Master Techniques in Otolaryngology - Head and Neck Surgery: Reconstructive Surgery, 1ed.

18. Management of the Composite Through-and- Through Defect: Scapular Free Flap

Brian B. Burkey

INTRODUCTION

Large composite defects of the head and neck produced by extensive surgical ablation or trauma can pose a distinct challenge for the reconstructive surgeon. In particular, the three-dimensional reestablishment of juxtaposed skin, soft tissue, and bone requires careful tissue importation and realignment to ensure an appropriate return of form and function.

Multiple methods of reconstruction are available for large composite tissue defects. Previously, soft tissue muscular regional flaps, such as the pectoralis major myocutaneous flap, trapezius flap, sternocleidomastoid flap, latissimus dorsi flap, and platysma flap, were used to repair the soft tissue defect, and the mandible was repaired with a plate or left to “swing.” However, over the last 25 years, the vascularized transfer of both bone and soft tissue (osteocutaneous and osteomyocutaneous free flaps) has become a widely used and successful means for single-stage reconstruction of the composite tissue defect. Urken et al. reported a high success rate of 96% for oromandibular microvascular reconstruction. Vascularized bone reconstruction yields optimal results for several reasons: (1) Reconstruction of an osseous defect with similar tissue provides the most ideal construct to retain its three-dimensional form; (2) vascularized bone is able to sustain the inherent mechanical forces and structural demands required; and (3) vascularized bone has a greater ability to survive in the bacteria-rich environment of the head and neck.

The osteocutaneous and osteomyocutaneous free flaps most often used by head and neck reconstructive surgeons for composite tissue reconstruction are the iliac crest–internal oblique flap, scapula flap, and fibula flap. Among these, the scapula flap provides a substantial amount of skin, muscle, and bone, which are able to be harvested and are uniquely oriented to fill large defects. For this reason, the scapula flap is ideal for reconstruction of large composite defects and is the most versatile of the bone-containing flaps.

The scapular flap, based on branches of the circumflex scapular vessels, and its use in free tissue transfer were first described by dos Santos in 1980. Shortly thereafter, Swartz and Sullivan described the use of this flap in nearly 60 patients for both maxillary and mandibular reconstruction, establishing its role in reconstruction of various defects in the head and neck.

Anatomy

The vasculature of the scapular and parascapular fascia and skin, latissimus dorsi muscle, and medial, lateral, and tip segments of the scapula bone emanate from the subscapular arterial arcade. The axillary artery branches into the subscapular artery and then to a posterior branch called the circumflex scapular artery (CSA). However, in 3% of cadaver dissections, the CSA originates directly from the axillary artery. The subscapular artery further branches into a descending branch called the thoracodorsal artery (TDA), which supplies the latissimus dorsi muscle, with several branches extending to the serratus anterior muscle, allowing for use of both muscles on the same pedicle.

The CSA is found at the midlateral border of the scapula, passing posteriorly and under the subscapularis muscle. The artery curves around the lateral aspect of the scapula and emerges at the omotricipital space, a triangle created by the long head of the triceps muscle, the teres major muscle, and the teres minor muscle. This triangle can frequently be palpated as a depression just lateral to the scapular bone near its midpoint. By this point, the artery has provided branches to the subscapularis, teres major and minor, and infraspinatus muscles. The artery projects through the triangle and sends a branch to vascularize the lateral corticocancellous scapular bone prior to emerging from this space. These branches supply the periosteum of the scapula. Two main fascio-cutaneous branches then extend to form the scapular (transverse) and parascapular (descending) vessels. The horizontal scapular artery runs about 2 cm inferior to the spine of the scapula toward the spine. The descending branch runs approximately 2 cm medial and parallel to the lateral scapula border toward the scapula tip. These vessels define the two large fasciocutaneous paddles that may be harvested with the circumflex scapular system. These paddles may be harvested either separately or together and may incorporate the skin overlying the latissimus dorsi muscle.

