Vạt Da Và Phẫu Thuật Tái Tạo (Flaps and Reconstructive Surgery)

CHAPTER 39 — Trapezius Flap
e143
the more the arc of rotation can be extended, thus avoiding
impairment of muscle function.
Two different types of flap composition are possible:
• Myocutaneous
• Muscle flap
If defect coverage without bone reconstruction is needed,
flaps based on the DSA can reach most regions up to the
midface and orbits without the disadvantage of possible
severe donor site morbidity.
SPECIAL CONSIDERATIONS
SOFT TISSUE DEFECTS OF THE ANTERIOR NECK AND
LOWER FACE
Myocutaneous flaps based on the DSA or SCA (donor site
morbidity exists) are ideally harvested as an island flap with
a vertically or transversally planned skin island as needed. It
could be helpful to provide microvascular augmentation to
ensure blood supply to a large skin island by performing
microvascular anastomosis between segmental intercostal
arteries or the circumflex scapular vessels and arteries in the
recipient site.
SOFT TISSUE DEFECTS, INCLUDING A VISCERAL
PART, SUCH AS BASE OF TONGUE, HYPOPHARYNX,
OR ESOPHAGUS
Myocutaneous flaps based on the SCA or DSA are used. The
skin quality is not ideal for restoring mucosa and most of
these flaps are very bulky and difficult to fold so that these
flaps should only be used for this indication if there are no
other options.
OSTEOCUTANEOUS DEFECTS OF THE MANDIBLE
AND OVERLYING SOFT TISSUE
Osteocutaneous flaps based on the SCA are harvested,
including a segment of the scapular spine. The skin island
is usually planned transversally.
SOFT TISSUE DEFECTS OF THE MIDFACE AND
ORBITAL REGION
Myocutaneous flap based on the DSA is used. The skin
island can be extended far distally to the inferior angle of
the scapula and is planned vertically. One-third of the skin
island has to overlie the lower part of the trapezius muscle
to ensure vascularization. Flaps should be dissected as
islands but a muscle cuff can also be taken along with the
pedicle to facilitate elevation. To widen the arc of rotation,
the flap can be pulled through the levator scapulae muscle
after dividing the rhomboid minor muscle.
SOFT TISSUE DEFECTS OF THE BACK (INCLUDING
THE DORSAL SPINE), THE AXILLA, THE POSTERIOR
NECK, AND THE OCCIPITAL REGION
Myocutaneous flaps are harvested, based on the SCA or DSA
with a skin island as needed. Flaps can be ipsilateral or
contralateral. As the SCA ends variably in the upper or
middle part of the trapezius muscle, preoperative Doppler
ultrasound is useful for careful planning of the skin island.
In contrast, the course and the length of the DSA are very
constant.
All flaps based on the SCA or DSA can be elevated strictly
as island flaps. There is no need to take a muscle cuff along
with the vascular pedicle; in fact, this should be avoided to
minimize donor site morbidity. In any case, as it is techni­
cally easier to take a muscle cuff along with the pedicle, most
surgeons harvest the flap this way. When doing so, one must
take care to identify the pedicle vessel (DSA or SCA). To
ensure safe vascularization, both vessels can be included,
taking a broad muscle cuff along, but then the disadvan­
tages of serious donor site morbidity, limited arc of rotation,
and a bulky pedicle will have to be faced. The arc of rotation
is limited to the point between the rhomboid major and
minor muscles.
If only one vessel (DSA or SCA) is included, the arc of
rotation can be extended according to the individual
anatomy. Flaps based on the DSA after division of the rhom­
boid minor muscle can be pulled through under the levator
scapulae muscle and can reach the midface and the orbital
region.
Flaps based on the SCA can safely reach the neck and
lower face.
Of course, most flaps based on the SCA or DSA can be
used as muscle flaps covered with a skin graft without taking
a skin island along. For most indications, a skin island is
needed to achieve a good functional or cosmetic result.
The term “island flap” is reserved for flaps hanging
only on the vascular pedicle; therefore, an island flap
can be harvested with or without a muscle cuff underneath
the skin island. In creating the island flaps described in
this chapter, the surgeon always has to take a part of the
muscle along. To perform a perforator flap without any
muscle, the perforating branches are too small for this flap.
Therefore, for this flap, although muscle is always included,
there is no need to harvest a large cuff of muscle along with
the pedicle.
TRAPEZIUS FLAP BASED ON THE SCA
The acromion should be left intact. When a cutaneous com­
ponent is needed, the size of the harvested skin island
should allow direct closure of the donor site. Ideally, the
skin island is planned transversally, overlying the scapular
spine with its distal border. The expected arc of rotation
must guarantee that the flap can reach the recipient site
without tension on the vascular pedicle.
All skin incisions should be planned with the idea that
scar contractures in the shoulder and neck region can easily
lead to functional problems.
Three different types of flap composition are possible:
• Osteomyocutaneous
• Myocutaneous: transverse or vertical skin island
• Muscle flap
TRAPEZIUS FLAP BASED ON THE DSA
The skin island requires careful preoperative planning with
the patient in an upright position with arms hanging at the
sides. Only in this position can the distal border of the tra­
pezius muscle be marked with certainty.
Depending on the situation, the skin island is planned to
overlie the distal border of the muscle by at least one-third
of its diameter. The farther distally the skin island is planned,

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
vertically and 6 cm transversally. For an osteomyocutaneous
flap connected to the vertical skin island, the muscle cuff
can include a 10 × 2 cm segment of the scapular spine. If a
free or pedicled flap is vertical, the skin island can extend
to 30 cm in length.
Muscle Dimensions (Vertical and Transverse)
Length: 10 (8)  cm (range 5–30 (14)  cm)
Width: 7 (5)  cm (range 4 (3)–8 (7) cm)
Thickness: 1 cm (range 0.7–1.5 cm)
Normally, the muscle underneath the skin island is har­
vested with or without a muscle cuff along the pedicle.
When a flap based on the ascending branch of the SCA is
elevated, the skin island can be planned half distal to the
muscle insertion at the scapular spine.
Bone Dimensions
Length: 7 cm (range 3–12 cm)
Width: 1.5 cm (range 0.9–2 cm)
Thickness: 0.7 cm (range 0.4–1 cm)
The amount of bone that can be harvested from the
scapular spine varies according to the physical condition of
the patient.
TRAPEZIUS FLAP BASED ON THE DSA
Skin Island Dimensions (Fig. 39.10C)
Length: 8 cm (range 5–30 cm), maximum to close primar­
ily: 30 cm
Width: 6 cm (range 4–8 cm), maximum to close primarily:
8 cm
Thickness: 2.5 cm (range 1.5–3.5 cm)
Muscle Dimensions
Length: 5 cm (range 3–20 cm)
Width: 4 cm (range 2–8 cm)
Thickness: 1 cm (range 0.7–1.5 cm)
SOFT TISSUE DEFECTS OF THE MIDDLE AND LOWER
THORACIC SPINE REGION
A muscle flap is used, based on the segmental intercostal
arteries in a turnover technique with restricted arc of
rotation.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
There is no difference whether a flap based on the DSA or
SCA is designed and elevated as a pedicled flap or free flap.
Due to very limited indications and clinical experience, the
flap design must be adapted to the need of the patient.
When harvesting a free flap, a long skin island can be
taken along with an extra-long pedicle (up to 20–25 cm).
Myocutaneous perforators are very small and not constant,
so that perforator flaps or special incisions cannot be
recommended.
FLAP DIMENSIONS
TRAPEZIUS FLAP BASED ON THE SCA
Skin Island Dimensions (Vertical and Transverse)
(Fig. 39.10A,B)
Length: 10 (8)  cm (range 5–30 (14)  cm), maximum to close
primarily: 14 (30)  cm
Width: 7 (5)  cm (range 4 (3)–8 (6)  cm), maximum to close
primarily: 6 (8)  cm
Thickness: 2.5 (range 1.5–3.5 cm)
For a myocutaneous flap, the skin island can be outlined
transverse to the scapular spine or distal and vertical to the
medial border of the scapula. If a skin island is planned
vertically, the distal end should not extend over the middle
of the scapula to ensure inclusion of the vascular pedicle,
because the distal branches of the SCA are ending at this
height. To permit direct closure of the donor site, the
breadth of skin islands should not extend beyond 8 cm
Figure 39.10  Most frequently used flap design based on the ascending (A) and descending (B) branch of the SCA and on the DSA (C). Blue
marks the overlap with the trapezium muscle; red and black mark the outline of the skin island of the flap.
A
B
C

CHAPTER 39 — Trapezius Flap
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TECHNIQUE OF FLAP HARVEST
TRAPEZIUS FLAPS BASED ON THE SCA
(THREE FLAP TYPES)
PEDICLED MYOCUTANEOUS FLAP BASED ON
THE ASCENDING (SUPERIOR) BRANCH OF THE SCA
(Fig. 39.11)
Indications for this flap typically are soft tissue defects of the
anterior neck and lower face and mucosal defects of the
hypopharynx or upper esophagus, where the anterior neck
region has already been dissected. The limiting factor in
flap transfer is the variability of the draining veins and their
relationship to the accessory nerve; this means that the
pedicle has to be dissected before flap elevation. After the
anatomic situation has been clarified and it has been
decided that flap elevation is possible (the accessory nerve
passes deep or superficial to artery and veins), the course
of the SCA is followed under the anterior border of the
trapezius muscle. After dissection and preservation of the
accessory nerve, which runs close to the vessel, and identi­
fication of the ascending branch of the SCA, all other
branches can be divided and the transverse or vertical skin
island is elevated with a small muscle cuff carrying the
pedicle. In most cases, the resection of skin and muscle
includes the anterior border of the trapezius muscle but
even when a small muscle strip remains it should be divided
because of absent function. The pedicle vessels at the neck
are then dissected as far as possible.
PEDICLED OSTEOMYOCUTANEOUS FLAP BASED ON
THE ASCENDING (SUPERIOR) BRANCH OF THE SCA
The dissection of the neck is the same as for the myocutane­
ous flap. After identification of the pedicle artery, the
skin island (vertical) is outlined over the scapular spine with
its distal border 1 cm below the bone. Dissection is contin­
ued from distal, detaching the fibers of the supraspinatus
and deltoid muscles. Then the piece of the scapular spine
that is needed (up to 12 × 2 cm) is harvested, leaving at
least 2 cm of the lateral border (acromion) intact. The
muscle cuff connected to the bone is included and the
composite flap is elevated as described above as a straight
island flap.
For both flaps, the pedicle has to be freed completely and
it cannot be lengthened further due to the fact that the
dissection is close to the external carotid artery and there is
no indication to perform this flap as a free flap.
MYOCUTANEOUS FLAP BASED ON THE
DESCENDING (INFERIOR) BRANCH OF THE SCA
For a vertical skin island over the trapezius muscle in
between the scapula and the posterior median line down to
the middle of the height of the scapula, a myocutaneous
flap can be elevated. We find that the skin island should
not be outlined more distally, because in all of our cadaver
dissections (248 specimens), there was never a branch of
the SCA running down far into the ascending part of
the muscle. In publications describing this technique, the
whole muscle was elevated on a broad muscle cuff, sacrific­
ing the accessory nerve. For this procedure, the nerve,
A vertical skin island 8 cm wide and as long as needed
can be outlined. The skin island should not extend
more than 10 cm distal to the inferior angle of the scapula.
It must be guaranteed that one-third is positioned over the
trapezius muscle to ensure vascularization. The skin island
should be closer to the medial border of the scapula than
to the posterior median line, according to the course of the
DSA.
FLAP MARKINGS (Figs 39.8–39.10)
FLAPS BASED ON THE SCA AND DSA
The patient is placed in the standing or sitting position with
the arms adducted, and the handheld ultrasound Doppler
is used to mark the position and course of the arteries.
TRAPEZIUS FLAP BASED ON THE SCA
The anterior border of the trapezius muscle, the dimension
of the scapula and the spine of the scapula, and the acro­
mion are marked.
TRAPEZIUS FLAP BASED ON THE DSA
The medial border of the scapula and the rhomboid muscles
are outlined to identify the perforating point of the pedicle
artery. The posterior median line and the ascending (lower)
part of the trapezius muscle are marked. For an osteomyo­
cutaneous flap based on the SCA, the part of the scapular
spine to be included under the skin island has to be marked.
PATIENT POSITIONING
Most of the defects for which a flap based on the SCA is
recommended, are located in the anterior neck region or
in the face, so that it is rarely possible to keep the patient
in a prone position without shifting.
TRAPEZIUS FLAP BASED ON THE SCA
For an osteomyocutaneous or myocutaneous flap using
the ascending branch of the SCA as the pedicle artery,
the patient lies supine with a pillow deep under the
shoulder.
For a myocutaneous flap based on the descending branch
of the SCA with a vertical skin island, a prone position (for
defects on the back and neck) or lateral decubitus position
is obligatory, leaving the arm flexible to move the scapula
as necessary.
TRAPEZIUS FLAP BASED ON THE DSA
Depending on the defect’s location, the flap can be dis­
sected in the lateral decubitus position, with the arm flexi­
ble or in the prone position with the arms abducted (90°)
and the shoulder dropped to move the scapula laterally. In
both positions, it is important to leave the arm flexible to
allow shifting of the scapula, because of the vessel’s course
close to or under the medial margin of the scapula.
ANESTHETIC CONSIDERATIONS
Only general anesthesia can be recommended for flap har­
vesting based on the SCA and DSA.

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
nerve, which accompanies the distal course of the DSA
from the point between the rhomboid muscles close to
the descending branch of the artery under the rhomboid
major muscle. The dissection does not affect the superfi­
cial cervical artery or the accessory nerve.
The flap can then be transferred through a subcutaneous
tunnel to the recipient site, or dissection can continue
under the levator scapulae muscle to the lateral neck region
to widen the arc of rotation to about 5–7 cm. A microvascu­
lar transfer of this flap with its very long pedicle is also pos­
sible because the average diameter of the artery is sufficient
at this level.
FLAP MODIFICATION/FLAP HANDLING
EXTENDED TRAPEZIUS MYOCUTANEOUS FLAP
A so-called “extended trapezius myocutaneous flap” extends
the skin island far distally to the border of the muscle.
Taking a very long vertical skin island along, an extended
flap can be harvested with a pedicle or even as a free flap
based on the SCA or DSA.
The skin island is outlined parallel to the medial border
of the scapula overlying the muscle. When the descending
branch of the SCA is dissected, a wider arc of rotation can
be achieved using a pedicled flap. Dissecting the flap as a
free flap with both pedicle arteries (SCA, DSA) can produce
a long pedicle, but using the DSA, the accessory nerve never
has to be sacrificed.
Because of the large connecting zone between muscle
and skin island, there is no risk of partial skin necrosis.
When a short vertical skin island is harvested, the extended
flap modification should be limited to flaps based on the
DSA to ensure vascularization.
because of its course close to the vessel and the muscle, has
to be separated completely, which leads to major donor site
morbidity. Alternative reconstructive procedures should be
recommended instead. If a flap based on this pedicle is
elevated, the upper trapezius should be left intact, which
minimizes not only the arc of rotation but also the func­
tional complications.
TRAPEZIUS FLAP BASED ON THE DSA
One-third of the skin island has to be planned to be over
the trapezius muscle closer to the vertebral spine to
ensure musculocutaneous blood supply; it should not be
extended more than 10 cm distal to the inferior angle of
the scapula. After incision and identification of the
margin of the latissimus dorsi and trapezius muscles, the
muscle is elevated and the course of the dorsal scapular
artery can be seen. Then an incision is made along the
medial border of the scapula and the flap is elevated by
cutting the muscle fibers and following straight along the
pedicle vessels (a small muscle band can be left over the
pedicle to make the dissection faster and easier). Because
of the size and course of the vessels at this level, magnifi­
cation can be helpful. The descending branch of the
dorsal scapular artery running deep to the major rhom­
boid muscle has to be divided at the point where it
appears between the rhomboid muscles. The minor rhom­
boid muscle can be divided to widen the arc of rotation if
necessary. Subsequently, from this point the pedicle
vessels, which consist of the artery and always two veins,
can be prepared under the superior angle of the scapula.
If needed or for free flap harvesting, the division can be
continued up to the levator scapulae muscle, achieving an
average diameter of the dorsal scapular artery of 1.94 mm.
Care has to be taken not to injure the dorsal scapular
Figure 39.11  (A–D) Elevation, pedicle dissection, and positioning of a myocutaneous flap based on the ascending branch of the SCA.
A
B
C
D

CHAPTER 39 — Trapezius Flap
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TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• The dissection should always have as its goal a straight
pedicled island flap based on clearly defined vessels. The
pedicle thus has to be dissected under direct view.
• One can take along a small muscle band over the pedicle,
elevating a flap based on the DSA or SCA, because dissec­
tion is easier and the donor site does not suffer greater
damage.
• Greatest care should be taken not to affect the function
of the descending and transverse part of the muscle and
to preserve the accessory nerve.
FLAP USAGE
It has to be stressed that the trapezius flap based on the
SCA is rarely the best option in reconstruction. An experi­
enced reconstructive surgeon would generally prefer a free
flap, but under certain circumstances, especially in tumor
surgery, microsurgery might be contraindicated. In these
cases the trapezius flap offers a fast and safe reconstructive
option.
PEDICLED
HEAD AND NECK
Based on the Ascending Branch of the SCA
The pivot point is defined by the origin of the pedicle vessels,
so that the arc of rotation varies between 10 and 15 cm.
Myocutaneous with a Transverse Skin Island
• Soft tissue defect of the anterior neck region
• Soft tissue defect of the lower face, including the parotid
and buccal region
• Soft tissue defect of the lower occipital region
• Mucosal defects of the base of the tongue, the hypophar­
ynx, the trachea, and the esophagus
Osteomyocutaneous with a Transverse Skin Island
• Combined defect of the mandible and the overlying soft
tissue
• Combined defect of the mandible and the oral or buccal
mucosa
• Combined defect of the lateral wall of the orbit and the
overlying soft tissue
• Combined defect of the malar region and the overlying
soft tissue
Based on the Descending Branch of the SCA
Due to the position of the vertical skin island, the arc of
rotation can be extended up to 25 cm.
Myocutaneous with a Vertical or Transverse Island
• All indications listed for a myocutaneous flap based on
the ascending branch of the SCA
When a flap based on the descending branch of the SCA
is used to ensure safe vascularization, it could be useful to
provide microvascular augmentation by anastomosing inter­
costal arteries.
TRAPEZIUS MUSCLE FLAP
For certain indications that do not require a skin island, a
muscle flap based on the SCA or DSA can be elevated
axially. Especially when a defect is too large for the skin
island and does not allow primary closure, muscle flaps
covered with skin grafts could be an alternative. In any case,
donor site morbidity for muscle flaps based on the SCA
might be unacceptable.
TRAPEZIUS MUSCLE TURNOVER FLAP
As described, turnover muscle flaps based on intercostal
arteries (between the third and sixth intercostal spaces) can
be a good treatment option for soft tissue defects of the
middle and upper thoracic spine.
FUNCTIONAL MUSCLE TRANSFER
The only indication we see for functional muscle transfer
is the transfer of the insertion of the trapezius to
restore function of the deltoid muscle in nerve palsy
situations.
Whatever the indication, as much muscle function as
possible should be conserved, especially of the upper
and middle parts of the trapezius. In our experience
and according to the anatomy (course of the accessory
nerve), this goal is easier to achieve when a flap based on
the DSA is elevated. When flaps are based on the ascend­
ing branch of the SCA, the nerve has to be sacrificed in
one-third of patients, who then face major functional
problems.
DONOR SITE CLOSURE AND
MANAGEMENT
FLAPS BASED ON THE ASCENDING BRANCH OF
THE SCA
After a myocutaneous or osteomyocutaneous flap is har­
vested, a normal suction drain is inserted and the donor site
can be closed directly, depending on the size of the skin
island with or without tension in two layers. Because of the
localization of the closed wound and when there is more
tension, the shoulder should be immobilized for 2 weeks to
aid healing.
FLAPS BASED ON THE DESCENDING BRANCH OF
THE SCA OR ON THE DSA
If only a small muscle cuff is harvested or the flap is dis­
sected as an island, the muscle can be adapted with resorb­
able sutures. Direct wound closure in two layers after
insertion of a suction drain should not pose any problems.
Shoulder immobilization is not necessary.

