Lengthening the pedicle of a scapular osseous free flap by angular branch reconnection within the subscapular artery system

Abstract

This report describes a case of a patient who underwent secondary reconstruction of the maxilla using a combined scapular osseous and thoracodorsal artery perforator (TAP) flap, in which the pedicle of the scapular osseous flap was lengthened by reconnecting the angular branch of the thoracodorsal artery to the serratus branch. The patient was a 62-year-old man who had undergone left total maxillectomy for maxillary carcinoma and came for reconstruction of left deformity. A reconstructive procedure involving a vascularized scapular osseous and TAP flap transfer was planned. However, the patient's ipsilateral superficial temporary artery and facial artery was found stenosed due to previous radiotherapy and chemotherapy and were not suitable for use as recipient vessels. Thus, a long flap pedicle was needed for anastomoses to the contralateral recipient vessels. We lengthened the pedicle of the scapular osseous flap by reconnecting the angular branch of the thoracodorsal artery to the serratus branch within the chimeric free flap and then anastomosed it to the contralateral facial vessels. The postoperative course was uneventful, and the left cheek deformity was well corrected. Using the technique of reconnection of branches within the blood supply system, a chimeric flap with a long pedicle may be elevated safely whilst avoiding the need for vein grafts.

Reliability of eccentric position of the pedicle instead of central position in a thoracodorsal artery perforator flap

“…Vein grafting is a conventional and useful technique, and vascular loop technique and arteriovenous interposition graft is a modification of conventional vein grafting. Other new procedures have been based on using the natural vascular branching pattern of the subscapular vascular tree or branches of anterolateral thigh flap . The double free flap technique is an extreme method of pedicle lengthening, which uses the additional flap as a vascular conduit .…”

“…Many efforts to extend the vascular pedicle have been described . The recently developed perforator flaps generally have longer vascular pedicles than conventional flaps due to intramuscular dissection .…”

Reconstruction of severe atherosclerotic and obstructive diabetic feet using thoracodorsal artery perforator flaps with long vascular pedicles

“…Vein grafting is also a conventional and useful technique (Flores, Rad, Shridharani, Stapleton, & Rosson, ; Karanas, Yim, Johannet, Hui, & Lineaweaver, ), and the vascular loop technique (Jandali, Diluna, Storm, & Low, ; Lind, McCarthy, Derman, & Jacobs, ) and arteriovenous interposition grafting (Echo & Bullocks, ; Zenn, Pribaz, & Walsh, ) is a modification of conventional vein grafting. Other new procedures are based on using the natural vascular branching pattern of the subscapular vascular tree (Usami, Okazaki, Tanaka, Homma, & Yano, ) or branches of the ALT flap (Huang, Hsieh, Lai, Lin, & Chang, ). The double free flap technique is an extreme method of pedicle lengthening that uses an additional flap as a vascular conduit (Hwang et al, ; Kamei et al, ; Kim, Kim, Kim, & Lee, ; Kim, Ng, Youn, Kim, & Kim, ).…”

Intraoperative flap design using ICG monitoring of a conjoined fabricated anterolateral thigh/tensor fasciae latae perforator flap in a case of extensive soft tissue reconstruction at the lower extremity

“…By changing flap design it was necessary to anastomose the TFL perforator vessels to a sidebranch of the ALT artery, a technique described by Koshima et al Koshima described this technique as mosaic principle, in a more recent publication by Hallock the terminology of the resulting flap was given as “conjoined fabricated” flap . This technique can also be used to lengthen the pedicle of flaps as described by Usami et al The possibility to combine an ALT and TFL perforator flap has been previously described by Hallock and Kimura et al There is also the possibility to harvest a large flap for complex reconstruction combining ALT and a myocutaneous TFL flap as described by Sasaki et al as well as chimeric flaps using a combined ALT flap, TFL myocutaneous flap and vascularized iliac crest have also been described by Gottlieb and coworkers . However, their proximal part of the flap consisted of the myo‐ and/or fasciocutaneous TFL flap and not a TFL perforator flap, thus sacrificing an important structure for lateral hip stabilization.…”