Circumflex Scapular Artery Research Articles

The Haemodynamics of the Distal Arterial Y-shaped Autograft Bypass-flap in a Porcine Experimental Model

Background The haemodynamic effects of revascularisation with combined bypass and free-muscle flap remain controversial. In a porcine experimental model, we investigated the transplantation-induced changes in the haemodynamics of a Y-shaped combined arterial autograft bypass-muscle flap (AABF). Methods Anatomy of AABF was identified in eight dissections in four porcine cadavers. In five animals, AABF served as a superficial femoral artery (SFA) defect replacement. Modelled, triggered pulsatile pressure ( P) and flow ( Q) waves delivered mean haemodynamics and PQ hysteresis loops before and after transplantation at days 0 and 10. Results Anatomically, AABF combined subscapular and circumflex-scapular arteries, and thoracodorsal artery as latissimus dorsi flap pedicle. Surgical feasibility and AABF patency were confirmed in each case. At day 0, the proximal flow was increased in the grafted Y-shaped AABF, which also adopted the specific SFA pulsatile haemodynamics. Regulatory mechanisms of AABF vasomotricity were preserved and AABF-flow-dependence amplified the flow in the distal segment, which otherwise preserved its own flow dependence. At 10 days, the AABF flow was unchanged in the distal segment, and remained elevated in the proximal and pedicle segments. Conclusions Combined AABF, as a single one-piece arterial autograft, was shown highly adaptive to the receiving arteries. The transplantation-induced changes in AABF pulsatile flow profile and vascular reactivity improve the overall graft flow, and strongly advocate for beneficial effects on the blood propelling capacity of the grafted circulation.

The thin circumflex scapular artery perforator flap

The development of microsurgery has most recently been focused upon the evolution of perforator flaps, with the aim of minimising donor site morbidity, and avoiding the transfer of functionally unnecessary tissues. The vascular basis of perforator flaps also facilitates radical primary thinning prior to flap transfer, when appropriate. Based upon initial clinical observations, cadaveric, and radiological studies, we describe a new, thin, perforator flap based upon the circumflex scapular artery (CSA). A perforator vessel was found to arise within 1.5cm of the CSA bifurcation (arising from the main trunk, or the descending branch). The perforator arborises into the sub-dermal vascular plexus of the dorsal scapular skin, permitting the elevation and primary thinning of a skin flap. This thin flap has been employed in a series of five clinical cases to reconstruct defects of the axilla (two cases of hidradenitis suppurativa; pedicled transfers), and upper limb (one sarcoma, one brachial to radial artery flowthrough revascularisation plus antecubital fossa reconstruction, and one hand reconstruction with a chimeric flap incorporating vascularised bone, fascia, and thin skin flaps; free tissue transfers). No intramuscular perforator dissection is required; pedicle length is 8-10cm and vessel diameter 2-4mm. There was no significant peri-operative complication or flap failure, all donor sites were closed primarily, patient satisfaction was high, and initial reconstructive aims were achieved in all cases. Surgical technique, and the vascular basis of the flap are described. The thin circumflex scapular artery perforator flap requires no intramuscular dissection yet provides high quality skin (whose characteristics can be varied by orientation of the skin paddle), and multiple chimeric options. The donor site is relatively hair-free, has favourable cosmesis and no known functional morbidity. This flap represents a promising addition to the existing range of perforator flaps.

Macroscopic and Microangiographic Anatomy of the Teres Major Muscle: A New Free Functional Muscle Flap?