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
defects of the base of the tongue, the hypopharynx, and the
esophagus, or even the trachea. In doing so, one has to
localize exactly the position of the skin island needed. Ideal
indications for this flap are defects resulting from tumor
resection, necessitating division of the accessory nerve, so
that the trapezius muscle is already denervated and the
course of the nerve does not compromise the pedicle vessels.
If there is a defect of the mandible, a combined osteomyo­
cutaneous flap is indicated and serves as an alternative to
microsurgical procedures. The arc of rotation is limited and
the skin island should not be so large as to preclude direct
wound closure. In one-third of patients, the accessory nerve,
because of its course between the pedicle vessels, has to be
divided, which leads to complete functional loss of the tra­
pezius muscle. For this reason, we feel that this procedure
cannot be recommended.
After definition of the needs of the recipient site (size of
the skin island needed and volume of soft tissue to fill up
dead space, size of the bone segment needed and relation­
ship to the skin island), the flap is planned and the pedicle
vessels are dissected first to clarify the anatomic situation,
especially the course of the accessory nerve (if not divided
during tumor surgery). From this point, the flap can be
elevated with a fast and straightforward dissection. Techni­
cally, it is useful to divide all the anterior fibers of the tra­
pezius muscle. After identification, the descending branch
of the SCA has to be divided to complete flap mobilization.
When the pedicle vessels are freed they are prepared up to
the pivot point and the flap is inserted into the defect. The
bone is fixed with a plate or, in mucosal reconstruction, the
skin island is sutured in (with resorbable sutures) in a turn­
over procedure.
PEDICLED FLAPS BASED ON THE DESCENDING
BRANCH OF THE SCA
• Soft tissue defects of the anterior neck, lower face,
midface, orbital region
• Mucosal defects
• Soft tissue defects of the posterior neck and over the
cervical and thoracic spine
There are two typical indications for this flap: first, soft
tissue defects of the posterior neck up to the occipital region
and defects over the cervical and thoracic spine. In these
cases, a vertical skin island is usually outlined, not exceeding
the lower part of the scapula to ensure vascularization.
Because of the vessel course, the incision and the skin island
are outlined in the middle between scapula and vertebral
column. The pedicle vessel can be identified in the upper
part of the back, and a muscle cuff is harvested along with
it. At the level of the rhomboid minor muscle, it might be
necessary to divide the branch of the DSA if it was harvested
with the flap. The pivot point should not be positioned too
high, so as not to denervate or divide the upper part and
too many fibers in the middle part of the trapezius muscle.
This is very important because the accessory nerve accom­
panies the descending branch of the SCA. In these cases the
flap coverage is a fast and secure procedure, with the patient
always in a prone position.
The second type of indications we see are defects, espe­
cially after ablative tumor surgery, where the accessory nerve
has already been divided during tumor resection or neck
• Soft tissue defects of the midface up to the orbital region
• Soft tissue defects of the temporal and upper occipital
region
• Soft tissue defects over the cervical spine
Based on the DSA
The flap is elevated in the normal way; the pivot point is at
the level of the rhomboid minor muscle, providing an arc
of rotation of up to 25 cm. Extending the pedicle by divid­
ing the rhomboid minor muscle and pulling the flap
through under the levator scapulae muscle, the arc of rota­
tion can be extended up to 30 cm or even more.
Myocutaneous with a Vertical Island
• All indications listed for a myocutaneous flap based on
the ascending or descending branch of the SCA
• Soft tissue defects on the contralateral side of the lower
neck.
TRUNK
Based on the DSA
Myocutaneous with a Vertical Skin Island
• Soft tissue defects over the upper thoracic spine
• Soft tissue defects of the contralateral side of the back
Based on the Intercostal Segmental Arteries
The short intercostal arteries, mostly appearing between the
third and sixth intercostal spaces, allow the lower part of the
trapezius muscle to be turned over.
Muscle Flap Only
• Soft tissue defect over the thoracic spine
FREE FLAP
To our knowledge, only a few cases of free flaps based on
the SCA or on the DSA have been published to date.
MYOCUTANEOUS FLAPS BASED ON THE SCA
OR DSA
• Soft tissue defects of the head and neck or the extremi­
ties, where an extra-long pedicle (20 cm or even more)
is needed to avoid vessel grafts
• Soft tissue defects of the trunk or the extremities, where
an extra-long skin island (30–35 cm) is indicated
FLAP USAGE
TYPICAL INDICATIONS FOR THIS FLAP
PEDICLED FLAPS BASED ON THE ASCENDING
BRANCH OF THE SCA
• Soft tissue defects of the anterior neck, lower face
• Mucosal defects
Typical indications for a myocutaneous flap are soft tissue
defects in the anterior neck and lower face. Skin islands also
can be used to reconstruct the inner layer (mucosa) for

CHAPTER 39 — Trapezius Flap
e149
reconstructive surgery of a lower extremity, we recommend
7 days’ clinical monitoring and immobilization of the
patient.
RECIPIENT SITE
Depending on the localization of the recipient site, a
special bed or mattress (air cushion) has to be used to
avoid postoperative pressure on the flap (skin island or
muscle in a turnover procedure) or the pedicle (back,
neck, occipital region, and defects over the vertebral
column). With pedicled flaps, it is most important that
there be no tension or pressure on the pedicle vessels.
With a skin island for mucosal reconstruction, internal
monitoring (e.g., measurement of oxygen partial pres­
sure) can be helpful.
DONOR SITE
After elevation of a pedicled flap based on the ascending
branch of the SCA (myocutaneous or osteomyocutaneous),
with or without division of the accessory nerve, we recom­
mend shoulder immobilization with the arm in an adducted
position for 2 or 3 weeks to avoid wound healing problems.
Thereafter, physiotherapy is indicated to strengthen muscle
agonists for the upper trapezius such as the levator scapulae
muscle.
If a pedicled flap is harvested on the descending branch
of the SCA and the accessory nerve had to be divided, post­
operative immobilization is not necessary but physiotherapy
to strengthen the muscle agonists should be begun as soon
as possible.
When a pedicled flap is performed based on the DSA
or SCA without compromising the accessory nerve and
with division only of the lower trapezius muscle, immobili­
zation does not seem to be necessary, but the muscle ago­
nists such as the rhomboid major muscle should be
exercised. In any case, regular physiotherapy for at least 6
weeks postoperatively is essential for all types of flaps. In
cases of complete denervation of the muscle, a severe
functional deficit with shoulder joint arthrosis and defor­
mities of the spine has to be expected. Reconstructive pro­
cedures such as transposition of the insertion of the
rhomboid muscles or the levator scapulae muscle or fixa­
tion of the medial border of the scapula with a fascia lata
graft should be offered to the patient according to the
deficits present.
OUTCOMES
EXPECTED OUTCOMES
GENERAL
Respecting the anatomic findings and carefully planning
and dissecting the flap should help to ensure a good
outcome. Muscle function of course plays a central role in
determining the outcome, as division of the accessory
nerve or the entire muscle leads to major functional prob­
lems as described. These cases often require reconstructive
procedures. For these reasons, we find that division of the
nerve or entire muscle is never acceptable during flap
dissection. In these cases the pedicle is dissected, dividing
the trapezius muscle up to the anterior neck without any
consequences. The ascending branch of the SCA is divided
at the end of the preparation. This flap allows a wide arc of
rotation but should be strictly limited to the indication men­
tioned above. One can reach the anterior neck up to the
orbital region with this procedure, as well as defects of the
mucosa. If needed, some sensibility could be restored by
coaptation of a segmental intercostal nerve to a nerve in the
recipient site.
PEDICLED FLAPS BASED ON THE DSA
• Soft tissue defects of the anterior neck, lower face
• Mucosal defects
• Soft tissue defects of the posterior neck and over the
cervical and thoracic spine up to the occipital and pari­
etal region
Defects in the occipital up to the parietal region, the
posterior neck and shoulder, and especially over the verte­
bral column are easily reached with a standard pedicled flap
(island or with a muscle cuff along the pedicle). The flap
can be transferred to the ipsilateral or contralateral side as
needed through a subcutaneous tunnel. With an anterior
neck defect, coverage is possible up to the mental region.
If, as described above, the pedicle is drawn under the levator
scapulae muscle after division of the minor rhomboid
muscle, the arc of rotation can be widened by pulling the
flap through several centimeters under the muscle. The skin
island is outlined closer to the scapula border according to
the vessel course. Dissection under the lower part of the
trapezius muscle is demanding because of the very small
vessels. Harvesting only a little muscle makes the flap thin
and pliable. If needed, some sensibility could be restored by
coaptation of a segmental intercostal nerve to a nerve in the
recipient site.
ATYPICAL INDICATIONS FOR THIS FLAP
FREE FLAPS BASED ON THE DSA OR SCA
A myocutaneous free flap can be created with a very
long pedicle (up to 20 cm) or an extra-long skin island,
compared with other flaps with low donor site morbidity.
Preparation of the pedicle is technically demanding, so
this procedure should be limited to cases that require a
long pedicle and where other flaps are contraindicated.
This free flap could be an option, particularly for defects
in the frontal or parietal region or for lower extremity
surgery with no local vessels for microanastomoses,
to avoid vessel grafts. Further clinical experience is neces­
sary before this procedure can be recommended for
routine use.
POSTOPERATIVE CARE
GENERAL
For the first 5 days, the flap (skin island or muscle) is moni­
tored clinically. No special medication is needed, and the
hospital stay can be limited to 10 days, depending on
the patient’s general condition. With free flaps and

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
rhomboid muscles and the levator scapulae muscle for func­
tional muscle reconstruction or static traction of the scapula
with fascia strips.
If the donor site cannot be closed directly, there can be
wound healing problems, scar contractures, or cosmetically
disturbing areas of grafted skin. Corrective procedures such
as skin expansion or split-thickness skin grafts might be
necessary.
The long scars over the back after flap elevation (based
on the descending branch of the SCA or on the DSA) are
visible and cosmetically disturbing, especially in young
patients.
LONG-TERM OUTCOMES
GENERAL
The myocutaneous flaps are expected to heal and maintain
long-term stable results. Since most of the flaps are har­
vested as island flaps with a small amount of muscle included,
minimal atrophy is expected. When the entire muscle is
included with the flap, a 30% rate of atrophy in size is
expected. The patient who did not have sacrifice of the
spinal accessory nerve is not expected to have any handicap­
ping long-term functional deficits.
CONCLUSIONS
The osteomyocutaneous and myocutaneous flaps based on
the ascending (superior) and descending (inferior) branch
of the SCA find their indication in reconstruction of a
variety of soft tissue or combined defects. Free tissue trans­
fers, however, are now performed routinely and are superior
to this procedure. The large variability of the pedicle vessels
(draining veins) and the fact that the upper part of the
trapezius muscle has to be divided can lead to donor site
problems. For this reason, these flaps should be limited to
cases where microsurgery is not an option or the accessory
nerve had to be divided during tumor resection.
The pedicled myocutaneous flap based on the DSA is a
well-established procedure and can be strongly recom­
mended for a variety of defects, especially of the posterior
trunk and neck region, due to the short duration of surgery
and low donor site morbidity. This flap can be an alternative
to free flaps reaching the anterior neck and the lower face
up to the orbita. In special cases, a free flap based on the
SCA or DSA could be indicated.
elevation. Indications for these flaps should be limited to
cases where the accessory nerve was divided during tumor
resection. The color of elevated skin islands in the poste­
rior and anterior neck and the back is good. In the lower
and midface, the skin color is too light and so cannot be
seen as ideal.
FLAPS BASED ON THE ASCENDING BRANCH OF
THE SCA
When an osteomyocutaneous flap is used for mandibular
reconstruction, bone grafts can be expected to heal and
become remodeled within 3–4 months. The bone defect of
the scapular spine normally does not cause any functional
problems. When the skin islands described are planned and
executed to permit direct skin closure, there is no scar con­
traction in the neck and shoulder region.
FLAPS BASED ON THE DESCENDING BRANCH OF
THE SCA AND ON THE DSA
When the accessory nerve is preserved during flap elevation,
there are only minor functional problems due to the divi­
sion of the lower trapezoid. Only in rare cases is the flap so
bulky (face) that secondary defatting procedures might be
necessary.
DONOR SITE
If the accessory nerve is not divided and enough muscle
function, especially in the upper and middle part, can be
preserved, the functional outcome of the donor site is more
than acceptable.
UNTOWARD OUTCOMES
GENERAL
Elevating a very distally planned skin island to widen the arc
of rotation (flaps based on the descending branch of the
SCA or on the DSA) might lead to partial skin necrosis due
to arterial inflow problems. In elevating a flap based on the
descending branch of the SCA, one can be confronted with
anatomic variations or might injure the accessory nerve
because of its course close to the pedicle vessels.
DONOR SITE
Loss of function of the whole trapezius muscle (sacrificed
accessory nerve or divided muscle) should be avoided. This
can lead to a winged scapula and a decrease in shoulder and
arm elevation. Special cases may require transfer of the

CHAPTER 39 — Trapezius Flap
e151
Figure 39.12  (A–C) Planning, elevation, and positioning of a myocutaneous flap based on the ascending branch of the SCA. (Reprinted
with permission from Plastic and Reconstructive Surgery 2004; 113.)
A
B
C
Figure 39.13  (A,B) Clinical result 1 year postoperatively.
A
B
A 64-year-old patient, after radical neck dissection and partial
parotidectomy due to lymph node metastases infiltrating the
surrounding soft tissue. The accessory nerve had to be divided
during tumor resection. A trapezius flap based on the ascending
branch of the SCA, including a 6 × 10 cm skin island, was trans-
ferred and used to reconstruct the soft tissue defect in the cheek.
CASE 39.1  Lower Cheek Soft Tissue Defect Reconstructed with a Myocutaneous Flap
Based on the Ascending Branch of the SCA

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 56-year-old patient after resection, that included the external
cortical bone, of a third recurrence of a squamous cell carci-
noma in the occipital region, ended up with 19 × 8 cm defect in
the occipital area. A trapezius flap (10 cm below the angle of the
scapula) was transferred to reconstruct this soft tissue defect.
Postoperative healing was uneventful and long-term follow-up
showed only minimal impairment of scapula movement and
shoulder function (Fig. 39.15).
CASE 39.2  Occipital Defect Reconstructed with a Pedicled Myocutaneous Flap Based on
the DSA
Figure 39.14  (A–C) Planning, positioning, and postoperative view of a myocutaneous flap based on the DSA. (Reprinted with permission
from Plastic and Reconstructive Surgery 2004; 113.)
A
B
C
Figure 39.15  Shoulder motion after harvesting of a myocutaneous flap based on the DSA. (Reprinted with permission from Plastic and
Reconstructive Surgery 2004; 113.)
A
B

CHAPTER 39 — Trapezius Flap
e153
A 37-year-old patient with multiple basal cell and squamous cell
carcinomas in the head and neck region showed a chronic defect
with free frontal bone on the left side. Because of previous
surgery, local flaps were not a treatment option and there were
no recipient vessels that could be used for microsurgery, in close
proximity to the defect. A flap with an extra-long pedicle was
therefore needed. A free trapezius flap was performed without
complications, tunneling the pedicle to the facial artery and vein
for microanastomoses. At 1 week after the flap transfer, it was
thinned and covered by a split-thickness graft.
CASE 39.3  Frontal Defect Reconstructed with a Free Flap Based on the DSA
Figure 39.16  (A) Preoperative defect, (B) flap elevation, and (C) positioning after performing the microanastomoses and (D) postoperative
view of a myocutaneous free flap based on the DSA.
A
B
C
D

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
A 71-year-old man s/p local excision and primary irradiation for
a squamous cell carcinoma in the zygomatic region now with
recurrence. A lower island trapezius flap was transferred to
reconstruct the defect.
CASE 39.4  Temple Defect Reconstructed with a Pedicled Lower Island Trapezius Flap
Figure 39.17  (A) Intraoperative view of the patient showing a recurrence of a squamous cell carcinoma in the zygomatic region.
(B) Surgical cheek defect. (C) Harvested lower island trapezius flap. Area above the line to be de-epithelialized. (D) De-epithelialized flap
prior to rotation into the defect. (E) Flap rotated into the cheek defect. (F) Immediate postoperative result. (G) The 8-month postoperative
result when patient returned for additional small skin cancer resections. (Case 4)
A
B
C
D
E
F
G
F

CHAPTER 39 — Trapezius Flap
e155
A 67-year-old man with postauricular squamous cell carcinoma
requiring resection and reconstruction. The tumor was resected
and a pedicled lateral island trapezius flap was transferred to
reconstruct the defect.
CASE 39.5  Posterior Auricular Defect Reconstructed with a Lateral Island Trapezius Flap
Figure 39.18  (A) Intraoperative view showing a postauricular squamous cell carcinoma. (B) Surgical defect. (C) Lateral island trapezius
harvest. (D) Immediate postoperative result. (E) 12 months postoperatively. (Case 5)
A
B
C
D
E

