OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY

THORACODORSAL SCAPULAR TIP (TDAST) FLAP FOR HEAD AND NECK RECONSTRUCTION Douglas Chepeha

The scapular tip flap is Benefits of TDAST the osseous (bone) component of the latissi- mus dorsi flap. The thoracodorsal artery • Long vascular pedicle 1,2 supplies the scapular tip and the latissimus • Triangular 3-dimensional shape 2 dorsi muscle (with overlying skin). There- • Bone paddle easily shaped without fore, the scapular tip can be harvested as an osteotomy to reconstruct the infrastruc- independent osseous paddle or with the ture of the maxilla 3 or with the latissi- • Bone is surrounded by attached muscle mus dorsi muscle and overlying skin or in that can be used to help close defects of some combination with the serratus muscle. maxillary and mandibular alveolus bone There are many possible combinations of • Can be harvested as a chimeric flap with skin, muscle and bone paddles that make a variety of skin and muscle paddle this arterial donor system valuable for head options 3-5 and neck reconstruction. In addition, the • Independently mobile skin paddle 2,3 thoracodorsal arterial system can be com- • Thoracodorsal artery and are large bined with the circumflex scapular arterial vessels and most commonly connect to system (both arise from the sub- larger subscapular vessels scapular system or are directly adjacent to one another) to further increase the skin and Caveats of TDAST bone paddle options. Although it would not always be ideal, this donor site could be • Overall harvest is manageable but one used to reconstruct all defects in the head must exercise caution with the identifi- and neck. cation of the angular branch and its

connection to either the thoracodorsal The scapular tip and lateral border have a artery or the serratus artery unique shape. The tip of the is the • Shorter bone length (12cm) than fibula shape of the maxillary infrastructure when 6-8 inset in an axial plane. It also mimics the rim of the orbit, depending on the extent of • If the angular branch does not appear to the defect, and can be inset in axial or supply the superior aspect of the lateral coronal planes. The lateral border of the tip border of the scapula, then the circum- of the scapula is the shape of a hemiman- flex scapular artery may have to be dible and is well suited for mandibular harvested to ensure vascularity reconstruction. For posterior mandibular • Wide skin donor sites can be hard to reconstruction the tip can be used for the close and can limit shoulder mobility angle and inset in a sagittal plane to recon- • The skin donor sites may be thicker than struct the ramus. For anterior defects it can the forearm, anterolateral thigh and the be inset axially in a manner similar to lateral flaps depending on body maxillary reconstruction or it can be osteo- habitus and gender 9,10 tomised and inset in a coronal orientation. • Reduced shoulder mobility • Prior ipsilateral thoracotomy may limit In this chapter we address the use of the skin paddle donor options bone paddle supplied by the thoracodorsal • Two-team surgery if a hydraulic arm artery. holding device is not used 11

Anatomy 3. Subscapularis arises from the subsca- pular fossa (the part of the scapula that Harvesting the scapular tip involves tran- faces anteriorly toward the thorax) and secting a portion of, or all the origins of the inserts into the lesser tubercle of the infraspinatus, subscapularis, teres major, humerus. It rotates the humerus medial- the insertion of the serratus and, if a skin ly on the glenohumeral joint. paddle is harvested, dissection and possible 4. Teres major is encountered surgically harvesting of the latissimus dorsi flap. but is not a rotator cuff muscle. It arises Several of these muscles are part of the four from the inferior angle of the scapula muscles that form the rotator cuff that and attaches to the anterior surface of stabilises the glenohumeral joint (Figure 1). the humerus, on the medial lip of the intertubercular sulcus. It allows medial Supraspinatus Suprascapular notch (foramen) rotation and adduction of the humerus Cut edge of deltoid on the glenohumeral joint. The long head of the triceps brachii is also Cut edge of trapezius encountered in this region as it origi- Teres minor nates in the infraglenoid tubercle of the Infraspinatus Surgical neck of humerus Triangular space Medial lip of inter- scapula. It serves as an accessory adduc- tubercular sulcus tor, an extensor of the forearm and a Quadrangular space stabiliser of the glenohumeral joint

Triangular Vascular Anatomy Teres Major interval

Long head of triceps brachii The arises from the third part of the (Figure 2). Cut edge of lateral head of triceps brachii

Figure 1: Posterior view of shoulder and Subscapular artery arm

Rotator Cuff and Muscle Anatomy

Four muscles originate from the scapula and stabilise the glenohumeral joint (Figure 1):

