Operative Technique in Plastic Surgery – Kevin C.Chung

AlloDerm may be used to supplement the closure (FIG 7A,B).
Secondary Alveolar Cleft Repair
■ Papillary (or gingivobuccal) incisions are marked, extending from within the
cleft to the first molar with a backcut planned cephalad into the buccal
mucosa.
■ Local anesthetic with epinephrine is injected along the incisions and under
the flaps.
■ A no. 15 blade is used to make the incisions, and subperiosteal degloving of
the maxilla and nasal region is performed with a periosteal elevator.
■ With the maxillary mucosal flaps elevated, lateral backcuts are made
underneath the flaps in the periosteum to provide a release for a “sliding
sulcus” advancement.
■ Within the cleft, elevation of the lateral cleft flap (from the lesser segment)
and the medial cleft flap (from the premaxilla), including a vomer flap, is
performed in a subperiosteal plane.
■ Separation or bisection of flaps is sharply performed for intraoral palatal
and nasal floor closures.
■ Nasal floor closure is performed with interrupted Vicryl or chromic suture on
a P-2 needle. Intraoral palatal closure is performed with vertical mattress
chromic sutures.
■ Resorbable collagen matrix impregnated with BMP-2 (with or without
demineralized bone matrix) is implanted into the alveolar cleft defect and
along the piriform aperture for alar base support.
■ Lateral gingivobuccal flaps are advanced to the anterior mucosal flap for
closure over the implanted graft. Dental Coe-Pak is placed as a dressing.
■ Cranial Defect Repair
■ Although a coronal zigzag incision is preferred when marking, previous
craniotomy incisions must be considered. Scalp hair is removed by limited
clipping to access previous scars and plan incisions that maximize scalp
blood supply.
■ The incision is made down through the periosteum overlying the bone. In the
area of the defect, an elevator is placed between the subgalea and scarred
dura to protect the deep structures.
■ Skin flaps are raised and subperiosteal dissection around the entire defect is

performed. Along the bony borders of the defect, a small endocranial rim is
developed. Power burring is performed along the osseous borders to promote
osteoconductive healing.
■ A 3D CT scan skull model is helpful for shaping the resorbable mesh plates
(Resorbex, KLS Martin, Jacksonville, FL) (FIG 8A,B).
■ The endocranial plate is placed on the endocranial side of the model,
trimmed, and molded with hot saline.
■ Resorbable pins (7 mm) are placed through holes and welded to the plate
as supportive columns.
■ BMP-2 is soaked onto the resorbable collagen matrix for 20 minutes and
then placed with DBM around the pins.
■ The ectocranial plate is contoured to the ectocranial surface of the model
allowing 1 cm of plate to overlap the in situ bone for fixation.
■ The endocranial plate is then placed on top of the pins (columns) and
collagen seeded with BMP-2.
■ This is welded together with a flat sonic weld tip to create the bilaminar
“sandwich” (FIG 9A,B).
■ The bilaminar construct is implanted into the cranial defect and sonic weld
pins are used for fixation.
■ Skin flaps are closed in two layers over a drain placed away from the
construct.
■ Mandibular Defect Repair
■ A gingivobuccal incision or Risdon incision is marked depending on
previous incisions.
■ Recreation of the mandibular skeletal defect is performed by dissecting
subperiosteally to bone and retained hardware.
■ Intervening soft tissue is excised.
■ A fresh osteotomy cut or burring at the bony edges is performed to ensure
influx of preosteoblasts for implant healing.
■ The titanium or resorbable crib is fashioned to outline the mandibular defect
with lingual lip and complete coverage of the inferior and anterior borders.
■ The crib is secured with screws (for titanium plate) or pins (for resorbable
implant).
■ Resorbable matrix impregnated with BMP-2 (for 20 minutes) with or

without demineralized bone matrix is packed into the crib.
■ Meticulous closure is performed with running, locking 3-0 chromic sutures.
■ Temporary placement into maxillomandibular fixation is recommended.
■ Rare Tessier Cleft Repair
■ During the initial soft tissue repair when flaps are raised, there is excellent
access to the osseous defect.
■ Autologous bone donor sites may be limited in infants and young children,
so the use of BMP-2 becomes a good option (FIG 10A,B).
■ An example of this is a no. 3 or 4 rare facial cleft with ocular-sinus-oral
communication.
■ Soft tissue flap designs respecting natural facial aesthetic lines are used with
nasal rotation, eyelid switch flaps, and lateral cheek advancement.7
■ After injection and incisions, thick flaps are raised to ensure an adequate
blood supply.
■ Skeletal defects are completely dissected, and intervening soft tissue is
excised. For complete clefting, deep mucosal flaps within the cleft are raised
for closure.
■ After closure of the deep flaps, BMP-2 is applied to collagen matrix for 20
minutes and implanted into the skeletal defect.
■ Anterior flaps are rotated, transposed, and closed in layers with resorbable
sutures.
PEARLS AND PITFALLS
Techniques
■ Implant and construct must have enough structure to conform to the
defect area and prevent soft tissue collapse into the defect.
■ Complete closure with well-vascularized tissues is important for
healing and to resist exposure of the implant and infection in the
perioperative period.
■ To limit ectopic bone formation, the implant with BMP-2 should be
confined to the defect area.
Alveolar
■ For primary alveolar grafting during infancy, limited dissection

defect
during GPP is required to avoid growth disturbances.8
■ “67” Beaver blade should be used to make incisions.
Cranial
vault
■ Large surface area of resorbable plates may cause soft tissue swelling
during resorption phase, months after healing.
Mandibular
defects
■ Dental implants can be placed in select patients, months after osseous
healing, but “jaw in a day” (implants at the time of free fibular
reconstruction) cannot be performed.4 This technique is limited to
smaller defects.
Tessier
Clefts
■ Bone reconstruction with BMP-2 may be performed during the initial
soft tissue repair when soft tissue flaps are raised and defects are most
accessible.
POSTOPERATIVE CARE
■ Alveolar cleft repair: Soft diet for 1 week or until complete mucosal healing.
For secondary repair, remove the Coe-Pak at 1 week.
■ Cranial vault repair: Customized helmet provides protection for the first few
weeks but is not absolutely necessary. Avoid contact sports for 6 weeks.
■ Mandibular defect repair: Placement into MMF for a week; liquids until
complete mucosal healing and then soft diet for 1 week
OUTCOMES
■ Alveolar cleft repair: Francis et al. retrospectively reviewed 55 patients who
underwent secondary alveolar cleft reconstruction, 36 of whom received
rhBMP-2 with demineralized bone matrix (DBM) scaffold; the remainder
underwent the standard iliac crest bone grafting.9
■ Bone stock was evaluated using occlusal radiographs. Clefts repaired with
rhBMP/DBM was 97% successful (based on volumetric fill), compared with
84% in patients with iliac-derived bone grafts.
■ Patients with iliac bone grafts had a significantly higher rate of intraoral
infection postoperatively.
■ Cranial defect repair: rhBMP has been used in the pediatric population, for
whom availability of split grafts can be limited. Beidas et al. demonstrated that
the addition of rhBMP can improve rates of defect closure when added to
particulate autogenous bone graft.10
■ Mandibular defect repair: Sweeny et al. retrospectively reviewed 17 cases of
vascularized bone grafting to the mandible for osteoradionecrosis in which

rhBMP-2 was added to the union of native bone and fibula flap. Rates of
infection and malunion were similar; there was no increase in cancer
recurrences noted with the use of rhBMP-2.11
■ Rare Tessier cleft repair: Because these clefts are rare, no randomized studies
of these patients have been performed; however, early bony healing in these
cases has been documented. Secondary procedures during midchildhood and at
skeletal maturity for patients with rare craniofacial clefts are more common
and may require grafting with rhBMP-2.
COMPLICATIONS
■ Local reactions
■ Graft failure
■ Infections
■ Wound complications12
FIG 7 • View of the palate and alveolar segments in a
patient with left cleft lip and palate. A. Pre-NAM shows
wide separation of the alveolar segments. B.
Postoperative image after NAM and GPP with BMP-2
shows healing of the alveolar segments just prior to
cleft palate repair.