The CSA averages 4 mm wide at its origin and may range between 2 and 6 mm in diameter. The artery is accompanied by two venae comitantes that usually converge before draining into the axillary vein, but the venous drainage may be variable in position and pattern. The length of the pedicle from the lateral border of the scapula is approximately 6 cm. About 2 to 3 cm of pedicle length exists between the scapular border and the fasciocutaneous segment. This allows the skin segment independent maneuverability from the bone, which is the defining characteristic of this flap and the advantage it has over all of the other osseous flaps.

The skin segments are classified as fasciocutaneous flaps that are supplied by vertical perforators from the fascial layer deep to the subcutaneous adipose tissue. A subcutaneous vascular plexus additionally supplies the skin. Therefore, the flap may be peripherally debulked of subcutaneous adipose tissue and fascia, although care must be taken when doing this to protect any dominant perforators. Additionally, the fasciocutaneous segment may be divided into separate skin islands based on the dominant perforators.

The lateral aspect of the scapular bone is harvested with the lateral circumflex system, starting just inferior to the glenohumeral fossa. Typically, the bone is 1.5 cm thick, 3 cm wide (as the bone is cut at this distance from the lateral edge), and 10 to 14 cm long. The bone is thinnest at the midpoint of the scapula, which may pose a significant drawback to this flap. The tip of the scapula is supplied by the angular branch of the TDA and may be confidently harvested with the inclusion of this vascular branch. The tip can then be left attached to the lateral border of the scapular bone or can be detached on its own pedicle, the latter allowing for a second piece of bone with this flap that can be placed well distant (>10 cm) from the primary bone segment.

Finally, the latissimus muscle or muscle and overlying skin, and/or the serratus muscle, can be harvested with this flap with the inclusion of the TDA, by taking the flap vessels at the subscapular artery and vein (the “megaflap”). This muscle and additional soft tissue may then be used to fill large soft tissue defects in the parapharyngeal space and neck, all with tissue from one harvest and on one vascular system demonstrating the unique ability of this versatile flap and vascular system.

Patients typically present with complex tumors, benign and malignant, or trauma involving the head and neck. The scapula free flap is ideal for large, composite tissue reconstruction. Typically, these patients have through-and-through defects or anticipated defects involving the maxilla and/or the mandible (requiring skin, bone, and mucosal reconstruction). This flap is ideal in these circumstances because it affords the ability for osseous reconstruction coupled with simultaneous fasciocutaneous coverage by two large cutaneous paddles, which may be placed distant from the bone.

A history of prior shoulder surgery should be investigated, including rotator cuff surgery, as this may damage the vasculature of the flap. Also, inquiries about prior neck surgery may give clues to preexisting damage to neck recipient vessels or to cranial nerve (CN) XI. The latter may cause significant shoulder dysfunction prior to and after harvest of the scapular flap and is a relative contraindication to the ipsilateral use of this flap.

A thorough examination of the defect site is required, along with necessary imaging to determine the extent of the defect. Preoperative shoulder function should also be evaluated. Detachment of the teres major muscle during harvest may hinder a preoperatively weak shoulder girdle. As previously noted, patients should be identified who have had a previous ipsilateral radical neck dissection with sacrifice of the spinal accessory nerve or other surgery or trauma to the scapular area.

The benefit of this flap is its great versatility. The flap affords the advantages of a variety of different muscle, bone, and skin paddle components that may be customized to reconstruct a large composite defect. Additionally, there is a relative maneuverability of these segments allowing added ability to inset tissues as needed, without undue tension on individual segments.

In my practice, this flap has four specific uses. First, patients with through-and-through defects of the oromandibular complex, and/or with facial skin defects extending superior to the oral commissure, will require extensive intraoral and extraoral soft tissue reconstruction that is not possible with any other osseocutaneous flap. In these defects, the dual skin paddles are particularly useful with one skin paddle being used to line the intraoral mucosal defect, while the other can be used for soft tissue or skin reconstruction of the extraoral defect. Obviously, simultaneous bone reconstruction may also be achieved by the same flap should the defect involve a segmental mandibulectomy. The cheek area superior to the oral commissure can be repaired without tension due to the freedom of the skin paddle from the bone segment.