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PART 4 — CONVENTIONAL WORKHORSE FLAPS
Expert Commentary 
Bassem T. Elhassan, MD
The trapezius muscle anatomy, tension, and excursion make it
an excellent muscle transfer option for numerous upper extrem-
ity disorders. Its innervation by cranial nerve XI makes it a very
attractive muscle for functional transfer in patients with brachial
plexus injury.
We did describe the transfer of lower trapezius transfer inser-
tion to the infraspinatus tendon to restore shoulder external
rotation in 2008 and since that time we have done more than
250 cases with good to excellent results in the majority of
cases. The harvesting of the lower trapezius insertion is rela-
tively straightforward. A small 5 cm incision is placed around
1 cm medial to the medial spine of the scapula, and after skin
elevation, the lateral margin of the lower trapezius is identified
as it is heading toward its insertion on the medial spine of the
scapula. The tendinous insertion is dissected and detached
from the medial spine of the scapula, and the interval between
middle and lower trapezius is developed while protecting the
spinal accessory nerve. Once full excursion of the muscle is
obtained, it is transferred to the infraspinatus tendon, and direct
tendon-to-tendon repair is performed.
We also used the same transfer prolonged with tendon
allograft to restore massive irreparable rotator cuff tear in non-
paralytic shoulder.
When the ipsilateral lower trapezius is not available for trans-
fer because of muscle or nerve injury or because of prior spinal
accessory nerve transfer, then the contralateral trapezius origin
could be transferred to the ipsilateral infraspinatus tendon to
restore shoulder external rotation.
The lower trapezius muscle origin could be used as a func-
tional flap transfer option to restore triceps function (elbow
extension) and potentially also for elbow flexion.
The upper/middle trapezius could also be options for transfer
to restore shoulder flexion/abduction.
There are several described techniques for this transfer. The
most common technique entails transfer of the upper/middle
trapezius on their bony acromial insertion to the proximal
humerus. Additionally, the acromion could be preserved to act
as lever arm for better abduction/flexion, and the muscle could
be transferred on top of the acromion prolonged with tendon
allograft.
REFERENCES
1. McCraw JB, Magee WP, Kalwaic H. Uses of the trapezius and ster­
nomastoid myocutaneous flaps in head and neck reconstruction.
Plast Reconstr Surg 1979;63:49–57.
2. Demergasso F, Piazza MV. Trapezius myocutaneous flap in recon­
structive surgery for head and neck cancer: an original technique.
Am J Surg 1979;138:533–6.
3. Baek SM, Biller HP, Krespi YP, et al. The lower trapezius island
myocutaneous flap. Ann Plast Surg 1980;5:108–14.
4. Mathes SJ, Nahai F. Muscle flap transposition with functional pres­
ervation: technical and clinical considerations. Plast Reconstr Surg
1980;66:242–9.
5. Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: experimental and clinical correlation. Plast Reconstr Surg
1981;67:177–87.
6. Ogawa R, Marukami M, Vinh VQ, et al. Clinical and anatomical
study of superficial cervical artery flaps: retrospective study of
reconstructions with 41 flaps and feasibility of harvesting them as
perforator flaps. Plast Reconstr Surg 2006;118:95–101.
FURTHER READING
Donald PJ, Chole RA. Superior based trapezius flap. Laryngoscope
1984;94:969–73.
Dufresne C, Cutting C, Valauri F, et al. Reconstruction of mandibular
and floor of mouth defects using the trapezius osteomyocutaneous
flap. Plast Reconstr Surg 1987;79:687–96.
Guillamondegui OM, Larson DL. The lateral trapezius musculocutane­
ous flap: its use in head and neck reconstruction. Plast Reconstr Surg
1981;67:143–50.
Haas F, Weiglein A, Schwarzl F, et al. The lower trapezius musculocu­
taneous flap from pedicled to free flap: anatomical basis and clinical
applications based on the dorsal scapular artery. Plast Reconstr Surg
2004;113:1580–90.
Lynch JR, Hansen JE, Chaffoo R, et al. The lower trapezius musculo­
cutaneous flap revisited: versatile coverage for complicated wounds
to the posterior cervical and occipital regions based on the deep
branch of the transverse cervical artery. Plast Reconstr Surg
2002;109:444–50.
Mardini S, Chen HC, Salgado CJ, et al. Extended trapezius myocutane­
ous free flap for the reconstruction of a foot defect lacking adjacent
recipient vessels. J Reconstr Microsurg 2004;20:599–603.
Netterville JL, Panje WR, Maves MD. The trapezius myocutaneous flaps.
Arch Orolaryngol 1987;113(3):271–81.
Netterville JL, Wood DE. The lower trapezius flap: vascular anatomy
and surgical technique. Arch Otolaryngol 1991;117:73–6.
Panje WR. Trapezius osteomyocutaneous island flap for reconstruction
of the anterior floor of the mouth and mandible. In: Strauch B,
Vasconez LO, Hall-Findlay EJ, editors. Grabb’s encyclopedia of flaps.
Philadelphia: Lippincott-Raven; 1998. p. 697–9.
Papadopoulos O, Tsakoniatis N, Georgiou P, et al. Head and neck soft-
tissue reconstruction using the vertical trapezius musculocutaneous
flap. Ann Plast Surg 1999;42:457–8.
Tan KC, Tan BK. Extended lower trapezius island myocutaneous flap
based on the dorsal scapular artery. Plast Reconstr Surg
2000;105:1758–63.
Urken ML, Naidis RK, Lawson W, et al. The lower trapezius island
musculo-cutaneous flap revisited. Arch Orolaryngol Head Neck Surg
1991;117:502–11.
Vacher C, Accioli de Vasconcellos JJ. The anatomical basis of the osteo-
musculo-cutaneous trapezius flap in mandibular reconstruction.
Surg Radiol Anat 2005;27:1–7.
Weiglein AH, Haas F, Pierer G. Anatomic basis of the lower trapezius
musculocutaneous flap. Surg Radiol Anat 1996;18:257–61.
Weiglein AH, Moriggl B, Schalk C, et al. The arteries in the posterior
cervical triangle in man. Clin Anat 2005;18:553–7.

432
Scapular and
Parascapular Flaps
Claudio Angrigiani  |  Matthew M. Hanasono
40 
INTRODUCTION
The skin and subcutaneous tissue of the back may be har­
vested as a flap supplied by the cutaneous or superficial
branch of the circumflex scapular artery, originally named
by Manchot.1 This branch is termed the “superficial circum­
flex scapular artery.” This skin artery divides into several
branches: the horizontal (transverse) and vertical (descend­
ing), as well as the ascending and lateral branches. The
horizontal and vertical branches supply the scapular and the
parascapular cutaneous flaps, respectively.
Although the scapular flap was first described by dos
Santos2 and the parascapular flap by Nassif et al.,3 the cuta­
neous arteries, which irrigate these flaps, were first demon­
strated by Manchot1 in his work on the arteries of the skin
and later by Michel Salmon.4 The name of Iginio Tansini is
frequently coupled with the latissimus dorsi musculocutane­
ous flap; nevertheless, it was later observed from his pub­
lished diagram of the surgical technique that he was actually
performing a parascapular flap.5 He eventually added the
latissimus dorsi muscle to the original technique.6 A com­
bined scapular and parascapular flap was first described by
Koshima et al.7
The use of the main trunk of the superficial circumflex
scapular artery with all its branches allows harvesting of a
larger skin surface from the hemi-back (extended circum­
flex scapular flap). Local and distant uses of these flaps have
been extensively reported in the literature.
There is a direct vascular connection between the cir­
cumflex scapular vascular pedicle and the scapular bone.
It is possible to elevate and irrigate a segment of the lateral
scapular bone from the spine up to 2 cm inferior to the
scapulohumeral joint based on this vascular network. This
bone flap may be elevated independently or combined
with the cutaneous flap. Alternately, the angular branch of
the thoracodorsal artery supplies the inferior angle or
tip of the scapular bone and can serve as the vascular
blood supply for a bone flap that includes the tip as well
as the adjacent medial and/or lateral scapular bone. There
are numerous possibilities for chimeric flaps involving
the scapular bone and skin in combination with other
muscle, skin, and bone flaps arising from the subscapular
system.
Figure 40.1  Scapular and parascapular flaps.
Teres minor
Transverse
branch
Triceps
Subscapular
artery
Superficial
circumflex
scapular
artery
Horizontal branch
of superficial
circumflex
scapular artery
Latissimus dorsi
Trapezius
Infraspinatus
Vertical branch of
superficial circumflex
scapular artery
Parascapular flap
Scapular flap
Teres major
Perforating
intercostal
artery
Posterior cutaneous
branches of dorsal
rami of spinal
nerves
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION D  —  LOCAL AND FREE FLAPS IN THE BACK

CHAPTER 40 — Scapular and Parascapular Flaps
433
by the triceps muscle laterally, the teres minor superiorly,
and the teres major inferiorly. The lateral border of the
scapula might be considered to be the medial border of a
“quadrangular space.” The main trunk of the circumflex
scapular artery continues toward the lateral border of the
scapular bone. At this level it gives off several branches: a
descending branch to the lateral border of the scapular
bone (which eventually anastomoses at the tip of the
scapula with the angular branch of the thoracodorsal
artery), a branch to the teres minor muscle, another to the
teres major muscle, a branch to the infraspinatus muscle, a
cutaneous or superficial branch to the skin, and a main
terminal branch that enters the subscapularis muscle and
distributes in the periscapular arterial network. The
FLAP ANATOMY (Figs 40.1, 40.2, 40.3 and
see Figs 11.1, 11.3, 11.4)
ARTERIAL SUPPLY OF THE FLAP (Figs 40.1, 40.2,
40.3 and See Figs 11.1, 11.4)
The subscapular artery is a branch of the axillary artery. At
2–3 cm after its origin, it divides into the thoracodorsal
and circumflex scapular arteries. The circumflex scapular
artery reaches the lateral border of the scapula; at this
level it gives off a superficial cutaneous branch (the super­
ficial circumflex scapular artery), which passes toward the
subcutaneous tissue through a triangular space bounded
Figure 40.2  Anterior view of the right axilla of an anatomic specimen injected with colored latex. (A) The anterior lateral border of the latis­
simus dorsi muscle is retracted with a hook. The axillary artery, the subscapular artery, and its division into the circumflex scapular and the
thoracodorsal arteries are observed. (B) Same specimen, posterior view. The superficial circumflex scapular artery and its branches are observed
emerging from the triangular space. Part of the subcutaneous tissue has been removed around that space in order to show the anatomic
landmarks (teres minor and major muscles). (C) Anatomic specimen injected with blue latex through the subclavian artery. The superficial
circumflex scapular artery is observed.
A
B
C
Figure 40.3  (A) Anatomic specimen injected with green latex through the subclavian artery, posterior view. A skin and subcutaneous flap was
elevated from the midline toward the anterior axillary line. The parascapular artery and the muscle perforators of the thoracodorsal artery
through the latissimus dorsi are visualized in the subcutaneous tissue. The deep fascia is not included in the flap. (B) Same specimen: the
deep fascia and the medial part of the latissimus dorsi muscle are sectioned and elevated. The main trunk of the thoracodorsal artery is
observed.
A
B
A

434
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Numerous anatomic dissections in injected specimens
revealed that the horizontal and vertical branches are almost
equal in diameter, although there are variations in different
specimens.
The circumflex scapular artery can be dissected proxi­
mally to the level of the subscapular artery to extend the
pedicle length and diameter (10–12 cm and 4 mm).
However, this is usually not necessary and requires extensive
effort.
The skin and subcutaneous tissue is an organ that pro­
vides protection and sensation. As with any other organ in
the body, it has its own vascular anatomy, which is a regular
uniform flexible vascular network. This network is irrigated
by numerous arteries and drained by numerous veins that
reach this organ from the depth. Once they enter the integ­
ument organ (the skin and subcutaneous tissue) they
belong to, they are part of that uniform vascular network.
What we observe by anatomic dissection of integument vas­
cular pedicles is just a picture of the state of the vasculature
at a determined moment or the artifact that we produced
by the injection, which may have a similarity to the normal
vascular physiology. The vertical branch of the superficial
circumflex scapular (parascapular) forms a real vascular
arcade with the thoracodorsal perforator, while the hori­
zontal branch forms an arcade with the medial intercostals.
These arcades are consistent all over the body in the subcu­
taneous tissue. They are “choke” anastomoses. It is there­
fore difficult to pinpoint the exact length of certain vessels.
If we raise a 30 cm long flap irrigated by the parascapular
artery, it would be logical to think that the artery has that
length. However, it is overlapping with the anatomy of the
thoracodorsal perforator and the lower intercostals. Do we
assume that there is a simultaneous double arterial parallel
pathway? It is more logical to accept the vascular network
idea; in this case the vertical branch is part of that network.
The cutaneous artery is the superficial or cutaneous circum­
flex scapular and the vertical, horizontal, and ascending
arteries are arborizations of the former one. The superficial
circumflex scapular artery is one of the largest skin arteries
of the body.
SCAPULAR CUTANEOUS FLAP
Dominant:  horizontal branch of the superficial circum­
flex scapular artery
Length: 20 cm (range 10–24 cm)
Diameter: 1.2 mm (range 0.8–1.4 mm)
The superficial branch of the circumflex scapular artery
reaches the subcutaneous tissue at the level of the triangu­
lar space, which is approximately two-fifths of the distance
from the scapular spine to the scapular tip. At this point, it
arborizes into several branches. The main two branches
(considering their diameter) are the horizontal and the
vertical ones; there are also an ascending branch and two
or three lateral small branches to the shoulder area and
axilla.
The horizontal branch runs parallel to the superior
border of the latissimus dorsi muscle, 5–6 cm superiorly
approximately, above the deep fascia almost attached to the
fascia. In Figure 40.2, the injected anatomic specimen shows
the position of the horizontal and vertical branches.
branch to the subscapularis muscle and to the periscapular
arterial network should be considered the main trunk of
the circumflex scapular because it is always larger in diam­
eter than the other branches, including the cutaneous
branch.
The superficial branch emerges and arborizes in the sub­
cutaneous tissue of the back. There are two main branches
in that arborization, the horizontal and the vertical, that
distribute in the subcutaneous tissue of the back and anas­
tomose with neighboring cutaneous arteries such as the
perforators of the latissimus dorsi muscle, the perforators
of the intercostal arteries, etc. (Figs 40.1, 40.2). The super­
ficial circumflex scapular artery does not pierce any fascia
or septum while coursing through the areolar tissue of the
triangular space from its origin to the surface; however, it
does pierce the deep fascia with terminal small branches to
the muscles (infraspinatus, teres major, and latissimus
dorsi). Once it reaches the subcutaneous tissue, it distrib­
utes above the deep fascia of the back. The deep fascia
receives blood supply from the subcutaneous level via the
cutaneous branches.
The vascularization of the lateral aspect of the scapular
bone comes mainly from the main trunk of the circumflex
scapular artery and its descending branch. Although the
descending osseous branch supplies the lateral border
directly, the main trunk gives profuse blood supply to the
bone through its muscular branches.
The blood supply of the medial border of the scapular
bone primarily comes from the deep branch of the dorsal
scapular artery. The dorsal scapular artery is also known as
the deep branch of the posterior scapular artery or trans­
versa colli. There are interconnections between the dorsal
scapular artery end branches and the circumflex scapular
artery.
There is a branch of the thoracodorsal artery that sup­
plies the tip of the scapular bone, which can be elevated
independently with this pedicle. This branch is known as
the angular branch and travels deep to the latissimus dorsi
muscle within a fat pad lateral to the scapular bone. The
branch terminates at the dorsal surface of the angle of the
scapular bone.
As was mentioned above, there is a profuse vascular anas­
tomosis between the lateral and medial vessels around the
scapula; therefore, it is possible to perfuse different seg­
ments of the bone by any of these sources. However, it is
technically difficult to raise a medial bone flap supplied by
the circumflex scapular or, vice versa, a lateral border bone
flap supplied by the dorsal scapular, as it would be necessary
to disrupt the normal anatomy to a large degree.
Although the circumflex scapular artery most commonly
originates from the subscapular artery, it may originate
directly from the axillary artery (3% of the cases reported
by Rowsell et al.8). Upton et al. reported the variation of the
emergence of the descending branch; in some cases it
pierces into the subcutaneous tissue inferior to the teres
major muscle between this muscle and the superior border
of the latissimus dorsi muscle.9
To our knowledge, there is no “dominance” of either of
the two main cutaneous branches. The superficial branch
of the circumflex scapular artery truly bifurcates into the
horizontal and vertical branches. Clinical observation dem­
onstrates that equal flap length is supplied by these branches.

CHAPTER 40 — Scapular and Parascapular Flaps
435
The angular branch most commonly arises from the latis­
simus dorsi pedicle, but may also arise from the serratus
anterior pedicle, as a trifurcation with the latissimus dorsi
and serratus anterior pedicles, or proximal to the latissimus
dorsi and serratus anterior pedicles. The angular branch of
the thoracodorsal artery may be up to 7 cm long and is
about 2.5 mm in external diameter. The pedicle can be
extended up to 17 cm if the proximal thoracodorsal artery
and subscapular artery are included.
VENOUS DRAINAGE OF THE FLAP
SCAPULAR AND PARASCAPULAR (CUTANEOUS,
OSTEOCUTANEOUS, AND OSSEOUS) FLAPS
Paired venae comitantes are intimately associated with the
circumflex scapular and subscapular arteries and ultimately
drain into the axillary vein. The venous drainage of the back
has two main watersheds: the axillary region and the inter­
costal vein perforators, especially at the second, third, and
fifth intercostal spaces near the vertebral column where
large vein perforators accompany the cutaneous branches
of the intercostal arteries. The laterally oriented veins even­
tually drain into the axillary vein.
Primary:  venae comitantes of the horizontal and vertical
branches of the circumflex scapular artery
The horizontal and vertical branches drain into the cir­
cumflex scapular vein, then the subscapular vein, and then
the axillary vein.
Two venae comitantes are always present. In more than
250 cases we have never observed absence of the venae
comitantes. They may vary in diameter following the com­
pensatory law of Dubreuil Chambardell. If one is larger than
usual, the other is smaller.
Secondary:  the intercostal veins, especially in the superior
part of the thorax, have a large diameter.
There is a large perforator pedicle at the second intercos­
tal space near the midline, which can be used easily as an
arterial and venous donor vessel for a free flap.
SCAPULAR TIP BONE FLAP
The venous drainage of the flap parallels the arterial supply.
The angular branch of the thoracodorsal artery is accompa­
nied by paired vena comitantes.
FLAP INNERVATION
Sensory (see Figs 11.7, 11.9):  the third, fourth, and fifth
intercostal nerves through the lateral and posterior branches
supply this region.
There is no single nerve that innervates a large region
and it is therefore not used as a sensitized flap. When
used for face and neck reconstruction, the scapular flap
regains very good sensation without any special nerve
connection.
Motor:  there is no motor nerve involvement in these
procedures.
If muscles supplied by the same vascular pedicle are
included with the flap such as the latissimus (thoracodorsal
nerve), serratus (long thoracic nerve), or teres major (lower
subscapular nerve, a branch from the posterior cord of the
brachial plexus), the corresponding nerves would have to
be included with the harvest (Fig. 11.1).
The same pedicle irrigates the extended scapular flap.
The vertical ascending branch of the superficial scapular
artery irrigates the ascending scapular flap. The extended
circumflex scapular flap is irrigated by all the branches of
the superficial circumflex scapular artery.
Minor:  second and third intercostals medial perforator
It is possible to raise this flap in reverse medial form irri­
gated by these vessels.
Length: 10 cm (range 8–12 cm)
Diameter: 1.0 mm (range 0.8–1.2 mm)
The scapular flap horizontal design can be vascularized
from the medial side through the intercostal skin perforator
of the second space.
PARASCAPULAR CUTANEOUS FLAP
Dominant:  vertical branch of the superficial circumflex
scapular artery
Length: 20 cm (range 10–26 cm)
Diameter: 1.2 mm (range 0.8–1.4 mm)
The vertical branch of the superficial circumflex scapular
artery originates at the level of the triangular space. It
descends parallel to the lateral border of the latissimus dorsi
muscle, approximately 6–8 cm medially. A few centimeters
from its origin, it gives off an anterior branch, which is
directed toward the inframammary fold and the anterior
axillary line.
The anterior branch of the vertical branch of the super­
ficial circumflex scapular artery is the vascular base of the
inframammary extended circumflex scapular (IMECC)
flap.
SCAPULAR BONE FLAP
Dominant:  superficial circumflex scapular artery
Length: 20 cm (range 10–26 cm)
Diameter: 1.2 mm (range 0.8–1.4 mm)
The circumflex scapular artery gives off multiple branches
that supply the lateral border of the scapula before dividing
into horizontal and vertical branches, which supply the
scapular and parascapular cutaneous flaps. While an iden­
tifiable medullary artery is often not found, there are mul­
tiple small vessels that have been observed by dye injection
studies that clearly show vascularization of the scapular
bone. A medial scapular bone flap vascularized by the hori­
zontal branch of the superficial circumflex scapular artery
has been described, although the primary blood supply to
this region of bone is the dorsal scapular artery. The lateral
scapular bone flap is usually preferred over the medial scap­
ular bone flap due to its thicker bone stock and more ver­
satile pedicle blood supply, allowing for many combinations
of chimeric flaps.
SCAPULAR TIP BONE FLAP
Dominant:  angular branch of the thoracodorsal artery
Length: 7 cm (range 6–8 cm)
Diameter: 2.5 mm (range 1–3 mm)

