|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
| When isolated in the triangular space, the circumflex scapular pedicle averages 4 to 6 cm, and can be extended by deeper dissection to the subscapular origin. The circumflex scapular artery is consistently large (1.5 to 3.0 mm) and constant in position, 24 commonly accompanied by two large, thin-walled veins. The vessels may vary slightly in size and length, and are somewhat larger in men.24
The scapular flap is outlined transversely over the central portion of the scapular area, extending medially within 2 to 3 cm of the midline and laterally to the axilla, with the tip over the posterior axillary fold. It may be extended superiorly to the spine of the scapular and inferiorly to within 2 cm of the angle of the scapula. The maximum dimensions of the flap are 20 cm in length and about 10 cm in width, although larger flaps have been reported. 11,14 Primary closure of the defect is possible if the flap is about 8 to 10 cm wide.
The flap is elevated from a medial-to-lateral direction in the relatively bloodless plane superficial to the fascia over the scapular muscles. Others have suggested incision over the triangular space first to localize the pedicle, followed by medial to lateral elevation as soon as the artery has been protected. 11,12 After elevation has begun, transillumination of the flap is helpful in identifying the cutaneous branches of the circumflex scapular artery as they come through the triangular space. The cleft between the teres major and minor muscles becomes more distinct and filled with yellow fat as one approaches the base of the triangular space. The sterile Doppler probe is also helpful in isolating the pedicle. The pedicle can be lengthened by tracing the circumflex scapular vessels through the triangular space into the axilla. Small flaps can actually pass through the triangular space, and the vascular pedicle can be developed up the subscapular artery to the axillary vessels, providing a pedicle around 13 cm long and permitting the flap to be transposed to the anterior surface of the axilla and chest. This vascular origin from the subscapular system permits the scapular flap to be developed in combination with the latissimus dorsi, serratus, vascularized scapular border, ribs, or a combination of all four.
No cutaneous nerves accompany the vascular pedicle from the circumflex scapular system. Innervation may be provided by tracing the posterior cutaneous branches of the intercostal nerves, which enter the flap from a medial-to-lateral direction. Unfortunately, these are extremely small in the cutaneous island, but can be picked up as the nerves and accompanying vessels pierce the fascia over the long paraspinus muscles.
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