• Archives of Reconstructive Microsurgery
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• v.14 no.1
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• pp.18-23
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• 2005

Purpose: To report the results and the efficacy of the sensory bearing scapular free flap which is known as non-sensible flap. Materials and Methods: Authors underwent 24 cases of sensory bearing scapular free flap to the hands and feet from March 1995 to November 2002. average follow-up period was six year three months. The used flaps were a ordinary scapular flap in fifteen cases, and a parascapular flap in nine. Sensibility of the flaps were checked every one month. Actual sensory evaluation was mostly depends on objective feeling of the patients. Two point discrimination test was performed in all cases. Results: 23 flaps had good skin circulation after microvascular anastomosis among 24. Objective deep touch sensation were observed about three months later after the operation in three cases, between three and six months in nine. In three case whose results were excellent than others, two point discrimination was 2.7 cm at last follow-up. Most of the sensory recovery is confined in deep touch, temperature and light touch sensation was recovered limitedly in 3 cases during our follow-up period. Conclusion: Authors can propose that sensory bearing free scapular flap was considered as one of useful methods for the reconstruction to hand with soft tissue defect and mutilating hand.

• Archives of Reconstructive Microsurgery
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• v.7 no.1
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• pp.20-27
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• 1998

Among many kinds of introduced free flaps, scapular freeflap is one of the most popularly using modalities in fasciocutaneous defect coverage with minimal donor defect and easier procedure and constant vascular patterns of the donor. Many surgeons who had experience of this flap pointed out deficit of the reliable sensation of the transplanted flap is the main shortcoming of the scapular free flap. If we can subjugate that point, scapular free flap is the most excellent procedure in such a cases as heel pad reconstruction and hand reconstruction which are relatively important to have skin with protective sensation. Author performed anatomical literature review, 10 cadaveric dissections and 12 clinical dissections. In surgical anatomical aspect, the upper six dorsal rami of the thoracic nerves have medial branches which pierce Longissimus thoracis and Multifidus muscle with small cutaneous twigs which pierce Latissimus dorsi and Trapezius muscle. Among that cutaneous twigs, several twigs distribute to the skin of the back from midline to lateral aspect which territory is identical to scapular free flap. We analysed clinical experiences of that sensory bearing scapular free flap surgical anatomy and one year follow-up studies with several results. 1) Two to three cutaneous twigs which pierced from the Trapezius muscle over the scapular free flap region. 2) Each twigs has two to four nerve fascicles with small artery. 3) The nerve distributed to the ordinary scapular free flap and large enough size and pedicle length to neurorrhapy with various recipient site nerves. 4) The inconvenience of this procedure is the vascular pedicle and nerve pedicle have opposite directions, vascular pedicle of that comes from lateral direction from subscapular vessels, but nerve pedicle comes from medial direction from trapezius muscle. Author can found constant cutaneous nerve branches which come from piercing the Trapezius. This nerves are helpful for protective sensation in transplanted scapular free flap. We can't had enough follow-up and evaluation of the nerve function of this procedure, we need continuous research works to application of this procedure. The in conveniences come from directional differences of pedicle can solve with longer harvest neural pedicle and change direction of the neural pedicle.

• Archives of Reconstructive Microsurgery
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• v.5 no.1
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• pp.24-34
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• 1996