1. Supraspinatus and infraspinatus mus- cles originate in fossae above and below the scapular spine and attach to the greater tubercle of the humerus. The supraspinatus initiates the first 15º abduction of the arm, whereas the infra- spinatus allows lateral rotation of the Figure 2: Origin of subscapular artery from arm on the glenohumeral joint axillary artery 2. Teres minor arises from the lateral edge of the scapula and attaches to the greater It gives rise to two branches: the thoraco- humeral tubercle. It also allows lateral dorsal artery, and circumflex scapular rotation of the arm artery (Figure 3). The thoracodorsal artery

2 and/or thoracodorsal vein can arise from the within 1.5cm of the serratus artery branch , separate from the subscapular or from the serratus branch within 1.5cm of artery and/or the subscapular vein 12 its branchpoint with the thoracodorsal artery. The origin of the vein and artery of Dorsal scapular artery the pedicle can be divided Descending branch transverse cervical Transverse scapular between the thoracodorsal branch and the Scapular circumflex serratus branch. The total length of the dissected pedicle and bone paddle (distance from the axilla to the scapular tip) can be as long as 27cm 1,2,14. This is likely to be an overestimate; the total length is closer to 20cm.

The descending and transverse thoraco- Subscapular dorsal branches are within the latissimus Thoracodorsal muscle and can be used to supply some or all of a myogenous paddle, a myocutaneous paddle, or a cutaneous perforator (if pre- sent), and can be dissected through the Termination of subscapular muscle. Figure 3: Vascular anatomy around the scapula The circumflex scapular artery (Figure 3) travels through the triangular space 3 The thoracodorsal artery arises from the created by the teres major inferiorly, teres subscapular artery, descending, roughly minor superiorly, and long head of triceps parallel to the lateral boarder of the scapula anteriorly (Figure 1). It divides into a termi- in an envelope of adipose tissue that emana- nal descending branch to the bone of the tes from the axilla (Figure 3). The thoraco- lateral border of the scapula; the circumflex dorsal artery passes between the teres major scapular artery continues toward the skin and the thoracic cage (Figure 2) 12. The and divides into transverse cutaneous and thoracodorsal artery supplies the latissimus descending cutaneous branches. The ter- dorsi, serratus anterior, and scapular tip 13. minal descending branch supplies the lateral border of the scapula and the maxi- The thoracodorsal artery gives rise to a mal bone length is 12cm. The transverse direct cutaneous branch, the serratus cutaneous branch can be used to create a artery, the angular artery to the scapular scapular cutaneous paddle 3. The descen- tip, the descending branch within the ding cutaneous branch is used to create latissimus muscle and the transverse parascapular cutaneous paddle 3. branch within the latissimus muscle. The direct cutaneous branch is present 47% of Nerve Anatomy the time (reference Taylor 1984) and supplies the skin inferior to the axilla. The The (Figures 4, 11) serratus branch supplies the serratus runs along the pedicle to the latissimus muscle that can be used for myogenous muscle. The nerve is about 2mm in diame- reconstruction or as an innervated subunit. ter. When harvesting the scapular tip, it should not be sacrificed and is a good guide The angular branch to the scapular tip for the direction of the pedicle and can help arises from the thoracodorsal branch 6 open the space over the pedicle. In the

3 axilla, the cords of the brachial plexus run Surgical Setup immediately superior to the axillary artery and vein. Care should be taken not to put The surgical setup is very similar to the traction on these nerves. setup described in the chapter on latissimus dorsi flaps.

Patient Positioning

A key advance is to avoid repositioning by putting the patient in a semidecubitus 2 and using a beanbag to secure the patient’s donor site about 20 degrees above the plane of the bed. Ensure that the entire scapula is accessible. Access to the scapula can be improved by abduction or medial rotation with the shoulder in an adducted position. Unfortunately, this setup still does not make Figure 4: Anterior view of right thora- 2-team surgery straightforward. codorsal nerve (Human Anatomy Online) A positioning device can be used to hold the 11 Preoperative Evaluation arm in position (Figure 5). These devices are in common use for rotator cuff repair No specific vascular testing is required. If and are available at many hospitals with a patient has a history of shoulder dislo- orthopaedic programs. Take care to put the cation, rotator cuff tear, rotator cuff surgery, arm in the device for the duration of the arthroscopy, joint replacement or brachial elevation and closure to avoid a tourniquet plexus injury one should avoid using the effect on the forearm (Figure 6). flap. Consideration must be given to the patient’s occupation and recreational activi- ties, as lifting heavy weights above the head is affected 2.

Informed Consent

Preoperative counselling should address general complications related to autoge- nous transplant including scarring, delayed wound healing, donor or recipient site hae- matomas, seromas, infection and transplant failure.

