Oral Cancer Reconstruction Using the

Supraclavicular Artery Island Flap:

Comparison to Free Radial
Forearm Flap
Christian Welz, MD,* Martin Canis, MD,y Sabina Schwenk-Zieger,z
Jennifer L. Spiegel, MD,x Bernhard G. Weiss, MD,k and Yiannis Pilavakis, MD,{
Purpose: To evaluate whether the pedicled supraclavicular artery island flap (SCAIF) is a sufficient alter-
native to the fasciocutaneous radial forearm free flap (RFFF) for oral reconstruction in cancer surgery.
Patients and Methods: The authors designed and implemented a retrospective cohort study composed
of all consecutive patients who underwent head and neck reconstruction after cancer surgery at their ter-
tiary university hospital from 2013 to 2016. Demographics and peri- and postoperative information were
recorded and statistically analyzed.
Results: Of 83 patients who underwent head and neck reconstruction after cancer, 50 were identified as
having stage III or IV squamous cell carcinoma of the oral cavity and oropharynx and underwent surgery
and reconstruction with the SCAIF (n = 25) or the RFFF (n = 25). Total surgery time (411.0 vs 576.4 mi-
nutes; P < .001), flap elevation time (39.00 vs 93.78 minutes; P < .001), need for intensive care observation
(32 vs 96%; P < .05), and rate of tracheotomy (64 vs 88%; P < .05) were significantly lower in the SCAIF
group. There was no statistical difference in the postoperative complication rate or postoperative func-
tional swallowing ability between the 2 groups. Total perioperative costs were significantly lower in
patients who underwent reconstruction with the SCAIF (2,621.15 vs 4,453.77V; P < .01).
Conclusion: The results of this study suggest that the SCAIF is a straightforward and reliable flap with
shorter operative times and comparable outcomes compared with the RFFF.
Ó 2017 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 75:2261-2269, 2017

Previously, reconstruction of the oral cavity and more and more relevant and at least equivalent. In
oropharynx after extensive cancer surgery aimed to the past decade, the fasciocutaneous radial forearm
reconstruct anatomic defects and decrease postopera- free flap (RFFF) has enabled the resection and func-
tive complications. Currently, functional aspects are tional reconstruction of previously inoperable oral

*Assistant Medical Director and Senior Physician, Department of Bernhard G. Weiß and Yiannis Pilavakis contributed equally to
Otorhinolaryngology, Head and Neck Surgery, Georg August this work.
University, Goettingen, Germany. Conflict of Interest Disclosures: None of the authors have any
yProfessor and Head, Department of Otorhinolaryngology, Head relevant financial relationship(s) with a commercial interest.
and Neck Surgery, Georg August University, Goettingen, Germany. Address correspondence and reprint requests to Dr Welz:
zMedical-Technical Assistant, Department of Otorhinolaryngology, Department of Otorhinolaryngology, Head and Neck Surgery, Georg
Head and Neck Surgery, Ludwig Maximilians University, Munich, August University, Robert Koch Strasse 40, Goettingen 37075,
Germany. Germany; e-mail: [email protected]
xResident, Department of Otorhinolaryngology, Head and Neck Received December 15 2016
Surgery, Georg August University, Goettingen, Germany. Accepted February 19 2017
kResident, Department of Otorhinolaryngology, Head and Neck Ó 2017 American Association of Oral and Maxillofacial Surgeons
Surgery, Georg August University, Goettingen, Germany. 0278-2391/17/30226-4
{Resident, Department of Otorhinolaryngology, Head and Neck http://dx.doi.org/10.1016/j.joms.2017.02.017
Surgery, Georg August University, Goettingen, Germany.