Second, I use this flap in patients who require osseous reconstruction but have severe lower extremity atherosclerotic disease and/or diabetic sequelae preventing the use of a fibula free flap. If preoperative vascular imaging (such as by magnetic resonance angiography) finds significant bilateral lower extremity vascular disease that puts the fibula flap or the lower leg at risk of insufficiency, my flap of choice is the scapula free flap. The iliac crest–internal oblique donor site can be quite morbid due to gait changes and hernia, and the skin component is often quite thick in Western populations and therefore I prefer the scapula flap over the iliac crest flap despite the inability of a two-team approach.

Third, patients who may need a “megaflap” for an abundance of skin and soft tissue required for adequate reconstruction along with bone are good candidates for this flap. The scapula free flap allows the unique ability to harvest the scapular (transverse) and parascapular (descending) skin paddle systems, along with the thoracodorsal system, as a single unit. The thoracodorsal system may be simultaneously harvested to create a “megaflap” that provides latissimus dorsi and serratus anterior muscles and overlying skin for reconstructing massive soft tissue defects. Generally, the harvest site is able to be closed primarily given the laxity of the skin of the back.

Finally, I prefer this option in patients who have extensive maxillectomy defects, which require reconstruction of the orbital floor, skull base, palate, and cheek soft tissue/skin. The thinner bone of the tip of the scapula is ideal for reconstruction of the orbital floor, while the thicker bone can be used for the reconstruction of the maxilla, malar eminence, alveolus, medial buttress, or lateral buttress. The dual skin paddles are useful as one paddle may be deepithelialized for soft tissue filling while the other is used for lining of the palate or replacement of the skin of the cheek depending on the exact requirements of the defect.

The versatility of the scapula flap is afforded by providing two large skin paddles and bone. However, there is no innervation or nerve graft accompanied with the scapula flap. Therefore, this flap cannot be used where reinnervation is planned. The flap harvest may add additional morbidity to an individual who has ipsilateral preexisting shoulder compromise from prior shoulder surgery or CN XI sacrifice. In this situation, the contralateral side or a different flap may be better choices. It should be noted that harvesting the scapula flap in patients without this history has no long-term effect on shoulder function or mobility.

Due to the relative short width and bulk of the harvested bone (2 to 3 cm), dental rehabilitation with implants will probably not be achievable. Additionally, if the amount of bone length required is greater than 14 cm (i.e., greater than angle-to-angle reconstruction), then the scapula may not provide enough bone length. In these situations, the fibula free flap may offer greater cortical bone thickness for implant placement and bone length for reconstruction of a very large bone segment.

A thorough preoperative medical evaluation should be pursued in patients who are potential candidates for this flap, particularly patients with cancer of the head and neck as they are at high risk for perioperative and postoperative complications including pulmonary embolism, alcohol withdrawal, stroke, pulmonary insufficiency, pneumonia, myocardial infarction, and deep vein thrombosis. Ideally, malnutrition and hypothyroidism should be corrected preoperatively to aid in healing.

Patients who have undergone previous significant head and neck surgery should obtain preoperative imaging with computed tomography angiography to determine the patency of recipient vessels. In particular, in patients who have had neck dissection with resection of the internal jugular vein, the contralateral neck should ideally be used for recipient vessels. Preoperative imaging of the subscapular vascular system is not necessary. In my experience, these vessels are rarely affected by atherosclerotic disease or congenital anomalies, and the vessels are well suited for anastomosis to recipient vessels in the neck.

Importantly, surgical planning must include a discussion among the entire ablative and reconstructive surgical teams regarding intraoperative positioning of the patient and the sequence of surgical procedures. Although it is possible to perform some of the harvest during the tumor resection, this requires cordial interaction among the surgeons so that typically the harvest is performed at the conclusion of the tumor resection and vessel preparation in the neck. This lack of a simultaneous two-team approach is the major disadvantage of the scapular system of flaps.

A physical therapy evaluation should be obtained preoperatively to document shoulder girdle function, range of motion, and strength. Physical therapy exercises should be maintained in the postoperative period.