436
PART 4 — CONVENTIONAL WORKHORSE FLAPS
this area is normally not involved by disease in the medium-
sized arteries.
FLAP DESIGN
FLAP MARKINGS (Fig. 40.4)
• Black: scapular flap
• Blue: ascending vertical flap
• Red: parascapular flap
• Green: IMECC flap
ANATOMIC LANDMARKS AND MARKINGS
(Fig. 40.4 and See Figs 11.4 and 11.7)
The angle between the superior border of the teres major
muscle and the lateral border of the scapula is palpated and
marked as it is the main landmark of this flap. This is the
point where the superficial circumflex scapular artery
emerges into the subcutaneous tissue.
A line drawn from that point parallel to the superior
border of the latissimus dorsi muscle indicates the direction
of the horizontal branch. When a horizontal (scapular) flap
is planned, the skin island is centered over this horizontal
line. The proximal end of the flap is located at the posterior
axillary line. The distal end is the midline; however, it may
be extended to reach the medial border of the contralateral
scapular bone.
With the arm adducted, the lateral border of the scapula
indicates the direction of the vertical parascapular branch.
The longitudinal axis of the flap follows this line. The proxi­
mal end of the flap is placed at the axillary crease. The distal
end reaches the 12th rib. The amount of laxity allows deter­
mination of the width that can be harvested to allow for
primary closure.
When an extended scapular flap is elevated, both branches
are included in the flap design.
The landmarks for the extended scapular flap design are
the spine of the scapular bone, the 12th rib, the lateral
border of the latissimus dorsi muscle, and the midline ver­
tebral spines.
The landmarks for the inframammary extended circum­
flex scapular (IMECC) flap are the triangular space and the
inframammary crease. These two points mark the longitu­
dinal axis of the flap, which has a more convenient direction
for closure. The flap can be safely raised up to the anterior
axillary line.
An L-shaped design or a combination of scapular and
parascapular flaps has been described by Koshima.7 This
combination of two independent skin areas provides a con­
venient tool in cases of large defects.
GENERAL THOUGHTS ABOUT FLAP DESIGN
As mentioned, there are several possibilities based on this
vascular pedicle: the scapular, parascapular, extended scap­
ular, IMECC, biscapular, and bilateral circumflex scapular
flaps. If a regular-sized free thin skin flap is required, the
parascapular or the IMECC (the anteriorly designed para­
scapular flap) are better choices than the scapular flap
FLAP COMPONENTS
The flap is a skin and subcutaneous flap that may include
bone (lateral border up to and including the tip, which can
be irrigated by the same pedicle), fascia (deep fascia, dorsal
thoracic fascia), and muscle (part of the latissimus dorsi,
teres minor or infraspinatus, etc.). Although raising the ser­
ratus and the rib with this pedicle is technically possible, it
requires including the latissimus pedicle plus the teres
major muscle, which has to be sectioned, plus the serratus
muscle, and is not of practical use.
ADVANTAGES
• These flaps are extremely reliable with a consistent vascu­
lar pedicle of good length and large caliber.
• It is one of the best options when a large skin and subcu­
taneous flap is needed.
• There is no functional morbidity at the donor site. There
is no impairment of shoulder motion at all. Some discom­
fort and minimal pain are present in the first week
postoperatively.
• Depending on the individual, this area may provide non–
hair-bearing skin.
• The color of the back skin may provide a better match
for head and neck reconstruction than the radial forearm
or thigh flaps.
• Two team approach can be used in cases of lower extrem­
ity reconstruction
DISADVANTAGES
• When large flaps are harvested (such as extended scapu­
lar), the donor area may not be closed directly and has
to be skin grafted. Therefore, aesthetic sequelae must be
considered. Pre-expansion of the donor site avoids this
inconvenience but adds a secondary operative procedure
as well as possible complications.
• The flap cannot be harvested with a single sensory nerve
for sensory reinnervation.
• The flap can only be harvested in the lateral decubitus or
prone position, making it inconvenient when anterior
defects are to be reconstructed.
PREOPERATIVE PREPARATION
No special studies are required prior to the operative
procedure.
Deep scars at the flap pedicle area are contraindications
to raising the flap. Superficial burns do not provide a con­
traindication to harvesting of these flaps even if the burn
reaches the deep dermis.
There is no special preparation required except for ade­
quately assessing the clinical condition of the patient and
providing medical management accordingly.
Age in itself does not provide a contraindication to har­
vesting these flaps as clinical cases have been reported for
patients ranging from 2 to 76 years old. There are no limita­
tions as far as the size of the patient is concerned, but it
must be borne in mind that obese patients have consider­
able thick back subcutaneous tissue. Patients with diabetes
or arteriosclerosis are candidates for this type of flap because

CHAPTER 40 — Scapular and Parascapular Flaps
437
is no need for modification of the skin design. The bone is
harvested from the lateral border once the skin island is
already elevated.
Muscle may be included in the flap. The teres minor
muscle, as well as a segment of the infraspinatus or the
subscapularis muscles, may be included with a vascular
pedicle, which originates from the main trunk of the cir­
cumflex scapular, independently from the skin island. The
latissimus dorsi and teres major muscles may be included in
two different ways:
1. Through their main pedicles: the latissimus dorsi needs
sectioning of the teres major to incorporate the trunk of
the inferior scapular artery and the two branches (cir­
cumflex scapular and thoracodorsal)
2. By raising a segment of the teres major or the latissimus
dorsi supplied by the muscle branches that originate
from the horizontal and the vertical cutaneous branches
of the circumflex scapular which runs from the surface
to the depth, perforating the fascia to reach the muscles
because they have less bulky tissue. The subcutaneous tissue
is thicker in the area of the horizontal branch. An elliptic
skin island measuring 15 × 8–10 cm can be closed directly
without difficulty.
Flap lengths are similar in both cases: the parascapular
flap may safely reach the 12th rib and the scapular flap may
be safely designed up to the medial border of the contralat­
eral scapula. The midline is not a limit for flap vasculariza­
tion. The extended scapular flap, for example, reaches the
contralateral side. One can raise a 30 cm long flap on the
horizontal branch; as it has a horizontal axis, one may pass
the midline without any problem. A delay procedure is a
possibility to increase or at least determine in advance where
the distal limit of the flap is.
When a long and large extended circumflex scapular flap
is designed (e.g., 26 × 18 cm), it is important to avoid includ­
ing axillary skin in the flap in order to avoid impairment in
joint motion.
When a combined skin and bone flap is harvested, the
skin island is independent of the bone and therefore there
Figure 40.4  Anatomic landmarks and markings. (After Standring et al., editors. Gray’s anatomy. 39th ed. Elsevier, Churchill Livingstone; 2005.)
1
2
3
4
5
7
6
1
2
3
4
1. External occipital protuberance
2. Trapezius
3. Inferior angle of scapula
4. Latissimus dorsi
5. Erector spine
6. Posterior superior iliac spine underlying sacral dimple
7. Rectal cleft
1. Median furrow
2. Lateral border of erector spine
3. Gluteus maximus
4. Gluteal fold
Black: scapular flap
Blue: ascending vertical flap
Red: parascapular
Green: IMECC flap

438
PART 4 — CONVENTIONAL WORKHORSE FLAPS
PARASCAPULAR FLAP
Skin Island Dimensions
Length: 26 cm (range 6–32 cm)
Width: 12 cm (range 8–16 cm), maximum to close primar­
ily: 10 cm
Thickness: 2 cm
The extended circumflex scapular flap measures 28–30 × 
18–20 cm.
BONE
Lateral Scapula Bone
Length: 10–14 cm (from the glenoid fossa to the scapula
tip)
Width: 2–3 cm
Thickness: 1.5–3 cm
Harvest of the bone requires division of the teres major
and minor muscle from their attachments to the scapula.
Medial Scapula Bone
Length: maximum up to 10–14 cm
Width: 2–3 cm
Thickness: 1–2 cm
Harvest of the medial bone of the scapula requires divi­
sion of the rhomboid muscle from its attachment.
The location of the bone segment in the distal aspect of
the flap allows for a greater arc of rotation and a longer
effective pedicle length.
This flap is thinner than the lateral bone but avoids the
need for detaching muscles involved in the rotator cuff of
the shoulder. However, its major blood supply is the dorsal
scapular artery with minor contributions from the circum­
flex scapular artery.
SCAPULAR TIP (ANGLE OF SCAPULA)
Length: maximum up to 20 cm (approximately 10 cm of
medial and lateral bone)
Width: 2–3 cm
Thickness: 1–2 cm
Both medial and lateral bone extending from the inferior
tip of the scapula may be included. If so, the rhomboid
major muscle, the teres major muscle, and possibly the teres
minor muscle if a lengthy amount of lateral scapular bone
is included with the flap, may be detached from the scapular
during flap harvest and should be reattached to the remain­
ing scapula.
PATIENT POSITIONING
The patient is placed in a lateral decubitus position with the
side to be harvested away from the table. The arm is pre­
pared in the operative field and positioned in a way to allow
for full range of motion. The prone position is not a good
option because the dissection of the proximal part of the
pedicle becomes difficult. When the flap is raised as a local
There is no need to include the deep fascia in this flap
as in other flaps in the body. The dorsal thoracic fascia is
irrigated from above and from below by different sources.
The fascia is the deep limit of vascularization: it does not
carry vessels. A segment of thoracic fascia can be harvested
as a vascularized tissue supplied by the fascial branches of
the superficial (or cutaneous) branch of the circumflex
scapular artery.
SPECIAL CONSIDERATIONS
The parascapular flap design almost completely overlaps an
oblique design of the latissimus dorsi musculocutaneous
flap or the thoracodorsal perforator flap. The surgeon can
select the more suitable vascular pedicle according to the
clinical situation. The same area can actually be nourished
through the intercostal perforators. It is possible to design
the flap with the longitudinal axis oriented in an ascending
direction. This maneuver is useful in cases where the back
skin is involved in burn sequelae and the flap is indicated
for local use as axillary scar release.
The horizontally oriented scapular flap can be vascular­
ized from the medial side through the intercostal skin
perforator of the second space. The extended scapular
flap is the horizontal design lengthened across the
midline.
The extended circumflex scapular flap is raised from the
whole hemi-back; it is irrigated by all the branches of the
superficial circumflex scapular artery.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
When the flap is raised for local or regional use, there is no
need to extend the dissection beyond the triangular space.
As a pedicled flap, the design is often a peninsular rather
than an island flap. As a free flap, it is always designed as an
island flap. The design for the free flap sometimes neces­
sitates an extension of the incision anteriorly in order to
extend the pedicle length through the triangular space or
even anteriorly to trace the pedicle up to the subscapular
artery.
FLAP DIMENSIONS
SCAPULAR FLAP
Skin Island Dimensions
Length: 18–20 cm (range 6–30 cm), maximum to close pri­
marily: 8–9 cm
Width: 7–8 cm (range 4–16 cm), maximum to close primar­
ily: 8 cm
Thickness: 2 cm (range 1.5–3 cm)
The flap can be thinned to the level of the superficial
fascia, resulting in a thickness of 8 mm or 9 mm.
It is usually possible to close directly a horizontal flap
8 cm wide, a vertical flap 10 cm wide, and an IMECC flap
12 cm wide.

CHAPTER 40 — Scapular and Parascapular Flaps
439
discomfort. This method of anesthesia can be performed in
adults only. Bony or osteocutaneous flaps are always har­
vested under general anesthesia.
TECHNIQUE OF FLAP HARVEST (Fig. 40.5)
The area of skin incision is infiltrated with Xylocaine 2%
with epinephrine or any other vasopressor agent. Plain
normal saline solution is infiltrated under the flap just above
the deep fascia. Precise dermis injection must be done when
the procedure is performed under local anesthesia. Other­
wise the technique is almost the same. The flap is elevated
from distal to proximal, considering the vascular pedicle.
The skin is incised inferior to the pedicle location.
Dissection is performed above the deep fascia (without
including the fascia) in the subcutaneous plane under optic
magnification (×2–4). Care must be taken when the teres
major muscle is reached as the vascular pedicle appears
immediately superior to the superior border of this muscle.
Once the vessels are exposed, the superior skin incision is
completed. Then, dissection proceeds from superior to infe­
rior; the teres minor muscle is exposed and the vessel is
observed at the inferior border of this muscle.
If the flap is used as a pedicled flap, there is no need for
further dissection. If a free flap is harvested, it is convenient
to continue the dissection inside the quadrangular space in
order to obtain major vessel length and larger vessel diam­
eter. Several small branches must be coagulated and sec­
tioned: the muscular branch to the teres minor muscle, two
flap the patient can be placed in the prone or lateral posi­
tion. However, if the surgeon needs to go deep in the trian­
gular space for pedicle lengthening or because the flap is
being raised as a free flap, it is much better in the lateral
decubitus with the arm free and held by an assistant. It is
best to stretch the arm and dissect free the several branches
to the scapular bone and then ligate and section. The
surgeon can easily approach the main trunk of the circum­
flex scapular, which is preferred for a safe anastomosis. It is
rare to raise a free scapular flap in any of its variations in a
prone position.
ANESTHETIC CONSIDERATIONS
The flap is usually harvested under general anesthesia. This
is the preferred method but it can be harvested under seda­
tion plus local anesthesia, especially when general anesthe­
sia is risky for a particular patient’s medical condition.
Local anesthesia plus neuroleptanalgesia (administration
of a narcotic and a major tranquilizer [neuroleptic], pro­
ducing a state of calmness and indifference without loss of
consciousness) is frequently utilized when the flap is locally
transferred as an island pedicle (i.e., axillary coverage).
The cutaneous flap can be raised under local anesthesia
with sedation using Dormicum (midazolam). An amount of
30 cc Xylocaine (lidocaine) 2% with epinephrine is injected
into the dermis where the skin incision will be placed. The
skin is incised 15 min later. An extra dose of 1/10 cc is
injected into the cutaneous nerves once they are exposed
during dissection. Pedicle dissection does not produce
Figure 40.5  Operative technique. (A) The patient is positioned in the right lateral decubitus position. The left extended scapular flap is elevated.
The skin has been incised down to subcutaneous tissue. (B) The flap is elevated from distal to proximal above the deep fascia. (C) Above the
deep fascia the vascular pedicle is clearly observed at the superior border of the teres major muscle. (D) The vascular pedicle is approached
from the superior part of the flap in the same suprafascial plane. (E) The flap is completely elevated up to the level of the quadrangular space
to be used as an island. (F) Dissection is performed inside the quadrangular space to increase pedicle length. The retractors are placed at the
scapular bone and at the teres major muscle.
A
B
C
D
E
F
C

440
PART 4 — CONVENTIONAL WORKHORSE FLAPS
structed, a cutaneous island may be included as de­scribed
above. The circumflex scapular vessels are exposed as
they exit the triangular space. Careful dissection into the
triangular space exposes a number of small muscular and
musculoperiosteal branches that enter the musculature
originating and inserting on the lateral border of the
scapula. These branches are cautiously preserved. The de­
sired segment of bone is palpated and outlined along the
lateral border of the scapula harvesting as much as 3 cm in
width and 12 cm in length. The infraspinatus muscle can be
retracted laterally to better expose this area. The incision is
then carried down to the bone, dividing muscle fibers of the
teres minor superiorly and teres major inferiorly as well as
the underlying periosteum along the desired outline. Oste­
otomies are then performed along this outline using an
oscillating or reciprocating saw. Elevation of the scapula by
the tip will facilitate the osteotomies. The cephalad osteot­
omy should be located at least 2 cm below the shoulder joint
capsule to avoid inadvertent entry and injury to the joint.
The bone segment can then be retracted laterally exposing
the underlying fibers of the subscapularis muscle, which are
then divided, leaving a thin stippling of muscle on the bone
to avoid damage to the periosteal blood supply. The vascular
dissection continues proximally until the desired length of
vascular pedicle is achieved.
MEDIAL SCAPULA BONE FLAP
The medial bone may also be harvested, although it is tech­
nically more difficult and generally a second choice to the
lateral scapular bone. A scapular skin flap is outlined, as
previously described, and the lateral incisions are made.
The medial portion of the flap, overlying the medial scapula
border is left attached. The pedicle dissection proceeds as
previously described. The medial or distal portion of the
flap remains attached by its fascial and muscular attach­
ments to the medial scapula, which can be exposed by incis­
ing the skin island inferior and superior to this area. The
desired bone segment is outlined around these attachments.
As much as 3 cm in width and 12 cm in length can be har­
vested between the scapula spine and the tip. The medial
edge of the bone is palpated and identified by detaching
the rhomboid muscle. By lifting the scapula off the chest
wall, the serratus anterior muscle is also divided along the
medial border of the bone. A tunnel is then created between
the infraspinatus muscle and the scapula, 3–4 cm lateral
to the attachment of the flap to the medial edge of the
scapula. The muscle is then incised along this line, exposing
the scapula periosteum below. Osteotomies are performed
with an oscillating or reciprocating saw, and attachments of
the rhomboid major, the subscapularis and serratus anterior
muscles are divided leaving only a thin stippling of muscle
on the bone and thereby freeing the bone from its bed.
Alternately, the deep branch of the dorsal scapular artery
supplies the medial scapular bone and can be used as its
pedicle blood supply.
SCAPULAR TIP BONE FLAP BASED ON THE ANGULAR
ARTERY (Fig. 40.6)
Exposure can be obtained through parascapular cutaneous
free flap or the latissimus dorsi muscle or myocutaneous
free flap harvest incisions. If only a scapular osseous free
flap is indicated to reconstruct a given defect, then an
to three branches to the lateral border of the scapular bone,
and the main trunk of the circumflex scapular artery at the
site where it courses underneath the scapula.
Dissection is continued up to the origin of the thora­
codorsal artery. There is no major gain in length by continu­
ing the dissection up to the axillary artery as the subscapular
artery is a short vessel. However, it may be convenient to
incorporate the subscapular artery in the flap when a larger
flap vessel is indicated for better matching with a deter­
mined recipient vessel.
Dissection is performed above the deep fascia, which is
never incised or sectioned. Once the pedicle is clearly
observed emerging from the triangular space just superior
to the superior border of the teres major, dissection contin­
ues into that space in the middle of the areolar tissue.
As a general rule, we favor identifying the vascular pedicle
to the flap before proceeding with the majority of dissection
of the flap.
FLAP MODIFICATION/FLAP HANDLING
THINNED SCAPULAR OR PARASCAPULAR FLAP
The flap may be thinned during initial harvest by dissecting
below the superficial fascia, discarding the fat deep to this
fascia. We do not perform this technique normally as it may
impair vascularization.
DELAYED FLAP
Flap delay is very useful when extremely large flaps are uti­
lized and it is necessary to be sure about complete viability
of the tissue. For example, when a complete face is to be
resurfaced, it is a good idea to prove complete flap survival
prior to flap transfer. In this case, the flap is delayed and
transferred after 48–72 h, not to increase flap survival length
but to ensure that no tissue ischemia will be observed after
transference.
TISSUE EXPANDED FLAP
The flap may be pre-expanded for better and easier donor
site closure. Two 400–500 cc rectangular expanders are
placed in the lateral thoracic wall and the medial part of the
back longitudinally, leaving the area to be raised untouched
so the normal anatomy of the vascular pedicle, especially
near the triangular space, is not disrupted. The expansion
is done for closure of the donor area. The flap is not
expanded.
OSTEOCUTANEOUS FLAPS (see Case 40.1)
It is possible to include vascularized scapula bone based on
the osseous branches of the circumflex scapular artery.
Alternately, the bone of the scapular tip extending medially,
laterally, or both can be harvested as a bone flap based on
the angular branch of the thoracodorsal artery.
LATERAL SCAPULAR BONE FLAP
The patient is positioned and prepared as outlined in the
previous sections. Depending on the defect to be recon­

