Central Annals of Otolaryngology and Rhinology

Cite this article: Standlee AG, Harsha1 WJ, Marmolejo VL (2016) Safe Supraclavicular Artery Island Flap (SCAIF) Harvest using the SPY-Elite Intra operative Perfusion Assessment System (SPY). Ann Otolaryngol Rhinol 3(7): 1120.

*Corresponding author

Aurora G Standlee, Department of Otolaryngology Head and Neck Surgery, Madigan Army Medical Center, 9040 Jackson Ave, Tacoma WA 98431, USA, Tel: 253-968-1430, Fax: 253-968-3154, Email:

Submitted: 26 May 2016

Accepted: 17 June 2016

Published: 18 June 2016

ISSN: 2379-948X

Copyright© 2016 Standlee et al.

OPEN ACCESS

Keywords•SupraclaviculararteryIslandflap•Indocyanine green angiography•Spy-elite intraoperative Perfusion assessment system•Head and neck reconstruction

Case Report

Safe Supraclavicular Artery Island Flap (SCAIF) Harvest using the SPY-Elite Intra operative Perfusion Assessment System (SPY)Aurora G Standlee1*, Wayne J Harsha1 and Valerie L Marmolejo2

1Department of Otolaryngology, Madigan Army Medical Center, USA2Clinical Marketing Specialist and Research Liaison, University Place, USA

Abstract

Objectives: Indocyanine green angiography is a useful intraoperative tool to assess flap survivability that has been successfully applied in many areas of reconstructive surgery. Herein, we describe the first application of indocyanine green angiography in assessing the viability of a supraclavicular artery island flap (SCAIF) with the goal of demonstrating its usefulness in preventing major post-operative complications.

Methods: We present a case report of a patient who had previously undergone multiple neck surgeries and neck irradiation that subsequently developed a laryngo cutaneous fistula amenable to closure with a SCAIF. The SPY-Elite Intraoperative Perfusion Assessment System (SPY) was used to assess intra-operative flap viability.

Results: The distal flap end was shortened at two separate occasions during the case when a SPY perfusion assessment demonstrated poor distal flow. Post-operatively, the flap healed with 100% take, and the patient did not experience any complications from the surgery.

Conclusion: Our application of the SPY to assess the viability of a SCAIF intra-operatively prevented a major post-operative complication. Overall, indocyanine green angiography is a useful tool in head and neck reconstruction, and we believe that its use should be applied liberally to the SCAIF to prevent distal flap necrosis.

ABBREVIATIONSSCAIF: Safe Supraclavicular Artery Island Flap; SPY: SPY-Elite

Intraoperative Perfusion Assessment System

INTRODUCTIONThe Supraclavicular artery island flap (SCAIF) is a useful

loco regional flap in head and neck reconstruction. Pallua first described the modern SCAIF in 1996 and its application in the release and reconstruction of post burn mentosternal contractures [1]. The SCAIF has also been described in tracheostomal and pharyngeal reconstruction, covering large head and neck defects such as exposed great vessels or improving facial contour of post-parotidectomy wounds [2]. It is indicated in almost all oncologic defects of the lower third of the face or neck. Advantages of the SCAIF include rapid flap harvest, minimal donor site morbidity, good skin color match, and pliability allowing for improved cosmesis of the repair. Additionally, it obviates the need for micro vascular free tissue transfer, which is not an option for every patient. Major complications following

SCAIF reconstruction include distal flap necrosis and wound dehiscence, often secondary to poor tissue perfusion. The overall incidence of major complications after SCAIF reconstruction is as high as 38% in some series and can lead to returns to the operating room, longer patient stays, increased costs of care, and overall increased patient morbidity [3].