The operating bed is equipped with a bean bag, prior to the patient arriving in the operating room. The patient is placed in the supine position, and general anesthesia is accomplished. The patient is then rolled into a lateral decubitus position to expose the axilla and the midline spine. The ipsilateral arm is left free of IVs and other attachments to allow its full sterile prep in the field. A clothed 1-L bag of IV solution is then placed under the side of the patient, approximately 12 cm inferior to the axilla, to avoid compression of the brachial plexus during the case. The bean bag is deflated to maintain the patient in this position, and the sterile prep is then carried out to include the entire head and neck and back within a single surgical field. Drapes are placed and the patient is allowed to roll back into the supine position, and the oromandibular resection is carried out by the extirpative team. The patient is then rolled back into the lateral decubitus position and the bean bag used to maintain the patient in this position, as before.

The scapula osteocutaneous flap is usually harvested with a single segment of bone from the lateral border and two skin paddles. This description focuses on that procedure, with small comments made for other flap variations. The lateral border and tip of the scapula are outlined and the ipsilateral arm extended (Fig. 18.1A) The omotricipital triangle is palpated, and the presumed site of the artery is marked. The superior border of the skin incision is marked approximately 2 cm inferior to the scapular spine and extending as far medial as necessary for size and is extended laterally just beyond the tip of the omotricipital triangle. Larger skin paddles are encouraged until the surgeon is experienced, in order to accommodate all of the major skin perforators. The medial skin incision is drawn from the lateral tip of the previous incision and extending inferiorly approximately 4 cm lateral to the lateral border of the scapula, again as far as is necessary for the reconstruction. Curvilinear borders to the individual skin paddles are then drawn and allowed to connect over the body of the scapula, so that the skin paddles are harvested as one unit and only divided once the harvest is complete and the requirements for the inset determined (Fig. 18.1B).

FIGURE 18.1 Skin paddle design and elevation. A. Design of scapular and parascapular skin paddles over the left scapula Note the outline of the scapular spine and the scapular tip. B. The skin paddles have been incised to expose the underlying soft tissue, but the skin connection is maintained laterally.

The skin and subcutaneous tissues are then incised down to muscle or the fascia of the infraspinatus, as appropriate, and elevated in this plane from medial to lateral. Of note, I leave the very lateral edge of the skin intact initially to avoid inadvertent disruption of the skin segment. The skin is elevated to the lateral border of the scapula and then stopped to avoid disruption of the cutaneous pedicle. Usually, these pedicles can be identified on the underside of the flap during elevation. Likewise, the skin is elevated off of the deltoid, latissimus, and teres muscles and the latissimus muscle retracted inferiorly (Fig. 18.2). If a latissimus myocutaneous flap is to be harvested as part of a “megaflap,” the skin segment should be outlined and the latissimus flap can be harvested to the edges of the scapula at this time, with final connections made at the conclusion of the scapular harvest.

FIGURE 18.2 Skin paddle elevation is completed with the delineation of the latissimus muscle (arrow) inferiorly and the teres major muscle superiorly.

The teres major muscle is now isolated in 360-degree fashion near its insertion on the lateral scapular border and divided with care not to injure underlying vessels. The muscle can then be retracted with a Deaver retractor. The arm is retracted laterally and rotated internally, thus exposing the contents of the axilla. The proximal CSA can now be identified with its venae comitantes, running laterally into the axilla from the lateral border of the scapula. Fascial attachments can be divided over the vessels and the vessels followed into the axilla. The branches to the teres major must be divided to allow further dissection. I prefer small and medium clips to control these vessels. The TDA can be identified at this point going inferiorly, along with its branch to the scapular tip. If the harvest of the scapular tip and/or the latissimus flap is desired, the TDA is left intact. Likewise, if I feel that the length and caliber of the vessel are sufficient with the harvest of just the CSA, further dissection of the vessel is not necessary. Otherwise, the TDA pedicle is divided, and the artery and venae comitantes are followed to the subscapular vessels. Again, usually the venae comitantes form one vein, which may then divide prior to entering the axillary vein. Meticulous dissection and hemostasis are critical at this point to allow identification of all anatomic structures and avoid injury to the vessel. Blunt dissection is discouraged, and hemostasis can be aided by the use of bipolar cautery.

