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13 The Free Fibula Flap
21. Fichter AM, Ritschl LM, Georg R, et al. Effect of segment length and number of osteotomy sites on cancellous bone perfusion in free bula aps. J Reconstr Microsurg.
2019;35(02):108–16.
22. Schusterman MA, Reece GP, Miller MJ, Harris S.The osteocutaneous free bula ap: is the
skin paddle reliable? Plast Reconstr Surg. 1992;90(5):787–93; discussion 794–8.
23. Ducic Y, Defatta R, Wolfswinkel EM, Weathers WM, Hollier LH Jr. Tunneling technique for
expedited bula free tissue harvest. Craniomaxillofac Trauma Reconstr. 2013;6(4):233–6.
https://doi.org/10.1055/s- 0033- 1349208.
24. Harris BN, Bewley AF. Minimizing free ap donor-site morbidity. Curr Opin Otolaryngol
Head Neck Surg. 2016;24(5):447–52.
25. Shimbo K, Okuhara Y, Yokota K. Closure of a free osteofasciocutaneous bula ap donor
site using local skin grafts or aps: a systematic review and meta-analysis. Microsurgery.
2022;42(2):192–8.
26. Momoh AO, Yu P, Skoracki RJ, Liu S, Feng L, Hanasono MM. A prospective cohort study
of bula free ap donor-site morbidity in 157 consecutive patients. Plast Reconstr Surg.
2011;128(3):714–20.
27. Shokri T, Stahl LE, Kanekar SG, Goyal N. Osseous changes over time in free bular ap
reconstruction. Laryngoscope. 2019;129(5):1113–6.
28. Hidalgo DA, Rekow A.A review of 60 consecutive bula free ap mandible reconstructions.
Plast Reconstr Surg. 1995;96(3):585–96; discussion 597–602.
29. Ling XF, Peng X.What is the price to pay for a free bula ap? A systematic review of donorsite morbidity following free bula ap surgery. Plast Reconstr Surg. 2012;129(3):657–74.
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Scapular Free Tissue Transfer forHead
andNeck Reconstruction
WesleyMcilwain andWeitaoWang
History
In 1978, Saijo etal. [1] used dye injection cadaveric dissections to study the suitability of the dorsal thoracic anatomy suitable for ap harvesting. He predicted that
the fasciocutaneous ap based on the circumex scapular artery (CSA) could supply up to 15×20cm2 of thin, pliable skin supplied by a pedicle sufcient for microvascular reconstruction. The scapular ap was reportedly rst described by dos
Santos in 1980 [2, 3]. In 1982, Gilbert and Teot [4] successfully used the scapular
ap in four lower extremity reconstructions. In 1981, Teot etal. [5] described the
use of the lateral scapular border as a pedicled osteocutaneous ap. In 1982, Nassif
etal. [6] described the parascapular ap via designing the skin paddle along the
lateral border of the scapula using the descending branch of the CSA. In 1986,
Koshima and Soeda [7] described the ability for use of a chimeric ap, combining
both the scapular and parascapular skin paddles to cover a large leg defect. In 1986,
Swartz etal. [8] described their experience with osteocutaneous scapular ap for
mandibular and maxillary reconstruction in 26 patients. This group reported that the
lateral border of the scapula can be harvested with up to 14cm of thick, straight,
corticocancellous bone.
The angular artery was subsequently described as a major blood supply to the
scapular tip, facilitating a longer vascular pedicle [9]. Coleman and Sultan [10]
described a bipedicled osteocutaneous ap for mandibular and midface reconstruction, using the angular artery to harvest the scapular tip and the CSA to harvest a
fasciocutaneous paddle. This study demonstrated the longer arc of rotation between
14
W. Mcilwain
Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, TX, USA
W. Wang (*)
Department of Otolaryngology Head and Neck Surgery, University of Rochester,
Rochester, NY, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_14
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W. Mcilwain and W. Wang
the skin supplied by the CSA the bone supplied by the angular branch of the thoracodorsal artery. Baker and Sullivan [11] reported the advantage of the separate pedicles for simultaneously reconstructing soft tissue defects up to 12×10cm2 and
segmental bone gaps of up to 14.5cm. Moscoso etal. [12] reported that the thickest
portion of the scapula is distal to the glenohumeral joint and that 78% of cadaveric
specimens were suitable for dental implants. With newer positioning technique
described to facilitate a two-team approach [13], this ap has gained signicant
popularity to reconstruct complex head and neck defects [14–16].
