**8. Scapular flap**

The scapular region is an excellent source of cutaneous, fascial, muscular, osteomuscularcutaneous free or pedicled flaps based on the subscapular artery and its branches. In 1978, the scapular free flap was introduced by Sajio. The flap was based on the circumflex scapular vessels. These vessels supply the vast thoracodorsal fascial network of the back, which provide an abundant tissue source beyond the flap margin. The scapular osteocutaneous free flap has been used mostly in reconstruction of craniomaxillofacial defects, including the orbit, the maxilla and palatal defects. [13] Scapular bone provides thin bone for restoring orbital floor defects in conjunction with malar regions, orbital rim and alveolar defects.

#### **8.1. Flap anatomy**

The subscapular artery gives rise to the circumflex scapular artery supplying the scapular and parascapular skin. The superficial branch of the circumflex scapular artery reaches the subcutaneous tissue at the level of the triangular space. At this point it provides several branches. The main two branches are the horizontal and vertical ones. [41] Venae comitante of the horizontal and vertical branches of the circumflex scapular vein are the venous drainages of the flap. The horizontal and vertical branches drain into the circumflex scapular vein, then the subscapular vein and finally the axillary vein. The third, fourth and fifth intercostal nerves through lateral and posterior branches provide sensory innervation of this region. There is no motor nerve involvement in this procedure (Figure 11).

**Figure 11.** Anatomy of the scapular flap.

#### **8.2. Flap components**

This is a skin and subcutaneous flap which may include bone, fascia and muscle. These flaps are extremely reliable with a consistent vascular pedicle of good length and large caliber. The color of the back skin may provide a better match for head and neck reconstruction.

#### **8.3. Flap dimensions**

Skin island length is 18-20 cm with 7-8 cm width and 2 cm thickness. The bone length is about 10-14 cm with 2-3 cm width and 1.5-3 cm thickness.

### **8.4. A common scapular flap harvesting technique**

been used mostly in reconstruction of craniomaxillofacial defects, including the orbit, the maxilla and palatal defects. [13] Scapular bone provides thin bone for restoring orbital floor

The subscapular artery gives rise to the circumflex scapular artery supplying the scapular and parascapular skin. The superficial branch of the circumflex scapular artery reaches the subcutaneous tissue at the level of the triangular space. At this point it provides several branches. The main two branches are the horizontal and vertical ones. [41] Venae comitante of the horizontal and vertical branches of the circumflex scapular vein are the venous drainages of the flap. The horizontal and vertical branches drain into the circumflex scapular vein, then the subscapular vein and finally the axillary vein. The third, fourth and fifth intercostal nerves through lateral and posterior branches provide sensory innervation of this region. There is no

This is a skin and subcutaneous flap which may include bone, fascia and muscle. These flaps are extremely reliable with a consistent vascular pedicle of good length and large caliber. The

Skin island length is 18-20 cm with 7-8 cm width and 2 cm thickness. The bone length is about

color of the back skin may provide a better match for head and neck reconstruction.

defects in conjunction with malar regions, orbital rim and alveolar defects.

motor nerve involvement in this procedure (Figure 11).

636 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 11.** Anatomy of the scapular flap.

**8.2. Flap components**

**8.3. Flap dimensions**

10-14 cm with 2-3 cm width and 1.5-3 cm thickness.

**8.1. Flap anatomy**

The site of flap incision is infiltrated with lidocaine with2% epinephrine. The outline of skin paddle is marked. It is important to mark the location of the flap on the patient's back relative to flap size, and to mark the orientation relative to the pedicle and its branches. An incision is made from the posterior border of the deltoid muscle 3 cm lateral and parallel to the lateral border of the scapula, ending approximately at the angle. The dissection of the cutaneous flap is extended medially in a plane just superficial to the deep muscular fascia of the infraspinatus muscle. The thoracodorsal fascia is preserved during dissection. The circumflex vessels arise sharply over the lateral edge of the scapula and are just superficial to the facial base of dissection. [13] The lateral scapular bone flap and the branches to the bone from the pedicle are carefully dissected and preserved in the triangular space. An incision is made 2 to 3 cm medial to the bone edge through the muscles on the scapula inferior to the bone. If a bipedicle bone flap is desired with 2 vascular sources on the same pedicle, in this situation the angular branch from thoracodorsal vessel should be included in the flap design. The donor site is closed primarily, with the use of appropriate drain placement and the patient is turned to the supine position (Figure 12).

**Figure 12.** A skin paddle of the scapular flap.

#### **8.5. Complications**

Extended scapular flap loss is a major problem because a large area remains uncovered. Closure of the donor site under tension will result scar dehiscence and an unsightly result.

#### **8.6. Scapular flap updates**

The scapular tip free flap (STFF) has been used in reconstruction of mandibular defects. Low morbidity, early ambulation time, possibility of simultaneous harvesting with the tumor resection and large musculocutaneous paddles in the chimerical version of the flap are advantages of the STFF. This makes it a good choice in elderly patients, when other bone containing free flaps are not indicated because of the related morbidity, when other flaps are not available or when wide composite defects are approached.[42] Fibular and scapular osseous free flaps for oromandibular reconstruction were compared based on a patientcentered approach to flap selection. Results demonstrated the free fibula flaps and subscapular flaps are complementary options for oromandibular reconstruction. The fibular free flaps are ideal for younger patients, extended defects, multiple osteotomies, and limited soft-tissue requirements. The subscapular system free flaps are excellent options for (1) elderly patients; (2) those with significant comorbidities, such as peripheral vascular disease; and (3) mandible defects associated with complex soft-tissue requirements.[43] For immediate mandibular reconstruction, a scapular flap provides short-term results equivalent to those with a fibular flap but with less donor-site morbidity. The major drawbacks of the fibular flap include prolonged healing of the donor site and the delayed mobilization of patients. Although our first choice of vascularized bone graft is the fibular flap, the scapular flap is an alternative for those patients, especially elderly patients, in whom fibula harvest can result in significant morbidity. [44] Minimally invasive harvesting techniques may reduce potential donor-site morbidity. A reverse-flow scapular osteocutaneous flap has been introduced for head and neck reconstruction. The distal end of the thoracodorsal artery and subscapular vein were used in this type of the flap. There has been no report on endoscopically assisted harvesting of the scapular adipofascial flap. [45, 46]
