The relationship between the subclavian vessels and brachial plexus and the overlying clavicle: Anatomical study with application to plate osteosynthesis.

A subclavian artery aneurysm after clavicle fracture and plate osteosynthesis in a suspected case of a screw that was too long led us to investigate body donor cadavers. The aim was to verify clavicle variability, and the course of the neurovascular bundle in relation to the clavicle and to the osteosynthesis plate, in order to clarify safe zones for plate and screw fixation. We used one fresh frozen and 25 embalmed donors for in situ measurements: (1) length and craniocaudal thickness of the clavicle, (2) distances between the sternal end of the clavicle and the center of parts of the neurovascular bundle. The clavicle was 15.15 cm long. The mean distances from the sternal end of the clavicle were 5.62 cm to the subclavian vein, 6.75 cm to the subclavian artery and 8.42 cm to the cords of the brachial plexus. The subclavius muscle was 1 cm thick. Because of sex differences in length and distances, we recorded the distances between the sternal end and parts of the neurovascular bundle as ratios of clavicle length (at-risk area) to provide sex-independent parameters: 0.379 for the vein, 0.449 for the artery and 0.554 for the nerve. The neurovascular bundle runs below the clavicle between the medial fourth and three fifths of clavicle length. To avoid iatrogenic neurovascular injuries, special caution is necessary during drilling and screwing the osteosynthesis. We also recommend using screws shorter than 1.4 cm.

Morphometric analyses of clavicle's nutrient foramen.

PURPOSE: Fractures of the clavicle, which has an important location and function in the upper extremity and shoulder joint, compose 10% of all fracture cases. During the osteosynthesis of clavicle fractures and in the post-operative period of patients, considering the detailed morphometric and topographic properties of the nutrient foramen of clavicle is important to avoid the disruption of arterial nutrition of the clavicle and prevent unexpected injuries. The aim of this study was to investigate the morphometric properties of the nutrient foramen of clavicle in more detail using computedtomography images. METHODS: Computed tomography images of 116 healthy individuals (56 women/60 men) who had no pathology history were included in the presented study. Computed tomography images were reconstructed three-dimensionally using free-licensed Horos v3.3.3 software. Then, distances from clavicle's nutrient foramen to sternal end, anterior and posterior edges of the clavicle were measured. Statistical analyses were completed using SPSS v21 software. RESULTS: Our results demonstrated that the nutrient foramen of clavicle was located closer to the sternal end of the clavicle. The shortest distance to the sternal edge of clavicle was measured as 3.3 cm. Analyses of gender differences indicated that statistically significant differences were in favor of men. However, topographic properties of the clavicle's nutrient foramen were not affected by age. CONCLUSION: Nutrient foramen is mostly located closer to the sternal end of clavicle. Especially during osteosynthesis of clavicle fractures at the sternal end, maintaining the arterial supply of clavicle is of great importance for increasing the post-operative life quality of patients.

Anatomical study of the perforator flap based on the acromial branch of the thoraco-acromial artery (abTAA flap): a cadaveric study.

PURPOSE: The aim of this anatomical study was to describe a local perforator flap, for covering shoulder defects, by determining the features of the acromial branch of the thoraco-acromial artery (abTAA), and the supplied cutaneous area. METHODS: Thirteen fresh cadaveric thoraxes were dissected bilaterally. A precise and reproducible protocol was performed. For each abTAA flap cadaveric dissection, the following parameters were measured after arterial injection: distances between the origin of the perforator artery on the abTAA and the sternum, the acromion, the clavicle, diameter of the perforator artery of the abTAA, length of the perforator pedicle course through major pectoralis muscle, and rotation arc. We also calculated the surface of the injected skin paddle. These measurements were related to morphometric parameters evaluated through the distance between sternum and acromion. RESULTS: The mean distances measured from the origin of the perforator artery on the abTAA were 14.25 cm to the sternum, 3.45 cm to the acromion, 5.65 cm to the clavicle. The mean diameter of the abTAA was 1.20 mm ± 0.2. The arc of rotation was 180°, and the length of the perforator pedicle could be extended to 7.46 cm ± 1.15. We observed an colored elliptical cutaneous paddle with a longer radius 18 cm and a small radius 15 cm. CONCLUSIONS: Our results suggest that this type of flap could be useful in clinical practice for reconstruction and covering of the acromial area with a thin cutaneous flap with low sequelae on the donor site.

