The thin circumflex scapular artery perforator flap

Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 1082e1096

The thin circumflex scapular artery perforator flap*

J. Dabernig a,b,c,d, K. Sorensen a, J. Shaw-Dunn b, A.M. Hart a,c,d,e,*

a Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UKb Integrated Biological and Life Sciences, Section for Human Anatomy, University of Glasgow,University Avenue, Hillhead, Glasgow, UKc Department of Surgical and Perioperative Science, Section for Hand and Plastic Surgery,University Hospital, Umea, Swedend Department of Integrative Medical Biology, Section for Anatomy, Umea University, Umea, Swedene Blond-McIndoe Research Laboratories, Plastic and Reconstructive Surgical Research, The University of Manchester,Stopford Building, Room 3.106, Oxford Road, Manchester M13 9PT, UK

Received 19 November 2005; accepted 13 October 2006

KEYWORDSPerforator flap;Thin flap;Chimeric;Flowthrough;Revascularisation;Reconstruction;Free tissue transfer

Summary The development of microsurgery has most recently been focused upon the evo-lution of perforator flaps, with the aim of minimising donor site morbidity, and avoiding thetransfer of functionally unnecessary tissues. The vascular basis of perforator flaps also facili-tates radical primary thinning prior to flap transfer, when appropriate.

Based upon initial clinical observations, cadaveric, and radiological studies, we describe a new,thin, perforator flap based upon the circumflex scapular artery (CSA). A perforator vessel wasfound to arise within 1.5 cm of the CSA bifurcation (arising from the main trunk, or the descendingbranch). The perforator arborises into the sub-dermal vascular plexus of the dorsal scapular skin,permitting the elevation and primary thinning of a skin flap. This thin flap has been employed ina series of five clinical cases to reconstruct defects of the axilla (two cases of hidradenitis suppur-ativa; pedicled transfers), and upper limb (one sarcoma, one brachial to radial artery flowthroughrevascularisation plus antecubital fossa reconstruction, and one hand reconstruction with achimeric flap incorporating vascularised bone, fascia, and thin skin flaps; free tissue transfers).No intramuscular perforator dissection is required; pedicle length is 8e10 cm and vessel diameter2e4 mm. There was no significant peri-operative complication or flap failure, all donor sites wereclosed primarily, patient satisfaction washigh, and initial reconstructiveaims were achieved in allcases. Surgical technique, and the vascular basis of the flap are described.

The thin circumflex scapular artery perforator flap requires no intramuscular dissection yetprovides high quality skin (whose characteristics can be varied by orientation of the skin paddle),

* This work was presented, in part, at the Scottish-Irish Plastic Surgery Meeting, October 2005, and the Federation of European Societiesfor Surgery of the Hand Meeting, 2006.

* Corresponding author. Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK. Tel.: þ44 141211 5788; fax: þ44 141 211 4639.

E-mail address: [email protected] (A.M. Hart).

1748-6815/$-seefrontmatterª2006BritishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.doi:10.1016/j.bjps.2006.10.002

mailto:[email protected]

Thin circumflex scapular artery perforator flap 1083

and multiple chimeric options. The donor site is relatively hair-free, has favourable cosmesis andno known functional morbidity. This flap represents a promising addition to the existing range ofperforator flaps.ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Microvascular anatomical knowledge has become increas-ingly refined since the first descriptions of predictable axialpattern flaps in the 1970s,1e4 and the subsequent develop-ment of free tissue transfer5,6 and detailed description ofmuscle and cutaneous vascular anatomy.7e12 There ensuedan explosion in the description of new flaps as surgeonssearched for the best trade-off between flap composition,and reliability, ease of elevation, and donor morbidity.During this period certain cutaneous flaps came to thefore. Along with the radial forearm, groin, and lower ab-dominal flaps, the scapular and parascapular flaps13e15

have withstood the test of time, each flap having a uniquecost-benefit profile that has, to a large degree, led to rec-ognition of separate indications for each.

