Technical refinements of the scapular tip-free flap for mandibular reconstruction

BACKGROUND

The use of scapular tip chimeric free flaps (STFFs) for reconstructing mandibular defects has recently become popular, but its utility relative to other bone-containing free flaps remains debatable. The aim of the report is to describe how technical modification of STFF impacted in its use for mandibular reconstruction also commenting results obtained in a unicentric series of patients.

PATIENTS AND METHODS

Patients undergoing mandibular reconstruction using an STFF from January 1, 2014 to June 1, 2022 were retrospectively enrolled in this report. We collected data on chimeric flap type, bone management, vascular pedicles, and the final outcomes. In total, 31 patients (13 men and 18 women) with a mean age of 68 years were enrolled. According to the classification system of Urken, 15 patients had body defects, while 7 had ramus defects, another 7 had symphysis defects, and 2 had both ramus and bodily defects. STFF was always harvested working in two equips simultaneously, in supine position. Dissection included preparation of chimeric components of the flap as latissimus dorsi, serratus and scapular tip. After pedicle dissection scapular bone was cut basing on reconstructive needing with a rectangular (stick) shape including the border of the scapula. In cases of longer bone harvesting, circumflex pedicle was also included to perfuse the upper portion of the scapular border. In five cases, the STFF was harvested with only the scapular angle component, and was thus a composite osteomuscular flap; for the remaining 26 cases, a chimeric STFF was used. Circumflex pedicle was included for eight patients. Six of the seven patients with symphyseal defects underwent a single osteotomy.

RESULTS

The average length of the harvested was 69.92 mm (maximum length = 104 mm). The average height of transplanted bone was 26.78 mm (maximum height = 44.2 mm). Mouth-opening was normal in 25 patients, limited in 6 patients, and severely impaired in no patients. The cosmetic results were rated as excellent by 20 patients, good by 8 patients, and poor by 3 patients.

CONCLUSION

The STFF is an excellent option for mandibular reconstruction when other flaps are not available and for patients in poor general condition. Technical innovations here presented made possible to harvest long bone segments with accurate shape thanks to osteotomies if needed and with adequate soft tissues components of the chimeric flap, ensuring satisfactory functional and cosmetic results.

Virtual Surgical Guidance Improves Quality of Life Following Scapular Free-Flap Reconstruction of Maxillary Defects

BACKGROUND

The best approach to maxillary reconstruction with negative impact on the patient's quality of life (QOL) remains the subject of debate.

PURPOSE

This study was designed to evaluate the QOL outcomes following maxillary reconstruction using a scapular-free flap, with and without the computer-aided design and computer-aided manufacturing (CAD/CAM) technique.

STUDY DESIGN, SETTING, SAMPLE

A prospective randomized controlled clinical trial was performed following the CONSORT checklist. To be included, patients suffering from maxillary defects without previous surgery or lymph node involvement were selected. Patients with poor oncological prognosis, deficient performance status, preoperative chemotherapy, or radiotherapy, besides vascular contraindications, were excluded.

PREDICTOR VARIABLE

The predictor variable was the reconstruction technique, grouped into two equal categories. Patients were randomly assigned to reconstruction with a scapular-free flap, with the control group not utilizing a guide and the study group utilizing a CAD/CAM-customized guide.

MAIN OUTCOME VARIABLE

The primary outcome variable was the various domains of QOL, measured using the University of Washington Quality of Life score, 12 months after reconstruction.

COVARIATES

Age; sex; scapular flap side; and maxillary defect tumour type, histopathology, side, length, class, sagittal, and axial differential areas were considered.

ANALYSES

Shapiro-Wilk and Kolmogorov-Smirnov tests were performed for normality. For comparisons between the two groups, Student's t-test and Mann-Whitney test were used. The category variables were compared using the χ2 test. P ≤ .05 was considered statistically significant.

RESULTS

The sample was composed of twenty-two eligible patients, eleven in each group. The mean age of the control group was (50.09 ± 17.14) years, and 45.45% were male, while in the study group, the mean age was (48.36 ± 14.14) years, with 36.36% male. All the patients were evaluated, showing statistically significant differences between control and study groups in terms of pain, appearance, chewing, swallowing, speech, and shoulder (P ≤ .05), indicating that the scapular-free flap with a CAD/CAM osteotomy guide had improved the patient's QOL.

CONCLUSION AND RELEVANCE

The findings of this study indicate that virtual surgical planning with a CAD/CAM customized osteotomy guide using a scapular-free flap can improve QOL in maxillary reconstruction in terms of pain, appearance, chewing and swallowing food, pronouncing words, and shoulder QOL outcomes.

Use of scapular tip flaps in the reconstruction of head and neck defects: a systematic review and meta-analysis

Scapular tip flaps (STF) may be used as an alternative to traditional methods of reconstruction of head and neck cancer (HNC) defects. This study aimed to establish the success and complication rates for STF in HNC reconstruction. A literature search was conducted on PubMed, BMJ Journals, DARE, EMBASE databases and Cochrane (CENTRAL) register. (Registry CRD42023428012). A total of 23 studies fulfilled the inclusion criteria with 474 patients who underwent reconstructive procedures using the STF. 100% of STF used were free flaps (STFFs). The most common reason for reconstruction was following malignancy (81.4%, n = 386). The pooled success rates in all studies using scapular tip flaps in head and neck reconstruction was 99% (95% CI, 97 to 100, p = 1.00; I2 = 0). Pooled total complication rates were 38% (95% CI, 25 to 51, p < 0.01; I2 = 90%). 19.6% required return to theatre with only 1.5% being for repeat flap coverage. The STF demonstrated an overall success rate of 99%. This is higher than other documented success rates with mainstay flaps for HNC defect reconstruction. Complication and re-operation rates were also like recorded rates. This review demonstrates the advantage of STF as a safe and versatile reconstructive option for HNC related defects. Evaluation of the literature is limited by poor-quality studies and comparability bias.

Osseointegration and Bone Resorption of Scapula Tip Free Flaps in Mandibular Reconstruction

OBJECTIVES

Bone resorption of more conventional vascularized bone grafts have been well described showing minimal resorption over time. Few studies have evaluated osseous union and bone resorption in scapula tip free flaps (STFF) in the reconstruction of mandibulectomy defects. We aimed to describe our series on STFF with respect to osseous union and bone resorption over time.

METHODS

Retrospective chart review of patients receiving STFF from January 2014-January 2017 (n = 25). A neuroradiologist analyzed follow-up CT scans to assess (1) STFF complete, partial, or no osseous union with native mandible and (2) STFF volume change over time in a subset with multiple follow-up scans (n = 18).

RESULTS

Twenty-three of 25 patients (92%) showed complete or partial STFF osseous union with native mandible either distally or proximally. STFF volume change ranged from +4.8 to -54% (median -0.5%) over median follow-up interval of 23 months. History of chemoradiation therapy, bisphophonate use, sex, age, or smoking history did not correlate with bone resorption.

CONCLUSIONS

STFFs shows high rates of osseous union and limited bone resorption that is equivalent to, or less than, vascularized fibular and iliac crest flaps. Clinically, this translates into both optimal healing and functional and cosmetic outcomes, especially in the setting of prior therapies.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2597-2602, 2023.