FIG 8 • Large pediatric cranial vault defect involving the
frontal, parietal, and occipital regions. A. 3D model
created for reconstructive planning using bilaminar
resorbable plate construct with intervening BMP-2. B.
3D CT scan 6 months after surgery demonstrates
healing at the periphery and centrally. The patient
demonstrated complete calvarial healing at 1 year.
FIG 9 • Intraoperative apical views during reconstruction

with bilaminar resorbable plate and BMP-2. A. View
following placement of endocranial plates with
supportive struts (pins) and BMP-2–impregnated
collagen. B. View after ectocranial plates have been
placed and fixated to surrounding bone edges.
FIG 10 • 3D CT scan of Tessier no. 4 orbitofacial cleft
and accompanying inset of patient with no. 4 cleft. A.
CT scan at birth demonstrates the osseous defect with
communication between the orbit, maxillary sinus, and
oral cavity. B. CT scan demonstrates bone healing of
the maxilla and alveolus after primary soft tissue and
BMP-2 repair. Orbital reconstruction is planned in the
future.
■ Ectopic bone formation
■ Transformation in an oncologic field13
■ In pediatric reconstructions
■ Closure of nearby facial sutures after alveolar cleft treatment
■ Closure of cranial sutures after cranial vault defect treatment10
REFERENCES
1. Kumar AR, Bradley JP, Harshbarger R, et al. Warfare-related craniectomy

defect reconstruction: early success using custom alloplast implants. Plast
Reconstr Surg. 2011;127(3 suppl):1279-1287.
2. Ferretti C, Rikhotso E, Muthray E, Reyneke J. Interim reconstruction and
space maintenance of mandibular continuity defects preceding definitive
osseous reconstruction. Br J Oral Maxillofac Surg. 2013;51(4 suppl):319-325.
3. Rana M, Warraich R, Rashad A, et al. Management for comminuted but
continuous mandible defects after gunshot injuries. Injury. 2014; 45(1
suppl):206-211.
4. Levine JP, Bae JS, Soares M, et al. Jaw in a day: total maxillofacial
reconstruction using digital technology. Plast Reconstr Surg. 2013;131(6
suppl):1386-1391.
5. Hagan M, Bradley JP. Syndrome of the trephined: functional improvement
after reconstruction of large cranial vault defects. J Craniofac Surg. 2017;28(5
suppl):1129-1130.
6. Kohan E, Roostaeian J, Yuan JT, et al. Customized bilaminar resorbable mesh
with BMP-2 promotes cranial bone defect healing. Ann Plast Surg. 2015;74(5
suppl):603-608.
7. Longaker MT, Lipshutz GS, Kawamoto HK. Reconstruction of Tessier no. 4
clefts revisited. Plast Reconstr Surg. 1997;99(6 suppl):1501-1507.
8. Santiago PE, Grayson BH, Cutting CB, et al. Reduced need for alveolar bone
grafting by presurgical orthopedics and primary gingivoperiosteoplasty. Cleft
Palate Craniofac J. 1998;35(1 suppl):77-80.
9. Francis CS, Mobin SS, Lypka MA, et al. rhBMP-2 with a demineralized bone
matrix scaffold versus autologous iliac crest bone graft for alveolar cleft
reconstruction. Plast Reconstr Surg. 2013;131(5 suppl):1107-1115.
10. Beidas OE, Deschamps-Braly JC, Morgan AM, et al. Safety and efficacy of
recombinant human bone morphogenetic protein 2 on cranial defect closure in
the pediatric population. J Craniofac Surg. 2013;24(3 suppl):917-922.
11. Sweeny L, Lancaster WP, Dean NR, et al. Use of recombinant bone
morphogenetic protein 2 in free flap reconstruction for osteoradionecrosis of
the mandible. J Oral Maxillofac Surg. 2012;70(8 suppl):1991-1996.
12. Woo EJ. Adverse events reported after the use of recombinant human bone
morphogenetic protein 2. J Oral Maxillofac Surg. 2012;70(4 suppl):765-767.
13. Rochanawutanon S, Suddhasthira T, Pairuchvej V, Vajaradul Y. Long term
follow-up of reconstruction with allogeneic mandibular bone crib packed with
autogenous particulate cancellous bone marrow. Cell Tissue Bank. 2002;3(3
suppl):183-197.

33
CHAPTER
Section IV: Mandibular
Surgery
Costochondral
Reconstruction for Absent
Temporomandibular Joint
Patrick A. Gerety and Scott P. Bartlett
DEFINITION
■ Costochondral graft is a rib graft harvested with osseous and cartilaginous
portions.
■ Hemifacial microsomia (HFM) is a congenital condition in the distribution of
the 1st and 2nd branchial arch embryology affecting the mandible, ear, orbit,
facial soft tissue, and facial nerve function.
■ Pruzansky-Kaban modified classification system1 is a four-point scale (I, IIA,
IIB, III) used to rate mandibular hypoplasia in patients with HFM.
ANATOMY
■ Mandibular anatomy (FIG 1A)
■ Ramus: vertical, posterior height often deficient in HFM patients; often
shifted medially in HFM; site of costochondral reconstruction
■ Coronoid process: insertion of temporalis muscle; affected by ramus
hypoplasia
■ Condyle: may be hypoplastic or absent in HFM
■ Body
■ Symphysis/parasymphysis
■ Alveolar process

■ Temporomandibular joint (TMJ; FIG 1B)
■ Synovial articular joint of the mandible
■ Complex multicomponent structure that includes the condyle, glenoid fossa,
capsule, articular disk, lateral pterygoid muscle, and ligaments
■ Joint allows rotation and anterior translocation.
■ Glenoid fossa
■ Site of mandibular articulation on the temporal bone just anterior to the
external auditory meatus/canal
■ In severe HFM, this structure is absent/hypoplastic.
■ Rib osteocartilaginous junction (FIG 1C) is located at approximately the
midclavicular line. This location will allow a portion of rib that has a long
osseous and shorter cartilaginous portion for mandible reconstruction.
PATHOGENESIS
■ Disorder of 1st and 2nd branchial arch development causing facial hypoplasia
■ Theories:
■ Stapedial artery disruption/hematoma
■ Neural crest cell migration error
NATURAL HISTORY
■ The hypoplastic mandible does grow but does not attain catch-up growth and
is outpaced by the normal side.2
■ Facial asymmetry may worsen with growth in more severe cases.
FIG 1 • A. Mandible. B. Temporomandibular joint. C. Rib
harvest. An incision is designed in the inframammary