The teres major can be seen as an additional head of the latissimus dorsi muscle for three-dimensional movement of the arm. It gained importance in pedicled muscle transfers for the treatment of plexus palsies and shoulder instability. Its supplying vessels belong to the subscapular system. According to the literature, the muscle was transferred only once as a free microvascular but nonfunctional graft. Eleven flaps from fresh cadavers were dissected and perfused with radiopaque media. The detailed macroscopic and microangiographic anatomy was investigated to determine its potential use as a free functional muscle flap. Three different access routes are possible. The mean length of the flap was 158 mm, and the distal and proximal tendinous widths were 24 mm and 52 mm, respectively. A Taylor type 1 nerve and Mathes type 2 vessel distribution was found in all specimens. The main pedicle is situated in the middle third of the superomedial border of the flap and derives almost exclusively from the circumflex scapular artery. Radioangiograms indicate possible splitting of the muscle in the transverse and longitudinal directions. The nerve could always be isolated to a considerable length (66 mm) before reaching the posterior cord. This anatomical study indicates that the teres major can be seen as a separate entity in the subscapular system and can be transferred as a free flap either alone or in combination. According to what is known from pedicled transfers, the donor-site morbidity should be low if the latissimus dorsi is left intact.

Bilateral arterial and nervous variations in the human upper limb: A case report

During routine dissection, we found bilateral arterial and nervous anomalies in a female cadaver. On the left side the axillary artery divided into a medial brachial artery and lateral profunda brachii artery, and the musculocutaneous nerve arose from the upper trunk of the brachial plexus, before the formation of the lateral cord. On the right side a common trunk that divided into the circumflex scapular artery, thoracodorsal artery and posterior circumflex humeral artery was observed, while the musculocutaneous nerve fused with the median nerve.

4.7 The circumflex scapular artery flap, a new perforator flap with chimeric and flow-through options

4.7 The circumflex scapular artery flap, a new perforator flap with chimeric and flow-through options

Oblique scapular flap

We report an axial transposition flap based on the anterior branch of the descending branch of the circumflex scapular artery. This has some advantages, including a hidden donor site, easy transfer with no abnormalities, no distortion of the structures, and much pliable tissue.

Anatomy of Y-Shaped Configurations in the Subscapular Arterial System and Clinical Application to Harvesting Flow-Through Flaps

A flow-through flap is useful in cases where the recipient artery must not be sacrificed. The aim of this study was to investigate Y-shaped configurations in the subscapular arterial system that can safely be used in harvesting a flow-through flap from the scapular region. Sixteen dissections of the subscapular arterial system were carried out in eight embalmed cadavers. The origins and external diameters of branches in the subscapular arterial system were recorded. The distances between the origins of each branch were measured. The branches that showed a consistent presence and had a reliable diameter of more than 1.0 mm were the circumflex scapular artery, the bony branch of the circumflex scapular artery, the thoracodorsal artery, the angular branch, and branches to the serratus anterior and latissimus dorsi muscles. It was demonstrated that using the Y-shaped configuration between these branches enables the harvesting of a flow-through flap in various length versions of the Y-shaped vascular pedicles. A significant anatomical variation (i.e., both the thoracodorsal and circumflex scapular artery arose directly from the axillary artery) was found in three of 16 dissections. In this vascular variation, sacrificing the axillary artery must be avoided, so Y-shaped pedicles using the origin of the thoracodorsal or circumflex scapular artery cannot be created. On the basis of these results, flow-through flaps using this arterial system were applied in 10 patients for reconstruction of lower extremities, and satisfactory results were obtained. The results of our study are available for determining preoperatively and intraoperatively which Y-shaped configuration to use in harvesting a flow-through flap from the scapular region.

A Pedicle-Lengthening Technique for Free Latissimus Dorsi Muscle Flaps: The “Y-V-I” Principle

This article describes a pedicle-lengthening procedure (the Y-V-I principle) that reverts a Y-shaped vascular structure into an I-shaped vascular structure, and its application to the latissimus dorsi muscle. If the Y-shaped vascular structure is divided proximal to the branching point and ligated, it becomes a V-shaped vascular structure. To obtain a linear I-shaped vascular structure, the V is opened, and the length of the vascular pedicle will become equal to the combined length of both limbs of the V. This report indicates that the latissimus dorsi flap may be transferred based on the circumflex scapular artery or the serratus branch.