Versatility of the subscapular system of flaps in head and neck oncologic reconstruction

PURPOSE OF REVIEW

This review analyzes the different ways of applying the subscapular system of flaps (SSSF) as a convenient and versatile solution for a large variety of head and neck oncologic defects.

RECENT FINDINGS

The ventral approach permits safe and efficient harvest of various chimeric SSSF in a supine position, thus allowing simultaneous flap preparation and tumor ablation. Conformational studies have revealed how similar the tip of the scapula is to the hard palate in terms of dimensions, shape, and conformation. This has led to favor horizontal placement of the scapular tip for palate reconstruction in most instances, addressing the vertical extension of the postmaxillectomy defect using denuded bony grafts surrounded by well vascularized chimeric muscular components.

SUMMARY

The SSSF possesses an unparalleled versatility to efficiently address small-medium sized soft tissue defects up to vast and complex composite resections. The chimeric components of these flaps benefit from a considerable independency provided by the length of the named arteries arising from the thoracodorsal pedicle, offering a high degree of freedom to accomplish the required in-setting. This reconstructive option should be implemented in every head and neck surgical team and offered to suitable patients.

Survival of vascularized osseous flaps in mandibular reconstruction: A network meta-analysis

Objective

An evidence regarding which bony flap for reconstruction of mandibular defects following tumour resection is associated with the highest survival rate is still lacking. This network meta-analysis (NMA) aimed to guide surgeons selecting which vascularized osseous flap is associated with the highest survival rate for mandibular reconstruction.

Methods

From inception to March 2021, PubMed, Embase, Scopus, and Cochrane library were searched to identify the eligible studies. The outcome variable was the flap survival rate. The Bayesian NMA accompanied by a random effect model and 95% credible intervals (CrI) was calculated.

Results

Twenty-two studies with a total of 1513 patients, comparing four osseous flaps namely fibula free flap (FFF), deep circumferential iliac artery flap (DCIA), scapula flap, and osteocutaneous radial forearm flap (ORFF) were included. The respective survival rates of FFF, DCIA, Scapula, and ORFF were 94.50%, 93.12%, 97%, and 95.95%. The NMA failed to show a statistically significant difference between all comparators (FFF versus DCIA (Odd ratio, 1.8; CrI, 0.58,5.0); FFF versus ORFF (Odd ratio, 0.57; CrI, 0.077; 2.9); FFF versus scapula flap (Odd ratio, 0.25; CrI, 0.026; 1.5); DCIA versus ORFF (Odd ratio, 0.32; CrI, 0.037; 2.1); DCIA versus scapula flap (Odd ratio, 0.14; CrI, 0.015; 1.1) and ORFF versus scapula flap (Odd ratio, 2.3; CrI, 0.16; 34)).

Conclusion

Within the limitations of the current NMA, FFF, DCIA, Scapula, and ORFF showed a comparable survival rate for mandibular reconstruction. Although the scapula flap reported the highest survival rate compared to other osseous flaps for mandibular reconstruction; however, the decision making when choosing an osseous flap should be based on many factors rather than simply flap survival rate.

3D printed models in mandibular reconstruction with bony free flaps

The aim of the study was to compare two types of mandible reconstructive operations with scapula and fibula free flaps: procedures with 3-D models from thermoplastic materials and conventional planning surgeries. 8 patients were treated due to an advanced oral cavity squamous cell carcinoma. In four patients with a mandibular defect, a physical 3-D model consisting of the reconstructed and unaffected sites was prepared for a reconstruction protocol. The 3-D models were designed based to high resolution CT scans. Assessment of comparative functionality (stability of junction, mobility, mastication ability) and cosmetics was examined in both groups, following a 8 weeks healing period with better results in group with 3D model. 3-D models for mandible and donor bones allow to obtain better functionality of restored mandible in comparison to the traditional method also significantly decreases time of the operation and allows to achieve the desired shape and esthetic effect within the 1/3 of the lower face.

Massive trapezial metastasis from gastric adenocarcinoma resected and reconstructed with a vascularized scapular bone graft: A case report

RATIONALE

Isolated metastasis to the hand bones is very rare. Only seven cases of metastasis to the trapezium have been reported. To the best of our knowledge, this is the first report of a single metastasis to the trapezium from a gastric adenocarcinoma.

PATIENT CONCERNS

A 62-year-old man presented with pain and massive swelling in the right carpometacarpal joint of the thumb.

DIAGNOSES

The patient was diagnosed with trapezial metastasis of advanced gastric adenocarcinoma.

INTERVENTIONS

The patient underwent systemic chemotherapy with cisplatin and S-1, radiotherapy to the metastatic bone, and treatment with denosumab. One year later, the huge metastatic tumor was resected, and the hand was reconstructed using vascularized scapular bone.

OUTCOMES

Eighteen months postoperatively, the patient was satisfied with the appearance of the reconstructed hand and was able to use his right thumb in activities of daily living.

LESSONS

Although rare, metastasis to the trapezium should be considered in patients with persistent and progressive thumb CMC joint pain.

Optimization of bone-block positioning in the Bristow-Latarjet procedure: a biomechanical study

BACKGROUND

In the Bristow-Latarjet procedure, optimal positioning of the coracoid bone-block on the anterior aspect of the glenoid (standing or lying on the glenoid rim) remains debated. A biomechanical study assessed the effect of the position of the bone-block with its attached conjoint tendon on anterior and inferior stabilization of the humeral head.

MATERIALS AND METHODS

The Bristow-Latarjet procedure was performed on 8 fresh cadaveric shoulders. The bone-block size was systematically at 2.5×1×1 cm. Anterior translation of the humeral head was stress induced under 30-N traction, in maximum external rotation at 0° and at 90° abduction: respectively, adduction and external rotation (ADER), and abduction and external rotation (ABER). Under radiological control, displacement of the center of the humeral head was compared with the glenoid surface at the 3, 4 and 5 o'clock (medial, antero-inferior and inferior) positions for the 2 bone-block positionings.

RESULTS

The lying position at 4 o'clock substantially decreased anterior and inferior displacement of the humeral head respectively in ADER and ABER; and in ABER it also tended to decrease anterior translation, but not significantly. The standing bone-block position did not affect translation.

CONCLUSIONS

Positioning the bone-block so that it lies on the anterior aspect of the glenoid in the middle of the antero-inferior quarter of the rim at 4 o'clock can decrease anterior displacement of the humeral head and inferior glenohumeral translation, especially in ADER for anterior displacement and in ABER for inferior displacement.

STUDY DESIGN

Laboratory study.

[Reconstruction of maxillary defects using a free scapular angle flap]

BACKGROUND

In addition to prosthetic rehabilitation, maxillary defects can also be surgically reconstructed. Soft-tissue reconstruction employs a radial forearm or latissimus dorsi muscle flap, while bony reconstruction can be achieved using a fibula, iliac crest, or scapular flap. Reconstruction using a scapular flap is further divided into two subgroups: the traditional scapular flap with the circumflex scapular artery as the donor vessel and the scapular angle flap with the angular artery originating from the thoracodorsal artery as the donor vessel.

MATERIALS AND METHODS

We report on four patients who underwent successful reconstruction with a free scapular angle flap between 2009 and 2011, following maxillary resection due to malignancy.

