Reconstructing Wide Palatomaxillary Defects Using Free Flaps Combining Bare Serratus Anterior Muscle Fascia and Scapular Bone

Abstract

Wide palatomaxillary defects, mostly after tumor resections, can cause severe functional and esthetic problems. Although prosthetic obturator devices or local flaps are mostly adequate for uncomplicated small-size defects, free flaps are preferred for a 3-dimensional multitissue reconstruction of more complicated defects. Regarding the anatomical structure of the palatomaxillary region, the flap must be thin enough to separate the oral and nasal cavities while not compromising palatal function, yet rigid enough for adequate dental restoration. This goal is usually accomplished with a combined or complex free flap. Numerous free flaps containing both soft tissues and bone have been described in the literature. In this study, we present a novel use of the free scapular bone flap combined with serratus anterior fascia and its functional and esthetic results. Nine cases are presented whose wide composite palatomaxillary defects were repaired with free angular scapular bone flap combined with serratus anterior fascia based on the subscapular vascular system, between 1999 and 2003. Scapular bone wrapped with the naked serratus anterior fascia, like a sandwich, was used to repair the palate. The naked fascia was epithelialized with the help of the surrounding mucosa in 4 to 6 weeks. Results were satisfying with regard to breathing, eating, speech, and facial contour after follow-ups for 2 months to 6 years. For the reconstruction of wide palatomaxillary defects, a combined flap of angular scapular bone wrapped with naked serratus anterior fascia was conceived useful for obtaining satisfactory functional and esthetic results.