2261
2262 SCAIF VS RFFF FOR ORAL CANCER RECONSTRUCTION

tumors with good functional outcomes and has Patients and Methods
become the new workhorse flap in the reconstruction
of mucosal defects of the head and neck.1-3 PATIENTS AND DATA COLLECTION
One of the challenges of free flap reconstruction is The authors retrospectively reviewed the medical
that it requires specialized centers and reconstructive records of all consecutive patients who underwent
surgeons with microvascular training. It involves a reconstruction of the head and neck region with the
long operative time and more complex postoperative SCAIF (n = 51) or RFFF (n = 32) at their institution
monitoring. In the current era of health care cost from January 2013 through June 2016. Inclusion
containment, greater emphasis is placed on efficiency, criteria for this study were stage III or IV squamous
improving postoperative outcomes, and lowering cancer of the oral cavity or oropharynx and surgery
overall costs. Because of a demographic shift, patients with a primarily curative intent. Patients under pallia-
requiring reconstructive surgery are older with more tive care and after salvage surgery were excluded
comorbidities and poor vessel status. This makes from this study. Patients with recurrent or second pri-
them suboptimal candidates for oral reconstruction mary disease or patients who previously underwent ra-
by a microvascular anastomosed RFFF. Taking these diation therapy in the head and neck region were
factors into account, axial pedicled regional flaps included. In total, 50 patients with squamous cancer
could be preferred to free flaps in a large proportion of the oral cavity or oropharynx who underwent can-
of patients because they have a short harvest time cer surgery and mucosal reconstruction, with inciden-
and do not require microvascular anastomosis. Never- tally equivalent-size cohorts (SCAIF, n = 25; RFFF,
theless, the established pedicled flaps in head and neck n = 25), at the Department of Otorhinolaryngology,
reconstruction, such as the latissimus dorsi or pector- Head and Neck Surgery, Georg August University
alis major myocutaneous flap, are not suitable for (Goettingen, Germany) were included.
reconstruction of most oropharyngeal regions. The All procedures performed in studies involving
bulkiness and inflexibility of these flaps make them human participants were in accordance with the
inferior to the RFFF or other free flaps. The supraclavic- ethical standards of the institutional or national
ular artery island flap (SCAIF) seems to combine the research committee and with the 1964 Declaration
flexibility and volume of an RFFF with the time- and of Helsinki and its amendments or comparable ethical
comorbidity-decreasing benefits of a pedicled flap. standards. The institutional ehtics committee of the
The SCAIF is not a new flap, but its anatomy and University Medical Center of Goettingen approved
blood supply were much better understood in 1979 this retrospective study (number 22/8/15). For this
when Lamberty4 first described it as an axial pedicled type of study, formal consent is not required.
flap. It was rarely used during the 1980s and 1990s Only 2 surgeons (C.W. and M.C.) performed the can-
because of a reported high incidence of necrosis and cer surgery and reconstruction procedure. These sur-
poor reliability.5 The interest in its use was revived af- geons are trained and experienced microvascular
ter Pallua et al6,7 reported on several successful cases surgeons and frequently perform pedicled and free
of reconstruction of cervicomental scar contractures. flap procedures. For the SCAIF flap elevation proced-
Since then, several studies have reported on the ure, the technique was performed as described by
SCAIF as a reliable flap with good postoperative Granzow et al.14 The authors routinely use intraopera-
healing capacity when used in oncologic tive Doppler guidance to find and mark the supracla-
reconstructive surgery and have indicated very good vicular artery. After measuring the pharyngeal
postoperative functional results.8-11 More recently, surface that has to be reconstructed and the pedicle
investigators have even challenged the supremacy of length, the flap is elevated distally to proximally and
the RFFF by reporting equivalent or improved rotated into the pharynx and the required epithelial
outcomes with lower perioperative costs.12,13 part is marked. The pedicle is de-epithelialized and
At their institution, the authors have been using the the flap is adapted by absorbable sutures. For all pa-
SCAIF for defects, including the oral cavity and tients included in this study, and as a standard in the
oropharynx, since 2014 with excellent results. During authors’ institution, all SCAIF donor sites were closed
this time, they have identified the advantages offered primarily and covered with a pressure dressing for at
by this flap. To objectively quantify all the advantages, least 1 week. In contrast, RFFF donor sites were
they directly compared outcomes of reconstructions routinely closed by a mashed split-thickness skin graft
performed with the SCAIF and RFFF that have taken from the anterior thigh and underwent vacuum-
place at their institution. Thus, the authors hypothe- assisted therapy for 8 days. Postoperatively, all patients
sized that shorter operative times and stays in the received nutrition through a nasogastric tube for
intensive care unit (ICU) would lower perioperative 10 days. Only after inconspicuous barium swallow
costs and result in the same or even better postopera- was the nasogastric tube removed and then an oral
tive outcomes. diet was initiated.
WELZ ET AL 2263

