RECONSTRUCTION OF MANDIBULAR DEFECTS USING THE SCAPULAR TIP FREE FLAP BERNARDO BIANCHI, M.D.,1 ANDREA FERRI, M.D.,1* SILVANO FERRARI, M.D.,1 CHIARA COPELLI, M.D.,1 GIUSEPPE PERLANGELI, M.D.,1 MASSIMILIANO LEPORATI, M.D.,1 TEORE FERRI, M.D.,2 and ENRICO SESENNA, M.D.1

Purpose: Purpose of the article is to present the use of the scapular tip free flap (STFF) for the reconstruction of oromandibular defects. Patients: Eleven patients who underwent oromandibular reconstruction with STFF were retrospectively evaluated with regards to form and function assessing mouth opening, dietary intake, and cosmetic outcome. Donor site morbidity was evaluated using the Constant–Murley test for the shoulder unit. Results: Follow-up ranged from 6 to 35 months (mean 20.6 months). Good or excellent results in mouth opening and cosmesis were achieved in eight patients, speech was assessed as intelligible or normal in all but one patient and mean ambulation time after surgery was 2.5 days. Results of Constant score ranged from 45 to 70 (mean 60.6), and the main limitation encountered was elevation of the arm above the head, which was seen in all but one patient confirming the low impact of the technique on the shoulder system. Conclusion: Low morbidity, early ambulation time, possibility of simultaneous harvesting with the tumor resection, large musculocutaneous paddles in the chimeric version of the flap are advantages of the STFF and makes it a good choice in elderly patients, when other bone containing free flaps are not indicated because of the related morbidity, when other flaps are not available or when wide C 2014 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2014. composite defects are approached. V

Reconstruction

of oromandibular defects can be managed with various bone-containing free flaps harvested from the fibula, iliac crest, radial forearm, or scapula as donor sites. Selection of the flap can be customized based not only on the defect but also on the patient in terms of general condition, donor site availability, and requirement for dental rehabilitation.1 The scapular tip free flap (STFF), based on the angular branch of the thoracodorsal artery, has been widely used for palatomaxillary reconstruction,2 and has recently been proposed by some authors as an adjunctive technique for reconstruction of segmental oromandibular defects.3 This flap offers unique advantages, such as the long pedicle, large amounts of skin and muscle that can be harvested when a paddle of musculocutaneous latissimus dorsi flap is included in the chimera, the independence of the bony and musculocutaneous components of the chimeric flap that allows complex three-dimensional reconstruction, the low rate of atherosclerosis of the vessels in this area, and the possibility of a two-team approach with reduction of operative time compared to harvesting of the lateral border of the scapula. Finally, the very low morbidity related to harvesting of this flap is one of the major advantages of this technique.

1 Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy 2 Otolaryngology Head Neck Surgery Division, Head and Neck Department, University Hospital of Parma, Parma, Italy *Correspondence to: Andrea Ferri, via Gramsci 14, 43100 Parma, Italia. E-mail: [email protected] Received 13 April 2014; Revision accepted 23 May 2014; Accepted 28 May 2014 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22285

Ó 2014 Wiley Periodicals, Inc.

Initially, we considered this flap only as a secondary option for use in cases in which the fibula and iliac crest were not available. However, our indication for use of the scapular tip flap for reconstruction of oromandibular defects has increased markedly. Purpose of this article is to review retrospectively the functional and cosmetic results achieved with this technique. PATIENTS AND METHODS

From January 1, 2011 to December 31, 2013, 11 patients undergoing mandibular reconstruction with STFF were evaluated retrospectively. Due to the retrospective nature of the study, Institutional Review Board approval was not required. The study was performed in accordance with the declaration of Helsinki. This series consisted of four males and seven females, ranging in age from 43 to 83 years (mean 74.1 years). Data are summarized in Table 1. Primary squamous cell carcinoma (SCC) of the retromolar trigon was diagnosed in four patients; recurrence of SCC in the same area occurred after surgery and adjuvant radiation therapy in two patients; primary SCC of the posterior mandibular alveolar crest was diagnosed in three patients; mandibular body osteoradionecrosis was treated in one patient and a third recurrence of extensive keratocyst of the mandibular angle and ramus was diagnosed in the last patient (Fig. 1). In all patients affected by malignancies, resection included bone, mandibular crest mucosa, and vestibular and cheek mucosae. In four patients, the soft palate and tonsillar pillar were also resected; in three patients, resection extended to the floor of the mouth and in one case the skin of the cheek and submandibular area was also resected because of tumor invasion.