Redefining the morphometry of subclavian vessels for clavicle fracture treatments.

PURPOSE: Clavicle fractures are common injuries in adults and children. Although neurovascular damage is rarely seen, acute subclavian artery pseudoaneurysms and injuries to subclavian vessels were reported for closed fractures of the clavicle. The aim of this study was to identify the morphological details of the subclavian vessels and their relation to the sternoclavicular joint and body of the clavicle. METHODS: 127 patients (66 females and 61 males) were evaluated using reconstructed three-dimensional computed tomographic angiographies. The point at which the subclavian artery crossed posterior to the clavicle was detected as a landmark. The medio-lateral distance between the sternal end of the clavicle, landmark, antero-posterior distance between the clavicle and the subclavian artery, diameter of the artery and vein, angle between the subclavian artery and vein, distance of the subclavian vein to the subclavian artery and the clavicle at the landmark were measured. Measurements were compared according to gender and right and left sides, and age correlation was determined. RESULTS: Morphometric relationship between the subclavian vessels and clavicle presented differences between genders. We measured the antero-posterior distance between the subclavian artery and the clavicle to be less than 1 cm (0.91 cm). CONCLUSION: The subclavian artery travelled longer distances in men than women to reach the point that it crossed the clavicle. Our results demonstrated that the subclavian artery does not pass from the inferior margin of the clavicle, thus, superior plate osteosynthesis does not have any risk to injury against the subclavian vessels during the management of the clavicle fractures.

The distributed pattern of the neurovascular structures around clavicle to minimize structural injury in clinical field: anatomical study.

INTRODUCTION: The aim of this study was to determine the location and distribution pattern of neurovascular structures superior and inferior to the clavicle by detailed dissection. METHODS: Fifteen adult non-embalmed cadavers with a mean age of 71.5 years were studied. For measurements, the most prominent point of the sternal end of the clavicle (SEC) on anterior view and the most prominent point of the acromial end of the clavicle (AEC) were identified and divided five equal sections before dissection. A line connecting the SEC and AEC was used as a reference line. The surrounding neurovascular structures were investigated. RESULTS: The supraclavicular nerve was mainly distributed in the second and the third sections (distribution frequency: 41.30% and 30.43%, respectively) from AEC. Branches of the thoracoacromial artery were mainly distributed in the second, third, and fourth sections (distribution frequency: 21.15%, 26.92%, and 28.85%, respectively). Branches of the subclavian vein were mainly distributed in the third and fourth sections (distribution frequency: 23.26 and 30.23%, respectively). Distribution frequency of subclavian vein, subclavian artery, and brachial plexus ranged from 31.3 to 57.5%. DISCUSSION: When the clavicle was divided into five sections, there was relatively little distribution of neurovascular damage in the first section or the fifth section. This study reveals the average location of subclavian vein with artery and brachial plexus. Results of this study could be used as reference during surgery.

Variations of the cephalic vein anterior to the clavicle in humans.

BACKGROUND: Clinicians should understand that jugulocephalic vein (JCV) variants may be occasionally found. This study aims to classify JCV variants and obtain their frequency. MATERIALS AND METHODS: We investigated anatomical variants of the cephalic vein in 55 human cadavers during a gross anatomy course at our medical school. RESULTS: The percentage of JCVs that pass through the anterior part of the clavicle and anastomose to the jugular vein as per previous studies and our study was 2-5%. Five cases with anastomosis between the cephalic and external jugular veins that pass through the anterior part of the clavicle were found. The courses were classified into 1A, 1B, 2A, and 2B. Type 1 extends beyond the clavicle and anastomoses with the external jugular vein. Type 2 follows the same course as type 1, but anastomoses with the subclavian vein. Subtype A does not have a branch that anastomoses with the axillary vein, whereas subtype B does. We encountered two cases of type 1A and three of type 1B. CONCLUSIONS: Four anatomical variants of the cephalic vein around the clavicle were identified. Clinicians' knowledge of these variants is expected to decrease possible complications if venous access via the cephalic vein is needed.

Supraclavicular Flap Reconstruction of Cutaneous Defects Has Lower Complication Rate than Mucosal Defects.

