Subscapular Axis

Vessel diameters 1. Subscapular artery – 3mm 2. CSA – 1.77mm 3. TD – 1.3mm

Combinations include 1. Scapular flap 2. Parascapular flap 3. Dorsal thoracic fascia 4. Serratus anterior 5. Serratus fascia 6. Latissimus dorsi 7. Vascularised lateral scapular border 8. vascularised tip scapular (angular branch) 9. Ribs

Circumflex scapular artery 1. pedicle length 3-6cm 2. arises 4cm from the origin of subscapular artery. 3. travels with 2 venae commitantes (subscapularis has 1) 4. Emerges from the lateral border of scapula at the medial triangular space (omotricipital space). Locate by: a. Palpation b. line 2/5th along the lateral border of the scapular (from superior) c. (distance of midpoint of middle of spine to tip -1 cm) / 2 5. No cutaneous nerves accompany the pedicle a. Flap may be neurotised using posterior cutaneous branches of intercostal nerves (very small) – enter in a medial to lateral direction 6. Branches a. Transverse - Scapular flap b. Descending - Parascapular flap i. 30x15cm

Scapular Flap  Skin paddle: i. 2cm from the midline, 2cm below the spine, 2cm above the scapula tip, laterally to the posterior axillary fold ii. 24 cm long iii. 8-12 cm width (directly closed)  Raised from medial to lateral superficial to fascia over rhomboid and infraspinatus – very messy if deep to this fascia  Identify the cleft between teres major and teres minor – i. Space is filled with a fat pad ii. Fascia over teres minor is thick and white iii. Fascia over teres major is thinner and red  If SCA is chased into the triangular space, pedicle may be up to 13cm  If raising bone i. dissect skin paddle and vascular pedicles out first ii. strip off teres major above the periosteum iii. portion of teres minor taken with the flap iv. strip off subscapularis extraperiosteally v. origin of long head of triceps may need to be cut vi. teres minor is sutured to subscapularis vii. teres major is sutured to angle of scapula viii. long head of triceps is reinserted under neck of glenoid ix. Shoulder immobilized in adducted position for 2 weeks

 Angular branch courses in the fascial gliding layer between serratus and teres major/subscapularis to the inferior angle of the scapula 