crease to harvest an osseocartilaginous rib graft.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ OMENS+ classification describes abnormalities in HFM patients.3
■ Stands for orbit, mandible, ear, facial nerve, and soft tissue
■ Extracraniofacial manifestations—requires medical workup
■ Mandibular hypoplasia can be variable in morphology and degree (FIG 2A).
■ Vertically shortened ramus—loss of posterior facial height and blunted gonial
angle
■ Occlusal cant up toward the affected side
■ Loss of posterior facial width with a medially shifted mandible
■ Displaced dental midline
■ Severity of mandibular hypoplasia
■ Pruzansky-Kaban classification
• Type I: small mandible with normal morphology
• Type IIA: mandible with a ramus that is abnormal in size and shape, but
with a TMJ that is normally situated
• Type IIB: abnormal ramus and a TMJ that is medially displaced
• Type III: absent ramus, condyle, and TMJ (FIG 2B)
FIG 2 • A. Hypoplastic mandible. Features include an
occlusal cant, vertically short ramus with loss of facial
height, effacement of the gonial angle, and

medialization of the ramus-condyle. B. Pruzansky type
III mandible deformity. The ramus, coronoid process,
and condyle are absent.
■ This classification system has been shown to have low inter-rater reliability,
which is largely related to the highly variable morphology of the hypoplastic
mandible in HFM. There is no system in use that has better inter-rater
reliability.
■ Ramus and condyle reconstruction typically performed on type IIB and type
III patients
IMAGING
■ Three-dimensional (3D) computed tomography (CT) of the craniofacial
skeleton provides definitive assessment of mandibular morphology.
DIFFERENTIAL DIAGNOSIS
■ Hemifacial/craniofacial microsomia
■ Treacher Collins syndrome
■ Condylar-coronoid collapse
■ Condylar hyperplasia
■ Hemifacial hypertrophy
SURGICAL MANAGEMENT
Preoperative Planning
■ CT scan to determine mandibular and TMJ morphology
■ Orthodontic evaluation and preparation
Positioning
■ Supine
■ Nasal intubation
Approach
■ Splints delivered by orthodontist or via computer planning service
■ Two-team approach:
■ Rib harvest
■ Mandibular exposure

■ Surgical goals:
■ Leveling of mandibular occlusal cant
■ Alignment of dental midline
■ Creation of neo-TMJ (“pseudoarthrosis”)
■ Rigid fixation plus maxillomandibular fixation (MMF)
T E C H N I Q U E S
■ Open Costochondral Graft Harvest
Rib Harvest (see FIG 1C)
■ Incision: 5 to 8 cm at inframammary crease, midclavicular line.
■ Typically allows access to rib 5, 6, or 7
■ Infiltration: An epinephrine-containing local anesthetic is placed in the
wound at all levels including directly onto the rib to aid hemostasis and limit
intraoperative narcotic use.
■ Skin incision is made sharply.
■ Electrocautery is used through the subcutaneous tissue and superficial fascia
down and through the pectoralis major/rectus muscle fascia.
■ Muscle division
■ Either the rectus muscle may be divided in the direction of the rib directly
over the chosen rib or it may be divided along the direction of its fibers and
retracted.
■ The senior author generally divides the muscle directly. This allows for
rapid visualization of the rib and much less strenuous retraction.
■ Rib dissection
■ This portion of the harvest should be performed carefully to avoid large
pleural tears and defects with possible lung injury. Large defects are
typically impossible to close primarily and may require local intercostal
muscle flaps and/or a thoracostomy (chest) tube.
■ Many rib approaches have relied upon subperichondrial dissection, but we
find this to be time-consuming, difficult, and unnecessary.
■ Maintaining perichondrium on the rib is also critical to the stability of the
osteocartilaginous junction.
■ The osteochondral junction is identified as a sharp ridge medially.

■ The anterior surface of the rib is now completely exposed.
■ A rib dissector is now carefully rotated around the back side of the rib
around the midpoint of the desired graft. This dissector is then moved up and
down the rib. This is a typically a fairly forceful maneuver. Dense intercostal
muscle fibers that are encountered can be divided with cautery.
■ The surgeon performing mandibular exposure should communicate the
expected length of rib that is required.
■ Length is typically 6 to 10 cm (this can be planned from the preoperative
CT).
■ The cartilaginous medial margin is transected with a fresh knife. Place a
protective retractor on the pleural side.
■ 1 cm of cartilage should be harvested to serve as the articular surface at the
TMJ. This end will be rounded before inset. The total length of the final
osteocartilaginous construct is typically 7 cm.
■ The rib is then elevated, and any deep muscle fibers can be cut with cautery.
■ The osseous, lateral end is then cut with a bone cutter.
■ The chest is examined for an air leak using saline solution in the dissection
pocket with a Valsalva maneuver performed by anesthesia (typically 20-cm
H2O above peak inspiratory airway pressure for 5–10 seconds).
■ The wound is closed in layers with particular attention to a quality muscle
closure.
■ Bupivacaine rib blocks or an On-Q pump may be used to decrease
postoperative pain.
■ A drain is typically not placed.
Mandible Exposure and Pocket Creation
■ A submandibular incision is marked below the mandibular border, typically
one to two fingerbreadths below the border (TECH FIG 1A).
■ The incision should be infiltrated with epinephrine-containing local
anesthesia.
■ The incision is made sharply and extended through the platysma (TECH
FIG 1B).
■ Blunt dissection is used to expose the inferior border of the mandibular
periosteum.
■ The periosteum is incised with a knife or cautery.
■ A subperiosteal dissection is performed with an elevator. Dissection should

be fairly wide to place a reconstruction bar.
■ A tunnel is made bluntly toward the temporal bone; this will create a pocket
for the rib graft.
TECH FIG 1 • Submandibular approach. A. An
incision is placed one to two fingerbreadths below the
mandibular border (one in children, two in adults). B.
The facial vessels may need to be divided. The
marginal mandibular branch is preserved by designing
a low incision, dividing the platysma low after
confirming with a nerve stimulator that no branches
are present. The platysma is then reflected, and the
inferior border of the mandible is approached.
■ This can be done with a uterine sound, a Cobb elevator, or a gloved finger.
■ There will not be a normal glenoid fossa present.
■ Creation of a narrow tunnel that firmly ends at the temporal bone will allow
articulation at the pseudoarthrosis, maintenance of posterior facial height,
adequate facial width, and less chance of graft migration.
■ The patient is then placed into occlusion using an orthodontic splint and
intermaxillary fixation (IMF) screws. This levels and aligns occlusion and
corrects midline asymmetries.
Rib Placement and Fixation

■ The graft is moved to the face.
■ An approximately 0.7- to 1.0-cm cartilaginous end should be kept. This
should be rounded with a knife.
■ The graft is then inserted into the pocket and firmly placed against the
temporal bone.
■ The graft should lie lateral to the mandibular body, where there will be bone-
bone contact.
■ The native mandible and rib graft are then fixated with bicortical screws
through the rib into the mandibular body (TECH FIG 2).
■ A single hole of a miniplate can be used as a washer to increase the surface
area of the screw head to prevent fracturing/splintering of the graft.
■ Some surgeons advocate a suspension suture placed through the neocondyle
and then high into the pocket.
■ This is a technically difficulty maneuver and may not be necessary with a
narrowly defined pocket and good fixation.
■ The deep fascia/pterygomasseteric sling, platysma, and skin are then closed
in layers. A drain is not typically used.
TECH FIG 2 • A. Placement of rib graft. B. Rib graft in
place with patient in dental splint and MMF via bone-
anchored IMF screws.

