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Osteocutaneous Scapula Free Flap

last modified on: Fri, 12/01/2017 - 15:41

Osteocutaneous Scapula Free Flap

 return to:Microvascular Surgery Protocols

 

  1. GENERAL CONSIDERATIONS
    1. Indications
      1. The scapula fasciocutaneous flap is now used infrequently due to the emergence of the forearm flap for oral and pharyngeal soft tissue reconstruction.
      2. The osteofasciocutaneous flap remains a viable reconstructive option, particularly for composite defects in which skin, bone, and potential muscle, such as latissimus or serratus, are required on a single vascular pedicle.
      3. For routine mandibular reconstruction, the fibula flap is often preferred.
      4. The scapula flap has been used extensively for oromandibular and oromaxillary reconstruction. The ability to three-dimensionally orient the bone with respect to the skin paddle has made it a popular flap choice in central facial, orbital, and maxillary reconstruction.
      5. The scapular and parascapular skin paddles provide better color match with facial skin than most other cutaneous free flaps.
    2. Contraindications
      1. See General microvascular protocol
      2. Scapula flap specific contraindications include previous axillary or thoracic surgery in the region of intended flap harvest.
      3. Relative contraindications include the need to reposition the patient for flap harvest, inability to perform simultaneous flap harvest and head and neck ablation, and the limited bone stock available in small females.
      4. The scapula flap should not be harvested from the side of the dominant hand if possible.
    3. Pertinent Anatomy
      1. The scapula flap is a component of the subscapular system of flaps, which includes all tissues that may be harvested with the subscapular artery as the common vascular pedicle. The latissimus flap is another subscapular system flap and is discussed elsewhere.
      2. The scapular flap is supplied by the circumflex scapular branch of the subscapular artery and may be harvested as either a cutaneous flap or osteocutaneous flap with the lateral border of the scapular bone.
      3. A variety of skin paddle designs are possible based on the terminal branches of the circumflex scapular artery, which originate at the lateral border of the scapula about half way between the scapular spine and the scapular tip.
      4. A straight segment of lateral scapula bone up to 14 cm in males and 10 cm in females is available.
      5. One beneficial feature of the scapular flap is that the bone and skin paddle have a large degree of mobility relative to one another that facilitates flap insetting in complex composite reconstruction.
  2. PREOPERATIVE PREPARATION
    1. Evaluation
      1. Exclude previous trauma or surgery to intended donor shoulder and axilla with history and physical examination. Anticipate using nondominant shoulder.
      2. Consent including general microvascular and flap-specific complications.
      3. Describe need for shoulder physical therapy program following surgery.
    2. Potential Complications
      1. See General microvascular protocol.
      2. Generally recognized flap-specific complications include wound separation, shoulder weakness and stiffness, arm and hand weakness, and long thoracic nerve injury with resultant "winged scapula."
      3. Many patients will have objectively measurable limitations of shoulder motion in the immediate postoperative period; however, very few report that this affects their activities of daily living after 2-4 weeks.
  3. Nursing Considerations
    1. Room Setup
      1. See Free Flap Room Setup
      2. Vacuum beanbag mattress on bed for positioning patient on side
    2. Instrumentation and Equipment
      1. Standard
        1. Major Instrument Tray 1, Otolaryngology
        2. Major Instrument Tray 2, Otolaryngology
        3. Bipolar Forceps Trays
        4. Microsurgery Instrument Tray, Otolaryngology x 2
      2. Special
        1. Hall Micro Sagittal Saw Tray (Pneumatic) or Midas Rex Drill Tray
        2. Bien Otologic Electric Drill Tray
        3. KLS Free Flap Implant - Instrument Tray or
        4. KLS Locking Reconstruction Threadlock Instrument Tray or
        5. KLS mandibulectomy tray or
        6. KLS Free Flap Implant - Instrument Tray or
        7. KLS maxillectomy tray
        8. Dermatome set-up (available only)
    3. Medications (specific to nursing)
      1. Heparin sodium injection, 1,000 units per ml, 10 ml vial
      2. Papaverine injection, 30 mg/ml
      3. PhysioSol irrigation solution, 500 ml (warm)
    4. Prep and Drape (see photos Prep and Drape for Latissimus and Scapula Free Flap )
      1. Standard prep, 10% providone iodine
        1. Prep accordingly for specific procedure done in conjunction with the scapula flap.
        2. Shave chest and axilla. Prep the entire donor side arm and hand, axilla, and back to 3 cm beyond the midline of the back.
        3. Prep back from hairline to level of iliac crest 3 cm past midline and staple a waterproof barrier and drape up the midline from the bottom to the top of the back prep.
        4. The entire prep of the back is done prior to starting the head and neck procedure so that all that needs to be done to harvest the flap is to roll the patient and inflate the bean bag.
        5. Prep ipsilateral thigh for possible skin graft.
      2. Drape
        1. Drape the head and neck separately from free flap operative site.
        2. Patient will be in a lateral decubitus position with contralateral axillary roll during flap harvest.
        3. Place towels to separate the ipsilateral arm from head incision.
        4. Towels to square off operative site including ipsilateral arm, chest, abdomen, and back to midline (also include ipsilateral thigh for possible skin graft)
        5. Impervious drape underneath patient as far as possible so back stays sterile while patient is supine
        6. Split sheet
    5. Drains and Dressings
      1. Varidyne vacuum suction drain: 7 mm or 10 mm
      2. Velcro shoulder immobilizer to secure forearm to the abdomen (no straps around neck)
    6. Special Considerations
