Application of Bilateral Supraclavicular Artery Island Flaps in the Repair of Hypopharyngeal and Cervical Skin Defects: A Case Report
In the field of head and neck surgery, the management of advanced malignancies presents significant challenges, particularly in cases where tumors recur after comprehensive treatments such as surgery or radiotherapy. These recurrent tumors often invade both the mucosa and skin, creating complex defects that require meticulous reconstruction. The primary goals of such reconstructions are twofold: first, to restore the digestive tract and ensure the patient’s ability to swallow, and second, to rebuild the skin and soft tissue of the neck to protect vital structures. This case report details the successful application of bilateral supraclavicular artery island flaps in the repair of extensive hypopharyngeal and cervical skin defects in a patient with advanced laryngeal cancer.
The patient, a 66-year-old male, had been diagnosed with laryngeal cancer (T2N0M0) six years prior to the current presentation. He underwent a vertical partial laryngectomy followed by radiotherapy (60 Gy/33F) and was regularly monitored. However, three months before admission, he developed redness and swelling on the anterior neck, accompanied by difficulty eating and dyspnea. His condition progressively worsened, necessitating an emergency tracheotomy. Clinical examination revealed swelling, skin ulceration, and a ruptured area measuring approximately 2 cm × 1 cm in the anterior neck. Laryngoscopy identified scar-like changes in the glottis, immobility of the left hemilarynx, and edema of the mucosa. Neck imaging confirmed the presence of irregular soft-tissue masses in the laryngopharyngeal cavity, measuring approximately 4.9 cm × 3.6 cm, with involvement of the anterior neck skin, left cervical sheath, sternocleidomastoid muscle, and thyroid cartilage plate. Pathologic examination of the cervical ulcer confirmed squamous cell carcinoma.
Given the patient’s history of surgery and radiotherapy, the surgical team opted for a local tissue flap repair strategy. The surgical plan included resection of the affected neck skin with a 2 cm safety margin, total laryngectomy, hypopharyngeal wall resection (with a mucosal margin of 0.5–1 cm), cervical lymph node dissection, and tracheostomy. Intraoperative rapid pathologic examination confirmed negative surgical margins and the absence of tumor metastasis in the bilateral IV and V lymph nodes. The supraclavicular blood vessels were found to be well-developed, making them suitable for flap reconstruction.
For the repair of mucosal and skin defects, bilateral supraclavicular artery island flaps were designed. The left flap, measuring 7 cm × 4 cm, was sutured to the posterior wall of the hypopharynx to address the mucosal defect. The right flap, measuring 10 cm × 7 cm, was used to repair the anterior cervical skin defect. The donor sites were closed directly without the need for skin grafting. Postoperative pathologic examination confirmed highly differentiated squamous cell carcinoma with negative margins and no lymph node metastasis. The final diagnosis was recurrent laryngeal carcinoma (rT4aN0M0).
The postoperative course was uneventful, with the wound healing well and no signs of infection, swelling, or pharyngeal fistula. The patient resumed oral feeding on the 12th postoperative day and achieved a normal diet one month later. Esophageal angiography confirmed the absence of stenosis, and neck magnetic resonance imaging six months postoperatively showed no significant flap atrophy.
The use of bilateral supraclavicular artery island flaps in this case highlights their advantages in repairing complex head and neck defects. These flaps are particularly beneficial in patients with a history of radiotherapy, where free flap transplantation may be challenging due to compromised vascular pedicles. The supraclavicular artery island flap, derived from branches of the transverse carotid artery, was first described by Pallua et al. in 1997 and has since gained popularity in plastic and reconstructive surgery. Its advantages include a thin and flexible structure, ease of shaping, and the ability to close the donor site without affecting shoulder function. Additionally, the flap can be harvested without the need for microvascular anastomosis, making it a simpler and safer option for elderly patients or those with comorbidities.
However, the use of supraclavicular artery flaps is not without limitations. In cases where the supraclavicular area has been included in the radiotherapy field, the microcirculation of the flap may be compromised, necessitating careful preoperative evaluation. Intraoperative assessment of the cervical lymph nodes is also crucial to ensure the absence of tumor metastasis before proceeding with flap reconstruction.
This case underscores the importance of selecting appropriate reconstruction techniques for complex head and neck defects, particularly in patients with a history of surgery and radiotherapy. The bilateral supraclavicular artery island flap offers a safe, effective, and straightforward solution for repairing penetrating defects of the pharyngeal mucosa and neck skin, with satisfactory functional and aesthetic outcomes.
doi.org/10.1097/CM9.0000000000000831
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