Anatomy oftheScapular Flap
Vascular System
The versatility of the scapular system is due to its robust vascularity. Roswell etal.
[17] performed 100 cadaveric dissections to study the subscapular-thoracodorsal
arterial system. The subscapular artery originates from the axillary artery in 97% of
cases and absent in 3% of cases. The subscapular artery divides into the CSA and
the thoracodorsal artery. The CSA may originate directly from the axillary artery in
3% of cases [17].
The CSA proceeds to give off the supercial circumex scapular artery, a
descending branch to the lateral scapular border, and branches to the subscapularis,
teres major, teres minor, and infraspinatus muscles. The supercial CSA travels
toward the subcutaneous tissue through areolar tissue through a triangular space
bounded by the long head of triceps brachii muscle laterally, teres minor muscle
superiorly, and the teres major muscle inferiorly. The artery pierces through the
deep fascia and subsequently divides into the horizontal (transverse), vertical
(descending), ascending, and lateral branches. The horizontal and vertical arteries
supply the scapular and parascapular fasciocutaneous aps, respectively [18].
Paired venae comitantes, with one frequently larger than the other, are associated
with the circumex scapular and subscapular arteries that drain into the axillary vein.
The thoracodorsal artery is a branch of the subscapular artery in 94% of cases but
can be a direct branch of the axillary artery in 5% of cases and direct branch of the
lateral thoracic artery in 1% of cases [17]. The thoracodorsal artery, with an average
length of 8.4cm and diameter of 3mm, gives at least one branch to the serratus
anterior muscle [17]. The angular artery supplying the scapular tip is a branch of the
thoracodorsal artery in 59% of cases and travels deep to the latissimus dorsi muscle
within a fat pad lateral to the scapular bone. The branch terminates at the dorsal
surface of the angle of the scapula. In 41% of the cases, the angular artery may
originate from the serratus anterior pedicle, as a trifurcation with the latissimus
dorsi and serratus anterior pedicles, or proximal to the latissimus dorsi and serratus
anterior pedicles [10]. If a combined latissimus-scapula ap is planned, one should
remember that up to 6% of cases that the subscapular artery will not be available as
a single pedicle for both components [17].
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The length of the pedicle available depends on the ap type harvested. The distance of the combined subscapular and circumex scapular pedicle from the axillary artery to the lateral scapular border varies from 4 to 9cm, and the pedicle from
bone to the overlying horizontal skin paddle is approximately 2–3cm [10, 17, 18].
The descending parascapular ap is 11–14cm [6]. If the angular artery is used, an
additional length can be obtained between the bone harvested and the skin paddle,
with up to 15cm of vascular pedicle from the bone to the axillary artery [10].
Muscle
The muscles encountered during ap elevation include the infraspinatus, teres
minor, teres major, and the latissimus dorsi muscles. The infraspinatus muscle originates medially at the infraspinous fossa and the teres minor originates from the lateral border of the scapula. Both muscles insert at the greater tubercle of the humerus
and primarily function to externally rotate and adduct the arm. The teres major
muscle originates from the inferior angle and lateral border of the scapula and
inserts into the lesser tubercle of the humerus. This muscle acts to extend, adduction, and internally rotate the humerus.
The latissimus dorsi muscle is a large supercial posterior trunk muscle originating from the lower thoracic spine, posterior iliac crest, and the thoracolumbar fascia.