Specific complications include reduced shoulder mobility that makes full abduction Figure 5: The patient’s left arm and thorax and lifting heavy object above the head are shown with the arm in a position of more difficult 15. Larger bone paddles are elevation for the thoracodorsal artery associated with greater shoulder disability. transplant (TDAST)

4 and they have mobile necks (Figure 7). In such cases, 2- team surgery is easier to accomplish

Figure 6: The patient’s left arm and thorax are shown, with the arm in a resting position. To reduce the likelihood of a tourniquet effect on the arm, avoid wrapping the arm tightly, minimise the time the arm is wrapped and be mindful of a Figure 7: For patients who have a rounded positive fluid balance during the procedure thoracic cage, a scapula that has a lateral position and a flexible neck may undergo harvest on the side contralateral to the head • Rotate the ipsilateral pelvis and bend and neck extirpation site (note lipoma in the knee; this will help keep the thorax axilla) off the surgical table

• To prevent compression of the brachial Surgical Steps plexus the contralateral clavicle (non-

operative shoulder) needs to be at 90 Surface Markings degrees to the cervical spine. A shoulder

roll will not help prevent brachial • To safely locate the bone paddle the plexus compression. The purpose of a latissimus muscle and scapular tip have shoulder roll is to lift the thorax off the be palpated and marked out prior to operative table when the patient is in a incision. This is usually straightforward fully decubitus position so that the (Figure 8) clavicle does not compress the brachial

plexus • Protect the contralateral (non-operative side) superficial peroneal nerve, radial nerve, ulnar nerve and brachial plexus • Secure the patient to the operating table with a belt and tape over the pelvis to prevent him/her sliding off the table • Place the patient on a gel mat over a beanbag. Be sure that there is an edge (or lip) on the beanbag ipsilaterally and contralaterally to hold the patient in Figure 8 Patient is turned to left side with position left arm superiorly and harvesting on the • Some patients can undergo a contra- left thorax. Locate and mark the scapular lateral scapular tip harvest if they have tip by palpation. The arm is in a neutral a very rounded thorax in cross-section, position at the upper right of the photo. their scapula is in a very lateral position Arrow points to bone paddle 5 • The anterior edge of the latissimus mus- harvested with preservation of the trans- cle is marked by the midaxillary line. It verse portion of the thoracodorsal nerve is best to mark the midaxillary line prior to prepping because the pelvis is usually Posterior approach covered by the belt that secures the patient to the operating table • More difficult but more direct • Locate the midaxillary line by drawing • An advantage for harvesting a thoraco- a line from the middle of the axilla to a dorsal perforator flap point on the pelvis that is equidistant • Good choice if scapular tip is sole donor between the anterior and posterior paddle superior iliac spines • Good choice if direct cutaneous branch • Identify the latissimus muscle. It forms of thoracodorsal artery or a perforator of the posterior axillary fold as it crosses thoracodorsal artery is anticipated with from the thorax to insert onto the hume- the harvest rus. The superior aspect of the latissi- mus muscle curves across the tip of the Raising the Bone Paddle: Anterior Ap- scapula as it heads to the origin of the proach muscle from thoracic vertebrae 6-12 • Locate the scapular tip at the inferior • Mark out an incision 1.5cm anterior to aspect of the scapula, and mark it with the midaxillary line from a level just the shoulder adducted (arm at patient’s below the tip of the scapula tip to the side) axilla. In the axilla, it is better to angle the incision to run parallel to the relaxed Raising the Bone Paddle - Anterior versus axillary skin tension folds (Figure 6) Posterior Approach

The scapular tip can be approached either from the anterior, or the posterior aspect of the latissimus muscle. The anterior ap- proach is the most commonly used. There is no distinct advantage of an anterior versus a posterior approach.

Anterior approach Figure 9: Patient is turned to left side axilla • Considered easier and more flexible on right of picture and harvesting on the left • Easier to dissect all the branches of the thorax. The yellow arrow points to the bone thoracodorsal vascular pedicle paddle template. The latissimus muscle is in • Efficient if a myocutaneous skin/latis- contact with and anterior to the scapula. simus muscle paddle is part of the re- The skin paddle (red arrow) is over the constructive plan primary angiosome. The skin paddle over- • Advantagous if a series of paddles are to lies the latissimus muscle. The location of be harvested that includes the circum- the skin paddle as shown in the figure is flex scapular system, as the pedicle and helpful for perforator dissection. If a longer the associated skin paddles are easier to pedicle to the skin paddle is desired, then expose in a single surgical field the skin paddle can be elevated in a position • Favoured if the descending branch of that is just inferior to the scapular tip along the thoracodorsal artery is going to the midaxillary line

