Operative Technique in Plastic Surgery – Kevin C.Chung

disease may preclude use of the fibula flap.
■ The oral cavity is examined and the expected defect analyzed for quantity of
bone and lining required.
■ Patients with poor dentition who will require adjuvant radiotherapy may
benefit from dental extraction.
■ Occlusion is assessed and carefully noted, as one goal of surgery is to
maintain native occlusion.
■ Distal lower extremity pulses and skin texture are examined.
■ Patients with potential vascular disease should undergo preoperative imaging
to evaluate three-vessel runoff.
■ Patients with taut or thin skin will likely require a split-thickness skin graft
for donor-site closure.
IMAGING
■ Craniofacial CT scans are performed to assess the extent of disease (tumor,
traumatic defect, osteoradionecrosis, infection).
■ Three-dimensional renderings are helpful but not necessary.
■ Lower extremity angiography is commonly performed (CTA or MRA) to
assess three-vessel runoff. If these studies are inadequate, conventional
angiography is performed.
■ Patients must have at least a patent anterior tibial or posterior tibial artery (in
addition to the blood supply of the flap derived from the peroneal artery) to be
candidates for fibula flap harvest.
SURGICAL MANAGEMENT
Preoperative Planning
■ Excellent communication between the extirpative and reconstructive surgeons
is necessary to coordinate perioperative planning, including staging of disease,
imaging, labs, and clearance for surgery.
■ In delayed reconstruction, eg, in patients treated for traumatic defects, it is
helpful to have two surgeons involved (one to recreate the defect and expose
recipient vessels and the other to elevate the flap). However, this is not an
absolute requirement.
■ A secure airway is required in the perioperative period, as flap swelling,
abnormal deglutition, and secretions can compromise the airway. In addition,
emergent reintubation may compromise microsurgical reconstruction and

disrupt the repair. As a result, a tracheostomy is almost always indicated until
adequate healing has occurred to allow decannulation.
■ Adequate nutrition is important in the perioperative period.
■ A flexible nasogastric or nasoduodenal tube is often placed at the end of
surgery for early initiation of tube feedings.
■ If patients are malnourished prior to surgery, a percutaneous endoscopic
gastrostomy tube may be considered.
Positioning
■ Patients are placed in supine position with a bump under the shoulders and the
neck extended.
■ A folded towel or blanket is placed under the hip to facilitate internal rotation
when the hip and knee are flexed.
■ A padded roll or IV bag is secured to the table so the foot can rest on it with
the hip and knee flexed (and internally rotated). This facilitates exposure and
dissection.
■ The heels and lower extremity are padded to avoid pressure sores during these
long procedures.
■ The entire lower extremity is prepped and a sterile tourniquet is used so the
thigh can later be used as a donor site for a split-thickness skin graft if needed.
Approach
■ If the defect is truly central, and both necks are available for recipient vessels,
then either extremity can be utilized to harvest a fibula flap.
■ The left is preferable as most patients use their right leg for driving, etc., but
angiographic findings may also dictate which side to use.
■ An ipsilateral flap (with respect to the location of the defect in the jaw) is
typically used. This approach places the septum carrying the cutaneous vessel/s
externally and inferiorly.
■ This allows the septum and skin to be brought over the hardware and into the
oral cavity for standard gingiva/floor of mouth defects.
■ In addition, using the ipsilateral flap places the pedicle vessels laterally on
the fibula flap thus localizing the vessels in optimal position for
microsurgical anastomosis to the neck vessels.
■ A contralateral flap will place the septum and skin island internally and
superiorly, which may be preferable when there is a large intraoral defect that

extends beyond the gingiva/floor of mouth.
■ A two-team approach is preferable to reduce operative time.
■ The flap can be elevated during extirpation, provided there is good
communication between the two operative teams and an accurate estimate of
the defect is made.
■ It is prudent to take more flap than you think you might need.
■ The neomandible can be created in situ on the leg, further reducing both
operative and ischemic time.
T E C H N I Q U E S
■ Maintaining Native Condyle Position and
Occlusion
■ Mandibular discontinuity leads to abnormal condylar positioning and
malocclusion, as the muscles of mastication contract each segment
unopposed. Significant distortion of native condylar positioning when re-
establishing mandibular continuity can lead to malocclusion and/or abnormal
movement when chewing.
■ If the disease process has not distorted the outer border of the mandible,
prior to resection a reconstruction bar can be appropriately bent and secured
to it using two screws on the nonpathologic side of each planned extirpative
osteotomy.
■ Following resection, the bar is replaced and the fibula flap can usually be
secured to it, provided it maintains occlusion and there are not large gaps
(greater than 3 mm) between the bar and fibula.
■ Locking screws are required when gaps exist, to prevent distortion of the
bony segments and gaps between bone and bone (worse than gaps between
bone and hardware).
■ If necessary, a new bar can be appropriately bent (using osteotomy
templates) and secured, although it may be necessary to place the patient in
temporary mandibulomaxillary fixation (MMF) to maintain occlusion during
the revised osteosynthesis.
■ If the disease process has grossly distorted the external surface of the
mandible, placing the patient in temporary MMF after resection will maintain

condylar positioning and proper occlusion for bony inset of the fibula flap.
■ For edentulous patients, a reconstruction bar can be bent around the tumor
and secured to the normal segments of the bone as above. This bar can be
replaced with a new bar that is bent using the osteotomy templates. In this
case, the initial bar should be secured to the normal segments using holes
that are not near the cortex designated for final osteosynthesis.
■ The author’s preference is to avoid postoperative MMF if the teeth easily
come into good occlusion following final flap inset.
■ It is unlikely that significant malocclusion following osteosynthesis of the
neomandible will be corrected with MMF. Adjusting how the bony
segments are secured to the hardware may be necessary to optimize native
occlusion.
■ For edentulous patients, occlusion is not a factor and anatomic inset is not
as critical.
■ Creating Anatomic Templates
■ The lowest axial cut of the mandible on preoperative CT is printed and the
outer surface traced and cut to create linear segments separated by distinct
angles (TECH FIG 1A,B).
■ Mandibular angle templates are based on the appropriate sagittal image.
■ Although it is possible to print 1:1 (“life size”) images of the CT, the
osteotomy angles are the same regardless of magnification.
■ A template is created for each osteotomy by tracing the printed CT onto a
plastic sheet (eg, a sterile plastic bowl) that is sterilized with Betadine or
chlorhexidine (TECH FIG 1C,D).
■ It is critical to draw the inner (lingual) lines parallel to the outer (buccal)
lines and the exact same distance from them (ideally 1 cm).
■ The junction of these lines forms a point that is critical in subsequent steps
(TECH FIG 1E).

TECH FIG 1 • The lowest axial cut of the mandible on
preoperative CT is printed (A) and the outer surface
traced (B) and cut to create linear segments
separated by distinct angles. C,D. A template is
created for each osteotomy by tracing the printed CT
onto a plastic sheet (eg, a sterile plastic bowl) that is
sterilized with betadine or chlorhexidine. E. It is
important to draw the inner (lingual) lines parallel to
the outer (buccal) lines and the exact same distance
from them (ideally 1 cm). The junction of these lines
forms a point that is critical in subsequent steps.
■ Fibula Flap Elevation
■ Doppler interrogation along the septum between the lateral and superficial
posterior compartments (2 cm posterior to the fibula) at the junction of the
middle and distal thirds of the lower extremity should reveal several signals.
■ An appropriate skin paddle is designed centered on the septum and marked
Doppler signals.
■ The incision should extend proximal to the skin island to facilitate
exposure of the tibioperoneal trunk.
■ The leg is elevated and exsanguinated with manual compression or an

