**Region:** Head and Neck # Supraclavicular Flap ## Anatomy - Pedicle: supraclavicular artery (most commonly a branch of the transverse cervical artery) - Parent vessel: transverse cervical artery (reported diameter 2.5–3.5 mm). - Supraclavicular artery diameter: reported 1.0–1.5 mm. - Origin/location: origin typically found in the supraclavicular fossa; the artery emerges at the middle third of the clavicle in 70–90% of cases. The origin lies within a triangle bounded by the posterior border of the sternocleidomastoid (SCM) medially, the external jugular vein laterally, and the clavicle inferiorly. - Course: penetrates the deep fascia of the deltoid and runs superficially toward the acromioclavicular joint, giving multiple consistent perforators along its route; distal branches anastomose with thoracoacromial, posterior circumflex humeral, and superficial branches of the transverse cervical artery. - Pedicle length/arc: axial pedicle allowing up to 180° rotation for pedicled transfer; recommended safe flap dimensions cited as width 4–12 cm and length 20–30 cm (a commonly used practical sizing is 10 × 20 cm). Flap lengths beyond ~18 cm increase risk of distal ischemia. - Venous drainage: two venae comitantes accompany the artery and most commonly drain into the transverse cervical vein (reported mean diameter 0.22 ± 0.8 cm); the second vein is more variable and may drain into the transverse cervical or externally into the external jugular or subclavian veins (reported mean diameter 0.24 ± 0.07 cm). - Perforator pattern: multiple consistent perforators along the supraclavicular course; distal perfusion is supported by subdermal linking vessels and connections with humeral perforators—directly linked vessels decrease distally after deltoid insertion, explaining distal-tip vulnerability. - Nerves: - Sensory: supraclavicular nerves (C3–C4 dorsal rami branches) supply the flap territory. The anterior cutaneous branch commonly lies ~1–2 cm anterior/posterior to the vascular pedicle and smaller branches (range 2–5) run through the flap and may be preserved for a sensate reconstruction. - Motor: no muscle is routinely harvested; motor nerves are not intentionally included; preserve accessory nerve during medial dissection to avoid trapezius weakness. - Included tissues: - Skin, subcutaneous tissue, superficial fascia (fasciocutaneous flap). - Thickness: relatively thin with minimal bulk and low hair density—suitable for intraoral/oropharyngeal resurfacing. - Arc of rotation: up to 180° as a pedicled flap; reach depends on patient habitus and pedicle dissection length. - Common variants/anomalies: - Supraclavicular artery may arise from the suprascapular artery in a minority of cases. - Venous drainage variable (external jugular or subclavian drainage reported). - Origin position and perforator density vary with anatomy and prior surgery/radiation. ## Dissection Steps 1. Positioning, markings, landmarks. - Position: patient supine; head turned contralateral; ipsilateral shoulder slightly elevated with a bump. For pedicled supraclavicular cutaneous flap an abducted ipsilateral arm may be used to improve exposure. - Landmarks to mark: clavicle, posterior border of SCM, external jugular vein, supraclavicular fossa triangle, path of the supraclavicular artery traced toward the acromion with a handheld Doppler. Mark intended skin paddle centered over Doppler signal. - Typical Doppler/marking targets: - Pedicle origin located within triangle (SCM posterior border / EJV / clavicle). - For supraclavicular cutaneous pedicled flap the main pedicle commonly lies ~2 cm posterior to the posterior border of the clavicle. 2. Plane (suprafascial/subfascial), perforator identification (handheld/IO Doppler). - Elevation plane: raise flap in a lateral-to-medial subfascial plane over deltoid, trapezius and SCM; remain above clavicular periosteum anteriorly. - Dissection technique: - Distal two-thirds may be elevated with monopolar cautery. - Switch to sharp dissection or bipolar cautery on approach to the proximal one-third/medial pedicle to avoid thermal injury. - Perforator identification: preoperative Doppler mapping of perforators and tracing toward acromion; identify pulsatile pedicle as you approach medial flap margin. 3. Pedicle dissection: exposure, control, division; transfer/inset; perfusion checks. - Lateral→medial harvest: - Elevate distal flap first, proceed medially toward the pedicle in a controlled subfascial plane. - Preserve perivascular fat; routine skeletonization of the pedicle is unnecessary and discouraged unless extra length is required. - When pedicle encountered, complete proximal incision to free flap and allow rotation. - Gaining length: - Limited skeletonization or proximal dissection to origin of transverse cervical or subclavian can increase length when required. - In pedicled supraclavicular cutaneous flap, division of the thin white investing fascia around the pedicle increases available length. - Deepithelialization/tunneling: - If tunneling under skin bridge, deepithelialize proximal portion after the pedicle is identified, preserving the subdermal venous plexus. - Create a wide tunnel to avoid pedicle compression. - Transfer/inset: - Rotate flap (up to 180°) into defect; shape and suture into place. - Intraoperative perfusion checks: handheld Doppler over pedicle; confirm brisk distal tip bleeding before inset; trim distal tip until adequate bleeding if needed. - Consider supercharging (microvascular augmentation) to posterior circumflex humeral artery or other local vessel when very large/extended flaps or tenuous perfusion are anticipated. 