The muscle inserts in the intertubercular groove of the humerus. The muscle’s primary function is to adduct the arm and internally rotate the shoulder. The latissimus
dorsi is innervated by the thoracodorsal nerve (C6–C8) [19]. The nerve is usually
located 3cm medial to the origin of the subscapular artery in the axilla. The nerve
runs in proximity to the thoracodorsal artery to innervate the deep surface of the
latissimus dorsi muscle. The nerve divides into lateral and medial branches with its
vascular counterparts. This nerve can be harvested with the latissimus dorsi muscle
with minimal donor morbidity. The latissimus dorsi can be harvested as a component of the subscapular system ap with or without an overlying skin paddle and has
the potential to cover a large surface area (25×40cm2) [20]. Simultaneous harvest
of the latissimus dorsi allows for signicant versatility given its own vascular source
of the thoracodorsal artery.
The serratus anterior muscle originates from the rst through eighth ribs on the
lateral chest and inserts along the entire medial border of the scapula. The muscle is
deep to the subscapularis muscle. The muscle functions to pull the scapula anteriorly toward the thorax. The muscle is innervated by the long thoracic nerve. The
long thoracic nerve originates from the C5, C6, and C7 cervical spinal nerves,
pierces through the scalene muscles, travels deep to the clavicle, and lies along the
supercial surface of the serratus anterior muscle [19]. Injury to this nerve can lead
to scapula alata (i.e., winged scapula). Scapula alata can limit a person’s ability to
lift their arm and push against resistance. Therefore, harvest of this nerve is not
recommended.
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Bone
The scapula bone is primarily cancellous with a thin cortical rim, contrary to the
more robust cortex associated with the bula or iliac crest. The thickest bone available is approximately midway between the inferior angle and the glenoid. The entire
lateral scapula and angle may be available to harvest, with a straight segment of
bone up to 14cm in males and 10cm in females [8]. An additional 3–4cm of bone
at the inferior angle can be harvested based on the angular artery.
Fasciocutaneous Flaps
The horizontal fasciocutaneous ap is most used. The limits of dissection typically
include the scapular spine, the inferior scapular angle, the posterior axillary line,
and the midline. The maximum width that allows primary closure is approximately
12cm. The parascapular fasciocutaneous ap is based on the descending branch
and can extend 25–30cm from the scapular spine. However, distal blood supply to
this ap beyond the scapular angle may be questionable [18]. The approximate
width harvested to allow primary closure is approximately 14cm [6]. The ascending
oriented ap can also be used based on the ascending branch [21]. The lateral margin of the ascending ap is the axilla, and the superior margin is the root of the neck.
The width can be approximately 10 cm, and the distal portion of this ap may
receive a large component of its blood supply through communication with the
perforating branches of the transverse cervical and suprascapular arteries.
Operative Technique
Preoperative Evaluation
The primary objectives for defect reconstruction should be analyzed to determine
the most appropriate type of ap. Moreover, each patient’s soft tissue should be
assessed, as body habitus and skin elasticity can vary from patient to patient. The
fasciocutaneous paddle thickness can vary signicantly between patients. Moreover,
the pedicle length must be considered. For instance, the ap should be designed on
the angular branch for longer pedicle length to reach from the midface defect to the
neck. If a scapular system ap is determined to be appropriate for reconstructing the
defect, the preoperative workup is minimal compared to other aps. There are no
age restrictions for this ap, but the patient should be medically t for prolonged
general endotracheal anesthesia. The medium-sized vessels of this ap system are
typically not compromised by diabetes and arteriosclerosis. No preoperative imaging is thus required to investigate vascular integrity. Relative contraindications to
ap harvest include prior history of axillary dissection or extensive trauma involving the scapula or humeral joint as this can potentially result in compromise of the
pedicle. If possible, the nondominant arm is preferred. Moderate to severe obesity
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14 Scapular Free Tissue Transfer forHead andNeck Reconstruction
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can make the thickness of the skin paddle difcult to use for intraoral contouring
and inset. Most of donor skin defects can be closed primarily. There is minimal
donor site morbidity [18]. Sullivan etal. [22] reported that exion, abduction, and
external rotation were most affected initially postoperatively, but all patients subjectively felt that their function was adequate. Nonetheless, a structured physical therapy program focused on shoulder range of motion is typically provided for
1–2weeks postoperatively.