Background The objective of this study was to determine whether there was a difference in complication rate between cutaneous and mucosal defects reconstructed with the supraclavicular artery flap. Methods Retrospective review of postoperative complications in 63 patients from 2008 to 2015 with cutaneous and mucosal head and neck defects following oncologic ablation reconstructed with the supraclavicular flap, with a minimum follow-up duration of 6 months. Of the 63 patients, 38 patients had cutaneous defects, whereas 25 had mucosal defects. Patients were followed up postoperatively to determine the presence of wound infection, partial flap necrosis, complete flap necrosis, and fistula formation. Complications in both defect groups as well as a statistical comparison of total complications were analyzed. Results Patients with cutaneous defects reconstructed with the supraclavicular flap had significantly lower postoperative complications than those with mucosal defects (p = 0.002). Flap necrosis, both partial and complete, was also lower in this same group (p = 0.0052). Conclusion The supraclavicular artery flap may be a more suitable option for patients with cutaneous defects, given the reliability and lower propensity for postoperative complications Level of Evidence The level of evidence is 4.

Ultrasound confirmation of central venous catheter position via a right supraclavicular fossa view using a microconvex probe: an observational pilot study.

BACKGROUND: Visualisation of a central venous catheter (CVC) with ultrasound is restricted to the internal jugular vein (IJV). CVC tip position is confirmed by chest radiography, intracardiac ECG or transoesophageal/transthoracic echocardiography (TEE/TTE). OBJECTIVE: We explored the feasibility, safety and accuracy of a right supraclavicular view for visualisation of the lower superior vena cava (SVC) and the right pulmonary artery (RPA) as an ultrasound landmark for real-time ultrasound-guided CVC tip positioning via the right IJV. Ultrasound was then compared with chest radiography. DESIGN: An observational pilot study. SETTING: Bonn, University Hospital, Germany. From July to October 2012. PATIENTS: Fifty-one patients scheduled for elective surgery. Reasons for exclusion were emergency procedure, thrombosis or small IJV lumen and mechanical obstacle to guidewire advancement. INTERVENTION: In 48 patients, CVC insertion via the right IJV and progress of the guidewire into the lower SVC were continuously guided by an ultrasound transducer in the right supraclavicular fossa. MAIN OUTCOME MEASURES: CVC tip position in lower SVC and tip-to-carina distance were assessed with chest radiography as a reference method and additionally with TEE in cardiothoracic patients. Insertion depth was compared with intracardiac ECG and body-height formula. RESULTS: The guidewire tip was seen in the SVC of all patients. In four patients, the tip was not visible in proximity of the RPA. Chest radiography and TEE confirmed CVC tip position in the lower SVC (zone A). Bland-Altman analysis revealed an average of difference of 1.6 cm for ultrasound versus ECG (95% limit of agreement -2 to 5 cm) and an average of difference of 1 cm for ultrasound versus body-height formula (95% limit of agreement -2 to 4 cm). CONCLUSION: Ultrasound via a right supraclavicular view is a feasible, well tolerated and accurate approach and should be further explored. Chest radiography confirmed CVC position in the lower SVC.

Tracheostoma reconstruction with the supraclavicular artery island flap.

Tracheostoma wounds are complex defects that commonly occur in patients with vessel-depleted necks after cervical lymphadenectomy, who have multiple medical comorbidities, and a history of radiation therapy. The authors report reconstruction of 5 tracheostoma wounds using a pedicled, supraclavicular artery island flap as a reconstructive alternative. There were no flap losses, fistulas or leaks, revisions, or other complications. The supraclavicular artery island flap is a versatile, reliable, and effective option for tracheostoma reconstruction.

Use of Dual, Tubularized Supraclavicular Artery Island Flaps in Series to Restore Gastrointestinal Continuity After a Failed Ileocolic Esophageal Reconstruction.

The supraclavicular artery island flap (SCAIF) is a versatile pedicled flap that can be an excellent alternative to free flap reconstruction in complex head and neck defects. We use the SCAIF routinely as a first-line option for many of our soft tissue head and neck reconstructions. Here we describe a novel application of dual SCAIFs used in series for proximal esophageal reconstruction. This followed esophagectomy for neoplastic disease and failed gastric pull-up and colonic interposition procedures.

Pedicled Supraclavicular Artery Island Flap Versus Free Radial Forearm Flap for Tongue Reconstruction Following Hemiglossectomy.