4. Donor-site closure techniques. - Undermine pectoralis major anteriorly and trapezius posteriorly to facilitate primary closure. - Primary closure usually possible for AP donor defects up to ~10 cm; the perforator chapter notes donor sites up to 10 cm can generally be closed primarily. - If primary closure not possible: split-thickness skin graft or local flap; place closed-suction drain to prevent seroma/hematoma. ## Indications and Contraindications - Indications: - Cervical burn contractures and mentosternal contracture release. - Oncologic resurfacing of lower one-third of face and neck (cutaneous and cervicofacial defects). - Intraoral/oropharyngeal lining: glossectomy, pharyngeal and circumferential oropharyngeal reconstruction (tracheostomal defects, pharyngeal/oesophageal lining). - Skull-base/postauricular defects and coverage of complex lateral neck defects (pedicled or tunneled applications). - Salvage option when free flaps are unsuitable or in vessel-depleted necks. - Sensate reconstruction when supraclavicular nerves preserved (pedicled variant). - Practical flap sizing: up to about 6–10 × 20–30 cm reported; 10 × 20 cm commonly used. - Contraindications (absolute/relative reported in source texts): - Prior radical neck dissection that has sacrificed the transverse cervical vascular tree. - Prior radiation injury to the cervical/shoulder region that compromises pedicle or tissue mobility. - Absent Doppler signals or unfavorable CTA mapping (inconclusive patency). - Local infection or scarring that precludes safe tunneling or pedicle preservation. ## Postoperative Care - Monitoring schedule/method: - Frequent clinical checks of flap color, capillary refill and bleeding from distal tip in early postoperative period. - Handheld Doppler over the pedicle for immediate and serial checks. - Routine use of a closed-suction drain at donor site to prevent seroma/hematoma. - Warming/antithrombotic practice: - Standard warming and limb positioning to avoid compression of pedicle; specific antithrombotic protocols not specified in the cited sources. - Positioning/splinting: - Avoid tight dressings/tunnels; keep neck/shoulder positioned to limit pedicle tension or kinking. - Drains, mobilization, diet/analgesia: - Closed-suction drain in donor site; early shoulder range-of-motion exercises as tolerated; analgesia and wound care per routine head-and-neck protocols. - Return-to-OR thresholds and time windows: - Urgent return to OR for suspected pedicle injury or progressive ischemia/venous congestion. - Early re-exploration advised when pedicle compromise is suspected (clinical signs, loss of Doppler signal, progressive congestion), since full-thickness necrosis may require operative intervention. Superficial distal necrosis often managed nonoperatively but should be followed closely. ## Complications (rates & management) - Distal superficial necrosis: - Reported incidence: 4–22%. - Typical presentation: superficial tip necrosis or venous congestion, more common with flap lengths >18 cm, tight tunnels, compression, irradiated tissue or hematoma/seroma. - Management: local wound care/dressings; most superficial defects re-epithelialize without reoperation. - Full-thickness flap loss: - Reported incidence: 2–6% (reported as full-thickness necrosis usually due to pedicle injury). - Management: urgent operative exploration for salvage or debridement/removal if unsalvageable. - Venous congestion / arterial compromise: - Presentation: early congestion or loss of Doppler signal. - Management steps (as described in sources): release compressive dressings or tunnel, remove constriction, return to OR for exploration if persistent; consider supercharging or microvascular augmentation if planned/available. - Seroma / hematoma: - Seroma incidence reported up to 15%. - Management: aspiration/drainage; place or reinsert closed-suction drain if needed; address hematoma promptly to prevent flap compromise. - Donor-site issues: - Primary closure failure/dehiscence for defects >10 cm anteroposterior likely; management includes debridement, negative-pressure wound therapy, skin grafting. - Shoulder morbidity: minimal; shoulder pain usually mild; up to 20% reported referred sensation to shoulder region; frank motor deficit (trapezius dysfunction) possible if accessory nerve injured—avoid medial dissection injury. - Sensory changes: - Referred sensation to shoulder in up to 20% of patients; preservation or selective ligation of supraclavicular sensory branches may modify this outcome. - Management algorithms (summarized from sources): - Suspected compression/venous congestion: immediately check and release tunnel/dressings, assess distal bleeding, apply topical measures; if unresolved → take to OR for exploration. - Suspected pedicle injury/arterial thrombosis or absent Doppler signal: urgent re-exploration. - Superficial tip necrosis: conservative care with dressings; debridement if non-healing. - Seroma: aspiration or drain placement; hematoma: operative evacuation if contributing to compromise. ## Key Clinical Pearls - Map and mark the pedicle preoperatively with handheld Doppler; the supraclavicular pedicle origin lies in the supraclavicular triangle (SCM posterior border / external jugular vein / clavicle) and commonly emerges at the middle third of the clavicle (70–90% of cases). - Respect the proximal third: use sharp dissection or bipolar cautery as you approach the pedicle; avoid monopolar cautery near the pedicle to reduce thermal injury. - Preserve perivascular fat and avoid routine skeletonization of the pedicle; skeletonize only when additional length is absolutely required. - Create a wide tunnel for tunneled inset and deepithelialize the proximal flap only after pedicle identification; narrow tunnels and compression are leading causes of venous congestion and distal necrosis. - Check brisk distal bleeding before inset and trim the tip until bleeding is reliable; this reduces distal-tip necrosis. - Safe practical sizing: plan within the recommended window (width 4–12 cm, length 20–30 cm; commonly 10 × 20 cm); be wary of pushing length beyond ~18 cm without augmentation. - Preserve the anterior supraclavicular sensory branch (~1–2 cm anterior to the vessel) if a sensate flap is desired. - If very large flaps or doubtful perfusion anticipated, plan for microvascular supercharging (posterior circumflex humeral or other local artery) rather than excessive skeletonization.