Esmarch bandage. The sterile thigh tourniquet is inflated to 250 to 350 mm
Hg.
■ The anterior incision is made and dissection is carried down to the fascia
with cautery.
■ Is it prudent to bevel out several centimeters and then make the fascial
incision, to ensure that the septum is incorporated into the flap.
■ During the anterior dissection, it is important to try and avoid injury to the
superficial peroneal nerve.
■ Following the fascial incision, Allis clamps are placed on the fascial edges,
and the flap is elevated off the underlying peroneus longus using blunt
dissection and cautery.
■ The septum will be present on the posterior surface of the peroneus longus,
and a septocutaneous branch of the peroneal vessel should be visualized.
■ The lateral compartment musculature is then pulled away from the fibula and
elevated off the bone, leaving a small (2 mm) cuff of muscle on the bone to
avoid thermal injury to the periosteum.
■ The septum between the anterior and lateral compartments will be
encountered and should be incised carefully to avoid injury to the anterior
tibial vessel and deep peroneal nerve.
■ Retractors are placed to elevate the anterior tibial vessel and deep peroneal
nerve, and the anterior compartment musculature is elevated off the fibula as
above.
■ The interosseous membrane is next encountered and is incised along its
length by preserving roughly 6 cm of fibula proximally and distally.
■ The critical structures to avoid are the peroneal vessels and nerve proximally
and the ankle syndesmosis distally.
■ Preserving 6 cm proximally and distally typically accomplishes this, but
dissection should follow individual anatomic landmarks and not static
measurements.
■ The anterior incision is temporarily stapled and the posterior incision is
made. As above, beveling out several centimeters at the level of the fascia
will ensure the septocutaneous branch of the peroneal vessel is preserved.
■ It is prudent to avoid injury to the sural nerve during the superficial posterior
dissection.
■ The fascia is incised and grasped with Allis clamps, and the skin paddle is
elevated off the underlying soleus muscle. This should isolate the skin paddle

on the septum.
■ The attachments of the soleus muscle to the fibula are taken down with blunt
dissection and cautery, exposing a potential space between the soleus muscle
and flexor hallucis.
■ Multiple large branches of the peroneal pedicle to the soleus muscle are
typically observed proximally and ligated.
■ A right-angled clamp is placed around the fibula proximally and distally,
taking great care not to injure the peroneal neurovascular bundle proximally.
■ The clamp is used to bluntly dissect a space that will accept an Army-Navy
retractor, which is then used to protect the soft tissues as the proximal and
distal osteotomies are performed with a sagittal saw.
■ The distal bone is gently grasped with a bone clamp and pulled out of the
wound, which should expose the distal peroneal pedicle to be ligated.
■ The epimysium of the flexor hallucis is incised via the posterior approach,
which allows easier retraction of the flap.
■ The author’s preference is to transect the flexor hallucis distally and include
it with the flap.
■ If the muscle is left behind, it is avascular and has no origin. This can result
in a hammertoe deformity due to contracture.
■ Most patients do not notice its absence, except young athletes or dancers.
■ With an ipsilateral flap, the muscle will hang below the neomandible,
buttressing the floor of mouth repair and filling in the soft tissue defect
from lymphadenectomy. If the cutaneous pedicle is injured, the muscle can
serve to close floor of mouth and other defects.
■ While retracting the distal flap out of the wound, the tibialis posterior will be
visible from the anterior approach, with its characteristic chevron fiber
orientation.
■ This muscle is divided from the fibula leaving a 1-cm cuff to avoid injury
to the flap.
■ Posterior to this muscle lies the septum between the superficial and deep
posterior compartments. This septum is carefully incised, to avoid injury to
the peroneal pedicle immediately below.
■ The flap is elevated from distal to proximal, where the peroneal vessels are
identified and dissected to their origin off the tibioperoneal trunk. The veins
often have multiple branches, necessitating careful dissection.
■ The tourniquet is let down, and hemostasis is achieved.

■ During flap inset, it is helpful to have a second surgeon perform donor-site
closure.
■ The wound is irrigated and hemostasis achieved.
■ A drain is placed and the skin is closed with interrupted deep dermal and
running subcuticular absorbable suture.
■ It is critical to avoid compartment syndrome and therefore surgeons should
have a low threshold to place a split-thickness autograft if primary closure is
too tight.
■ Sterile dressings and a well-padded posterior splint is applied.
■ Patients may get out of bed to a chair with their leg elevated but do not
ambulate until postoperative day 5.
■ Marking the Osteotomy Sites
■ The length of each segment is estimated by measurement of the defect
and/or specimen, and osteotomy sites are marked on the fibula (TECH FIG
2A,B).
■ It is possible to use the template in determining segment length, but only if
it is printed out as a 1:1 image and not overly affected by the disease
process (in which case the contralateral mandible may be used as a mirror
image).

TECH FIG 2 • A,B. The length of each segment is
estimated by measurement of the defect and/or
specimen and osteotomy sites are marked on the
fibula. C–F. The outer point of the template is lined up
with the point of osteotomy and one edge of the
template is held parallel to the anterior surface of the
fibula. The point formed by the junction of the two
inner (lingual) borders of the template is used to mark
one side of the closing wedge osteotomy, then the
other edge of the template is held parallel to the outer
surface of the fibula and the marking for the closing
wedge is finalized. G–I. It is important to recognize
that the inner angle of the template is used, and not
the outer borders; otherwise, an inverse angle
osteotomy will be formed.
■ The outer point of the template is lined up with the point of osteotomy and

one edge of the template is held parallel to the anterior surface of the fibula.
■ The point formed by the junction of the two inner (lingual) borders of the
template is used to mark one side of the closing wedge osteotomy, then the
other edge of the template is held parallel to the outer surface of the fibula,
and the marking for the closing wedge is finalized (TECH FIG 2C–E).
■ It is important to recognize that this inner angle is used, and not the outer
borders of the template, or else an inverse osteotomy will be formed (TECH
FIG 2F–I).
■ It is critical not to design an osteotomy where the septocutaneous branch of
the peroneal vessel emerges.
■ This can be avoided by moving the planned osteotomy 1 cm to either side
of the vessel to avoid injury during osteotomy.
■ Closing Wedge Osteotomies
■ Closing wedge osteotomies are then performed using a reciprocating
pneumatic or electric saw, protecting the peroneal vascular pedicle by passing
a snap under the bone to place it between the periosteum and vascular
pedicle.
■ The osteotomies created should match the template with a high degree of
accuracy (TECH FIG 3A–C).
■ Reconstruction of the mandibular angle can be performed in the same
manner (TECH FIG 3D–G).
■ Osteotomies can be performed with the raised fibula flap in situ by using the
measurements and templates (TECH FIG 3H).
■ Miniplates or reconstruction bars can be bent using the template for even
more accuracy in constructing the neomandible (TECH FIG 3I).1
■ Although it is potentially more accurate to use miniplates, it is often easier
and faster to use a reconstruction bar. This typically yields a similar result.
However, in the event of an infection, it is far easier to remove miniplates
than a reconstruction bar.
■ The important thing is that occlusion and aesthetics are optimized.
■ For three or more osteotomies, a virtually planned osteotomy jig should be
considered to create three-dimensional osteotomies.
■ Osteotomies can be performed in situ on the leg (to reduce operative and
ischemic time) or during flap inset.

TECH FIG 3 • A–C. Closing wedge osteotomies are
performed using a reciprocating saw, protecting the
peroneal vessels by passing a snap under the bone to
place it between the periosteum and vascular pedicle.
The osteotomies created should match the template
with a high degree of accuracy. D–G. Reconstruction
of the mandibular angle can be performed using a
closing wedge osteotomy on the outer surface of the
fibula in the same manner as described above. H.
Osteotomies can be performed with the raised fibula
flap in situ utilizing the measurements and templates.
I. Miniplates or reconstruction bars can be bent using
the template to optimize accuracy in constructing the
neomandible.
■ To facilitate inset of the skin island, the septum can be incised if needed, if
the septocutaneous branch of the peroneal vessel is preserved and not overly
twisted.
■ The skin island is appropriately trimmed and inset using interrupted