Transplantation of free scapular flap to repair soft tissue defects in hand and wrist

目的 探讨游离肩胛皮瓣在修复手腕部软组织缺损中的应用价值.方法 1997年1月至2002年6月,用游离肩胛皮瓣修复手腕部软组织缺损25例,其中单纯手背侧缺损14例,手背、腕背均缺损9例,手掌侧缺损2例.按常规切取游离肩胛皮瓣,面积最大23cm×12cm,最小8cm×6cm;以旋肩胛动脉为血管蒂,蒂长4～6cm,平均5.1cm.结果 25例皮瓣全部存活,其中1例术后出现动脉危象,手术探查证实为吻合口栓塞,取栓后重新吻合血管,皮瓣存活.术后随访6个月～3年,皮瓣色泽、质地良好,厚度适宜.结论肩胛皮瓣血供可靠,切取方便,是修复手腕部软组织缺损较理想的皮瓣,可作为修复手背部软组织缺损的首选皮瓣。

Clinical and basic research on occipito-cervico-dorsal flaps: including a study of the anatomical territories of dorsal trunk vessels.

The authors have carried out a clinical study of all the patients who underwent reconstructions with occipito-cervico-dorsal flaps in their department between 1994 and 2003 and analyzed the outcomes of the surgery. The reconstructed areas ranged from the cheek to the anterior chest. Twenty-eight cases underwent reconstruction with microvascular augmented occipito-cervico-dorsal flaps, and four were reconstructed with single pedicle occipito-cervico-dorsal flaps. In five cases, distal partial necrosis was observed. The largest flap size was 43 x 23 cm (5 x 5-cm pedicle). In the microvascular augmented occipito-cervico-dorsal flaps, the circumflex scapular artery and veins were used in 28 cases, and dorsal intercostal perforators were used together with circumflex scapular artery and veins in five cases. The follow-up term was between 1 and 8 years. Neck scar contractures were released in all cases, and good results were obtained not only functionally but also aesthetically. In an anatomical study, the authors used 20 preserved cadavers and took angiograms of the dorsal region. Five cadavers were used to confirm the territory of each of the vessels that have close relations to the occipito-cervico-dorsal flap (the occipital artery, transverse cervical artery, circumflex scapular artery, and dorsal intercostal perforator artery). Each anatomical territory was clearly seen and its area identified.

Dysvascular lower extremity reconstruction using free flaps with a "Y" configuration of the arterial pedicle.

For patients with a dysvascular lower extremity, free flaps have been transferred by end-to-side anastomosis, in order to maintain peripheral circulation. For such patients, the authors have applied free flap transfers with a "Y" configuration of the arterial pedicle. Eight free flaps with a Y configuration of the arterial pedicle were used in seven patients: latissimus dorsi musculocutaneous flaps in six, and scapular flaps in two. For the former, flaps were harvested with the subscapular and circumflex scapular arteries forming a Y pedicle in three cases, and with the thoracodorsal artery and the branch of the serratus anterior muscle in three. For the scapular flap transfers, the flap was harvested with the subscapular and thoracodorsal arteries forming a Y pedicle in one case, and with the circumflex scapular artery and the descending branch in the other. This procedure was performed for single-artery extremities in two cases. One developed arterial thrombosis of the branch to the foot, but removal of the thrombus and reanastomosis resulted in peripheral blood circulation being maintained. Eventually, all flaps survived. This procedure is indicated in patients with lower-leg reconstruction, especially with vascular disease.

