Modified Scapular Free Flap with Additional Protective Sensibility

Reconstruction of a hand with large soft-issue defects is a most challenging procedure. If the defect is too large to cover with local or island flaps, free flaps from distant parts of the body are required. Various free flaps have been introduced. Among them, the scapular free flap was one of the most popular in use for fasciocutaneous defect coverage, with the advantages of minimal donor deficit, an easier surgical procedure, and constant vascular pattern of the donor. Many surgeons who had experience with this flap pointed out the lack of a reliably sensible flap as the main shortcoming of the scapular free flap. If this lack could be addressed, the scapular free flap would be a good procedure in cases of heel- pad reconstruction and hand reconstruction, in which it is important to have skin with protective sensation. The authors investigated the sensory nerve of the scapular free flap and tried to evaluate the sensory scapular free flap in hand reconstruction. They studied 10 cadaveric and 16 clinical dissections in nerves to the scapular free flap. There were six dorsal rami of the thoracic nerves which have medial branches with small cutaneous twigs that pierce the longissimus thoracis and multifidus muscles and go on to pierce the latissimus dorsi and trapezius muscles. Among these cutaneous twigs, several twigs distribute to the skin of the back from the mid-line to the lateral aspect, identical to the area for the scapular free flap. Etiologies of clinical soft- tissue defects were 8 industrial injuries, 2 traffic accidents, 2 electric burns, and 2 severe frostbites. All of the patients were males with an average age of 31 years. The average follow-up period was 5.4 years. The authors observed the location of the cutaneous nerve, length of its neural pedicle, and number of nerve fascicles. The scapular free flap is based on the circumflex scapular artery from the subscapular artery, which comes from the third portion of the axillary artery. The circumflex scapular artery divides into a transverse branch and longitudinal branch. For a sensory flap, flap elevation should begin at the mid-line of the body, because the neural pedicle can be found on the medial side of the flap, which is in counter direction from the vascular pedicle. From the medial skin incision and elevation of the subcutaneous tissue, the fascial structure of the trapezius muscle is reached with special care. Then, the medial cutaneous branches of the thoracic nerve are met, which