This document describes the scapular flap procedure. It details the relevant surgical landmarks and arterial system around the scapula. The flap can include skin, muscle, and bone from the scapula region. The flap is designed and harvested by following the path of the circumflex scapular artery. For a bone flap, the periosteal branch is dissected to access bone from the lateral border of the scapula. The scapular flap provides a large volume of soft tissue and bone to reconstruct significant defects, such as after extensive maxillectomies or mandibular resections.

1. SCAPULAR FLAP
JAMEEL KIFAYATULLAH

2. Surgical landmarks
• Anatomy
• The surgical landmarks of the
scapula are as follows
• The lateral border of the
scapula
• The scapular spine
• The scapular angle
• The triangular space created
by the three muscles
– Teres major muscle
– Teres minor muscle
– Long head of triceps muscle
• The latissimus dorsi and
anterior serratus muscle

3. Arterial system
• The main trunk of the scapular
vascular system is the
subscapular artery. This artery is
the origin of two main branches,
the circumflex scapular and the
thoracodorsal artery.
• The Circumflex scapular divides
into the following branches of
relevance:
• Transverse cutaneous which
supplies the scapular flap
• descending cutaneous which
supplies the parascapular flap
• The deep periosteal branch which
supplies the scapular bone flap.

4. Arterial system
• The thoracodorsal artery
divides into the following
branches of relevance:
• The angular branch, vein
supplies the scapular
angle
• The branch to the
serratus anterior which
supplies the serratus
anterior muscle flap
• The transverse and
vertical branch to the
latissimus dorsi muscle

5. Flap design
• The flap is harvested inferior
to and in parallel with the
scapular spine. The skin
paddle has to incorporate the
triangular space.
• The limits of the skin paddle
design is:
• 2cm below the scapular spine,
• 2cm above the scapular tip,
• 2cm lateral to the midline
• Maximum length: 24 cm
• Superior to the lateral scapular
border

6. Flap design
• 2cm below the scapular
spine,
• 2cm above the scapular
tip,
• 2cm lateral to the
midline

7. BONE FLAP
• The bone flap is limited in
size by the following
borders:
• 2-3 cm medially from the
lateral border of the
scapula
• 2 cm inferiorly to the
glenohumeral joint
• If only the scapular tip is
harvested, maximum 4-5
cm is available measured
from the tip.

8. Flap harvest
• The anatomical landmarks are
marked and the skin flap
outlined within its maximum
limits.
• If a smaller flap is indicated, it
is advisable to perform a pre-
operative ultrasound Doppler
to identify the location and
path of pedicle.
• To illustrate the procedure, we
will show the harvest of the
transverse flap. The harvest of
the parascapular flap follows
the same principle.

9. Flap Harvest
• Starting medially, the
skin is incised down to
the deep fascia of the
skin and a subfascial
elevation from the
infraspinatus muscle is
performed.

10. Flap Harvest
• As the flap is raised, the
pedicle on the
undersurface of the
cutaneous layer can be
identified.

11. Flap Harvest
• A vertical skin incision is made at the
lateral edge to allow for the retraction
of the skin and the dissection of the
pedicle.
• The dissection is continued laterally
until the teres minor muscle is
encountered and the origin of the
pedicle can be found in the triangular
space.
• Meticulous dissection is performed
expose the circumflex scapular artery
up to the bifurcation (maximum limit)
of the subscapular artery.
• The skin incision is completed and the
flap is mobilized from the underlying
muscles.
• When scapular bone is not needed, the
cutaneous flap is now ready and can
be transected when the recipient site is
ready.

12. Flap Harvest
• A drain is inserted and a
primary wound closure
performed.

13. Bone harvest
• While taking great care
not to damage the
Circumflex scapular
artery, dissection along
the CSA is performed until
the subscapularis artery is
encountered.
• If bone is required, The
deep periosteal branch of
the CSA can be identified
as running inferiorly and
entering the lateral
border of the scapula.

14. Bone harvest
• The teres minor is incised
3 cm medially from the
lateral border of the
scapula and retracted
medially to expose the
bone. A small cuff of the
teres minor is left
attached to the scapular
bone in order to protect
the blood supply of the
bone flap.

15. Bone harvest
• The teres major and
part of the latissimus
dorsi muscles which are
attached to the
segment that is
harvested are
transected.

16. Bone harvest
• The teres major is
retracted superiorly and
an osteotomy is
performed as planned
with a saw.

17. Bone harvest
• The bone is retracted
laterally and freed from
the subscapularis
muscle (deep part of
scapular bone).
• Taking care not to
compromise the CSA
and the deep periosteal
branch, the teres minor
still attached to the
bone is transected.

18. Flap harvesting
• The flap is now
completely mobilized
and the pedicle is
transected when the
recipient site is ready.

19. ADVANTAGES
• Large volume supply of different soft tissue
components
• Rarely affected by vascular occlusive disease

20. Indications
• Very useful in situations where significant soft
tissue volume has to be replaced such as
segmental mandibular resections in
conjunction with glossectomy procedures or
extensive full thickness skin defects
• Composite scapula flap very useful for midface
reconstruction after extensive maxillectomies