Table 1. PATIENT DEMOGRAPHICS AND HISTORY

Variable SCAIF (n = 25) RFFF (n = 25) P Value

Age (yr), mean  SD 68.9  10.6 61.5  7.1 .01

Gender, n (%)
Men 19 (76) 22 (88) .274
Women 6 (24) 3 (12)
Follow-up (mo), mean  SD 6.9  6.6 22.8  19.4
Previous HNSCC, n (%) 2 (8) 2 (8)
Previous CRT, n (%) 2 (8) 0 (0)
pTNM, n (%)
T2 4 (16) 2 (8) .848
T3 16 (64) 19 (76)
T4 5 (20) 4 (16)
N0 8 (32) 6 (24) .496
N1 1 (4) 8 (32)
N2 15 (60) 10 (40)
N3 1 (4) 1 (4)
UICC stage, n (%)
III 8 (32) 12 (48) >.05
IV 17 (68) 13 (54)
Abbreviations: CRT, chemoradiation; HNSCC, head and neck squamous cell carcinoma; RFFF, radial forearm free flap; SCAIF,
supraclavicular artery island flap; SD, standard deviation; UICC, Union for International Cancer Control.
Welz et al. SCAIF vs RFFF for Oral Cancer Reconstruction. J Oral Maxillofac Surg 2017.

Medical records and computer-based documenta- necronectomy, microvascular revisions, and total flap
tions were used for data collection. Demographic loss (TFL). Donor site complications involved the
data, history of head and neck cancer, previous chemo- shoulder for patients receiving the SCAIF or the radial
radiation, and TNM classification were recorded for forearm for patients receiving the RFFF. Functional
each patient (Table 1). Despite advanced tumor stag- data were collected for all patients, including postop-
ing with spread in different areas of the oropharynx erative barium swallow test results.
and oral cavity, primary tumor localization was subdi-
vided (Table 2). COST ANALYSIS
All perioperative data, including flap size, per-
formed tracheotomy, operating room times, and For cost analysis, only costs associated with the
length of ICU stay, were recorded and compared be- operative procedure and the postoperative ICU stay
tween the 2 groups. For analysis, preoperative workup were included (ie, perioperative costs). Other costs,
time (defined as time from operating room entrance to such as intraoperative materials, intraoperative and
incision), total surgery time (defined as time from inci- postoperative pathology and pathologists, normal
sion until leaving the operating room), flap procedure ward stay, and adjuvant therapy, were excluded
time (estimated time from beginning with elevation to because they were almost identical and thus did
wound closure), and harvesting time (estimated time not influence the statistical comparison. Personal
of flap elevation) were noted by the nursing stuff
and were transferred to the medical record. ICU stay
Table 2. TUMOR LOCALIZATION
was documented in an institutional database.
Postoperative information, including recipient site Localization SCAIF, n (%) RFFF, n (%)
complications, donor site complications, length of
stay, and follow-up, were extracted from medical re- Tonsil, soft palate, pharynx 11 (44) 9 (36)
cords. The authors distinguished minor complica- Tongue base, tongue body 7 (28) 7 (28)
tions, which included every complication that could Lateral edge of tongue 7 (28) 9 (36)
be managed conservatively, from major complications, Total 25 (100) 25 (100)
which required an operative intervention. Minor com- Abbreviations: RFFF, radial forearm free flap; SCAIF, supracla-
plications included small flap dehiscences, small vicular artery island flap.
fistulas, and partial necrosis (<30% of volume). Welz et al. SCAIF vs RFFF for Oral Cancer Reconstruction. J Oral
Major complications included partial necrosis with Maxillofac Surg 2017.
2264 SCAIF VS RFFF FOR ORAL CANCER RECONSTRUCTION

Table 3. TEAMS AND COST CALCULATIONS

Type of Reconstruction Medical Professionals n Wage/hr (V) Costs/hr (V)

SCAIF
(Flap) surgeon 1 41.80
Surgeon (resident) 1 26.41
Nurse (OP) 2 21.51
Anesthesiologist (ANA) 1 26.41
Nurse (ANA) 1 12.25
/ 128.40
RFFF
Total surgery time (Flap) surgeon 1 41.80
Surgeon (resident) 1 26.41
Nurse (OP) 2 21.51
Anesthesiologist (ANA) 1 26.41
Nurse (ANA) 1 12.25
/ 128.4
Flap procedure time (Flap) surgeon 1 41.80
Surgeon (resident) 1 26.41
Nurse (OP) 1 21.51
/ 89.72
Abbreviations: ANA, anesthesiology; OP, operating room nurse; RFFF, radial forearm free flap; SCAIF, supraclavicular artery
island flap.
Welz et al. SCAIF vs RFFF for Oral Cancer Reconstruction. J Oral Maxillofac Surg 2017.