RESULTS

Vertical positioning of the scapular angle flap enables reconstruction of the facial contour, whereas its horizontal alignment and microvascular anastomosis makes a bony reconstruction of the hard palate possible.

CONCLUSIONS

The versatility, low rate of donor site morbidity and shape of the scapular angle flap--which resembles that of the hard palate--render it ideal for plastic reconstruction. The suitability of bone quality for dental rehabilitation with implants is a topic of controversial discussion. The scapular angle flap represents an alternative to obturator prosthesis for the reconstruction of maxillary defects ≥ grade I according to Okay et al.

Reconstruction of isolated mandibular bone defects with non-vascularized corticocancellous bone autograft and graft viability

OBJECTIVE

The aim of this study is to discuss the use of non-vascularized bone grafts in mandibular reconstruction and their viability.

METHODS

In this study, 11 patients with mandibular defect treated by surgery using non-vascularized bone grafts between 2011 and 2012 were reviewed. All patients underwent preoperative and postoperative 3-dimensional computerized tomography scan for surgical planning and evaluation of success after surgery. Grafts were used for defects caused by mandible tumors in 2 patients and firearm injuries in 9 patients. Reconstruction was achieved by using various non-vascularized bones, including iliac crest, fibula and scapula. To improve graft supply, periosteum of the grafts was spared and multiple bores were created on the graft during surgery by drilling. At the postoperative period, Dextran 70 and Bencyclane Hydrogen Fumarate was given in order to enhance micro-circulation. On the postoperative day 5, 15 and 30, Tc-99m methylenediphosphonate scintigraph, blood-pool single photon emission computed tomography and it's bone phase were performed in order to assess viability of bone grafts greater than 3cm.

RESULTS

Mean age was 32. 27±13.33 (min=10-max=56). Of the 11 patients, 10 (90. 9%) were men and 1 (9. 1%) was woman. Mandibular defects were at right corpus in 3 patients; at right ramus and angulus in 1 patient; at left corpus in 1 patient; at left ramus and angulus in 1 patient; at left ramus, angulus and corpus in 1 patient; left parasymphysis in 1 patient; at bilateral corpus in 1 patient; at symphysis in 1 patient and at whole segment from right corpus to left one in 1 patient. The following grafts were used: iliac crest grafts in 9 cases, scapula graft in 1 case and fibula graft in 1 case. The smallest graft used was 1×2cm in size, while the greatest, single piece graft was 7cm in size. The greatest multi-piece graft was a fibula graft of 14cm in length. All grafts with a size of 3 and 7cm had been supplied at the end of first month. No bone resorption or donor site morbidity was observed in any patient.

CONCLUSION

Non-vascular bone grafts can be successfully used in isolated bone defects of mandible in case of appropriate graft selection for fitting anatomical region. A single piece iliac crest grafts up to 7cm can be revascularized in long-term.

CLINICAL ANATOMICAL STUDY OF PEDICLED VASCULARISED SCAPULAR BONE GRAFT USING THE ANGULAR BRANCH

This study is an anatomical investigation of the angular branch of thoracodorsal artery, and examines the possible range of clinical targets for pedicled vascularised scapular bone graft.

Forty-six cadavers were studied. The blood vessel length was calculated, and the distance required to reach the distal humerus from the lower end of the articular surface of the humeral head as reference point was compared with bone length.

The length from reference point was an average of 121.7 mm. It was thought that the maximum distance to arrive in reference point to the distal humerus was a total of blood vessel length and transplantation bone length, which was an average of 246.3 mm. This was longer than the average of 240.8 mm of bone length from reference point to humeral medial condyle.

This study had confirmed that a pedicled vascularised scapular bone graft using the angular branch could be transplanted to the distal humerus.

Coracoid graft osteolysis after the Latarjet procedure for anteroinferior shoulder instability: a computed tomography scan study of twenty-six patients

BACKGROUND

The Latarjet procedure has been advocated as an option for the treatment of anteroinferior shoulder instability in certain patients. However, progression of the transferred coracoid bone graft to osteolysis has been reported in the literature. We propose that the coracoid bone graft osteolysis could be one of the causes of failure of the Latarjet procedure.

MATERIALS AND METHODS

A computed tomography scan analysis was done of 26 patients prospectively followed-up after the Latarjet procedure to determine the location and the amount of the coracoid graft osteolysis.

RESULTS

The most relevant osteolysis was represented by the superficial part of the proximal coracoid, whereas the distal region of the coracoid bone graft, especially in the deep portion, was the least involved in osteolysis and had the best bone healing.

DISCUSSION

To our knowledge, this is the first study to quantify and localize coracoid osteolysis after Latarjet procedure for anteroinferior shoulder instability using CT scan analysis.

CONCLUSION

Our study suggests that the bone-block effect from the Latarjet procedure may not be the principal effect in its treatment of anteroinferior shoulder instability in patients without significant bony defects.

[Vascularized bone transfer of scapula apophysis]

The vascularized bone transfer of the scapular apophysis was described for the first time by Gilbert and Téot (1982) [1]. The growing pattern of this specific apophysis has large capacity and the plasticity during remodeling is unique. Primarily used for mandibular reconstruction, the scapular crest is also suitable for humeral or femoral reconstruction as well as for carpal stabilization in radial hand malformation, which is considered to be the main clinical indication. The radial hand malformation is characterized by an insufficient ulnar carpal stabilization which leads to luxation and radial deviation of the carpus. Using the vascularized scapular transfer in volar apposition to the ulnar, it enables enlarging the contact surface area with the carpus, thus stabilizing the wrist. Due to the preserved epiphyseal vascularization, good remodeling and integration of the scapular crest is achieved until consolidation takes place.

The scapular free flap: when versatility is needed in head and neck reconstruction

OBJECTIVE

To review the experience with scapular free tissue transfer at the University of Western Ontario and to describe the various applications of both the fasciocutaneous and osteocutaneous versions.

DESIGN

Retrospective review.

SETTING

Tertiary care centre.

METHODS

A retrospective review was conducted of patients who underwent a scapular free flap reconstruction between 1997 and 2007. Osteocutaneous and fasciocutaneous flaps were included. Demographic data including gender and age were collected. Defect analysis and complications were also reviewed.

MAIN OUTCOME MEASURES

Defect analysis, flap-related complications, and non-flap-related complications.

RESULTS

Sixty procedures, including 31 osteocutaneous and 29 fasciocutaneous flaps, were performed. Most fasciocutaneous flaps were used for large lateral skull base and facial defects (70%). The skin paddle dimensions ranged from 4 × 3 to 15 × 10 cm. All osteocutaneous flaps were used for mandibular reconstruction. The length of the bony defect ranged between 4 and 12 cm. Eleven patients required osteotomies. In most cases, the facial or external carotid arteries and internal jugular or facial veins were selected as recipient vessels. A vein graft was required in four cases. The total flap failure rate was 5%. Seven patients who had osteocutaneous flaps suffered medical complications, including one mortality.

CONCLUSIONS

Scapular free flaps are reliable options. Fasciocutaneous applications are suitable for defects requiring facial contouring or complex skull base defects. Osteocutaneous flaps are acceptable options for patients with comorbidities requiring bony reconstructions. The flap complication rates were acceptable even in medically higher-risk patients.