広背筋穿通枝皮弁を使用したデスモイド腫ようの一例

A-68-year-old man had a tumor on the thoracic wall for two years. It had a diameter of 10cm, and was elastically hard. Histopathological findings showed fibrous tissue made of compact and mature fibroblasts and collagen fibers. Fbbroblasts are small, slender nuclei with rare mitotic figures. We diagnosed that tumor as a desmoid tumor. Tumor resection was performed; a large defect (20×20cm) in the trunk had to be reconstructed. We showed a new strategy of repairing soft-tissue defects in the thoracic wall. We utilized two flaps, which are both pedicled latissimus dorsi muscle perforator flaps. One is perforated from the circumflex scapular artery, which we call a scapular flap, and the other is perforated from the intercostal artery. We propose these flaps latissimus dorsi perforator flaps and demonstrated some points of technique for the repairing of soft-tissue defects in the thoracic wall and rising musculocutaneous flaps. [Skin Cancer (Japan) 2001; 16: 305-309]

Sellection of Flaps for Cranio-Maxillo-Facial Reconstruction

Sellection of Flaps for head and neck, especially cranio-maxillo-facial reconstruction is determined by the following factors. Firstly, there is the recipient vessels or not. Secondary, there are the bone defect and/or soft tissue defect. Further, the prognosis of malignant tumor and the patient's general condition, age, sex etc are determine the best flap selection. We require the following peculiarities for the flap of cranio-maxillo-facial reconstruction. So called, three-dimensional maneuverability of the skin flap relative to the bone and the simplicity of bone trimming. The separated osteocutaneous scapular flap preserving the angular branch includes the ability to design multiple skin paddles (scapular, para-scapular, and ascending scapular flap) and two separated bone flaps (the lateral border and tip of the scapula) allowing improvment in three-dimensional spatial relationships for maxillary reconstruction. In addition, the scapular osteocutaneous free flap can be combined with such other flaps as the latissimus dorsi flap and the serratus anterior flap because the vascular supplies of these flaps also originate from the subscapular vessels. The essential elements of the maxillectomy defect are the body components of the hard palate, the anterior alveolar ridge, the anterior maxillary wall, and the medial nasal wall. Extending the defect into the orbit also entails loss of orbital rim, orbital floor, and medial nasal wall, and, occasionaly, the skin of the anterior cheek. We have performed maxillary reconstruction using the separated osteocutaneous scapular flap preserving the angular branch and the combined flaps with subscapular vessels. That is to say specifically, we use the lateral border of the scapula supplied by the periosteal branches of the circumflex scapular artery for reconstruction of the zygomatic body and anterior maxillary wall, and so the tip of the scapula supplied by the angular branch for reconstruction of the orbital rim and floor. The scapular or para-scapular flaps are used for reconstruction of the medial nasal wall or hard palate.

The axial bilobed flap for burn contractures of the axilla

The axial bilobed flap, based on the transverse and descending branches of the circumflex scapular artery, was used to successfully reconstruct burn contractures of the axilla. The main advantages of this flap are that the donor site is closed primarily, it provides an adequate amount of healthy and pliable skin with an excellent blood supply and no chance of contraction, and it is an easy technique. In this paper, two cases are presented.

Inferior angle of the scapula as a vascularized bone graft: an anatomic study.

In reconstructing patients with massive midface losses, the authors required a vascularized bone graft that could be used to reconstruct the palate and orbital floor, provide vertical maxillary support, and provide soft tissue. The inferior angle of the scapula appears to be a promising source of vascularized bone stock, and until now, there has been no clear description of its vascular anatomy. The purpose of this study was to define the vascular anatomy of the inferior angle of the scapula. Thirteen fresh cadavers were studied. The subscapular artery was injected with Microfil (Flow Tec, Carver, MA) at its origin. Two branches of the subscapular artery were found to converge on the angle of the scapula: the descending osseous branch of the circumflex scapular, and the transverse branch of the thoracodorsal. The descending osseous branch of the circumflex scapular artery supplied the inferior angle of the scapula in 100 percent of cases. The transverse branch of the thoracodorsal artery supplied it in 76 percent of cases. The descending osseous branch of the circumflex scapular artery is the principal artery supplying the inferior angle of the scapula.