The SPY-Elite Intraoperative Perfusion Assessment System (SPY) (distributed in North America by Novadaq Technologies, Inc., Bonita Springs, FL), which uses indocyanine green angiography, was design to allow for the intraoperative and/or post-operative visual assessment of tissue perfusion [4]. Indocyanine green has an excellent safety profile and rapid half-life allowing for safe repetitive use during a single surgery. Indocyanine green angiography has been used successfully in many areas of reconstructive surgery to accurately predict regional and free flap viability [4]. For example, indocyanine green angiography has been used to successfully predict the viability of free flap anastomoses, skin flap perfusion, lymphatic mapping, and perforator mapping [5]. Prospective trials

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examining the accuracy of indocyanine green angiography have found 88% sensitivity and 83% specificity for the prediction of skin flap necrosis [6]. Use of the SPY-Elite system can add significant expense to an operation, however, so some studies have suggested it be reserved for “high risk” cases [7].We posit that indocyanine angiography is useful not only in free-flap reconstruction, but also in regional flap reconstruction, especially in patients with multiple prior surgeries and neck irradiation. Herein, we report the first case of intraoperative indocyanine green angiography in the assessment of SCAIF perfusion in a patient who had previously undergone multiple neck surgeries and neck irradiation. As demonstrated in this case report, the use of the SPY prevented almost-certain distal flap necrosis and further wound complications.

CASE PRESENTATIONThe patient is a 65 year old male with a history of glottic

squamous cell carcinoma treated primarily with radiation therapy. He experienced persistence of disease and underwent a left vertical partial laryngectomy, selective neck dissection, and tracheotomy. His postoperative course was complicated by development of a laryngo cutaneous fistula refractory to conservative measures and meeting indications for surgical closure with a loco regional flap, specifically a SCAIF. Intraoperative, a hand-held Doppler was used to mark the course of the Supraclavicular artery coming off the transverse cervical artery until the distal-most point at which the Doppler signal could be heard. An edge 5 cm distal to this point was marked as the distal-most end of flap to be harvested. Next, two milligrams of Indocyanine green were injected intra vascular, and the SPY was used to record flow through the Supraclavicular artery. The marking of the distal end of the flap was adjusted one centimeter proximally due to decreased perfusion evident at the tip (Figure 1). The marked Supraclavicular artery island flap was then harvested in a standard fashion [1]. The SPY was used to assess flap perfusion immediately after harvest with evidence of adequate perfusion to the distal tip and confirmation that the Supraclavicular artery pedicle was intact (Figure 2). The laryngo cutaneous fistula was prepared and closed in a standard layered fashion, and the flap was rotated into its intended position in the neck and sewn loosely in place. The SPY was again used to assess perfusion of the flap, and the distal tip appeared black with minimal perfusion (Figure 3). The area of poor perfusion was removed and the flap re-sewn into place. The SPY was used once more after inset, and good perfusion was seen extending to the flap tip (Figure 4).The patient was followed over the next 6 months in the ENT clinic. His flap healed with 100% stake and no distal tip necrosis or other complications.

DISCUSSION The SCAIF is a useful loco regional flap in head and neck

reconstruction. It is a thin, pliable flap with good color match to the head and neck that can be rapidly elevated with primary closure of the donor site [2]. Since this is a rotational flap, it is also extremely useful in situations where micro vascular free tissue transfer is not an option, and in cases of multiple prior surgeries limiting current reconstructive options. Major complications requiring a return to the operating room are not uncommon following SCAIF reconstruction, especially among patients with

previously irradiated necks and other comorbidities3. In some reports, the incidence of distal tip flap necrosis is as high as 22% [3]. Doppler is a useful tool in initial planning of a SCAIF, but distal extension of a SCAIF that can be safely harvested during surgery is not reliably predicted with Doppler alone. Indocyanine green angiography is a useful intra-operative tool designed to assess tissue perfusion and flap survivability, and it has previously been successfully applied to multiple areas of head and neck reconstruction. Taylor and Jorgensen (2015) used fluorescent angiography in their series of patients undergoing radial forearm and fibular free flap reconstruction and reported no cases of post-operative digital or acute ischemic events [8]. Matsui et al.,

Figure 1 Initial flap marking based on Doppler and SPY assessment. Both the supraclavicular and internal mammary arteries were marked with Doppler, as indicated by an ‘x’, and the proposed distal aspect of the SCAIF 5cm beyond the distal-most Doppler signal is marked with a hash. The harvested distal tip was refined more proximally after SPY assessment, and the adjusted edge is marked with a solid line contiguous with the lateral borders of the SCAIF.