costs were calculated after identifying the average or RFFF were performed by the first author (C.W.)
hourly wage of every medical professional taking and co-author (M.C.). After applying the inclusion
part in the procedure (consultants, residents, and criteria over this 3-year period, 50 patients with
nurses). Depending on the procedure, different advanced head and neck squamous cell carcinoma
personnel were needed intraoperatively. There were (HNSSC) of the oral cavity or oropharynx who under-
different teams for the SCAIF and RFFF operations, went reconstruction using the SCAIF (n = 25) or RFFF
which were included in the overall calculation. (n = 25) were identified. Follow-up time ranged from
Teams and average hourly wages are presented in
Table 3. The institutional accounts department calcu-
lated the costs for an ICU stay at 65.50V per hour,
which was multiplied by the recorded stay in hours
of each patient.

STATISTICAL ANALYSIS
Statistical analysis was performed using SPSS 23
(IBM GmbH, Ehningen, Germany). Before comparing
the SCAIF and RFFF groups, all parameters and vari-
ables were tested for normal distribution by the
Kolmogorov-Smirnov goodness-of-fit test. Equality of
variances was assessed by the Levene test. Depending
on these results, differences between the 2 groups
were tested by performing the unpaired 2-sided Stu-
dent t test or the nonparametric Mann-Whitney U
FIGURE 1. Comparison of total surgery time and flap procedure
test. Differences were considered significant at time. Standard boxplots (lower quartile, median, upper quartile)
P values less than .05 before statistical analysis. are used to illustrate the results in the SCAIF group (total surgery
time, n = 25; flap procedure time, n = 14) and the RFFF group
(n = 25). Dots denote mild statistical outliers (interquartile range,
Results 1.5 to 3 times). RFFF, radial forearm free flap; SCAIF, supraclavicu-
lar artery island flap.
From January 2013 through June 2016, 83 consec- Welz et al. SCAIF vs RFFF for Oral Cancer Reconstruction. J Oral
utive head and neck reconstructions with the SCAIF Maxillofac Surg 2017.
WELZ ET AL 2265

chemoradiotherapy. Tumor localization (Table 2) and

distribution of pTNM classification were well
balanced between the cohorts and did not differ
significantly (P = .848 for tumor stage; P = .496
for nodal stage).

PERIOPERATIVE DATA
Analysis showed that the rate of tracheotomy was
significantly lower for the SCAIF group versus the
RFFF group (64 vs 88%; P < .05). Total surgery time
was significantly shorter in the SCAIF group (411.0
vs 576.4 minutes; P < .001; Fig 1). Flap procedure
time for the SCAIF was 122.0  21.4 minutes
(mean  standard deviation; n = 14), and performing
FIGURE 2. Flap elevation time (minutes). Standard boxplots (lower the RFFF took 409.2  83.20 minutes (n = 25). There
quartile, median, upper quartile) are used to illustrate the results. was a marked statistically significant difference when
Mean elevation times were 39.0  10.00 minutes for the SCAIF comparing these durations (P < .001). Flap elevation
and 93.78  28.6 minutes for the RFFF. RFFF, radial forearm free
flap; SCAIF, supraclavicular artery island flap. P <.001 time also showed a marked statistically significant dif-
ference (P < .001). Mean SCAIF elevation time was
Welz et al. SCAIF vs RFFF for Oral Cancer Reconstruction. J Oral
Maxillofac Surg 2017. 39.00  10.00 minutes and mean RFFF elevation
time was 93.78  28.6 minutes (Fig 2, Table 4).
In addition to operation times, the need for an ICU
10 days to 13 months (6.0  6.9 months) in the stay and length of ICU stay were compared between
SCAIF group and from 3.4 months to 3.5 years the 2 groups. Eight of 25 patients in the SCAIF group
(22.8  19.4 months) in the RFFF group. required ICU monitoring postoperatively compared
with 24 patients (96%) in the RFFF group (P < .001;
PATIENT DEMOGRAPHICS AND HISTORY Table 4). When ICU observation was necessary post-
Analysis of patient demographics and history operatively, the length of stay was significantly shorter
(Table 1) showed a notable age difference between in the SCAIF group compared with the RFFF group
the 2 cohorts. The mean age of patients in the SCAIF (24.3  61.2 vs 36.8  26.5 hours; P < .05).
group was 68.9 years and that in the RFFF group
was 61.5 years (P < .05). There was a male predom- POSTOPERATIVE DATA
inance in the 2 cohorts and no statistical difference Statistical analysis of overall complications of the
between them (76% of SCAIF group vs 88% of RFFF recipient site between the 2 groups showed no signif-
group; P = .274). A history of HNSCC (local recur- icant difference (P = .547). Seven patients in the SCAIF
rence) was recorded in 8% of cases in the 2 groups. group and 8 patients in the RFFF group developed
In the SCAIF cohort, 2 patients (8%) had a history of complications at the recipient site.