Positioning andMarking
The patient is placed in the lateral decubitus position supported by a vacuum bean
bag and the contralateral arm protected with an axillary roll, while the ipsilateral
arm is completely prepped into the eld. This allows manipulation intraoperatively
to facilitate deep axillary dissection. The supine position has been described as well,
which may facilitate two-team harvest [13]. Once positioned, the CSA is found
within the triangular space on the lateral border of the scapula approximately twofth of the distance from the scapular spine to the inferior angle. [4] The Doppler
probe can locate the arterial pulse passing through this triangle. In obese patients,
these landmarks are distorted, and a Doppler probe should be used to mark out the
main cutaneous perforator. For a scapular fasciocutaneous ap, a line is drawn at
this point medially parallel approximately 5–6cm superior to the superior border of
the latissimus dorsi muscle. The proximal end of the ap is located at the posterior
axillary line. The distal endpoint may be extended to reach the medial border of the
contralateral scapular bone. The parascapular fasciocutaneous ap travels in line
with the lateral border of the scapula when the arm is adducted. The proximal end
of this ap can originate at the axillary crease, and the distal ap has been shown to
end at the 12th rib. In general, the subcutaneous tissue is thicker in the scapular ap
compared to the parascapular ap. When harvesting a chimeric ap including the
latissimus muscle, the anterior border of the latissimus is marked as a line between
the mid-axillary and posterior superior iliac spine and the skin paddle designed just
posterior to this line. The angular artery does not require Doppler and will be identied during ap harvest. The ipsilateral arm is abducted 90° and medially rotated to
expose the lateral border. A third assist may be necessary to support the arm during
ap harvest, or alternatively a spider-arm rest/mayo stand can be used to support the
arm. For scapula tip and latissimus chimeric aps, a lazy (30° rotation of the upper
torso) lateral decubitus position can be used to afford rapid two team harvest. The
senior author prefers full lateral decubitus positioning when harvesting the lateral
border for ease of making osteotomies.
Flap Harvest
The fasciocutaneous paddle is elevated from distal to proximal in the direction of
the pedicle. The depth of dissection is supercial to the deep muscular fascia
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W. Mcilwain and W. Wang
overlying the muscle. The dissection proceeds proximally by bluntly separating the
fasciocutaneous ap from the infraspinatus and teres minor muscles. The cutaneous
branch of the CSA will be identied superior to the teres major muscle attachment
to the lateral scapular border. Once the cutaneous branch is identied laterally, the
lateral portion of the fasciocutaneous paddle is dissected circumferentially to mobilize the ap.
Next, the CSA is traced proximally between the fascia of the teres minor and
teres major. As the teres minor is retracted medially, the perforators to the bone are
identied and protected. The lateral border of the scapula is then accessed via incising the infraspinatus and teres minor muscles parallel to the scapular border inferiorly and then transected perpendicularly superior to the perforator artery to prepare
for the osteotomy. The teres major muscle is then undermined and retracted to visualize the angular artery. If not planning on using the thoracodorsal artery system,
then this artery can be divided. The teres major muscle is then divided to fully
expose the inferior lateral border of the scapula. The deep surface of the scapular
border is bluntly dissected, and the osteotomies are planned by harvesting approximately 3cm in width and 12cm in length. Cutting guides can be placed at this time
if planned. Otherwise, the osteotomies are created inferiorly, medially, and superiorly usually using an oscillating or reciprocating saw. Once the osteotomies are
completed, the bone ap is rotated laterally, and the subscapularis muscle is divided
on its deep surface. The remaining soft tissue attachments are divided as the pedicle
is traced proximally. Complete mobilization of the vascular pedicle requires division of several muscular branches to the teres major, subscapularis, and infraspinatus muscles. If the latissimus dorsi muscle is not harvested, you can divide the
thoracodorsal artery at its origin, and the pedicle can be dissected to the axillary
artery to include the subscapular artery. However, the extra length obtained with the
subscapular artery is nominal, so you may want to preserve vascularity to the latissimus dorsi for future ap harvest by dividing the CSA at its origin.
