Description

The scapular system of flaps consists of multiple bone and soft tissue free flaps that can be harvested alone or in combination based on a single vascular pedicle (the sub-scapular artery). The most popular is the scapular osteocutaneous flap, which is a type B flap originally described by Swartz et al. in 1986 for mandibular reconstruction (46). The circumflex scapular artery and the thoracodorsal artery are the two main tributaries of the subscapular artery. The circumflex scapular territory includes the lateral border of the scapula and a 500 cm2 area of overlying skin. The thoraco- |

dorsal territory includes the latissimus muscle and the lower slips of the serratus anterior muscle.

Up to 14 cm lateral border of the scapula can be harvested in men based on the 3

circumflex scapular artery. Although the entire lateral border of the scapula is supplied by the circumflex scapular artery, the distal third including the tip is additionally supplied by the angular artery from the thoracodorsal system. Preservation of the thoracodorsal contribution allows the harvest of independent bone segments and ensures viability of the bone distal to shaping osteotomies. The lateral border

Figure 48 Hypertrophic scarring that developed several weeks after harvest of a radial forearm flap in an African-American woman.

of the scapula provides a cylindrical segment of corticocancellous bone that is able to accommodate osseointegrated implants. The diameter of the bone is relatively small compared to the fibula and iliac crest and it is unable to restore the vertical height of the mandible in most cases. Conforming dentures will not be successful, but implant-borne dentures are usually workable.

The fasciocutaneous territory of the circumflex scapular system is extremely large and nearly all the skin of the upper hemiback can be harvested. However, to provide for primary closure of the donor site, the flaps must be limited in size: 6 x 15 cm transverse flap and up to 12 x 20 cm parascapular flap. These flaps can be separated and manipulated independently on their respective arterial vascular pedicles (the transverse and descending branches of the circumflex scapular artery).

The thoracodorsal territory includes the latissimus muscle and overlying skin, and the lower three or four muscular slips of the serratus anterior muscle with the underlying ribs. The latissimus muscle is an extremely broad and thin muscle with the potential for motor reinnervation via the thoracodorsal nerve. The skin is highly dependent upon direct musculocutaneous perforators from the underlying latissimus muscle and only the skin directly over the muscle should be transferred. The serratus anterior muscle originates from the first nine ribs, forming independent bands of muscle that course posterosuperiorly to insert as a broad conjoined tendon onto the medial and inferior borders of the scapula. The lower three or four muscular slips can be transferred as free tissue supplied by branches of the thoracodorsal artery and long thoracic nerve.

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