Once the vessels are identified and freed in 360-degree fashion from the axillary vessels to the lateral border of the scapula, the harvest of the bone can begin. The glenohumeral joint is palpated, and the superior border of the bone harvest is defined 1 to 2 cm inferior to this landmark. The required length of bone is then measured, with some leeway, and marked. If the tip is to be included, it is best to preserve the angular vessels and so dissect these free from the tip to the proximal pedicle. A bone width of 3 cm is then measured from the lateral border, and incisions are now carried through the infraspinatus muscle to isolate the bone margins, with division of the periosteum. This area is relatively vascular, and the patience of the surgeon is necessary to gain complete control of periosteal vessels. The superior bone margin has several large vessels nearby, and these are near the vascular pedicle, so careful control in this area is especially important. Once defined, osteotomies are carried out with a sagittal bone saw, with care not to injure the vascular pedicle, which should be protected with small retractors during this maneuver. Finally, the bone is released, and now incisions are carried just deep to the bone, through the subscapularis muscle, again with care to visualize and not to injure the vascular pedicle. Once the bone is released, bleeding is controlled and final soft tissue attachments at the skin/adjacent flaps are divided, and any further dissection required on the proximal pedicle is completed. The flap is now ready for harvest with the transection of the CSA or subscapular vessels. The donor vessels should be controlled with permanent 2-0 silk sutures.

Meticulous hemostasis is assured, and closure of the incision is begun. Small drill holes are placed in the new lateral border of the scapula approximately 2 cm apart, and the teres major muscle is now approximated with 2-0 absorbable sutures (PDS or Vicryl). The skin is widely undermined and closed in layers over flexible drains, which are placed to bulb suction. The patient is now rotated into the supine position for reconstruction. A sterile dressing can be applied now or at the conclusion of the case. The surgical defect is now inspected (Fig. 18.3).

FIGURE 18.3 A through-and-through composite defect of the anterior oromandibular region, as viewed from inferiorly. Note the remaining lateral mandibular segments and the small remnant of the base of the tongue.

An osteotomy may be necessary during plating of the scapular bone (Fig. 18.4). The blood supply of the bone is primarily through the periosteum, and therefore, at the site of a closing ostectomy, the periosteum should be carefully conserved and osteotomies made with a saw or Rongeur biting forceps. The superior bone is the thickest and will require a saw, but the more inferior bone can occasionally be divided with the biting forceps. It should be noted that the pedicle to the bone usually enters at the more superior location. If the angular artery to the tip is preserved, this section of the bone may be completely detached from the remainder of the bone and moved on its separate vascular pedicle.

FIGURE 18.4 The osseous reconstruction of the composite defect. A. The composite defect with a reconstruction plate and the scapular bone in place, viewed from laterally. Note the connected skin paddles suspended and draped inferiorly. B. The same view from above, after closing ostectomies were performed and plating of the scapula bone segments.

Once the bone is in place in the recipient site, the vessels are anastomosed and the flap is revascularized. This is generally relatively easy given the large caliber and excellent quality of the flap pedicle. The skin paddles can now be divided into the sizes required by the reconstruction (Fig. 18.5). The pedicle to the skin paddles can be identified visually or with Doppler, and incisions are made appropriately. The skin and soft tissue can be divided down to the deep fascia as this is the layer with the blood supply. This allows for mobilization of the skin paddles from each other and from the bone segment of the flap, allowing for complex three-dimensional reconstructions, as noted previously.

FIGURE 18.5 The cutaneous reconstruction of the composite defect. A. The skin paddles have been separated and one placed externally, in the area of the mentum, as seen from this lateral view. B. The other skin paddle is placed intraorally to reconstruct the anterior tongue defect.

