The P-D-T anatomical classification system for supraclavicular artery perforator flap: technical optimization and clinical validation in 78 head and neck reconstructions

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. 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. 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. 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.