The Scapular Tip Osseous Free Flap as an Alternative for Anterior Mandibular Reconstruction

Sir: Anterior segmental mandibular defects resulting from oncologic resection are reconstructed with vascularized bone whenever possible. For anterior mandibular reconstruction, the fibula free flap is the method of choice for many surgeons. In patients who are not candidates for a fibula free flap caused by injury or stenosis of the lower extremity vessels, the iliac crest free flap is advocated by some but can only be used for defects smaller than 12 cm, and its blood supply may also be compromised in patients with vascular disease. We have successfully used the scapular tip osseous free flap for anterior mandibular reconstruction in seven patients with peripheral vascular disease precluding fibula free flap harvest. These cases are novel in that the inferior angle of the scapula is oriented transversely and used to recreate the anterior mandible, obviating the need for bony osteotomies. This flap is based on the angular branch of the thoracodorsal artery rather than the circumflex scapular artery, which is the traditional blood supply of the scapular flap.1,2 The angular branch can reliably supply up to 20 cm of bone from both the medial and lateral scapula, compared with 12 cm of bone in the traditional scapular flap.3 The pedicle length can reach 17 cm if the subscapular vessels are included, which is considerably longer than the length of pedicle in the traditional scapular free flap (approximately 6 cm).3–5 The flap is harvested with the patient in the lateral position. The angular branch pedicle originates from the thoracodorsal artery and lies within a submuscular fat pad beneath the latissimus dorsi and teres major muscles (Fig. 1). To increase the pedicle length and incorporate other free flaps (e.g., parascapular, latissimus dorsi myocutaneous, and/or serratus anterior muscle/myoosseous) as part of a chimera, the dissection may extend to the subscapular artery and vein.Fig. 1.: (Left) Diagram showing the blood supply to the scapular bone, including the angular branch of the thoracodorsal artery. (Right) The right scapula and angular branch of the thoracodorsal artery exposed after retraction of the latissimus dorsi muscle inferolaterally. The forceps points to where the angular branch vessels enter the inferior angle of the scapular bone.The rhomboid major and teres major muscles are partially released from the medial and lateral borders of the scapula, respectively. The infraspinatus muscle is also partially elevated from the superficial surface of the scapula. Osteotomies are made and the flap is oriented in the transverse direction such that the inferior tip of the scapula replaces the mentum of the mandible and the superficial surface of the scapula is oriented cephalad (Figs. 2 through 4). The flap is inset into notches cut into the native mandible bilaterally, creating tongue-in-groove joints, and secured with titanium plates. The teres major and rhomboid major muscles are reattached with sutures to the remaining scapula.Fig. 2.: (Above) Chimeric free flap including a scapular tip osseous free flap based on the angular branch of the thoracodorsal artery and a parascapular cutaneous free flap based on the circumflex scapular artery. (Below) Diagram showing the transverse orientation of the scapular tip free flap and tongue-in-groove fixation to the native mandible.Fig. 3.: Flap inset with the scapular tip flap oriented transversely.Fig. 4.: Lateral view of a patient 6 months after anterior composite mandibular resection and reconstruction with a scapular tip osseous free flap.A drawback associated with the scapular tip free flap is that the location of the scapula precludes a simultaneous two-team approach to mandibular resection and flap dissection. However, harvest of this flap is straightforward and rapid. Another limitation is that the bone thickness of the scapular tip free flap is usually inadequate to accommodate osseointegrated implants and therefore we reserve this technique for patients who are not candidates for fibular free flap reconstruction. In our experience, no patients developed scapular winging or limited shoulder movement. Matthew M. Hanasono, M.D. Roman J. Skoracki, M.D. Department of Plastic Surgery University of Texas M. D. Anderson Cancer Center Houston, Texas DISCLOSURE The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for the work presented in this article.