Plastic & Reconstructive Surgery:
The Scapular Tip Osseous Free Flap as an Alternative for Anterior Mandibular Reconstruction
Hanasono, Matthew M. M.D.; Skoracki, Roman J. M.D.
Department of Plastic Surgery; University of Texas M. D. Anderson Cancer Center; Houston, Texas
Presented at the American Society for Reconstructive Microsurgery 2010 Annual Meeting, in Boca Raton, Florida, January 9 through 12, 2010
Correspondence to Dr. Hanasono, Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 443, Houston, Texas 77030, firstname.lastname@example.org
Anterior segmental mandibular defects resulting from oncologic resection are reconstructed with vascularized bone whenever possible. For anterior mandibular reconstruction, the fibula free flap is the method of choice for many surgeons. In patients who are not candidates for a fibula free flap caused by injury or stenosis of the lower extremity vessels, the iliac crest free flap is advocated by some but can only be used for defects smaller than 12 cm, and its blood supply may also be compromised in patients with vascular disease.
We have successfully used the scapular tip osseous free flap for anterior mandibular reconstruction in seven patients with peripheral vascular disease precluding fibula free flap harvest. These cases are novel in that the inferior angle of the scapula is oriented transversely and used to recreate the anterior mandible, obviating the need for bony osteotomies. This flap is based on the angular branch of the thoracodorsal artery rather than the circumflex scapular artery, which is the traditional blood supply of the scapular flap.1,2 The angular branch can reliably supply up to 20 cm of bone from both the medial and lateral scapula, compared with 12 cm of bone in the traditional scapular flap.3 The pedicle length can reach 17 cm if the subscapular vessels are included, which is considerably longer than the length of pedicle in the traditional scapular free flap (approximately 6 cm).3–5
The flap is harvested with the patient in the lateral position. The angular branch pedicle originates from the thoracodorsal artery and lies within a submuscular fat pad beneath the latissimus dorsi and teres major muscles (Fig. 1). To increase the pedicle length and incorporate other free flaps (e.g., parascapular, latissimus dorsi myocutaneous, and/or serratus anterior muscle/myoosseous) as part of a chimera, the dissection may extend to the subscapular artery and vein.
The rhomboid major and teres major muscles are partially released from the medial and lateral borders of the scapula, respectively. The infraspinatus muscle is also partially elevated from the superficial surface of the scapula. Osteotomies are made and the flap is oriented in the transverse direction such that the inferior tip of the scapula replaces the mentum of the mandible and the superficial surface of the scapula is oriented cephalad (Figs. 2 through 4). The flap is inset into notches cut into the native mandible bilaterally, creating tongue-in-groove joints, and secured with titanium plates. The teres major and rhomboid major muscles are reattached with sutures to the remaining scapula.
A drawback associated with the scapular tip free flap is that the location of the scapula precludes a simultaneous two-team approach to mandibular resection and flap dissection. However, harvest of this flap is straightforward and rapid. Another limitation is that the bone thickness of the scapular tip free flap is usually inadequate to accommodate osseointegrated implants and therefore we reserve this technique for patients who are not candidates for fibular free flap reconstruction. In our experience, no patients developed scapular winging or limited shoulder movement.
Matthew M. Hanasono, M.D.
Roman J. Skoracki, M.D.
Department of Plastic Surgery
University of Texas M. D. Anderson Cancer Center
The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for the work presented in this article.
1.Allen RJ, Dupin CL, Dreschnack PA, Glass CA, Mahon-Deri B. The latissimus dorsi/scapular bone flap (the “latissimus/bone flap”). Plast Reconstr Surg. 1994;94:988–996.
2.Uglesic V, Virag M, Varga S, Knezevic P, Milenovic A. Reconstruction following radical maxillectomy with flaps supplied by the subscapular artery. J Craniomaxillofac Surg. 2000;28:153–160.
3.Seneviratne S, Duong C, Taylor GI. The angular branch of the thoracodorsal artery and its blood supply to the inferior angle of the scapula: An anatomical study. Plast Reconstr Surg. 1999;104:85–88.
4.Seitz A, Papp S, Papp C, Maurer H. The anatomy of the angular branch of the thoracodorsal artery. Cells Tissues Organs 1999;164:227–236.
5.Wagner AJ, Bayles SW. The angular branch: Maximizing the scapular pedicle in head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2008;134:1214–1217.
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