Table 4. PERIOPERATIVE DATA

Variable SCAIF (n = 25) RFFF (n = 25) P Value

Tracheotomy, n (%) 16 (64) 22 (88) <.05

Minimum operation time, mean  SD
Preoperative workup 61.6  23.5 58.4  17.6 .12
Total surgery time 411.0  119.05 576.4  144.17 <.001
Flap procedure time 122.0  21.4* 409.2  83.20 <.001
Elevation time 39.00  10.00* 93.78  28.6 <.001
ICU stay—yes, n (%) 8 (32) 24 (96) <.001
ICU stay (hr), mean  SD 24.3  61.2 36.8  26.5 <.05
Flap size (cm2), mean  SD 26.5  5.6 34.0  9.8

Abbreviations: ICU, intensive care unit; RFFF, radial forearm free flap; SCAIF, supraclavicular artery island flap; SD, standard
deviation.
* n = 14.
Welz et al. SCAIF vs RFFF for Oral Cancer Reconstruction. J Oral Maxillofac Surg 2017.
2266 SCAIF VS RFFF FOR ORAL CANCER RECONSTRUCTION

Table 5. FREQUENCY OF POSTOPERATIVE COMPLICATIONS

Variable SCAIF (n = 25), n (%) RFFF (n = 25), n (%) P Value

Complications at recipient site 7 (28) 8 (32) .547

Minor 4 (16) 1 (4) <.05
Major/total flap loss 3 (12)/1 (4) 7 (28)/3 (12) <.05
Complications at donor site 10 (40) 10 (40) .708
Minor 8 (32) 8 (32)
Major 2 (8) 2 (8)
Abbreviations: RFFF, radial forearm free flap; SCAIF, supraclavicular artery island flap.
Welz et al. SCAIF vs RFFF for Oral Cancer Reconstruction. J Oral Maxillofac Surg 2017.

When major and minor complications were FUNCTIONAL POSTOPERATIVE DATA

compared separately, patients with SCAIF reconstruc- A barium swallow was routinely used 2 weeks after
tion showed significantly fewer major complications the operation to assess the functional ability of pa-
but significantly more minor complications tients. Four patients (16%) in the RFFF group and 6
(P < .05; Table 5). (24%) in the SCAIF group showed a tendency to aspi-
The most frequent minor complication in the SCAIF rate. There was no statistical difference between the
group was a fistula (n = 3) detected by barium swallow, 2 groups (P = .63). These patients were supported
which was routinely performed on postoperative day with regular swallowing therapy after discharge.
10. In the RFFF group, 3 TFLs (12%) were recorded,
whereas 1 TFL (4%) occurred in the SCAIF group.
Two of 25 patients (8%) in the SCAIF cohort developed COST ANALYSIS
partial flap necrosis (PFN), which required necronec- As described in the Patients and Methods section,
tomy under total anesthesia. different teams of surgeons and nurses were needed
For complications of the donor site, the overall com- for the SCAIF and RFFF procedures (Table 3), and costs
parison and the comparison of major and minor compli- for 1 hour of SCAIF reconstruction were estimated at
cations showed no statistically significant difference 128.40V. For RFFF operations, 128.4 plus 89.72V
(P = .708). In the SCAIF group, 2 patients (8%) developed per hour during the flap procedures was included in
a major complication. These 2 patients had impaired the personal cost calculations. In summary, mean total
wound healing with dehiscence at the critical acromial personal costs for each operation were
shoulder region. In these cases 3 months after primary 1,026.58  303.54V in the SCAIF group versus
surgery, a small rotational skin flap was successfully per- 2,044.76  463.69V in the RFFF group. Statistical anal-
formed. Table 6 lists all complications of the recipient ysis (Fig 3) showed a marked significant difference
and donor sites by name and frequency. Mean length (P < .001). Total perioperative costs (personal costs
of hospital stay in the 2 groups was 28 days and did plus ICU costs) for 1 patient of the SCAIF group was
not show a significant difference (P = .89). 2,621.15 versus 4,453.77V for 1 patient in the RFFF

