Scapular Flap

The scapular flap remains probably the workhorse of skin flaps. It is a thin, usually hairless, skin flap from the posterior chest and can be de-epithliazed and used as subcutaneous fascial flap, pedicled or free flap.

The flap is perfused by the cutaneous branches of the circumflex scapular artery (CSA) and drained by its venae comitantes. The CSA is a major tributary of the sub-scapular artery and the CSA is the artery supplying blood to the scapula, the muscles that attach to the scapula, and the overlying skin. The length of the pedicle is 5 cm and the diameter of the artery is 2.5 mm. The vascular pattern of this territory makes it possible to raise multiple skin flaps on a single vascular pedicle or to harvest the lateral border of the scapula as an osteocutaneous flap for a complex reconstruction (Fig. 8.3).

The cutaneous territory can be 20 x 7 cm2 and can be divided in two components: a horizontal territory (horizontal scapular flap) and a vertical territory (parascapular flap) based on the branches of the circumflex scapular artery after the vessel courses through the triangular space.

Innervated by the lateral posterior cutaneous branches of the intercostal nerves, this flap has no potential for being used as a sensate flap. Preliminary expansion of the territory of the scapular flap will increase the flap dimensions and permit direct donor site closure.

Flap Harvesting Parascapular Flap

The patient is positioned midlateral or in an oblique position. The flap is elevated retrograde. Start with low medial incision. Identify the epifascial plane. The fascia is elevated cranially beneath the deep fascia, to the area of the triangular space. Complete the skin incision (the upper part). Carefully retract the flap medially. Identify the junction of the parascapular and horizontal branches of the circumflex scapula vessels. Horizontal branches are divided and the circumflex scapular pedicle is dissected into the triangular space. Identify thoracodorsal or scapular artery.

Scapular Flap

Same strategy of dissection as for the parascapular flap. The dissection is started laterally and proceeded towards the triangular space. As in the parascapular flap, the vascular pedicle can also be identified first in the course of the dissection.

Some authors favor the identification of the vascular pedicle as the first step of the dissection, especially in cases of microvascular transplant. This is accomplished with palpation of the triangular space and confirmation of pedicle location with a Doppler probe. Two approaches are available for scapular and parascapular flap elevation and preparation for the microvascular transplantation: lateral (initial pedicle identification) and medial (retrograde flap dissection). This flap can be combined with other flaps based on subscapular blood supply and may greatly facilitate certain complex reconstructions. These include the latissimus dorsi and serratus anterior flaps, which can supply additional skin, muscle, and bone (rib) if necessary.19-21

The primary indication for the scapular flap is a defect requiring a relatively thin, large cutaneous flap.22 These kinds of defects are often found in the foot.23 The

Parascapular Free Flap

Fig. 8.3. Scapula flap

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