The dorsal scapular flaps are well described, clinicallyand anatomically,13e17 and favoured for their predictablepedicle anatomy, ease of dissection, and provision ofpotentially large areas of robust skin from a concealabledonor site. The skin also commonly gives a good cosmeticmatch for the face, and is relatively free of hair. Variousmodifications have been described to increase the flap’sutility, but in all cases the main drawback has been therelative bulk of subcutaneous tissue that is incorporatedbetween the axial vessels and overlying skin. This can causedifficulties with flap insetting, and commonly necessitatessecondary thinning procedures. These limitations have re-sulted in the dorsal scapular flaps being discounted formany applications, such as distal extremity or flexuralcrease coverage, where excessive thickness is cosmeticallyor functionally inappropriate.

The search for thin flaps for such applications led to theuse of inherently thin tissues such as the radial forearm,and dorsalis pedis flaps, but these may carry unacceptabledonor morbidity.18,19 The discovery of perforator flaps per-mitted an alternative paradigm for the design of cutaneousflaps with minimal donor morbidity.20 Perforator flaps canalso be primarily thinned to meet the needs of the recipientwound.21e24 Examples include the widely used anterolat-eral thigh flap25 (lateral circumflex femoral artery perfora-tor, LCFAP-vl/s20), the thoracodorsal artery perforatorflap26 (TDAP-ld20), and the paraumbilical perforatorflap.23 Each of these has their proponents, and specific in-dications, but also has specific limitations in terms of diffi-culties of pre-operative planning, donor site cosmesis,hirsutism, and the likelihood of an intramuscular perforatordissection.

It is likely that the search for thin flaps vascularised byperforator vessels has not yet exhausted the potentialanatomical options. This study aimed to explore thepossibility of a flap based on perforators from the circum-flex scapular system in order to benefit from its hair-freeskin, easily concealed donor scar, and consistent mainpedicle. Another theoretical advantage of this pediclewould be the avoidance of an intramuscular perforator

dissection. It would also increase the options for pedicledcoverage of the axilla, and chimeric flap creation.

Having noted the presence of potentially suitable vesselsduring pedicle dissection of standard scapular/parascapularflaps, and melanoma resection, exploratory cadaveric in-jection studies of the circumflex scapular axis were un-dertaken. These confirmed the presence of upto fourperforating vessels originating from the circumflex scapularartery, and its transverse branch. These perforators fed thesub-dermal plexus via distal arborisations. The largest perfo-rator arose from the circumflex scapular artery or its trans-verse branch, within w1 cm of its bifurcation into transverseand descending branches. This main perforator’s existencewas further confirmed clinically by power Doppler ultra-sound, and the clinical safety and utility of a thin skin flapbased upon it is now presented in a series of clinical cases.

Methods

Preliminary investigations

A single preliminary cadaveric study was undertaken ina Caucasian subject. The circumflex scapular artery (CSA)was identified at its origin in the axilla, and directlyinjected with embalming fluid, followed by a three-partdilution of ammonia, then an ink/latex rubber solution.Once set this provides a firm, flexible cast of the arterialsystem. Subsequently the dorsal scapular skin was raised,and the CSA traced distally. In addition to the well-described direct osseous branch to the lateral scapula,and trifurcation into ascending, transverse, and descendingbranches, one perforator arose from the CSA (1 cm lateralto lateral border of scapula) and three from its transversebranch (3.5 cm, 6.5 cm, and 9 cm medial to lateral borderof scapula). The largest of these arose 1 cm proximal tothe trifurcation, perforated the overlying fascia and sup-plied the sub-dermal plexus. In four subsequent dissectionstudies the largest perforator arose 1.0, 1.2 cm proximalto the CSA bifurcation into ascending and descendingbranches and 0.8, 1.1 cm distal to it.

This perforator vessel’s existence has been furtherinvestigated by high-resolution power Doppler scanningof two volunteers. The CSA was easily identified exitingbetween the teres muscles, and a branch ascendingtowards the subdermis could be readily visualised in threeof four dorsal scapular regions studied.

