|
Multiple flap combinations can be harvested on the
subscapular axis, allowing for the creation of complex and composite
vascularized flaps. Both the scapular and parascapular flaps can be
harvested with scapular bone, as illustrated below, or in combination with the
latissimus muscle, serratus muscle, or a component of dorsal thoracic fascia.
This combination of flaps on a single vascular axis is valuable because it
requires a single donor area and allows complex reconstructions with very mobile
pedicles while necessitating only one arterial and venous anastomosis.
Vascular Anatomy
The subscapular artery arises from the axillary
artery. It sends a circumflex scapular branch posteriory through the
triangular space . This vessel provides cutaneous branches to the scapular
and parascapular flap and also an ascending branch. The circumflex
scapular may also provide an osseous branch that can also be used to harvest
lateral scapula. The subscapular artery continues into the thoracodorsal
artery. This artery provides a significant branch that nourishes the
inferior portion of the scapula and another branch to the serratus muscle..
Operative Technique
The scapular or parascapular flap is raised as
described in those chapters and as diagrammed below. The scapular segment
to be taken can be quite large (light blue) or smaller (dark blue). The
large segment can be taken on the descending osseous branch from the circumflex
scapular vessel. Slightly more complex, but allowing a greater vascular
leash, is harvest of an inferior segment of the scapula (dark blue). When
harvesting a smaller portion, we usually base this on the thoracodorsal branch.
This requires dissection of the thoracodorsal system as well as the circumflex
scapular system.
The thoracodorsal vessel is visualized in the
triangular space or by elevating the latissimus muscle. By identifying the
thoracodorsal vessels in the triangular space the vessels can be followed
distally, retracting or dividing the teres major muscle (pictured below).
The branch to the inferior pole of the scapula bone is identified and isolated
on the required scapula segment. The bone is usually cut with a small
oscillating saw. The bone and scapula flap (pictured below) or
parascapular flap (not pictured) can then be isolated to their common
subscapular artery.
|
