Abstract
BACKGROUND: The supraclavicular artery perforator (SAP) flap represents an excellent option for head and neck reconstruction; however, anatomical variability of the supraclavicular artery (SCA) impedes surgical standardization. This study aimed to establish a P-D-T (Pectoral-Deltoid-Trapezius) anatomical classification system based on vascular trajectory, validate the “point-line antegrade dissection” (PLAD) technique, and evaluate the impact of classification types on shoulder function and flap tolerance to prior radiotherapy. METHODS: We retrospectively analyzed 78 patients (80 flaps) undergoing SAP flap reconstruction between June 2016 and June 2025. Follow-up was censored on December 31, 2025. The P-D-T classification was established through cadaveric dissection of 20 hemibodies. Corrected pharyngocutaneous fistula rate was calculated among 65 digestive tract reconstructions. Radiation analysis included 59 patients (irradiated: 16; non-irradiated: 43). Shoulder function was assessed using Quick-DASH in 48 patients with minimum 6-month follow-up. RESULTS: The 80 flaps were classified as Type I (Pectoral, 16.25%), Type II (Deltoid, 72.5%), and Type III (Trapezius, 11.25%). Overall flap survival was 98.75% (79/80), with corrected fistula rate of 6.2% (4/65). No significant difference in complication rates was observed between irradiated and non-irradiated groups (12.5% vs. 9.3%, P = 0.658). Quick-DASH scores differed significantly among types (P = 0.019); Type II showed higher scores than Type I (16.2 ± 7.3 vs. 9.1 ± 2.8, P = 0.017), but this difference (7.1 points) remained below the MCID threshold of 12–15 points. CONCLUSIONS: The P-D-T classification combined with the PLAD technique enables precise SAP flap harvest. Preliminary findings support the feasibility of SAP flap in irradiated necks, demonstrating a complication profile comparable to non-irradiated cases, though validation in larger cohorts is warranted. Type II flaps demonstrate statistically significant but clinically mild shoulder functional impact.