Clinical series

The indications for flap surgery in five clinical cases aresummarised in Table 1. Defects arose from trauma (n Z 2),sarcoma excision (n Z 1), and axillary hidradenitis suppura-tiva (n Z 2). Patients were aged 24e50 years (median 48),

1084 J. Dabernig et al.

Table 1 Summary of clinical cases

Case Age Sex Indication Flapdimensions

Perforatororigin

Flap composition Free/pedicled

Recipientvessels

1 50 \ Refractory axillaryhidradenitis

11� 7 cm 1.2 cmproximal

Thin cutaneous flap Pedicled Pedicled

2 48 _ Arm revascularisationþantecubital soft tissuereconstruction

12� 8 cm 1.5 cm distal(descendingbranch)

Thin cutaneous flapþdescending branch ofCSA as flowthrougharterial conduit

Free Brachial arteryflowthrough intoradial artery;basilic veinend-to-end

3 37 \ Refractory axillaryhidradenitis

12� 7 cm 1.5 cm distal(descendingbranch)

Thin cutaneous flap Pedicled Pedicled

4 24 _ Thumb replantationþcomplex compositetissue injury to secondray


Chimeric thin cutaneousCSAP flapþ parascapularfascial flapþ vascularisedscapular bone flap

Free Radial artery;cephalic veintributary

5 50 _ Sarcoma excisionupper arm


Thin cutaneous flap Free Posterior radialcollateral arteryand venacommitans

two of five were smokers and two had a BMI> 30 kg/m2. Twoflaps werepedicled, and three were free tissue transfers. Fol-low-up has been for a median of 3 weeks (range, 1.5e5). Thesurgical technique will be described for each case, and a pro-posed approach to future cases detailed subsequently.

Pre-operative marking and peri-operative care

The surface landmark of the CSA was used to direct pre-operative marking (Fig. 1), and provisional perforator

Figure 1 Planning the CSAP flap. As show on the left of thisdiagram the surface marking of the circumflex scapular artery(vertical position: (D-1)/2, horizontal position 2 cm lateral tolateral border of scapula) is used to direct location of the likelyperforator position by handheld Doppler. As shown on the right,the skin paddle can then be designed in one of three main ori-entations directed by the desired orientation of the donor sitescar, and nature of skin required (1, transverse flap: thick,maximally robust skin; 2, vertical flap: pliable, moderate thick-ness skin; 3, lateral oblique flap: thin, pliable infra-axillaryskin). The most defensive approach to raising the flap is to firstincise the shared superolateral border of the potential flaps(solid line), and identify the CSA in the omotricipital space.

location with a handheld 8-MHz Doppler ultrasound probe(Vascutech, USA). Although appropriately sited signals weredetected in all cases, it is impossible to be certain whetherthis represents the perforator, the main circumflex scapularartery or another perforating vessel. The flap was raisedwith the patient in the lateral decubitus position, with appro-priate padding and stabilisation, and perforator location con-firmed surgically. All patients received thromboprophylacticlow-molecular weight heparin (Clexane 20 mg/day, Rhone-Poulenc Rorer). Adjuncts such as aspirin, and intravenousdextran or heparinisation were not routinely employed.Warmed sterile normal saline was used for wound irrigation,and the anastomotic field and vessel lumen were irrigatedwithwarmed heparinised saline (1000 U/ml). A calcium chan-nel blocker (2.5 mg/ml Verapamil�, Abbott Laboratories,UK) was applied topically. Patients were nursed for 24e72 hin a high ambient temperature with the operated limb restedin slight elevation, and received intravenous crystalloids tomaintain a urine output of �1 ml/kg/h.

Results

All flaps were raised, transferred and anastomosed (freeflaps only) with the patient in the lateral decubitusposition. There were no peri-operative complications, orflap loss, and the reconstructive aim was achieved in allcases. Marginal necrosis (2� 1.5 cm) occurred in case 4, butdid not compromise outcome. None of the patients had in-creased analgesia requirements because of the donor site,and all rated it as acceptable.

Case 1

This 50-year-old female with severe, left axillary hidrade-nitis suppurativa refractory to previous excisions opted foraxillary excision and flap reconstruction. The patient wasplaced in the lateral decubitus position, the surface


markings of the CSA were confirmed and a strong Dopplersignal located in its vicinity. After adequate excision of theaxillary skin and involved subcutaneous tissues, a verticallyoriented, islanded CSAP flap was planned (Figs. 2.1 and 3A).

