Parascapular Pedicle Fasciocutaneous Flaps for Regional ...

Oct. 2011, Volume 8, No. 10 (Serial No. 83), pp. 626-637 D
Journal of US-China Medical Science, ISSN 1548-6648, USA DAVID PUBLISHING

Parascapular Pedicle Fasciocutaneous Flaps for
Regional Reconstruction, Evaluation Study

Mahdi Hameed Abood1 and Dana A. Abdilkarim2

1. Al Wasity Teaching Hospital, Baghdad, Iraq
2. Suliamania Teaching Hospital, Suliamania, Iraq

Abstract: Background: Since their description, scapular and parascapular flaps, had become workhorse fasciocutaneous flaps,
initially as free flaps and later as pedicled flaps, for reconstruction of any extensive skin defect almost in any part of the body where
thin, supple, large, well-vascularized, healthy tissue is required. These flaps have been used in the armamentarium of reconstruction
of axilla, shoulder and chest wall by many authors with good functional and aesthetic outcomes and acceptable donor morbidity.
Objective: It is to evaluate the reliability and the versatility of pedicled fasciocutaneous parascapular flaps in the treatment of
axillary, lateral chest, and shoulder defects. Methods: This prospective study was conducted in Al-Wasity hospital for reconstructive
surgery, Baghdad and the teaching hospital in Sulaimanyiah. Eleven patients, four males and seven females, were managed by twelve
parascapular pedicled fasciocutaneous flaps from February 2008 to September 2009 with minimum follow up of 6 months. Their
ages ranged from 8 months to 23 years, mean age 11.7 years. The flaps designed as island parascapular in two flaps, peninsular
parascapular in eight flaps, and island scapular and parascapular in two flaps. The causes of the defects were, postburn scarring and
contractures release in axilla and lateral chest wall in 9 patients, axillary hydradinitis suppurativa excision in one patient (2 flaps) ,
and trauma to the shoulder and axilla in one case. Ten patients were managed unilaterally. Only one patient managed bilaterally who
was complaining of bilateral hydradinitis suppurativa in both axillae. Results: In an average adult a donor site up to (25×11 cm)
closed primarily, larger than 11 cm width required skin grafting of donor site. Eight flaps went uneventful. Four flaps were
complicated. Partial dehiscence encountered around the flap in one patient and partial dehiscence in the donor site in two flaps.
Partial flap loss occurred in three flaps. Conclusion: Parascapular pedicled flaps were effectively used for management of defects in
axilla, lateral chest wall, and shoulder. The flap provides good functional and aesthetic results with a reduced necessity for prolonged
splintage and secondary procedures and low donor-site morbidity.

Key words: Parascapular and scapular flaps, postburn contractures, hydradinitis suppurativa.

1. Introduction  further demonstrated the anatomy of the circumflex
scapular artery and coined the name parascapular
The clinical use of the horizontal cutaneous branch artery and the parascapular cutaneous flap as a free
of circumflex scapular artery was first described in cutaneous work horse flaps [2]. Soon after this
English literature by Lucinda F. dos Santos. It was a anatomical findings literature become replete with the
remarkable anatomical finding demonstrating the applications of these flaps in microsurgery including
great potential of this donor site and its safe harvest of 14 cm bone from the lateral border of the
application in microvascular reconstructive surgery scapular for bone or composite reconstruction [3, 4].
[1].
Kim and Lewis, 1981, reported the parascapular
The first to describe the cutaneous territory supplied flap as a pedicled flap for reconstruction of a shoulder
by the oblique cutaneous branch of circumflex and upper arm soft-tissue defect [5]. Kim cited the
scapular artery (CSA) was Nassif et al in 1981. He works of Mayou, 1981, and Mehmet Mutaf cited the
                                                            work of Yani et al., 1985, both of them has described
the use of pedicle parascapular cutaneous flaps in
Corresponding author: Mahdi Hameed Abood, Consultant reconstruction of post burn contractures in axilla and
Plastic Surgeon, research fields: plastic and reconstructive
surgery. E-mail: [email protected].

