Revisiting the Free Scapula Flap for Reconstruction of Extensive Maxillary Defects

Introduction: Oncologic resections in the maxillary region often require advanced reconstruction of soft tissue and bone defects. The free fibula osteocutaneous flap remains the workhorse flap, however, in extensive defects, additional soft tissue flaps may be required, resulting in increased morbidity. We present the outcomes for maxillectomy patients reconstructed with a single, chimeric osteomyocutaneous free scapula flap, utilizing CAD/CAM technology.

Methods: Patients who underwent maxillary reconstruction with free scapula flap at MD Anderson Cancer Center from January to December 2017. Patient demographics, type and extend of defect, surgical technique, intraoperative and postoperative events were recorded. A new approach in the design of the free scapula flap is introduced, by adding chimeric elements based on the thoracodorsal artery, harvesting the osseous component off the angular artery and utilizing CAD/CAM technology.

Results: 5 patients were included. Average operative time was 663 minutes (range 321-1137) and average ischemia time 122 minutes (range 50-212). The scapula flap was designed based off the subscapular (n=1), thoracodorsal (n=3) or circumflex scapular artery (CSA) (n=1). The dominant pedicle for the osseous component was the CSA (n=2) or angular artery (n=3). CAD/CAM utilization required no intraoperative adjustments or additional osteotomies. Long-term outcomes were assessed using DASH questionnaires and VAS scores.

Conclusion: We suggest considering reconstruction with single, chimeric osteomyocutaneous free scapula flap in patients with large maxillary defects involving the palate and/or the orbit, elderly patients requiring early postoperative mobilization or when other options are unavailable. CAD/CAM may decrease operating time, optimize preoperative planning and accuracy of reconstruction and improve patient outcomes.