British Journal of Plastic Surgery (I 982), 35, 8-l 3 0007-1226/82/0283-@!I08 $02.

00
0 1982 The Trustees of British Association of Plastic Surgeons

The scapular flap-an anatomical and clinical study

B. J. MAYOU, D. WHITBY and B. M. JONES

Department of Plastic Surgery, St. Thomas’ Hospital, London and the Departments of Anatomy and Surgery,
Charing Cross Hospital, London

Summary-The scapular flap is a medium-sized flap combining many of the good qualities of
others, such as thinness and minimal donor site deficit, with the ootentialities of a consistentlv
long pedicle that allows combination with other adjacent flaps. The anatomy of the flap and its
application in nine clinical cases is described.

The anatomy of a new axial-pattern flap based
on a cutaneous branch of the circumflex scapular
artery (C.S.A.) was described by Fonseca dos
Santos (1980). Gilbert (1980) used this as a free
flap and suggested a limited use primarily for
covering small areas on the posterior surface of
the body. Fonseca dos Santos suggested that the
flap should be cut transversely, whereas Gilbert
recommended an oblique flap, presumably to
gain extra length and allow easier closure. We
have re-examined the flap and gained clinical
experience in an attempt to find a wider
application.
the area of skin stained is bounded by the surface
markings of the scapula below the spine, but
extending laterally to include a variable area of
skin over the deltoid. This cutaneous branch was
present in all 18 dissections and had a mean
external diameter of 1.72mm. It was accom-
panied by two venae comitantes in two thirds of
the dissections and a single vein in the remainder.
The distance from the flap to the origin of the
cutaneous branch was 4.3cm (mean), although
the pedicle could be lengthened by division of

Anatomy
Anatomical dissections were carried out on 18
cadavers, 12 to 72 hours after death. The circum-
flex scapular and thoracodorsal arteries were
injected in the axilla with india ink and a
coloured radiopaque gel (Chromopaque: Pilot
Chemical Co.). The vessel branches were then
dissected to their termination. The C.S.A. is the
first major branch of the subscapular artery,
though in one dissection it arose from the axil-
lary artery. The C.S.A. passes posteriorly through
the triangular space between subscapularis, teres
major and the long head of triceps and ends by
dividing into a number of branches deep to teres
minor (Fig. 1). The cutaneous branch passes
posteriorly between the teres minor above and
teres major below. It then turns medially over the
lateral border of the scapula and runs directly
transversely, superficial to the deep fascia over Fig. 1 Circumflex scapular artery passing through the
teres minor and infraspinatus, breaking up into a triangular space with subscapularis above, teres major below
fan of smaller vessels, Injection studies show that and the long head of triceps laterally.

8
THE SCAPULAR FLAPS- AN ANATOMICAL AND CLINICAL STUDY 9

muscular branches. These other terminal latissimus dorsi flap. These could be included as
branches of the C.S.A. supply the muscles and bone independent units or conjoined as a giant flap
of the infraspinous fossa anastomosing with the (Fig. 3). The only structure separating the
suprascapular artery and at the inferior angle scapular flap from the rest of the pedicle was the
with the descending scapular artery (Fig. 2). teres major muscle; therefore, if one large flap is
There was no corresponding discrete sensory required, this must be detached. If however, an
nerve supply to this area of skin. It is supplied independent scapular flap on the subscapular
segmentally by the posterior primary rami pedicle is required, it may be passed through the
medially and by the lateral cutaneous branches of triangular space without detaching teres major.
the intercostal nerves laterally. We investigated
the possibility of including innervated muscle or
Elevation of the scapular flap
bone on the same C.S.A. pedicle. Neither was
feasible, because both the motor nerves and the The patient may be positioned prone or on the
bone were deep to the muscle and inaccessible. side with the arm abducted. The latter position is
Finally, the possibility of extending the pedicle generally more useful as it allows better access to
to the subscapular artery itself was considered. the axilla for the dissection of the extended
This would not only provide a pedicle of 15cm, pedicle and often avoids any turning of the
but would also allow other flaps based on bran- patient for transfer of the flap.
ches of the subscapular artery to be on the The space through which the pedicle passes
pedicle. These are the cutaneous axillary flap, may be palpated with the thumb (Fig. 5). At this
(Baudet et al., 1976), the serratus anterior and level it is bounded by the lateral edge of the
ribs (Bailey and Godfrey, 1982) and the scapula. the teres major and the deltoid. The