Parascapular Pedicle Fasciocutaneous Flaps for Regional Reconstruction, Evaluation Study 627

breast [6]. Since then these flaps become essential arteries almost always are joined by two venae
donors in reconstruction of defects in axilla, shoulder, comitantes, one that is usually larger than the other,
upper arm, and anterolateral chest whenever thin, principally at the level of the subscapular artery and
supple, large, well vascularized, healthy tissue is proximal portion of the circumflex scapular artery.
required [7-9].
3. Patients and Methods
2. Anatomy
Eleven patients with their ages ranging from 8
The cutaneous parascapular artery is a terminal months to 23 years old were managed by 12
branch of the circumflex scapular artery. Almost parascapular and combined parascapular/scapular
consistently the circumflex scapular artery (CSA) flaps. Four male patients were treated by five flaps
emerges from the subscapular artery at about 4 cm 41.7%. Seven female patients treated by seven flaps,
from its origin from the axillary artery (Fig. 1). It 58.3% (Table 1).
divides into one infrascapular branch, which runs
horizontally toward the subscapularis muscle, and a According to etiology and location, in nine of the
descending branch (Fig. 2), which runs backwards and flaps the defects were caused by postburn contracture
emerges posteriorly from the upper triangular space release and hypertrophic scar excision in axillae and
right at the edge of the lateral border of the scapula lateral chest wall (75%). In one patient (8.3%) the
(Fig. 3). The descending branch divides into the cause of defect was trauma to the axilla and shoulder.
cutaneous scapular artery, which runs horizontally All of the flaps were unilateral except for only one
over the posterior aspect of the scapula, and the patient treated bilaterally by parascapular peninsular
cutaneous parascapular artery, which proceeds to the flap for covering axillary hydradinitis suppurativa
tip of the scapula that it overreaches (Fig. 4). These excision defect (16.7%).

Fig. 1 Subscapular artery. Courtesy of the interactive atlas of human anatomy, Novartis, 1998.

628 Parascapular Pedicle Fasciocutaneous Flaps for Regional Reconstruction, Evaluation Study

Fig. 2 Schematic illustration of subscapular and circumflex scapular arteries. Courtesy of Nassif, T. M, Laurent Vidal, Bovet,
J. L., and Jacques Baudet. The Parascapular Flap: A New Cutaneous Microsurgical Free Flap. Plast. Reconstr. Surg. 69:591,
1981.

Fig. 3 The triangular space. Courtesy of the interactive atlas of human anatomy, Novartis, 1998.

Parascapular Pedicle Fasciocutaneous Flaps for Regional Reconstruction, Evaluation Study 629

Fig. 4 Scapular and parascapular arteries and flap territories. Courtesy of Nassif, T. M, Laurent Vidal, Bovet, J. L., and
Jacques Baudet. The Parascapular Flap: A New Cutaneous Microsurgical Free Flap. Plast. Reconstr. Surg. 69:591, 1981).

Table 1 Gender and flap distribution. edge of deltoid muscle. Then with the patient in the
lateral decubitus position the arm abducted at 90
Gender No of patients No of flaps degrees, the emerging of the pedicle is first
5 determined by accurate location of the triangular
Male 4 7 space at the lateral edge of the scapula. The triangular
12 space is easily palpable two cm above and medial to
Female 7 the tip of posterior axillary fold, or one can use the
following measurement formula: the triangular space
Total 11 is usually located at distance D1 from the middle part
of the spine of the scapula, given by the formula D1 =
According to flap designs, the flaps designed as (D-1)/2, where D is the distance between the middle
island in two flaps (16.7%), peninsular in 8 flaps part of the spine and the tip of the scapula (Figs. 5-6).
(66.7%), and island scapular/parascapular in two flaps The contralateral normal posterior axillary fold can be
(16.7%). used as mirror image land mark aiding the localization
of the pedicle on the scarred side.
3.1 Patient Selection and Preoperative Preparations
Doppler ultrasound probe can also be utilized to
Thorough examination of proposed donor for skin locate the pedicle in the triangular space even more
texture, elasticity, and scars on the back was done. precisely.
Examination of the breasts, lateral chest walls,
contralateral shoulder range of movement, and Once the triangular space is localized, the main axis
contralateral axilla also done for comparison, of the parascapular flap is outlined along the lateral
treatment and follow up planning. Preoperative border of the scapula. The lower edge can be situated
photographs were taken and the surgery was as far as 25 to 30 cm from the pedicle.
thoroughly explained for the patients.
Infiltration of diluted adrenaline aids hemostasis and
3.2 Operative Technique surgical plane identification. The first incision starts at
the upper lateral edge of the flap. The triangular space
Initial marking was done while the patient is in
sitting or standing position hand resting on the
ipsilateral iliac bone. Triangular space palpated above
and behind posterior axillary fold, below the lower