absorbable suture, and the remainder of the surgical wounds are closed over
drains after irrigation.
■ To test intraoral closure, gauze can be placed in the neck under the closure
and the mouth irrigated with dilute methylene blue solution.
■ If the gauze has blue staining, then the closure is not tight enough.
PEARLS AND PITFALLS
Preoperative
planning
■ Review the patient’s exam findings and imaging with the extirpative
surgeon to anticipate the location and size of the defect.
■ Careful physical examination is more important than imaging,
which may include lower extremity angiography.
■ Consider placing a reconstruction bar prior to resection, to maintain
native condylar positioning and dental occlusion.
Approach
■ An ipsilateral flap is typically used, which optimizes inset for the
microsurgical anastomosis to the ipsilateral neck vessels and closure
of the floor of mouth and gingival defects.
■ A two-team approach is helpful for both immediate and delayed
reconstructions to reduce operative time.
Positioning
■ A hip bump (eg, folded towel) and secured/padded foot rest allow
the donor extremity to be positioned with hip/knee flexion and
internal hip rotation, thus facilitating exposure.
Creating a
template
■ The lowest axial cut of the mandible on CT is printed and the outer
surface traced and cut to create linear segments separated by distinct
angles. This forms the basis for plastic templates specific to each
osteotomy.
Closing
wedge
osteotomies
■ Templates are used to mark each closing wedge osteotomy. Use the
inner angle of the template, not the outer surface.
■ Protect the peroneal pedicle with a snap during each osteotomy.
POSTOPERATIVE CARE
■ Patients are admitted to an intensive care unit for ventilator management and
hourly flap checks.
■ The author’s preference is to use clinical exam to monitor most flaps,
reserving internal Dopplers or tissue oximeters for difficult cases where the

pretest probability of flap failure is higher, thus increasing the positive
predictive value of the monitoring device.
■ For buried flaps, an internal Doppler is usually used if the microanastomosis
proved difficult.
■ Tube feeds are initiated on postoperative day 1 or 2, and oral care with
chlorhexidine solution is provided every 8 hours.
■ The head of bed is maintained in an elevated position, with no pillows or
circumferential neck ties to prevent kinking or compression of the pedicle.
■ The donor leg is kept elevated on pillows.
■ Antibiotics are typically discontinued after 24 hours. However, longer course
of treatments can be considered in high-risk patients (eg, those with a
preoperative history of radiation, heavy smokers, compromised skin, or
preoperative infection).
■ Subcutaneous heparin or enoxaparin is given preoperatively and
postoperatively until discharge.
■ Drains are removed when output is less than 30 mL/d.
■ A formal swallow study is rarely performed unless a leak is suspected. A
bedside swallow evaluation is performed to guide diet advancement.
OUTCOMES
■ This technique is a very simple way to create anatomic closing wedge
osteotomies. For most patients requiring one or two osteotomies, this technique
is successful in restoring preoperative occlusion and facial aesthetics (FIG 1).
■ For patients without good dentition, this technique reliably restores condylar
positioning. For patients requiring three or more osteotomies, or osteotomies in
multiple planes (eg, subtotal mandibulectomy), a more accurate reconstruction
is likely to be achieved using a custom three-dimensional osteotomy guide
created preoperatively based on the patient’s CT scan.2,3

FIG 1 • This technique is a simple way to create
anatomic closing wedge osteotomies that restore
preoperative occlusion and facial aesthetics.
COMPLICATIONS
■ Complications are similar to other head and neck microvascular reconstruction
cases and can include flap necrosis, orocutaneous fistula, wound dehiscence,
and functional problems with speech and swallowing (that usually improve
with time and therapy).
■ Malunion or nonunion of the bony segments is rare, although late hardware
infection can occur. This usually manifests as an intraoral wound with
hardware exposure or an external sinus tract with granulation tissue.
■ Donor-site complications include wound dehiscence, exposure of peroneus
longus tendon, hammertoe, skin graft loss (if used), compartment syndrome,
and functional problems with gait.
■ Young patients tolerate fibula harvest well. Older patients may require use of a
walker or cane, at least initially.
■ It is common for patients to have pain and swelling late in the day, which
persists for months after surgery.
REFERENCES
1. Al-Bustani S, Austin GK, Ambrose EC, et al. Miniplates versus reconstruction
bars for oncologic free fibula flap mandible reconstruction. Ann Plast Surg.
2016;77(3):314-317.

2. Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. Reconstruction of the mandible
with osseous free flaps: a 10-year experience with 150 consecutive patients.
Plast Reconstr Surg. 1999;104(5):1314-1320.
3. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast
Reconstr Surg. 1989;84(1):71-79.
SUGGESTED READING
Seruya M, Fisher M, Rodriguez E. Computer-assisted versus conventional free
fibula flap technique for craniofacial reconstruction: an outcomes comparison.
Plast Reconstr Surg. 2013;13(5):1219-1228.

12
CHAPTER
Mandible Reconstruction
With Scapula Flap
Mouchammed Agko and Hung-Chi Chen
DEFINITION
■ Reconstruction of the mandible requires bone to replace osseous defects and
soft tissues to reconstruct the floor of mouth, tongue, soft palate, and/or
external skin. This combined soft tissue and osseous reconstructive needs, in
combination with vascular anatomy and other patient factors, determine the
optimal donor site. In specific circumstances, the subscapular system of flaps
can be employed for this purpose.
■ The subscapular vascular system is one of the most versatile and reliable donor
sites with consistent anatomy that can provide a multitude of skin, fascia,
muscle, and osseous flaps combinations.
■ Saijo and dos Santos laid the anatomic foundations for the scapular flap
leading to the first successful microsurgical transfer by dos Santos, Gilbert, and
Teot.1–3 Nassif subsequently described the parascapular flap.4
■ In 1981, Teot et al. reported use of an osseous scapular flap based on the
circumflex scapular artery (CSA).5 Later, Swartz et al. popularized the use of
the osteocutaneous scapular flap for mandibular reconstruction.6
■ Historically, it is interesting to note that although Ignio Tansini is credited for
the first description of the latissimus dorsi flap, his initial depictions of the flap
have been actually determined to be consistent with that of a parascapular flap.
ANATOMY
■ The subscapular artery (SSA) arises at the distal border of the subscapularis
muscle from the third portion of the axillary artery.
■ It measures 2 to 4 mm in diameter and courses for 2 to 3 cm prior to dividing
into the CSA and thoracodorsal artery (TDA).

■ The CSA, which is 1.5 to 3.5 mm in diameter, courses for 3 to 4 cm before it
gives off the branches to the lateral border of the scapula.
■ It enters the triangular space (omotricipital triangle) that is formed by
divergence of the teres muscles from the lateral scapula (teres minor
superiorly, teres major inferiorly) and the long head of the triceps laterally.
■ At this level, it sends branches to the subscapularis muscle and numerous
musculoperiosteal branches to the lateral border of the scapula.
■ Subsequently, it gives off branches to the infraspinatus and teres muscles.
■ It is the musculoperiosteal branches between the anterior subscapularis muscle
and the posterior teres muscles that provide the vascularization of the upper
two-thirds of the lateral scapula and have to be preserved during harvest of the
lateral osseous flap.
■ The distance from the axillary artery to these branches (effectively the
pedicle length of the flap) is 6 to 8 cm.
■ After emerging through the triangular space, the CSA is encased in the dorsal
thoracic fascia.
■ An areolar space separates this from the underlying deep muscle fascia.
■ The CSA courses caudally for 2 to 3 cm before it divides into its terminal
branches: ascending, transverse, descending, and anterior.
■ Although all these can serve as the source for axial flaps overlying the
specific branch, the two most commonly used are the scapular and
parascapular flaps based on the main transverse and descending branches,
respectively (FIG 1).

FIG 1 • The vascular supply of the
scapular/parascapular skin paddles and the lateral
edge/tip of the scapula osseous flaps are shown. After
giving off musculoperiosteal branches to the lateral
border of the scapula (lateral osseous flap), the
circumflex scapular artery emerges through the
triangular space and divides into its terminal branches.
The transverse and descending branches supply the
scapular and parascapular skin paddles, respectively.
The tip of the scapula receives its blood supply from the
angular artery that is a branch of the thoracodorsal
artery itself or its serratus anterior branch.
■ The circumflex scapular system has two veins of disparate size that coalesce
before joining the single vein of the thoracodorsal system to form the

subscapular vein (SSV) (2.5–4 mm in diameter).
■ Anatomic variations:
■ Double CSA (8%–14%)
■ Double circumflex scapular vein (CSV) (14%)
■ CSA originating separately from the axillary artery (4%–8%)
■ CSV originating separately from the axillary vein (12%)
■ Descending branch of the CSA (parascapular flap pedicle) coursing anterior
to the teres major muscle (TM) and emerging between the inferior border of
the teres minor muscle (Tm) and the superior border of the latissimus dorsi
muscle (7 of 30 cases)
■ SSA and thoracoacromial arteries sharing a common origin from the axillary
artery (2–47 cases)
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The shoulder and axillary area is carefully examined. Range of motion of the
shoulder joint and strength of the parascapular muscles are determined.
■ Previous injuries and surgical interventions in the vicinity are scrutinized to
assess potential damage to the vascular structures precluding safe harvest.
■ Although scars involving just the skin do not preclude harvesting the
cutaneous portion of the flap, deeper scars (eg, previous thoracotomy incision,
previous axillary lymph node dissection) may have injured the pedicle or the
flap.
■ Special attention is paid to identify spinal accessory nerve injury by examining
trapezius muscle bulk and function. Further compromise of parascapular
muscles may exacerbate winging of the scapula.
IMAGING AND OTHER DIAGNOSTIC STUDIES
■ No preoperative studies are required.
■ In cases of previous injury or surgery, angiography (conventional, computed
tomography, or magnetic resonance) can be employed to confirm intact
vascular anatomy.
■ Theoretically, x-rays of the scapula or computerized tomography with 3D
reconstruction could be used for preoperative planning.
■ For the purposes of photographic documentation, preoperative photos of the
donor site and shoulder function are obtained.
SURGICAL MANAGEMENT

