The osteomuscular dorsal scapular (OMDS) flap: an alternative technique of mandibular reconstruction

doi:10.1016/j.bjps.2008.10.014

Journal of Plastic, Reconstructive & Aesthetic Surgery

Volume 63, Issue 2, February 2010, Pages 198-204

https://doi.org/10.1016/j.bjps.2008.10.014 Get rights and content

Summary

Free tissue transfer has become the dominant reconstructive tool for segmental defects of the mandible, except in case of severe peripheral vascular disease. In these cases, we propose to use the osteomuscular dorsal scapular (OMDS) flap as an alternative technique. This flap is pedicled on the dorsal scapular vessels with the harvesting of the medial border of the scapula and the lateral part of the rhomboid muscles.

Methods

Thirteen cadaveric dissections have been performed after arterial injection of coloured latex in order to describe the surgical landmarks of the dorsal scapular pedicle. Six patients have been operated after lateral resection of the mandible.

Results

The mean length of the pedicle was 66 mm (±2.61). The pedicle was located 41.2 mm (±5.51) lateral to the superior angle and 24.6 mm (±7.50) lateral to the medial angle. The size of the medial border that could be used for mandibular reconstruction was 116.46 mm (±7.48). The width of the medial border was 2.62 mm (±0.77) on the upper part and 3.35 mm (±0.90) on the inferior part. The clinical results were satisfying; good symmetry of the mandible was restored with normal opening of the mouth. Normal elevation of the shoulder was retained without recourse to physiotherapy.

Discussion

The advantages of this method over other pedicled flaps include the length of the bone that can be harvested (>12 cm) allowing reconstruction of defects from the condylar process to the canine region and the preservation of scapular elevation. The superior part of the trapezius was not harvested, in order to allow passage of the flap in the tunnel under the upper trapezius to preserve the scapular elevation. The main disadvantages of the OMDS flap are the impossibility of placing implants in the bone that have been harvested because of its thickness and the lateral position that has to be changed to supine to allow access for resection of the tumour.

Section snippets

Anatomical study

The investigations used 13 scapulas from 13 fresh cadavers, which had been injected with coloured latex. The subclavian artery had been exposed and 50 ml of green-coloured latex was injected into it. The upper limb, including the scapula and the clavicle, were removed 2 days after the injection. The number of arterial branches running on the inner aspect of the scapula near its medial border have been noted and the following horizontal distances between the dorsal scapular artery or its branches

Anatomic study (Table 1)

The dorsal scapular artery was running in close contact to the superior border of the scapula, coming from the subclavian artery to the superior angle. Near the superior angle of the scapula, the dorsal scapular artery gave a medial branch to the levator scapulae and the rhomboid muscles, and a lateral one which ran on the anterior face of the scapula lateral to the medial border and gave small branches to the rhomboid muscles, and a very small posterior branch to the posterior face of the

Discussion

In our experience, free microvascular fibula transfer has been the preferred technique for reconstruction of mandibular defects. We present, here, an alternative method for unilateral defects, which involves pedicled transfer of an osteomuscular flap, including the rhomboid muscles and the medial border of the scapula. The point of rotation lies on the anterior border of the clavicular insertion of the trapezius. The flap reaches the condylar process cranially and the canine region ventrally.

References (14)

R. Srikanth et al.
A simple classification for standardisation of nomenclature in free flap outcome
J Plast Reconstr Aesthet Surg
(2006)
J.B. Epstein et al.
Osteoradionecrosis: clinical experience and a proposal for classification
J Oral Maxillo-fac Surg
(1987)
S. Goldie et al.
The Functional Intraoral Glasgow Scale (FIGS) in retromolar trigone cancer patients
J Plast Reconstr Aesthet Surg
(2006)
P.G. Cordeiro et al.
Mandible reconstruction
D.A. Hidalgo et al.
Free-flap mandibular reconstruction: a 10-year follow-up study
Plast Reconstr Surg
(2002)
R.P. Mehta et al.
Mandibular reconstruction in 2004: an analysis of different techniques
Curr Opin Otolaryngol Head Neck Surg
(2004)
K.A. Hurvitz et al.
Current options in head and neck reconstruction
Plast Reconstr Surg
(2005)

There are more references available in the full text version of this article.