Postoperative flap monitoring is particularly important to observe for warning signs of venous congestion and arterial insufficiency. This is most commonly accomplished by continuous monitoring with a handheld Doppler and physical examination of the visible skin paddle. Hematoma, infection, or dehiscence of the incision may compromise the flap, which mandates surgical exploration. If vascular compromise is evident, the flap pedicle and anastomosis should be explored in an effort to salvage the flap. The drain is removed when output is less than 30 mL per 8-hour period, for 3 consecutive periods.

In the initial postoperative recovery, the ipsilateral arm should be positioned anteriorly and medially, usually supported on the patient’s abdomen by a pillow. Once the patient is ambulating, the arm is supported by a shoulder sling, which supports the elbow and prevents inferior drift of the arm. Inpatient physical therapy is initiated once the patient is mobile. A postoperative physical therapy regimen is established with the patient to be maintained after hospital discharge. The sling is used for 2 to 3 weeks and physical therapy maintained until postoperative function is optimized, usually 4 to 6 weeks.

Patients are typically discharged from the hospital 5 to 10 days after surgery, depending on their postoperative course and comorbidities. Close outpatient follow-up after discharge is recommended for evaluation of surgical sites.

There are few complications related to this approach; however, the most important aspect of the scapular reconstruction is related to the vascular anatomy. When planning a flap that requires both a bone graft and a latissimus muscle, the subscapular system must give rise to the thoracodorsal vascular system. If the thoracodorsal system has a separate takeoff (from the axillary vessels), then the combined flap (megaflap) cannot be harvested as a single flap. This will require two separate microvascular anastomoses. This vascular anomaly can only be determined with certainty at the time of surgery.

Multiple authors in their published series of cases have demonstrated excellent success using the scapula osteocutaneous free flap. Swartz et al. demonstrated the application of this flap in 26 patients with large defects secondary to cancer surgery or severe trauma. Five patients underwent reconstruction for maxillectomy defects and 21 for complex composite oromandibular defects. Their report described the multiple and versatile flap orientations to reestablish these complex three-dimensional defects, while having no flap failures. Osteotomies performed did not adversely affect the vascularity of the bone as long as the periosteum was maintained intact. Only two patients in their series developed difficulties with shoulder motion due to noncompliance with postoperative range of motion physical therapy exercises.

Sullivan et al. described the use of the scapular free flap in 36 patients. Three patients suffered flap failure due to arterial insufficiency, venous thrombosis, and gross contamination of the neck due to fistula. They demonstrated osseous reconstruction of angle-to-angle defects of up to 14.5 cm in length in two patients; however, in most patients, the upper limit of harvestable bone length is 14 cm. Multiple skin paddles were used in many of the reconstructions. Six months postoperatively, all patients stated that their shoulder was functional but half had mild to moderate shoulder limitations, particularly in abduction and external rotation. The authors found that noncompliance with physical therapy and preoperative accessory nerve function was important as a predictor of postoperative shoulder dysfunction.

Coleman and Sultan further advanced the versatility of the scapula free flap by defining the angular vascular pedicle that supplies the inferior aspect of the lateral scapula. This allows the distal tip of the scapula to be safely harvested in continuity or used as a second free vascularized bone segment.

In my experience, the scapula osteocutaneous free flap is an ideal choice for the reconstruction of complex osseous and soft tissue defects. Its versatility is due to its dual soft tissue skin paddles and ample bone to reconstruct complex oromandibular, maxillary, and lateral skull base defects. Because of this versatility and its minimal harvest site comorbidities, the scapula free flap became used more commonly than other methods of osseous free tissue transfer in my practice.

In my series, the mean bone length that was harvested was 8.4 cm (range 6 to 12 cm), and the mean cutaneous area harvested was 109 cm² (range 48 to 240 cm²). Compared to the iliac crest and fibula free flaps, the scapula free flap provided similar bone length while supplying significantly larger skin and soft tissue paddles (up to double in overall area) that were further able to be divided into separate vascularized islands. The ability to harvest multiple and maneuverable skin paddles gives this flap a distinct advantage over other osteocutaneous reconstructive options. Among 24 scapula free flaps, I have experienced one flap failure, and all donor sites were able to be successfully closed primarily. An objective study of shoulder limitations postoperatively (average 17.6 months) showed only minimal reductions in strength and range of motion. Subjectively, most patients stated that their activities of daily living were limited minimally or not at all.