■ The available reconstructive options for mandibular defects are as follows:
■ Osteocutaneous fibula flap
■ Vascularized iliac crest flap
■ Osteocutaneous scapula flap
■ Osteocutaneous radial forearm flap
■ Vascularized rib with blood supply from the latissimus dorsi muscle
■ Vascularized medial femoral condyle corticoperiosteal flap for short defects
of the mandible
■ Reconstruction plate covered with pedicle or free myocutaneous flap
■ Delayed repair with nonvascularized bone graft
■ Anterior, sagittal, or hemimandibular defects can be restored with the
osteocutaneous scapula flap.
■ Specific indications for the use of the osteocutaneous scapular flaps in
mandibular reconstruction include the following:
■ Composite defects of the mandible with large soft tissue requirements for
intraoral lining, external coverage, and/or soft tissue augmentation.
■ The soft tissue defect is not directly adjacent to the osseous defect and
relative independence is required between the bone and soft tissue component
for optimum inset.
■ Fibula is not available due to vascular disease, aberrant anatomy, injury, or
previous harvest.
■ Patient wants to avoid the morbidity of vascularized iliac crest harvest.
■ Medical status prohibiting lengthy procedures under general anesthesia would
preclude the use of this flap.
■ Relative contraindications include the following:
■ Osseous defect larger than 14 cm in men or 10 cm in women
■ Need for multiple osteotomies that could endanger viability of the osseous
flap
■ Pre-existing shoulder disorders limiting range of motion and periscapular
muscle strength
■ Damage to the vascular pedicle due to injury or procedure (eg,
lymphadenectomy)
■ Skin of the back too thick (obese patients)
■ There are numerous advantages of this flap compared to other options for
mandibular reconstruction.
■ The hairless nature of the scapular skin flap closely resembling the texture

and sometimes color of the facial skin.
■ The vascular pedicle can be dissected to the appropriate length and diameter
to match the recipient vessels.
■ Additional flaps can be carried on a single arterial and venous anastomosis
except in cases of anatomical variations.
■ The soft tissue elements can be spatially oriented independently of each other
or the bone enabling coverage of complex composite defects.
■ Primary closure of large skin flaps is possible providing more skin than other
osteocutaneous flaps.
■ Limited morbidity with minimal loss of shoulder function if no preoperative
limitation exists.
■ The vascular pedicle is reliable even in patients with diabetes or
arteriosclerosis.
■ Scapular osteocutaneous flaps also have some limitations.
■ Some authors have described flap harvest in a modified semilateral position
to avoid redraping. However, most surgeons prefer to reposition the patient
before and after flap harvest.
■ Two-team approach is not possible. Mandibular resection/recipient site
preparation has to be completed prior to proceeding with the flap harvest.
■ Revascularization of the flap can only be performed after donor-site closure.
■ If undue tension is present at closure, the donor-site scar may be widened.
However, patients rarely complain as the scar is not easily visible to them.
■ If skin grafting becomes necessary, this is an inherently unfavorable site.
■ Dissection of the CSA pedicle through the triangular space can be tedious
and time-consuming.
■ Because the sensory branches from the 3rd to 5th intercostal nerves are
divided during elevation of the flap, primary sensory innervation is not
possible. However, when transferred to the head and neck region, the flap
may regain satisfactory sensation without nerve repair through spontaneous
regeneration from the tissue bed.
■ Bone stock may be limited in women precluding dental rehabilitation.
Preoperative Planning
■ For preoperative marking and flap design, the patient is seated or stands
comfortably with the arms resting at the sides.
■ The borders of the scapula and its spine are marked.
■ The triangular space is identified by palpating the lateral border of the scapula

at 2/5th of the distance between the center of the spine and the inferior angle of
the scapula.
■ The posterior axillary fold formed by the teres major (TM) is pinched between
the thumb and the remaining fingers to identify the upper border of the muscle.
■ The emergence point of the CSA from the triangular space can be located at
area where the upper border of the TM meets the lateral border of the scapula.
■ A pencil Doppler can confirm the location of the CSA and the course of its
branches.
■ Scapular fasciocutaneous flap
■ The axis of the scapular flap is a line parallel to the spine of the scapula
extending from the emergence point of the CSA to the posterior midline.
■ The flap itself is marked from the posterior axillary line to the posterior
midline in a lenticular fashion with the medial end extending over the
triangular space. The design is limited superiorly by the spine of the scapula
and inferiorly by the inferior angle.
■ An additional 2 cm passing across the midline can be included as an
extension based on random perfusion.
■ Usual flap dimensions allowing primary closure are 20 cm × 10 cm, with the
length ranging from 6 to 25 cm and the width from 4 to 16 cm.
■ Medial osseous flap
■ The scapular fasciocutaneous flap can carry an osseous segment from the
medial border of the scapula (10–12 cm × 3 cm × 0.71–1.5 cm) through its
fascial attachments to the bone.
■ Parascapular fasciocutaneous flap
■ The axis of the flap corresponds to the lateral border of the scapula when the
arm is in adduction.
■ The flap is marked from the posterior axillary crease superiorly and can
extend to the 12th rib or midway between the inferior angle of the scapula and
posterior superior iliac spine.
■ The width that would allow primary closure is confirmed by pinching the
skin and subcutaneous tissue.
■ Usual flap dimensions allowing primary closure are 24 cm × 12 cm, with the
length ranging from 6 to 32 cm and the width from 8 to 20 cm.
■ Lateral osseous flap
■ The length of the lateral scapular bone that can be reliably elevated on the
periosteal branches of the CSA depends on number of planned osteotomies.

■ Usually up to 10 cm in women and 14 cm in men can be harvested, when one
proximal osteotomy is planned.
■ The bone can be up to 3 cm wide with variable thickness (1.5–3 cm) along
the length of the flap.
FIG 2 • Bone flaps that can be harvested. A. Lateral
osseous flap based on the periosteal branches of the
circumflex scapular artery (CSA). B. Extended lateral
osseous flap including the tip of the scapula where both
the periosteal branches of the CSA and the angular
artery are preserved. C. Tip of the scapula osseous flap
based on the angular artery only.
■ If more and/or distal osteotomies or longer bone is needed, the scapular tip
(an additional 3 to 4 cm of bone) can be safely and simultaneously harvested
based on the angular artery. Alternatively, the tip of scapula can be harvested
as a separate vascularized bone segment (FIG 2).7
■ The angular artery branches off the TDA or the serratus branch and travels on
top of the serratus muscle beneath the TM.
■ Because of the dedicated periosteal branches from the CSA, the lateral
osseous flap is not dependent on the overlying skin for its vascular supply.
Therefore, depending on the soft tissue defect, it can be elevated with a
scapular or parascapular fasciocutaneous flap, or a combination of them
(either combined in an L-shaped bilobed configuration or as separate skin
paddles).
Positioning

■ Although prone and modified lateral decubitus positioning has been suggested,
the lateral decubitus position with the arm fully prepped in the operative field
allows optimal access (FIG 3).
FIG 3 • The patient has been placed in right lateral
decubitus position with the left arm abducted at 90
degrees. The scapular and parascapular skin paddles
have been delineated in blue. The subscapular artery
(SSA) is shown branching into the thoracodorsal (TDA)
and circumflex scapular arteries (CSA). The CSA is
shown emerging through the triangular space bound
superiorly by the long head of the triceps (TriL),
medially by the teres minor (Tm), and laterally by the
teres major (TM). After giving musculoperiosteal
branches to the lateral osseous flap (marked in light
green), the CSA gives off a descending branch coursing
caudally and a transverse branch coursing medially that
supply the parascapular and scapular skin paddles,
respectively. The outline of the latissimus muscle is also
shown in black.

