WP Chung O T in in Flaps in Plastic and Reconstructive Surge

3

Chapter 1 Osteocutaneous Parascapular Flap for Mandibular Reconstruction

is vascularized by a circumflex scapular pedicle branch independent from the branch supplying the skin paddle. ■■ The bone can be inset into segmental defects of the mandi- ble or used as a mandibular onlay, whereas the skin paddle can be safely rotated up to 180 degrees in relation to the bone. Preoperative Planning ■■ Determine the anticipated length of the bony deficit at the recipient site and whether a scapula flap will provide suf- ficient bone to reconstruct the defect. ■■ Discuss with the patient and surgical team the functional goals of the reconstruction. Most male patients will be able to accommodate osteointegrated implants into their scapula flaps, although some female patients will have insufficient bone stock. 5 ■■ Decide whether a two-team approach will be possible based on the positioning needs of the team working at the head and neck prior to transfer of the microsurgical free flap. Positioning ■■ The patient is placed in the supine position for induction of general anesthesia. ■■ A bump is placed under the shoulder ipsilateral to the flap harvest site. This provides sufficient exposure of the upper back, and no beanbag is required for immobilization. ■■ Following flap harvest, the bump may be removed, enabling a simple transfer to the supine position.

■■ A Z-arm is placed on the side of the operating table opposite the back ( FIG 2A ). The patient’s arm will be suspended to this following sterile preparation and draping. ■■ The arm ipsilateral to the flap harvest site is prepped and draped in addition to the upper back. ■■ A Mayo stand cover is placed over the Z-arm, and this is wrapped with two rolls of gauze ( FIG 2B ). ■■ A sleeve is placed over the prepped arm past the level of the elbow ( FIG 2C ). The sleeve is secured with a roll of gauze wrapped from the hand up. ■■ Two Kocher clamps are then used to suspend the patient’s arm to the Z-arm ( FIG 2D ). ■■ This technique avoids any areas of concentrated pressure on the arm and minimizes the risk of peripheral nerve injury. ■■ The back is then draped with sterile towels and sheets. Approach ■■ The operative approach to raising the osteocutaneous para- scapular flap depends upon the design of the skin paddle. We tend to design the skin paddle on the back along the axis of the arm so that the donor-site scar will be hidden under the arm. However, the skin paddle can be oriented in any direction around the triangular fossa. ■■ Once the skin paddle has been designed, we approach flap elevation and pedicle identification by raising the flap from caudad to cephalad. However, the flap pedicle may also be approached by raising the skin paddle from its lateral or medial aspect.

FIG 2  • A. The patient is positioned with a bump under the back on the side of flap harvest. The arm is elevated and will be suspended to a Z-arm that crosses the patient’s body. B. The goal of the setup is to minimize pressure on the forearm and avoid complications of neurapraxia and nerve palsy. A sterile Mayo stand cover is placed over the Z-arm and secured in place with two rolls of gauze. C. A sterile arm sleeve is placed over the arm after it has been sterilely prepared. D. The sleeve is secured to the arm with a gauze roll, and then, the gauze is secured to the Z-arm using two Kocher clamps. This strategy provides plenty of cushioning for the forearm without creating any areas of focal pressure that could result in nerve injury.

Chung-Flaps1e9781975129491-P1-ch001.indd 3

2/19/2019 3:11:09 PM