6 • Commence the incision inferiorly to • The pedicle is in a pocket of areolar verify the location of the anterior tissue; therefore, gentle finger dissect- border of the latissimus muscle to tion will improve the efficiency of the confirm that the surface marking has dissection been made in the correct location • It is important to skeletonise the thora- (Figure 10) codorsal pedicle and the branch(es) to the serratus muscle before any major branches are clipped because the bran- ching pattern of the angular branch to the scapular tip is variable (Figure 11)

1 5

4

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3 5 6

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Figure 11: A different patient with more extensive bone harvest. The patient’s axilla is at the right of the picture, and the harvest Figure 10: Dissection of the myocutaneous is on the left thorax. The skin paddle (supe- donor paddle; with an anterior approach, riorly) has been dissected and the remain- the skin paddle is dissected first ing latissimus muscle (5) is retracted at the

lower edge of the photo. The thoracodorsal • Once the location of the latissimus artery (1) can be seen supplying the muscle has been confirmed, extend the latissimus muscle. The angular branch (2) incision up to the axilla can be seen supplying the scapular tip (3 = • Critical point: It is important to under- template of bone paddle, 4 = thoracodorsal stand that the incision crosses the ex- nerve, 6 = serratus branch) pected location of the thoracodorsal pedicle. Therefore, once the anterior • The angular branch arises within border of the latissimus is identified at 1.5cm of the branch point of the serratus the level of the scapular tip, dissect just artery. The angular branch may arise superficial to the medial aspect (the side from the thoracodorsal branch (the main closest to the thorax) of the latissimus pedicle) or it may arise from the serratus muscle until the thoracodorsal pedicle is branch. The serratus branch comes off seen penetrating the muscle the thoracodorsal branch before it termi- • Once the thoracodorsal pedicle has nates in the latissimus muscle and after been identified, trace it toward the the circumflex scapular branch (Figure axilla. The thoracodorsal nerve is a 11) good landmark and speeds up the dis- • Key point: The angular branch arises section within 1.5cm of the serratus pedicle • Retract the latissimus muscle to open branch point. The angular artery and the the space around the pedicle angular vein may arise separately (but

7 in close proximity) to the thoracodorsal infraspinatus, or serratus can be harves- branch and the serratus branch ted • Locate the angular branch. First iden- • Caveat: Verify that the muscle has tify the anterior border of the scapular adequate blood supply for the planned tip. This area can be seen by retracting reconstruction prior to transecting the the latissimus muscle. Generally, the pedicle and transferring the flap to the artery can be seen running along the recipient site anterior border of the scapula and can be traced back to the area around the 1

branch point of the serratus branch from 2 4 3 the thoracodorsal pedicle • Key point: Fully dissect the angular branch before transecting any bran- 8 6 5 ches greater than 1mm. The angular branch is variable and circuitous and is vulnerable to transection before the 5 course of the branch has been identified in its entirety Figure 12: The teres major is transected. • Uncommonly, if the angular branch is Both the angular branch (inferiorly) and not easily seen along the anterior the circumflex scapular branch (superiorly) border of the scapula: are shown supplying the muscle (1 = thora- o Dissect anteriorly, leaving a cuff of codorsal artery, 2 = angular artery, 3 = fat over the serratus about 1.5cm thoracodorsal nerve, 4 = subscapular mus- anterior to the scapular tip. Dissect cle, 5 = latissimus muscle, 6 = serratus layer-by-layer through fascia and fat branch, 8 = bone paddle template o If the angular branch is still not seen, move superiorly staying well ante- rior to the scapula until the dissect- tion is taken up to the thoracodorsal Bone paddle pedicle. As this space is carefully Angular opened the branch to the scapular tip artery is seen coming off the serratus or the thoracodorsal pedicle • After the pedicle has been identified, Skin paddle mobilise it by transecting the branches to the tissues that are not part of the Circumflex donor system (Figure 12) artery • Mark out the segment of bone that is to Pedicle Thoracodorsal artery osteotomized into the skin paddle Figure 13: The bone paddle is the lateral (Figure 12) border of the scapula with scapular tip. The • If muscle is not needed for the recon- skin paddle is a myocutaneous paddle struction, it should be harvested with the based on the descending branch of the bone in moderation. A cuff of about thoracodorsal artery 7mm should be left on the scapular tip

to ensure adequate vascular supply

(Figure 13)