■ During harvest of the skin paddle and bone, the arm is best kept in abduction
for easy identification of the teres muscles.
■ During harvest of the pedicle at the depths of the triangular space and
exposure of the subscapular pedicle in the axilla, manipulation of the arm will
allow easy exposure.
■ An axillary roll and appropriate padding of pressure points are important to
prevent brachial plexus injury and decubitus ulcer, respectively.
Approach
■ Two different approaches exist for the harvest of the skin component of the
flap, whether it is a scapular or parascapular one.
■ In the medial approach, the skin paddle is elevated peripherally prior to
dissection of the CSA.
■ On the contrary, with the lateral approach, the pedicle is identified first
through a limited incision followed by dissection of the skin island.
T E C H N I Q U E S
Video p3-c012
■ Preparation of Recipient Site
■ Prior to flap harvest, the recipient site should be examined to determine
location, configuration, and size of the different components of the defect.
00:00 / 00:00

■ The viability of remaining tissues should be assessed. If necessary, any tissue
of questionable viability should trimmed further.
■ Recipient vessels should be exposed and prepared for expeditious
revascularization after closure of the donor site and repositioning of the
patient.
■ After careful assessment of the defect and the recipient vessels, the
following decisions on the specific flap design can be made: length of the
osseous component, osteotomy sites and number, number and size of skin
paddles, additional muscle flaps, optimal pedicle length, and inset of the flap.
■ The axillary hair is clipped.
■ The ipsilateral arm is fully prepped and included in the operative field as is
the shoulder, axilla, and lateral torso from sternum and umbilicus anteriorly
to spine posteriorly.
■ The ipsilateral thigh should be prepared separately for possible skin graft
harvest.
■ Skin Flap Harvest
■ The skin flap can be harvested through either a medial or a lateral approach.
Medial Approach (Retrograde, Distal to Proximal)
■ The course of the terminal branches of the CSA, transverse or descending,
can be reliably estimated using anatomic landmarks and confirmed with a
Doppler.
■ The skin flap design is centered over this vascular axis by marking the
triangular space and using a pencil Doppler to map out the vessel (see FIG
3).
■ At the distal end of the flap, an incision is made through the skin down to,
but not including, the deep muscle fascia (TECH FIG 1A).
■ The dissection proceeds expeditiously in an areolar plane between the deep
thoracic fascia, which carries the pedicle, and the underlying deep muscle
fascia. Dissection over the latissimus muscle is done rapidly as the skin
perforator in this area is in the flap (TECH FIG 1B).
■ The skin incisions are extended proximally on both sides of the pedicle that
is clearly visualized on the undersurface of the flap.
■ Once the lower border of the teres major is identified, a more careful

dissection is required to safely expose the pedicle exiting the triangular space
between the teres major inferiorly and the teres minor superiorly.
■ The pedicle gives off small branches to the teres major and minor that
require care for ligation.
■ After the pedicle is shown entering the flap, the remaining proximal
incisions are completed to create a flap island (TECH FIG 1C).
■ Separating the teres major and minor with a self-retaining retractor and
abduction of the arm facilitates dissection of the flap.
Lateral Approach (Antegrade, Proximal to Distal)
■ Proximal flap incisions are made first in the vicinity of the triangular space
along the preoperative markings. The deltoid, triceps, and teres muscles are
exposed.
■ The deltoid is retracted cephalad and the CSA is identified at the hiatus
between the teres major and minor.
■ The direction of the transverse and descending branches is confirmed.
■ The skin paddle can then be adjusted if necessary and centered over the
vascular pedicle under direct vision as the dissection proceeds from
proximal-to-distal direction.
■ Once the distal incisions are made, the skin island is isolated on the CSA
pedicle.
■ The pedicle is completely dissected and the vessels are separated in
anticipation of flap harvest. It is important to complete pedicle dissection
prior to osteotomies because the bleeding from the cut bone edges will
complicate this process.

TECH FIG 1 • A. The scapular skin paddle has been
partially elevated and retracted laterally with a skin
hook. B. The scapular skin paddle has been reflected
laterally. The skin hook is retracting the parascapular
skin paddle to be elevated next. C. Both scapular and
parascapular flaps have been completely islandized.
■ Inclusion of Latissimus Dorsi Muscle
■ A portion of the latissimus or serratus anterior fascia can be included in the
flap based on the shared blood supply of these structures with the flap.
■ Dissection of the pedicle to include the takeoff of the TDA and the serratus
anterior branches is performed.
■ This dissection enables transfer of a large soft tissue component that can be
used to repair complex defects of the head and neck.
■ Bone Harvest
■ Bone harvest continues in a similar fashion with both the lateral and medial

approaches to skin flap harvest.
■ The multiple muscle branches from the CSA are carefully divided as the
dissection continues into the triangular space.
■ It is important to avoid dissection between the CSA and lateral border of the
scapula.
■ The teres muscles and the infraspinatus muscle are divided 2 to 3 cm medial
from the lateral border down to the scapular bone along the intended vertical
osteotomy line (TECH FIG 2A).
■ The muscles are then elevated off the lateral scapula leaving a muscular cuff
to avoid injury to the periosteal blood supply (TECH FIG 2B).
■ This is especially true as the lateral border of the scapula is approached
where 1 cm of muscle cuff is left attached to bone.
■ The divided teres muscles are reflected laterally.
■ The vascular branches to the lateral border of the scapula are identified and
preserved (TECH FIG 2C).
■ The periosteum is sharply divided along the vertical osteotomy line and
elevated medially. A saw or an osteotome is used to cut through the bone
(TECH FIG 2D).
■ The inferior transverse osteotomy is made first (TECH FIG 2E).
■ The vertical osteotomy is parallel to the lateral border and extends from 1 to
2 cm below the glenoid fossa/shoulder joint superiorly to the planned
distance inferiorly (TECH FIG 2F).
■ During the superior transverse osteotomy between glenoid fossa superiorly
and the CSA inferiorly, great care is taken to avoid injury to these structures
(TECH FIG 2G).
■ The bone is then everted laterally to allow easy detachment of the underlying
subscapular muscle by similarly preserving a muscular cuff on the bone
(TECH FIG 2H).
■ If the tip of the scapula is to be included, the angular artery is identified,
preserved, and traced to its junction to the serratus branch or the TDA itself.
The serratus anterior insertion to the tip is divided leaving a muscle cuff.
■ Any bleeding from the muscle cuff of the bone flap is controlled with bipolar
cautery.
■ The CSA and its comitant veins are traced proximally toward their junction
with the thoracodorsal artery and its accompanying vein (TECH FIG 2I).

TM CSA Tm IsM Lateral scapula Parascapular Lateral osseous scapular lateral osseous flap Lateral osseous fl Inferior transverse

TECH FIG 2 • A. Both scapular and parascapular skin
paddles have been reflected laterally exposing the
circumflex scapular artery (CSA). The origins of teres
major (TM) and teres minor (Tm) muscles from the
lateral border of the scapula have been divided to
expose the underlying bone (lateral scapula). Please
note the infraspinatus muscle (IsM) retracted medially.
B. The periosteum is elevated alone the planned
vertical osteotomy line. C. An osteotome is used to
perform the inferior horizontal osteotomy. The
scapular and parascapular skin paddles have been
reflected superiorly to expose the underlying lateral
osseous flap. The lines point to the vascular supply of
the flaps—musculoperiosteal (lateral osseous),
descending (parascapular), and transverse (scapular)
branches, respectively. D. Due to the periosteal
vascular supply, the osteotomies should be performed
with great care. The periosteum should be minimally

stripped at the planned osteotomy site. Multiple
contouring osteotomies might jeopardize the blood
supply to the bone. Inclusion of the angular artery
would “supercharge” the osseous flap allowing more
than one osteotomy. The osteotomies are performed
in the following sequence: inferior transverse (E),
vertical (F), and superior transverse (G). H. After the
osteotomies (dashed line) are completed, the lateral
osseous flap is elevated to allow division of the
subscapular muscle attachments. I. A closeup view of
the subscapular artery and vein (SSA&V) branching
into the thoracodorsal artery/vein (TDA/V) and
circumflex scapular artery/vein (CSA/V). Note the very
short length of the subscapular vein. In this case, two
separates venous anastomosis might be required,
especially if there is a valve at the short segment of
the subscapular vein.
■ The subscapular pedicle is then followed proximally to the axillary vessels,
and any remaining branches are ligated.
■ It is important to preserve the nerves to the surrounding muscles during this
dissection.
■ The pedicle is divided at an appropriate length.
■ The donor site has to be closed, before the flap can be inset.
■ In the meantime, if available, a second surgeon can prepare the flap at the
back table (osteotomy, vessels). This will allow more expeditious inset and
revascularization.
■ After division of the pedicle, the donor-site closure begins with reattachment
of the divided muscles to the remaining scapular bone.
■ Two or three drill holes allow suture fixation of the cut muscle ends to the
edge of the scapula.
■ Large-bore suction drains are placed in the axilla and the back.
■ With adequate undermining, most defects can be closed primarily in two
layers. Otherwise, skin grafts are used as necessary.

