Anatomic Configurations in Midfacial Reconstruction Using Scapula and Scapular Tip Flaps

Background: Midfacial reconstruction presents numerous functional and cosmetic challenges that can be addressed with bony free flaps. The parascapular system affords a variety of soft tissue and bony combinations to optimize reconstructions. This project will describe how numerous configurations of scapular tip and scapular lateral border free flaps can be used to accomplish diverse midfacial reconstructive goals.

Methods: Retrospective database review of patients at a single institution who underwent osseous parascapular system free flaps for reconstruction of midfacial defects. Operative notes and postoperative imaging were reviewed. Cordeiro defect classification was used to stratify ablative defects.

Results: Thirty-nine patients were identified. Lateral border placed in a horizontal configuration is useful for type two defects, allowing bone stock for midfacial projection and possibly dental rehabilitation. Scapular tip can also be used to create a new hard palate. For type 3b defects, scapular tip placed in a vertical configuration can recreate a resected anterior maxillary wall, with the thicker portion of the bone reforming either the inferior orbital rim or alveolus. For type 3a defects, the thin central portion of the scapula can be harvested to reconstruct the orbital floor and support the preserved globe. Type 4 defects with orbital rim resection can have restoration of perioral contour with scapular tip or scapular border. Medial orbital reconstruction can provide rigid support to maintain nasal patency. Superior orbital reconstruction supports the skull base and prevents ptosis of the soft tissue filling the orbital exenteration defect. Parascapular flaps also afford the option of harvesting skin or muscle off separate pedicles not fixed to the underlying bone. In all 39 patients, at least one soft tissue component was harvested. Soft tissue components can be used to close oroantral fistulas, fill maxillectomy defects, fill exenteration cavities, line the skull base to protect against cerebrospinal fluid leak, and replace skin defects. Significant surface area of scapular bone harvest is well tolerated with minimal comorbidities. Scapular flaps placed in vertical and horizontal configurations had low complication rates with nasocutaneous fistula being the most common (10% of patients).

Discussion: The bone stock from the parascapular system has similarities in shape and thickness to the midface, making it a good option for free flap reconstruction with several cosmetic and functional advantages. A variety of soft tissue components can also be harvested to accomplish additional reconstructive goals, avoiding a second free flap in large defects.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
12 February 2021