CHAPTER 40 — Scapular and Parascapular Flaps
441
FASCIAL FLAP
The incision is made in a horizontal fashion over the
marking of the vascular pedicle to be included (horizontal
or vertical branch). The incision is carried below the dermal
plexus and skin flaps are elevated to expose the area of the
flap. The design of the flap is similar to that described for
the skin flaps; however, a larger territory may be included
without regard to closure of the donor site. The flap cannot
be harvested as a true fascia flap since the vessels course
above the fascia and in the subcutaneous tissue.
The fascia can have blood supply through two different
sources. One is to have the fascia supplied from below and
that would happen through perfusion from one or more of
the thoracodorsal artery perforators, or the fascia can be
supplied from above through cutaneous branches of the
circumflex scapular. In the latter case the biscapular flap is
performed and the subcutaneous tissue is incorporated to
secure adequate vascularity. This is a delicate procedure in
order to preserve skin vascularization. It is questionable
whether the so-called “dorsal thoracic fascia,” which is ele­
vated as a flap for volume increase in defects such as hemi-
facial microsomia, is really harvested as a fascia flap or
whether the abundant subcutaneous tissue of that part of
the body, especially in the lateral thoracic wall, is what the
flap is really composed of.
DONOR SITE CLOSURE
AND MANAGEMENT
Narrow flaps (<10 cm) are closed directly. Large flaps,
which are commonly used for neck or face reconstruction,
cannot be closed directly. An initial edge wound approxima­
tion is done. No attempt to close directly is undertaken
because impairment of thoracic expansion may be pro­
duced. Often, a 4–5 cm wide gap remains; we no longer skin
graft this gap. Secondary closure eventually occurs. The
unaesthetic final scar is revised 6 months later.
For scapular bone and osteocutaneous flaps, muscles that
attach to the scapular bone are reattached to the scapular
remnant when divided, either through drill holes or a sturdy
needle can often pierce the thin central bone of the scapula
without the need for a drill. These muscles include the
rhomboid major muscle medially and the teres major and
teres minor muscles laterally. Close suction drains are used.
We do not immobilize the shoulder. Within several days,
following surgery, range of motion exercises are started as
long as the wound closure is intact and healing well. Range
of motion is generally regained in a month. For poorly
compliant patients, a formal consultation with a physical
therapist is indicated.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• During flap harvesting, we believe it is convenient to
maintain dissection superficial to the deep fascia for
easier and faster operative procedure.
• Once the triangular space is approached, the assistant
mobilizes the arm to 90–100° abduction, neutral rotation,
incision over the lateral border of the scapula should be
made. The angular branch pedicle originates from thora­
codorsal vessels, and is identified by retracting the latissimus
dorsi muscle laterally and inferiorly. The angular branch lies
within the fat pad beneath the latissimus dorsi and roughly
parallels the lateral border of the scapula. The teres major
muscle is partially released from the lateral border of the
scapula and the rhomboid major muscle is partially released
from the medial border of the scapula. The infraspinatus
muscle is also partially elevated from the superficial surface
of the scapula just enough to expose the amount of bone
needed. On completion of osteotomies, the underlying
fibers of the subscapularis muscle are divided.
CHIMERIC FLAP
The term “chimeric flap” indicates inclusion of other flaps
and flap components based on the subscapular axis or one
of its branches. Chimeric flaps based on the subscapular axis
may include some combination of the following flaps: scapu­
lar cutaneous, parascapular cutaneous, scapular bone, based
on the circumflex scapular artery and/or the angular
branch of the thoracodorsal, latissimus dorsi muscle/
myocutaneous, thoracodorsal artery perforator cutaneous,
serratus anterior muscle. Using a chimeric free flap, complex
defects requiring coverage of multiple surfaces or many
tissue types can be reconstructed while only requiring one
set of arterial and venous anastomoses to recipient blood
vessels. If the latissimus dorsi muscle is included with the
flap, the teres muscle must be disinserted in order to widen
the triangular space enough to pass the latissimus dorsi
muscle through. The serratus anterior muscle may carry
the 6th rib, and the latissimus dorsi muscle may carry the
9th rib.
Figure 40.6  Exposure of the angular branch of the thoracodorsal
artery and vein beneath the medial border of the latissimus dorsi. The
angular branch can be seen entering the angle or tip of the right
scapular bone.

442
PART 4 — CONVENTIONAL WORKHORSE FLAPS
HEAD AND NECK
The cutaneous scapular or parascapular flap is indicated for
face and neck skin reconstruction. The bone or osteocuta­
neous flap is used for mandibular reconstruction and
maxilla reconstruction.
TRUNK
Anterior thoracic wall, breast reconstruction.
UPPER EXTREMITY
Shoulder and axilla reconstruction, often as a pedicled flap.
An osteocutaneous free flap or osteomyocutaneous chime­
ric free flap can be used for composite bone and skin
defects.
LOWER EXTREMITY
Complete anterior leg or whole ankle skin resurfacing.
An osteocutaneous free flap or osteomyocutaneous chime­
ric free flap can be used for composite bone and skin
defects.
TYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
The most frequent and typical indication for a scapular
and/or parascapular flap for local or regional use is axillary
coverage. As a free flap, they are indicated for skin defect
reconstruction in limbs, face, and neck. Extended scapular
flaps have been used for reconstruction of the anterior neck
aesthetic unit and cheek aesthetic unit reconstruction
(especially in males). De-epithelialized parascapular flaps
are used for volume reconstruction of the face in cases of
hemi-facial atrophy or microsomia.
This flap is clearly indicated when a large and long
uniform texture thin flap is necessary, such as when the
anterior neck aesthetic unit is resurfaced, the complete
ankle region must be resurfaced or the anterior leg with no
involvement of the tibial bone. In these cases a thin flap is
necessary without muscle and ideally with uniform texture,
especially in the face and neck. It is also indicated for
resurfacing the extensor part of the elbow and the whole
functional unit of the popliteal fossa. It is favored in the
face and neck because of the reasonable color match and
relative hairlessness in most patients compared with flaps
harvested from the thigh or abdomen. Although flap
quality is excellent for upper limb reconstruction, it is not
frequently used when it is necessary to change patient posi­
tion during the operative procedure. Other flaps such as
the anterolateral thigh or deep inferior epigastric artery
perforator flap have the same qualities and avoid this
inconvenience.
The scapular bone or osteocutaneous free flap is most
commonly used for mandibular or maxillary reconstruction.
The lateral scapular bone, supplied by the descending
branch of the circumflex scapular artery, is typically used
for lateral or hemi-mandibular reconstructions and can
tolerate osteotomies. Occasionally, the bone of the scapu­
lar tip, supplied by the angular branch of the thora­
codorsal artery, is utilized for anterior mandibular or
maxillary reconstruction. In this case, the bone is oriented
pulling the arm softly. This maneuver highly facilitates the
dissection as it separates the scapula from the rib cage.
The muscle and bone arterial and venous branches are
ligated with metal clips and then sectioned.
• The vascular pedicle runs in the triangular spaces sur­
rounded by an areolar tissue; it consistently gives off
branches to the teres major and teres minor muscles,
which must be carefully dissected and ligated.
• An anomaly in the arterial system has been described
where the emergence point of the parascapular artery
may appear in the subcutaneous between the teres major
and the superior border of the latissimus dorsi muscle.
Care must be taken during flap dissection when reach­
ing this point. If this anomaly is present, the teres major
muscle must be sectioned and the pedicle passed
through.
• Care is taken during the lateral decubitus position
to avoid potential ulcerations, brachial plexus problems,
etc.
• Include lateral skin beyond the triangular space in order
to cover the pedicle during the inset. It is possible to
expose the vascular pedicle initially but it is not necessary
to do so. It is more practical, easier, and faster to raise the
flap from distal to proximal. It might be indicated when
small flaps are raised, especially very narrow ones, since
it is mandatory to include the vessel. That is not the case
when a conventional large extended flap is raised, when
it is impossible to miss the vascular pedicle.
• Care is taken when the dissection is performed from
lateral to medial to avoid injury to the skin vessel at the
point where it emerges from the triangular space. At the
lateral border of the scapula extra care is taken.
• When a free flap is performed, only one comitant vein is
anastomosed since it provides adequate drainage and
expedites the procedure.
• When deciding whether to thin the flap in the primary
setting, we have considered the fact that for most recon­
structions, particularly of the head and neck region, there
is often a need to do secondary procedures to obtain
good aesthetic results. Therefore, there is no need to thin
the flap initially as you may jeopardize flap perfusion.
Even minimal distal flap ischemia and potentially necrosis
will impair the final aesthetic result, so it is better to place
the flap without touching the subcutaneous tissue and
proceed later with thinning and molding.
FLAP USAGE
PEDICLED
The island flap is indicated for axillary and shoulder recon­
struction. The arc of rotation of the island flap can be
extended by sectioning the teres major muscle so the flap
can be passed anteriorly toward the anterior thoracic wall
and breast areas.
FREE FLAP
This is an extremely reliable flap that can be used as a free
tissue transfer when a large flap is necessary. The extended
scapular flap is one of the largest flaps available.

CHAPTER 40 — Scapular and Parascapular Flaps
443
any restriction or limit in shoulder motion. For bone or
osteocutaneous flap harvest, range of motion exercises are
started within several days of surgery as long as the wound
is intact and healing well. We do not immobilize the shoul­
der, even after bony excision. In both cases, full shoulder
function is normally regained in 1 month.
There is no rehabilitation program for donor site recov­
ery, except for uncooperative patients who need physical
therapy to avoid joint stiffness. In cases with large flaps
where primary donor site closure is not possible, a non-
adherent dressing is applied at the donor site. This dressing
is changed twice a week until secondary healing eventually
occurs.
OUTCOMES
EXPECTED OUTCOMES
GENERAL
The scapular cutaneous flap provides an excellent quality
of tissue coverage for resurfacing of aesthetic units of
the face and neck. It is also a very good choice for resur­
facing large superficial defects of the leg and knee joint
areas.
UNTOWARD OUTCOMES
Extended scapular flap loss is a real problem because a large
area remains uncovered. If there is any doubt about flap
viability, it is preferable to inset the flap without resecting
any scar or healthy tissue. The scar is opened and the flap
is secured. A few days later, once complete survival is
ensured, the flap is placed on the aesthetic unit.
Distal flap tissue loss must not be corrected by immediate
advancement of the healthy flap tissue as further tissue
ischemia may ensue. Initial conservative treatment and
eventually a secondary flap closure are advised.
DONOR SITE
The donor site is easily closed when narrow flaps are ele­
vated and the final result is an acceptable linear scar. The
donor site for large flaps when allowed to heal secondarily
presents a noticeable aesthetic defect, which can be amelio­
rated through revision procedures. Pre-expansion of the
donor site produces a better aesthetic result. When the bone
is harvested, range of motion exercises are important to
maintain shoulder mobility.
LONG-TERM OUTCOMES
Long-term patient evaluations in cases of anterior neck skin
reconstruction in children have revealed that the flap
accompanied the child’s growth. In all the cases sensory
recovery of the flap was observed after 2 years. No flap
innervation was performed in any case.
DONOR SITE
The donor area will relax with time and secondary comple­
mentary procedures allow narrowing of the skin-grafted
area and even complete resection of the skin graft with
direct closure in most cases.
transversely, so that the natural curvature of the scapular tip
or angle mimics the curvature of the anterior mandible or
maxilla. The scapular bone and osteocutaneous free flaps
are generally considered secondary choices compared to
the fibula or deep circumflex iliac artery (iliac crest) free
flaps because a two-team approach to head and neck tumor
resection and reconstruction is usually not feasible, a posi­
tion change is usually necessary, and the thickness of the
bone is often inadequate (though not always so) for stable
osseointegrated implant placement.
Scapular bone and osteocutaneous free flaps as well as
scapular bone and latissimus dorsi muscle chimeric free
flaps can also be used for composite bone and skin coverage
extremity defects, such as composite wounds of the ulna or
radius or to buttress bone fixation or allograft long bone
reconstruction. Such flaps may be appealing because they
offer a large skin paddle or muscle component, if the latis­
simus dorsi muscle is included as part of a chimeric free
flap.
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
CRANIAL RECONSTRUCTION
The thin, flat bone of the scapula can be used to recon­
struct calvarial defects. An advantage of using the scapular
bone is that the scapular skin or latissimus dorsi muscle
flap (covered with a skin graft) is easily combined with it
for composite calvarial and scalp reconstruction. Cranial
defects can require the use of vein grafts, or using the
angular branch of thoracodorsal vessel can extend the
pedicle.
POSTOPERATIVE CARE
GENERAL
Direct observation every 2 h during the first 48 h is neces­
sary for free flap monitoring.
Although no special hospital facilities are necessary, good
nursing care is mandatory. For most cases, the length of
hospital stay is 5 days. Analgesics are given in the postopera­
tive period but no other medication.
RECIPIENT SITE
A plaster splint is applied for limb reconstruction. Dressings
are usually unnecessary for cases of neck and face recon­
struction. Around the 30th postoperative day, a foam pad
held in place by a neck brace can be used to put low-grade
pressure on the flap. This procedure will mold the flap in
a few weeks. Once the initial edema disappears, comple­
mentary thinning procedures can be undertaken.
DONOR SITE
There are no special recommendations for the donor area
after skin flap harvest and any treatment may be instituted.
A period of 3–4 weeks is usually necessary for complete
healing of the donor incision. There is no indication for

444
PART 4 — CONVENTIONAL WORKHORSE FLAPS
CONCLUSIONS
The circumflex scapular artery irrigates a wide and long
area of skin and subcutaneous tissue. It also directly supplies
the lateral and medial scapular bone via its descending and
transverse branches, respectively. This pedicle is consistently
present and has good length and good vessel diameter for
anastomosis. Based on this artery, osteocutaneous flaps as
well as chimeric skin and bone flaps can be designed. The
various flaps that can be harvested through this pedicle are
extremely reliable and provide good-quality skin that is con­
sidered by many as first choice for reconstruction of neck
and cheek aesthetic units. Additionally, the angular branch
of the thoracodorsal artery supplies the angle or tip of the
scapular bone and can serve as a separate flap, or combined
with flap(s) supplied by the circumflex scapular artery as a
chimeric flap based on the subscapular arterial axis.
Commentary
Scapular and Parascapular Flaps
Geoffrey G. Hallock, MD
The scapular and parascapular flaps should be an essential part
of the repertoire of all reconstructive surgeons, as these are
“workhorse” flaps if a large cutaneous flap is demanded. In
reality, little needs be added to this comprehensive description
by the incomparable anatomist Dr. Angrigiani regarding these
important flaps. Over their long history they have been described
as fasciocutaneous flaps (since often including the dorsal tho­
racic fascia), septocutaneous flaps (as the cutaneous branch of
the circumflex scapular travels in the septum between the teres
major and minor), and perforator flaps (based on a septocuta­
neous perforator of the dorsal thoracic fascia). They can be
combined with bone (scapula, rib) or muscle (latissimus dorsi,
serratus anterior, teres major or minor) via intrinsic branches of
the circumflex scapular or an extension of the subscapular axis
to form conjoint and/or chimeric flaps. Caution must be
observed if this option is considered though as, not infre­
quently, the anatomy may be unfavorable if the circumflex
scapular originates from the axillary vessels directly, which may
require an additional intraflap microanastomosis.
The scapular and parascapular flaps are quite reliable as
the existence and location of its vascular pedicle is extremely
consistent. Since the parascapular territory overlies that of
the thoracodorsal artery perforator flap, and the latter per­
forators often are found to be inconsistent in size and loca­
tion, many would first consider using a parascapular flap for
no other reason than it is a simpler flap harvest. Just as with
the so-called “true” perforator flaps, there is no functional
donor site morbidity as muscle need never be dissected. The
vascular pedicle is always of reasonable length if used as a
free flap and caliber (sometimes it is even too large). The
approach to the cutaneous branch of this vascular pedicle
may be easiest by elevating the flap from medial to lateral
rapidly until the lateral border of the scapula is reached. More
lateral dissection, while visualizing the septum between the
teres major and minor, will then safely lead to the pedicle
(which does not always enter the triangular space at a specific
location).
As with any flap donor site, there are drawbacks that must
be considered. The author is correct in that too wide a flap will
require an aesthetically unacceptable skin graft that can, in the
long term, be unstable, especially if near the scapula itself.
Since the prone or lateral position will be required for donor
site access, many anterior recipient sites may not be reached
without a time-consuming change in the patient’s position. If
similar alternatives are needed, the anterolateral thigh flap may
be a more “ideal” choice, and for many today has altogether
supplanted use of the back as a donor site.

CHAPTER 40 — Scapular and Parascapular Flaps
445
4. Salmon M. Les artères de la peau. Paris: Masson; 1936.
5. Tansini I. Nuovo processo per l’amputazione della mammella per
cancro. Riforma Med 1896;1:3.
6. Tansini I. Sopra il mio nuevo processo di amputazione della mam­
mella. Gazz Med Ital 1906.
7. Koshima I, Soeda S. Repair of a wide defect of the lower leg
with combined scapular and parascapular flap. Br J Plast Surg
1985;38:518.
8. Rowsell AR, Davies DM, Eisenberg N, et al. The anatomy of the
subscapular-thoracodorsal arterial system: study of 100 cadaver dis­
sections. Br J Plast Surg 1984;37(4):574.
9. Upton J, Albin RE, Mulliken JB, et al. The use of scapular and para­
scapular flaps for cheek reconstruction. Plast Reconstr Surg 1992;
90:959.
Access Figures 40.8, 40.9 and 40.10, as well as
case examples 40.2, 40.3 and 40.4 and further
reading online at
.inkling.com
REFERENCES
1. Manchot C. Die Hautarterien des menschlichen Körpers. [The cuta­
neous arteries of the human body]. Leipzig: FCW Volgel; 1889.
2. dos Santos LF. Retalho escapular: um novo retalho livre microcirur­
gico. [The scapula flap: a new microsurgical free flap]. Rev Bras Cir
1980;70:133.
3. Nassif TM, Vidal L, Bovet JL, et al. The parascapular flap: a new
cutaneous microsurgical free flap. Plast Reconstr Surg 1982;69:591.
Figure 40.7  (A) Mandibular defect following cancer resection. (B,C) Parascapular cutaneous and scapular bone chimeric flap dissection
and harvest. (D) Flap inset and microvascular anastomosis to right neck vessels. (E,F) Postoperative photographs.
A
B
C
D
E
F
A patient with a floor of mouth squamous cell carcinoma and
severe peripheral vascular disease underwent a segmental man-
dibulectomy involving removal of her mandible from mid-body
to mid-body. A chimeric flap including the parascapular cutane-
ous flap, supplied by the circumflex scapular artery, and a scapu-
lar tip flap, supplied by the angular branch of the thoracodorsal
artery, was harvested and used for floor of mouth and anterior
mandible reconstruction.
CASE 40.1  Mandibular Reconstruction with a Scapular Bone and Parascapular Cutaneous
Chimeric Free Flap

CHAPTER 40 — Scapular and Parascapular Flaps 445.e1
Figure 40.8  (A) Leg defect. (B) Flap design. (C) Flap harvested. (D) Flap inset.
A
B
C
D
C
A large cutaneous defect of the leg in a 17-year-old patient.
Unstable scar and repetitive skin breakage and ulcers, treated
with complete scar removal and extended parascapular flap
anastomosed in an end-to-side fashion to the popliteal artery and
vein.
CASE 40.2  Large Leg Soft Tissue Defect Reconstructed with an Extended Free
Parascapular Flap

445.e2 PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 40.9  Cutaneous defect at the ankle region caused by burn sequelae. (A) Preoperative. (B–E) Postoperative.
A
D
E
B
C
Burn sequelae at the ankle region with ulceration. The scar and
the ulcer are removed and the skin defect is reconstructed with
an extended scapular flap that surrounds 90% of the circumfer-
ence of the ankle.
CASE 40.3  Ankle Soft Tissue Defect Reconstructed with an Extended Scapular Flap

CHAPTER 40 — Scapular and Parascapular Flaps 445.e3
Figure 40.10  Anterior neck burn sequelae previously skin grafted. (A,B) Preoperative photographs. (C–F) Postoperative photographs.
A
D
E
F
B
C
Anterior neck burn sequelae treated with complete scar resec-
tion and an extended scapular flap coverage in a 27-year-
old woman. Soft tissue transection at the level of the hyoid
bone and extended scapular flap placed at the level of hair
growth was performed. Interrupted nonabsorbable 4-0 nylon
stitches were placed between the flap and the hyoid area to
immediately re-create the cervico-mental angle. An end-to-end
anastomosis to the facial artery and vein (preferred recipient
vessels) was performed.
Three complementary open defatting procedures (liposuc-
tion was not indicated) were performed at 1-month intervals,
starting 3 months after the initial flap transference. Suction
drainage was applied for 2 days after each of these complemen-
tary procedures.
CASE 40.4  Neck Contracture Release Resulting in a Defect Reconstructed with an
Extended Scapular Flap

