Circumflex Scapular Artery Research Articles

Anatomic Considerations for a Modified Posterior Approach to the Scapula

A modified posterior approach to the scapula was tested on 20 cadavers. The approach also was used in 2 cases with fractures involving the scapular neck and glenoid fossa. The incision is C shaped, with the convexity directed toward the lateral angle of the scapula. The posterior muscle fibers of the deltoid are reflected laterally after detaching them from their origin. The infraspinatus is mobilized without division to expose the posterior surface of the scapular neck and glenoid. Access to the rest of the posterior and the superior surfaces of the glenoid can be achieved by osteotomizing the acromion. The suprascapular neurovascular bundle is identified and protected at an average of 1.4 +/- 0.1 cm from the glenoid rim, where it is adherent to the spinoglenoid angle of the scapula. The circumflex scapular artery is protected at the lateral border of the scapula at an average of 2.8 +/- 0.5 cm from the inferior glenoid margin. The axillary nerve is protected inferior to the teres minor. However, care should be taken not to excessively retract the teres minor because the nerve lies in close proximity to the shoulder joint capsule.

Mandibular Reconstruction Using A Vascularized Osteocutaneous Scapular FLap

Mandibular reconstructive surgery is an indispensable operative procedure for a patient who received a radical surgery for oropharyngeal cancer to maintain their speech, swallowing, respiratory and masticating function. Serious cosmetic problem appearance would also arise after the craniofacial operation that associate with major mandibular defects. Primary mandibular reconstruction frequently require provision for interoral lining, tongue and as well as lateral wall of oropharynx.Scapular osteocuntaneous free flap is preferred for reconstruction of mandible. Because scapular osteocutaneous free flap has great flexibility in three-dimensional reconstruction and can be combined with other flaps based on the circumflex scapular artery. In this study, masticating function among 20 cases of mandibular reconstruction by scapular osteocutaneous flap were quantitated using dental prescale occluzer system.The postoperative mandibular mastication was dependent on the number of remaining natural teeth, the presence of adhesion between denture and the mobility of remaining tongue. Good mastication are expected in the case of good adherence of denture and remaining natural teeth were obtained. Osteointegrated implants are adequate for total mandibular reconstruction.

Anatomic Studies and Clinical Experience with Fasciocutaneous Flap Closure of Large Myelomeningoceles

Thirteen patients have undergone reconstruction of large lumbosacral myelomeningoceles with bilateral paralumbar fasciocutaneous flaps. Fasciocutaneous flap closure is supported by a rich vascular network with three main dominant vascular territories. In the middle third of the flaps, a prominent transverse segmental vascular pattern originating from the muscular perforators and lateral cutaneous branches of the costal groove segment of the lower intercostal arteries was noted. The parascapular and scapular fascial branches of the circumflex scapular artery supplied the upper lateral portion of the flaps. Prominent lateral extensions of the superficial circumflex iliac arterial system formed the dominant fascial vasculature of the lower lateral flap, richly arborizing with the middle segmental intercostal extensions. All 13 patients tolerated the procedure without blood transfusion and without perioperative complications. Stable, durable cutaneous coverage was achieved in all patients. Two postmortem neonate humans with large lumbosacral myelomeningoceles were studied angiographically. Radiopaque silicone-rubber-lead-chrome matrix (Microfil) was infused under physiologic pressures in a 7-day neonate after successful defect closure with bilateral fasciocutaneous flaps. The flaps were reevaluated postmortem, and high-contrast, digitally enhanced computed radiographic imaging confirmed the rich vascular support of the bilateral fasciocutaneous flaps, identifying the dominant vascular pedicles. Rich vascularity was further documented by photographing the orange opaque Microfil cast vessels through the reelevated flaps. A second postmortem (stillborn) myelomeningocele specimen was studied with barium infusion with particular emphasis on the anomalous lumbar aorta. Angiographic studies provide a new understanding of the unique vascular anatomy of both the anomaly and the paralumbar fasciocutaneous flap.

下肢の広範囲皮膚欠損に対する治療経験

Since May 1981, we have performed 25 cases cf Peroneal vascular island flap, 9 cases of free peroneal flap, 8 cases of free scapular flap, 9 cases of free groin flap and 5 cases of free latissimus dorsi flap. Our first selection for treating wide skin defects of the leg and foot is the peroneal vascular island flap which covers the exposed bone, vessels and nerves. In regard to free flaps, our first choice is to use a scapular flap.The advantages of this flap are that the subcutaneous fat is thin, the branch of the circumflex scapular artery can be easily located, the vascular pedicle is long and vessel diameter is 1.2 to 2.0mm. In cases with wide skin defects from the knee to ankle joint we use a latissimus dorsi flap.