630 Parascapular Pedicle Fasciocutaneous Flaps for Regional Reconstruction, Evaluation Study

Fig. 5 Schematization of the dividing branches of the circumflex scapular artery: the cutaneous scapular artery and the
cutaneous parascapular artery The outlining of the parascapular flap and the measurement procedure (D and D1 ) to
determine the emerging of the pedicle are shown.

is easily found, and the vascular pedicle is identified parascapular flap. Prefabrication of the flap with tissue
between the teres major and teres minor muscles. expanders certainly will aid the closure of the donor
Then, further incision is carried out around the whole site.
flap, which is raised with the underlying muscular
fascia (Fig. 9). Nassif et al. recommend retrograde Flap suturing done in layers. Corrugate or close
dissection for maximizing the recognition of the suction drains put whenever primary closure of donor
vascular pedicle. He also states that the safe length site was possible. When split thickness skin grafting
varies directly with the height of the patient. He (STSG) was necessary to close the donor sites of
proposed that the maximum length of the flap in parascapular flap no drains were put for donor site or
centimeters is equal to height of the patient multiplied flap beds. Dressing was done in layers for flap suture
by the factor of 16.5 in meters. edges and donor site by moisture retaining greasy non
adherent gauze, povidine iodine, dry gauze, and fluffy
Closure of the wound is easily achieved by direct gauze. Post operative splinting done only for three
approximation after undermining the surrounding skin cases. Operative time average was 120 minutes.
and the subcutaneous plane. For wide flaps,
undermining of the surrounding skin and release of 3.3 Post Operative Care and Follow Up
tension on the suture line by numerous deep mattress
sutures is necessary. The skin grafting of the donor After proper recovery from anesthesia, the patient
site for major tissue defects is necessary when undue kept in hospital for 3-7 days with proper medical
tension is noticed, or primary closure can be achieved treatment including parentral intravenous fluid, pain
if both scapular and parascapular flaps are removed in killers and antibiotic therapy. No blood has been
an inverted-L, then the scapular flap can be used as a transfused to any of our patients’ postoperatively. Flap
secondary flap to close the donor defect of the monitoring in early postoperative period done

Parascapular Pedicle Fasciocutaneous Flaps for Regional Reconstruction, Evaluation Study 631

clinically depending on color, temperature and defect (Fig. 8) and the other two were a widely taken,
capillary filling test. more than 11 cm wide, parascapular flap (Table 3).

The patients followed up after discharge by 5. Discussion
multiple outpatient visits and photographing. Drains
removed when minimum discharge was noticed. The remarkable anatomic finding demonstrates the
Sutures removed after 10 days. importance of the great potential of the scapular donor
site and its safe application in reconstructive surgery
4. Clinical Results was first clinically described in English literature in
1983 in the original article by dos Santos [1, 24-27].
Eight flaps, 66.7%, went uneventful and four flaps, Salmon and Santos have oriented the anatomic studies
33.3%, were complicated. The complications rates per in cadavers toward a new donor site for a large
total number of flaps were, tip necrosis in three flaps,
dehiscence in the donor site in 2 flaps, and dehiscence Table 2 Complications. No.
around the flap in one patient (Table 2). Complication 3
1
In nine flaps (75%) the donor site had been closed Flap tip necrosis 2
primarily without undue tension for the maximum Dehiscence around flap 5
width not exceeding 11 cm (Fig. 7 and Fig. 10). STSG Dehiscence around donor site
used only in three donor sites (25%), one of which
was combined scapular/parascapular with wide donor Total

Table 3 Comparison with other author approaches in utilization of parascapular and scapular flaps for management of

axillary, shoulder, and anterolateral chest defects.