Revascularized free scapular flaps in mandibular reconstruction. Report of 93 cases (April 1997 - October 2009)

OBJECTIVE

The aim of the present article is to demonstrate the relevance of revascularized free scapular flap in mandibular reconstruction in oncological cervicofacial salvage surgery. We will discuss the advantages and the disadvantages, indications and contraindications, together with possible complications and sequelae for this type of surgical flap.

MATERIAL AND METHODS

Retrospective study of 93 revascularized free scapular flaps used to reconstruct segmental substance defects in the mandible from April 1997 to October 2009 (in 91 patients). All patients benefited from 10 months to 12 years follow-up surgical and functional results. Functional assessment following anatomic site restoration focused on the quality of feeding and deglutition.

RESULTS

The anatomical success rate was 94.63% (5 complete necroses out of 93 flaps). Results were considered to be good (normal or close to normal function for feeding and deglutition) in the majority of patients (83% at 6 months, 91% at 18 months). On the donor site: Functional sequelae were moderate when post-operative reeducation was correctly performed.

CONCLUSION

Vascularized free scapular flap bone graft is very interesting for the reconstruction of mandibular discontinuity, composite (soft tissue and cutaneous resection) or exclusively osseous defects (not in excess of 13 cm), secondary to oncologic or osteoradionecrotic resections.

The osteomuscular dorsal scapular (OMDS) flap: an alternative technique of mandibular reconstruction

Free tissue transfer has become the dominant reconstructive tool for segmental defects of the mandible, except in case of severe peripheral vascular disease. In these cases, we propose to use the osteomuscular dorsal scapular (OMDS) flap as an alternative technique. This flap is pedicled on the dorsal scapular vessels with the harvesting of the medial border of the scapula and the lateral part of the rhomboid muscles.

METHODS

Thirteen cadaveric dissections have been performed after arterial injection of coloured latex in order to describe the surgical landmarks of the dorsal scapular pedicle. Six patients have been operated after lateral resection of the mandible.

RESULTS

The mean length of the pedicle was 66 mm (+/-2.61). The pedicle was located 41.2 mm (+/-5.51) lateral to the superior angle and 24.6 mm (+/-7.50) lateral to the medial angle. The size of the medial border that could be used for mandibular reconstruction was 116.4 6 mm (+/-7.48). The width of the medial border was 2.62 mm (+/-0.77) on the upper part and 3.35 mm (+/-0.90) on the inferior part. The clinical results were satisfying; good symmetry of the mandible was restored with normal opening of the mouth. Normal elevation of the shoulder was retained without recourse to physiotherapy.

DISCUSSION

The advantages of this method over other pedicled flaps include the length of the bone that can be harvested (>12 cm) allowing reconstruction of defects from the condylar process to the canine region and the preservation of scapular elevation. The superior part of the trapezius was not harvested, in order to allow passage of the flap in the tunnel under the upper trapezius to preserve the scapular elevation. The main disadvantages of the OMDS flap are the impossibility of placing implants in the bone that have been harvested because of its thickness and the lateral position that has to be changed to supine to allow access for resection of the tumour.

Penile reconstruction by the free scapular flap and malleable penis prosthesis

BACKGROUND

: Penile reconstruction has always been a challenging problem for plastic surgeons while facing patients with severe congenital deformities and gender dysphoria and those who have suffered penile loss because of trauma, self-amputation, malignancy, and so on. Since 1936, when Bogoras first constructed a total penis, attempts have been made by different techniques, including skin flaps or myocutaneous flaps. And with development of free tissue transfer and microsurgical techniques, various free skin flaps, such as the radial free forearm flap, the superficial inferior epigastric artery flap, the superficial circumflex iliac artery flap, have been attempted for phallic construction, with the goal of functional (including a competent neourethra that allows voiding while standing and sexual intercourse) and cosmetic result. The purpose of our study was to evaluate the scapular free flap and implantation of malleable penile prosthesis for penile reconstruction.

PATIENTS AND METHODS

: Since March 2000, 20 patients with penile loss were reconstructed in a 1-stage procedure by transferring scapular flap and implantation of a malleable penile prosthesis. The age of the patients ranged between 21 and 36 years old. Of these patients, 12 had penile amputation resulting from an electric accident; the other 8 were self-amputated.

RESULTS

: All the flaps remained 100% viable postoperatively. Follow-up ranged from 1 to 5 years. There were no cases of urethral fistula, urethral stenosis, prosthesis extrusion, or infection. The reconstructed penis yielded satisfactory function and esthetic appearance.

CONCLUSION

: The scapular free flap is an ideal flap that achieves satisfactory function and esthetic appearance for penile reconstruction because of its adequate amount of tissue, reliable vascularity, acceptable donor-site morbidity, and reliable blood supply.

The pedicled vascularised scapular bone flap for proximal humerus reconstruction and short humeral stump lengthening

The vascularised scapular bone free flap is popular in mandible reconstruction, but it is less commonly used as a pedicled flap to reconstruct the upper humerus. We analysed our experience with pedicled scapular crest flaps in humerus reconstruction and compared our results with cases reported in the literature. We considered the age at surgery, the time elapsed before reconstruction, the time required to obtain solid bony union, the operative indication, the osteosynthesis procedure used and whether circumflex scapular vessels or angular vessels were used. There were eight patients (seven men and one woman, mean age=33): four humerus stump lengthenings, two upper-third humerus bone and soft tissue defects and two multioperated established humerus non-unions. Flaps were pedicled either on circumflex scapular vessels (three) or angular vessels (five). The mean size of the scapular bone used was 9.4 cm (range 7-11 cm). We associated a covering flap for seven patients. All the flaps survived and bone healed in a 3.75 month mean delay (range three to six months), and there was one accidental secondary fracture one year after reconstruction. For a vascularised reconstruction of the upper humerus, the pedicled scapular bone flap is a valuable option especially if a composite reconstruction is needed. For short humerus stump lengthening, this flap seems to provide a very satisfactory solution.

Le lambeau ostéomusculaire de muscle latissimus dorsi avec bord latéral de scapula: étude anatomique et application clinique

The goal of the reconstruction of complex defects of the leg is to restore morphology, trophicity and function. The purpose of our study was to analyse the reliability of the latissimus dorsi scapula flap in this indication. We realized an anatomical study on 12 cadaver dissections. The presence of the angular artery was found to be constant with four types of origins described in this article. The same technique was applied on three patients presenting a complex tissue loss of the middle third of the tibia. This clinical application confirmed the validity of the technique.

Reconstructing Wide Palatomaxillary Defects Using Free Flaps Combining Bare Serratus Anterior Muscle Fascia and Scapular Bone

PURPOSE

Wide palatomaxillary defects, mostly after tumor resections, can cause severe functional and esthetic problems. Although prosthetic obturator devices or local flaps are mostly adequate for uncomplicated small-size defects, free flaps are preferred for a 3-dimensional multitissue reconstruction of more complicated defects. Regarding the anatomical structure of the palatomaxillary region, the flap must be thin enough to separate the oral and nasal cavities while not compromising palatal function, yet rigid enough for adequate dental restoration. This goal is usually accomplished with a combined or complex free flap. Numerous free flaps containing both soft tissues and bone have been described in the literature. In this study, we present a novel use of the free scapular bone flap combined with serratus anterior fascia and its functional and esthetic results.