An anatomical variation of the thoracodorsal artery with comments on flaps based on the axillary artery

A rare variation of the axillary artery is presented. On routine anatomical dissection in one male cadaver the thoracodorsal artery was found to originate from the acromiothoracic artery independently from the circumflex scapular artery. Numerous flaps based on the branches of the axillary artery have been described. As a result of this case, and a review of the literature to gain further knowledge of anatomical variations, it is advised that preoperative angiography is indicated prior to utilizing flaps from this area.

遊離骨付き肩甲皮弁の臨床解剖学的研究 脈管系および肩甲骨について

The free scapular flap can be used for mandibular reconstruction, including the repair of soft tissue defects, but there have been few clinicoanatomical studies on this flap. The purpose of the present study was to clarify the anatomical basis of the free scapular flap. The following results were obtained from examinations of forty-two cadavers.Results of morphological examination: 1) Scapular vessels were classified into two types, with angular branches being observed in every case: the common trunk type and direct type. The common trunk type (the subscapular artery branched into the circumflex scapular artery and the thoracodorsal artery) accounted for 95% of cases. The direct type (the circumflex scapular artery and thoracodorsal artery arose from the axillary artery) accounted for 5%. 2) Each of the above types was cross divided into two types. The straight type, in which the circumflex scapular artery ramified into a few branches on the periosteum of the lateral border on the costal surface, accounted for 95%. The circuitous type, in which the circumflex scapular artery ramified into a few branches on the periosteum of the glenoid, accounted for 5%. 3) Venous valves appeared most often at bifurcations. 4) Most valves were bicuspid. Results of morphometric examination:(1) In the common trunk type, the maximum lengths that could be used as flap pedicles were 9.3 cm for arteries and 9.1 cm for veins. In the direct type, the maximum lengths that could be used as flap pedicles were 9.5 cm for arteries and 7.1 cm for veins.(2) In the common trunk type, the mean inner diameters of the vessels 2 mm distal from the bifurcation of the subscapular vessels were 2.8 mm for arteries and 3.3 mm for veins. In the direct type, the mean inner diameters 2 mm distal from the bifurcation of the circumflex scapular vessels were 1.8 mm for arteries and 3.3 mm for veins.(3) The maximum superior-inferior dimension of the scapular graft was 2.8 cm.(4) The maximum lateral dimension of the scapular graft was 1.2 cm.

Anatomical investigations of the cutaneous branches of the circumflex scapular artery and their communications

The vascular anatomy of the cutaneous branches of the circumflex scapular artery and their communications with perforators supplying adjacent territories are described, based on dissections of 20 scapular regions. The cutaneous branches of the circumflex scapular artery are distributed in three areas by the ascending, horizontal and descending branches. The existence of the ascending branch was constant, confirming the reliability of the ascending scapular flap.

The Use of Scapular and Parascapular Flaps for Cheek Reconstruction

This is a retrospective review of our experience with microvascular transfer of scapular and parascapular flaps for the correction of lateral facial contour deficiencies. Twenty-eight patients with congenital (n = 8) and acquired (n = 20) defects were treated with 30 flaps; two patients had bilateral flaps. The etiology of the defects included hemifacial microsomia (n = 2), oblique facial cleft (n = 1), Romberg's hemifacial atrophy (n = 5), neoplasm (n = 4), irradiation (n = 8), trauma (n = 4), tumor excision (n = 4), facial lipodystrophy (n = 2), and silicone granuloma (n = 2). The follow-up evaluation was from 2 to 13 years, with an average of 6 years. Fabrication of a facial moulage was part of the preoperative planning for each patient. These were compound flaps, including skin, deepithelialized skin, fat, fascia, and bone, if necessary. All flaps were constructed with an intact skin paddle for postoperative monitoring. Based on dissections and anatomic findings at operation, several variations in the level of emergence of the circumflex scapular artery from the triangular space and its branching patterns were noted. All flaps survived; changes in the patients' weights were reflected in the flaps. Twelve patients required secondary procedures: excision of skin monitor islands, scar revisions, debulking, or flap resuspension to the malar region. Bone grafts or alloplastic implants were necessary in four patients in whom the malar eminence could not be adequately corrected by transfer of a flap. The deepithelialized scapular/parascapular flap is preferred for correction of large lateral facial defects.

The Bipedicled Osteocutaneous Scapula Flap

Thirty-six adult dissections (14 cadaver and 22 operative) demonstrate the constant presence of the angular branch of the thoracodorsal artery as a vascular pedicle to the inferior pole of the scapula. This vessel originated in all cases just proximal or distal to the serratus branch of the thoracodorsal artery and arborized to the periosteum 6 to 9 cm from the bony branch of the circumflex scapular artery. In eight patients, scapular osteocutaneous flaps were raised preserving the angular branch and the circumflex scapular artery and dissecting up to the subscapular vessels. In all cases, bone was independently perfused by the angular branch. In all six cases where the angular branch was the sole supply to bone, technetium-99m scans demonstrated perfusion. Addition of this vascular pedicle to scapula bone allows two separate bone flaps with one microanastomosis and provides a longer arc of rotation between skin supplied by the circumflex scapular artery and bone. Donor-site morbidity was no greater than with the standard scapula flap.