• Should additional muscle be required for the reconstruction, then teres major, 8 Raising Bone Paddle: Posterior Approach • The size of the skin paddle and the option to use perforators from the trans- • Mark out the incision that is placed just verse branch of the latissimus pedicle, posterior to the posterior edge of the will result in a different incision loca- latissimus muscle to a position just tion. A perforator that is suitable for a below the scapular tip perforator based cutaneous skin paddle • Then mark an incision into the axilla is not always present that crosses the posterior axillary fold • Difficult step: It can be difficult to into the axilla and parallels the relaxed separate the teres major muscle from the axillary skin tension lines (Figure 14) latissimus muscle because the fibers may not be separated by an areolar layer. To assist with separation, increase the size of the operative field to identify the latissimus closer to its insertion and closer to its origin (Figure 13)

Latissimus dorsi Latissimus dorsi Teres Major

Scapular tip

Figure 14: The scapular tip is marked out first, then the midaxillary line, followed by the expected location of the latissimus Scapular muscle tip

• This incision is designed so that perfo- Figure 16: Separation of latissimus muscle rators can be picked up at the anterior from teres major muscle edge of the latissimus muscle for design of a thoracodorsal artery perforator flap • To harvest the scapular tip bone paddle, (Figure 15) retract the superior edge of the latissi- mus muscle inferiorly and anteriorly to expose the scapular tip (Figure 17) • Sometimes a perpendicular incision needs to be made in the superior aspect of the latissimus muscle over the Skin scapular tip so that the tip can be paddle visualised • Key point: Look for the angular branch right on the scapular tip as it passes onto the serratus muscle insertion (Figure 18).

• Follow the angular branch up to the Figure 15: A perforator has been located thoracodorsal branch or the serratus during the deep dissection and confirmed branch (Figure 19) with Doppler. The skin is loosely reapproxi- mated so that the donor skin paddle size can be matched to the size of the recipient site

9 3 1 5

2 4

Figure 20: The serratus branch has been clipped (1), and the scapula (2) is being rotated off the thorax with a retractor. The Figure 17: Retraction of latissimus muscle dissected angular artery (3) to the scapular inferiorly to expose scapular tip tip is well demonstrated (4 = teres major

muscle, 5 = infraspinatus muscle)

4 3 • If the angular branch cannot be seen at the tip, do not dissect the fat 2 immediately adjacent to the scapular 5 tip because critical perforators from the angular branch can be injured as they

6 pass to the scapular tip 1 o A better decision may be to transi- tion to the anterior approach Figure 18: The planned bone paddle is o Alternatively, one can do a more marked out in blue ink just proximal to the time consuming and difficult dissec- scapular tip (1). The angular artery (2) is tion as follows: Move the dissection seen travelling from the thoracodorsal anteriorly leaving a cuff of fat on the artery (3) down to a location just anterior anterior aspect of the scapular tip to the bone paddle. Because this is a and stay on the fascia on the medial posterior approach, the latissimus dorsi aspect of the latissimus muscle. muscle (4) is seen retracted along the upper Once the dissection is 1.5cm ante- aspect of the photo (5 = Serratus branch, 6 rior to the scapular tip, dissect = Teres major muscle) through the fascia and fat layer-by- layer. If the angular branch is not seen, move superiorly, staying well anterior to the scapula until the 2 dissection is taken up to under the teres major. As this space is careful- 1 ly opened the branch to the scapular tip or the thoracodorsal artery is revealed (Figure 17). o If the posterior approach does not reveal the pedicle, the dissection can still default to the anterior approach Figure 19: The ruler shows the angular because this provides a larger surgi- branch (1) coming off the thoracodorsal cal field and is its easier to landmark artery (2) and vein 1.5cm proximal to the the latissimus and serratus pedicles serratus artery and vein 10 • Mobilise the pedicle by dissecting Bone paddle towards the axilla Angular artery • The thoracodorsal nerve is a helpful guide for opening the space and should be preserved • Muscle transection and bone paddle harvest are performed in the same Pedicle manner as with the anterior approach (Figures 21-23) Thoracodorsal Skin paddle artery

Latissimus dorsi 2 1 Figure 23: A chimeric segment of scapula 2 adjacent to the scapular tip based on the angular branch and a 2nd skin paddle with a plug of muscle. This was inset into a defect that included the infraorbital rim and the 3 cheek skin