■ Preparation and Inset of the Flap
■ The osseous component of the flap is cut to appropriate length and
osteotomized as necessary to match the mandibular defect.
■ Because the blood supply of the scapula flap is based on periosteal
perforators, care should be taken to avoid stripping the bone for osteotomies.
In addition, the number of osteotomies should be minimized as much as
possible to avoid bone necrosis.
■ In addition, because the periosteal blood supply is critical, the periosteum
should be maintained in continuity during the osteotomies by careful, limited
elevation.
■ Osteotomy is made with a small reciprocating saw or fine burs while
shielding the periosteum.
■ If a prebent and appropriately marked reconstruction plate is available, this
can be done even before the division of the pedicle.
■ Alternatively, the flap can be prepared either by a second surgeon at the back
table while the donor site is being closed or immediately before inset.
■ However, it is best done before revascularization to avoid tension to or
accidental avulsion of the pedicle. Plating is best done at the time of the inset.
■ If the defect is small or access to it is limited, the flap destined to provide
intraoral lining can be completely or partially inset prior to bone fixation.
■ Osteosynthesis with the native mandible can be achieved with a single
reconstruction plate spanning the entire defect. Alternatively, small plates or
interosseous wires can be used.
■ Microvascular anastomosis is completed in the standard fashion.
■ Finally, soft tissue inset is completed.
■ Flap Variations
Medial Osseous Flap
■ An osteocutaneous flap can be harvested from the medial border of the
scapula between the scapular spine and the inferior angle. The
corticocancellous segment is 10 to 12 cm long and 2 to 3 cm wide.
■ The blood supply is provided from fascial attachments of the dorsal thoracic
fascia on the undersurface of the scapular flap to the underlying bone.

■ Nevertheless, the bone is thinner on the medial border of the scapula (1.5 cm
as compared to 3 cm on the lateral aspect) providing less bone stock.
Inframammary Extended Circumflex Scapular (IMECC) Flap
■ It is yet another option of skin paddle design that can be combined with the
lateral osseous flap to better disguise the scar in women.
■ The flap is centered over the anterior branch of the superficial CSA that
arises from the descending branch a few centimeters below the triangular
space and turns toward the ipsilateral inframammary fold.
Isolated Angular Bone Segment
■ The inferior angle of the scapula can be harvested as an isolated bone
segment in combination with any of the skin paddle options to reconstruct
composite mandibular defects of appropriate size.
■ The angular branch can arise from the TDA itself, the serratus branch, or the
latissimus dorsi branch. It reaches the scapula on top of the serratus muscle
and beneath the TM.
Additional Options
■ Several additional flaps can be elevated with the osteocutaneous flap on the
same subscapular pedicle:
■ Latissimus dorsi muscle
■ Latissimus dorsi myocutaneous flap (TECH FIG 3)
■ Latissimus dorsi muscle with rib
■ Dorsal thoracic fascia flap
■ Simultaneous elevation of serratus flaps is discouraged, as it is an important
muscle for shoulder stability.

TECH FIG 3 • A. All the components of a composite
osteomusculocutaneous flap are shown. B. Another
patient is shown in right lateral decubitus position with
both the scapular and latissimus dorsi skin paddles
islandized. The scapular osteocutaneous flap will be
used for mandibular reconstruction and intraoral lining.
On the other hand, the fleur-de-lis skin paddle and
underlying latissimus dorsi muscle (latissimus dorsi
musculocutaneous [LDMC] flap) will provide external
coverage of the lower jaw and allow release of a neck
contracture. C. On the same patient, the scapular skin
paddle is reflected to expose the underlying lateral
osseous component of the flap.
PEARLS AND PITFALLS

Axillary
incision
■ A counter incision in the axilla or extension of the existing
incision toward the axilla, though not necessary, will allow
identification and dissection of the subscapular vessels in a safer
and more rapid manner.
Skin over the
triangular
space
■ The triangular space should be included in all skin flap
geometries to ensure optimum blood supply.
Skin island
configurations
■ When the scapular flap is combined with a parascapular flap, they
can be raised in continuity in a reverse L-shaped configuration
(with de-epithelialization performed as necessary) or as two
separate skin islands.
Pedicle length
■ The effective maximum pedicle length for the lateral osseous flap
is 4–6 cm (subscapular artery plus CSA up to the periosteal
branches). Lateral osseous bone to scapular or parascapular skin
paddles 2–3 cm.
Lengthening
the pedicle
■ When suitable recipient vessels are found only on the
contralateral neck:
■ The TDA is harvested distally to an appropriate length and used
as the donor artery to provide blood supply in a reverse flow
fashion.
■ For venous outflow, either the SSV with a vein graft (reversed
thoracodorsal vein is readily available) can be used or the cephalic
vein can be transposed.
Simultaneous
recipient
vessel
dissection
■ In the lateral decubitus position, a second surgeon could explore
ipsilateral neck vessels simultaneously.
Additional
soft tissue
■ Subcutaneous dissection beyond the skin border can provide
additional soft tissue, if facial contouring is necessary.
Tissue
expansion
■ Pre-expansion can allow primary closure of larger than usual
flaps. Otherwise, postoperative expansion of the surrounding skin
can allow resurfacing of a previously grafted area.
Primary
closure of
large
parascapular
defect
■ A pedicled TDA perforator flap has been described for closure of
a large parascapular flap defect in an attempt to avoid skin
grafting.

Scapular vs
parascapular
skin island
■ If only one skin paddle is required, parascapular flap can be
preferred over the scapular flap as it facilitates the axillary
exposure for dissection of the pedicle and allows placement of the
scar in a less conspicuous area.
Skin grafting
■ Skin grafting at the donor site invariably results in poor graft
take, significant contour irregularity, and conspicuous scar.
Flap thickness
■ The flap may be thick in obese individuals. This should be taken
into consideration during planning of flap dimensions.
Dental
rehabilitation
■ If osteointegrated implants are planned for dental rehabilitation,
careful planning of the inset is necessary. The graft orientation
should be such that the bone segment with the optimum height
and width is placed at the area of interest.
Anatomic
variations
■ In case of double CSA or CSA/CSV that do not join the
SSA/SSV, additional recipient vessels are required if any
additional tissue is to be carried on the TDA.
■ If the pedicle of the parascapular flap (CSA descending branch)
courses behind the TM, the TM has to be divided during the
harvest of the skin island.
POSTOPERATIVE CARE
■ The shoulder/arm is kept immobilized for 1 week to allow healing and
minimize pain.
■ First, range-of-motion exercises are carefully initiated followed by shoulder
girdle muscle strengthening exercise 2 to 3 weeks after surgery.
■ The donor site requires 3 to 4 weeks to heal completely.
OUTCOMES
■ Although shoulder function limitation has been reported in the literature,
adhering to a meticulous technique and postoperative rehabilitation regimen
can prevent this complication.8
■ In large series of 105 patients undergoing osseous scapular flap harvest,
Gibber reported no such complication.9
■ For various reasons, still only a minority of patients eventually undergo
placement of osteointegrated implants irrespective of the implantability of the
reconstructed bone segment.
■ Anatomic studies have demonstrated bone stock amenable to implantation in
78% to 95% of specimens.10
■ Potential complications include

