flap is generally raised in a distal to
proximal fashion at the subfascial plane of the deltoid muscle, with special care taken as the acromion is
approached in order to prevent inadvertent injury to the pedicle. In this area, we routinely switch to bipolar