PATIENTS AND METHODS

Nine cases are presented whose wide composite palatomaxillary defects were repaired with free angular scapular bone flap combined with serratus anterior fascia based on the subscapular vascular system, between 1999 and 2003. Scapular bone wrapped with the naked serratus anterior fascia, like a sandwich, was used to repair the palate.

RESULTS

The naked fascia was epithelialized with the help of the surrounding mucosa in 4 to 6 weeks. Results were satisfying with regard to breathing, eating, speech, and facial contour after follow-ups for 2 months to 6 years.

CONCLUSION

For the reconstruction of wide palatomaxillary defects, a combined flap of angular scapular bone wrapped with naked serratus anterior fascia was conceived useful for obtaining satisfactory functional and esthetic results.

La reconstruction mandibulaire par lambeaux libres osseux: résultats fonctionnels

OBJECTIVES

The aim of this retrospective study is to evaluate functional results of oromandibular reconstruction with osseous free flaps.

MATERIAL AND METHODS

A total of 67 patients who underwent oromandibular reconstruction with fibula (n=60) or scapular (n=7) free flap between 2000 and 2004 were included in this study. We analysed functional results (alimentation, elocution, mouth opening and cosmetic appearance) and researched the potentially predictive factors of these results (age, comorbidity, preoperative irradiation, type of defect...; Chi(2) test).

RESULTS

The rate of free flap success was 89.6%. A functional result considered as normal or subnormal was obtained by more than 50% of patients. Oral alimentation (without tube feeding) and intelligible speech were recovered by 92.5% of patients. Through and through defects and free flap failures were determinant predictive factors of worse functional outcomes.

CONCLUSION

Fibula free flap is considered as the flap of choice for oromandibular reconstruction and allows excellent functional results.

Scapula osteocutaneous free flap reconstruction of the head and neck: Impact of flap choice on surgical and medical complications

BACKGROUND

The scapula osteocutaneous free flap is frequently used to reconstruct complex head and neck defects given its tissue versatility. Because of minimal atherosclerotic changes in its vascular pedicle, this flap also may be used as a second choice when other osseous flaps are not available because of vascular disease at a preferred donor site.

METHODS

We performed a retrospective chart review evaluating flap outcome as well as surgical and medical complications based upon the flap choice.

RESULTS

The flap survival rate was 97%. The surgical complication rate was similar for the 21 first-choice flaps (57.1%) and the 12 second-choice flaps (41.7%; p = .481). However, patients having second-choice flaps had a higher rate of medical complications (66.7%) than those with first-choice flaps (28.6%; p = .066). Age and the presence of comorbidities were associated with increased medical complications. All patients with comorbidities that had a second-choice flap experienced medical complications, with most being severe.

CONCLUSIONS

The scapula osteocutaneous free flap has a high success rate in head and neck reconstruction. Surgical complications occur frequently regardless of whether the flap is used as a first or second choice. However, medical complications are more frequent and severe in patients undergoing second-choice flaps.

Scapular angle osteomyogenous flap in postmaxillectomy reconstruction: Defect, reconstruction, shoulder function, and harvest technique

BACKGROUND

Maxillary reconstruction continues to challenge in terms of optimal aesthetic and functional outcomes. The aim of this study was to describe the utility of the scapular angle osteomyogenous flap in a series of maxillectomy patients and to examine the donor site morbidity.

METHODS

This is a retrospective series of 14 patients undergoing maxillectomy and either primary or secondary reconstruction. The scapular angle can be oriented vertically and horizontally. Aesthetic, functional, and operative morbidity is described. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to examine shoulder and upper limb morbidity.

RESULTS

Perioperative morbidity occurred in 4 patients. There were no free flap failures. Functional and aesthetic outcomes were acceptable with all patients having intelligible speech and none requiring nutritional supplementation. The DASH was completed by 12 of 14 patients. The mean and median DASH scores were 10.6 and 13, respectively. All patients gained full range of shoulder movement by 6 months after surgery.

CONCLUSIONS

The scapular angle flap is well suited for maxillary reconstruction and donor site morbidity is low.

The thoracodorsal artery perforator flap with a vascularized scapular segment for reconstruction of a composite lower extremity defect

High-energy trauma resulting in a composite defect of the lower extremity confronts the microvascular surgeon with more difficulties than do free flap reconstruction elsewhere in the body, since the choice of distant recipient vessels is particularly difficult. Combining principles of perforator flap surgery with those of composite tissue transfer, we designed a thoracodorsal artery perforator flap with a vascularized bone segment from the scapula for reconstruction of a composite lower extremity defect in a patient following a paragliding accident. This is the first report on the application of a composite thoracodorsal artery perforator flap with vascularized scapula in lower extremity reconstruction. Among its multiple advantages, such as preservation of latissimus dorsi function, it is a good tool for one-stage reconstruction of traumatic composite lower extremity defects because its low donor site morbidity and long vascular pedicle enables anastomosis placement outside the zone of injury.

[Osteomyocutaneous latissimus dorsi scapular combined flap with vascularized rib to repair the large defect of tibia]

OBJECTIVE

To design a combined flap of subscapular axis including vascularized lateral scapular, rib and latissimus dorsi to repair the large defect of tibia.

METHODS

The patient was a 39-year-old man who got a posttraumatic 12 cm defect of tibia after primary debridement and external fixation because of open fracture 5 months ago. There was a 12 cm x 6 cm scar involved the proximal medial segment of tibia. After resection of scar and fibular tissue over the bone defect floor, a latissimus dorsi myocutaneous flap 14 cm x 5 cm pedicled with subscapular artery-thoracodorsal artery, a flap 12.5 cm on the outside of the scapular pedicled with thoracodorsal artery, and 6th rib flap 13 cm by serratus were prepared. The tibialis posterior and saphenous vein were used for anastomosis. A proximal anatomic plate was applied to the fixation of tibia.

RESULTS

The compound flap survived the operation. The follow-up period was 2 years. Bone union occurred 6 months after operation.

CONCLUSION

This combined flap is successful and can provide alternative to the resolution of large defect of tibia.

[Microvascular study of the transmidline scapular flap vascularized by the contralateral circumflex scapular artery]

OBJECTIVE

To observe the microvascular distribution of the transmidline scapular flap supplied by the contralateral circumflex scapular artery.

METHODS

The integument and deep tissues of 6 fresh cadavers were dissected and radiographed after vermilion mixture was injected to the unilateral circumflex scapular artery.

RESULTS

The vascular tree passed the midline and reached to the contralateral acromion. The vessel density was the highest in the irrigating side of the back, which was higher in the middle area. In the contralateral side,the high vessel density concentrated in the upper part of the back.

CONCLUSIONS

The result revealed the direct evidence for the clinical application of the transmidline scapular flap. In design and elevating of the transmidline scapular flap, it should be slanting to the upper part of the contralateral back.

