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Use of Chimeric Subscapular Artery System Free Flaps for Soft-Tissue Reconstruction of the Oral Cavity and Oropharynx: Advantages and Donor-Site Morbidity

Girod, Angélique, M.D.; Nadaud, Françoise; Mosseri, Veronique, M.D.; Jouffroy, Thomas, M.D.; Rodriguez, José, M.D.

Plastic and Reconstructive Surgery: December 2009 - Volume 124 - Issue 6 - p 445e-446e
doi: 10.1097/PRS.0b013e3181bcf7ba

Head and Neck Oncologic Surgery Unit, Institut Curie, Paris, France

Correspondence to Dr. Girod, Head and Neck Oncologic Surgery Unit, Institut Curie, 26 rue d'ULM, 75005 Paris, France,

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Reconstruction of extensive musculomucosal defects of the oral cavity and oropharynx is now based on the use of free flaps that have been demonstrated to be effective and versatile.1,2

One flap is usually harvested to reconstruct the entire defect. Even when a composite flap providing a sufficient quantity of tissue is used, the spatial configuration of the flap is not always ideal. Chimeric subscapular artery system free flaps comprise spatially independent components, allowing a better anatomical result without plication of the flap, with only one vascular anastomosis. These flaps have been used in our center to improve the anatomical and functional results of reconstruction.

Between January 1, 2007, and January 31, 2007, a chimeric subscapular artery system free flap was performed in eight of the 60 free flaps performed in the unit (Table 1).

Table 1

Table 1

Five latissimus dorsi and serratus anterior free flaps; one latissimus dorsi and parascapular flap; one parascapular and serratus anterior flap; and one latissimus dorsi, serratus anterior, and parascapular flap were performed.

There were no flap failures or anastomotic revisions in this series. Four patients had intelligible speech and were able to talk on the telephone. One patient's speech was difficult to understand. Two patients were able to eat a normal diet, two patients ate a soft diet, and one patient ate a semiliquid diet with half of the daily ration administered by gastrostomy. Three patients could not be evaluated.

No patient complained of chest pain or shoulder pain. The mean Disabilities of the Arm, Shoulder and Hand self-administered questionnaire score was 11.31.3 No significant difference in the range of shoulder movement was observed between the operated side and the unoperated side (Table 2), and no case of scapula alata was observed.

Table 2

Table 2

Subscapular artery system flaps were used because of their numerous advantages. These chimeric flaps are composed of spatially independent flaps (latissimus dorsi, scapular, parascapular, and serratus anterior) with independent blood supplies, but with all sharing a common pedicle (subscapular artery). Microsurgery after flap transfer therefore requires only one vascular anastomosis.4 These flaps are also composite (i.e., they can comprise several tissue components, such as skin, muscle, fascia, and bone).

It can be difficult to reconstruct the oropharynx, tongue, and the skin of the neck and cover the carotid artery with a single flap, because of the quantity of muscle and because of the three-dimensional configuration of the flap. Flap plication can impinge on the flap blood supply, but the reconstruction may be unsatisfactory without plication.

The normal mean Disabilities of the Arm, Shoulder and Hand score in the general population is 10.1.5 It is therefore fairly remarkable that the Disabilities of the Arm, Shoulder and Hand score of patients undergoing a flap is equivalent to that of the general population. The same applies to the range of shoulder movement: shoulder movement was similar on the operated and unoperated sides.

In conclusion, the chimeric subscapular artery system free flap is a reliable solution for reconstruction of extensive soft-tissue defects of the oral cavity or oropharynx, allowing satisfactory three-dimensional conformation with a reliable flap blood supply without flap plication and with limited donor-site morbidity.

Angélique Girod, M.D.

Françoise Nadaud

Veronique Mosseri, M.D.

Thomas Jouffroy, M.D.

José Rodriguez, M.D.

Head and Neck Oncologic Surgery Unit

Institut Curie

Paris, France

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The authors have no financial interests to disclose.

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1. Haughey BH, Wilson E, Kluwe L, et al. Free flap reconstruction of the head and neck: Analysis of 241 cases. Otolaryngol Head Neck Surg. 2001;125:10–17.
2. Suh JD, Sercarz JA, Abemayor E, et al. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2004;130:962–966.
3. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand). The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29:602–608.
4. Hallock GG. Further clarification of the nomenclature for compound flaps. Plast Reconstr Surg. 2006;117:151e–160e.
5. Hunsaker FG, Cioffi DA, Amadio PC. The American Academy of Orthopaedic Surgeons outcomes instruments: Normative values from the general population. J Bone Joint Surg (Am.) 2002;84:208–215.

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