Mandibular reconstruction in osteoradionecrosis or salvage surgery can often be complicated by the lack of suitable recipient vessels in the ipsilateral neck and the associated requirement for significant extraoral skin reconstruction. The scapula tip with its long vascular pedicle and option of a chimeric soft tissue component offers a versatile reconstructive solution in such cases. This article reports four consecutive cases of mandibular reconstruction with poor ipsilateral vascular options and additional soft tissue requirements in which the scapula tip was justified and preferred. The blood supply to the lateral scapula through the circumflex scapular system is well established in the literature and this would be the preferred reconstruction in class I mandibular defects associated with a significant soft tissue requirement. The scapula tip would suit cases where the ipsilateral recipient vessels are compromised, and so justify the potential for mandibular reconstruction with inferior bone stock.
The angular branch of the thoracodorsal artery that supplies the scapula tip was first described by Deraemaeker et al. . Coleman and Sultan subsequently described harvest of the scapula tip with the latissimus dorsi muscle as a single free flap . The advantages of the scapula tip are a long vascular pedicle and a flexible soft tissue paddle ideal for extensive soft tissue loss, as well as oral reconstruction from the same pedicle. Drawbacks include the relatively limited bone stock: by maximum length and by unsuitability for implants. The reconstructive advantages overall have been summarized by Chepeha et al. as avoiding the need for two flaps or interpositional vein grafts .
The scapula tip has been described in the reconstruction of short posterior mandible defects, including those of the angle, using ipsilateral neck vessels (class I defects according to Brown et al. ) . In most of these cases, the authors’ practice would be to use the standard circumflex scapular option, or other donor sites, as pedicle length is not such an important factor. Although the use of, and indications for, the scapula flap in head and neck reconstruction has been described previously by this research group , only the use of the lateral border of the scapula based on the circumflex scapular artery is described in this series of cases involving the mandible.
The purpose of this report is to describe four cases in which the scapula tip was the most appropriate donor site option, not only compared to the circumflex scapular option but also fibula, radial, and iliac crest.
Patients and methods
All patients who had segmental mandibular defects reconstructed with a scapula tip flap were identified from the surgical database. Data collected included age, sex, diagnosis, previous treatment, class and size of the defect, harvest side, vessels used for anastomosis (recipients), complications, and other outcomes (e.g., implants or oral rehabilitation considered).
Four consecutive patients treated during the years 2014–2016 were identified and included in this case series. The indications for reconstruction with the scapula tip were the following: class I mandibular defect , where the ipsilateral neck was unsuitable for recipient vessel selection due to previous treatment for head and neck cancer or recurrent disease, necessitating vascular access to the contralateral neck ( Table 1 ). All four patients had successful reconstruction without any return to theatre.
|Patient||Age (sex)||Diagnosis||Previous treatment||Defect (size)||Side of harvest||Reconstruction||Recipient vessels|
|1||72 (M)||Osteoradionecrosis of the mandible (Notani grade 3)||Prior OPSCC surgery, ALT + PORT||Class I, right mandible, with 4 × 6 cm overlying cutaneous defect||Ipsilateral||Scapula tip and musculocutaneous LD||Contralateral facial artery and IJV|
|2||51 (M)||Recurrent adenocarcinoma of the face overlying the right angle/body of the mandible||Third recurrence over 5 years; prior ipsilateral neck surgery ×2, and adjuvant radiotherapy||Class I, right mandible, with overlying 6 × 8 cm cutaneous defect||Ipsilateral||Scapula tip and musculocutaneous LD||Contralateral facial artery and common facial vein|
|3||59 (M)||Osteoradionecrosis of the mandible (Notani grade 3)||Referred from another centre; alloplastic bridging reconstruction plate – prior OSCC surgery, with failed fibula flap, POCRT without reconstruction; contralateral fibula with compromised peroneal vessels||Class I, left mandible, with 10 × 6 cm cutaneous defect||Ipsilateral||Scapula tip and musculocutaneous LD||Contralateral facial artery and common facial vein|
|4||55 (M)||Ipsilateral regional recurrence of left T2N2bM0 OPSCC (mandibular involvement)||Primary chemoradiotherapy||Class I, left mandible, with 8 × 10 cm cutaneous defect||Ipsilateral||Scapula tip and musculocutaneous LD||Contralateral external carotid artery and common facial vein|