The teres major muscle: An anatomic study of its use as a tendon transfer

Eleven fresh-frozen cadaver shoulders were dissected to define the anatomy of the teres major muscle and tendon and to determine the muscle's potential for use as a tendon transfer to the humeral head. Of the 11 specimens, 7 had Mathes type II circulation. The primary and secondary pedicles, from the circumflex scapular artery, entered the muscle 4.1 cm and 0.5 cm from the scapula, respectively. The lower subscapular nerve entered 4.1 cm from the scapula. Mean tendon and muscle lengths were 2.0 and 11.8 cm, respectively. As a unipolar transfer, the tendon reached the greater tuberosity in all but 1 specimen. The bipolar transfer offered numerous theoretical possibilities. We believe that the teres major has an appropriate vascular supply and adequate length to make it suitable for tendon transfer to the humeral head.

The anatomical study of the ascending cutaneous branch of the circumflex scapular artery.

The anatomical study of the ascending cutaneous branch of the circumflex scapular artery.

The axillary tree as a source of musculocutaneous and fasciocutaneous flaps in a fixed-skin porcine model.

Our understanding of muscle, fascia, and skin flap physiology is based largely on data obtained from rodent, rabbit, or canine models. The presence of a well-developed panniculus carnosus confounds the extrapolation of data from these animals to humans. This study attempted to define microsurgically applicable musculocutaneous and fasciocutaneous flaps in the pig that would be comparable to flaps commonly used in humans. Lead oxide was injected into each axillary artery of three standard white domestic swine. Gross dissection and radiographic studies were used to define the specific anatomic fasciocutaneous territory served by the branches of the circumflex scapular artery. Eight musculocutaneous flaps based on the thoracodorsal artery and eight fasciocutaneous flaps based on the circumflex scapular artery were elevated. Although all flaps survived in their entirety, the fasciocutaneous flaps did not, as in man, have an easily dissectable axial blood supply. This finding suggests that the porcine scapular fasciocutaneous flap, although reliable as a pedicled flap, is difficult to employ as a free tissue transfer.

Three-dimensional reconstruction of cutaneous arteries of the back by computer graphic imaging.

Computer graphics using a personal computer were introduced to demonstrate the three-dimensional architecture of cutaneous arteries of the back in humans: the direct cutaneous artery of the circumflex scapular artery and the perforating cutaneous branches and musculocutaneous perforators of the superficial cervical, posterior intercostal, and thoracodorsal arteries. The entire thickness of the skin and underlying subcutaneous tissue over the deep fascia was obtained from five fresh cadavers injected systemically with lead oxide-gelatin mixture, and the integument was divided into the three layers; the skin, superficial adipofascial layer with the superficial fascia, and the deep adipofascial layer. Computer graphic reconstruction of the cutaneous arteries was performed using data based on angiograms of the three layers. The computer graphic depictions demonstrated in which layer cutaneous arteries branched and how the vessels were running in each layer by displaying each layer in different colors: red, yellow, and blue. Knowledge of the three-dimensional structure and architecture of the cutaneous arteries will aid in the development of flaps that use a portion of the skin and subcutaneous adipofascial tissue.

The inframammary extended circumflex scapular flap: an aesthetic improvement of the parascapular flap.

Parascapular free flaps traditionally have been designed obliquely across the back, corresponding to the descending branch of the circumflex scapular artery. The donor site of this workhorse flap has the drawback of a widened and frequently hypertrophic scar. In searching for aesthetic improvements in the donor site, we have progressively rotated the axis of this flap in an anterior direction. The end result of this modification is the flap we report here: the inframammary extended circumflex scapular flap. This flap has a longitudinal axis of rotation lying curvilinearly from the inframammary fold to the circumflex scapular artery within the triangular anatomic space. We have used this flap in 20 patients over the past 2 years. The vast majority of these cases were deepithelialized flaps with customized extensions of dorsal thoracic fascia to correct facial asymmetry. We feel that the inframammary extended circumflex scapular artery flap donor-site scar is well hidden within the inframammary fold, and that the unavoidable widening and hypertrophy of parascapular and scapular flap donor-site scars were minimized compared with traditional flap designs.