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Bianchi et al. Table 1. Patients: Diagnosis, Extension of Resection, and Kind of Flap are Presented

Sex

Age (years)

Diagnosis Recurrent cheratocyst ramus and angle SCC retromolar trigon

Bone resection

Soft tissues resection

Female

43

Ramus and angle 5 cm Ramus, angle, posterior body 5.5 cm Angle, posterior body 5.5 cm

Male

78

Female

83

SCC posterior alveolar crest

Female

81

SCC retromolar trigon

Ramus and angle 4.5 cm

Male

82

Female

79

SCC posterior alveolar crest Recurrent SCC retromolar trigon

Angle, posterior body 4 cm Ramus, angle, posterior body 6 cm

Female

71

SCC retromolar trigon

Female

78

Male

68

SCC posterior alveolar crest Recurrent SCC retromolar trigon

Male

73

Mandibular body ORN

Female

79

SCC retromolar trigon

Ramus, angle, posterior body 5.5 cm Posterior body 4.5 cm Ramus, angle, posterior body 5.5 cm Posterior body 6 cm Angle, posterior body 5 cm

Flap

No

STFF

Alveolar crest, cheek mucosa, tonsillar pillar, soft palate Alveolar crest, cheek mucosa, floor of the mouth Alveolar crest, cheek mucosa, tonsillar pillar, soft palate Alveolar crest, cheek

STFF 1 latissimus musculocutaneous paddle STFF 1 latissimus musculocutaneous paddle STFF 1 latissimus musculocutaneous paddle STFF

Alveolar crest, cheek mucosa and skin, tonsillar pillar, soft palate

STFF 1 latissimus musculocutaneous paddle 1 serratus paddle STFF 1 latissimus musculocutaneous paddle STFF

Alveolar crest, cheek mucosa, floor of the mouth Alveolar crest, cheek mucosa Alveolar crest, cheek mucosa, tonsillar pillar, soft palate Alveolar crest Alveolar crest, cheek mucosa, floor of the mouth

STFF 1 latissimus musculocutaneous paddle STFF STFF 1 latissimus musculocutaneous paddle

SCC: squamous cell carcinoma; ORN: osteoradionecrosis; STFF: scapular tip free flap.

Bone resection involved the inferior part of the ramus, angle, and posterior body in four patients; angle and posterior body in three patients; mandibular angle and ramus in two patients, and posterior body of the mandible in the other two patients. Bone defect length ranged from 4 to 6 cm. Surgical Procedure

STFF flap was harvested concomitant with tumor resection from the contralateral side with the patient in the supine position. Two operators seated at the side of the patient and a third moved the arm according to the first operator’s instructions. After identification of the free margin of the latissimus dorsi muscle by the pinch test, an incision was made on a line drawn between the midpoint of the axilla and the iliac spine, about 1 cm below the margin of the latissimus. The first step was identification of the free margin of the muscle that was indeed retracted exposing the vascular pedicles of the thoracodorsal system. The pedicle was dissected from the latissimus and preserved, and could be used for guidance to the main pedicle. Once the thoracodorsal artery and vein were identified, the pedicle was dissected from the Microsurgery DOI 10.1002/micr

Figure 1. Pre-operative ortopantomography showing the 3rd recurrence of keratocyst involving mandibular ramus and body.

serratus muscle. Before ligation and cutting of this pedicle, it was necessary to identify the angular branch of the scapular tip to avoid damage to this vessel that is sometimes derived early from the serratus pedicle. Dissection proceeded in the proximal portion of the pedicle where identification and ligation of the circumflex artery was performed to increase pedicle length, and the origin of the thoracodorsal artery was reached after extension of