445.e4 PART 4 — CONVENTIONAL WORKHORSE FLAPS
FURTHER READING
Angrigiani C. Aesthetic microsurgical reconstruction of anterior neck
burn deformities. Plast Reconstr Surg 1994;507:93.
Angrigiani C, Cabrera VN, Otero AC. Colgajo escapular ampliado con
microcirugía para las reconstrucciones de las sinequias mentotoraci­
cas postquemadura. [Extended scapular flap for anterior neck burn
sequelae reconstruction]. La Prensa Médica Argentina 1990;77:52.
Angrigiani C, Grilli D. Total face reconstruction with one free flap. Plast
Reconstr Surg 1997;99:1566.
Batchelor AG, Bardsley AF. The bi-scapular flap. Br J Plast Surg
1987;40:510.
Gilbert A, Teot L. The free scapula flap. Plast Reconstr Surg 1982;69:601.
Hallock GG, Okunski WJ. The parascapular fasciocutaneous flap for
release of axillary burn contracture. J Burn Care Rehab 1987;8:387.
Hamilton S, Morrison WA. The scapular free flap. Br J Plast Surg
1982;35:2.
Hanasono MM, Skoracki RJ. The scapular tip osseous free flap as an
alternative for anterior mandibular reconstruction. Plast Reconstr
Surg 2010;125(4):164e.
Hasan Z, Gore SM, Ch’ng S, et al. Options for configuring the scapular
free flap in maxillary, mandibular, and calvarial reconstruction. Plast
Reconstr Surg 2013;132(3):645.
Hwang JH, Hwang K, Bang SI, et al. Reliability of vascular territory
for a circumflex scapular artery-based flap. Plast Reconstr Surg
2009;123(3):902.
Maruyama Y. Ascending scapular flap and its use for the treatment of
axillary burn scar contracture. Br J Plast Surg 1991;44:97.
Nkenke E, Vairaktaris E, Stelzle F, et al. Osteocutaneous free flap
including medial and lateral scapular crests: technical aspects, viabil­
ity, and donor site morbidity. J Reconstr Microsurg 2009;25(9):545.
Sabino J, Franklin B, Patel K, et al. Revisiting the scapular flap: applica­
tions in extremity coverage for our U.S. combat casualties. Plast
Reconstr Surg 2013;132(4):577e.
Senevirantne S, Duong C, Taylor GI. The angular branch of the thora­
codorsal artery and its blood supply to the inferior angle of the
scapula: an anatomical study. Plast Reconstr Surg 1999;104:85.
Siebert J, Longaker MD, Angrigiani C. The inframammary extended
circumflex scapular flap: an aesthetic improvement of the parascapu­
lar flap. Plast Reconstr Surg 1997;99:70.
Testut L. Tratado de anatomia. Barcelona: Salvat; 1908.
Thoma A, Heddle S. The extended free scapular flap. Br J Plast Surg
1990;43:709.
Tolhurst DE, Haeseker B. Fasciocutaneous flaps in the axillary region.
Br J Plast Surg 1982;35:430.

446
Latissimus Dorsi Flap
Günter Germann  |  Matthias Reichenberger
41 
INTRODUCTION
The latissimus dorsi flap was introduced by Tansini in 1906
for the coverage of extensive mastectomy defects.1 Subse­
quently forgotten, it was re-described by Olivari in 1976 for
the coverage of large radiation ulcers of the chest wall.2
Boswick, in 1978, adopted Olivari’s idea and developed a
latissimus island flap for breast reconstruction.3 A further
development, together with the technical progress of micro­
surgery, was its use as a free musculocutaneous flap.
The latissimus dorsi flap, either as pedicled or as microvas­
cular free tissue transfer, is one of the most commonly used
flaps in reconstructive surgery, with large vessel diameters
and a long reliable pedicle. Its size and versatility make it an
extraordinary graft that has been a workhorse in reconstruc­
tive surgery for more than two decades.
Figure 41.1  Latissimus dorsi flap.
Axillary
artery
Subscapular
artery
Circumflex
scapular artery
Thoracodorsal
artery
Branch to
serratus
anterior
Descending
branch
Serratus
anterior
Latissimus
dorsi
Skin island
Transverse
branch of
thoracodorsal
artery
Thoracodorsal
nerve
Medial
perforators
Lateral
perforators
(Perforating posterior branches
of the posterior intercostal arteries)
Medial branch
of thoracodorsal
nerve
Lateral branch
of thoracodorsal
nerve
Long thoracic
nerve
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION D  —  LOCAL AND FREE FLAPS IN THE BACK

CHAPTER 41 — Latissimus Dorsi Flap
447
and medial rotator of the humerus. It holds the inferior
angle of the scapula against the chest wall and stabilizes and
elevates the pelvis when bringing the lower extremity
forward. It aids in coughing and, unduplicated by other
muscles, it pulls the arm posteriorly, directly behind the
back, a motion that is best described by the terminal action
of pushing off with a ski pole.
ARTERIAL SUPPLY OF THE FLAP (Figs 41.1, 41.2
and Figs 11.1 and 11.5)
The latissimus dorsi muscle has a dual blood supply from
the subscapular artery and the posterior paraspinous perfo­
rators. Both circulatory systems are diffusely interconnected
so that the muscle can survive in its entirety if either pedicle
is interrupted.
Dominant:  thoracodorsal artery, a branch of the subscap­
ular artery
Length: 8.5 cm (range 6.5–12 cm)
Diameter: 3 mm (range 2–4 mm)
The thoracodorsal artery courses from the axilla along
the anterior border of the latissimus dorsi muscle, enters
the muscle from underneath, and spreads into two or three
major branches at the undersurface of the muscle. Ana­
tomic variations can be seen where the thoracodorsal artery
can arise directly from the axillary artery or even from the
lateral thoracic artery in 3–5% of patients.
Heitmann et al.4 revisited the latissimus dorsi muscle to
provide a comprehensive synopsis of its anatomy. The neu­
rovascular hilus was found on the deep surface of the latis­
simus dorsi muscle approximately 4 cm distal to the inferior
scapular border and 2.5 cm lateral to the medial border of
the latissimus muscle. At that point there was a constant
bifurcation into a horizontal (medial or transverse) branch
It can be elevated as a muscle, a musculocutaneous or an
osteomyocutaneous flap. As a composite graft including
variable amounts of muscle, skin, and subcutaneous tissue,
it can be used in any variety for reconstruction in every area
of the body. The harvested flap can be as large as 20 × 35 cm,
but numerous combinations with other flaps nourished by
the subscapular system are possible to simultaneously recon­
struct more complex defects with several flaps, based on a
single pedicle.
FLAP ANATOMY (Figs 41.1, 41.2 and Figs 11.1,
11.2, 11.3, 11.4, 11.5 and 11.7, 11.8 and 11.9)
The latissimus dorsi muscle is the mirror image of the pec­
toralis major muscle. Its aponeurotic origin arises from a
broad front, extending from the seventh and lower thoracic
vertebrae, the lumbar and sacral spinal processes, to the
posterior and middle outer rim of the iliac crest via the
thoracodorsal fascia. The superior portion of the medial
aspect of the latissimus muscle is covered by the trapezius
muscle; otherwise, the latissimus muscle is superficial to all
other muscles in the back. The latissimus muscle covers a
portion of the paraspinal muscle and the majority of the
serratus anterior muscle. In the middle portion there is a
rather tight attachment to the 10th, 11th, and 12th ribs and
to the fibers that interdigitate with fibers of the serratus
anterior muscles. Superiorly it is adherent to the inferior
border of the teres major muscle. Its triangular large and
flat muscle belly converges into a flat, broad tendon. Near
its insertion into the lesser tubercle and the medial lip of
the intertubercular groove of the humerus (Figure 41.2) it
spirals 180° around and travels anterior to the tendon of the
teres major muscle.
There are numerous important functions of the latissi­
mus dorsi muscle. Primarily it acts as an extender, adductor,
Figure 41.2  The arterial supply of the latissimus dorsi muscle.
Posterior humeral
circumflex artery
Anterior humeral
circumflex artery
Circumflex scapular
artery
Serratus collateral
artery
Internal mammary
artery
Supreme (superior)
thoracic artery
Subscapular artery
Thoracodorsal artery
Intercostal artery
Lateral thoracic artery

448
PART 4 — CONVENTIONAL WORKHORSE FLAPS
musculocutaneous flap. In contrast, the lateral branches
initially were only occasionally mentioned as a source of
pedicled flaps, but later they were also used as donor vessels
for the reverse latissimus dorsi flap. Because of their short
pedicle, both the medial and lateral dorsal branches have
been confined to their use as pedicled flaps. Even if the
vascular pedicle is of sufficient length for a free flap, the
difficult and harmful preparation of the vessels through
the thick package of paraspinous muscles down to the
source vessels is justified only exceptionally.
These vessels predominantly supply the distal part of the
latissimus dorsi muscle. They are found in two rows as seg­
mental vessels 5–10 cm from the dorsal midline. There are
usually 4–5 vessels in each segmental row. The lateral row
derives its blood supply from branches of the posterior
intercostal artery and the medial row derives its blood
supply from the lumbar artery.
VENOUS DRAINAGE OF THE FLAP (Fig. 11.8)
Accompanying veins follow the arteries
Primary:  thoracodorsal vein
Length: 9 cm (range 7.5–10 cm)
Diameter: 3.5 mm (range 2–5 mm)
Usually, the thoracodorsal vein originates from the sub­
scapular vein. Anatomic variations in venous anatomy are
present in 3–5%. Most often, the thoracodorsal vein is
doubled or originates direct from the axillary vein.
In the majority of cases, the subscapular vein and artery
usually arise adjacent to each other but in about 10% of cases,
the axillary artery arises proximal to the subscapular vein.
The length of the subscapular vein averages 2 cm, with an
average diameter of 9 mm. The circumflex scapular vein can
arise directly from the axillary vein; two veins are normally
found, both with a diameter that allows microanastomosis.
Secondary:  concomitant veins, running with the perforat­
ing arterial vessels, provide secondary venous drainage
Length: 2 cm (range 1.5–2.5 cm)
Diameter: 2 mm (range 1.1–2.7 mm)
The venous drainage of the muscle parallels the arterial
supply but the presence of venous valves has important
implications for flap design. The lower and medial parts
of the muscle preferentially drain through the intercostals
and lumbar venous system and not via the thoracodorsal
system. Valves within the vein ensure this direction of flow.
Also, the circumflex scapular vein can provide secondary
drainage of the flap. In cases where a pedicled latissimus
flap is performed based on retrograde flow from the circum­
flex scapular artery, the vein can provide adequate drainage
to the flap.
In the arteries, reversal of flow can easily take place and
blood can reach the extreme parts of the muscle; on the
venous side there are problems in draining the inferior end
of the muscle into the thoracodorsal system. The result is
that the muscle-only flap suffers venous compromise in its
lower part, and any areas that appear suspect after
and a descending (lateral or vertical) branch, but there are
interconnections between the horizontal and descending/
lateral branches.
In more than 90% of cases, the thoracodorsal artery bifur­
cates into the medial and the slightly larger lateral branch.
The lateral branch characteristically parallels the lateral
border of the muscle, running approximately 2.5 cm from
its edge. The upper or medial branch separates from it
at an angle of about 45° and parallels the upper muscle
border. Within the muscle, both branches divide into lesser
branches, which run medially and anastomose with perfora­
tors from intercostals and lumbar arteries. A very significant
feature of these anastomoses is their large diameter.
In the remaining cases, the neurovascular tree splits
into three or four major branches. Both branching pat­
terns supply the muscle with long, parallel neurovascular
branches, which run in the fascia between bundles of
muscle fibers and thereby enable the muscle to be split into
independent vascularized innervated units.
Cutaneous perforator vessels could be traced to the
thoracodorsal artery and had a caliber of >0.5 mm. They
were always found in proximity to the horizontal or the
lateral branch. All thoracodorsal cutaneous perforators
originated within a distance of 8 cm distal to the neurovas­
cular hilus.
The thoracodorsal artery supplies predominantly the
latissimus dorsi muscle but also gives branches to the ser­
ratus anterior muscle, the axillary skin, and the subscapular
and teres major muscles.
The thoracodorsal artery gives off 1–3 branches of about
1 mm diameter to the serratus anterior, which penetrate the
muscle in its midportion along the course of the long tho­
racic nerve. Reversal of flow may take place in these vessels
and also in vessels from teres major in the paratenon around
the insertion and perhaps in other direct vessels entering
from axillary and intercostal vessels.
The thoracodorsal artery also gives off a cutaneous branch
in about 75% of cases, before it continues on to penetrate
and supply the latissimus dorsi. The cutaneous branch arises
between 0.5 and 2 cm beyond the bifurcation of the sub­
scapular artery.
The subscapular artery arises in general, as a branch of
the third portion of the axillary artery. Its average external
diameter at its origin at the axillary artery is about 6 mm
and its average length to the origin of the circumflex scapu­
lar artery is about 2.2 mm.
Usually the circumflex scapular artery (average length
4 cm, average diameter 4 mm) is found to be the first branch
of the subscapular artery but in about 3% the circumflex
scapular artery is a direct branch of the axillary artery.
The second major branch of the subscapular artery is the
thoracodorsal artery.
Minor:  perforating posterior branches of the posterior
intercostal arteries
Length: 2 cm (range 1.5–2.5 cm)
Diameter: 1.5 mm (range 1–2.1 mm)
The 9th, 10th, and 11th intercostal vessels provide the
three largest medial dorsal branches and have been the
major vascular pedicles for the reverse latissimus dorsi

CHAPTER 41 — Latissimus Dorsi Flap
449
perforator flap (TDAP) (see Ch. 56). The skin is nourished
via the fascia and the perforator vessels, which therefore
must be taken with the muscle in musculocutaneous flaps.
Combinations and extensions are possible with any com­
ponent from the subscapular system (i.e., bone, skin, fascia,
muscle). On the same pedicle, it can be elevated with the
serratus fascia or the serratus muscle, the accompanying rib
or part of the scapula, or with a scapular or parascapular
flap. In this way it is possible to harvest multicomponent
flaps to simultaneously reconstruct complex defects with
several flaps based on a single pedicle.
Advantages
• Latissimus dorsi dissection is rapid, easy, and safe because
of the reliable anatomy of the thoracodorsal and sub­
scapular vessels.
• Microvascular transfer is facilitated by the long pedicle
and large caliber of the vessels. The robust viability of
this large muscle flap constitutes its major commending
feature.
• A skin island can be orientated vertically, obliquely, or
transversely as desired or required by the defect.
• The latissimus dorsi flap, one of the largest flaps in the
body. It can be tailored to almost any size and shape. The
flap can extend from the axilla to almost the iliac crest.
Elevating the latissimus dorsi flap so far distal will result
in an extremely long vascular pedicle, making the flap
especially suitable for large skin defects or anastomotic
sites remote from the defect.
• As a pedicled flap, it is certainly one of the most versatile
flaps for reconstructive problems of the chest wall and the
upper arm. The pedicled muscle flap alone will also
supply coverage for massive defects of the head and neck
area as well as the shoulder.
• Where large areas of a thinner flap coverage are required,
the muscle alone can be transferred microsurgically and
then skin grafted to avoid excessive bulk at the recipient
area, and to avoid a large secondary skin defect in the
donor area.
• The musculocutaneous latissimus flap may be advanta­
geous in providing bulk for the correction of contour
defects.
Numerous combinations are possible. Combined (“chi­
meric”) flaps with other components from the subscapular
system can be designed, vascularized bone can be harvested
as rib grafts with the latissimus, or on a common pedicle
from the scapula, fascia can be added from the serratus
muscle.
The thoracodorsal nerve can be included so that the
muscle can be reinnervated for restoration of motor
function.
If the latissimus dorsi flap is harvested correctly, several
flaps such as the scapular flap or the serratus muscle/fascia
flap are still possible, although with smaller vessel diameters.
Overall, the usefulness of this remarkable flap far out­
weighs its recognized disadvantages.
Disadvantages
• This flap, especially the musculocutaneous type, is gener­
ally bulky, depending on the general physical constitution
of the patient. Exact intramuscular dissection with
reperfusing a free flap should be excised, as experience has
shown that these areas, which initially have an arterial inflow
but which ooze dark deoxygenated blood, do not survive.
By contrast, the musculocutaneous flap fares better in its
distal part, perhaps because venous blood from the muscle
can find an additional pathway of return through the sub­
cutaneous venous network.
FLAP INNERVATION (Fig. 41.1, and Figs 11.1,
11.7, 11.9)
Sensory:  the posterior branches of the lateral cutaneous
branches of the intercostal nerves provide cutaneous sensi­
bility laterally, and lateral branches of the posterior rami (VI
through XII) posteriorly.
Usually these branches are not used to reinnervate the
flap, but in the special case when a reverse pedicled flap is
performed based on the posterior intercostal vessels, its
sensory innervation can be preserved and so the sensory
innervation can be maintained.
Motor:  the thoracodorsal nerve arises from the posterior
cord of the brachial plexus and travels latero-inferiorly
behind the axillary artery and vein.
The thoracodorsal nerve is usually located 3 cm medial
to the origin of the subscapular artery in the axilla. It accom­
panies the vascular pedicle more closely, approaching the
entrance of the neurovascular bundle, and it is sometimes
difficult to preserve the nerve during elevation of the flap.
Even if only a small portion of muscle is included, the entire
muscle is denervated. The nerve divides into lateral and
medial branches approximately 1.3 cm proximal to the neu­
rovascular hilus and each branch runs with its vascular
counterpart.
Some authors have described an intramuscular dissection
of the nerve that allows for its preservation. Thus, if the
intention is to split the muscle and retain half of it on the
chest with an intact nerve supply, then the dissection is more
complicated. The vascular basis for splitting the flap is the
known bifurcation of the thoracodorsal artery within the
muscle, which enables either the superior horizontal part
of the muscle or the anterior vertical part to be harvested
on the thoracodorsal pedicle. In this situation, the part of
the muscle left on the chest is detached from the thora­
codorsal pedicle and receives its blood supply from the
intercostal perforators. If this part of the muscle is left in
continuity with the tendon of insertion and its innervation
is preserved, then some function should be retained in it.
The bifurcation of the thoracodorsal artery is, on average,
8.7 cm from the point where the subscapular artery arises
from the axillary artery.
Proprioceptive nerve fibers accompany motor fascicles of
the thoracodorsal nerve. This may be the reason why some
studies report deep sensation of a transferred latissimus
dorsi flap up to 18 months after coaptation of the thora­
codorsal nerve to a sensory recipient nerve.
FLAP COMPONENTS
The latissimus dorsi flap can be raised as a muscle, or a
musculocutaneous, an osteomusculocutaneous, or even a