Given the above described experiences, the scapula free flap is a superb choice for vascularized osteocutaneous reconstruction of complex defects. It bears significant reconstructive potential with minimal postoperative morbidity. In particular, the flap is ideal for the reconstruction of complex oromandibular and maxillectomy defects.

• Maintaining meticulous hemostasis and excellent visualization during the flap harvest is critical to the success of this operation. Retraction with a large retractor (e.g., Deaver) in the axilla is encouraged, as is adequate personnel to provide this retraction.

• The scapula osteocutaneous free flap is a versatile flap based on branches of the circumflex scapular vessels.

• A wide reconstructive potential is available due to this flap’s large dual skin paddles and bone component. Particularly, the skin islands and bone have separate vascular pedicles, allowing for variable orientations.

• The flap may be harvested in conjunction with the latissimus dorsi musculocutaneous flap with the incorporation of the thoracodorsal vessels (“megaflap”). In this case, the proximal pedicle is the subscapular vessels.

• The flap is ideal for reconstruction of (1) through-and-through composite defects of the oromandibular complex, involving resection of the mandible and intraoral and extraoral soft tissue/skin/mucosa and (2) complex and extensive maxillectomy defects that require reconstruction of the orbital floor, skull base, palate, and cheek soft tissue/skin.

• The scapula osteocutaneous flap is most useful where the soft tissue needs of the reconstruction surpass the capabilities of the radial forearm osteocutaneous and/or fibula osteocutaneous flaps. In this situation, the time to harvest the scapula flap outweighs both the harvest of a second flap and the potential complications that accompany trying to put an inadequate flap under tension in the oromandibular region.

• This flap should be considered in patients requiring osseous reconstruction but who have significant lower extremity atherosclerotic disease preventing the use of the fibula free flap.

• The use of postoperative physical therapy is essential for maintaining shoulder mobility and range of motion.

• Previous surgery in the axilla or shoulder may have caused injury or scarring to the flap vessels and may increase the risk of flap loss. In general, avoid harvest on the side of previous neck dissection.

• The risk of dissection in the axilla during harvest of the scapula flap should not be underestimated. Large vessels and/or the brachial plexus are in the field, and the surgeon should only undertake this operation after previous experience, best obtained in the cadaver lab.

• The bone stock that can be obtained with this flap is a relative disadvantage in those few patients where the future use of implant-borne dentures or other prostheses is likely. The iliac crest–internal oblique flap may be the best option in some of these cases.

• A major drawback of this flap is the need for intraoperative repositioning that is required for harvesting the flap.

• Standard head and neck surgery set

• Reciprocating saw

• Mandibular plating set

• Rongeur biting forceps

I gratefully acknowledge the assistance of Rahul Seth, MD, during the preparation of this manuscript. His effort and expertise made the completion of this work possible.

SUGGESTED READING

Rowsell AR, Davies DM, Eisenberg N, et al. The anatomy of the subscapular-thoracodorsal arterial system: study of 100 cadaver dissections. Br J Plast Surg 1984;37(4):574–576.

Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77(4):530–545.

Sullivan MJ, Baker SR, Crompton R, et al. Free scapular osteocutaneous flap for mandibular reconstruction. Arch Otolaryngol Head Neck Surg 1989;115(11):1334–1340.

Sullivan MJ, Carroll WR, Baker SR, et al. The free scapular flap for head and neck reconstruction. Am J Otolaryngol 1990;11(5):318–327.

Burkey BB, Coleman JR Jr. Current concepts in oromandibular reconstruction. Otolaryngol Clin North Am 1997;30(4): 607–630.

Coleman SC, Burkey BB, Day TA, et al. Increasing use of the scapula osteocutaneous free flap. Laryngoscope 2000;110(9):1419–1424.