Indications for the scapular flap in reconstructions of the head and neck

Composite free flaps that are available for reconstructions of the head and neck include those from the fibula, iliac crest, radial forearm, and scapula, but only that from the scapula precludes two-team operating, and consequently adds a further 2–3 h to the operating time. Here we clarify the indications for the subscapular system of composite flaps, and discuss their unique properties in terms of reliability of the bony segment, their resistance to atherosclerosis, and the diversity of the skin and muscular components that are available. We have had favourable results in composite resections of the anterior mandible that required substantial resections of the anterior tongue. In extensive oropharyngeal resections that require a segmental resection of the mandible, the skin island is reliable and provides sufficient bulk to reduce the risk of dehiscence and maintain a narrowed oropharynx to improve speech and swallowing. In reconstructions of the midface a combination of the latissimus dorsi and the scapula that is based on the angular branch of the thoracodorsal vessel (thoracodorsal angular flap) allows for a long pedicle, and adequate muscle and bone for high and low maxillectomy defects. We present a consecutive series of 46 patients who document the use of this option in routine head and neck practice.