PEARLS AND PITFALLS
Appropriate
shape of the
articular
surface
■ The neocondyle should be rounded to mimic a normal condyle.
Costal cartilage is used to avoid bony ankylosis.
Positioning of
the graft at the
cranial base
■ When possible, place the neocondyle in a symmetric position to
the other side, This requires attention to the A-P and medial-
lateral positioning. A tunnel that is too large or was made on
multiple attempts may not ensure that the graft stays where
intended. Positioning can be a challenge because of the curvature
of the rib. Most often, the glenoid fossa is absent; therefore, the
construct articulates with the cranial base just medial to the
zygomatic process of the temporal bone.
Avoidance of
pneumothorax
■ Careful dissection directly on the rib graft, and a postoperative
Valsalva check
MMF
management
■ Can be removed after 3 weeks if adequate internal fixation is
attained. If there is inadequate fixation, then a CT scan or panorex
should be used to follow bony union.
Management
of posterior
open bite
■ This can be done after MMF is removed with either orthodontic
rubber bands to brackets or bone anchors. This encourages
downward maxillary growth. A splint that is progressively ground
down may also be used.
POSTOPERATIVE CARE
■ Pain control particularly of rib harvest site
■ Perioperative antibiotics for 72 hours
■ MMF with pureed diet postoperatively
■ TMJ dysfunction—TheraBite4
■ Used if mouth opening is worse or inadequate; begins 4 to 8 weeks after
surgery
■ Protocol: five 30 second stretches, 5 times per day
OUTCOMES
■ Twenty-two HFM patients, 33 rib grafts, average age 7.2 years5
■ Eighty-two percent required no additional mandibular expansion (grafting,

distraction osteogenesis).
■ TMJ ankylosis was noted in one patient.5
COMPLICATIONS
■ Infection, abscess
■ Graft resorption
■ Bony nonunion
■ TMJ ankylosis
■ Overgrowth/undergrowth
REFERENCES
1. Wink JD, Goldstein JA, Paliga JT, et al. The mandibular deformity in
hemifacial microsomia: a reassessment of the Pruzansky and Kaban
classification. Plast Reconstr Surg. 2014;133:174e-181e.
2. Shetye PR, Grayson BH, Mackool RJ, McCarthy JG. Long-term stability and
growth following unilateral mandibular distraction in growing children with
craniofacial microsomia. Plast Reconstr Surg. 2006;118:985-995.
3. Horgan JE, Padwa BL, LaBrie RA, Mulliken JB. OMENS-Plus: analysis of
craniofacial and extracraniofacial anomalies in hemifacial microsomia. Cleft
Palate Craniofac J. 1995;32:405-412.
4. Kaban LB, Bouchard C, Troulis MJ. A protocol for management of
temporomandibular joint ankylosis in children. J Oral Maxillofac Surg.
2009;67:1966-1978.
5. Tahiri Y, Chang CS, Tuin J, et al. Costochondral grafting in craniofacial
microsomia. Plast Reconstr Surg. 2015;135:530-541.

34
CHAPTER
Prosthetic Reconstruction of
the Temporomandibular
Joint
Anthony P. Tufaro and Srinivas M. Susarla
DEFINITION
■ Alloplastic reconstruction of the temporomandibular joint (TMJ) is frequently
required to address myriad issues relating to skeletal derangements,1–6
including arthritic conditions (rheumatoid, osteoarthritis, and post-traumatic
arthritis), ankyloses, avascular necrosis of the condyle, sequelae from
condylar/subcondylar fractures, benign and malignant neoplasms, degenerative
joint disease, and congenital deformities (eg, hemifacial microsomia).2–4
ANATOMY
■ The TMJ is a diarthrodial synovial joint.
■ As a complex apparatus, it allows full range of mandibular movement.
■ The condylar head of the mandible on each side articulates with a
fibrocartilaginous disc to form, in conjunction with the glenoid fossa of the
temporal bone, a joint for hinge and gliding movements.
■ Derangements of the disc and the condyle frequently necessitate autologous or
alloplastic replacement.
■ Alloplastic joint replacement is commonly used to address end-stage
deformities in the adult skeleton, multiple operated joints, and those that have
failed prior autologous reconstruction.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients with end-stage TMJ disease can have widely variable clinical
presentations.
■ Pain is a commonly reported symptom but is not, in and of itself, an

indication for surgical intervention.
■ The clinical history obtained should focus on discomfort, limitation of motion,
difficulties with mastication/nutrition, prior operative and nonoperative
interventions, and a focused dental history relating to occlusion and
parafunctional habits.
■ A complete head and neck examination should be performed, with particular
emphasis on evaluation of the occlusion, TMJ findings (tenderness, crepitus,
maximal incisal opening, and right and left excursive movements) and
tenderness of the muscles of mastication.
IMAGING
■ Magnetic resonance imaging is the preferred modality for assessing disc
pathology and to obtain real-time imaging of the disc position during
mandibular motion.
■ Thin-cut helical maxillofacial computed tomography (CT) is the preferred
modality for assessing bone pathology of the joint (FIG 1).
■ This may be combined with angiography in cases of ankylosis, in which the
ankylotic mass shares an intimate relationship with major vessels in the region
(eg, pterygoid plexus, internal maxillary artery).
DIFFERENTIAL DIAGNOSIS
■ Myofascial pain
■ Arthritis
■ Ankylosis
■ Congenital deformity
■ Trigeminal neuralgia
■ Internal derangement of the TMJ

FIG 1 • Coronal (A) and axial (B) computed tomography
views of a patient with left-sided temporomandibular
joint ankylosis.
FIG 2 • Three-dimensional reconstruction demonstrating

a large ankylotic mass involving the left
temporomandibular joint. Ankylosis release and
arthroplasty with a stock or custom temporomandibular
joint prosthesis is one approach for management.
NONOPERATIVE MANAGEMENT
■ Diagnosis is the key to treatment. Patients should be evaluated by both a
surgeon and a facial pain or TMJ disorders specialist.
■ Many patients will benefit from trials of nonoperative therapy (muscle
relaxants, nonsteroidal anti-inflammatory drugs [NSAIDs], etc.) or dental
appliance therapy (mandibular repositioning appliances, occlusal equilibration,
bite guards, etc.).
■ Patients who fail nonoperative therapy often begin with diagnostic and
minimally invasive therapeutic maneuvers (arthroscopy, arthrocentesis), with
invasive interventions (arthroplasty) reserved for refractory cases or end-stage
deformities.
SURGICAL MANAGEMENT
Preoperative Planning
■ Preoperative planning for alloplastic TMJ reconstruction involves a
preoperative decision about the use of custom or stock TMJ prostheses. In both
situations, a maxillofacial CT scan with thin cuts is required to visualize the
local bony anatomy and for construction of three-dimensional (3D) model
templates for prosthesis fabrication (FIG 2).
■ Patients who are candidates for alloplastic reconstruction are those who have
failed conservative management and have end-stage joint disease.
■ Patients with active infections, those who are skeletally immature, those with
muscle hyperactivity disorders (clenching and grinding), and those with active
resorptive bony processes or inadequate bone stock are not candidates for
alloplastic reconstruction.3
Positioning
■ The operation is completed with the patient in the supine position on the
operating table.
■ Nasotracheal intubation is required, as the surgeon will have to verify the