Every patient has different skin elasticity and subcutaneous tissue components.
However, aps less than 10cm wide are typically closed directly. For osteocutaneous aps, the teres minor and major muscles are reattached to the scapular remnant.
Suction drains are placed. Shoulder range of motion exercises are begun as soon as
the patient is capable clinically.
Scapular Tip Flap
The scapular tip is similar in size and shape to the anterior wall of the maxilla and
the hard palate and has been extensively used for midface reconstruction. The vascular supply via the angular branch facilitates harvesting a longer vascular pedicle
to reach the neck for anastomosis. The dissection is similarly performed as described
in detail above, but with careful attention to preserving the angular branch from the
thoracodorsal artery. This angular branch is parallel to the lateral border of the scapula within the areolar tissue deep to the latissimus dorsi muscle. As described previously, the teres major, teres minor, and the infraspinatus muscles are divided with a
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14 Scapular Free Tissue Transfer forHead andNeck Reconstruction
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small cuff of muscle to visualize the scapular tip. Occasionally, rhomboid major
muscle is partially released from the medial border of the scapula. The planned
osteotomies are marked and performed. The vascular pedicle based on the angular
branch is then traced out, and the subsequent branches to the latissimus dorsi and
serratus anterior are divided. Yet, each of these muscles can be harvested as
described, which may be useful for dead space obliteration for midface reconstruction. Case example demonstrates the use of a chimeric scapula tip and latissimus
dorsi ap for reconstruction of a composite oral resection defect of the oor of
mouth, mandibular symphysis, mentum and neck skin for recurrent oral cavity
squamous cell carcinoma (See Figs. 14.1, 14.2 and 14.3).
Chimeric Flaps
The subscapular system provides signicant exibility with bringing in multiple
types of aps depending on the defect needed to be reconstructed. The large skin
paddle options can be manipulated completely separately from the bone ap making it an excellent option in otherwise challenging composite defects for bula
osteocutaneous free aps where the skin paddle and bone are relatively xed in
conguration. The ap can be designed to include multiple skin paddles with or
without muscle, scapular bone, and rib. Knowledge of the anatomy of this system
can facilitate complex three-dimensional reconstruction with multiple tissue types
based on a single vascular pedicle. See Fig.14.4 for the anatomic considerations
regarding chimeric ap design. Chimeric aps are useful for a combination of intraoral and extraoral defect reconstruction.
Fig. 14.1 Latissimus
myocutaneous with
scapula tip free ap for
oor of mouth and external
skin reconstruction
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Fig. 14.2 Scapula tip
secured along anterior
body with pre-milled
reconstruction plate.
Latissimus skin paddle is
de-epithelialized for
intraoral and extraoral
reconstruction
Fig. 14.3 Intraoral skin
paddle inset
W. Mcilwain and W. Wang
Fascial Flaps
Any of the previously mentioned fasciocutaneous aps can be harvested without the
overlying epidermis and dermis. This allows for greater harvest of tissue for the ap
without concerns for primary closure of the donor defect. The fascia of the scapular
and parascapular aps are supplied by vasculature originating from the CSA that
courses supercial to the fascia. These aps must be carefully elevated in a subcutaneous plane, leaving enough tissue overlying the fascia to preserve its blood supply.
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