STFF for the Reconstruction of Oromandibular Defects

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Figure 4. Post-operative ortopantomography showing insetting of STFF for mandibular ramus and angle reconstruction. This was the early post-operative panorex of the patient treated for keratocyst recurrence. Figure 2. Intra-operative picture showing the flap insetting: scapular tip was used to bridge mandibular defect in the body area, fixation was achieved with reconstructive plate and a paddle of latissimus dorsi musculocutaneous flap was rotated into the oral cavity to reconstruct soft tissues. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Figure 3. Post-operative ortopantomography showing insetting of STFF for mandibular body reconstruction.

the arm over the shoulder. At this point, we usually mobilized the scapular angle with Backhaus forceps with the third assistant providing intra-rotation of the arm to expose the posterior aspect of the scapular tip. After sectioning of the infraspinatus and serratus muscles, osteotomy was performed and the scapular tip with its pedicle was harvested. Finally, a paddle of latissimus dorsi muscle with overlying skin was harvested on its pedicle according to the need for soft tissue reconstruction. The thoracodorsal pedicle was sectioned and the flap was transplanted onto the recipient site (Figs. 2–4). Donor site primary closure was achieved in all cases. STFF was the primary choice in eight patients. In three patients, we used this flap because a fibula free flap was not available due to vascular anomalies detected on angio-CT and the use of an iliac crest free flap was considered too heavy for these patients. The last patient, a young female with keratocyst recurrence, specifically requested STFF for reconstruction to avoid visible scars on the leg or limb area.

In four cases, a standard STFF was harvested with the bone component and the overlying cuff of the Teres muscle. In the other seven patients, a chimeric flap was chosen. In six patients, the chimera was composed of the scapular angle and the latissimus dorsi musculocutaneous skin paddle, while in the last patient a paddle of serratus muscle was also included as a third component of the chimera. Musculocutaneous skin paddle extension ranged between 3 cm 3 6 cm and 12 cm 3 8 cm. A single osteotomy of the scapular tip was performed in five patients using a piezoelectric scalpel. Rigid fixation with a reconstructive plate was used in all cases (Fig. 5). Ipsilateral neck vessels were used as recipient vessels for microvascular anastomosis in all cases. The facial artery was used in five cases, superior thyroid artery in three cases, and lingual artery in the remaining three cases. Venous anastomosis was performed by terminolateral suture on the internal jugular vein in six patients and terminoterminal suture on an internal jugular vein branch in the remaining five patients. Reconstruction was functionally evaluated assessing mouth opening as severely limited, partially limited, good, or excellent; dietary intake as gastrostomy tubedependent, liquid, soft, or normal; and speech as unintelligible, partially intelligible, intelligible, or normal. Esthetic results were assessed by the patients as poor, acceptable, good, or excellent. Donor site morbidity was evaluated using the Constant–Murley4 test for the shoulder unit. This test explores different parameters as pain, daily activities, shoulder movements (flexion, abduction, external and internal rotation), and strength. A score ranging from 0 to 100 is finally calculated based on the results obtained for these parameters. RESULTS

All of the flaps were harvested and transplanted successfully without major complications. Minor complications, including intraoral wound dehiscence, occurred in Microsurgery DOI 10.1002/micr

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Bianchi et al.

Figure 5. STFF was harvested and fixed to the pre-bended reconstructive plate after a single osteotomy in the keratocyst patient. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

three patients and led to orocervical fistula in two cases, which was managed with daily flushing and medication. Ambulation time (days required to start ambulation postoperatively) ranged from 2 to 4 days (mean 2.5 days). Follow-up ranged from 6 to 35 months (mean 20.6 months). Patient outcome was functionally and aesthetically (Fig. 6) assessed by evaluating the results of reconstruction and donor site morbidity during the last follow-up. The results are summarized in Table 2. In the patients listed here, the Constant score ranged from 45 to 70 (mean 60.6), and the main limitation encountered was elevation of the arm above the head, which was seen in all but one patient. Despite the reduction of shoulder movement revealed by examination, none of the patients suffered from these limitations during daily activities.