Fig. 2 Terminal branches of the circumflex scapular artery. Cutaneous branch marked with an arrow
10
pedicle is marked. The flap may be marked in two
ways depending on whether the pedicle is re-
quired to enter the end, in which case it is
marked transversely across the back, or the
middle of the flap when it is marked vertically
(Fig. 3). Either way the flap is centered on the
surface markings of the scapula below the spine.
It may however be extended medially to within
3 cm of the mid-line and laterally for a few
centimetres into the axilla. The maximum width
of the flap is 1Ocm and is determined by the
amount of tissue which may be removed and yet
allow direct closure of the defect. In general, an
incision around the margins of the flap is all that
is necessary but if the extended pedicle of the
subscapular artery is required, then a further
lateral extension into the axilla allows access to
the subscapular artery.
Fig. 3 Variations of flap design. Vertical or transverse
in combination with the latissimus dorsi flap (right).
BRITISH JOURNAL OF PLASTIC SURGERY
The flap is raised from medial to lateral,
superficial to the fascia. This provides an easy,
relatively bloodless plane of dissection. As the
flap is turned back to the lateral edge of the
scapula, the cutaneous branch of the C.S.A. can
be seen on the undersurface of the flap. At this
point, the superficial margins of the triangular
space are defined superiorly and inferiorly.
Above, the deltoid overlies teres minor and,
below, the tendinous insertion of latissimus dorsi
curls around the fleshy teres major. When these
edges are retracted, the pedicle can be easily
traced towards the axilla. At a mean of 4.5cm
from the skin, other terminal branches of the
C.S.A. may be seen and are divided, thus giving a
pedicle of 6 to 9cm together with 1 or 2 venae
comitantes. Further length can be obtained by
dissection of the subscapular vessels in the axilla,
most easily done by following the thoracodorsal
vessels on the undersurface of latissimus dorsi
upwards towards the axillary artery. The C.S.A.
may be seen as the first major branch travelling
backwards behind teres major. With the pedicle
freed from behind and in front, the flap may be
passed through the triangular space into the
axilla and the dissection completed. If a single
giant flap is required, contiguous with the lat-
issimus dorsi flap, then the teres major must be
detached.
Clinical cases
Nine scapular flaps have been performed, eight as
free flaps and one as an island in combination
with the latissimus dorsi flap (Table 1).
The flap was used to cover medium-sized
defects, but with particular preference ‘in patients
who required a thin flap, such as on the face or
foot, or in whom it was particularly desirable to
have a good donor site scar. No flap was wider
than 10cm (the maximum defect that may be
closed directly) and the maximum surviving
length was 20cm. In case 3, the flap was taken
obliquely, as recommended by Gilbert, but the
medial and inferior portion of the flap that
extended beyond the surface markings of the
scapula was partially lost and required secondary
grafting. We would not, therefore, recommend
the oblique flap. Its use was not supported by
our anatomical dissections where the cutaneous
branch of the C.S.A. was seen to run transversely.
(left): In case 4 (Figs. 4-7) a 21 cm flap was raised by
extending the flap close to the vertebral spines.
THE SCAPULAR FLAP- AN ANATOMICAL AND CLINICAL STIJDY 11

Table 1 To illustrate the size of the flap and the length and diameter of the vascular pedicle in’9 scapular flap
transfers

Size Pedicle Artery Vein

OfPap(cm) length (cm) diameter (mm) diameter (mm)
_

Case 1 8x 15 9 1.5 2.0

Case 2 9x 19 I 1.4 I.5
Foot f

Case 3 10x23 8 1.5 1.8

&? ( Case 4 9x21 9 1.4 2.0:2.0
Case 5 8 x 14 13 2.5 3.0

Case 6 9x6 6 1.5 1.6

Face ( Case 7 12 x 1.5 6 1.2 7.0
Case 8 9x11 8 1.2 1.6

Axilla
and Case 9 18x33 Island flap combined with latissimus dorsi flap:
breast pedicle not dissected.

“’ ~~*,+; “I^

Fig. 4 (Case 4) Pre-operative defect over the left leg.

Fig. 5 Pre-operative markings of the scapular flap used in

Case 4. The thumb is palpating the site of the pedicle. Fig. 7 (Case 4) Post-operative donor defect over scapula
12 BRITISH JOURNAL OF PLASTIC SURGERY