[Composite scapular flap for reconstruction of complex humeral tissue loss: a case report]

We report a case of complex reconstruction after traumatic loss of bone and muscle of the upper third of the humerus. A composite flap using the lateral border of the scapula and the pediculated latissimus dorsi muscle was used. The latissimus dorsi flap covered the bony reconstruction and enabled elbow flexion. Outcome was very satisfactory at three years follow-up. The lateral border of the scapula is rarely used for bony reconstruction of the humerus. Free composite flaps with the lateral portion of the scapula and the latissimus dorsi muscle have been used to reconstruct tissue loss of the lower limb. We were unable to find another published case where this composite pediculated flap was used for the upper limb.

Osseous free tissue transfer in head and neck reconstruction

Large palatomaxillary and oromandibular defects have a dramatic impact on speech, deglutition, mastication, and cosmesis. Traditional methods of reconstruction, such as locoregional flaps, free bone grafts, alloplastic materials, and prosthetic devices, have difficulty providing meaningful aesthetic and functional reconstruction of these defects. This article discusses current concepts in the reconstruction of large composite palatomaxillary and oromandibular defects with an emphasis on the role of free tissue transfer, including the factors to be evaluated when choosing a method of reconstruction, indications for specific donor sites, and recent technical refinements.

Stability of dental implants in microvascular osseous transplants

Microvascular iliac crest and scapula transplants have been used in reconstruction of the lower jaw following tumor surgery. It has only been with the insertion of dental implants that a satisfactory prosthetic rehabilitation of the patient has been achieved. For this study, a follow-up of 38 patients with lower jaw tumors was carried out. The patients had been treated with partial resection of the lower jaw and neck dissection with microvascular iliac crest transplants (n = 20) or microvascular scapula transplants (n = 18); this was followed with dental implants (n = 143) in the region of the transplants or the local lower jaw. One hundred thirty-nine of the 143 dental implants were loaded by prosthetic superstructures. In all patients, the implant situation was evaluated on average 2 years 5 months after implantation. Periotest values, periimplant probing depths, and contact bleeding were registered, and the extent of periimplant bone loss was defined radiographically. The clinical situation in the region of the implant was compared for both types of implants and also with the nonresected lower jaw. The average Periotest values were within the normal range for all groups. In one scapula implant, however, a better average of Periotesting, -3.3, was found compared with implants of the iliac crest with Periotest values of -0.7. A measurement of -2.1 was found for the local lower jaw, similar to that of scapula implants. Pathologic probing depths were found for all three compared groups. The radiographically determined vertical loss of bone was the same for all three groups, on average 1 mm at 27 months postoperatively. The highest incidence of sulcus bleeding was found in the scapula implant group. Thus, it can be stated that the scapula transplants provide a similar transplant site to local lower jaw bone, whereas implants in iliac crest transplants show lesser bony stability. Periimplant soft-tissue conditions are worse for both types of transplants compared with local tissue of the lower jaw.

Evaluation of microvascular bone graft reconstruction of the head and neck with 3-D 99mTc-DPD SPECT scans

OBJECTIVE

We conducted a prospective investigation to evaluate the diagnostic accuracy of computer-aided 3-dimensional (3-D) technetium 99m dicarboxypropane methylene diphosphonate ((99m)Tc-DPD) single photon emission computed tomography (SPECT) reconstruction in the evaluation of microvascular bone flaps used for maxillofacial reconstruction.

STUDY DESIGN

Twenty patients who received 20 autogenous microvascular bone flaps for reconstruction of the mandible and maxilla were evaluated. Forty bone scans with subsequent computer-aided reconstruction were performed. Each graft could be assessed within 48 to 72 hours after surgery. The second bone scan was performed between 12 and 14 days after surgery.

RESULTS

Complications were observed in 5 grafts. SPECT investigation performed at the 2 time points after reconstruction showed a significantly higher tracer uptake in grafts with an uncomplicated further course than in those that developed complications.

CONCLUSIONS

Computer-aided 3D (99m)Tc-DPD SPECT reconstruction serves as a useful prognostic tool and helps in the very early recognition of complications. This technique adds significantly to the value of planar bone scintigraphy and conventional SPECT images.

Restoration of facial contour in Romberg's disease and hemifacial microsomia: experience with 118 cases

The experience with free flaps and conventional reconstructive procedures for 118 patients with Rombergapos;s disease and hemifacial microsomia over a 10-year period is presented. The groin free flap was used most frequently for patients with Rombergapos;s disease, whereas the scapular free flap was used for patients with hemifacial microsomia. The rectus abdominis or the latissimus dorsi free flap was chosen only when additional volume was required. To achieve better contour, secondary procedures, such as defatting the flap, pedicled temporal fascial flaps, cartilage and bone grafts, orthognathic surgery, and bone distraction were performed in severe cases. For patients with Rombergapos;s disease, excellent results were achieved in 35% (n = 28) of mild cases, in 72% (n = 27) out of 38 moderately and in 41% (n = 5) out of 12 severely affected patients. In hemifacial microsomia group (n = 40) excellent results were obtained in 66% of cases.

Mandibular reconstruction in children

Facial deformities due to loss of mandibular segments in children lead to severe functional and psychological disturbances. Such deformities should be corrected taking into account both contour and function. In addition, they should be planned for long-term growth and performed in the fewest possible surgical stages. This article presents the experience in seven cases of mandibular reconstruction in children after surgical ablation for benign conditions. We performed a scapular flap in one case and fibular flaps in six. The mean age of the patients was 9.1 years. Follow-up ranged from 1.5 to 5 years. All flaps survived. No osseous remodeling was needed in any case. All patients showed symmetrical facial and mandibular growth, as well as adequate masticatory function. Excision of the tumor and reconstruction should be carried out in the same surgical procedure whenever possible. The fibula was used in most cases because of its easy dissection, the ample amount of bone it provides, and the potential to redirect it. The author favors mandibular reconstruction in children with a free flap, as this approach offers adequate form and function in the long term.

Increasing use of the scapula osteocutaneous free flap

OBJECTIVES

To determine the appropriate use of the scapula osteocutaneous free flap (SOFF) and to document donor site morbidity.

STUDY DESIGN

Retrospective review and prospective physical therapy evaluation.

METHODS

A computer database of all free flap procedures performed at a single institution was created. Specific clinical and operative details from cases involving a bone flap were extracted from the database. Rates of usage of the various osteocutaneous flaps were compared over four successive 2-year intervals (1992-1999). A single physical therapist performed a structured evaluation of the donor site.

RESULTS

Overall, 64 bone flap procedures were performed, of which 24 (37.5%) were SOFF procedures. The SOFF utilization has increased from 6.6% to 63.6%, while fibula and iliac crest utilization has fallen significantly. This is in part because of the greater versatility of the SOFF, with the possibility of separate skin paddles and adequate bone length. The mean cutaneous area harvested with the SOFF was 110 cm2 (range, 48-200 cm2) compared with 55.4 cm2 (range, 25-102 cm2) and 77.6 cm2 (range, 50-120 cm2) for the fibula and iliac crest, respectively. Mean bone flap lengths were 8.37, 7.65, and 10.1 cm, respectively, for the SOFF, fibula, and iliac crest. Dual skin paddles were used in 50% of the SOFF procedures versus 2.8% for the fibula flap procedures. There were no significant complications of the donor site in any patient, and there was only one flap failure (4.1%). Related to the SOFF, donor site morbidity was subjectively judged as "mild," for pain, mobility, and strength. There were no complaints of poor appearance of the donor site. Activities of daily living were judged as "not limited" or 'limited a little" in the majority of patients. Objective measurements of range of motion revealed an average reduction of 1 degree to 12 degrees in five different shoulder functions. Elbow and arm ranges of motion were not limited. Strength was minimally reduced in the shoulder, while the arm and forearm showed no reduction in strength.