This study investigated the tongue function and donor-site morbidity of patients with malignant tumors who had undergone immediate flap reconstruction surgery. Twenty-seven patients who had undergone immediate reconstruction after hemiglossectomy were observed. Twelve patients were reconstructed using the pedicled supraclavicular artery island flap (PSAIF) and 15 patients using the free radial forearm flap (FRFF). Flap survival, speech and swallowing function, and donor-site morbidity at the 6-month follow-up were evaluated. All the flaps were successfully transferred. No obvious complications were found in either the transferred flaps or donor regions. Age, sex, defect extent, speech and swallowing function were comparable between the 2 groups. Donor-site complications were less frequent with PSAIF reconstruction than FRFF reconstruction. The PSAIF is reliable and well suited for hemiglossectomy defect. It has few significant complications, and allows preservation of oral function.

Safety of the supraclavicular artery island flap in the setting of neck dissection and radiation therapy.

BACKGROUND: The supraclavicular artery island flap (SAIF) has recently been repopularized as a versatile and reliable option for reconstruction of oncological head and neck defects. Prior ipsilateral neck dissection or irradiation is considered a relative contraindication to its use. The aim of this study was to describe the safety and utility of the SAIF for head and neck reconstruction in the setting of neck dissection and radiation. METHODS: A retrospective chart review was performed of consecutive SAIF reconstructions at two institutions between May 2011 and 2014. In addition to demographic data, comorbidities, indications, surgical characteristics, data about radiation treatment, and neck dissection were specifically recorded. Donor and recipient site complications were noted. Fisher exact test was performed to analyze if neck dissection or radiation were associated with complications. RESULTS: A total of 22 patients underwent SAIF reconstruction for an array of head and neck defects. Donor site infection was noted in one patient. Recipient site complications included, wound dehiscence (n = 2), orocutaneous fistula (n = 1), carotid blowout (n = 1), and total flap loss (n = 1). There was no association between prior neck dissection or radiation treatment and flap loss (p = 1.00). CONCLUSION: The SAIF is safe for use in patients who have had an ipsilateral neck dissection involving level IV or V lymph nodes and/or radiation treatment to the neck. It can be used alone or in combination with other flaps for closure of a variety of head and neck defects.

Three superficial veins coursing over the clavicles: a case report.

We report a unique bilateral combination of multiple variations in the superficial venous system of the neck of a 77-year-old male cadaver. On the right side of the neck, the external jugular vein (EJV) crossed superficial to the lateral third of the clavicle constituting a common trunk with the cephalic vein (CV) that drained into the subclavian vein (SCV). On the left side the EJV descended distally, passed over the anterior surface of the medial third of the clavicle and drained into the SCV. The posterior external jugular vein (PEJV) crossed superficial to the lateral third of the clavicle and terminated into the CV, providing an additional communicating branch to the EJV. Knowledge of both normal and abnormal anatomy of the veins of the neck plays an important role for anesthesiologists or cardiologists doing catheterization, orthopedic surgeons treating clavicle fractures and general surgeons performing head and neck surgery, to avoid inadvertent injury to these vascular structures.

Clinical significance of collateral superficial vein across clavicle in patients with cardiovascular implantable electronic device.

BACKGROUND: Obstruction of the access vein is a well-known complication after cardiovascular implantable electronic device (CIED) implantation. In that case, well-developed collateral superficial veins are frequently observed on the skin surface around the CIED. The aim of this study was to clarify the relationship between venous obstruction and development of a superficial vein across the clavicle. METHODS AND RESULTS: A total of 107 patients scheduled for generator replacement, device upgrade, or lead extraction were enrolled. The skin surface around the device was photographed. A 20-ml bolus of contrast medium was injected into a peripheral arm vein on the side of CIED implantation, and contrast venography was performed. Venous obstruction was defined as luminal diameter narrowing >75%. Venography showed venous obstruction in 27 patients (25.2%). There were no statistically significant differences in patient characteristics between the venous obstruction and no venous obstruction group. Of 107 patients, 44 (41.1%) had a superficial vein across the clavicle on the side of CIED implantation. The sensitivity of the presence of a superficial vein across the clavicle in the diagnosis of venous obstruction was 96.3% and specificity was 77.5% (P<0.001). CONCLUSIONS: The presence of a superficial vein across the clavicle is useful for the prediction of venous obstruction in patients with CIED.