The final 1 cm of the flap however was lost, centrally in the flap which was, therefore, raised
suggesting that it should not extend closer than vertically. In case 8, the flap was de-epithelialised
3 cm from the vertebral spines.. to pad out the cheek in a patient with a minor
The cutaneous branch could be dissected back degree of hemifacial microsomia. In this case, an
to the C.S.A. through the triangular space and if irregular vertical flap was raised with a central
the 2 or 3 muscular branches were divided, a pedicle for convenient anastomosis to the
pedicle of 6 to 9cm was gained. In case 5, the superficial temporal vessels.
pedicle was also dissected from the axilla to In case 9, an 18 cm long scapular flap was
include the subscapular vessels. After division of combined with a latissimus dorsi flap on the
the thoracodorsal vessels, the scapular flap was same subscapular pedicle making a bilobed island
passed through the triangular space into the flap to reconstruct both the axilla and the breast
axilla, giving a 13cm pedicle arising directly from in a lCyear-old girl with a burn injury (Fig. 8).
the axillary vessels. Although not used as such, The vertical dimension of the flap from the
its potential as an island flap became apparent. scapular spine to the iliac crest measured 33cm.
The flap could be positioned, not only to cover All but the distal 3 cm of the latissimus dorsi
the axilla and the shoulder, but also the breast element survived.
and the mid-line of the neck. This extended
pedicle would have been helpful in case 6. This
Discussion
was an early flap with a relatively short pedicle
which was used to reconstruct one side of the The scapular flap is versatile combining many of
forehead. The superficial temporal vessels were the good qualities of other well-established flaps.
unavailable and 12cm vein grafts were used for The anatomy is consistent and uncomplicated, so
anastomosis with the facial vessels. An initially that a flap on a 6 cm pedicle may be raised
well-vascularised flap failed suddenly three days reliably in 30 minutes. Extension of the pedicle to
post-operatively, due to clotted vein grafts. This include the full length of the subscapular vessel
could perhaps have been avoided by the use of
the extended subscapular pedicle.
The vessels in the pedicle were of convenient
diameter, the C.S.A. measuring between 1.2 and
1.5 mm with venae comitantes of 1.5 to 2mm.
Two veins were usually present. This was used to
advantage in case 4, where drainage into a vena
comitans of the leg was insufficient and the
second vena comitans of the flap was anasto-
mosed to a superficial leg vein.
The flap was generally thin, even in obese
patients. This was of particular advantage in the
face where it could be used without further
thinning. In case 7 the flap was used to recon-
struct half a nose after the failure of conventional
techniques because the area had been subjected
to large doses of radiotherapy. In this case, the
flap was turned on itself to provide both lining
and cover.
Case 1 was the only flap which required thin-
ning. The flap was used to close a radionecrotic
ulcer on the instep of the foot. Although only
1.5 cm thick when raised, it became so per-
sistently lymphoedematous as to restrict walking.
All but two of the flaps were raised trans-
versely with a pedicle at one end. However, in
case 7, the folded flap to reconstruct the nose, it Fig. 8 (Case 9) Combined bilobed island scapular flap with
was more convenient to have the pedicle arising latissimus dorsi myocutaneous flap.
THE SCAPULAR FLAP--AN ANATOMICAL AND CLINICAL STUDY 13

may extend the operating time by an hour. The Acknowledgements

convenience of the pedicle is second only to the
We would like to thank Mr P. K. B. Davis at St. Thomas’
dorsalis pedis flap and can be more readily Hospital and Mr I. W. Broomhead and Mr E. H. Gustavson
sacrificed. The flap is surprisingly thin, even in at the Hospital for Sick Children for allowing us to report on
the obese patient and this particular quality we patients under their care and the departments of anatomy,
have found of use in reconstructing the face and histopathology and medical illustration at Charing Cross
Hospital. for their help in the preparation and presentation of
foot. Greater sophistication in flap transfer
this work.
includes the donor site deficit. The direct closure of
the scapular flap defect gives an innocuous scar
which, despite some minor spreading, is cosmeti-
cally as acceptable as that of the groin flap but
less readily seen by the patient. References
The use of the flap as an island on the sub- Bailey, B. N. and Godfrey, A. (1982). Latissimus dorsi muscle
scapular pedicle after passage through the tri- free flaps. British Journal of Plastic Surgery, 35, 41.
angular space opens up unexplored possibilities in Baudet, J., Guimberteau, J. C. and Nascimento, E. (1976).
Successful clinical transfer of two free thoracodorsal axillary
the repair of defects of the shoulder, the axilla (as
flaps. Plastic and Reconstructioe Surgery, 58, 680.
in burn contractures and hidradenitis sup- Gilbert, A. (1980). Le lambeau scapulaire. VIPme Renconrres
purativa) the breast, the chest wall and the front Inwrnurionales de Microchirurgie 1980.
of the neck. DOS Santos, L. F. (1980). Retalho escapular: urn nova retalho
Transfer of the scapular flap along with other livre microcirurgico. Reuistu Brasileira de Cinrrgiu. 70, 133.

tissues on the same subscapular pedicle allows

great versatility. Combined with the latissimus
dorsi flap, it gives an exceptionally large flap as The Authors
in case 9. Independent use of the flap with the
latissimus dorsi flap and the serratus anterior and B. J. Mayou, FRCS. Consultant Plastic Surgeon St.
ribs, each with a 6 to 8cm pedicle, but combining Thomas’ Hospital, London.
D. Whitby, MBBS, Department of Anatomy. Charing Cross
to form a single pedicle for anastomosis, could Hospital, London.
simplify many composite reconstructions. For B. M. Jones, FRCS, Department of Surgery. Charing Cross
example, following a mandibular resection, the Hospital, London.
scapular flap may be used for lining, the ribs for
mandible and the latissimus dorsi for functioning
cheek. Likewise, the scapular flap and latissimus
dorsi together will provide an alternative tech- Requests for reprints to: B. J. Mayou. FRCS, Department of
nique for pharyngeal reconstruction. Plastic Surgery, St. Thomas’ Hospital, London SEI.

Editoriul Note:

This paper was received in the Editorial Office on the 4th

August 1981 and a paper on this topic was presented
at the Summer Meeting of the British Association of Plastic
Surgeons in Leicester in July 1981.