■ Hematoma
■ Seroma
■ Wound infection or dehiscence
■ Widened scar at the donor site
■ Limitation of shoulder movement and strength
■ Nonunion of mandibular reconstruction
■ Brachial plexus or long thoracic nerve injury
REFERENCES
1. Saijo M. The vascular territories of the dorsal trunk: a reappraisal for potential
flap donor sites. Br J Plast Surg. 1978;31:200-204.
2. dos Santos LF. The scapular flap: a new microsurgical free flap. Bol Chir
Plast. 1980;70:133-144.
3. Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg. 1982;69:601-
604.
4. Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular flap: a new
cutaneous microsurgical free flap. Plast Reconstr Surg. 1982;69:591-600.
5. Teot L, Bosse JP, Moufarrege R, et al. The scapular crest pedicled bone graft.
Int J Microsurg. 1981;3:257-262.
6. Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous scapular flap
for mandibular and maxillary reconstruction. Plast Reconstr Surg.
1986;77:530-545.
7. Coleman JJ III, Sultan MR. The bipedicled osteocutaneous scapula flap: a
new subscapular system free flap. Plast Reconstr Surg. 1991;87:682-692.
8. Roll C, Prantl L, Feser D, et al. Functional donor-site morbidity following
(osteo-) fasciocutaneous parascapular flap transfer. Ann Plast Surg.
2007;59:410-414.
9. Gibber MJ, Clain JB, Jacobson AS, et al. Subscapular system of flaps: an 8-
year experience with 105 patients. Head Neck. 2015;37:1200-1206.
10. Moscoso JF, Keller J, Genden E, et al. Vascularized bone flaps in
oromandibular reconstruction: a comparative anatomic study of bone stock
from various donor sites to assess suitability for enosseous dental implants.
Arch Otolaryngol Head Neck Surg. 1994;120:36-43.

13
CHAPTER
Lateral Mandible
Reconstruction With Soft
Tissue Flaps
Afshin Mosahebi, Evan Matros, and Babak J. Mehrara
DEFINITION
■ The mandible provides contour to the posterior lower third of the face and
plays a key role in mastication and maintenance of oral competence.
■ As a result, mandibular function is necessary for swallowing, speech, and
aesthetic contour of the face.
■ The most common indication for mandibular reconstruction is segmental bone
loss resulting from cancer ablation, trauma, osteoradionecrosis, and infection.
■ Defects of the lateral mandible are defined as those that extend posteriorly
from the mental foramen and can include the ramus or condyle.
■ Lateral mandibular defects that are most suitable for soft tissue–only
reconstruction defects include not only osseous defects but also extensive soft
tissue injury including the floor of the mouth, tongue, palate, pharynx, and
external skin. Mandibular defects that result in the complete loss of the
temporomandibular joint and the surrounding soft tissues may also benefit
from soft tissue–only reconstruction because insetting of bone flaps in these
defects may be difficult and associated with poor function.
ANATOMY
■ The mandible is anatomically divided into one horizontal component and two
vertical components.
■ The horizontal component comprises the symphysis and the body on each
side, forming a U-shaped arch that connects the two vertical segments.
■ Each vertical segment is composed of the angle, ramus, coronoid process and
condylar process. The vertical segment serves as the insertion site for the

muscles of mastication and forms the articulation of the mandible with the
skull.
■ The arterial supply of the mandible is derived from branches of the lingual,
facial, and inferior alveolar arteries.
■ The inferior alveolar nerve is the largest branch of the mandibular nerve. It
enters the mandible through the mandibular foramen on the medial surface of
the mandibular ramus and gives two terminal branches: the mental nerve and
the incisive nerve.
■ The mental nerve innervates the skin of the chin as well as the skin and the
mucosa of the lower lip.
■ The incisive nerve continues to travel in the mandible and provides sensory
innervation to the premolar, canine, incisor teeth, and their associated gingiva.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient history should include careful assessment of the pathology of the
anticipated mandibular defect and the previous treatments that have been
administered.
■ History of prior surgery, particularly those that may involve the vascular
supply of the mandible, should be obtained. This information is important in
surgical planning because damage to the ipsilateral neck vessels may require
the use of contralateral neck vessels or alternative plans.
■ Surgical plans should be reviewed with the head and neck surgeons (if they
are involved in the procedure).
■ History of radiation to the area should also be obtained because this treatment
may impede healing of soft and bony tissues, decrease availability of recipient
vessels, and increase the potential need for external skin coverage.
■ Past medical history, medical comorbidities, and risk factors for cardiovascular
disease (eg, hypertension, coronary artery disease, hyperlipidemia, history of
smoking, obesity, diabetes, etc.) should be reviewed.
■ This is common in patients with head and neck cancers because many of
these individuals have a history of smoking and ethanol use.
■ Patients with long-standing history of cardiovascular disease require medical
consultation for preoperative clearance and optimization.
■ Preoperative speech and swallowing should be documented and assessed
because these functions may be significantly affected by tumor invasion and
surgical ablation. In addition, preoperative mouth opening should be recorded
as interincisal distance.

■ Oral hygiene and dentition should be assessed because patients with poor oral
hygiene and dentition are at much higher risk of postoperative infections and
complications. Severe compromise of dentition or oral hygiene may also
require preoperative dental consultation.
■ The presence or absence of pain with mouth opening, chewing, swallowing, or
eating should be obtained.
■ The patient’s general nutritional status should be assessed by physical
examination and laboratory tests.
■ Personal and family history of bleeding abnormalities should be elicited.
■ The physical examination should also include assessment of the head and neck
area, anticipate the planned resection in the case of oncologic patients, assess
availability of recipient vessels, quality of intraoral and extraoral soft tissues,
and available donor sites for reconstruction.
■ A pulse examination of the extremities is necessary to document the potential
for peripheral vascular disease.
■ The quality (ie, thickness, pliability, etc.) of soft tissue donor sites should be
addressed, and alternative plans should be developed.
IMAGING
■ Preoperative computed tomography (CT) or magnetic resonance imaging
(MRI) may be helpful in assessing osseous defects and potential involvement
of the soft tissues.
■ Preoperative angiography may also be helpful in assessing availability of
recipient vessels in the head and neck area, although this is rarely necessary.
■ Preoperative imaging of donor sites may also be useful for assessment of
blood flow. However, this is rarely necessary for assessment of soft tissue flaps
such as the anterolateral thigh or rectus abdominis flaps commonly used in soft
tissue only reconstruction of complex lateral mandible defects.
SURGICAL MANAGEMENT
■ Lateral mandible defects that involve primarily the bone with limited resection
of the soft tissues are best reconstructed with bone flaps (eg, fibula, scapula,
iliac crest).
■ Soft tissue reconstruction of lateral mandible defects is indicated in patients
with an intact anterior mandibular arch (ie, bone resection is lateral to the
incisors) in combination with complex soft tissue defects involving the floor of
the mouth, tongue, palate, pharynx, or, in some cases, external skin.

■ It is useful in cases in which the temporomandibular joint is widely excised,
leaving a large defect at the base of the skull where bone flaps cannot be
adequately seated.
■ It may be needed in patients who do not have osseous donor-site options (eg,
severe peripheral vascular disease). However, this is less common because
multiple options for bone donor sites exist (eg, scapula may be a good choice
in these cases).
■ Of the variety of soft tissue flaps useful for reconstruction of complex lateral
mandibular defects, the vertical rectus abdominis myocutaneous flap and the
anterolateral (ALT) flap are most commonly used for the following reasons:
■ They provide large amounts of soft tissues and muscle that can be tailored to
complex defects.
■ They enable harvesting of multiple skin paddles that can facilitate combined
intraoral and extraoral defect reconstruction.
■ They have long pedicles that can easily reach neck recipient vessels even if it
is necessary to use vessels contralateral to the site of the defect.
Preoperative Planning
■ The defect is evaluated for reconstruction, taking into consideration the
volume of tissues necessary to maintain the remaining mandible in anatomic
position.
■ The need for intraoral and extraoral (if necessary) tissue reconstruction is
assessed.
■ Factors that are important in planning reconstruction of lateral mandibular
defects:
■ Medical comorbidities, functional and nutritional status, and oral hygiene
■ Extent of the mandibular defect
■ Anticipated soft tissue defects
■ Prior surgical procedures and availability of recipient vessels
■ The need for postoperative adjuvant therapies that may be necessary
■ Planned or anticipated secondary/tertiary reconstructions
Positioning
■ The patient is positioned in supine position.
■ In most cases, a tracheostomy is also performed because emergent reintubation
of a patient with an extensive reconstruction involving the lateral mandible
may be challenging and may result in iatrogenic injury to the free flap.