occlusion intraoperatively following prosthetic replacement (FIG 3A).
■ The anesthetist should be told not to use long-acting paralysis, as monitoring
of facial nerve branches may aid with dissection.
■ The nasotracheal tube is secured to the nasal septum using a 2-0 Vicryl
suture.
■ A moistened pharyngeal pack is not required, but may be preferred by some
surgeons.
■ The patient should have a mechanism for maxillomandibular fixation in place
prior to initiation of the operation. This can be orthodontic appliances, Erich
arch bars, or intermaxillary fixation screws.
■ If intermaxillary fixation appliances are to be applied intraoperatively, it is
necessary to do so before prepping and draping, so as to avoid contamination
of the facial incision with oral secretions.
■ Once the maxillomandibular fixation appliances are applied, the oral cavity
can be sealed off with a clear plastic occlusive dressing, and the face can be
prepared in the standard fashion (FIG 3B).
■ If the surgeon anticipates using fascia or fat grafts around the prostheses, the
donor site should be prepped and draped as appropriate.
Approach
■ Surgeons should be familiar with three sets of approaches to the TMJ.
■ Preauricular approach
■ This entails making an incision in the preauricular skin, sometimes with
extension into a coronal incision, depending on the indication.
FIG 3 • Standard views of patient preparation and

positioning. A nasotracheal intubation is performed to
afford access to the oral cavity for manipulation of the
occlusion (A). The oral cavity is isolated from the
surgical field for the majority of the case (B). (Reprinted
from Granquist EJ, Quinn PD. Total temporomandibular
joint replacement (Stock). In: Kademani D, Tiwana P,
eds. Atlas of Oral and Maxillofacial Surgery, 2015 with
permission from Elsevier.)
■ The frontal branch of the facial nerve is at risk with this approach. Traction
injury is the most common cause.
■ This approach provides excellent visualization of the zygomatic arch, glenoid
fossa, temporomandibular disc, and condylar head.
■ It is often insufficient as a single approach for alloplastic reconstruction and
is often combined with a submandibular approach.
■ Retromandibular approach
■ This approach entails making a skin incision over the posterior border of the
mandibular ramus, followed by a retro- or transparotid dissection to reach the
posterior mandibular ramus.
■ Structures at risk with this approach are the retromandibular vein and
branches of the facial nerve.
■ This approach affords excellent visualization of the entire posterior
mandibular ramus and is a single-incision technique for reconstruction.
■ Submandibular approach
■ This approach entails making an incision 2 cm below the inferior border of
the mandible to see the inferior border and lateral portion of the ascending
ramus. It provides limited access to the condyle and disc.
■ Structures at risk with this incision are the facial artery, facial vein, and
marginal mandibular branch of the facial nerve.
■ It is often combined with a preauricular approach.
T E C H N I Q U E S

■ TMJ Reconstruction With Stock/Custom
Prosthesis
Markings
■ The preferred surgical approach is marked. It is our preference to use a
combination of preauricular and submandibular or retromandibular approach
(TECH FIG 1).
■ The preauricular incision is marked from the helical insertion to
immediately superior to the lobule and crosses the tragus in an endaural
fashion.
■ The submandibular incision is marked by identifying the inferior border of
the mandible and the mandibular angle.
■ A linear incision is marked 2 cm inferior to the inferior border; this will
assist in avoiding the marginal mandibular branch of the facial nerve.
■ Once the incisions are marked, the areas are infiltrated with local anesthetic
with vasoconstrictor.
■ Alternatively, dilute epinephrine solution (1:100 000) may be used if there
is concern about local anesthetic effects on the facial nerve branches.
Preauricular Incision and Discectomy
■ The preauricular incision is made first.
■ A blade is used to incise through the skin and dermis.
■ The next layer encountered is the superficial musculoaponeurotic system,
which is contiguous superiorly with the galea. One should hug the tragal
cartilage as the dissection proceeds in this layer, for the frontal branch of the
facial nerve can be as close as 8 mm anterior to the tragus (TECH FIG 2).

TECH FIG 1 • Preauricular and
submandibular/retromandibular incisions marked.
(Reprinted from Granquist EJ, Quinn PD. Total
temporomandibular joint replacement (Stock). In:
Kademani D, Tiwana P, eds. Atlas of Oral and

Maxillofacial Surgery, 2015 with permission from
Elsevier.)
■ Once the dissection is through the SMAS, attention is directed toward
identifying the superficial layer of the deep temporal fascia, which is
contiguous with the pericranium superiorly and the parotidomasseteric fascia
inferiorly. This layer is easily identifiable above the zygomatic arch and is
distinct in its shiny white appearance.
■ Once identified, this layer can be incised at the level of the tragus and a
periosteal elevator can then be used to dissect toward the zygomatic arch.
■ Once the zygomatic arch is palpated, the pretragal incision can be extended
inferiorly to expose the zygomatic arch. Dissection in this manner will
elevate the facial nerve with the skin flap and avoid injury.
■ Once through the periosteum over the proximal zygomatic arch, the
dissection continues inferiorly to expose the lateral capsule of the TMJ. This
dense connective tissue is incised transversely, exposing the
temporomandibular disc and condylar head.

TECH FIG 2 • The preauricular dissection is initiated
first. Dissection through the skin and deeper tissues is
completed immediately anterior to the tragal cartilage,
so as to avoid the temporal branch of the facial nerve,
which crosses the zygomatic arch as close as 8 mm
from the tragus.
■ The disc is bluntly dissected free of its anterior, posterior, and medial
attachments, and removed. Caution should be exercised when dissecting the
disc posteriorly and medially, as these areas are common sources of bleeding.

■ Hemostasis is achieved with bipolar cautery.
■ The dissection continues to expose the condylar head and neck, in
preparation for condylectomy.
■ The condylar neck should be exposed to the level of the sigmoid notch. Once
this has been accomplished, the wound is inspected for hemostasis and
vasoconstrictor patties are placed into the bed.
Submandibular Incision and Condylectomy
■ Next, the submandibular incision is made (TECH FIG 3A). This is done
through skin and subcutaneous tissue, until the platysma is visible.
■ The platysma is then divided at the same level as the skin incision and the
superficial layer of the deep cervical fascia is identified.
■ This layer is developed bluntly and then incised, with careful monitoring
for marginal mandibular nerve branches.
■ Once through this layer, the dissection continues superiorly onto the
submandibular gland capsule, toward the inferior border of the mandible.
■ The inferior border is identified, and the fibers of the pterygomasseteric
sling are incised at the inferior border.
■ A periosteal elevator is used to develop a pocket lateral to the mandibular
ramus, in continuity with the previously developed preauricular dissection.
■ Once the zygomatic arch, glenoid fossa, TMJ, mandibular ramus, and
condyle are exposed, the condylectomy is performed (TECH FIG 3B,C).
This is done with a reciprocating saw or oscillating saw.
■ A malleable retractor is placed on the medial side of the condyle to prevent
inadvertent soft tissue injury.
■ The condylar osteotomy should be obliquely oriented, starting from the
sigmoid notch and angling posteroinferiorly to the posterior border of the
ramus.
■ Once complete, the condyle is removed and the bed inspected for
hemostasis.
■ The same exposure, discectomy, and condylectomy are then completed on
the contralateral side (for bilateral cases).