Figure 2 SPY perfusion assessment of the SCAIF immediately after harvest, prior to inset demonstrating poor distal tip perfusion.

Figure 3 SPY perfusion assessment after initial inset of the SCAIF demonstrating poor distal tip perfusion.

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Standlee AG, Harsha1 WJ, Marmolejo VL (2016) Safe Supraclavicular Artery Island Flap (SCAIF) Harvest using the SPY-Elite Intra operative Perfusion Assess-ment System (SPY). Ann Otolaryngol Rhinol 3(7): 1120.

Cite this article

(2010) evaluated the predictive capability of indocyanine green angiography in the survival of sub mental perforator flaps in a pig model and demonstrated that intraoperative use of fluorescence angiography accurately predicted flap perfusion at 72 hours [9]. We feel indocyanine angiography is useful in more than free flap and perforator flap evaluation, however. We present the first reported use of indocyanine green angiography to predict post-operative viability of a SCAIF, a regional rotational flap. Our patient had previously undergone neck irradiation and multiple neck surgeries that limited his reconstructive options and increased his risk of post-operative complications. He experienced complete flap survival, however, without minor or major complications at 6-month follow-up. The use of the SPY in this case caused us to modify our initial planning of the flap. Additionally, we further modified the length of the flap after partial inset when the SPY identified poor perfusion to the distal aspect of the SCAIF. We believe intraoperative use of the SPY system prevented a major post-operative complication of distal flap necrosis. Further, we plan to utilize this technology for all further uses of the SCAIF and other axial pattern flaps such as paramedian forehead and delto-pectoral flaps. In summary, indocyanine green angiography is a useful intraoperative tool to assess flap survivability that has been successfully applied in many areas of reconstructive surgery. Herein, we describe the first application of indocyanine green angiography in the assessment of the viability of a SCAIF with prevention of a major post-operative complication. Overall, indocyanine green angiography can be a useful tool in head and neck reconstruction, for regional and free flaps, and we believe that its use should be applied liberally to the SCAIF to prevent distal flap necrosis.

CONFLICT OF INTERESTThe second author (VM) is an employee of Novadaq, the

company that distributes the SPY-Elite system. She operates in an educational capacity and is not a sales representative. None of the authors have any financial interests, incentives, or personal relationships that could inappropriately influence our actions or the work presented herein.

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fasciocutaneous supraclavicular atery island flap for releasing post burnmentosternal contractures. Plast. Reconstr. Surg. 1997; 99: 1878-1884.

2. Chiu ES, Liu PH, Friedlander PL. Supraclavicular artery island flap for head and neck oncologic reconstruction: indications, complications, and outcomes. Plast. Reconstr. Surg. 2009; 124: 115-123.

3. Su T, Pirgousis P, Fernandes R. Versatility of supraclavicular artery island flap in head and neck reconstruction of vessel-depleted and difficult necks. J Oral Maxillofac Surg. 2013; 71: 622-627.

4. Gurtner GC, Jones GE, Neligan PC, Newman MI, Phillips BT, Sacks JM, et al. Intraoperative laser angiography using the SPY system: review of the literature and recommendations for use. Annals of Surgical Innovation and Research. 2013; 7:1-14.

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6. Newman MI, Jack MC, Samson MC. SPY-Q analysis toolkit values potentially predict mastectomy flap necrosis. Ann Plast Surg. 2013; 70: 595-598.

7. Chatterjee A, Krishnan NM, Van Vliet MM, Powell SG, Rosen JM, Ridgway EB, et al. A comparison of free autologous breast reconstruction with and without the use of laser-assisted indocyanine green angiography: a cost-effectiveness analysis. Plast Reconstr Surg. 2013; 131: 693-701.

8. Taylor SR, Jorgensen JB. Use of fluorescent angiography to assess donor site perfusion prior to free tissue transfer. Laryngoscope. 2015; 125: 192-197.

9. Matsui A, Lee BT, Winer JH, Laurence RG, Frangioni JV. Predictive capability of near-infrared fluorescence angiography in submental perforator flap survival. Plast Reconstr Surg. 2010; 126: 1518-1527.

Figure 4 Final SPY perfusion assessment after further tailoring the SCAIF demonstrating perfusion to the distal tip.