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14 Scapular Free Tissue Transfer forHead andNeck Reconstruction
191
Scapular flap and
its artery: transverse
branch of circumflex
scapular artery
Lateral osseous flap
rascapular flap and
its artery: descending
branch of circumflex
scapular artery
Periosteal branches
of circumflex scapular
artery
Tips of the scapula
osseous flap
Angular artery
Fig. 14.4 Scapular system ap schematic, respective osseous ap options, and relative blood supply for chimeric ap designs
Axillary artery
Subscapular
artery
Circumflex
subscapular
artery
Thoracodor
artery
Latissimus
dorsi muscle
Virtual Surgical Planning
Stereolithography generates a highly accurate three-dimensional (3D) model from
data of a computed tomography (CT) scan to assist with preoperative planning of
complex craniofacial defects. The technology has enhanced, and its expense has
been proven cost-effective by reducing operative times [23]. Virtual surgical planning ranges from printing of a stereolithographic model alone to allow for analysis
of the case preoperatively, to custom 3D models with cutting guides and patientspecic implants [24]. Free-hand osteotomies or two-dimensional (2D) cutting
guides require signicant experience and often require intraoperative adjustments,
prolonging operative times. With virtual surgical planning (VSP), surgeons can virtually plan osteotomies and subsequently generate preoperative models and intraoperative cutting guides. Moreover, patient-specic implants can be designed to
support complex reconstructions. Reconstructive surgeons meet in a virtual session
to mark out resection margins and decide on how many segments of bony
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192
W. Mcilwain and W. Wang
reconstruction are required. Once this is determined, the software outlines the harvest margins of the free bone ap and determines the trajectory of the osteotomies,
and an overlay of the resection and reconstruction is nalized. Kass etal. [25] recommended from their initial experience with VSP and scapular aps to use a cupshaped guide that can accommodate the various brous tip and muscle at the
scapular tip to facilitate stabilizing the guide to the scapula. Surgical guides and
models are created and sterilized for use intraoperatively. The major advantage of
using VSP with the scapula is that it can determine the highest quality bone stock
preoperatively [25]. VSP also minimizes excess osseous and soft tissue bulk of the
ap, facilitating easier inset and maximizing bony contact to increase the chances of
bony union [24]. Once the lateral border of the scapula is exposed as described previously, the clearly labeled cutting guides are placed in the precise position, and
osteotomies are rapidly performed. Patient-specic reconstruction plates and/or
implants are used to facilitate rapid and more accurate inset of the ap into the maxillary or mandibular reconstruction. Midface reconstruction is particularly challenging, and VSP has been shown to improve the anatomical accuracy of defect
reconstruction and the bony apposition of the scapular bone segments to native
bone [26].
Midface Reconstruction
The scapula tip can be used in a vertical dimension to reconstruct the anterior maxilla and alveolar ridge, and the soft tissue of the ap can be used to obliterate the
maxillary sinus and close an oroantral stula. The vertical orientation improves the
ability to use dental implants, although often additional bone grafting and soft tissue
surgery is required [24, 27]. Infrastructure maxillary defects can be reconstructed
with the scapular tip in the horizontal dimension, but the bone must be secured with
plates on the premaxilla and posteriorly intraorally to prevent inferior displacement
of the bone with time [26].