CONCLUSIONS

The SOFF is a versatile osteocutaneous free flap that can be used for a multitude of reconstructive problems. This and its relative lack of significant donor site morbidity have caused its use to increase significantly.

Neuronal structure of microvascular transplants with and without neuronal anastomosis

OBJECTIVE

Latissimus dorsi transplants have little neuronal regenerative capacity without neuronal anastomosis. Histologic differences between transplants with and without neuronal anastomosis and 2 distinct types of neurosurgical reanastomosis are highlighted in this study.

PATIENTS AND METHODS

Fifty-four patients with squamous cell carcinomas of the oral cavity (T4) were treated by tumor resection and homolateral neck dissection. The defect was covered with a microvascular latissimus dorsi transplant. In 15 patients, no neuronal anastomoses were performed. In 21 patients, the thoracodorsal nerves were used for microneurosurgical reanastomosis, whereas in 18 patients, the cutaneous branches of the intercostal nerves were used for microneurosurgical reanastomosis. The transplant was examined during surgery and 9 months after surgery by means of a histologic examination of a biopsy specimen. The number of fascicles, the degree of fibrosis, and the myelination were examined. Furthermore, a neurosensory examination was performed 9 months after surgery.

RESULTS

Overall, our patients had an average of 12.1 fascicles during surgery. After surgery, patients without neuronal anastomosis showed an average of 4.9 fascicles, patients with nerve anastomosis to the cutaneous branches of the intercostal nerve showed an average of 6.2 fascicles, and patients with anastomosis to the thoracodorsal nerve showed an average of 9.6 fascicles. In cases of nerve anastomosis, a lesser degree of fibrosis was found, together with good myelinization. The clinical examination showed the best neurosensory function in the transplants with anastomosis to the thoracodorsal nerve and the worst function in those without neuronal anastomosis.

CONCLUSION

Neuronal reanastomosis led to more surviving neuronal structures in the postoperative histologic specimen. The highest density of fascicles was found in the well vascularized thoracodorsal nerve. The neurosensory function agrees with the histologic result.

Reconstruction following radical maxillectomy with flaps supplied by the subscapular artery

The authors present their experience of 27 cases with repairs of defects following radical maxillectomies with free flaps. A total of 28 flaps were used (five latissimus dorsi, six scapula, 16 combination flaps of scapula and latissimus dorsi and one combination of scapula, latissimus dorsi and serratus anterior flap). Only one scapula flap was completely lost and in three cases where a combination of scapula and latissimus dorsi flap was used, partial necrosis of one component occurred. The authors first choice for reconstruction is a scapula bone flap raised on the angular artery combined with the latissimus dorsi flap. The combination of flaps with a long pedicle and of the bony and muscular components provides the surgeon with the option of customizing the flap to meet individual patient needs. For intraoral closure the authors prefer the latissimus dorsi muscle which rarely requires secondary procedures for prosthesis placement following epithelialization and atrophy. The main disadvantage of the flap is the difficulty of two teams working simultaneously, thus increasing the average operating time. All postoperative corrections and prosthetic rehabilitation should be postponed for at least 2 months following surgery because of postoperative swelling.

Comparison of the late results of mandibular reconstruction using nonvascularized or vascularized grafts and dental implants

PURPOSE

This study evaluates contour restoration in segmental defects of the mandible and the survival rate of endosseous implants placed into these reconstructions.

PATIENTS AND METHODS

Forty-four patients with 23 nonvascularized grafts and 21 patients with vascularized bone flaps were included in the study. The lateral and the sagittal extension of the contour of both the mandibular bone and the overlying soft tissues was determined from serial computed tomography (CT) scans in defined planes through the reconstructed mandible. The success rate of dental implants was determined by a life-table analysis.

RESULTS

Average lateral deviation of the reconstructed side from the nonreconstructed side was 4.3 mm (nonvascularized grafts) and 5.6 mm (vascularized grafts). The soft tissue contour followed the skeletal contour quite closely, with slightly smaller degrees of deviation. Asymmetry was greatest in the area of the horizontal ramus. In some cases, skeletal deviation was intentionally produced to compensate for a soft tissue deficit on the reconstructed side. However, in some cases, a major deviation of bone contour was associated with considerable deviation of the soft tissue contour (maximum, 10.5 mm). The cumulative implant success rate was 100% after 5 years and 60.3% after 10 years. None of the seven implant failures accounted for prosthetic failure.

CONCLUSIONS

Although there are minor differences, both nonvascularized and revascularized grafts allow for satisfactory contour restoration in segmental reconstructions of the mandible. Implants placed into these grafts provide a reliable basis for dental rehabilitation.

[Reconstruction of a complex defect of the upper third of the humerus by pedicle transplant of the lateral edge of the scapula. A case report]

Vascularized bone transfer of the lateral border of the scapula is exceptionally used in orthopaedic surgery. The authors report a case of pedicle transfer of the lateral border of the scapula designed to reconstruct a nine centimetre bone defect of the upper third of the humerus following a gunshot wound. A complementary conventional bone graft was performed one month later and consolidation was achieved at the fourth month.

Revascularized composite grafts with inserted implants for reconstructing the maxilla--improved flap design and flap prefabrication

We present a new technique including prefabrication of a revascularized composite scapular flap that will fit a maxillary defect exactly. The method is based on careful preoperative planning using three-dimensional reconstructions of data obtained from computed tomograms and stereolithographic models. A pedicled scapular flap with a split skin graft envelope that has endosteal implants already inserted is prepared and covered by a polytetrafluoroethylene (PTFE, Goretex) membrane. After 3-4 months these prefabricated grafts are harvested, inserted into the maxillary defects, and reanastomosed to the facial vessels. Two to three weeks later, after mucosal healing, a prosthesis can be fitted on the endosteal implants. Histological evaluation of the flap shows vital bone reactions and attachment of the split skin graft.

Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder

We performed ninety-five consecutive Latarjet procedures for the treatment of recurrent anterior instability of the shoulder between 1969 and 1983. In 1993, we retrospectively reviewed the clinical and radiographic results that were available for fifty-six patients (fifty-eight shoulders) who had been followed for an average of 143 years (range, ten to twenty-three years). The purpose of the study was to determine the prevalence of glenohumeral osteoarthrosis and the factors related to its development after the Latarjet procedure. The procedure was performed for the treatment of recurrent anterior dislocation in fifty shoulders and painful recurrent anterior subluxation in eight. All patients had a radiographic evaluation (three anteroposterior radiographs, with the humerus in external, neutral, and internal rotation, and one lateral radiograph) before the operation and at the latest follow-up examination. At the time of the latest follow-up, none of the patients had recurrent dislocation, six patients had apprehension with regard to possible dislocation, and one had occasional subluxation. According to the system of Rowe et al., fifty-one (88 per cent) of the fifty-eight shoulders had an excellent or good result; five (9 per cent), a fair result; and two (3 per cent), a poor result. Twenty-two shoulders had no glenohumeral osteoarthrosis. Thirty-four shoulders had centered glenohumeral osteoarthrosis (the humeral head remained in front of the center of the glenoid cavity), which was grade 1 in twenty-five shoulders, grade 2 in four, grade 3 in three, and grade 4 in two, and two shoulders had grade-4 eccentric glenohumeral osteoarthrosis (the humeral head was more proximal than normal in relation to the center of the glenoid cavity). Postoperative grade-1 glenohumeral osteoarthrosis, unlike the higher grades, had no effect on the function of the shoulder.

