Download PDF
Facial Plast Surg 2018; 34(04): 389-393
DOI: 10.1055/s-0038-1666784
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Tip-on-Tip Scapular (TOTS) Flap for Reconstruction of Combined Palatectomy and Rhinectomy Defects

Ryan A. Bartholomew
1   Harvard Medical School, Harvard University, Boston, Massachusetts
,
Joseph Zenga
2   Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Harvard University, Boston, Massachusetts
,
Derrick T. Lin
2   Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Harvard University, Boston, Massachusetts
,
Daniel G. Deschler
2   Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Harvard University, Boston, Massachusetts
,
Jeremy D. Richmon
2   Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Harvard University, Boston, Massachusetts
› Author Affiliations
Further Information

Publication History

Publication Date:
24 July 2018 (online)

    Permissions and Reprints

Abstract

Combination anterior palatectomy and rhinectomy defects result in complete loss of midface and nasal support and present a significant reconstructive challenge. A novel use of the scapular tip free flap—the tip-on-tip scapula flap—was developed to provide both palatal repair and restoration of intrinsic nasal support. The scapular tip bone is split into a large proximal segment for the anterior palate and a smaller distal bone segment for nasal framework reconstruction. Two patients undergoing reconstruction of both total palatectomy and partial rhinectomy defects at a single academic tertiary care center were reviewed. In both cases, the larger proximal segment of the scapular tip flap, used for the palatal defect, was based on the angular artery. The distal bone segment, used for nasal framework repair, was vascularized in one of two ways. In the osteomyogenous serratus-scapular tip variant, the serratus arterial branch provided periosteal blood supply to the bone through a cuff of attached serratus muscle. In the split-scapular tip variant, the periosteum of the scapular tip was kept in continuity with the distal bone segment and fed through the periosteal vascular arcade from the angular branch. In both patients, the distal bone segment demonstrated robust intraoperative vascularity and both flaps healed without complication. Both patients were able to resume oral diets and had good nasal breathing.

Keywords

scapular tip flap - palatectomy - rhinectomy - reconstruction
 

  • References

  • 1 Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent 2001; 86 (04) 352-363
    CrossrefPubMedGoogle Scholar
  • 2 Kim IA, Boahene KD, Byrne PJ, Desai SC. Microvascular flaps in nasal reconstruction. Facial Plast Surg 2017; 33 (01) 74-81
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 Stucker FJ, Daube D. Reflections on total and near total nasal reconstruction. Facial Plast Surg 1994; 10 (04) 374-381
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Thomas WO, Harris CN. Subtotal midfacial/total nasal reconstruction following shotgun blast to the face employing composite microvascular serratus anterior rib, muscle, and scapular tip. Ann Plast Surg 1997; 38 (03) 291-295
    CrossrefPubMedGoogle Scholar
  • 5 Hamahata A, Saitou T, Beppu T, Yamaki T, Sakurai H. A new nasal cavity and maxilla reconstruction method using jejunum flap with non-vascularised bone. J Plast Reconstr Aesthet Surg 2013; 66 (01) e12-e15
    CrossrefPubMedGoogle Scholar
  • 6 Clark JR, Vesely M, Gilbert R. Scapular angle osteomyogenous flap in postmaxillectomy reconstruction: defect, reconstruction, shoulder function, and harvest technique. Head Neck 2008; 30 (01) 10-20
    CrossrefPubMedGoogle Scholar
  • 7 Coleman III JJ, Sultan MR. The bipedicled osteocutaneous scapula flap: a new subscapular system free flap. Plast Reconstr Surg 1991; 87 (04) 682-692
    CrossrefPubMedGoogle Scholar
  • 8 Wagner AJ, Bayles SW. The angular branch: maximizing the scapular pedicle in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 2008; 134 (11) 1214-1217
    CrossrefPubMedGoogle Scholar
  • 9 Valentini V, Gennaro P, Torroni A. , et al. Scapula free flap for complex maxillofacial reconstruction. J Craniofac Surg 2009; 20 (04) 1125-1131
    CrossrefPubMedGoogle Scholar
  • 10 Miles BA, Gilbert RW. Maxillary reconstruction with the scapular angle osteomyogenous free flap. Arch Otolaryngol Head Neck Surg 2011; 137 (11) 1130-1135
    CrossrefPubMedGoogle Scholar
  • 11 Choi N, Cho JK, Jang JY, Cho JK, Cho YS, Baek CH. Scapular tip free flap for head and neck reconstruction. Clin Exp Otorhinolaryngol 2015; 8 (04) 422-429
    CrossrefPubMedGoogle Scholar
  • 12 Dowthwaite SA, Theurer J, Belzile M. , et al. Comparison of fibular and scapular osseous free flaps for oromandibular reconstruction: a patient-centered approach to flap selection. JAMA Otolaryngol Head Neck Surg 2013; 139 (03) 285-292
    CrossrefPubMedGoogle Scholar
  • 13 Seneviratne S, Duong C, Taylor GI. The angular branch of the thoracodorsal artery and its blood supply to the inferior angle of the scapula: an anatomical study. Plast Reconstr Surg 1999; 104 (01) 85-88
    CrossrefPubMedGoogle Scholar
  • 14 Satomi Y, Shimizu H, Beppu M, Hirata K, Takahashi T. Clinical anatomical study of pedicled vascularised scapular bone graft using the angular branch. Hand Surg 2007; 12 (01) 19-28
    CrossrefPubMedGoogle Scholar
  • 15 Seitz A, Papp S, Papp C, Maurer H. The anatomy of the angular branch of the thoracodorsal artery. Cells Tissues Organs 1999; 164 (04) 227-236
    CrossrefPubMedGoogle Scholar
  • 16 Brown JS, Lowe D, Kanatas A, Schache A. Mandibular reconstruction with vascularised bone flaps: a systematic review over 25 years. Br J Oral Maxillofac Surg 2017; 55 (02) 113-126
    CrossrefPubMedGoogle Scholar
  • 17 Kim PD, Blackwell KE. Latissimus-serratus-rib free flap for oromandibular and maxillary reconstruction. Arch Otolaryngol Head Neck Surg 2007; 133 (08) 791-795
    CrossrefPubMedGoogle Scholar