Mandible Reconstruction
The lateral border of the scapula and the scapula tip have had success with reconstructing mandibular defects and have been shown to achieve dental implantation
[22]. Large angle to angle composite oral defects including oor of mouth and cutaneous chin and neck defects are ideal for chimeric aps. The lateral border of the
scapula is of adequate length to reconstruct the mandible from angle to angle via
two or three segment osteotomies. The lateral border is relatively forgiving in regard
to need for wedge osteotomies commonly necessary for bula free aps given the
thin nature of the bone and thus the entire lateral border is often usable. The limitation of the scapula for extensive mandible reconstruction lies in the short pedicle
length, which typically limits the donor recipient vessels to be a facial artery and
vein or an external jugular vein branch. In salvage cases, vein grafts or
t.me/Dr_Mouayyad_AlbtousH
14 Scapular Free Tissue Transfer forHead andNeck Reconstruction
transpositions may be necessary. As discussed previously, pedicle length can be
improved with the scapular tip ap but large segment mandibular defects typically
require more bone than this can offer. Preservation of the angular and circumex
scapular artery contributions are ideal when making osteotomies to ensure each segment maintains their separate blood supply. In the event there is inadequate bone for
complete mandibular reconstruction, priority should be focused on reconstructing
the symphysis and body as bony gaps along the angle and ramus are generally better
tolerated with less risk of plate extrusion as long as technically sound plate reconstruction is completed.
193
Dental Implants
In 1994, Moscoso etal. [12] found that implants were only suitable in men and
limited to the proximal and distal portion of the lateral border of the scapula.
However, shorter and narrower implants have been used successfully in smaller
bone volumes, negating these previous claims. Patients have decreased mastication
forces after mandibular reconstruction, thus decreasing the stress on dental implants
compared to normal population. Lanzer etal. [28] demonstrated that bone density
increased after implants, favoring use for both males and females. Therefore, the
scapula is suitable for osseointegrated implants [27–30]. The scapular tip ap has
also been shown to be suitable for dental implants but may require additional bone
grafting and soft tissue surgery prior to implant placement and restoration [27].
Limitations
This ap has few limitations, as its versatility and robust vascular supply have been
described. However, positioning can still be a challenge during two-team approach.
Larger skin paddles cannot be closed primarily and may require skin grafting. Obese
patients have thicker, less pliable skin, so a fascial-only ap may be considered in
these patients. This ap is not a sensate ap.
Conclusions
The subscapular ap system has many options for ap components and can be used
to reconstruct simple to very complex head and neck defects. The scapula should be
considered for midface reconstruction and considered for mandibular reconstruction when a bula or iliac crest may not be suitable. Familiarity with this ap is
imperative for head and neck reconstruction in cases where bula harvest is contraindicated due to one or two vessel runoffs to the extremity. Donor site morbidity is
minimal, and the vascularity is consistent. Newer position techniques allow for
simultaneous harvest of the ap.
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W. Mcilwain and W. Wang
References
1. Saijo M.The vascular territories of the dorsal trunk: a reappraisal for potential ap donor sites.
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6. Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular ap: a new cutaneous microsurgical free ap. Plast Reconstr Surg. 1982;69(4):591–600. https://doi.
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8. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous scapular ap for mandibular and maxillary reconstruction. Plast Reconstr Surg.
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new osteomuscular unit for reconstruction after radical head and neck surgery. NewYork:
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10. Coleman JJ 3rd, Sultan MR. The bipedicled osteocutaneous scapula ap: a new subscapular system free ap. Plast Reconstr Surg. 1991;87(4):682–92. https://doi.
org/10.1097/00006534- 199104000- 00013.
11. Baker SR, Sullivan MJ. Osteocutaneous free scapular ap for one-stage mandibular reconstruction. Arch Otolaryngol Head Neck Surg. 1988;114(3):267–77. https://doi.org/10.1001/
archotol.1988.01860150049015.
12. Moscoso JF, Keller J, Genden E, etal. Vascularized bone aps in oromandibular reconstruction. A comparative anatomic study of bone stock from various donor sites to assess suitability
for enosseous dental implants. Arch Otolaryngol Head Neck Surg. 1994;120(1):36–43. https://
doi.org/10.1001/archotol.1994.01880250032004.
13. Eskander A, Kang SY, Ozer E, etal. Supine positioning for the subscapular system of aps: a
pictorial essay. Head Neck. 2018;40(5):1068–72. https://doi.org/10.1002/hed.25051.
