Scapular Osteocutaneous Flap

EDITORIAL COMMENT

This is an excellent technique for reconstruction of the mandible and either overlying skin or intraoral lining. The major drawback of the procedure is the need to reposition the patient, while in iliac-crest or fibula harvesting, the patient may remain supine for the entire procedure.

Scapular and parascapular cutaneous flaps of the back (1, 2, 3, 4, 5, 6) may be combined with the osseous territory of the lateral border of the scapula to provide versatile osteocutaneous free flaps based on the circumflex scapular artery. A wide variety of tissue combinations have been used extensively for head and neck reconstruction of both the mandible and maxilla (7) and also for reconstruction of tibial osseous defects (8).

INDICATIONS

The principal indication for the scapular osteocutaneous flap in head and neck surgery has been mandibular reconstruction. Osseous defects of the mandible of up to 14 cm, in conjunction with large cutaneous or intraoral mucosal defects, are well suited for this application. Great freedom in spatial orientation of skin and bone is allowed. Through-and-through defects of the cheek, combined with sagittal mandibular defects, also can be reconstructed with this flap, as can anterior mandible defects (9). The length of the vascular pedicle easily reaches the external carotid system under most conditions. In addition, the scapular bone can be used for the maxilla and the infraorbital rim in maxillectomy defects. A great amount and variety of soft tissues are available for restoring cheek skin, palatal tissue, or obliteration of the maxillary sinuses.

ANATOMY

The blood supply to the lateral border of the scapula is derived from a descending branch of the circumflex scapular artery just before its emergence through the triangular space, where it then arborizes to supply the cutaneous circulation. The distal third of the scapula is supplied additionally by the terminal branches of the thoracodorsal artery (Fig. 201.1). This anatomic relationship is important when planning osteotomies of the distal third of the scapula: If the thoracodorsal circulatory system is not included in the flap, osteotomies in the distal third risk necrosis of the bone. The entire border of the scapula, including the tip, may be well served by the proximal blood supply, provided that osteotomies in the distal third are not performed.

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