TECH FIG 3 • A. Division of the pterygomasseteric
sling to expose the mandible. (Reprinted from
Granquist EJ, Quinn PD. Total temporomandibular
joint replacement (Stock). In: Kademani D, Tiwana P,
eds. Atlas of Oral and Maxillofacial Surgery, 2015 with
permission from Elsevier.) B. Once the zygomatic
arch, condyle and articular disc, lateral ramus, and
inferior border are exposed, the condylectomy is
marked. C. The condylectomy should be performed at
least 15 mm below the glenoid fossa, to allow

adequate space for the fossa component and condylar
prosthesis.
Maxillomandibular Fixation and Prosthesis Insertion
■ Once both condylectomies and discectomies are complete, the wounds are
packed with sterile gauze and covered with sterile towels.
■ The surgeon, or assistant, then changes gloves and places his or her hand in
the oral cavity to verify that the mandible is freely mobile (particularly
important in cases of ankylosis) and that the occlusion is stable and
reproducible.
■ Once this is done, the patient is placed into intermaxillary fixation, and the
oral cavity is again isolated from the sterile field.
■ With the patient in maxillomandibular fixation, attention is now turned to
inserting the TMJ prosthesis.
■ The glenoid fossa component is inserted first and affixed using the
prescribed number of screws in the planning guide (TECH FIG 4A,B).
■ These screws are drilled under copious irrigation.
■ Following insertion of the fossa component, the condylar head component is
inserted through the submandibular incision and aligned with the fossa
component (TECH FIG 4C).
■ Once the condylar head position is seated correctly (it should be oriented
posteriorly and superiorly), the prosthesis is fixed using the prescribed
screws.
■ In bilateral cases, the procedure is repeated on the contralateral side.
Completion
■ The wounds are again packed with sterile gauze and covered. The surgeon
returns with glove change to the oral cavity and inspects the patient’s
occlusion.
■ Intermaxillary fixation is now released and verified to be stable and
reproducible with the prostheses in place. Once this is completed, the oral
cavity is again sealed off.
■ The wounds are irrigated thoroughly with antibiotic irrigation. Abdominal
fat or fascia can be used to cushion the prosthesis laterally.
■ A small (7–10 Fr) drain is placed, and the wounds are closed in layers.
■ The throat pack is removed, and the patient is returned to the anesthetist for

emergence from anesthesia.
TECH FIG 4 • A,B. The fossa component is inserted
and affixed into position after the patient has been
placed into maxillomandibular fixation (circle). (B,
Reprinted from Granquist EJ, Quinn PD. Total
temporomandibular joint replacement (Stock). In:
Kademani D, Tiwana P, eds. Atlas of Oral and
Maxillofacial Surgery, 2015 with permission from
Elsevier.) C. Meticulous attention to detail is required
to ensure the correct orientation of the condylar
component into the fossa. The insertion vector should
recapitulate the natural angulation of the condyle

relative to the inferior border of the mandible.
■ Design of a Custom Prosthesis
■ The surgical steps for a custom prosthesis are the same as for a stock
prosthesis. The difference is in the presurgical planning.
■ Once the diagnosis is established and the decision to proceed with total joint
replacement is made, the surgeon obtains a high-resolution maxillofacial CT
scan.
■ From this scan, a stereolithographic model of the TMJ and mandible is
made.
■ The condylectomies are performed on the model and the appropriate final
occlusion is established.
■ From this new mandibular position, the clinical engineer fabricates a wax-up
model of the TMJ prosthesis (TECH FIG 5A,B).
■ The surgeon will inspect the models, looking for appropriate contour, size,
and position.
■ Once the design is approved, the wax-up models are cast into metal
components (TECH FIG 5C).
■ These components are sterilized and ready for use.
■ Information from the 3D models and custom implants allows the engineer
to provide exact screw lengths for each fixation point on the prosthesis.

TECH FIG 5 • A,B. Stereolithographic model with wax-
up prosthesis. C. Cast titanium custom mandibular
joint prosthesis.
PEARLS AND PITFALLS
Hemostasis
■ At various points during the procedure, problematic bleeding can be
encountered. Meticulous hemostasis is necessary at all times, but
particularly during the medial dissection of the condyle and disc.
Nerve
injury
■ The facial nerve is at risk during any approach to the TMJ. Careful
attention to the local anatomy as well as conservative dissection and
nerve monitoring can help prevent injury.
Infection
■ Because a portion of the operation requires the surgeon to enter the

oral cavity, it is paramount that all members of the operative team be
aware of this to avoid cross-contamination. The protocols for
transitioning to intermaxillary fixation should be reviewed during the
procedure briefing and roles clearly established.
Condylar
malposition
■ The surgeon should ensure that the condylar position is appropriate.
The condylar inclination should be oriented posteriorly and
superiorly.
POSTOPERATIVE CARE
■ Patients are admitted to the inpatient unit for 1 to 3 days postoperatively.
■ Standard postoperative pain management should be initiated. It behooves the
surgeon to discuss pain management with the patient and any treating pain
specialists prior to surgery.
■ Many patients with TMJ disorders use chronic pain medications.
■ Inpatient pain service consultation should be used as needed.
■ Postoperative antibiotics are not indicated.
■ Patients may be kept in light intermaxillary fixation with elastics or full
intermaxillary fixation with wires, depending on the final occlusion and the
patient’s ability to reliably occlude.
■ A headwrap or JawBra may be useful for reducing edema and helping with
pain.
■ Patients should be maintained on a soft, nonchew diet for 6 weeks
postoperatively.
■ Lateral and anterior posterior skull films (or panoramic radiograph) are
sufficient to verify positioning of the implants and are cost-effective.
OUTCOMES
■ TMJ stock prostheses have been FDA approved for more than a decade.
■ Prospective data have demonstrated that, at 3 years postoperatively, patients
had decreased pain (mean of 8.5/10–2.8/10), with improved mouth opening
(20–29 mm), with 99% of patients reporting that they would undergo surgery
again.3–6
■ Reported revision rates are below 5% and are most commonly due to
infection or heterotopic bone formation.5 Mechanical failures are rare.
■ For custom joint prostheses, the results are similar, with noted improvement in
pain and mandibular motion.1,2
■ Eighty-five percent of patients with custom alloplastic reconstructions