Cited by (11)

Modification of the pedicled osteomuscular dorsal scapula flap to include a skin paddle
2023, International Journal of Oral and Maxillofacial Surgery
This article describes a reliable surgical alternative for the repair of wide oromandibular defects that require bone and soft tissues, which was applied in two patient cases. While microvascular free flap transfer, especially the fibula flap, is the gold standard for mandibular reconstruction, this reconstruction is challenging in patients with a vessel-depleted neck and/or severe arteriosclerosis. The pedicled osteomuscular dorsal scapular (OMDS) flap is a surgical alternative to free flap transfer in this clinical setting. The technique described involves harvesting of the OMDS flap to include a skin paddle, which is often required to close wide oral mucosal defects.
Twelve-year experience in mandibular reconstruction using osteo-muscular dorsal scapular pedicled flaps
2021, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
The origin of the dorsal scapular artery (DSA) is variable.20 An anatomical study was carried out by Vacher22,23 on 33 subjects. The DSA ran on average 0.5 cm ±0.8 lateral to the upper scapular angle.
Primary mandibular reconstruction after tumor removal or osteoradionecrosis treatment is a standard procedure. The most common reconstruction techniques are fibula, scapula, and iliac crest free flaps. Nevertheless, all patients are not eligible for microsurgery.
In this study, we assess 12 years of mandibular reconstruction using an osteo-muscular dorsal scapular pedicled flap (OMDS). We included 40 patients operated on using an OMDS flap. We collected parameters such as length of hospital stay, recurrence risk, and need for secondary flap for oral cutaneous fistula (OCF) treatment. Flap bone volume was assessed by segmenting the scapula on postoperative CT-scans using dedicated software.
Forty patients were included. Indications for OMDS flaps were severe cardiovascular history (27%), preoperative radiotherapy with a radiation neck and potentially unreliable blood vessel sutures (20%), previous fibula free flap failure (15%), and patient refusing free tissue transfer (8%). Aside from these medical indications, OMDS flaps were performed in 30% of cases due to organizational concerns. The mean flap length was 73±16 mm, with a maximum of 109 mm. Flap bone volume was stable over time, with negligible resorption (p = 0.761). Secondary pedicled flaps were used to treat OCF in 5 patients (12%). Secondary esthetic procedures were performed in 9 patients (22%). None of the 40 flaps were removed. None of the patients had long-term scarring complications in donor sites.
OMDS flaps merit consideration for mandibular reconstruction when free tissue transfer is contraindicated or impossible due to organizational issues.
A comparison of perioperative complications following transfer of fibular and scapular flaps for immediate mandibular reconstruction
2013, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
These data reflect the high reliability of soft tissue based on the subscapular system, which achieves good seals of the oral mucosa without leaving dead space.2 The main objection to the use of the scapular flap for mandibular reconstruction is the inconvenience of changing the patient's position during the operation.2,21 In the present study, the mean operation time for the scapular flap was approximately 1 h longer than that for the fibula flap.
The fibular flap and the scapular flap are widely used for immediate reconstruction after segmental mandibulectomy. The aim of this study was to compare perioperative complications between the fibular flap and the scapular flap in immediate mandibular reconstruction.
Data were retrospectively collected on 56 patients who had undergone immediate mandibular reconstruction with a fibular flap (38 patients) or a scapular flap (18 patients) after segmental mandibulectomy from 2005 to 2011. The rates of perioperative recipient-site and donor-site complications were compared between the groups.
The overall rate of recipient-site complications did not differ significantly between the fibula group and the scapula flap. However, the rate of donor-site complications was significantly higher in the fibula group than in the scapula group. Partial skin-graft loss in the fibula group occurred in as high as 13 out of 38 patients.
For immediate mandibular reconstruction, a scapular flap provides short-term results equivalent to those with a fibular flap but with less donor-site morbidity. The major drawbacks of the fibular flap include prolonged healing of the donor site and the delayed mobilisation of patients. Although our first choice of vascularised bone graft is the fibular flap, the scapular flap in an alternative for those patients, especially elderly patients, in whom fibula harvest can result in significant morbidity.
Planning of physiotherapeutic procedure in patients after mandible reconstruction taking into account donor site: a literature review
2023, European Journal of Medical Research
Comprehensive Atlas of Upper and Lower Extremity Reconstruction: From Primary Closure to Free Tissue Transfer
2021, Comprehensive Atlas of Upper and Lower Extremity Reconstruction: From Primary Closure to Free Tissue Transfer
The origin of the dorsal scapular artery: anatomic variations and surgical applications
2016, Surgical and Radiologic Anatomy

View all citing articles on Scopus

View full text

The osteomuscular dorsal scapular (OMDS) flap: an alternative technique of mandibular reconstruction

Summary

Methods

Results

Discussion

Section snippets

Anatomical study

Anatomic study (Table 1)

Discussion

J Plast Reconstr Aesthet Surg

J Oral Maxillo-fac Surg

J Plast Reconstr Aesthet Surg

Mandible reconstruction

Free-flap mandibular reconstruction: a 10-year follow-up study

Plast Reconstr Surg

Mandibular reconstruction in 2004: an analysis of different techniques

Curr Opin Otolaryngol Head Neck Surg

Current options in head and neck reconstruction

Plast Reconstr Surg