Exploration for the perforator commenced with a medialexploratory incision (Fig. 2.1, solid line). The transversebranch of the CSA was identified, traced proximally to itsorigin at the bifurcation of the CSA main pedicle, and thedescending branch also identified (Fig. 3B). A substantialperforating branch (with venae comitantes) arose 1 cmproximal to the bifurcation (Fig. 3B), was traced superfi-cially and the subcutaneous arborisation of the vessels con-firmed. At this point the flap design was finalised, itsmargins incised (Fig. 2.1, dashed line), and raised just su-perficial to the junction between deep and superficial adi-pose layers (Scarpa’s layer equivalent) except for a smallarea around the perforator (Fig. 3C). The CSA was ligateddistal to the perforator origin (Fig. 3D), thinning completedusing scissors (Fig. 3E), the ascending branch divided withbipolar diathermy, and the CSA main pedicle dissectedfree from between the teres muscles in the standard

1

3

2

4

5

Figure 2 Location of exploratory incision (solid line) used toconfirm perforator location prior to incising the periphery ofthe flap (dashed line) in each clinical case (numbered). The ori-entation and dimensions of each flap is diagrammatic only. Amedial approach was used in cases 1 and 2, identifying thetransverse branch of the CSA and tracing it proximally. Incase 3 the axillary wound was used as access for exploration.In case 4 a lateral approach had to be employed due to incor-rect positioning of the patient. In case 5 a superolateral ap-proach was employed, which is felt to be the most defensive,and rapid access for perforator identification. The orientationof the long axis of the flap is demonstrated, in case 5 passinganterior to the posterior axillary fold.

manner of raising a scapular flap. The 4.5� 14 cm, pedi-cled, thin CSAP flap was tunnelled into the axilla undera narrow skin bridge, the wound closed over suction drains,and the donor site closed primarily. There was no post-operative complication and the flap remained fully viablewith a satisfactory early clinical outcome (Fig. 3F).

Case 2

A 42-year-old male presented to the regional plastic surgeryunit 5 days after sustaining a fragmentation wound from theleft antecubital fossa up to the mid-triceps level, with lossof a 7-cm segment of brachial artery, division of bicepsbrachialis, partial division of brachialis and triceps, blunttrauma to the radial nerve, and a 14� 7 cm soft tissuedefect. A vein graft inserted at the referring centre hadthrombosed (Fig. 4), although ischaemia of the forearmwas not critical. No radial or ulnar pulse was palpable, noDoppler signal present over the radial artery, with only anextremely weak signal over the ulnar artery at the wrist.There was good sensation in median and ulnar nerve distri-butions, and though the patient was previously in good gen-eral health he smoked 40 cigarettes per day.

At operation 6 days after injury a residual 8 cm defect ofthe brachial, and proximal radial and ulnar arteries waspresent. The biceps tendon was repaired, and a free rightCSAP flap with a vertically orientated skin paddle wasplanned and designed, with the aim of using the circumflexscapular vessels as a flowthrough flap (Figs. 2.2 and 4B).The operation was carried out in left lateral decubitusposition to allow simultaneous surgery on the defect, andflap elevation. The transverse branch of the CSA was iden-tified medially (Fig. 2.2, solid line and Fig. 4C), preservedfor use as a brachial to radial artery ‘flowthrough’ recon-struction (Fig. 4C) and dissected back to the CSA bifurca-tion. The skin paddle was based upon a substantialperforator off the descending branch that arose 1 cm distalto the CSA bifurcation (Fig. 4D,E), and the circumflex scap-ular vessels dissected back to their origin. The distal 40%was thinned down almost to dermis (Fig. 4F).

After flap transfer the following anastomoses wereperformed: CSA to brachial artery, transverse branch ofCSA to radial artery, and vena comitans of CSA to basilicvein (Fig. 4G). Insetting was then completed (Fig. 4H). Bothanastomoses remained patent, the radial pulse restored,and flow was confirmed by colour Doppler studies on post-operative days 8 and 12 (Figs. 5 and 6). The perforatororigin remained detectable on ultrasound (Fig. 6A). A smallproximo-medial area of marginal necrosis (1� 2.5 cm)healed with dressings, but no significant complicationoccurred.