450
PART 4 — CONVENTIONAL WORKHORSE FLAPS
than muscle is needed, then the skin island should be based
toward the anterior edge of the muscle, where perforating
vessels can be found, which also form the base of the TDAP
(thoraco-dorsal artery perforator flap).
Several areas of skin can be raised separately on the same
muscle flap, so that many reconstruction possibilities are
available. The anterior edge of the muscle should always be
included because the greatest number of perforating vessels
supplying the skin is found there.
SPECIAL CONSIDERATIONS
BREAST RECONSTRUCTION
For breast reconstruction, the island over the upper free
muscle border should be designed in a way that closure of
the secondary defect leaves a transverse scar that is easily
concealed by a brassiere.
HEAD AND NECK RECONSTRUCTION
For head and neck reconstruction, if the flap is to be pedi­
cled, a skin island along the anterolateral margin of the
muscle is necessary because the transverse island will not
reach. Elevation of a muscle flap may be done through
either incision.
SOFT TISSUE DEFECT OF THE LOWER EXTREMITY
WITH A BONE DEFECT
When raising the flap with bone from the scapula, there are
variations in the anatomy to be considered. The general
scheme is shown with the angular branch supplying the
tailoring of the flap to the defect size can significantly
decrease the amount of muscle harvested. Even though
the muscle atrophies to some degree, skin islands in mus­
culocutaneous flaps are usually also bulky and require
secondary thinning and contour correction for satisfac­
tory aesthetic results.
• Surprisingly, the functional deficit of shoulder and arm
function from loss of the latissimus dorsi muscle is esti­
mated to average approximately 7% in most individuals.
If all the other muscles of the shoulder girdle are intact,
the loss of the latissimus dorsi muscular function is rarely
noticeable in normal activities. Occasionally, the harvest
of this muscle will result in some winging of the scapula,
even though the serratus anterior muscle is intact. It can
also compromise the motion of “posterior push,” an
important function in skiing, where the hand is pulling
the body weight forward. Loss of the latissimus in paraple­
gics may also seriously weaken upper extremity function
such as crutch-walking or bed-to-wheelchair transfer. Sim­
ilarly, in patients with poliomyelitis or other neuromuscu­
lar diseases, loss of the latissimus dorsi muscle may
seriously weaken pelvic stability.
• Other disadvantages are directly related to donor site
complications. Pains at the donor site and seroma forma­
tions are occasionally seen. Most of these symptoms disap­
pear over time, and persistent complaints are rare.
PREOPERATIVE PREPARATION
No preoperative vessel identification is necessary. In cases
of previous axilla dissection or radiation, muscle function
has to be evaluated preoperatively. If muscle function is
intact, the vessels are likely not violated. If the muscle func­
tion does not seem to be good or if the suspicion is high for
vessel injury, further studies such as tracing the vessel course
with high resolution ultrasound may be performed to see if
adequate perfusion is available, and if the muscle is viable
and can be used for wound coverage.
A donor site for possible skin grafting is also prepped and
draped. Preoperative antibiotics are not given routinely and
the decision is based on the recipient site and the condition
of the patient.
FLAP DESIGN
ANATOMIC LANDMARKS (Fig. 41.3)
The margins of the latissimus dorsi muscle extend from the
tip of the scapula to the midline of the back posteriorly and
with its fascial extension to the iliac crest inferiorly. The
anterior border of the muscle passes on an oblique line
from the mid-point of the iliac crest to the axilla. This
prominent border forms the posterior axillary fold, together
with the subscapular and the teres major muscles.
GENERAL THOUGHTS ABOUT FLAP DESIGN
The design of the latissimus dorsi flap can be varied accord­
ing to the requirements for skin or muscle. Therefore the
location and proportion of the skin island must be exactly
determined during preoperative planning. If more skin
Figure 41.3  Anatomic landmarks. (With permission from Standring
et al., editors. Gray’s anatomy. 39th ed. Elsevier, Churchill Livingstone;
2005.)
1. Axilla
2. Tip of scapula
3. Anterior margin of latissimus is palpable
4. Midline of back
5. Iliac crest
1
2
3
4
5
X

CHAPTER 41 — Latissimus Dorsi Flap
451
1. The scapular flap
2. The parascapular flap
3. The serratus fascia flap
4. The serratus anterior muscle flap
5. The lateral edge and also the inferior edge of scapula are
particularly well suited as a donor site for a segment of
bone.
Markings of the flap:
1. The transverse skin island of latissimus dorsi myocutane­
ous flap
2. The vertical skin island of latissimus dorsi myocutaneous
flap
3. For breast reconstruction the island should always be
oriented at right angles to the scar on the anterior chest
wall. Thus, a vertical skin island is needed for a transverse
scar, while a more transverse island is needed for a verti­
cal scar.
Before the operation the anterior edge of the latissimus
dorsi muscle has to be identified. It can be seen and felt
easily when the patient’s hands are placed on the hips. The
anterior muscle border and tip of the scapula are marked
to outline flap borders.
A line is then drawn from the middle of the iliac crest to
the posterior axillary fold. On this line the entry of the
pedicle into the muscle 10–12 cm below the axilla is marked.
After the size of the skin island has been determined, it is
drawn on the skin with the help of a template. Care should
be taken to position the skin island so that a sufficient
number of perforator vessels is included. Therefore, some
surgeons use the Doppler probe for design of the skin
island. This will eliminate any concern about perfusion of
the flap and the skin island. The Doppler is particularly
useful when a small skin island is planned as it becomes
more critical to make sure that there is at least one skin
vessel supplying the skin island.
PATIENT POSITIONING
Most surgeons would agree that a lateral decubitus position
is ideal for flap harvest, although it is possible with the
patient in a prone or even a supine position with a 45°
lateral tilt. The arm is abducted to 90°, the elbow also flexed
90°. More abduction may stretch the brachial plexus. The
arm is prepped sterile so that a limited mobility is permitted.
Wrapping with cotton bandages must also protect the ulnar
nerve at the elbow. This position allows excellent access to
the vascular pedicle, as well as the chest wall in case of a
pedicled transfer.
In cases of a free transfer to the lower extremity, the flap
is usually harvested from the contralateral side. The ipsilat­
eral leg is maximally flexed in the hip to allow a two-team
approach to the injured lower leg.
Also in cases of a free transfer to the upper extremity, the
flap is usually harvested from the contralateral side.
ANESTHETIC CONSIDERATIONS
General anesthesia is needed to harvest the latissimus dorsi
flap.
lower pole of the scapula and the circumflex scapular artery
the middle and upper thirds of the lateral border. The
angular branch arises directly from the thoracodorsal artery
just proximal to the origin of the branch of serratus.
In a small percentage of patients, the latissimus muscle
may play a significant role in raising the pelvis while walk­
ing. In patients with spinal cord injuries affecting this area,
the dimensions and thickness of the muscle may be quite
small.
The latissimus dorsi muscle can be carried on the highest
branch of the circumflex scapular artery, even if the thora­
codorsal artery is sacrificed. This smaller vessel usually pro­
vides a reliable blood supply for the muscle with the
exception of the most distal aspects.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
PEDICLED FLAP
In planning the pedicled flap, Chandra uses the horizontal
continuation of a line drawn through the nipples (with the
arm by the side) to surface mark the base of the flap. The
long axis of the flap then has its center line 1 cm anterior
and parallel to the edge of the latissimus dorsi. The largest
flap described by Chandra was 7 × 20 cm and all donor sites
were capable of direct closure.
FREE FLAP
Due to variability in the site of origin of the cutaneous
branch, which may even be absent, it is best to dissect the
axilla first and establish the anatomy.
FLAP DIMENSIONS
Muscle Dimensions
Length: 35 cm (range 21–42 cm)
Width: 20 cm (range 14–26 cm)
Thickness: 1.5 cm (range 0.5–4.5 cm)
The average dimensions are 4–6 cm more in male patients
than in female patients.
Skin Island Dimensions
Length: 18 cm (range up to 35 cm)
Width: 7 cm (range up to 20 cm), maximum to close pri­
marily: 8–9 cm
Thickness: 2.5 cm (range 1–5 cm)
The latissimus dorsi flap can be tailored to almost any size
with a maximum dimension of 20 × 35 cm. Primary closure
of the donor site can be achieved when the width is <8–9 cm.
Bone Dimensions
Length: 5 cm (range 1.5–8 cm)
Width: 2 cm (range 1–5 cm)
Thickness: 2 cm (range 1–3 cm)
FLAP MARKINGS (Fig. 41.4)
Design of over- and underlying structures that can be
included with the flap:

452
PART 4 — CONVENTIONAL WORKHORSE FLAPS
serratus anterior muscle. Caudally, sometimes sharp dissec­
tion is needed.
The latissimus dorsi muscle is divided below and posteri­
orly but remains still attached above. In this area, the rela­
tively small muscle is dissected free, protecting the pedicle
carefully (Fig. 41.5D).
The medial border of the muscle, which is always found
more medially than expected, should be identified by palpa­
tion. The incision depends on the type of muscle harvested
and the type of reconstruction planned. In breast recon­
struction or musculocutaneous flaps, the incision includes
the skin island and depends on the position of the skin
island.
The surgeon is positioned on either the anterior or
the posterior aspect of the patient. The anterior approach
facilitates access to the axilla and the pedicle; the poste­
rior approach permits a better overview of the dorsal
perforators.
TECHNIQUE OF FLAP HARVEST (Fig. 41.5)
The axis of the flap lies about 2 cm posterior to the anterior
edge of the latissimus dorsi muscle. The skin island can be
anterior to this edge of the muscle. Ideally, the flap is based
on the anterior edge of the muscle because of the concen­
tration of perforating vessels (Fig. 41.5A).
The first incision exposes the anterior edge of the latis­
simus dorsi muscle between the axilla and the proximal
edge of the flap (Fig. 41.5B).
The skin island is incised around its circumference and
elevated anteriorly from the serratus anterior muscle up to
the ventral edge of the latissimus dorsi (Fig. 41.5C). Then
the pedicle is easily found in the fatty connective tissue
medial to the muscle and exposed up to its entry into the
latissimus dorsi muscle. Next, the latissimus dorsi muscle
with its overlying skin island is dissected bluntly from the
Figure 41.4  Flap markings and underlying structures. (With permission from Standring et al., editors. Gray’s anatomy. 39th ed. Elsevier, Churchill
Livingstone; 2005.)
1. The scapular flap
2. The parascapular flap
3. The serratus fascia flap
4. The serratus anterior muscle flap
5. The lateral edge and also the inferior
edge of the scapula are particularly well
suited as a donor site for a segment
of bone
6. The transverse skin island of latissimus
dorsi myocutaneous flap
7. The vertical skin island of latissimus dorsi
myocutaneous flap
8. For breast reconstruction the island should
always be oriented at right angles to the scar
on the anterior chest wall. Thus, a vertical
skin island is needed for a transverse scar,
while a more transverse island is needed for
a vertical scar
1
2
3
4
5
6
7
8

CHAPTER 41 — Latissimus Dorsi Flap
453
the scapula, care must be taken not to confuse this artery
with the second branch to the muscle. The tendinous inser­
tion is left intact until the dissection is completed.
After the pedicle has been identified, dissection proceeds
along the medial border distally. The skin island is incised
circumferentially and the latissimus dorsi muscle is lifted
from the serratus anterior muscle by blunt dissection. To
prevent the skin from shearing off the muscle, some stay
sutures are applied. Meticulous hemostasis is mandatory
during the entire dissection. Smaller branches are coagu­
lated; larger perforators are clipped or even ligated. The
muscle is then divided distally by diathermy. Dissection now
moves toward the spine. At any point in dissection, the flap
can be tailored to its required shape.
Function-preserving harvesting techniques are technically
more challenging. Here, the pedicle has to be separated
from the thoracodorsal nerve. The flap can only comprise
those segments that are supplied by the vascular pedicle
after the nerve has also divided into segmental branches.
LATISSIMUS MUSCLE OR MYOCUTANEOUS FLAP
PEDICLED TRANSFER FOR BREAST OR CHEST
WALL RECONSTRUCTION
In pedicled flap transfer, a tunnel is made across the apex
of the axilla to pass the flap from the back to the front of
the chest or to the upper arm. Drains are inserted in the
In the standard harvesting technique, an incision is made
from the posterior axillary fold posteroinferiorly toward the
iliac crest, 3–5 cm posterior to the medial border of the
muscle. The length of the incision correlates only roughly
with the size of the muscle flap required. The entire muscle
can be raised from a rather short incision. We usually include
a monitoring island, placed in the course of the incision.
Generally, the musculocutaneous perforators from the latis­
simus dorsi are more numerous over the proximal two-
thirds of the muscle. Care should be taken to make this skin
island large enough to allow reliable clinical monitoring.
The muscle is then separated from the serratus fibers and
the medial border is followed cephalad. The pedicle should
be identified first. The course of the pedicle is relatively
constant, about 1–2 cm behind the anterior edge of the
muscle. By following this route, the serratus branch can be
identified and securely spared. The neurovascular bundle
lies in the fatty connective tissue between the undersurface
of the muscle and the chest wall. The pedicle is dissected
toward the axilla. Minor branches of the pedicle are clipped
or coagulated with a bipolar coagulation at a location
remote from the pedicle.
The circumflex scapular artery is left intact for possible
future use. Constant large perforator vessels at the tip of the
scapula are ligated. The dissection of the pedicle is finalized
by splitting the fascial leaf that separates the latissimus from
the teres muscles from dorsal. When ligating the branch to
Figure 41.5  (A–D) Technique of flap harvest.
A
B
C
D

454
PART 4 — CONVENTIONAL WORKHORSE FLAPS
intact, the dissection is continued. The incision is contin­
ued horizontally in the bra line. The flap is raised from
ventrally to the spine, and all perforator vessels are meticu­
lously coagulated or ligated. In the areas of the planned
inclusion of fat fascia, the plane of dissection is superior to
the fascia of Scarpa. This structure is easily detectable in
the scapular region. Below the tip of the scapula, there is
no clear anatomic distinction in the subcutaneous fatty
layer. Care has to be taken not to injure the subdermal
plexus of the back skin to avoid wound-healing complica­
tions at the donor site.
The flap is separated from its origin along the spine and
is custom tailored in its superior part. All tissue superior to
the entrance of the vascular pedicle should be resected care­
fully. The pedicle is considerably lengthened by this maneu­
ver, which must be performed meticulously to avoid damage
to the pedicle. Only the small vascular pedicle will remain
in the tunnel between the chest wall defect and the donor
site after passing through the flap. This technique avoids
bulk in the axillary line when the flap is transposed to the
chest wall. If the anterior axillary fold has to be recon­
structed, the insertion of the latissimus dorsi muscle may be
left in place.
Final tailoring is performed on the chest wall, and the
flap can be sutured to whatever shape is required. Some
anchoring sutures to the chest wall are mandatory to restore
a submammary fold and to prevent early sagging. The donor
site is closed with subdermal sutures, and skin closure is
performed with a running intracutaneous suture.
A second option is the lumbar extension of the latissimus
dorsi flap, as described by Hokin and Silfverskiold and Mar­
shall et al.6,7 However, the distal extensions are frequently
marginally perfused.
Another approach is to combine the flap with a serratus
muscle, a serratus fascia, a scapular or a parascapular flap.
With these extensions or combinations, the pedicle must be
dissected up to the axillary artery to rule out anomalies of
the vascular system so that all components are nourished by
one pedicle. If there are anomalies, the operative strategy
has to be adjusted to perform additional microanastomoses.
These techniques take time and can be technically difficult
but have very few limitations in terms of size.
The latissimus dorsi flap can be used in a reverse fashion
based on the intercostals and lumbar perforators to cover
defects of the contralateral midthoracic defect and inferior
thoracic lumbar region. The flap can actually be split and
used to cover the mid or inferior region.
As a chimeric flap, the latissimus dorsi flap can be com­
bined with the serratus anterior, scapular or parascapular
flap, or with vascularized scapular bone, using one vascular
pedicle of the subscapular vessels.
For the composite serratus–latissimus muscle flap the ser­
ratus anterior digitations from the 5th to the 10th ribs can
be taken for transfer. Usually, the digitations from the 5th
to the 8th ribs are chosen, because the 9th and 10th digita­
tions are sometimes not reliable.
After exposure of the anterior border of the latissimus
dorsi, the thoracodorsal artery and its branches to latissimus
dorsi and serratus anterior muscle are identified. Retracting
the proximal portion of the latissimus dorsi dorsally, the
main trunk of the thoracodorsal neurovascular bundle is
identified between the serratus anterior and latissimus
back and, after donor site closure, the patient is turned to
the supine position, where the flap is arranged in the desired
position. If there is injury to the thoracodorsal pedicle
during the axillary dissection, the flap may be raised on the
serratus branch.
FREE MICROVASCULAR TRANSFER FOR
DISTANT RECONSTRUCTION
In free flap transfer, the vascular pedicle is ligated after the
recipient site has been prepared for anastomosis. The tho­
racodorsal nerve is marked with a 5-0 suture to facilitate
manipulation of the pedicle during microsurgery. The
pedicle is rinsed with a heparin/NaCl solution (5000
units/100 mL). The flap is protected between two wet
swabs. Before closing the donor site, two suction drains are
inserted: one for the axilla and one for the lateral chest.
Endoscopic techniques have been applied to harvest the
latissimus dorsi muscle for both pedicled and microsurgical
transfers. The use of endoscopic techniques allows the
muscle to be mobilized alone or with overlying fat, which
can add volume when used for breast reconstruction. Often
the muscle can be harvested through existing incisions on
the breast or in the axilla without the need for any addi­
tional back incisions, although posterior secondary access
incisions are occasionally utilized. The use of an axillary
incision is particularly helpful, as this allows open dissection
of the neurovascular pedicle, leaving the endoscope to assist
in muscle mobilization. The endoscopic harvest is of par­
ticular use in patients with large segmental breast defects
who desire breast preservation but in whom a poor aesthetic
result can be predicted after radiation therapy. In some
centers, robotic surgery has been used to aid in dissecting
the latissimus flap (see Ch. 9).
FLAP MODIFICATION/FLAP HANDLING
ENLARGED FLAP
There are different approaches for enlarging the volume of
a conventional latissimus dorsi flap. This can be achieved by
maximizing the skin island and the amount of subcutaneous
tissue with a fleur-de-lis incision, as described by McCraw and
Papp.5
The flap design is marked preoperatively. The breast
volume of the contralateral side is estimated, and the form
and size of the breast are analyzed. The amount and posi­
tion of the fat fascia are drawn onto the back of the patient
according to the arc of rotation and the tissue deficits on
the chest wall. A horizontal line is drawn in the dorsal bra
line so that the skin incision is inconspicuous. The latissimus
function is examined for any hint of injury to the neurovas­
cular pedicle. In case of doubt, angiography and ultrasonog­
raphy of the vascular pedicle are recommended.
The flap is raised with the patient in the lateral position
and the shoulder elevated 90°. In most cases, an appropri­
ate skin island is raised horizontally in the bra line. A
fleur-de-lis skin incision pattern can be chosen in selected
patients. A vertical incision is made in the posterior axil­
lary fold, and the neurovascular pedicle of the latissimus
dorsi muscle is exposed. When the supplying vessels are