14. Gibber MJ, Clain JB, Jacobson AS, etal. Subscapular system of aps: an 8-year experience
with 105 patients. Head Neck. 2015;37(8):1200–6. https://doi.org/10.1002/hed.23738.
15. Brown J, Bekiroglu F, Shaw R. Indications for the scapular ap in reconstructions of the
head and neck. Br J Oral Maxillofac Surg. 2010;48(5):331–7. https://doi.org/10.1016/j.
bjoms.2009.09.013.
16. Urken ML, Bridger AG, Zur KB, Genden EM. The scapular osteofasciocutaneous ap: a
12-year experience. Arch Otolaryngol Head Neck Surg. 2001;127(7):862–9.
17. Rowsell AR, Davies DM, Eisenberg N, Taylor GI. The anatomy of the subscapularthoracodorsal arterial system: study of 100 cadaver dissections. Br J Plast Surg.
1984;37(4):574–6. https://doi.org/10.1016/0007- 1226(84)90152- 8.
18. Funk GF.Scapular and parascapular free aps. Facial Plast Surg. 1996;12(1):57–63. https://
doi.org/10.1055/s- 2008- 1064494.
19. Netter F.Atlas of human anatomy. 5, Saunders/Elsevier; 2011.
20. Friedrich W, Herberhold C, Lierse W.Vascularization of the myocutaneous latissimus dorsi
ap. Injection study on the thoracodorsal artery. Acta Anat (Basel). 1988;131(2):97–102.
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21. Ohsaki M, Maruyama Y.Anatomical investigations of the cutaneous branches of the circumex scapular artery and their communications. Br J Plast Surg. 1993;46(2):160–3. https://doi.
org/10.1016/0007- 1226(93)90152- 2.
22. Blumberg JM, Walker P, Johnson S, etal. Mandibular reconstruction with the scapula tip free
ap. Head Neck. 2019;41(7):2353–8. https://doi.org/10.1002/hed.25702.
23. Toto JM, Chang EI, Agag R, Devarajan K, Patel SA, Topham NS. Improved operative efciency of free bula ap mandible reconstruction with patient-specic, computer-guided preoperative planning. Head Neck. 2015;37(11):1660–4. https://doi.org/10.1002/hed.23815.
24. Breik O, Idle M, Martin T, Praveen P, Parmar S.Three-dimensional computer-assisted surgical
planning and manufacturing in complex maxillary reconstruction. Atlas Oral Maxillofac Surg
Clin North Am. 2020;28(2):151–64. https://doi.org/10.1016/j.cxom.2020.05.008.
25. Kass JI, Prisman E, Miles BA.Guide design in virtual planning for scapular tip free ap
reconstruction. Laryngoscope Investig Otolaryngol. 2018;3(3):162–8. https://doi.org/10.1002/
lio2.162.
26. Swendseid BP, Roden DF, Vimawala S, et al. Virtual surgical planning in subscapular system free ap reconstruction of midface defects. Oral Oncol. 2020;101:104508. https://doi.
org/10.1016/j.oraloncology.2019.104508.
27. Mertens C, Freudlsperger C, Bodem J, Engel M, Hoffmann J, Freier K.Reconstruction of
the maxilla following hemimaxillectomy defects with scapular tip grafts and dental implants.
J Cranio Maxillofac Surg. 2016;44(11):1806–11. https://doi.org/10.1016/j.jcms.2016.08.010.
28. Lanzer M, Gander T, Gratz K, Rostetter C, Zweifel D, Bredell M.Scapular free vascularised
bone aps for mandibular reconstruction: are dental implants possible? J Oral Maxillofac Res.
2015;6(3):e4. https://doi.org/10.5037/jomr.2015.6304.
29. Frodel JL Jr, Funk GF, Capper DT, etal. Osseointegrated implants: a comparative study of
bone thickness in four vascularized bone aps. Plast Reconstr Surg. 1993;92(3):449–55; discussion 456–8.