DISCUSSION

Most reconstructive surgeons consider bone reconstruction of segmental oromandibular defects as a standard procedure, most commonly using fibula and iliac crest free flaps.5 However, customization of reconstruction taking into consideration the defects and patient features should also take into account different options that Microsurgery DOI 10.1002/micr

Figure 6. Post-operative picture of patient showing the cosmetic results achieved in the keratocyst patient. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

may provide the best reconstruction of the defect in any given patient. Scapular donor site anatomy has been extensively described in the literature, and the versatility of the scapular system has been confirmed for harvesting of chimeric flaps.6,7 The STFF provides further advantages compared to other scapular and parascapular bonecontaining free flaps. One of the most important advantages is the possibility of a two-team approach with simultaneous harvesting of the flap during tumor resection. To allow a two-team approach, it is important for an assistant to manage the arm during flap harvesting8; extra- and intra-rotation of the arm expose different areas of the scapula and allow safe and precise bone section. Hyperextension of the arm over the shoulder allows exposure of the thoracodorsal pedicle and is mandatory during dissection of the proximal portion of the vessels when the STFF is harvested with the patient in the supine position. Another important technical point is elevation of the scapular tip with forceps to expose the posterior aspect of the scapular angle, thus allowing bone sectioning without placing the patient in the lateral decubitus position. However, harvesting in the supine position concomitant with tumor resection, and especially sawing of the bone in its posterior aspect, is technically difficult and requires a highly trained surgical team and deep knowledge of the anatomical area. The short-term morbidity related to harvesting of this flap is extremely low, as demonstrated by the early ambulation time reported here. Thus, this type of flap is

STFF for the Reconstruction of Oromandibular Defects

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Table 2. Results: Functional, Cosmetic, Ambulation Time, and Donor Site Morbidity Evaluations are Presented

Sex Female Male Female Female Male Female Female Female Male Male Female

Age (years)

Follow-up (months)

Mouth opening

Diet

43 78 83 81 82 79 71 78 68 73 79

23 28 32 30 35 18 6 12 15 8 20

Excellent Partially limited Good Good Good Severly limited Good Excellent Partially limited Excellent Good

Normal Liquid Soft Soft Soft Liquid Soft Normal Liquid Soft Soft

indicated in elderly patients when early ambulation is recommended to facilitate rehabilitation.9 In such patients, the possibility of starting ambulation usually on the second or third postoperative day without limitations represents an important advantage compared to other reconstructive options, such as fibula or iliac crest free flaps.10 Long-term morbidity of the shoulder must be considered taking into account the patient’s age and needs. Although the Constant test scores presented in the Results section were not excellent, it was interesting that none of the patients suffered because of the reduction of shoulder movements revealed by examination during daily activities, probably because elderly patients (the mean age in this series was 74.1) do not routinely perform extreme movements in daily life. This reduced morbidity and the absence of atherosclerosis of the vessels also allow bone reconstruction in patients that usually undergo reconstruction with soft tissue free flaps because of comorbidities or vascular anomalies, making bone reconstruction possible in all patients suitable for free flap reconstruction.11 Furthermore, due to the very long pedicle, this flap is also available in secondary reconstructions or in patients where ipsilateral neck vessels are not available for microvascular anastomosis.12 When considering the features of bone, although the fibula free flap provides the largest amount of bone stock in terms of length and the iliac crest is probably the best flap when height is required to restore defects in dentate mandibles,13 STFF can provide sufficient bone to bridge defects up to 8 cm if the inferior portion of the lateral border of the scapula is included in the flap, ensuring mandibular continuity and restoring form and function, especially when the patient does not require dental rehabilitation with implants.14 STFF is therefore indicated particularly in short lateral defects, including ramus, angle, and posterior body.15 The bone shape of the tip is ideal for angle reconstruction,16 but it is also possible to perform osteotomies of the harvested bone when body

Speech

Esthetic result

Ambulation time (days)

Costant– Murlay test score (1–100)

Normal Intelligible Intelligible Intelligible Normal Partially intelligible Intelligible Normal Intelligible Normal Intelligible

Excellent Acceptable Good Good Good Acceptable Good Excellent Acceptable Good Good