CHAPTER 41 — Latissimus Dorsi Flap
455
run on the deep surface of the muscle, led to the clinical
refinement of the bilobed split latissimus dorsi flap. The
neurovascular pattern may be defined by transillumination
or with the use of a stimulator. The skin paddle, marked
with several needles passed through the flap, is incised and
the muscle is split along the marked neurovascular pattern.
Some authors have even proposed filleting the muscle in a
horizontal plane with transfer of only the deep segment to
reduce bulkiness.
THORACODORSAL ARTERY PERFORATOR
(TDAP) FLAP
A fresh approach to the bulkiness of flaps was initiated with
the advent of perforator flaps. In anatomic studies, Taylor
and Palmer found more than 370 cutaneous perforators
larger than 0.5 mm throughout the body, and the schematic
diagrams revealed 5–9 of these perforators in the area of
the latissimus muscle.10 However, there were no further
details given regarding the specific location and origin of
the perforators. Angrigiani et al. were the first to apply the
principle of the perforator flaps to the latissimus dorsi
muscle.11 The perforators were followed through the muscle
to the thoracodorsal vessels, creating an adipocutaneous
flap without sacrifice of the muscle. Angrigiani and col­
leagues, among others, used the Doppler probe to localize
the perforators and to determine flap design.11 The skin
island of the TDAP flap must be centered above the free
upper or preferably medial border of the latissimus dorsi
muscle.
RIB–LATISSIMUS DORSI
OSTEOMUSCULOCUTANEOUS FLAP
The latissimus dorsi muscle covers the lower ribs from the
midline to the posterior axillary line. There are vascular
communications between the thoracodorsal artery and the
periosteal vessels of the ribs. The 9th or 10th rib can be
selected to be combined with the flap. A bony length of
about 12 cm is available. Flap elevation is begun distally and
must stop at the intercostal space inferior to the selected
ribs. Then the intercostal muscles are incised in the inter­
costal space and the rib is divided at both ends. The rib is
separated from the pleura. The component is then flipped
proximally, keeping it connected with the muscle. Intercos­
tal muscles proximal to the selected ribs are divided, and
the osteomusculocutaneous flap is isolated on the thora­
codorsal neurovascular pedicle.
The reliability of the rib when harvested as a vascularized
graft is compromised by its low mechanical stability. Because
of its cortical bone structure and its given convexity, its use
is quite rare.
THINNED MUSCLE FLAP
Protecting the nourishing thoracodorsal artery and its
branches running on the undersurface of the muscle even
during primary setting, the latissimus dorsi muscle can
be thinned from its superficial surface. Especially in the
upper part of the latissimus dorsi flap, where the muscle is
more bulky, this can be performed by using scissors for
tangential excision. Nevertheless, debulking of the muscle
dorsi. Dissection of the vessels leads to finding one or two
branches to the serratus anterior that arise from the tho­
racodorsal vessels 3–6 cm caudal to the entrance of the
latissimus dorsi. The long thoracic nerve can be found on
the surface of the muscle joining the vascular bundle at the
level of the 6th rib. Then the 5th to 8th digitations of the
serratus anterior are mobilized from the chest wall by care­
fully dividing attachments on the ribs with a cautery. The
upper and lower portions with their innervation should be
preserved in order to prevent a winging scapula and limita­
tion of arm movement. After dividing the muscle from its
scapular attachment, the serratus anterior muscle can be
raised.
REVERSE FLAP
The flap can be used in a reverse fashion based on the
intercostals and lumbar perforators to cover defects of the
contralateral midthoracic defect and inferior thoracic
lumbar region. The flap can actually be split and used to
cover the mid or inferior region.
EXTENDED FLAP
Germann et al. introduced the extended latissimus dorsi
flap in 1996 as a pedicled flap for breast reconstruction.8
It is a modification that attempts to increase the volume
by harvesting the scapular fat fascia in addition to the
conventional latissimus flap. The goal is to achieve a suffi­
cient volume to enable surgeons to reconstruct the breast
without using an implant (Figs 41.6, 41.8).
Since 1996, the flap design has been changed from an
optional to a mandatory fleur-de-lis pattern for the skin inci­
sion, centered above the brassiere lines. After incision of the
skin island, the dissection proceeds in the subcutaneous
plane superficial to Scarpa’s fascia. In this manner, a layer
of subcutaneous fat, 10 cm in the caudal direction and 5 cm
in both cranial directions, is included in the flap. Care must
be taken to maintain the integrity of the subdermal plexus.
This can be achieved by leaving approximately 5 mm of
subcutaneous tissue attached to the skin. The scapular fat
fascia extends cranially beyond the superior border of the
latissimus dorsi muscle. This area represents Taylor’s angio­
some 10 and is predominantly nourished by the circumflex
scapular artery.9 However, small perforators from the hori­
zontal branch of the thoracodorsal artery (Taylor’s angio­
some 12) course from the superior edge of the muscle into
this area.9 After division of the circumflex scapular artery,
these perforator vessels maintain the blood supply to the
scapular fat fascia. The humeral insertion of the latissimus
dorsi flap and the thoracodorsal nerve are transected, and
the part of the muscle superior to the entrance of the vas­
cular pedicle is resected to avoid unnecessary axillary bulk.
In microvascular transfers, this portion is frequently used to
cover the pedicle after the anastomoses. The skin island is
tailored to the amount of skin required for the specific type
of reconstruction.
BILOBED SPLIT LATISSIMUS DORSI FLAP
The anatomic findings of constant branching of the thora­
codorsal vessels into a horizontal and a lateral branch, which

456
PART 4 — CONVENTIONAL WORKHORSE FLAPS
FLAP USAGE
PEDICLED
• Anterior and posterior chest wall defects
• Sternum osteitis
• Major coverage problems of the axilla, shoulder, and neck
• Less often for intraoral defects
• Massive defects of the temporal area
• Breast reconstruction
• Excellent functional replacement for the biceps muscle
• Less commonly, functional replacement for the triceps
muscle
• Correction of surface coverage problems of the upper
arm extending to the elbow
• Proximally based obvious flap of choice for major upper
back and scapular defects
• As a reversed flap for defects of the lower thoracic and
lumbar areas
• Bilaterally, especially for soft tissue coverage in spina
bifida patients
ARC OF ROTATION
The latissimus dorsi, based on the major pedicle in the
axilla, has a wide arc of rotation.
• Anterior arc: will cover the lateral abdomen (musculofas­
cial flap), chest wall, and head and neck region.
• Posterior arc: will cover the lumbar, thoracic, and cervical
vertebrae and will reach the posterior neck.
FREE FLAP
HEAD AND NECK
Major coverage problems. Coverage of intraoral defects,
including mandibular reconstruction with a free rib.
Functional muscle transfer for facial reanimation with the
thoracodorsal nerve connected to the contralateral normal
facial nerve in a one-stage procedure.
TRUNK
Major coverage problems.
UPPER EXTREMITY
Major coverage problems. Free functional muscle transfer.
LOWER EXTREMITY
Major coverage problems. Treatment of chronic infections
because of its excellent vascular supply.
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
PEDICLED FLAP
Anterior Arc
The flap may be elevated as a muscle or musculocutaneous
island. The skin island can be oriented along the anterolat­
eral free border or over the upper border of the muscle.
For breast reconstruction, the island over the upper free
muscle border is preferable, as the secondary defect, when
closed, leaves a transverse scar that is easily concealed by a
brassiere.
or myocutaneous component during a secondary proce­
dure is much safer and should be the standard technique
for thinning the flap.
SPECIAL INSTRUMENTS
No special instruments are required for flap harvest or flap
inset.
DONOR SITE CLOSURE
AND MANAGEMENT
For standard flap designs, the donor site is closed as a direct
closure after at least two drains are inserted. No special
dressing is needed. Because of the high incidence of seroma
formation, which occurs even with adequate suction, drain­
age of the donor site has constituted the biggest disadvan­
tage of this flap. Progressive tension sutures can be used to
aid in preventing seroma formation. The donor site itself
does not create any significant surface depression or exces­
sive prominence of the ribs, but if more than 5 cm of skin
is carried with the muscle, a widened scar can be expected.
If a skin graft is required for the donor site, the resulting
contour deformity can be remarkably unattractive, particu­
larly in the obese patient.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
Even in a pure muscle flap, a skin island should be taken as
a monitoring point, especially in cases of microsurgical
transfer. This is of special importance in large training
units with a high number of residents. Clinical flap monitor­
ing is significantly easier and unnecessary flap failure result­
ing from poor judgment of the muscle perfusion can be
avoided.
• Additional skin should be harvested and stored in the
refrigerator. When the skin island is taken off after 5–6
days, stored skin can be transplanted as a bedside proce­
dure. Alternatively, the skin can be harvested from the
monitoring island before it is removed.
• Muscle flaps usually shrink over time so that contouring
is only required in approximately 50% of cases. Almost
all musculocutaneous flaps tend to sag so that many need
contouring or flap correction. In the case of functional
muscle transfers, readjusting muscle tension is sometimes
required.
• In breast reconstruction, we strongly recommend over­
correction of the desired breast size by 15–20% and iden­
tification of the thoracodorsal vessels at the beginning
of the operation, to determine their integrity, because
many patients have undergone axillary dissection or
irradiation.
• The length and diameter of the pedicle can be increased
by 2 cm for length and to 6 mm diameter by including
the subscapular artery.
• Identify the thoracodorsal artery before dividing the ser­
ratus branch. It is easy to take the serratus muscle with
the latissimus muscle in that area.

CHAPTER 41 — Latissimus Dorsi Flap
457
Free latissimus is an excellent option for restoration of
function at distant sites in the upper extremity. Functional
restoration with a free latissimus dorsi muscle transfer can
be combined in cases with loss of the forearm or finger
flexor or extensor system. In the lower extremity, the latis­
simus dorsi muscle does not have adequate strength, for
example, as a knee or foot extensor.
The free vascularized rib transfer is indicated where vas­
cularized bone is needed. Thus, it is used especially for
reconstruction in the facial area, for example, for mandibu­
lar reconstruction after large tumor resection. The natural
curvature of the rib is particularly suited for mandibular
reconstruction.
In the lower extremity, free vascularized rib is generally
too weak structurally to be used for bone transfers.
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
PEDICLED TRANSFER
Pedicled innervated latissimus muscle transfer may be used
for restoration of biceps or triceps function.
FREE MICROVASCULAR TRANSFER
A free latissimus muscle or myocutaneous flap may be used
for forearm flexion with or without finger flexion, or for
forearm extension with or without finger extension.
POSTOPERATIVE CARE
GENERAL
Postoperative nursing care in the first hours allows recogni­
tion of vascular complications. The classic picture of a
venous thrombosis is the blue flap. The phase of venous
thrombosis is marked by an increase in the number of pete­
chiae on the surface of the skin. The longer the occlusion
is present, the more they increase, particularly at the edges
of the transplant. The flap becomes red, then purple, and
finally blue.
Arterial thrombosis is rarer than venous thrombosis and
arises during the first few hours after the operation. The
typical sign of arterial thrombosis is that the flap becomes
white. This complication is easier to recognize in myocuta­
neous than muscle flaps. The signs of capillary filling are
absent: after local pressure is applied to the flap, the appear­
ance does not change. When the pressure is removed, the
capillary fill is not visible, and the white flap becomes patchy
and gray-blue, pale in the middle, and, after a few days,
necrotic.
Vascular spasm is common during operation of the
leg. Normally, the spasm resolves spontaneously, but if it
persists it can cause ischemia. To avoid vascular spasm,
warmth can help. Cold is a well-recognized cause of flap
loss and should be avoided. The body temperature can
be maintained by using warm ambient temperature,
heated inspired air, heated intravenous fluids, a heated
blanket, extremity wraps, and arctic body bags. Even the
fluids used to wash the surface of the skin should be
heated.
The pedicled latissimus dorsi muscle can be valuable for
immediate breast reconstruction either as a preoperatively
planned skin/muscle flap or an intraoperatively necessary
island muscle patch. The skin island to replace the mastec­
tomy defect can be designed on the back and transferred
with the underlying muscle. Its main advantage is its ability
to supply additional vascularized muscle and skin to the
breast mound in a predictable fashion during a single oper­
ative procedure but includes the disadvantage of creating a
new donor scar, and the transfer of autogenous tissue from
the back does not eliminate the need for an implant in
many cases. The operation is usually performed in the
lateral decubitus position.
In reconstructive breast surgery with an oblique mastec­
tomy scar that is inconspicuous and needs no correction,
the flap is recommended to be placed at the level of the
inframammary crease whenever possible since the greatest
projection is desired in that area. The use of two teams
can greatly accelerate the technical phase of the proce­
dure and can reduce the total operating time to about
2 h. This requires comprehensive preparations that
include the accurate pre-marking of the inframammary
line and all con­cavities to ensure the correct placement of
the muscle flap. In calculating the replacement volume, it
should be remembered that two-thirds of the latissimus
dorsi volume will be lost to atrophy in the ensuing 6
months.
For head and neck reconstruction, a skin island along the
anterolateral margin of the muscle is necessary because a
transverse island will not reach. Elevation of a muscle flap
may be done through either incision.
Posterior Arc
For posterior transposition over the spine, it is not necessary
to identify the pedicle. A longitudinal incision is made, and
the muscle or muscle and overlying skin is elevated and
transposed.
The insertion of the muscle into the intertubercular
groove of the humerus may be divided to extend the reach
of the flap. For functional muscle transfer and in breast
reconstruction, the muscle is sutured under tension and the
motor nerve preserved to prevent loss of muscle bulk. Elec­
tromyographic muscle reeducation may prove useful in
preservation of muscle bulk.
For coverage of the arm or functional biceps transfer, the
muscle or musculocutaneous unit is elevated as described
for the anterior arc and then transposed onto the arm
through an axillary tunnel.
FREE FLAP
As a free flap, the latissimus dorsi muscle is still an extremely
valuable technique for reconstruction of large surface area
defects. It has lost a little in popularity with the rise of cuta­
neous perforator flaps such as the anterolateral thigh (ALT)
flap. However, the possibility of combining the flap with
other components and the extreme versatility of the sub­
scapular system still make it one of the workhorses in recon­
structive surgery.
Due to its length, it can be used to reconstruct distal
defects in the extremity where recipient vessels are lacking,
therefore bringing in blood supply to the distal poorly per­
fused site while avoiding the need for vein grafts.

458
PART 4 — CONVENTIONAL WORKHORSE FLAPS
skin flap. Obesity, inexperience in flap design, and narrow
muscles are common causes of inaccurate flap design.
The arc of rotation of the flap is limited by the location
of the vascular pedicle and length of the flap. In thin
patients, the flap will reach much farther. These factors have
to be taken into account in preoperative planning. Further­
more, the orientation of the overlying skin on the muscle is
less precise in obese patients.
DONOR SITE
The donor site itself does not create any significant surface
depression or any excessive prominence of the ribs, but if
>5 cm of the skin is carried with the muscle, a widened
scar can be expected. If a skin graft is required for closure
of the donor site, the resulting contour deformity can be
remarkably unattractive, and it is difficult to achieve aes­
thetic closure of these donor sites, particularly in obese
patients.
Loss of function is not noticeable in normal individuals.
In patients requiring the use of crutches, the effect is notice­
able. Removal of the muscle can also affect pelvic stability
in paraplegic patients. Winging of the scapula is also present
in some patients. To avoid this, care must be taken not to
damage innervation to the serratus anterior muscle.
The donor site constitutes the biggest disadvantage of this
flap because of the high incidence of seroma formation,
which occurs even with adequate suction drainage. These
seromas are occasionally difficult to eradicate and can result
in the formation of a bursa. If this happens, it is usually
possible to collapse the cavity with a Penrose drain. After
4–6 weeks, this becomes an intractable problem, and it may
be necessary to abrade or excise the two surfaces of the
bursa to obtain healing.
CONCLUSIONS
The latissimus dorsi is the largest muscle in the human body.
It is one of the most versatile and widely used tissue transfers
in reconstructive surgery. There is a vast literature on this
flap describing operative procedures and technical refine­
ments in detail. Recently, anatomic studies have clearly elu­
cidated the gross anatomy of the latissimus dorsi muscle. A
more thorough understanding of the neurovascular anat­
omy of the muscle has enabled development of various
refinements, including osteomusculocutaneous tissue trans­
fer and splitting of the muscle with preservation of motor
function.
RECIPIENT SITE
The suction drains are removed after 3–5 days, or when they
accumulate <50 mL of fluid in 24 h. The skin clips or
sutures are left for at least 14 days. Mesh grafts are dressed
until the 5th day after the operation, and thereafter the
dressings are changed every 2nd day. After 10 days, the
wound can usually be left without dressing. Depending on
the flap’s healing process, the patient’s stay in hospital will
be about 2–3 weeks.
DONOR SITE
The suction drains are removed after 3–5 days, or when they
accumulate <50 mL of fluid in 24 h. The skin clips or sutures
are left for at least 14 days because of the tension. We recom­
mend absorbable barbed-wire sutures, which do not have to
be removed. Especially when the skin has been continuously
sutured, the sutures should not be removed before this.
Mesh grafts are dressed until the 5th day after the operation,
and thereafter the dressings changed every 2nd day. After
10 days, the wound can usually be left without dressings.
If the donor site has been closed under tension, careful
exercise of the affected shoulder can be started on the 3rd
day, because limitation in movement quickly sets in owing
to protective posturing, and not only in older patients.
OUTCOMES
EXPECTED LONG-TERM OUTCOMES
Depending on correct indication, excellent outcomes can
be achieved using a pedicled or free latissimus dorsi flap.
Several technical aspects of the reconstruction technique
intended to enhance the functional and aesthetic outcome
and/or reduce complications are believed to contribute to
good results, as mentioned above.
UNTOWARD OUTCOMES
Complications are those that are general and likely to be
seen with any muscle flap. These include planning errors,
technical intraoperative errors, and postoperative care
errors, all of which can contribute to flap failure.
Flap design requires a precise knowledge of the topo­
graphic anatomy of the muscle. Failure to align the skin ter­
ritory correctly over the muscle will result in necrosis of the

CHAPTER 41 — Latissimus Dorsi Flap
459
Figure 41.6  (A) Resection specimen in a skin sparing mastectomy in a T2 ductal carcinoma in a 52-year-old patient. (B) Reconstruction
with an extended latissimus dorsi flap. The skin island will serve as a basis for NAC reconstruction. The fat fascia/s already dissected to
increase the volume of the flap. (C) Immediate postoperative result. (D) Clinical appearance 1 year after the reconstruction. Excellent
symmetry has been achieved. The patient did not desire a nipple reconstruction. (E) Lateral view with excellent breast shape.
A
C
B
D
E
CASE 41.1  Breast Reconstruction with an Extended Pedicled Latissimus Dorsi
Myocutaneous Flap

460
PART 4 — CONVENTIONAL WORKHORSE FLAPS
CASE 41.2  Pneumonectomy Stump Defect Covered with a Pedicled Latissimus Dorsi
Muscle Flap Based on Paraspinal Perforators
A
B
C
D
E
F
G
Figure 41.7  (A) A 67-year-old smoker underwent a pneumonectomy and radiation therapy, presented with a bronchopleural fistula.
(B) A serratus flap was harvested. During the dissection the pedicled was injured and ultimately repaired (note the Cook Swartz wires for
monitoring of the repaired artery). (C) However, due to the gravity of having a muscle fail over a bronchopleural fistula, a latissimus muscle
flap was harvested inferior to the thoracotomy incision based on paraspinal perforators. (D) The flap was rotated to cover the bronchial
stump. (E) An intercostal flap was rotated and used to cover a defect in the diaphragm. (F) The patient was brought back to the operating
room 1 week later, the latissimus muscle was viable, and the serratus muscle had excellent perfusion and was used to fill the dead-space
in the pleural cavity. (G) The patient was seen in the clinic 3 months postoperatively and was doing well. (Courtesy of Samir Mardini, MD.)

CHAPTER 41 — Latissimus Dorsi Flap
461
Figure 41.8  (A) A 44-year-old patient who had a breast amputation after multi-focal cancer. (B) Preoperative markings for reconstruction
with an extended latissimus dorsi flap without additional implant. (C) The fat fascia of the scapular area, as described in 1996,8 has been
dissected to increase the volume of the muscular flap. (D) The fat fascia is freed from the muscular pedicle to avoid excessive bulk in the
axilla. (E) The patient approximately 2 weeks post-surgery. (F–H) Appearance 6 months post-surgery. Excellent symmetry has been
achieved. There is no further volume reduction due to muscle atrophy to be expected.
A
D
B
C
E
F
H
G
CASE 41.3  Breast Reconstruction with an Extended Pedicled Latissimus Dorsi Flap without
Additional Implant

462
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 41.9  (A) MRI immediately post-birth in a boy born with a congenital myo rhabdosarcoma. (B) Incisional biopsy was performed
within the first week, confirming the diagnosis. (C) Clinical situation after 12 weeks of chemotherapy. The tumor has almost vanished.
(D) Radical tumor excision including the extensor tendons. (E) Resection specimen. (F) Resection defect measuring 5 × 5 cm. The joint
capsule is exposed. (G) Clinical situation after tendon transfer from the other foot and free musculocutaneous latissimus dorsi transfer 15
weeks after birth (1 year after surgery). (H) Stable position while standing. The young boy was about to learn to walk. (I) Stable position
when he stands on the tips of his toes, demonstrating that the tendon transfer could provide normal function of the extensor system.
A
B
D
E
G
H
I
F
C
CASE 41.4  Dorsal Foot Defect Reconstructed with a Free Latissimus Dorsi
Myocutaneous Flap