reported improved quality of life.2
■ There is a paucity of long-term data regarding durability of the prostheses,
but reports in the literature suggest appropriate functioning at 10 years after
insertion and up to 14 years after insertion.2,7
COMPLICATIONS
■ Revision rates are relatively low (less than 5%) and are related to infection or
heterotopic bone formation.
■ Facial nerve injury is perhaps the most significant complication.
■ The risk of attendant nerve injury increases with previously operated sites or
otherwise aberrant anatomy (eg, tumor, ankylosis). Meticulous dissection and
intraoperative nerve monitoring are necessary to avoid nerve injury.
■ Many patients will experience a postoperative neuropraxia simply from
traction. This will typically resolve within 6 to 12 weeks.
■ Frank transections should be repaired immediately (within 72 hours).
■ Delayed recognition of a nerve injury or lack of recovery after 3 months
typically requires additional procedures (eyelid weights, facial reanimation)
for correction of the deficits.
REFERENCES
1. Mercuri LG. Alloplastic TMJ replacement: rationale for custom devices. Int J
Oral Maxillofac Surg. 2012;41:1033.
2. Mercuri LG, Edibam NR, Giobbie-Hurder A. 14-year follow-up of a patient
fitted total temporomandibular joint reconstruction system. J Oral Maxillofac
Surg. 2007;65:1140.
3. Quinn PD. Alloplastic reconstruction of the temporomandibular joint: selected
readings on oral and maxillofacial surgery. Select Read Oral Maxillofac Surg.
1999;7:1-20.
4. Westermark A. Total reconstruction of the temporomandibular joint: up to 8
years follow-up of patients with Biomet total joint prostheses. Int J Oral
Maxillofac Surg. 2010;39:951.
5. Giannakopoulos HE, Sinn DP, Quinn PD. Biomet microfixation
temporomandibular joint replacement system: a 3-year follow-up study of
patients treated during 1995 to 2005. J Oral Maxillofac Surg. 2012;70:787.
6. Leandro LFL, Ono HY, Loureiro CC, et al. A ten-year experience and follow-
up of 300 patients with the Biomet/Lorenz microfixation TMJ replacement
system. Int J Oral Maxillofac Surg. 2013;42:1007.

7. Mercuri LG, Wolford LM, Sanders B, et al. Long-term follow-up of the
CAD/CAM patient fitted total temporomandibular joint reconstruction system.
J Oral Maxillofac Surg. 2002;60:1440-1448.

35
CHAPTER
Osteocutaneous
Parascapular Flap for
Mandibular Reconstruction
Ravi K. Garg and John W. Siebert
DEFINITION
■ The parascapular osteocutaneous free flap serves as a versatile reconstructive
option for composite head and neck defects involving the mandible.
■ The lateral border and angle of the scapula are the most commonly used
osseous flap components, although harvest of the medial scapular border has
also been described.
■ Soft tissue elements that may be incorporated into the flap include skin, fat,
fascia, muscle such as the serratus and latissimus, and nerves, including the
thoracodorsal nerve.
ANATOMY
■ The parascapular osteocutaneous free flap is based on the subscapular system
emerging from the distal third of the axillary artery.
■ The circumflex scapular artery branches from the subscapular artery and
serves as the primary blood supply to the parascapular osteocutaneous flap.
■ The circumflex scapular artery can be reliably identified in the triangular
fossa, which is bound by the teres major and minor muscles as well as the long
head of the triceps (FIG 1).
■ The thoracodorsal artery also branches from the subscapular artery and sends a
branch to the scapular angle either directly or as a side branch of the serratus
muscle branch.
■ The angular artery can be useful for augmenting the blood supply of the
scapular border or can be used to harvest the scapular angle as a separate
osseous flap.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ Determine if the patient has had previous head and neck surgery that would
limit recipient vessel options or donor sites for microsurgical reconstruction.
■ Assess the patient’s level of function and which donor site will result in the
least morbidity.
■ A scapular flap may be advantageous for older patients with compromised
mobility who will have greater difficulty ambulating after surgery if a lower
extremity donor site is chosen.1
■ Inspect the patient’s dental occlusion and determine whether any diseased
dentition needs to be managed perioperatively and whether dental
rehabilitation will be performed.2
IMAGING
■ Preoperative CT angiography may be useful to exclude lower extremity flap
options such as the fibular flap in a patient with claudication and suspected
peripheral vascular disease.
■ Virtual surgical planning may be helpful for complex head and neck
reconstruction. A three-dimensional reconstruction of the recipient and scapula
donor sites can be produced using CT imaging. Osteotomy sites at both the
recipient and donor scapula locations may be planned preoperatively and a
cutting jig developed to facilitate scapular contouring and inset.3

FIG 1 • Demonstration of the cutaneous branch of the
circumflex scapular artery exiting the triangular fossa
defined by the teres major, teres minor, and long head
of triceps. The versatility of the scapular
osteocutaneous flap relates to the multiple soft tissue
elements including skin, fat, fascia, and the latissimus
and serratus muscles that can be elevated with the flap
based on the subscapular system. Additionally, the
lateral scapular border is perfused by both the
circumflex scapular and angular arteries, enabling
separate bone flaps to be harvested.
SURGICAL MANAGEMENT
■ The parascapular osteocutaneous flap is particularly useful for composite

tissue defects with a large soft tissue component.
■ Multiple skin paddles and muscle flaps, including the latissimus and serratus,
can be transferred with scapular bone based on the circumflex scapular
artery,2,4 enabling reconstruction of some of the most complex three-
dimensional defects.
■ This flap is unique among other choices used for mandibular reconstruction
including fibula, iliac crest, and radial forearm free flaps, because the lateral
scapular bone is vascularized by a circumflex scapular pedicle branch
independent from the branch supplying the skin paddle.
■ The bone can be inset into segmental defects of the mandible or used as a
mandibular onlay, whereas the skin paddle can be safely rotated up to 180
degrees in relation to the bone.
Preoperative Planning
■ Determine the anticipated length of the bony deficit at the recipient site and
whether a scapula flap will provide sufficient bone to reconstruct the defect.
■ Discuss with the patient and surgical team the functional goals of the
reconstruction. Most male patients will be able to accommodate
osteointegrated implants into their scapula flaps, although some female patients
will have insufficient bone stock.5
■ Decide whether a two-team approach will be possible based on the positioning
needs of the team working at the head and neck prior to transfer of the
microsurgical free flap.
Positioning
■ The patient is placed in the supine position for induction of general anesthesia.
■ A bump is placed under the shoulder ipsilateral to the flap harvest site. This
provides sufficient exposure of the upper back, and no beanbag is required for
immobilization.
■ Following flap harvest, the bump may be removed, enabling a simple transfer
to the supine position.
■ A Z-arm is placed on the side of the operating table opposite the back (FIG
2A). The patient’s arm will be suspended to this following sterile preparation
and draping.
■ The arm ipsilateral to the flap harvest site is prepped and draped in addition to
the upper back.

■ A Mayo stand cover is placed over the Z-arm, and this is wrapped with two
rolls of gauze (FIG 2B).
■ A sleeve is placed over the prepped arm past the level of the elbow (FIG 2C).
The sleeve is secured with a roll of gauze wrapped from the hand up.
■ Two Kocher clamps are then used to suspend the patient’s arm to the Z-arm
(FIG 2D).
■ This technique avoids any areas of concentrated pressure on the arm and
minimizes the risk of peripheral nerve injury.
■ The back is then draped with sterile towels and sheets.
Approach
■ The operative approach to raising the osteocutaneous parascapular flap
depends upon the design of the skin paddle. We tend to design the skin paddle
on the back along the axis of the arm so that the donor-site scar will be hidden
under the arm. However, the skin paddle can be oriented in any direction
around the triangular fossa.
■ Once the skin paddle has been designed, we approach flap elevation and
pedicle identification by raising the flap from caudad to cephalad. However,
the flap pedicle may also be approached by raising the skin paddle from its
lateral or medial aspect.