Closure and wound drainage Figure 21: The patient’s axilla is at the right, and the harvest is on the left thorax. Muscle closure should be performed with The serratus has been cut to help retract the the shoulder in full abduction. The rotator scapular tip from the thorax to aid dissec- cuff muscles should not be closed under tion. The infraspinatus muscle is being cut tension and the serratus muscle should be in preparation for the osteotomy. The = reattached to the remaining distal end of the thoracodorsal artery (1) is shown travelling scapula. to the mobilised skin paddle that is under the surgeon’s right hand (2 = latissimus The donor site is prone to seroma if the skin muscle, 3 = bone paddle) is loose after wound closure. Place drains in an inferior (dependent) location in the 2 donor site. On occasion, patient may be 3 Skin discharged from hospital with drains in paddle place until drainage is <20ml per day. 1

Postoperative Care

• Start a passive range of movement early Figure 22: The osteotomised scapular tip • For the first 3-7 days the donor site is (1) is shown in preparation for an axial painful with movement inset for an anterior mandibular defect. A • A large skin paddle harvest with tight reciprocating saw with a long triangular closure can limit mobility blade is used for scapular tip osteotomies. • Introduce active range of motion exer- Because of the curved shape of the scapula, cises within 1-2 weeks hold the edge of the scapula with a thumb • There will be some associated moderate and 2nd finger to gauge the width of the bone pain with this early program. It is that is being osteotomised (2 = thoraco- important for the patient to know that dorsal artery, 3 = latissimus muscle) 11 they will not be pain free when starting expected location of the circumflex the program scapular artery may be inadequately • The program is a combination of pas- perfused. In such cases the circumflex sive and active range of motion that scapular should be harvested to supply would be performed after rotator cuff this bone segment surgery and strengthening after neck • It also has a long pedicle that makes this dissection donor site useful for vessel-poor necks or when the reconstruction is in the mid- or upper face 2. Reconstructive Applications of Scapular • In addition, because of the multiple Tip Bone Paddle branches in the scapular subsystem there is a variety of skin paddle, muscle • The scapular tip is very versatile paddle, innervated muscle paddle, and because of its 3-dimensional shape that bone paddle options that provide is very similar to the size and shape of enough options that a second free flap many head and neck bone defects 2 donor site can be avoided • The scapular tip and lateral border of the scapula can be harvested based on the Maxillary Reconstruction angular branch (Figure 24) • Axial orientation is used for partial or total infrastructure maxillary recon- struction 1,9,10,15-17 (Figures 25, 26)

Figure 24: The maximum size of scapular harvest based on the angular branch. Figure 25: The most common use of a Darker blue indicates more reliable scapular tip transplant is a transverse vascularity insertion to replace part of, or the entire infrastructure of the maxilla • If the angular branch inserts very distally on the scapular tip the bone of the lateral border of the scapula adjacent to the lip of the glenoid fossa in the

12 • The chest CT can be preoperatively to see if the contour matches a fit that would allow for inset without osteo- tomy (Figure 28)

Figure 26: Total infrastructure palate

• A coronal orientation is used for hemi- Figure 28: Hemimandible reconstruction maxillectomy defects up to and inclu- 5,9 with ipsilateral scapula. With this orien- ding the infraorbital rim (Figure 27) tation the vascular pedicle is in a location that is less conducive to implants

• Sagittal orientation is used for the angle and ramus up-to-and-including the con- dyle of the 12 (Figures 29, 30). The pedicle exits anteriorly or inferior- ly. The tip of the scapula is used for re- construction of the condyle

Figure 27: Hemimaxillectomy; the scapula is in a coronal orientation and is used to reconstruct alveolus and orbital rim

Oral Cavity Reconstruction

• Sagittal orientation is used for most hemimandibulectomy reconstructions 7 Figure 29: Angle and ramus reconstruction

13 anterior composite resection of the oral cavity that includes the tongue because the bone requirements are less sophis- ticated

Figure 30: Condyle and ramus reconstruc- tion

• Axial orientation for the reconstruction of a portion of the symphysis and an- terior body of the mandible (Figure 31)

Figure 32: Bilateral symphysis and anterior body reconstruction

Orbital Reconstruction

• Use the natural curve of the scapular tip 19-21 • Make a template of the missing segment of orbit and find the best match to this curve on the tip of the scapula (Figure 33)

Figure 31: Partial symphysis and anterior body ipsilateral scapula reconstruction

• Axial orientation for anterior symphysis defect of the mandible. The tip of the scapula does not fit the as well as with the maxilla

but depending on the shape of the donor scapula, the fit can be adequate (Figure Figure 33: Lateral orbital rim reconstruc- 32). This approach works well for large tion

14 • For reconstruction of the orbital rim use Suitability for Implants a short segment (Figure 34) Implants can be used in the craniofacial skeleton (orbit) or the oral cavity (maxilla or mandible). Although it is possible to implant the scapula 23, there are several barriers and as a result, patients are infrequently implanted.