T E C H N I Q U E S
■ Horizontally Oriented Flaps
■ It is generally simplest to orient the flap horizontally along the axis of the
defect thus interposing the soft tissue flap between the cut end of the
mandible and the infratemporal fossa.
■ This orientation results in optimal positioning of the vascular pedicle with
respect to the neck vessels.
■ If the ipsilateral neck vessels are used, the flap is oriented with the vessels
exiting the flaps posteriorly.
■ Conversely, if it is necessary to use the contralateral neck vessels, the flap
is oriented with the vessels exiting the tissues medially (thus decreasing the
distance necessary to reach the contralateral vessels).
■ The patient shown in TECH FIG 1A has undergone a radical resection of
the right hemimandible, retromolar trigone, floor of the mouth, and partial
tongue for a recurrent squamous cell cancer involving the retromolar trigone
area.
■ Because the temporomandibular joint was resected, and the patient had a
paucity of recipient vessels preventing double free flap reconstruction, the
defect was reconstructed with a vertical rectus abdominis myocutaneous
(VRAM) flap (TECH FIG 1B).
■ The flap has been inset into the defect in the horizontal plane, thus
obliterating the defect in the mandible and maintaining normal positioning
of the remaining bone and, at the same time, obliterating the intraoral soft
tissue defect (TECH FIG 1C).
■ Rigid fixation with plates is rarely necessary in this type of reconstruction.
Plates placed in this manner routinely fail (necessitating additional surgery)
and complicate flap inset resulting in compression or pressure on the flap.
■ Microsurgical anastomosis was performed to the right superior thyroid
artery (end to end) and the internal jugular vein (end to side). In general,
the inset is performed at least partially to stabilize the flap followed by
microsurgical anastomosis.

TECH FIG 1 • A. Extensive lateral mandible defect
(lateral mandible, floor of the mouth, lateral tongue,
retromolar trigone, and temporomandibular joint) in a
patient treated for a recurrent squamous cell cancer.
B. Markings for a large VRAM flap. C. Flap inset
demonstrating horizontal orientation of the flap to
reconstruct the floor of the mouth, retromolar trigone,
and mandibular defect.
■ Nonhorizontally Oriented Flaps
■ It may be necessary to orient the flap slightly off axis or in a more vertical
direction. This most commonly happens when there is a combined intraoral
and extraoral defect.
■ The patient shown in TECH FIG 2A had a recurrent squamous cell cancer
of the right hemimandible with regional metastasis to the lateral cheek, floor
of the mouth, and retromolar trigone.
■ Resection of this recurrence resulted in an extensive intraoral and extraoral
defect involving the lateral mandible, floor of the mouth, buccal mucosa,

retromolar trigone, and external cheek skin (TECH FIG 2B). A fibula flap
alone would not be suitable for this reconstruction and would necessitate a
double free flap, which, given this patient’s medical comorbidities and
nutritional deficits, was not advisable.
■ A VRAM flap with a double skin island was designed to reconstruct all the
defects with one flap (TECH FIG 2C).
■ The flap was inset in a primarily vertical orientation with the skin paddle
and muscle obliterating the mandible defect and the inferior skin paddle
inset into the intraoral defect (TECH FIG 2D–F).
■ Note watertight closure of the defect.

TECH FIG 2 • A. Recurrent squamous cell cancer of
the lateral mandible involving the cheek and
retromolar trigone. Note abnormal adherence of the
tongue to the buccal mucosa and the preoperative
absence of the right marginal mandibular nerve
function. B. An extensive resection resulting in a
complex intraoral and extraoral defect has been
performed. C. Double-island VRAM flap is planned
and drawn in place with approximate measurements
of the skin paddles needed for reconstruction. D. Flap
positioning prior to inset. Note almost vertical
orientation lining up the inferior portion of the flap
intraorally. E. Flap has been inset into the intraoral
defect. F. Final flap inset demonstrating closure of
both intraoral and extraoral defects.

PEARLS AND PITFALLS
Planning
■ The plan should be discussed with the ablative surgeon
preoperatively because preservation of the anterior mandibular
arch is necessary.
■ Dental consultation is helpful in patients with carious teeth.
■ Preoperative imaging may be necessary to assess the extent of the
expected defect and availability of recipient vessels.
Recipient site
preparation
■ Recipient vessels should be preserved during resection and
prepared prior to flap transfer.
■ The defect should be carefully analyzed to design the optimum
flap and the best combination of skin, muscle, and fat to meet the
volume and soft tissue requirements of the defect.
Flap inset
■ Flap can be inset vertically or horizontally to best obliterate the
intraoral and extraoral (if present) defects.
■ Orientation of the flap with respect to recipient vessels should also
be considered.
Donor-site
closure
■ A two-team approach allows flap inset and donor-site closure
simultaneously, thus cutting down time under anesthesia.
Postoperative
care
■ The head should be kept neutral to minimize stress on the closure.
■ Drains should be kept away from the anastomoses.
■ Circumferential tracheostomy ties are strictly avoided as they can
compress the pedicle.
COMPLETION
■ The neck wound is copiously irrigated with warm saline or antibiotic solution
and the position of the vessels is confirmed with gentle ranging of the neck to
ensure that the vessels do not become kinked with patient motion.
■ One or two closed suction drains are placed in the neck with care taken to
avoid compression of the vein or suction near the anastomosis.
■ Skin wounds are closed after loose approximation of the platysma (if possible)
and skin closure with nylon sutures (4.0).
POSTOPERATIVE CARE

■ Tube feedings are begun within 48 hours of the conclusion of the procedure.
Irrigation of the oral cavity for hygiene is generally begun after 3 days.
■ The tracheostomy is left in place for 10 to 14 days, or until wound healing is
assured and it is clear that additional surgery is not needed.
■ Extensive defects, particularly those involving reconstruction of the pharynx
or retromolar trigone may benefit from swallow studies to ensure that there is
no leak into the neck and that the patient does not aspirate oral feeds. These are
usually done approximately 2 weeks postoperatively.
■ Patients who have extensive surgery in combination with a prior history of
radiation may benefit from longer recovery times (eg, 6 weeks) with swallow
assessment performed as an outpatient. In these cases, oral feeds are
maintained with nasogastric or, more commonly, gastric tubes.
OUTCOMES
■ The use of soft tissue reconstruction alone for extensive defects allow patients
to return to an oral diet relatively quickly.1
■ Mosahebi et al. evaluated 76 patients who underwent soft tissue reconstruction
of extensive posterolateral mandibular defects.
■ VRAM was used most commonly (89%) and mean length of stay was 18
days.
■ Most patients (54%) were able to tolerate oral feeds at discharge, and 60%
had normal or near normal speech.
■ Aesthetic outcomes were good in 49%, fair in 21%, and poor in 30%.
■ Salivary fistulas developed in 6.6% of patients and healed spontaneously in
over 80% with conservative management.
■ Kroll et al.2 reported on 21 patients treated in a similar manner with most
patients achieving good to excellent aesthetic outcomes, and excellent speech
and swallowing in 33%.
■ Most patients required secondary revisions to address neck fullness.
COMPLICATIONS
■ Potential complications are related to flap failure (generally less than 5%),
infections, hematoma, intraoral wound dehiscence (which may lead to
orocutaneous fistula formation), or functional complications (eg, impaired
speech, swallowing, mastication).
■ Flap donor-site complications may also be problematic in this patient
population.

REFERENCES
1. Mosahebi A, Chaudhry A, McCarthy CM, et al. Reconstruction of extensive
composite posterolateral mandibular defects using non-osseous free tissue
transfer. Plast Reconstr Surg. 2009;124:1571-1577.
2. Kroll SS, Robb GL, Miller MJ, et al. Reconstruction of posterior mandibular
defects with soft tissue using the rectus abdominis free flap. Br J Plast Surg.
1998;51:503-507.