Author Flap designed Modifica- Maximum Total flap Partial flap Dehiscence Other Other remarks
tion flap width
necrosis necrosis around the complications
closed
primarily flap
30×15 cm
Mandour Island scapular - -- - 6 cases, all closed
1 flap
(25%) primarily

Kadry Local Tolhurst 1:3 ratio - 2 flaps 1 infected 4 flaps
peninsula design (13 %)
donor. He

regarded dog ear

and posterior

fold deformity

as a constant

sequlea

Shalaby Island and Skin graft was 28×10 cm - - 12 patients treated

peninsular used to aid 30×15 cm by 15 flaps,
--
parascapular closure of
25×11 cm
axillary

release defect

Shouman Island Partially -- - - 5 patients, 5 flaps

parascapular scared donors --
- 3 flaps
elevated
(25%)
Khaled M. Pedicle - - - 5 cases,

E. parascapular 5 flaps

This series Island, - 1 Partial 11 cases, 12 flaps

of patients peninsular and dehiscence

combined around 1 flap

parascapular/sc (8%) and around

apular flaps. 2 donor sites

(16%).

632 Parascapular Pedicle Fasciocutaneous Flaps for Regional Reconstruction, Evaluation Study

Fig. 6 Identification of the people in the triangular space using the D1 formular A (2), B, and C, or simply 2 cm above and
behind posterior axillary fold D.

Fig. 7 Case example 2. Post burn contracture excision defect.

Parascapular Pedicle Fasciocutaneous Flaps for Regional Reconstruction, Evaluation Study 633

Fig. 8 Case example 3. Axillary post burn contracture release defect treated by island parascapular/scapular flap.

Fig. 9 Dissection after completing superior the dissection atarts distal to proximal in the areolar plane above latissimus fascia
(A and B) and continued to the area of pedicle which is either incompletely released and the flap designed as peninsular
fasciocutaneous, C or completely released from surrounding skin and designed as island fasciocutaneous, D.

634 Parascapular Pedicle Fasciocutaneous Flaps for Regional Reconstruction, Evaluation Study

Fig. 10 Case example 5. Axillary postburn scar excision defect treated by peninsular parascapular flap.

fasciocutaneous flap with minimal disadvantages; flap designs where both scapular and parascapular
Nassif et al. have proposed the terms cutaneous flaps are removed in an inverted-L fashion for
parascapular artery and cutaneous parascapular flap reconstruction of axilla.
for a new donor site based on the former. The
cutaneous parascapular artery is the direct terminal We have found that the scapular flap can be utilized
branch of the circumflex scapular artery [2]. as a secondary flap for closure of the donor site of a
primary parascapular flap which is consistent with the
Almost consistently the circumflex scapular artery original article by Nassif et al, although the best in
is present making this donor a reliable flap [2]. The terms of easier closure of the donor site is the
lower edge can be situated as far as 25 to 30 cm from parascapular flap [2]. This is also consistent with our
the pedicle. In the original article for parascapular findings. Most of the published literature on the
flaps, the width of the flap consistent with a closure of parascapular flap has dealt with microvascular free
donor site by direct approximation in an average adult tissue transfer [6]. However, since the description by
was up to 15 cm after undermining the surrounding Mayou Yani et al. who reported the use of a pedicled
skin, mainly from the area of the axillary [2]. parascapular flap for coverage of the axillary region
and Kim and Lewis who reported the parascapular
We have found that it’s difficult to close donor sites flap as a pedicled flap for reconstruction of a shoulder
greater than 11 cm in the use of parascapular and upper arm soft-tissue defect, these flaps have been
cutaneous flaps which is especially true for combined

Parascapular Pedicle Fasciocutaneous Flaps for Regional Reconstruction, Evaluation Study 635

