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Hussaini et al. Plast Aesthet Res 2022;9:30 https://dx.doi.org/10.20517/2347-9264.2021.132 Page 5 of 8

cautery to facilitate meticulous dissection. Anteriorly, the flap is raised to the clavicle, where the clavicular
periosteum may be harvested to further protect the pedicle. Posteriorly, the flap is raised to the anterior
border of the trapezius, where branches of the spinal accessory may be encountered. Generally, it is
preferred to avoid excessive skeletonization of the pedicle; however, level V adipose and nodal tissue may be
dissected if a longer arc of rotation and reach is needed. If the flap is to be tunneled, the proximal skin
paddle must be de-epithelized. Prior to inset, the distal edge of the flap is judiciously trimmed to ensure
adequate perfusion. After the flap has been transposed and tunneled into the defect to be reconstructed, the
donor-site defect is widely undermined in order to facilitate tension-free primary closure. Typically a single
drain is placed into the donor site bed to prevent hematoma and seroma formation.

Pitfalls
Overall, the SCAIF is a versatile, reliable locoregional flap that can be easily tailored to address a variety of
oncologic defects. Despite these characteristics, there are a few limitations to its utility. First, given that the
flap is often relatively far from its area of inset, efforts to elongate the cutaneous paddle increase the risk of
[26]
distal flap necrosis. In a retrospective case series of 45 patients, Kokot et al. reported that a total flap
length greater than 22 cm was correlated with flap necrosis. Similar findings are also reported in studies
evaluating the SCAIF for post-burn neck reconstruction . In addition to a maximal length of a flap that
[27]
may be harvested, another important consideration is the feasibility of flap harvest in the setting of a level V
lymph node dissection. Surgery in this area has the potential to disrupt the vascular pedicle supplying the
flap. However, this challenge may be overcome by meticulous dissection. Furthermore, a history of
radiation to the cervical region in the setting of salvage surgery has the possibility of both disrupting the
vascularity of the flap, as well increasing the technical difficulty of harvesting the flap secondary to
[25]
radiation-induced fibrosis .

OUTCOMES COMPARED TO FREE TISSUE TRANSFER
Renewed interest in LRPF has led to increased investigations into its utility and functional outcomes
compared to FTT. A number of recent studies have challenged the traditional notion that more intricate,
complex reconstruction with FTT is required to achieve the best functional outcomes.

A recent retrospective study by Kozin et al. directly compared the SCAIF and FTT for a variety of head
[28]
and neck defects and found that the former offered decreased total operative time, length of hospitalization,
and cost, with comparable rates of wound healing and post-operative complications, including wound
infections, dehiscence, and hematoma. In addition, Zhang et al. compared functional outcomes between
[29]
the SCAIF and radial forearm flap (RFFF) for hemiglossectomy defects and found no significant differences
in post-operative speech and swallow function at six months. Additionally, the SCAIF group was noted to
have a significantly lower rate of donor-site complications with a reduced length of hospitalization.

Similar investigations have been undertaken for the SIPF. A recent meta-analysis by Jørgensen et al.
[30]
compared the SIPF to the RFFF and anterolateral thigh flap and found no significant difference between the
groups in terms of complete flap loss and need for debulking procedures. Of note, total operative time and
length of hospitalization were found to be significantly lower. Furthermore, there was no difference in local,
regional, and distance recurrence of tumor, highlighting the oncologic safety of transposing tissue from the
[30]
level I region . Finally, much like the SCAIF, studies have demonstrated comparable speech and swallow
outcomes between the SIPF and FTT [31,32] .