Indications

The scapular system of flaps provides a huge amount of tissue with multiple components that can be transferred based on a single vascular pedicle (the subscapular artery). Rarely is such an enormous amount of tissue required. However, such a flap

Figure 49 The subscapular system of flaps is extensive with multiple components all based on the subscapular vessels. Although rarely needed, this megaflap includes transverse and parascapular skin paddles, scapular bone, musculocutaneous latissimus flap, and serratus muscle and underlying rib.

is useful for a combined composite defect of the tongue, floor of mouth, mandible, and neck skin. The mega flap would consist of a transverse scapular flap (tongue), a parascapular flap (chin/cheeks), the lateral scapula (mandible), and a musculocutaneous latissimus flap (neck) (Fig. 49).

Most patients require only certain components of the scapular system alone or in combination. The most useful flap within the circumflex scapular system is the osteocutaneous scapular (parascapular) flap consisting of scapular bone and an associated fasciocutaneous flap for composite mandibular defects (Fig. 50). Although the bone is too short for extensive mandibular defects, it is capable of reconstructing anterior or lateral defects up to 14 cm in length. An osteocutaneous flap is also suitable for reconstruction of complex composite midfacial defects (e.g., radical maxillectomy with an overlying cheek defect). The lateral wall of the nasal cavity and facial skin defect is closed with the parascapular and transverse fas-ciocutaneous flaps while the alveolar ridge and hard palate are reconstructed with the scapular bone. The thinner medial portion of the scapula can also be used for reconstruction of the floor of the orbit.

The fasciocutaneous flaps alone are useful for simple soft tissue coverage, through-and-through defects of the cheeks, or as a filler or barrier in their fascial or de-epithelialized forms. The scapular fasciocutaneous flap is a second-line alternative in covering surface skin defects of the scalp and lateral skull base because of bulk and color problems (Fig. 51). The combination of transverse and parascapular flaps

Figure 50 An osteocutaneous scapular flap. The bone is relatively short compared to the fibula and iliac crest.

is useful for through-and-through defects owing to their capacity for complete separation and maneuverability. The de-epithelialized or fascial flap is a first-line alternative for filling subcutaneous deficiencies in the face secondary to trauma or hemifacial microsomia.

The latissimus musculocutaneous flap is useful for extensive hemifacial or cervical cutaneous defects. The latissimus muscle with a split-thickness skin graft is the method of choice for reconstruction of extensive surface defects of the scalp. A musculocutaneous free tissue transplant is described for functional tongue reconstruction after subtotal or total resection (59). The fibers of the latissi-mus muscle are oriented transversely and secured to the angles of the mandible to create a mound of skin and muscle at the level of the soft palate. The thoraco-dorsal nerve is anastomosed to the hypoglossal nerve and subsequent movement of the flap towards the soft palate occurs during speech and swallowing. The movement is quite gross but improvements in articulation and swallowing are reported compared to patients reconstructed with nonfunctional tissue.

The latissimus muscle has recently been described as a single-stage method for reanimation of the paralyzed face (60). The thoracodorsal nerve is able to reach |

the opposite face (and donor facial nerve branches), obviating the need for cross-face nerve grafting. In the report by Harii et al., the muscle acquired functionality c at a mean of 7 months postoperatively, which is better than expected based on ^

clinical experience using nonvascularized nerve grafting techniques. The serratus anterior muscle is more typical of free muscle transplants for facial reanimation. The lower three slips of the serratus anterior muscle are useful for facial reanimation. Preservation of the insertions and nerve supply (long thoracic nerve) of the upper muscular slips is important to prevent winging of the scapula. This will

Figure 51 Scapular fasciocutaneous flap used to resurface a lateral skull defect. Note the transverse skin flap pedicled on its feeding vessels coming from deep within the triangular -g space (upper photo). Intraoperative and postoperative results depicted in lower photos.

result in a relatively short nerve pedicle, but preserving the upper long thoracic c nerve must take priority. Cross-face nerve grafting is usually required several ^

months prior to flap transfer.

The serratus anterior is occasionally harvested with the underlying sixth and seventh ribs for composite defects in the head and neck. Combined latissimus muscle (with or without skin) and serratus anterior myo-osseous flaps are described for large composite defects of the mandible and scalp (61). The main benefit of @

this combination is that the musculocutaneous component can be completely separated and maneuvered independently from the myo-osseous component.

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