The parascapular flap for treatment of lower extremity disorders.

The parascapular flap was used as a free microvascular transfer for soft-tissue resurfacing of 11 lower extremities. The diagnoses included four cases of osteomyelitis, three cases of vascular ulceration, one case of combined osteomyelitis and vascular ulceration, two cases of posttraumatic heel defects, and one case of extensive soft-tissue contracture overlying a posttraumatic defect of the femur. All cases were successful clinically. Anatomically, the parascapular flap is supplied by the cutaneous parascapular artery, a branch of the circumflex scapular artery, which itself derives from the subscapular artery. Flap territory may reach 15 x 30 cm, and the vascular pedicle can extend 14 cm if the subscapular artery is taken. Advantages of this flap include the constancy, length, and caliber of the vascular pedicle; the length and width attributes, which allow both coverage of large wounds and primary closure of the donor defect; and an absence of disruption of musculoskeletal function.

The serratus anterior scapular flap —A new osteomuscular unit

Dye and contrast studies of 32 scapular regions have demonstrated a reliable blood supply of the scapula based on a terminal branch of the serratus anterior artery. This artery, called the “angular branch” in our paper, provides the vascular supply of a new osteomuscular flap. The anatomical study also illustrated the relationship between this angular branch and the circumflex scapular and dorsal scapular arteries. The features of this flap are as follows: 1) a constant and long pedicle based on the subscapular-thoracodorsal axis; 2) the possibility of a bony shape similar to the anterior part of the mandible and the hard palate, the maximum length being 22 to 26 cm; 3) the malleable muscular component, suitable for cover of adjacent defects alone or in combination with other regional flaps. The use of the flap for partial reconstruction of the hard palate is described.

The Dorsal Thoracic Fascia

The anatomic distribution and potential arterial flow patterns of the circumflex scapular artery were investigated by Microfil injection. These studies demonstrated that the circumflex scapular artery lies within the dorsal thoracic fascia, which plays a significant role in the circulation of the overlying skin and subcutaneous tissue. We conclude that scapular/parascapular flaps are fasciocutaneous flaps, the dorsal thoracic fascia can be transferred as a free flap without its overlying skin and subcutaneous tissue, and intercommunication exists between the myocutaneous perforators of the latissimus dorsi myocutaneous flap and the vascular plexus of the dorsal thoracic fascia. We present microvascular cases in which the vascular properties of the dorsal thoracic fascia facilitated wound closure with free fascia flaps or expanded cutaneous or myocutaneous flaps.

Structures passing through the triangular space of the human upper limb.

Structures passing through the triangular space of the human upper limb have been studied in 50 upper limbs from 25 cadavers. In all the specimens used in this study, a branch of the circumflex scapular artery with an accompanying vein was found to pass through this space.

The scapular free flap

A purely cutaneous free flap overlying the infraspinous region of the scapula has been used successfully in three cases. It is of intermediate thickness, predominantly hairless and is based on the cutaneous branch of the circumflex scapular artery. The dissection of the flap is easy, quick and safe, resulting in a minimal pedicle length of 3 cm but this can be lengthened significantly by the inclusion of the more proximal vessels. The vessel diameter and its distribution make revascularization predictable. In this series, the longest flap used was 24 cm and the widest was 12 cm, the width being limited by the ability to achieve primary closure. The only donor site disability is related to a tight linear transverse scar. There is no functional limitation nor distortion of the axillary contours. This contrasts with the thicker and widely used latissimus dorsi free flap. The scapular flap should replace the latissimus dorsi flap where the size of the defect to be covered is within the critical dimensions of this flap. The scapular flap can be combined with the latissimus dorsi flap for larger areas of skin cover, or the two flaps can be separated still based on their common vascular pedicle to cover two areas with diverging axes.

The Latissimus Dorsi Muscle

The primary neurovascular pedicle of the latissimus dorsi muscle was studied in 50 fresh cadaver dissections and pertinent dimensions and anatomic relations was recorded. Some findings applicable to clinical reconstructive surgery are: 1. Vascular pedicle of 11 cm mean length (subscapular-thoracodorsal artery and vein). 2. Consistent T-shaped relationship among subscapular artery, thoracodorsal artery, circumflex scapular artery, and serratus arterial branch(es). 3. Large serratus anterior branch(es) from the thoracodorsal artery (1.1 mm mean diameter). 4. Consistent posterior location of neurovascular hilus at muscle junction. 5. Bifurcation of neurovascular structures at the hilus into superior and lateral intramuscular bundles (86 percent of dissections), making various surgical options with the latissimus dorsi skin-muscle flap possible. 6. Lengthy thoracodorsal nerve (12.3 cm mean length). 7. Low incidence of atherosclerosis in the subscapular artery (8 percent) and no significant atherosclerosis seen in the thoracodorsal artery.