      1. Heparin sodium injection 5,000 units in sodium chloride 0.9% 500 ml in syringe, Luer tip 5 cc syringe with 24-gauge IV cannula is used to irrigate vessels.
      2. Papaverine 60 mg in 500 cc sodium chloride 0.9% in a Luer tip 10 cc syringe with 18-gauge IV cannula will be used topically to irrigate for vasospasm.
      3. The wound should be periodically irrigated with warm PhysioSol irrigation solution.
      4. Use all measures to keep body temperature at least 37.6°C (warming blanket, room temperature).
      5. See Skin graft protocol if necessary for procedure.
      6. Bone cutting and contouring
        1. Hall microsagittal saw or reciprocating saw is preferred. Use Bien otologic electric drill for bone contouring and smoothing.
      7. Microvascular
        1. See General microvascular protocol.
      8. Bone fixation
        1. Locking screw system (preferred for scapula). May use 2.0 mm or 2.4 mm mandibular plating system if scapular bone stock is robust.
  4. ANESTHESIA CONSIDERATIONS
    1. General
      1. Patient should be on a beanbag and a warming blanket.
      2. An axillary roll should be placed.
      3. It should be easy to roll patient into a lateral decubitus position to perform prep. The table will be turned 180° from the anesthesiologist.
    2. Specific
      1. No IV, arterial lines, or blood pressure cuff on donor side upper extremity.
      2. Sterile long anesthesia tubing may be required.
  5. OPERATIVE PROCEDURE
    1. Identify the omotricipital triangle by palpation of the teres major and lateral scapular border. The circumflex scapular artery pulse may be identified within the triangle using a Doppler probe. A portion of the skin paddle must be situated over this point to capture a terminal branch of the circumflex vessel.
    2. Elevate the scapular skin paddle (based on the transverse perforator) from medial to lateral just above the deep muscular fascia and below the dorsal thoracic fascia. The parascapular skin paddle (based on the descending perforator) is elevated from inferior to superior in the plane of the latissimus dorsi. Identify the teres major muscle. The circumflex artery will be identified within the omotricipital triangle just superior to the teres major muscle. If a bone flap is to be harvested, divide the teres major muscle attachments to the scapula.
    3. Division of the teres major allows access into the axilla. Follow the circumflex vascular pedicle to the subscapular and axillary artery. Division of several muscular branches to the teres major, teres minor, and subscapularis muscles will be required. Identify the angular artery if possible. If the pedicle is to include the subscapular artery and the latissimus will not be harvested with the flap, the thoracodorsal vessels to the latissimus will need to be divided.
    4. If bone is to be harvested, the teres minor and long head of the triceps are released from the lateral scapular border. The bone available for harvest includes the lateral scapular border from approximately 1 cm below the glenohumeral joint to the scapular angle. A width of approximately 2 to 3 cm is usually harvested. The osteotomy may be facilitated by use of a reciprocating saw. The scapular angle may be harvested independently if the angular vessels are identified and preserved. The teres major is itself vascularized by a branch of the circumflex scapular artery, and can be harvested along with the flap if needed.
    5. Reflect the infraspinatus muscle medially and incise the periosteum along the intended osteotomy line. The bone cuts are then made with care not to injure the joint capsule during the superior cut.
    6. At this point, the subscapularis muscle is sharply incised from the deep surface of the bone. The flap may be delivered following division of the vascular pedicle. If bone contouring can be done prior to pedicle division, this is performed prior to delivering the flap. In most cases, however, this is best done while the back is being closed so that inset may begin as soon as that is completed.
    7. The teres muscles and long head of triceps may be reattached to the remaining scapula with sutures placed through drill holes along the lateral border. If the teres major muscle appears devascularized, it should be removed rather than left in the wound. One suction drain is placed deep in the axillary dissection defect and a second under the skin flaps. The skin is closed with deep 2-0 and 3-0 vicryl sutures and staples.
    8. Flap inset and bone fixation are performed as per the General microvascular protocol and the Free bone flap fixation protocol.
  6. POSTOPERATIVE CARE
    1. See General microvascular protocol
    2. A Velcro shoulder immobilizer can be placed on the patient in the operating room. The immobilizer secures the forearm to the abdomen. There are no straps around the neck.
    3. The patient begins shoulder physical therapy on postoperative day 5.
  7. SUGGESTED READING
    1. Aviv JE, Urken ML, Vickery C, et al. The combined latissimus dorsi-scapular free flap in head and neck reconstruction of the head and neck. Arch Otolaryngol Head Neck Surg. 1991;117:1241-1250.
    2. Frodel JL, Funk GF, Capper DT, et al. Osseointegrated implants: a comparative study of bone thickness in 4 vascularized bone flaps. Plast Reconstr Surg. 1993;92:449-455.
    3. Funk GF. Scapular and parascapular free flaps. Facial Plast Surg. 1996;12:57-63.
    4. Granick MS, Ramasastry SS, Newton ED, et al. Reconstruction of complex maxillary defects with the scapular-free flap. Head Neck. 1990; 12:377-385.
    5. Ohsaki M, Maruyama Y. Anatomical investigations of the cutaneous branches of the circumflex scapular artery and their communications. Br J Plast Surg. 1993;46:160-163.
    6. Rowsell AR, Davies DM, Eisenberg N, Taylor GI. The anatomy of the subscapular-thoracodorsal arterial system: study of 100 cadaver dissections. Br J Plast Surg. 1984;37:574-576.
    7. Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg. 1986;77:530-545.
    8. Ngo K, Goldstein D, Neligan P, Gilbert R. Colorimetric evaluation of facial skin and free flap donor sites in various ethnic populations. J Otolaryngol. 2006 Aug;35(4):249-54.