Case 3

A 38-year-old female with a body mass index (BMI) of 38presented with moderately severe, and very painful,hidradenitis suppurativa of the left axilla 10 months afterwide excision and skin grafting.

Wide excision of residual hidradenitis in skin, skin graftand subcutaneous fat was carried out. The CSA wasapproached from the axillary wound (Fig. 2.3, solid line),


Figure 3 Case 1. (A) Surgery was performed with the patient in the right lateral decubitus position, pre-operative markings showthe planned axillary hidradenitis excision and flap designed around the Doppler signal of the circumflex scapular artery perforator.(B) Dissection was commenced medially, identifying the circumflex scapular artery (CSA), its transverse (T) and descending (D)branches, and the perforator upon which the flap is based (P). (C) The flap was raised peripherally on the surface of the planebetween deep (DAL) and superficial adipose layers (SAL) (equivalent of Scarpa’s fascia). (D) The CSA was then ligated distal tothe perforator origin (arrow). (E) The flap is shown before transposition into the axillary defect. (F) Outcome is shown 4 weekslater.

dissecting laterally over the latissimus to the omotricipitalspace because of anticipated difficulty with perforator lo-cation in an obese patient. In fact, a perforator was easilyidentified originating from the CSA 1 cm proximal to itsbifurcation, and traced into the subcutaneous fat. Avertically orientated flap (Fig. 3.3) was elevated justsuperficial to Scarpa’s fascia, and the CSA pedicle dissectedfrom the omotricipital space to permit transposition of theflap. The donor site closed primarily.

Post-operative wound healing was uneventful with a sat-isfactory post-operative result.

Case 4

A 25-year-old, right hand-dominant male manual workerwas admitted 2 h after a band-saw injury to the right hand.He sustained complete amputation of the right thumbthrough the proximal phalanx, and a complex tangential in-jury to the second ray (Fig. 7AeF). This involved loss of thedorsal w50% of the proximal phalanx, 80% of the metacar-pophalangeal joint (MCPJ), and w60% of the distal half ofthe second metacarpal, with an additional transverse meta-carpal fracture. There was a 9� 4 cm loss of dorsal skin

Figure 4 Case 2. (A) Thrombosed vein graft (VG) repair of brachial artery defect (brachial to radial artery), plus overlying soft tissuedefect. The ulnar artery had been ligated near its origin. Radial nerve (RN). (B) Vertically orientated CSAP flap designed around Dopplersignal from the perforator vessels. (C) Dissection was commenced medially, identifying the transverse branch of the circumflex scapularartery (indicated by forceps), which was intended for use as the flowthrough segment of the flap. The perforator is seen to lie directlyunder the Doppler marking. (D) The bifurcation of the circumflex scapular artery, and the perforator origin from the descending branchhavebeendefined. (E) Close-upviewdemonstrating the circumflex scapular artery (CSA), its descending (D) and transverse (T) branches,and the perforator (P). (F) The flap was raised peripherally on the surface of the plane between deep and superficial adipose layers, thenthinned further to give a mean thickness of 4 mm. (G) The flap is shown after being partially inset, with anastomoses between the cir-cumflex scapular and brachial arteries (CSA/BA), and the transverse branch and radial artery (T/RA) to give antegrade arterial flow, witha perfect size match at the proximal anastomosis, and a 3/5 discrepancy distally. (H) The flap fully inset, with three drains.


Figure 5 Outcome of case 2, 4 days after reconstruction. (A) The flap is viable, the forearm well perfused, and wrist drop is pres-ent due to radial nerve dysfunction. (B) The donor site. The drain was subsequently removed, and no complication or shoulder dys-function arose during initial recovery. (C) A colour Doppler study of the radial artery at the wrist was performed. (D) The radialartery is shown in colour Doppler mode, antegrade pulsatile flow was present. (E) Doppler flow study at the same site in the radialartery confirmed good volume flow within the vessel, although the waveform suggests a degree of turbulence in comparison to thatfound in a normal volunteer’s radial artery at the same level (F).

over the first webspace, index finger, MCPJ, and metacar-pal fracture site, and an 8 cm segmental loss of extensortendons to the index finger. The index was vascularisedand sensate with an intact flexor mechanism.