FIG 2 • A. The patient is positioned with a bump under
the back on the side of flap harvest. The arm is
elevated and will be suspended to a Z-arm that crosses
the patient’s body. B. The goal of the setup is to
minimize pressure on the forearm and avoid
complications of neurapraxia and nerve palsy. A sterile
Mayo stand cover is placed over the Z-arm and secured
in place with two rolls of gauze. C. A sterile arm sleeve
is placed over the arm after it has been sterilely
prepared. D. The sleeve is secured to the arm with a
gauze roll, and then, the gauze is secured to the Z-arm
using two Kocher clamps. This strategy provides plenty
of cushioning for the forearm without creating any areas
of focal pressure that could result in nerve injury.

T E C H N I Q U E S
■ Flap Elevation
Flap Design
■ Landmarks: lateral scapular border, teres major, teres minor, long head of
triceps
■ The skin paddle of the flap is designed around the triangular fossa through
which the circumflex scapular artery passes.
■ A depression superior to the teres major can usually be palpated and used
to identify the triangular fossa (TECH FIG 1A).
■ The teres major measures two fingerbreadths wide and runs almost parallel
to the lateral scapular border.
■ If the muscle cannot be palpated, then the lateral border of the scapula may
be identified and traced just proximal to the glenohumeral joint.
■ The triangular fossa is located two fingerbreadths medial to this junction of
the lateral scapular border and glenohumeral joint.
■ Confirmation can be performed with a pencil Doppler.
■ A skin paddle 5 to 10 cm in width and 16 to 46 cm in length can be
harvested and enable primary closure (TECH FIG 1B).
■ Cadaver studies have demonstrated that branches of the circumflex
scapular artery emerge radially from the triangular fossa and even perfuse
the anterior chest wall at least as far as the anterior axillary line.6 The
implication is that a long skin paddle can be harvested and followed into
the inframammary fold to keep the donor site discrete.
Soft Tissue Dissection
■ Once the patient is prepped and draped in a sterile fashion, skin cuts are
made along the outline of the elliptical skin paddle.
■ The skin paddle is elevated from caudad to cephalad using electrocautery
(TECH FIG 2A).
■ Elevation can be performed in a subfascial or suprafascial manner.
■ If additional flap bulk is desired, a subfascial dissection may be desirable
and may incorporate a fascial extension beyond the borders of the skin
paddle.

■ Paralyzing agents are used to facilitate electrocautery dissection.
■ As the superior border of the teres major is approached, a tenotomy is used
to expose the border of the muscle until the cutaneous perforator to the skin
paddle is identified.
■ The cutaneous perforator is followed proximally to the main trunk of the
circumflex scapular vessels.
■ As the vessels are traced, distinct branches will be identified that directly
penetrate the lateral scapular border or that travel closely along the muscle
and fascia overlying the lateral scapular border (TECH FIG 2B).
■ Usually, the circumflex scapular artery sends two or three branches directly
to the lateral scapular bone (TECH FIG 2C).
■ A transverse branch investing the overlying scapular muscle and fascia
supplies the medial scapular border and may serve as the basis for a medial
scapular osteocutaneous flap.
■ We tie this branch off and prefer to use the lateral border of the scapula for
reconstruction.
■ Distinct, descending branches of the circumflex scapular vessels travel
along the lateral border of the scapula and are identified and preserved
(TECH FIG 2D).
■ At this point, the remainder of the skin paddle is elevated cephalad to the
cutaneous branches of the circumflex scapular vessels.
■ The skin paddle is now completely free and perfused only by these
cutaneous branches (TECH FIG 2E). This enables the skin to be moved
back and forth to facilitate exposure of the lateral scapular border.
■ The skin paddle can be rested on a stack of green towels to help expose the
scapular border while minimizing tension on the circumflex scapular
vessels.
■ The teres minor and portions of the teres major and infraspinatus muscles are
dissected off the lateral border of the scapula in order to prepare the bone for
osteotomy.
■ A thin cuff of muscle is left on the lateral bone in order to preserve its
periosteal blood supply.

TECH FIG 1 • A. The triangular fossa, where the
cutaneous branch of the circumflex scapular artery
emerges, can be identified on physical examination.
The teres major is pinched cephalad to the latissimus.
The depression superior to the teres major is where
the cutaneous branch emerges and can be confirmed
with Doppler. B. The skin paddle to be elevated is
outlined based on the course of the circumflex
scapular artery. The scapula is palpated and the
lateral border is marked.

TECH FIG 2 • A. After completing the skin cuts, the
skin paddle is elevated from caudad to cephalad. The
dissection was performed leaving some fascia over
the latissimus muscle. Midway through the skin paddle
elevation, the cutaneous pedicle became visible (black
arrow). B. The cutaneous pedicle is followed into the
triangular fossa. Here, the teres major is being
retracted with a forceps and the pedicle to the skin
paddle (white arrow) can be seen branching from the
circumflex scapular artery. C. Further dissection of the
circumflex scapular artery (CSA) reveals multiple

direct branches to the bone (arrowheads) and a
descending branch traveling along the lateral scapular
border (white arrow) in addition to the cutaneous
pedicle (black arrow). D. The skin paddle is flipped the
opposite direction and the circumflex scapular arterial
branch traveling along the muscle cuff at the lateral
scapular border (white arrow) can be easily seen. A
transverse branch traveling across the scapula has
been tied off (black arrow). E. The skin paddle has
been dissected completely off the back now that the
circumflex scapular artery is fully defined in the
triangular fossa. Arrow points to the cutaneous
pedicle.
Bone Flap Creation
■ At least 1 cm of lateral scapular bone is preserved below the glenoid fossa to
avoid disruption of the glenohumeral joint.
■ The area of bone to be harvested incorporates the direct bony branches to
the scapula as well as the descending scapular branch, resulting in a robust
blood supply to the bone (TECH FIG 3A).
■ Electrocautery is used to divide the infraspinatus muscle directly over the
portion of the scapular bone that will be harvested.
■ A sagittal or reciprocating saw is then used to make transverse cuts through
the bone beginning at the lateral border as well as a longitudinal cut to join
these initial osteotomies.
■ An osteotome is used to release any areas of bony adherence.
■ The osteotome is then levered through the caudal, transverse bone cut,
exposing the subscapularis muscle on the undersurface of the scapular bone.
■ The muscle is divided parallel to the border of the bony cut, leaving the
entire bony segment free with a cuff of infraspinatus and subscapularis
muscle on each surface (TECH FIG 3B).

TECH FIG 3 • A. The segment of lateral scapular bone
to be harvested is outlined with purple ink. The outline
incorporates the direct bony perforators of the
circumflex scapular artery in addition to the
descending branch along the scapular border. The
muscle is then divided down to bone along the
marking, and a sagittal saw is used to perform the
osteotomies. B. The lateral scapular bone segment
has been completely freed from the donor site in
addition to the cutaneous paddle. The circumflex
scapular artery is seen (arrow) tethering the
composite flap to the triangular fossa.
■ The total length of lateral scapular bone that may be harvested including the
scapular angle is approximately 10 to 14 cm in an adult.
Vascular Pedicle Dissection
■ With the skin paddle and bony components of the flap free, the circumflex
scapular vessels are now followed through the triangular fossa to gain pedicle
length.
■ Side branches of the circumflex scapular vessels to the surrounding
musculature are ligated.
■ The pedicle can be followed to the bifurcation of the subscapular artery
into circumflex scapular and thoracodorsal branches.
■ The vascular pedicle is approximately 2 to 3 mm in diameter, and the pedicle
length is about 4 to 9 cm.7