Table 6. PATTERN OF COMPLICATIONS

Complication SCAIF (n = 25) n (%) RFFF (n = 25) n (%)

Major at recipient site (managed Partial necrosis with 2 (8) Flap vessel occlusion 3 (12)
by revision) necronectomy
Total flap loss 1 (4) Total flap loss 3 (12)
Flap dehiscence 1 (4)
Minor at recipient site Fistula 3 (12) Fistula 1 (4)
Partial necrosis 1 (4)
Major at donor site Dehiscence 2 (8) Postoperative bleeding 1 (4)
Necrosis 1 (4)
Minor at donor site Dehiscence 7 (28) Impaired wound healing 4 (12)
Necrosis 1 (4) Partial necrosis 4 (12)

Abbreviations: RFFF, radial forearm free flap; SCAIF, supraclavicular artery island flap.
Welz et al. SCAIF vs RFFF for Oral Cancer Reconstruction. J Oral Maxillofac Surg 2017.
WELZ ET AL 2267

The present results indicate equal or fewer postop-

erative complications in the SCAIF group compared
with the RFFF group, which are comparable to those
previously reported in the literature.12,13
There were fewer major recipient site complica-
tions and 1 TFL in the SCAIF group (4%). With a major
recipient site complication rate of 12% (8% PFNs, 4%
TFLs), the present results are totally in line with the
literature.8,10,15-17
In the 2 cohorts, 10 of 25 patients developed donor
site complications, with most (>90%) being minor com-
plications. This rate is equal or a bit higher than that re-
ported in the literature.9,18,19 There were 2 major donor
site complications in the SCAIF group, which involved
impaired wound healing with dehiscence at the critical
FIGURE 3. Cost analysis. Standard boxplots (lower quartile, me- acromial shoulder region. In these cases, a small
dian, upper quartile) are used to illustrate the results in the SCAIF
group (n = 25) and RFFF group (n = 25). Dots denote mild statistical rotational skin flap was successfully performed
outliers (interquartile range, 1.5 to 3 times). Asterisks denote achieving good wound healing.
extreme statistical outliers (>3 times interquartile range). ICU, inten- This study, which included only patients with stage
sive care unit; RFFF, radial forearm free flap; SCAIF, supraclavicular
artery island flap. III or IV squamous cancer of the oral cavity or
Welz et al. SCAIF vs RFFF for Oral Cancer Reconstruction. J Oral
oropharynx, identified good postoperative functional
Maxillofac Surg 2017. results. Postoperative swallowing ability according to
barium swallow results appeared to be similar be-
tween the 2 groups.
group (P < .001). This represents a cost increase of 1.7 In this study, there was a marked difference in tra-
times in the RFFF group. cheotomy rates. Patients undergoing reconstruction
with the RFFF were more likely to receive a tracheot-
omy (88%) compared with the SCAIF group (64%).
Discussion
This is another noteworthy finding because the pres-
In this study, the authors retrospectively compared a ence of a tracheotomy can prolong hospital stay, is
wide range of peri- and postoperative outcomes of pa- associated with a decrease in mental health postoper-
tients with advanced HNSCC of the oral cavity or atively, and is known to worsen self-esteem.20 The au-
oropharynx undergoing mucosal defect reconstruc- thors do not have a clear explanation for this finding,
tion using the SCAIF (n = 25) or RFFF (n = 25). To because the cohorts were well matched by TNM clas-
the authors’ knowledge, only 2 other publications sification and tumor localization. They presume that
have compared SCAIF and free flap outcomes. Gran- the lower tracheotomy rate in the SCAIF cohort is
zow et al12 and Kozin et al13 compared the SCAIF the result of a shorter procedure and less manipulation
with the RFFF and anterolateral thigh flap for different at the recipient site. Nevertheless, a departmental bias
indications (temporal bone, pharynx, or cutaneous toward a tracheotomy for patients receiving free tissue
defect reconstruction) and different patients (onco- transfer cannot be ruled out.
logic and traumatic). This is the first study comparing There was a marked difference in the follow-up
the SCAIF exclusively with the RFFF for a single period of patients undergoing the RFFF versus SCAIF
indication. procedure. This is due to the fact that in their institu-
Patients in the SCAIF group were markedly older tion, the authors started performing SCAIF reconstruc-
than patients in the RFFF group (68.9 vs 61.5 yr). tions frequently only since 2014. Before 2014, free
Although the authors tried to narrow the difference flaps were used primarily to reconstruct the
by matching the 2 groups, this was a retrospective oropharynx or oral cavity.
study, which is susceptible to selection bias. In gen- One of the most noteworthy results of this study was
eral, the authors did not preselect the patients and identified after analyzing the operation times. Total sur-
included consecutively performed reconstructions gery time was considerably shorter in the SCAIF group
of the oral cavity or oropharynx. The age difference (411.0 vs 576.4 minutes). The single team performing
can be explained by the use of the SCAIF as a the SCAIF surgery saved time from the absence of an
reconstruction modality in patients with a poor anastomosis and a shorter elevation time. These results
vascular status, pathologic Allen test result, or are in line with the literature, where shorter total sur-
serious comorbidities that occur more frequently gery times and elevation times shorter than 60 minutes
in older patients. are frequently reported.19,21-24 The authors consider
2268 SCAIF VS RFFF FOR ORAL CANCER RECONSTRUCTION