2 3 3 3 2 4 2 2 3 2 2

70 65 55 55.6 60 45.6 65.7 60 70 65 55

defects are reconstructed. This procedure is difficult and dangerous but ensures optimal cosmesis. We usually perform monocortical osteotomies using a piezoelectric scalpel and completing the shaping and bending of the bone manually, and adapting it to the reconstructive plate. Horizontal placement of the tip for reconstruction of the symphyseal area has also been proposed,17 but we reserve this option as a last resort in cases in which all other bone-containing free flaps are unavailable because of the poor cosmetic results usually obtained in this critical area. The possibility of harvesting a chimeric flap, including a latissimus dorsi musculocutaneous paddle, is another great advantage of STFF compared to fibula or iliac crest flaps, particularly when approaching complex and extensive oromandibular defects.18,19 These defects are usually reconstructed using two free flaps: a bonecontaining flap (such as fibula or iliac crest flaps) for reconstruction of the bony component, and a soft tissue free flap (such as anterolateral thigh or radial forearm flaps) for restoration of the soft tissues in the oral cavity.20 In these situations, the tremendous amount of skin and muscle available with the chimeric STFF and the independence of its musculocutaneous paddle allow ideal and reliable three-dimensional reconstruction of the soft tissues included in the resection. In harvesting a chimeric flap, extreme care must be taken to avoid twisting of the angular branch and latissimus dorsi pedicles, especially during bone section and later during insetting of the flap. Indeed, we prefer to harvest the latissimus dorsi paddle as the last action to reduce the possibility of pedicle twisting during scapular tip sawing. As reported by other authors, it is possible to use the Teres cuff of muscle surrounding the scapular tip for reconstruction of buccal mucosa when approaching small defects.14,16 This is a very good option when only the alveolar crest or small portions of the cheek are resected, or in benign tumors when subperiosteal resection is performed. However, Microsurgery DOI 10.1002/micr

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Bianchi et al.

when the resection leads to three-dimensional complex defects that include the soft palate, the tonsillar pillar, or a large amount of cheek mucosa, it is preferable to include the chimeric paddle of the latissimus dorsi in the flap to provide adequate restoration of the oral cavity defect. This does not add significant morbidity and does not increase the surgical time, as dissection of the latissimus dorsi pedicle is usually performed concomitant with harvesting of the STFF. The use of a chimeric flap with latissimus or even with an adjunctive independent paddle of serratus muscle,21 as in one patient in the series reported here, is even more useful in approaching an extensive through and through oromandibular defect: in such cases the skin paddle of the latissimus dorsi can be used for external coverage reconstruction, while the serratus and Teres muscles can be used for reconstruction of the oral cavity, allowing extensive three-dimensional defect restoration. Although STFF represents the optimal choice for elderly patients when “low-cost” bone reconstruction of the mandible is required, there are some drawbacks in its indications that must be taken into consideration. For example, there are drawbacks associated with the bone harvested due to the impossibility of reconstructing defects greater than 8 cm in length, difficulties in achieving an ideal mandibular shape, and the thinness of the harvested bone makes rehabilitation with dental implants difficult. CONCLUSIONS

Although fibula and iliac crest free flaps remain the first-line treatment for reconstruction of oromandibular defects, the chimeric STFF represents a good option, especially for management of short lateral defects in elderly patients, when reduction of morbidity and bone reconstruction without dental rehabilitation are the main goals, or when other flaps are not available. The large amount of tissue provided by the latissimus dorsi paddle makes this flap an ideal solution when extensive soft tissues resection is planned and double free flap reconstruction must be avoided. The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see: http://www.textcheck.com/certificate/uRRG3C

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Microsurgery DOI 10.1002/micr