There are many kinds of free flaps for management of extensive soft tissue defect of extremities in orthopaedic field. Free vascularized scapular flap is one of the most useful and relatively easy to application. This flap has been utilize clinically from early eighties by many microsurgical pioneers. Authors performed 102 cases of this flap from 1984 to 1995. We have to consider about the surgical anatomy of the flap, technique of the donor harvesting procedures, vascular varieties and anatomical abnormalities and success rate and the weak points of the procedure. This flap nourished by cutaneous branches from circumflex scapular vessels emerges from the lateral aspect of the subscapular artery 2.5-5cm from its lateral origin passing through the triangular space(bounded by subscapularis, teres minor, teres major, long head of triceps). The terminal cutaneous branch runs posteriorly around the lateral border of the scapular and divided into two major branches, those transeverse horizontally and obliquely to the fascial plane of overlying skin of the scapular body. We can utilize these arteries for scapular and parascapular flap. The vascular pedicle ranged from 5 to 10 cm long depends on the dissection, usually two venae comitantes accompanied circumflex scapular artery and its major branches. The diameter of the circumflex scapular artery is more than 1mm in adult, rare vascular variation. Surgical techniques : The scapular flap can be dissected conveniently with prone or lateral decubitus position, prone position is more easier in my experience. There are two kinds of surgical approaches, most of the surgeon prefer elevation of the flap from its outer border towards its base which known easier and quicker, but I prefer elevation of the flap from its outer border because of the lowering the possibilities of damage to vasculature in the flap itself which runs just underneath the subcutaneous tissue of the flap and provide more quicker elevation of the flap with blunt finger dissection after secure pedicle dissection and confirmed the course from the base of the pedicle. There are minimal donor site morbidity with direct skin closure if the flap size is not so larger than 10cm width. This flap has versatility in the design of the flap shape and size, if we need more longer and larger one, we can use parascapular flap or both. Even more, the flap can be used with latissimus dorsi musculocutaneous flap and serratus anterior flap which have common vascular pedicle from subscapular artery, some instance can combined with osteocutaneous flap if we include the lateral border of the scapular bone or parts of the ribs with serratus anterior. The most important shortcoming of the scapular free flap is non sensating, there are no reasonable sensory nerves to the flap to anastomose with recipient site nerve. Results : Among our 102 cases, overall success rate was 89%, most of the causes of the failure was recipient site vascular problems such as damaged recipient arterial conditions, and there were two cases of vascular anomalies in our series. Patients ages from 3 years old to 62 years old. Six cases of combined flap with latissimus dorsi, 4 cases of osteocutaneous flap for bone reconstruction, 62 parascapular flap was performed - we prefer parascapular flap to scapular. Statistical analysis of the size of the flap has less meaningful because of the flap has great versatility in size. In the length of the pedicle depends on the recipient site condition, we can adjust the pedicle length. The longest vascular pedicle was 14 cm in length from the axillary artery to the enter point cutaneous tissue. In conclusion, scapular free flap is one of the most useful modalities to manage the large intractable soft tissue defect. It has almost constant vascular pedicle with rare anatomical variation, easy to dissect great versatility in size and shape, low donor morbidity, thin and hairless skin.

• 대한미세수술학회:학술대회논문집
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• 1996.10a
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• pp.173.2-174
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• 1996

• Archives of Reconstructive Microsurgery
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• v.13 no.1
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• pp.14-23
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• 2004

Introduction: The hand and wrist are particularly susceptible to electrical burn. Skin defect with damage or exposure of underlying vital structure requires coverage by skin flap especially in case of the need for late reconstruction. We are reporting 4 cases of electrical burned hand treated by posterior tibial arterial free flap. The commonly used skin flaps such as scapular flap or groin flap are too bulky so that they are not satisfactory in function and cosmetic appearance. So we tried to cover them with a more thin skin flap. Materials and Method: From January 2002 to June 2003, four cases of hand and wrist electrical burn were covered using posterior tibial arterial free flap. All the cases were due to high voltage electrical burn. Age ranged from 31 years to 38 years old and all the cases were male patients. Recipient sites were 2 wrist, one thenar area and one knuckle of 2.3rd MP joint. Additional procedures were flexor tenolysis (simultaneous), FPL tenolysis and digital nerve graft (later) and extensor tendon reconstruction (later). Result: All the flap have survived totally without any complication including circulatory concern about the donar foot. Posterior tibail arterial free flap was so thin that debulking procedure was not required. Conclusion: For skin coverage of the hand & wrist region, posterior tibial arterial free flap have many advantages such as reliable anatomy, easy dissection and easy anastmosis with radial or ulnar artery and possibility of sensory flap. The most helpful advantage for hand coverage is its thinness. So we think this flap is one of the very useful armamentarium for reconstructive hand surgery.