this to be a very important contributing factor in the References

postoperative course, because it associated with
1. Cannady SB, Rosenthal EL, Knott PD, et al: Free tissue transfer
fewer ICU admissions and overall lower costs. for head and neck reconstruction: A contemporary review.
ICU admissions and time spent in an ICU were JAMA Facial Plast Surg 16:367, 2014
considerably decreased in the SCAIF group. The au- 2. Welkoborsky HJ, Deichmuller C, Bauer L, et al: Reconstruction
of large pharyngeal defects with microvascular free flaps and
thors presume that this has to do with a shorter oper- myocutaneous pedicled flaps. Curr Opin Otolaryngol Head
ative time and the traditional view among Neck Surg 21:318, 2013
reconstructive surgeons that patients need to be 3. Avery CM: Review of the radial free flap: Is it still evolving, or is it
facing extinction? Part one: Soft-tissue radial flap. Br J Oral Max-
closely monitored postoperatively after receiving illofac Surg 48:245, 2010
the RFFF. 4. Lamberty BG: The supra-clavicular axial patterned flap. Br J Plast
In the current era, health care systems are on the Surg 32:207, 1979
5. Blevins PK, Luce EA: Limitations of the cervicohumeral flap in
brink of failure because of increasing costs and head and neck reconstruction. Plast Reconstr Surg 66:220,
increasing demands for efficiency. After comparing 1980
the perioperative costs of reconstructions using the 6. Pallua N, Machens HG, Rennekampff O, et al: The fasciocutane-
ous supraclavicular artery island flap for releasing postburn
SCAIF versus the RFFF, reconstructions using the mentosternal contractures. Plast Reconstr Surg 99:1878, 1997
RFFF increased the cost 1.7 times more. 7. Pallua N, Magnus Noah E: The tunneled supraclavicular island
Patients had a longer ward stay compared with what flap: An optimized technique for head and neck reconstruction.
Plast Reconstr Surg 105:842, 2000
is usually reported in the literature after reconstruc- 8. Chiu ES, Liu PH, Friedlander PL: Supraclavicular artery island
tion using the SCAIF or RFFF.13 This is attributed to 2 flap for head and neck oncologic reconstruction: Indications,
important factors. First, many patients had a very complications, and outcomes. Plast Reconstr Surg 124:115,
2009
low socioeconomic status, with residential problems. 9. Teymoortash A, Mandapathil M, Hoch S: Indications for recon-
The authors always aim to address these issues before struction of mucosal defects in oropharyngeal cancer using a
discharge, resulting in extended hospitalizations. Sec- supraclavicular island flap. Int J Oral Maxillofac Surg 43:1054,
2014
ond, postoperative management of all patients in- 10. Kokot N, Mazhar K, Reder LS, et al: The supraclavicular artery
cludes nasogastric tube feeding in the first 10 island flap in head and neck reconstruction: Applications and
postoperative days, extensive tooth sanitation, and limitations. JAMA Otolaryngol Head Neck Surg 139:1247,
2013
presentation to the department of radiotherapy before 11. Herr MW, Bonanno A, Montalbano LA, et al: Shoulder function
discharge. following reconstruction with the supraclavicular artery island
The major limitation of this study is its retrospective flap. Laryngoscope 124:2478, 2014
12. Granzow JW, Suliman A, Roostaeian J, et al: Supraclavicular ar-
nature that inherently has biases. Another limitation is tery island flap (SCAIF) vs free fasciocutaneous flaps for head