Thoracic outlet syndrome: a neurological and vascular disorder.

Thoracic outlet syndrome (TOS) is a condition arising from compression of the subclavian vessels and/or brachial plexus as the structures travel from the thoracic outlet to the axilla. Despite the significant pathology associated with TOS, there remains some general disagreement among experts on the specific anatomy, etiology, and pathophysiology of the condition, presumably because of the wide variation in symptoms that manifest in presenting patients, and because of lack of a definitive gold standard for diagnosis. Symptoms associated with TOS have traditionally been divided into vascular and neurogenic categories, a distinction based on the underlying structure(s) implicated. Of the two, neurogenic TOS (nTOS) is more common, and typically presents as compression of the brachial plexus; primarily, but not exclusively, involving its lower trunk. Vascular TOS (vTOS) usually involves compression of the vessel, most commonly the subclavian artery or vein, or is secondary to thrombus formation in the venous vasculature. Any anatomical anomaly in the thoracic outlet has the potential to predispose a patient to TOS. Common anomalies include variations in the insertion of the anterior scalene muscle (ASM) or scalenus minimus muscle, the presence of a cervical rib or of fibrous and muscular bands, variations in insertion of pectoralis minor, and the presence of neurovascular structures, which follow an atypical course. A common diagnostic technique for vTOS is duplex imaging, which has generally replaced more invasive angiographic techniques. In cases of suspected nTOS, electrophysiological nerve studies and ASM blocks provide guidance when screening for patients likely to benefit from surgical decompression of TOS. Surgeons generally agree that the transaxillary approach allows the greatest field of view for first rib excision to relieve compressed vessels. Alternatively, a supraclavicular approach is favored for scalenotomies when the ASM impinges on surrounding structures. A combined supraclavicular and infraclavicular approach is preferred when a larger field of view is required. The future of TOS management must emphasize the improvement of available diagnostic and treatment techniques, and the development of a consensus gold standard for diagnosis. Helical computed tomography offers a three-dimensional view of the thoracic outlet, and may be valuable in the detection of anatomical variations, which may predispose patients to TOS. This review summarizes the history of TOS, the pertinent clinical and anatomical presentations of TOS, and the commonly used diagnostic and treatment techniques for the condition.

Versatility of supraclavicular artery island flap in head and neck reconstruction of vessel-depleted and difficult necks.

PURPOSE: The advent of microvascular free tissue transfer has given reconstructive surgeons a vast repertoire of treatment options for reconstruction of head and neck defects. However, the success of free flaps in head and neck reconstruction depends on the presence and quality of the recipient vessels in the neck for microvascular anastomosis. The supraclavicular artery island flap can be used to reconstruct a variety of head and neck defects, allowing the reconstructive surgeons to circumvent some of the problems inherent in vessel-depleted necks. The present study reports the use of the supraclavicular artery flap (SCAF) in the reconstruction of vessel-depleted neck and in difficult necks. MATERIALS AND METHODS: The present study was a retrospective study of patients who had undergone reconstruction with an SCAF and who also had a difficult neck or vessel-depleted neck in the head and neck surgery section from 2011 to 2012. Our inclusion criteria were patients treated at our institution with an SCAF who also had undergone multiple previous neck surgeries or patients with severely restricted donor options for soft tissue reconstruction. We excluded any patient for whom we did not have adequate follow-up or if the flap procedure was not performed by the faculty of the head and neck section. RESULTS: We identified 8 patients with a total of 9 SCAFs. One patient received bilateral SCAFs. Of the 8 patients, 6 were men and 2 were women. With the exception of 1 patient, all had received previous radiotherapy to the head and neck region. All the patients had undergone multiple surgical procedures. The flap survival was 100%. However, 2 patients had partial loss of the flap, and 2 had partial donor site wound dehiscence. Our overall complication rate was 38%, including dehiscence of the flap and partial loss of the flap. CONCLUSIONS: The SCAF is a sound option for reconstructing defects in the head and neck region in patients with previous radiotherapy and in multiple neck surgeries. The surgeon and patient should be aware of the high incidence of complications associated with this reconstructive option.

Ultrasound-guided infraclavicular axillary vein puncture is effective to avoid pinch-off syndrome: a long-term follow-up study.