Postoperative function after implant insertion in vascularized bone grafts in maxilla and mandible

Between 1988 and 1992, 80 Brånemark-type implants were inserted in 18 patients during reconstruction of the mandible or maxilla with vascularized iliac crest or scapula grafts with or without additional soft tissue pedicles. In these procedures, nine vascularized bone grafts were combined with a primary insertion of 32 implants and a secondary insertion of 48 implants. Twelve patients are currently wearing the implant-borne dentures. From 32 implants inserted primarily, eight could not be used for prosthodontic rehabilitation because three were lost with a graft, three were left as sleepers, and two demonstrated a lack of osseointegration. None of the implants inserted secondarily in grafts were lost. Primary implant insertion should be performed only in close cooperation with the prosthodontist and in selected cases, for example, in free-end reconstruction of the mandible with a straight graft and where a limited number of implants is needed. Although restoration of masticatory function in patients with head and neck cancer can be achieved, compared with a healthy control group, functional impairments remain. Patients subjectively favor the nonreconstructed side of the mandible or maxilla for chewing. These findings can be correlated with a postoperative follow-up investigation using a miniature force transducer and the T-scan system.

Value of a dynamic MR scan in predicting vascular ingrowth from free vascularized scapular transplant used for treatment of avascular femoral head necrosis

We have treated three patients with avascular osteonecrosis using vascularized scapular bone graft. To predict blood perfusion in both the diseased femoral head and the transferred bone, all the hips were followed up using dynamic magnetic resonance (MR) scans, performed 1 and 7 months after surgery. In the present cases, it was shown that conventional enhanced MR imaging sometimes depicts increased intensity in bone marrow without blood perfusion due to the leakage of gadolinium-DTPA (Gd-DTPA) from the capillaries surrounding the avascular tissue. It was found that Gd-DTPA remaining in the dead bone marrow resulted in a false-positive image. By contrast, the dynamic MR scan evaluated only those images taken before the leakage. This is one of the advantages of the dynamic study, which reflects actual blood flow in the bone. The fast rise in the time-intensity curve following bolus injection of Gd-DTPA indicates that there is fast blood perfusion in the bone. The dynamic MR scan has demonstrated that there is little blood perfusion in the diseased bone 1 month after the operation and that vascular ingrowth from the transferred bone flap proceeds gradually between 1 and 7 months after surgery. These findings indicate that the dynamic MR scan is very useful in demonstrating vascular ingrowth after surgery in avascular necrosis of the femoral head and can be a reliable monitoring technique for anastomotic patency of the vascularized bone flap.

The latissimus dorsi/scapular bone flap (the "latissimus/bone flap")

During the past 4 years, our trauma and reconstructive service has treated a number of patients with lower extremity trauma involving the loss of both soft tissue and significant segments of tibia. While there are many methods for reconstruction of such defects, we became interested in providing a one-stage reconstruction of both the soft tissues and the missing bone segments. Since our standard flap for lower extremity reconstruction is a latissimus dorsi flap, we became interested in transferring a portion of the lateral border of the scapula along with the latissimus muscle. We dissected 34 cadaver scapulas in order to verify the reliability of the blood supply to the lateral border of the scapula based on the thoracodorsal artery. We then performed 12 "latissimus/bone flaps" from 1988 to 1992. Prior to flap transfer, control of the wound was obtained with surgical debridement and aggressive wound management. The flap usually was performed 5 to 7 days after initial contact with the patient. The muscle was skin grafted. All patients reported are ambulating, with x-ray evidence of bony incorporation of the transferred bone segment into the tibia. We feel that inclusion of the lateral scapula bone with the latissimus dorsi is a useful adjunct in the management of lower extremity trauma.

Use of osteomuscular free flaps after extended maxillectomy and craniofacial resection. About two cases

A composite free flap with the lower part of the scapula and the serratus muscle has been used in two clinical cases for reconstruction after extensive maxillectomy and craniofacial resection. The palatal defect was reconstructed with the lower part of the scapular bone and the bone and the serratus muscle was used to restore facial contour. This type of osteomuscular free flap based on the thoracodorsal artery and veins provides a one-stage reconstruction of complex facial defects, including bone and soft tissue. The main advantages of this flap are the configuration of its bony component that closely matches the hard palate and its versatility that allows other regional flaps such as the latissimus dorsi and/or the serratus to be raised on the same vascular pedicle.

[Mandibular reconstruction using a vascularized osteocutaneous scapular flap]

Composite tissue defect of the mandible following the surgical resection of head and neck neoplasma or osteoradionecrosis causes functional and cosmetic disorders. Mandibular reconstruction is, therefore, necessary to obtain satisfactory results. The introduction of microvascular surgery has made it possible to transfer various types of vascularized bone grafts and this technique is considered one of the most reliable procedures for mandibular reconstruction. Recently it has been reported that an osteocutaneous scapular flap is useful for mandibular reconstruction. We have performed, over the last 2.5 years, 13 mandibular reconstructions using a vascularized osteocutaneous scapular free flap, and successful results have been achieved. The features of this flap are as follows: 1) it provides a consistent blood supply to the bone and the skin and has a constant vascular pedicle; 2) since the skin island and bone flap have separate pedicles, three-dimensional reconstructions are facilitated; 3) if needed, two skin flaps can be elevated; 4) the skin island is not so bulky; 5) the lateral border of the scapula provides highly vascularized bone of thick cortical density and osteotomies are safely performed; 6) using an angular branch based on thracodorsal artery, a bi-pedicled scapula bone can be raised and two completely vascularized bone segments can be transferred with a single pedicle. Thus, a vascularized osteocutaneous scapular flap has proven very useful for complex mandibular reconstructions.

Free scapular flap reconstruction of the head and neck

The scapular flap network is unsurpassed in versatility in its application to head and neck reconstructive problems. There are rare contraindications to the use of the flap, including previous extensive axillodorsal surgery or radiation. In this case, the opposite back could be the donor site (unless the spinal accessory nerve was sacrificed on that side and an osteocutaneous flap is planned). The disadvantages are relatively minor: the need for repositioning the patient, the lack of sensation in the flap, and the limitation of the length of the bone available on the direct bone pedicle to 14 cm (not counting the bone available vascularized through the thoracodorsal fascia medially). Every microsurgeon faced with the usual complicated reconstructive problems in the head and neck would benefit from familiarity with this important donor site, with its long history of safe application in microvascular surgery.