that the authors did not routinely assess postoperative and neck reconstruction. Otolaryngol Head Neck Surg 148:
quality of life for these patients. They have incorpo- 941, 2013
13. Kozin ED, Sethi RK, Herr M, et al: Comparison of perioperative
rated this in their practice and their future results outcomes between the supraclavicular artery island flap and fas-
will include patients’ perceptions of reconstruc- ciocutaneous free flap. Otolaryngol Head Neck Surg 154:66,
tive surgery. 2016
14. Granzow JW, Suliman A, Roostaeian J, et al: The supraclavicular
In conclusion, the ideal flap for reconstructive artery island flap (SCAIF) for head and neck reconstruction: Sur-
oncology procedures should restore the form and gical technique and refinements. Otolaryngol Head Neck Surg
function of the defect in a single-stage procedure, be 148:933, 2013
15. Sandu K, Monnier P, Pasche P: Supraclavicular flap in head and
reliable and straightforward to harvest, save time, neck reconstruction: Experience in 50 consecutive patients.
lower costs, and have no donor site comorbidity. Eur Arch Otorhinolaryngol 269:1261, 2012
Such an ideal flap does not exist, but the SCAIF ap- 16. Vinh VQ, Van Anh T, Ogawa R, et al: Anatomical and clinical
studies of the supraclavicular flap: Analysis of 103 flaps used
pears to satisfy most of these criteria. It is ideal to reconstruct neck scar contractures. Plast Reconstr Surg
when treating patients with many comorbidities and 123:1471, 2009
poor vascular status. It is thin and pliable and can 17. Razdan SN, Albornoz CR, Ro T, et al: Safety of the supraclavicular
artery island flap in the setting of neck dissection and radiation
be used for complex reconstructions of the therapy. J Reconstr Microsurg 31:378, 2015
oropharynx, making it equivalent to the RFFF and su- 18. Su T, Pirgousis P, Fernandes R: Versatility of supraclavicular ar-
perior to other pedicled flaps. Moreover, as shown in tery island flap in head and neck reconstruction of vessel-
depleted and difficult necks. J Oral Maxillofac Surg 71:622,
this study, it has equivalent or even improved postop- 2013
erative outcomes and is associated with lower rates of 19. Zhang B, Yan D, Zhang Y, et al. Clinical experience with the
tracheotomy, fewer ICU admissions, and substantially supraclavicular flap to reconstruct head and neck defects.
Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 50:468, 2015
lower costs. In the authors’ institution, use of the (in Chinese)
SCAIF has increased dramatically in the past 2 years. 20. Hashmi NK, Ransom E, Nardone H, et al: Quality of life and self-
It is a reliable alternative to the RFFF and appears to image in patients undergoing tracheostomy. Laryngoscope
120(suppl 4):S196, 2010
be even superior when reconstruction for patients 21. Alves HR, Ishida LC, Ishida LH, et al: A clinical experience of the
with serious comorbidities is needed. supraclavicular flap used to reconstruct head and neck defects
WELZ ET AL 2269

in late-stage cancer patients. J Plast Reconstr Aesthet Surg 65: 23. Giordano L, Di Santo D, Occhini A, et al: Supraclavicular artery
1350, 2012 island flap (SCAIF): A rising opportunity for head and neck
22. Anand AG, Tran EJ, Hasney CP, et al: Oropharyngeal reconstruc- reconstruction. Eur Arch Otorhinolaryngol 273:4403, 2016
tion using the supraclavicular artery island flap: A new flap alter- 24. Liu PH, Chiu ES: Supraclavicular artery flap: A new option for
native. Plast Reconstr Surg 129:438, 2012 pharyngeal reconstruction. Ann Plast Surg 62:497, 2009