Scapular Flap

Scapular Flap

    Parascapular Flap

    scapular and parascapular osteocutaneous flaps

    Latissimus Muscle flap

    TAP FLAP

combined latissimus flaps

    Dorsal Thoracic Fascia Flap

    Serratus Muscle Flap

    combined serratus flaps

The scapular flap has become clinically popular because it provides a large area of fasciocutaneous tissue and is relatively straight forward to harvest.  It features consistent anatomy, a large pedicle and thick but pliable skin.  The fascial component of the flap - the dorsal thoracic fascia - can be harvested alone as a free fascial flap.  The donor defect can be closed primarily if the width does not exceed 10 centimeters.  If the defect cannot be closed it can be skin grafted, but this results in a significant scar deformity.  The scar result even when closed primarily must be considered in flap selection.

The anatomy of the scapular flap allows it to be harvested with a large number of other flaps on a single pedicle, allowing for complex and large reconstructions of composite tissue defects.  The scapular flap can be combined with any one of these tissues on the subscapular vessel axis:

• Parascapular flap

• Scapular bone

• Latissimus muscle

• Serratus muscle

• Serratus with rib

The contralateral scapular flap can be harvested in conjunction with the scapular flap on a second pedicle.

Anatomy

Back muscles

The above view is based posteriorly, exposing the muscles of the back.  The deltoid muscle has been removed for clarity.  The scapular flap is outlined with the dashed line.  The apex of the flap is centered over the triangular space, where the circumflex scapular artery provides the vessel to this flap after it travels through the triangular space.  The borders of the triangular space are made up of the

• Teres minor

• Teres major

• Long head of triceps

The trapezius and infraspinatus muscles are important landmarks since flap dissection proceeds from medial to lateral and these are identified early in the dissection.  The elevation of the flap is performed in the areolar fascial layer just above the thick muscular fascia of the back. The infraspinous fascia overlying the infraspinatous muscle and the teres minor fascia overlying the teres minor are particulary thick. If the flap is elevated deep to the this muscular fascia, the dissection can become confusing and especially difficult around the pedicle where the fascia surrounds the triangular space.

Vascular Anatomy

The circumflex scapular artery is a branch of the subscapular artery which takes origin off the axillary artery.  The circumflex scapular arises about 1 to 4 centimeters from the origin of the subscapular artery, but can on occasion arise directly from the axillary artery.  After the circumflex scapular artery pierces the triangular space it sprouts a transverse cutaneous scapular branch and a vertical parascapular branch.  The parascapular branch forms the basis of the parascapular flap.  

The subscapular artery pedicle can be from 3 to 6 cm in length with vessel circumference at this level up to 3 millimeters in size.  Although the circumflex scapular artery is usually accompanied by two venae comitans, the subscapular artery is typically accompanied by one vein.

Flap Dissection

The patient is placed in the lateral decubitus position on a beanbag.   Optionally, the prone position can be used if a posterior wound must be resurfaced.  It can be more difficult since arm positioning can not be adjusted as easily as in the lateral decubitus position.  We will assume lateral decubitus positioning for further discussion.  The ipsilateral arm is left free and included in the operative scrub. A stockinette around the arm and mayo stand with a well-padded pillow helps to rest the arm during surgery.

The incision is marked using the scapula as a guide.  The scapula is outlined and an elliptical incision is used to mark the flap.  It must include the triangular space within its border so the pedicle vessel is captured in the flap.  A point roughly one fingerbreadth below the mid point of the scapula on its lateral aspect marks the triangular space. A pencil Doppler probe can help confirm the pedicle location. The width of the flap can easily reach 10 centimeters with primary closure and has been reported to be as long as 25 centimeters. A point just crossing or touching the midline of the back is a safe distance.

The flap is elevated from medial to lateral. The elevation of the flap is performed in the areolar fascial layer just above the thick muscular fascia of the back. The infraspinous fascia overlying the infraspinatous muscle and the teres minor fascia overlying the teres minor are particulary thick. If the flap is elevated deep to the this muscular fascia, the dissection can become confusing and especially difficult around the pedicle where the fascia surrounds the triangular space. In the inferior incision the descending arterial branch can be visualized and is ligated to continue flap elevation in a lateral direction. 

As the triangular space is identified and the pedicle traced into the triangular space, self retaining retractors and adjusting the right arm position to maximize exposure are helpful. Numerous branches must be isolated and ligated at this level before the flap is traced to the circumflex scapular artery and if needed the subscapular artery. A counter incision in the axilla can be helpful to expose and dissect the subscapular system.

References

1. Allen RJ, Dupin CL, Dreschnack PA, et al: The latissimus dorsi/scapular bone flap (the "latissimus/bone flap"). Plast Reconstr Surg 94:988-996, 1994

2. Alpert BS, Brody GA: The Osteocutaneous Scapular Flap. In Buncke HJ (ed): Microsurgery: Transplantation and Replantation. Philadelphia: Lea and Febiger, 1991

3. Barwick WJ, Goodkind DJ, Serafin D: The free scapular flap. Plast Reconstr Surg 69:779-787, 1982

4. Batchelor AG, Bardsley AF: The bi-scapular flap. Br J Plast Surg 40:510-512, 1987

5. Coleman JJ, 3rd, Sultan MR: The bipedicled osteocutaneous scapula flap: a new subscapular system free flap. Plast Reconstr Surg 87:682-692, 1991

6. dos Santos LF: The vascular anatomy and dissection of the free scapular flap. Plast Reconstr Surg 73:599-604, 1984

7. Funk GF: Scapular and parascapular free flaps. Facial Plast Surg 12:57-63, 1996

8. Gilbert A, Teot L: The free scapular flap. Plast Reconstr Surg 69:601-604, 1982

9. Granick MS, Newton ED, Hanna DC: Scapular free flap for repair of massive lower facial composite defects. Head Neck Surg 8:436-441, 1986

10. Hamilton SG, Morrison WA: The scapular free flap. Br J Plast Surg 35:2-7, 1982

11. Hong GX, Zhu TB, Wang FB, et al: Free scapular flap for repair of soft tissue defects of extremities. Acta Acad Med Wuhan 5:116-119, 1985

12. Kleinert HE: Bone and osteocutaneous microvascular free flaps. J Hand Surg [Am] 8:735-737, 1983

13. Kon M: The free parascapular flap. Neth J Surg 40:80-83, 1988

14. Nassif TM, Vidal L, Bovet JL, et al: The parascapular flap: a new cutaneous microsurgical free flap. Plast Reconstr Surg 69:591-600, 1982

15. Reid CD, Taylor GI: The vascular territory of the acromiothoracic axis. Br J Plast Surg 37:194-212, 1984

16. Swartz WM, Banis JC, Newton ED, et al: The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 77:530-545, 1986

17. Taylor GI: The current status of free vascularized bone grafts. Clin Plast Surg 10:185-209, 1983

18. Urbaniak JR, Koman LA, Goldner RD, et al: The vascularized cutaneous scapular flap. Plast Reconstr Surg 69:772-778, 1982

19. Van Thienen CE: The angular branch of the thoracodorsal artery and its blood supply to the inferior angle of the scapula: an anatomical study. Plast Reconstr Surg 106:222-224, 2000

20. Whitney TM, Alpert BS, Buncke HJ: The Scapular Cutaneous Flap. In Buncke HJ (ed): Microsurgery: Transplantation and Replantation. Philadelphia: Lea and Febiger, 1991

21. Wu WC, Chang YP, So YC, et al: The combined use of flaps based on the subscapular vascular system for limb reconstruction. Br J Plast Surg 50:73-80, 1997