There are a number of barriers to implanta- tion: the bone must be in a location that facilitates an occlusal plane; the implants should be placed prior to radiation to reduce implant failures; soft tissue reconstruction has to result in an implantable alveolar subunit; and the tongue must be able to Figure 34: Supraorbital rim reconstruction reach around the front of the prosthetic to clear food during mastication. • For reconstruction of the orbital rim and orbital floor with an intact orbit. Use a It is important to note that implant-borne small fragment of free bone or a prostheses can cover critical sensate tissue MEDPORE orbital floor prosthesis and/or impair tongue mobility. As a result, (Figure 35) the long-term use of implant borne prosthe- ses is limited because many patients can eat more efficiently with a softer diet without an implant borne prosthesis. The most frequent area of success with implant use is in the maxilla because the bone placement is more straightforward, the prosthesis does not impair tongue function or cover a criti- cal sensate area. Of course, if the bone is placed prior to radiation, it will not be suitable for implantation. Implants can be placed around the orbit to retain an orbital prosthesis but most often, instead of a prosthesis, the orbit is filled with soft tissue 19 Figure 35: Infraorbital rim reconstruction and this achieves patient acceptance .

Cricoid Reconstuction Summary

• This is a very advanced reconstruction The thoracodorsal artery scapular tip flap is • The curved scapular segment is 3mm the osseous (bone) component of the latissi- wide and must be covered with mus dorsi flap. The donor material is extre- vascularised muscle 22 mely flexible, and presents many possible • The inset is difficult because vascularity combinations of skin, muscle and bone of the scapular segment is required paddles that makes this arterial donor system valuable for head and neck recon-

15 struction. In addition, the thoracodorsal ar- seous free flaps for oromandibular re- terial system can be combined with the construction: a patient-centered ap- circumflex scapular artery system (both proach to flap selection. JAMA Otolar- arteries arise from the subscapular system yngol Head Neck Surg. 2013;139(3): or are directly adjacent to one another) to 285-92 further increase the skin paddle and bone 8. Yoo J, Dowthwaite S, Fung K, Franklin paddle options. Although not always ideal, J, Nichols A. "A new angle to mandi- this flap may be used to reconstruct almost bular reconstruction: the scapular tip all defects in the head and neck. free flap. Head Neck. 2013;35(7):980-6 9. Clark J, Vesely M, Gilbert R. Scapular angle osteomyogenous flap in postmax- References illectomy reconstruction: defect, recon- struction, shoulder function, and harvest 1. Uglešić V, Virag M, Varga S, Knežević technique. Head Neck-J Sci Spec, 2008; P, Milenović A. Reconstruction follow- 30(1):10-20 ing radical maxillectomy with flaps 10. Miles B, Gilbert RW. Maxillary recon- supplied by the subscapular artery. J struction with the scapular angle osteo- Craniomaxillofac Surg. 2000;28(3):53- myogenous free flap. Arch Otolaryngol 60 Head Neck Surg. 2011;137(11):1130-5 2. Chepeha D, Khariwala S, Chanowski E, 11. Stevens J, Rosko A, Marchiano E, Zumsteg J, Malloy K, Moyer J, Prince Haring C, Chinn S, Malloy K, Prince M, M, Sacco A, Lee J. Thoracodorsal artery Casper K, Moyer J, Chepeha D, Stucken scapular tip autogenous transplant: vas- C, Spector M. The Spider Limb Posi- cularized bone with a long pedicle and tioner in subscapular system free flaps. flexible soft tissue. Arch Otolaryngol Oral Oncol. 2018; 85:24-8 Head Neck Surg. 2010;136(10):958-64 12. Seitz A, Papp S, C. Papp Maurer H. The 3. Sullivan M, Carroll W, Baker S, Cromp anatomy of the angular branch of the ton R, Smith-Wheelock M. The free thoracodorsal artery. Cells Tissues scapular flap for head and neck recon- Organs. 1999;164(4):227-36 struction. Am J Otolaryngol. 1990; 13. Rowsell A, Davies D, Eizenberg N, 11(5):318-27 Taylor G. The anatomy of the subscapu- 4. Urken M, Bridger A, Zur K, Genden E. lar-thoracodorsal arterial system: study The scapular osteofasciocutaneous flap: of 100 cadaver dissections. Br J Plast a 12-year experience. Arch Otolaryngol Surg.1984;37(4):574-6 Head Neck Surg. 2001; 127(7):862-9 14. Wagner A, Bayles S. The angular 5. Brown J, Bekiroglu F, Shaw R. Indica- branch: maximizing the scapular pedi- tions for the scapular flap in reconstruc- cle in head and neck reconstruction. tions of the head and neck. Br J Oral Arch Otolaryngol Head Neck Surg. Maxillofac Surg. 2010;48(5):331-7 2008;134(11):1214-7 6. Seneviratne S, Duong C, Taylor G. The 15. Kakibuchi M, Fujikawa M, Hosokawa angular branch of the thoracodorsal K, Hikasa H, Kuwae K, Kawai K, artery and its blood supply to the Sakagami M. Functional reconstruction inferior angle of the scapula: an of maxilla with free latissimus dorsi- anatomical study. Plast Reconstr Surg. scapular osteomusculocutaneous flap. 1999; 104(1):85-4 Plast Reconstr Surg. 2002;109(4):1238- 7. Dowthwaite S. Theurer J. Belzile M, 44 Fung K, Franklin J, Nichols A, Yoo J. 16. Hanasono M, Skoracki R. The scapular Comparison of fibular and scapular os- tip osseous free flap as an alternative for