2. Piazza C, Paderno A, Taglietti V, Nicolai P. Evolution of complex palatomaxillary reconstructions: The scapular angle osteomuscular free flap. Curr Opin Otolaryngol Head Neck Surg 2013;21:95–103. 3. Chepeha DB, Khariwala SS, Chanowski EJ, Zumsteg JW, Malloy KM, Moyer JS, Prince ME, Sacco AG, Lee JS. Thoracodorsal artery scapular tip autogenous transplant: vascularized bone with a long pedicle and flexible soft tissue. Arch Otolaryngol Head Neck Surg 2010;136:958–964. 4. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160–164. 5. Bianchi B, Ferri A, Ferrari S, Leporati M, Copelli C, Ferri T, Sesenna E. Mandibular resection and reconstruction in the management of extensive ameloblastoma. J Oral Maxillofac Surg 2013;71: 528–537. 6. Moukarbel RV, White JB, Fung K, Franklin JH, Yoo JH. The scapular free flap: When versatility is needed in head and neck reconstruction. J Otolaryngol Head Neck Surg 2010;39:572–578. 7. Chen CC, Lin CH, Lin YH. Chimeric partial scapula and latissimus dorsi muscle flap for midfoot reconstruction: A case report. Microsurgery 2012;32:485–488. 8. Baj A, Cappare P, Autelitano L, DE Riu G, Beltramini GA, Segna E, Giannı AB. The park-bench position in cervico-facial reconstructive surgery: A technical note. Acta Otorhinolaryngol Ital 2013;33: 129–132. 9. Clark JR, Vesely M, Gilbert R. Scapular angle osteomyogenous flap in postmaxillectomy reconstruction: Defect, reconstruction, shoulder function, and harvest technique. Head Neck 2008;30:10–20. 10. Ferrari S, Copelli C, Bianchi B, Ferri A, Poli T, Ferri T, Sesenna E. Free flaps in elderly patients: Outcomes and complications in head and neck reconstruction after oncological resection. J Craniomaxillofac Surg 2013;41:167–171. 11. Seneviratne S, Duong C, Taylor GI. The angular branch of the thoracodorsal artery and its blood supply to the inferior angle of the scapula: An anatomical study. Plast Reconstr Surg 1999;104:85–88. 12. Seitz A, Papp S, Papp C, Maurer H. The anatomy of the angular branch of the thoracodorsal artery. Cells Tissues Organs 1999;164: 227–236. 13. Trignano E, Fallico N, Faenza M, Rubino C, Chen HC. Free fibular flap with periosteal excess for mandibular reconstruction. Microsurgery 2013, doi: 10.1002/micr.22159. 14. Dowthwaite SA, Theurer J, Belzile M, Fung K, Franklin J, Nichols A, Yoo J. Comparison of fibular and scapular osseous free flaps for oromandibular reconstruction: A patient-centered approach to flap selection. JAMA Otolaryngol Head Neck Surg 2013;139:285–292. 15. Boahene KD, Owusu JA, Collar R, Byrne P, Ishii L. Vascularized scapular tip flap in the reconstruction of the mandibular joint following ablative surgery. Arch Facial Plast Surg 2012;14:211–214. 16. Yoo J, Dowthwaite SA, Fung K, Franklin J, Nichols A. A new angle to mandibular reconstruction: The scapular tip free flap. Head Neck 2013;35:980–986. 17. Hanasono MM, Skoracki RJ. The scapular tip osseous free flap as an alternative for anterior mandibular reconstruction. Plast Reconstr Surg 2010;125:164e–166e. 18. Aviv JE, Urken ML, Vickery C, Weinberg H, Buchbinder D, Biller HF. The combined latissimus dorsi-scapular free flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1991;117: 1242–1250. 19. Tachi M, Toriyabe S, Imai Y, Takeda A, Hirabayashi S, Sekiguchi J. Versatility of chimeric flap based on thoracodorsal vessels incorporating vascularized scapular bone and latissimus dorsi myocutaneous flap in reconstructing lower-extremity bone defects due to osteomyelitis. J Reconstr Microsurg 2010;26:417–424. 20. Bianchi B, Ferri A, Ferrari S, Copelli C, Boni P, Baj A, Sesenna E. Reconstruction of lateral through and through oro-mandibular defects following oncological resection. Micrsosurgery 2010;30:517–525. 21. Trignano E, Fallico N, Nitto A, Chen HC. The treatment of composite defect of bone and soft tissues with a combined latissimus dorsi and serratus anterior and rib free flap. Microsurgery 2013;33:173–183.

Reconstruction of mandibular defects using the scapular tip free flap.

Purpose of the article is to present the use of the scapular tip free flap (STFF) for the reconstruction of oromandibular defects...
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