With the patient in the right lateral decubitus position,the wounds were debrided and the thumb replanted(Fig. 7G). A second surgical team simultaneously raiseda composite ‘chimeric’ free CSAP flap from the left

scapular region. The intention was to incorporate vascular-ised scapula as dorsal bone stock for a temporising MCPjoint arthrodesis, a parascapular fascial flap to wrap aroundpalmaris grafts for extensor reconstruction, and a CSA per-forator thin skin flap to provide soft tissue cover.

In this case dissection was commenced laterally(Fig. 2.4), but difficulties were encountered because of in-correct skin markings. A handheld Doppler signal had


Figure 6 Colour Doppler outcome study of case 2, 13 days after reconstruction. (A) The origin of the perforator is demonstrated,with pulsatile flow present. (B) A longitudinal view of the proximal anastomosis (brachial artery to circumflex scapular artery). (C)Waveform of flow across the proximal anastomosis confirms high-volume pulsatile flow, with expected degree of turbulence. (D)Waveform within the middle of the flowthrough conduit (transverse branch of CSA) confirms pulsatile flow, with reduced turbu-lence. (E) Longitudinal colour Doppler view through the distal anastomosis (transverse branch of CSA to radial artery). (F) Pulsatileflow across this anastomosis is confirmed.

erroneously been interpreted as the transverse branch ofthe CSA, but in actuality was a large superficial branch ofthe CSA perforator running laterally towards the axilla.Once this was apparent, dissection proceeded to the omo-tricipital space where the CSA, a large perforator and thedescending and transverse branches were readily identi-fied. The chimeric flap with vascularised bone, fascia and‘thin’ skin flap was then elevated (Fig. 7H), with the skinbased upon the perforator, fascia upon the descending

branch and bone upon a large marginal branch of the CSAto the scapula (Fig. 7I).

The flap was inset with anastomoses of CSA to theterminal radial artery (after interrupting flow with a micro-vascular clamp to ensure perfusion of the digits, andreplanted thumb was maintained) and CSA vena commitansto the cephalic vein. The access incision to the anastomoseswas decompressed using the excess 4 cm of length of theskin flap (Fig. 7J). No complication arose, and satisfactory


Figure 7 Case 4. (AeD) Injury to the dominant right hand sustained from an industrial band saw that resulted in a transverseamputation of the thumb through the proximal phalanx, and a tangential injury to the second ray with loss of the majority ofthe dorsum of the proximal phalanx of the index finger, the second metacarpophalangeal joint surfaces, and the second metacar-pal, which had an additional transverse fracture. There was soft tissue loss amounting to 8 cm of the extensor mechanism of theindex finger, and dorsal skin overlying the bony injury, and first webspace. (E,F) Radiological views of the injury. (G) With the pa-tient in the right lateral decubitus position the thumb was replanted successfully while a chimeric CSAP flap was raised simulta-neously. (H) The chimeric flap in situ. (I) Close-up view of the flap, demonstrating the circumflex scapular artery divided at itsorigin from the subscapular artery (CSA), its vena commitans (VC), and descending branch (D) upon which a parascapular fascial


Figure 7 (continued).

post-operative recovery occurred (Fig. 7L). The aim, allbeing well, is to carry out an MCP joint arthroplasty in thelonger term.

Case 5

A previously healthy 60-year-old man presented with anincompletely excised, w2 cm diameter high-grade subcuta-neous sarcoma overlying the distal lateral intermuscularseptum of the left arm. After wide excision with a layerof underlying muscles, a free CSA perforator flap was raisedto repair the defect.