PURPOSE: Pinch-off syndrome (POS) is a serious complication encountered during the long-term management of totally implantable access ports (TIAPs). The aim of this study was to examine the effect of ultrasound-guided infraclavicular axillary vein puncture to avoid POS in patients with long-term use of a TIAP. METHODS: This was a retrospective review of 207 consecutive TIAPs: one hundred devices implanted using an anatomical landmark technique were used as historical controls (Landmark group), while 107 devices were implanted using an ultrasound (US)-guided puncture method (US group). The pinch-off grade (POG) was determined using chest X-ray findings following the definition of Hinke, and the progression of POG during the follow-up period of the Landmark and US groups was compared. RESULTS: Sixteen cases in the Landmark group were POG-1 and 3 were POG-2, while all cases in the US group were POG-0 at the time of venipuncture (p < 0.001). Eleven patients in the Landmark group showed some degree of progression of the POG during the follow-up period. In contrast, there were no cases showing progression of the POG in the US group (p = 0.002). CONCLUSIONS: US-guided infraclavicular axillary vein puncture was found to effectively make it possible to avoid POS for the long-term management of TIAPs, as well as at the time of implantation.

Infraclavicular sensor site: a new promising site for transcutaneous capnography.

BACKGROUND: Transcutaneous measurement of carbon dioxide is routinely done at the earlobe site. In patients receiving non invasive ventilation or in the intensive care setting with necklines, an alternate measurement site would be useful. We started to use the infraclavicular site for transcutaneous measurements of carbon dioxide using a new digital sensor. AIM: Comparison of transcutaneous carbon dioxide with arterial carbon dioxide at the infraclavicular site. METHODS: We retrospectively compared transcutaneous carbon dioxide at the infraclavicular site with arterial carbon dioxide in 50 samples. The Sentec Digital Monitoring System (Sentec AG, Therwil, Switzerland) was used. The V-Sign digital sensor was placed on the infraclavicular site at the medial two third and one third point from the sternoclavicular joint and acromioclavicular joint. RESULTS: When comparing P(c)CO(2) with P(a)CO(2) values, the Bland-Altman analysis revealed a bias of 0.02 kPa (95% CI: [- 0.1; 0.14]) with a precision of 0.42 kPa. Linear regression analysis describes the relationship between the two methods. The slope of the linear model was 0.85 ± 0.04 and the intercept was 0.77 ± 0.21 (RSE = 0.37, R(2) = 0.91). CONCLUSION: The measurement of transcutaneous carbon dioxide at the infraclavicular site is feasible with a digital sensor and has a good correlation with the carbon dioxide values obtained from the arterial blood gas. The findings of the current study form the basis for further clinical studies for its regular application in clinical use.

The supraclavicular artery flap: a versatile flap for neck and orofacial reconstruction.

PURPOSE: The supraclavicular skin is thin and pliable; it closely resembles that of the neck and facial skin, making it the perfect source of tissue for neck and orofacial reconstructions. The author sought to provide a concise compilation of the use of the supraclavicular artery flap, including surgical landmarks, modifications, uses, common complications, and anomalies, and experience with the use of the flap in a sub-Saharan African country. MATERIALS AND METHODS: A literature search was performed on the Internet and PubMed for anatomic and clinical studies/reports in the English language on the supraclavicular artery flap with a minimum of 10 subjects and sufficient data on postoperative complications. RESULTS: Five anatomic studies (2 of which included clinical cases) and 12 clinical series qualified for inclusion. These articles included 146 flaps from 73 cadaveric studies and 376 supraclavicular flaps in patients (including a series of 22 flaps by the present author). The supraclavicular artery was present in 99% of anatomic dissections and was a branch of the transverse cervical artery in 91% of anatomic dissections. Safe margins for elevation of the supraclavicular artery flap were delimited anteriorly by the clavicle, posteriorly by the superior border of the trapezius, and distally by the insertion of the deltoid muscle. Common flap complications included tip and partial flap necroses. The flap was used successfully in nononcologic and oncologic reconstructions, even with concurrent neck dissection. CONCLUSIONS: The pedicled supraclavicular fasciocutaneous flap is emerging as a versatile reconstructive tool for the neck and orofacial regions. It is an excellent option, especially in resource-poor environments and in patients in whom free flaps may be technically difficult. Anatomic and clinical studies have shown it to be consistently reliable, with excellent color matching for the face and neck regions, and have established reliable surgical landmarks, modifications, uses, common complications, and anomalies.