16 anterior mandibular reconstruction. Other flaps described in The Open Access Plast Reconstr Surg, 2010;125(4):164e- Atlas of Otolaryngology Head & Neck 6e Operative Surgery 17. Pagedar N, Gilbert R, Chan H, Daly M, Irish J, Siewerdsen J. Maxillary recon- • Pectoralis major flap struction using the scapular tip free flap: • Buccinator myomucosal flap a radiologic comparison of 3D morpho- • Buccal fat pad flap logy. Head Neck. 2012;34(10):1377-82 • Nasolabial flap 18. Chanowski E, Casper K, Eisbruch A, • Temporalis muscle flap Heth J, Marentette L, Prince M, Moyer J, Chepeha D. Restoration of the orbital • Deltopectoral flap aesthetic subunit with the thoracodorsal • Paramedian forehead flap artery system of flaps in patients • Upper and lower trapezius flaps undergoing radiation therapy. J Neurol • Cervicofacial flaps Surg B Skull. 2013;74(5) 279-85 • Submental artery island flap 19. Chanowski E, Casper K, Eisbruch A, • Supraclavicular flap Heth J, Marentette L, Prince M, Moyer • Latissimus dorsi flap J, Chepeha D. Restoration of the orbital aesthetic subunit with the thoracodorsal • Local flaps for facial reconstruction artery system of flaps in patients under- • Radial free forearm flap going radiation therapy. J Neurol Surg • Free fibula flap B Skull. 2013;74(5):279-85 • Rectus abdominis flap 20. Chepeha D, Wang S, Marentette L, • Anterolateral free thigh flap Bradford C, Boyd C, Prince M, Teknos • Principles and technique of T. Restoration of the orbital aesthetic microvascular anastomosis for free subunit in complex midface defects. tissue transfer flaps in head and neck Laryngoscope. 2004;114(10):1706-13 reconstructive surgery 21. Moyer J, Chepeha D, Prince M, Teknos T. Microvascular reconstruction of the Author orbital complex. Facial Plast Surg Clin N Am. 2009;17(2):225-37 Professor Douglas Chepeha MD, MSCPH, 22. Chanowski E, Haxer M, Chepeha D. FRCSC, FACS Microvascular cricoid cartilage recon- Head & Neck Oncology, Reconstructive struction with the thoracodorsal artery Microsurgery scapular tip autogenous transplant. Universtiy Health Network, Princess Laryngoscope. 2012;122(2). 282-5 Margaret Hospital 23. Blumberg JM, Walker P, Johnson S, Department of Otolaryngology-Head & Johnson B, Yu E, Lacasse MC, Lam Neck Surgery DK, Rittenberg B, Yao CM, Chepeha University of Toronto D, de Almeida JR. Mandibular recon- Toronto, Ontario, Canada struction with the scapula tip free flap. [email protected] Head Neck. 2019; doi: 10.1002/ hed.25702. [Epub ahead of print] Acknowledgements

Carolyn Barsoum BSc University of Manatoba Winnipeg, Manitoba, Canada [email protected]

17 Feben Alemu BSc University of Toronto Toronto, Ontario, Canada [email protected]

Editor

Johan Fagan MBChB, FCS (ORL), MMed Professor and Chairman Division of Otolaryngology University of Cape Town Cape Town, South Africa [email protected]

THE OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY www.entdev.uct.ac.za

The Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery by Johan Fagan (Editor) [email protected] is licensed under a Creative Commons Attribution - Non-Commercial 3.0 Unported License

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