30. Burgess M, Leung M, Chellapah A, Clark JR, Batstone MD.Osseointegrated implants into a
variety of composite free aps: a comparative analysis. Head Neck. 2017;39(3):443–7. https://
doi.org/10.1002/hed.24609.
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The Osteocutaneous Radial Forearm
Free Flap
FatemehMirzamohammadi, SpenceerR.Anderson,
KaitlynnePak, SunishkaM.Wimalawansa,
andSameepP.Kadakia
Introduction
Head and neck microvascular reconstructive procedures are often challenging
because of the extent of resection and anatomical structures involved. When dealing
with complex segmental resections, composite tissue aps can reconstruct such soft
tissue and bony decits in a single-stage procedure. Flap options must provide adequate and reliable soft tissue coverage, appropriately match tissue thickness, and, in
some cases, donate adequate bone stock. To optimize the nal results, these recipient site reconstructive needs must be balanced against the risks of donor site
morbidity.
The radial forearm free ap (RFFF) is a well-known and well-described ap
commonly utilized in head and neck reconstruction [1–5]. The RFFF offers thin,
pliable soft tissue ideal for both intra- and extra-oral reconstruction [2, 5]. With a
long vascular pedicle, the RFFF can be quite versatile for coverage and allows the
ability to perform vascular anastomoses outside a zone of radiation, even reaching
the contralateral neck when needed. The RFFF’s forearm donor site is often reconstructed using split-thickness skin grafts and/or local soft tissue advancement aps.
15
F. Mirzamohammadi · S. R. Anderson · S. M. Wimalawansa
Department of Orthopedic and Plastic Surgery, Boonshoft School of Medicine at Wright State
University, Dayton, OH, USA
K. Pak
Boonshoft School of Medicine at Wright State University, Dayton, OH, USA
e-mail: pak.5@wright.edu
S. P. Kadakia (*)
Department of Orthopedic and Plastic Surgery, Boonshoft School of Medicine at Wright State
University, Dayton, OH, USA
Premier Comprehensive Head and Neck Oncology and Reconstructive Surgery Program,
Miami Valley Hospital, Dayton, OH, 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_15
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F. Mirzamohammadi et al.
While the donor site reconstruction may appear unsightly, its functional decits and
morbidity are generally minimal.
The osteocutaneous radial forearm free ap (OCRFFF) offers all of the benets
of the RFFF while including vascularized bone. It is indicated in head and neck
reconstruction when thick bone stock is not required or available, such as in the case
of midfacial reconstruction, reconstruction of the edentulous mandible, or in scenarios when there are contraindications to utilizing the bula-free ap, such as poor
vasculature of the lower extremity (Figs.15.1 and 15.2) [6–9].
Previously, the OCRFFF fell out of favor secondary to donor site pathologic
fracture of the radius. However, the advent of prophylactic plating of the radius
harvest site to prevent pathologic fracture complications has renewed surgeon interest in this ap option [4, 7, 8]. In this chapter, we describe important considerations
when applying the OCRFFF in the reconstruction of head and neck defects, including key local anatomy and anatomical variations, preoperative planning, operative
technique, postoperative management, and complication management.
Historical
The RFFF, otherwise known as the “Chinese Forearm Flap,” was rst described in
1978 when Guofan, Baoqui, and Yuzhi utilized this ap for the correction of severe
neck burn contractures at the Shenyang Military Hospital [2, 10]. The introduction
of the RFFF became a mainstay for head and neck defect reconstruction, especially
those defects out of reach of local pedicle ap options. In 1982, Biermer extended
the RFFF technique to include a vascularized segment of the radius as an osteocutaneous forearm ap for reconstruction of the thumb [10]. With similarities to the
RFFF, the OCRFFF offered familiarity amongst reconstructive surgeons and was
adopted as a reconstructive modality.
