Lateral border and scapular tip free flaps: Old school versus new school

Abstract

Free tissue transfer from the subscapular system provides a wide array of options for both soft tissue and bony reconstruction. When bone stock is required for head and neck reconstruction, both the lateral scapular border free flap (LSBFF), supplied by the circumflex scapular artery, and the scapular tip free flap (STFF), supplied by the angular artery, are excellent options.Issues with positioning had previously prevented the widespread use of these bony subscapular system flaps. However, through the use of a Spider Limb Positioner, current clinical practice patterns allow for two team approaches in both of these free flaps. The following pictorial essay compares and contrasts the specific positioning and harvesting technique used for both the LSBFF and STFF, while discussing the clinical advantages and drawbacks of each. Both the lateral border scapula and scapular tip free flaps provide excellent bone stock for head and neck reconstruction. By positioning with currently available technology, both of these free flaps can be harvested through a two team approach. K E Y W O R D Shead and neck reconstruction, lateral scapular border free flap, scapular tip free flap, spider limb, subscapular flap

Double Arterialized Scapular Tip Free Flap for Mandibular Reconstruction

“…Therefore, careful evaluation of bone length and meticulous vessel dissection is needed before definitively deciding whether to include the circumflex pedicle in the flap. [19][20][21][22][23] Bone resorption has been described as one of the main issues when using STFF for reconstruction, especially when long bone stocks are harvested. In the patient series reported here, there were no cases of bone resorption on postoperative computed tomography, underlining the efficacy of this double perfusion technique.…”

“…Although the fibula and iliac crest free flaps remain superior options for mandibular bone restoration because of the higher quality of bone (in terms of length and height, respectively), STFF can be considered an excellent second option in cases where these flaps cannot be harvested because of vascular anomalies or previous surgeries. Moreover, fibula and iliac crest flaps are related to higher rates of morbidity than STFF, and the latter type of flap is usually preferred in elderly patients or those in poor general condition, as well as in cases of complex defects when 2 free flaps are indicated but the patient is unsuitable for such a major surgery 22–24 …”

“…Sometimes, the angular branch enters very distally, thereby providing perfusion to a very small piece of tip, while in other cases it enters proximally, especially when it originates as a trifurcation with the latissimus and serratus pedicles, or as a vessel independent from the thoracodorsal artery proximal to its division into the serratus and latissimus pedicles. Therefore, careful evaluation of bone length and meticulous vessel dissection is needed before definitively deciding whether to include the circumflex pedicle in the flap 19–23 …”

“…Moreover, fibula and iliac crest flaps are related to higher rates of morbidity than STFF, and the latter type of flap is usually preferred in elderly patients or those in poor general condition, as well as in cases of complex defects when 2 free flaps are indicated but the patient is unsuitable for such a major surgery. [22][23][24] One of the main limitations of STFF for mandibular reconstruction relates to the length of bone harvested. In the standard harvesting procedure, scapular tip perfusion is provided by the angular branch that arises from the thoracodorsal system and has anatomic variations.…”

Innovations with the scapula and subscapular system for head and neck microvascular reconstruction

“…These modifications have allowed for flap harvest concurrent with either part of or the entirety of the extirpative portion of the operation without any increase in positioning-related complications [31] . A technique for harvest of the scapular flap in a fully supine position with concurrent partial ablation has also been described [33] . These refinements have resulted in the increased frequency of the parallel, two-team approach when utilizing the subscapular system for harvest [34,35] .…”