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Combined Use of Acellular Dermal Matrix and Supraclavicular Artery Island Flap for Oropharyngeal Reconstruction

Persichetti, Paolo M.D., Ph.D.; Aveta, Achille M.D.; Segreto, Francesco M.D.

Plastic & Reconstructive Surgery: April 2013 - Volume 131 - Issue 4 - p 641e–642e
doi: 10.1097/PRS.0b013e31828277d0

Plastic, Reconstructive, and Aesthetic Surgery Unit, Campus Bio-Medico of Rome University, Rome, Italy

Correspondence to Dr. Aveta, Plastic, Reconstructive, and Aesthetic Surgery Unit, Campus Bio-Medico of Rome University, Via Alvaro del Portillo, 200, 00128 Rome, Italy

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We read with great interest the article by Anand and colleagues entitled “Oropharyngeal Reconstruction Using the Supraclavicular Artery Island Flap: A New Flap Alternative.”1 As pointed out by the authors, oropharyngeal reconstruction is a challenging procedure because of its functional involvements and because of the exposure to saliva and digestive enzymes. We would like to share our experience in this field by introducing a modification of the technique not previously described in the literature.

A 58-year-old patient was diagnosed with pharyngeal squamous cell carcinoma and underwent chemotherapy and radiotherapy. In the ensuing 2 years, recurring fistulization and cervical necrotizing fasciitis occurred. Subsequently, a pectoralis major flap was performed for reconstruction. Two weeks after the procedure, the patient presented at our institution (Fig. 1, left) with relapse of the fistula and cervical fasciitis promoted by Enterococcus faecalis, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The pectoralis major flap was necrotic and colliquated in its distal third: the exposure to saliva and its enzymes had digested the muscle and promoted the infection. First, parotid glands were injected with 50 units of botulinum toxin to reduce sialorrhea; then, surgical débridement was performed. One month later, the patient presented with fistulization and was unable to flex or extend the neck. We decided to perform a supraclavicular artery island flap for reconstruction. The supraclavicular artery was identified preoperatively by means of a handheld Doppler device. A 18 × 7-cm flap was harvested using the distal-to-proximal technique described by Pallua and Demir.2 A sheet of Permacol (Covidien plc, Dublin, Ireland) was placed and sutured to close the anterior pharyngeal wall. The flap was then rotated 180 degrees and sutured to cover the sheet of Permacol and the loss of substance. The procedure required approximately 90 minutes. A permanent tracheostomy was necessary because of the loss of the epiglottis cartilage. The patient was given nothing by mouth until modified barium swallow (Fig. 2, right) showed no leaks and was then started on liquids and gradually advanced. The patient's postoperative clinical course was uneventful (Fig. 1, right) and, 2 months after surgery, endoscopy (Fig. 2, left) and histologic examination showed the integration of the collagen matrix with the surrounding mucosa.

Oropharyngeal reconstruction is a challenging procedure. Regional flaps, such as pectoralis major, trapezius, deltopectoral, or their modifications,3 may result in significant functional morbidity. Microsurgical reconstruction may be severely hampered in cases of irradiated or infected surgical fields, such as in our patient, or contraindicated in patients with poor clinical conditions. In this context, the supraclavicular artery island flap is a reliable option, being pedicled and harvested easily, quickly, and with minimal donor-site morbidity.1,4 Permacol is an acellular porcine dermis composed of type I and type III collagen and a small amount of elastin. Its biocompatibility has been shown, with the integration of host cells and neovascularization in the collagen matrix of the implant; moreover, it can be used in contaminated surgical fields.5 As pointed out by Anand and colleagues, the main drawback of the supraclavicular artery island flap is the postoperative fistula rate, which is further increased by radiation therapy. In our patient, who had been irradiated and was locally infected, the supraclavicular artery island flap allowed local coverage and neck mobility, and mucosal lining with the acellular dermal matrix promoted regeneration of orthotopic tissue. This tissue, combined with preventive treatment of parotid glands by botulinum toxin injection, provided a higher resistance to saliva and digestive enzymes than the cutis of a flap, thus allowing the closure of the 3 × 3-cm fistula. In our experience, the combination of supraclavicular artery island flap with Permacol allowed the achievement of a solid reconstruction with no fistula relapse.

Paolo Persichetti, M.D., Ph.D.

Achille Aveta, M.D.

Francesco Segreto, M.D.

Plastic, Reconstructive, and Aesthetic Surgery Unit, Campus Bio-Medico of Rome University, Rome, Italy

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The authors have no commercial associations that might pose or create a conflict of interest with information presented in this communication. No funding was received.

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1. Anand AG, Tran EJ, Hasney CP, Friedlander PL, Chiu ES. Oropharyngeal reconstruction using the supraclavicular artery island flap: A new flap alternative. Plast Reconstr Surg. 2012;129:438–441.
2. Pallua N, Demir E. Postburn head and neck reconstruction in children with the fasciocutaneous supraclavicular artery island flap. Ann Plast Surg. 2008;60:276–282.
3. Persichetti P, Francesco Marangi G, Gigliofiorito P, Segreto F, Brunetti B. Myocapsular pectoralis major flap for pharyngeal reconstruction after cervical necrotizing fasciitis. Plast Reconstr Surg. 2010;126:2279–2281.
4. Liu PH, Chiu ES. Supraclavicular artery flap: A new option for pharyngeal reconstruction. Ann Plast Surg. 2009;62:497–501.
5. Balayssac D, Poinas AC, Pereira B, Pezet D. Use of Permacol in parietal and general surgery: A bibliographic review. Surg Innov. E-published ahead of print June 13, 2012.
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Plastic and Reconstructive Surgery
Reply: Combined Use of Acellular Dermal Matrix and Supraclavicular Artery Island Flap for Oropharyngeal Reconstruction
Chiu, ES; Friedlander, PL
Plastic and Reconstructive Surgery, 131(4): 642e-643e.
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