regarded as invaluable pedicled donors in abduction for 1-2 weeks, until removal of the sutures
reconstruction of axillae, lateral chest, shoulder, and [13]. Dressing was changed at 1 week postoperative
upper arm reconstruction with good functional and and physiotherapy at 3rd week postoperative. Shalaby
aesthetic outcomes and acceptable donor morbidity [5, had thirteen uneventful flaps and 2 flaps with tip
7-15]. necrosis. More than 10 cm width closed by STSG in
his patients. He also used STSG to fill some defects
We have successfully covered anterior shoulder that could not be closed fully by the flap alone. We
defect using parascapular flap as an alternative to removed stitches in 10-14 days, used abduction splint
latissimus dorsi flap which is consistent with the for less than one week in only few cases and started
original case report by Kim et al. which states that postoperative shoulder movement after suture removal.
parascapular flaps can be utilized successfully as an We did not find it necessary to use skin grafts to fill
alternative to latissimus dorsi flap with nearly the the remaining defect during flap inset. If any
same arc of rotation. The local musculocutaneous remaining defect existed after flap inset, then only by
flaps available for reconstruction about the shoulder performing undermining around it (within the range of
include the pectoralis major, the trapezius, the serratus the dimensions of defects encountered in our series of
anterior, and the latissimus dorsi. With these patients) would closure be possible without use of
dimensions, the parascapular flap can reach the STSG.
posterior scalp, side of face, and anterior chest wall, as
the latissimus dorsi flap can. Thus when a latissimus Shouman describe management of five post burn
dorsi myocutaneous flap is utilized only as a means of patients by unilateral parascapular flaps with 100%
carrying the skin, the same may be accomplished by a survival, no complications, no postoperative splinting
parascapular flap. By doing so, the function of the and 10 days hospitalization [14], as compared to our
latissimus dorsi muscle would be preserved, three flaps with tip loss, four flaps exhibited bulk, and
preventing reduction of shoulder strength, flexion, and two flaps with donor site dehiscence and one flap
abduction [5]. partial dehiscence, and in three flaps short term
splinting used.
More recently such methods as the free flap and the
island flap have been reported. In these newer For the patients complained about contour
methods, a flap of sufficient thickness with less deformity, this is consistent with many new literatures
likelihood of recurrence and no need for splinting in that still prefer skin grafting as first line management
inset of the flap into the axilla are preferred [14]. of wide axillary defects following excision or release
of postburn scars in axillae if no vital structures are
Mandour described use of scapular flaps in 6 cases, exposed regardless of postoperative follow up,
complication free [11]. splintage and physiotherapy [7]. Shouman also
reported maximum width of flap of 15 cm to be closed
Kadry used the posterolateral chest wall primarily whereas in our cases maximum of 11 cm
fasciocutaneous flap in the design that was originally was possible to be closed primarily (Table 3).
described by Tolhurst in 1982 for 4 post burn axillary
contracture released patients, one of which suffered tip One case of axillary hydradinitis suppurativa was
necrosis and another suffered infection. He regarded treated by parascapular flaps bilaterally giving
dog ear at pivot point and scar widening at donor site comparable results to what previously described by
as a consequence of the procedure rather than a other authors. Flap benefits are earlier mobilization
complication [12]. less hospitalization, less dependency better healing
and patient satisfaction, Skin grafting to cover the
Shalaby described use of 15 island and peninsular
parascapular flap in 12 patients keeping arm in

636 Parascapular Pedicle Fasciocutaneous Flaps for Regional Reconstruction, Evaluation Study

resulting defect has its limitations. It is not a good (4) Retrograde dissection i.e. from periphery of the
choice because of poor vascularity and bacterial flap toward the pedicle is safe and expeditious.
contamination of the subcutaneous fat leading to
failure of complete graft take [16]. Splintage of the (5) Quilting sutures is a safe measure to help
axilla with shoulder in abduction is uncomfortable primary closure of the donor site and helps
especially in bilateral axillary excision. Further, after obliterating dead space reducing chances of
skin grafting the patient can develop shoulder joint postoperative hematoma or seroma formation.
stiffness because of immobilization. In most cases,
excision of the involved area leads to exposure of (6) We did not find it necessary to use prolonged
axillary vessels which preferably require a flap cover axillary splinting postoperatively.
[16]. Other problems associated with skin grafting are
poor aesthetic appearance, hyper-pigmentation and (7) Although many authors find it possible to close
dryness. The ideal method for resurfacing a defect wide donor site defects of parascapular
near a joint is coverage with a flap, nevertheless some fasciocutaneous flaps, we strongly recommend that,
authors find it unnecessary to use flaps in patients of whenever primary closure of the donor site is a
excision of hydradinitis suppurativa in axillae [17, 28]. primary concern, flap width decision should be strictly
individualized.
The aesthetic and functional outcomes of these
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