However, in the late 1990s, the OCRFFF faced a temporary decline in popularity
when several publications reported high rates of donor site morbidity secondary to
radius fracture at the osteotomy donor site [2, 5, 8]. Thereafter, alternative
Fig. 15.1 Intraoperative
photograph of the OCRFF
being used to reconstruct
an edentulous mandible in
conjunction with a
preplanned titanium
mandible plate
t.me/Dr_Mouayyad_AlbtousH
15 The Osteocutaneous Radial Forearm Free Flap
Fig. 15.2 Intraoperative
photograph from the same
patient from Fig.15.1
following inset of the
external skin paddle
utilized to augment the
external skin closure and
serve as a monitoring
paddle with Doppler stitch
in place
199
bone- based aps from the bula, scapula, and iliac crest increased in popularity,
seemingly replacing the need to perform the OCRFFF.
Subsequently, orthopedic surgeons and otolaryngologists at the University of
Kansas Medical Center described how immediate prophylactic plating of the donor
radius harvest defect signicantly reduced the incidence of donor site radius fracture. This modication essentially reintroduced the OCRFFF as a versatile and reliable option for modern head and neck reconstruction [1, 6–8, 11].
Anatomy
The OCRFFF is an excellent and versatile ap for complex head and neck reconstructive cases because of its consistent donor site anatomy, low-prole bony donor
site, long reliable vascular pedicle, and potential for complex ap design with multiple skin islands [2, 9]. The standard approach to this ap involves harvesting radial
forearm skin and subcutaneous tissues overlying the radial artery, which can be
extended ulnarly and proximally as needed, to include a section of volar radius and
a cuff of exor pollicis longus muscle (Fig.15.3). The palmaris longus can also be
included if a tendon graft is needed for the reconstruction. Concomitant prophylactic donor site plating facilitates safe harvest of up to 50% of the radial bone circumference [8, 12].
The OCRFFF is supplied by the radial artery. Here, fasciocutaneous perforators
pierce the antebrachial fascia supercially to supply the skin paddle while deep
perforating branches traverse the radial septum to feed the radius bone (Fig.15.4).
The distal radial artery is easily identiable via palpation in the distal forearm and
averages about 3mm in diameter and 14–22cm in length for an average adult [13].
At the antecubital fossa, the radial and ulnar arteries arise from the bifurcation of the
brachial artery. Physiologic variants of the radial artery have been documented in
the literature. The most commonly reported adjacent arterial variation is the persistence of the median artery, which is found parallel to the median nerve in the carpal
tunnel in approximately 8–10% of the population [14].
t.me/Dr_Mouayyad_AlbtousH
200
Fig. 15.3 Photograph
demonstrating the
osteocutaneous radial
forearm free ap with skin
paddle, volar radius bone,
and long pedicle with dual
drainage system
F. Mirzamohammadi et al.
Fig. 15.4 Illustration of traditional radius osteotomy planning. (This gure was modied from
Matthews etal. by Springer Nature. Matthews J, Ng W, Archibald S, Levis C.The use of the radial
styloid in the extended osteocutaneous radial forearm free ap. Plast Surg (Oakv). 2016;24(2):89–95)
Most radial artery vascular variations occur proximally in the forearm. Therefore,
tracing the radial artery from distal to proximal can be benecial to identifying its
true anatomy. Most commonly, the brachial artery bifurcates into the radial and
ulnar arteries approximately 1 cm distal to the antecubital fossa; however, this
occurs in only 70% of patients. The radial artery then runs between the brachioradialis and pronator teres muscles in the proximal third of the forearm and follows
the lateral (radial) intermuscular septum between the brachioradialis and exor
carpi radialis at the distal forearm. A high bifurcation off the axillary or brachial
artery was reported in 9.2% of 120 cadavers, with 18.1% originating in the axilla
and 81.8% in the bicipital groove [15, 16]. Distally, the radial artery becomes more
supercial. At this level, it is covered by the deep fascia, supercial fascia, and the
skin. Other variations reported in the reconstructive literature include duplication of
the radial artery (most commonly lateral to the dominant radial artery), congenital
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