An initial incision was made superolateral to thesurface marking of the CSA (Fig. 2.5). Two perforating ves-sels were identified from the main trunk of the CSA, onea small branch 3 cm proximal to the bifurcation and pass-ing towards the axilla. The other, larger perforator origi-nated 1 cm proximal to the bifurcation, and ranvertically to its subcutaneous arborisation. An obliquelyorientated flap (Fig. 2.5) was raised superficial to Scarpa’sfascia and extended laterally into the lower part of theaxilla.

The CSA vessels were anastomosed to the radial collat-eral vessels, having divided the CSA pedicle relatively close

flap (PF) was based. The perforator vessels supplying the thin skin flap are shown (P), as is a direct osseous branch supplying thescapular bone flap (S). Acne scarring is visible on the skin surface. (J) Intraoperative view of the reconstructed hand after thumbreplantation, plating of the bone flap into the second ray, extensor indicis and communis reconstruction with palmaris longus ten-don grafts isolated within the parascapular fascial flap, and insetting of the thin skin flap. (K) The flap donor site was closed pri-marily. (L) View of the hand 5 days after reconstruction.


Figure 8 Case 5. (A) Intraoperative view after flap anastomosed and inset. The surgery was performed in the right lateral decu-bitus position (image rotated by 90�), with simultaneous resection of a left arm sarcoma, and elevation of an ipsilateral free thincircumflex scapular artery perforator flap. The skin paddle was orientated obliquely to the perforator as the donor closure into theaxilla demonstrates. (B) Close-up view of the flap at the end of the procedure. (C) Early post-operative outcome (1 week), andclose-up view of the flap (D).

to its bifurcation in order to ensure an appropriate sizematch. No post-operative complication arose. The flap isdemonstrated in Fig. 8.

Summary of intraoperative findings

Perforator location is variable, but all have arisen within1.5 cm of the CSA bifurcation, most commonly off the CSAitself. Perforator dissection proved straightforward andrapid due to its purely fascial course, and dissection backto the CSA origin from the subscapular axis gave a total ped-icle length in the order of 6e8 cm, an artery of w2 mm, anda vein of 3e4 mm in diameter. Skin perfusion was verygood, and unaffected by thinning to match the needs ofthe recipient wound. In this series all flaps were thinnedto 3e4 mm. Pedicled flaps comfortably reached the ante-rior axilla, and there were no anastomotic difficulties inthe free flaps, except a degree of size mismatch at the dis-tal anastomosis of the flowthrough conduit (case 2).

Dermal thickness varied with the location of the skinpaddle relative to the CSA surface marking. If the flap istaken medial to this point increasing thick dorsal skin isincluded, but if taken vertically or laterally, the skinbecomes increasingly thin and pliable as the infra-axillaryskin is approached (Fig. 1).

As with all new techniques there was a learning curve inthe surgical technique, but this applied overwhelmingly to

location of the perforator, the remaining steps in theprocedure being straightforward.

Summary of circumflex scapular arteryperforator anatomy

Accompanied by its venae commitans, the circumflexscapular artery arises from the subscapular axis, turnsposteriorly through the triangular omotricipital space be-tween teres minor superiorly, teres major inferiorly, andthe long head of triceps laterally. Shortly after exiting thisspace the artery consistently splits into transverse anddescending branches, plus a variable ascending branch.

A preliminary cadaveric injection study revealed thepresence of a direct cutaneous perforator arising 1 cmproximal to the trifurcation. The presence of the vesselwas confirmed in subsequent dissections, and clinically bypower Doppler studies of normal volunteers. Five subse-quent clinical cases have revealed the perforator to be con-sistently present, arising from the CSA within 1.5 cm of itsbi-/trifurcation in three out of five cases, and from theproximal 1 cm of the descending branch in two out of fivecases. The perforator ascends directly into the overlyingsub-dermal plexus, arborising within a 1e2 cm2 region.The anatomy of the flap is summarised in Fig. 9, and theplanes in which dissection takes place in order to raisethe flap, and to thin it further as required.


Discussion

The current focus of microsurgical development is alongtwo lines. The first is a simplification and refinement oftechniques in order to make tissue transfers shorter, morereliable, and with less associated donor site morbidity. Thesecond aims to use increased anatomical knowledge topermit the design of flaps that contain only the tissuesnecessary for a particular reconstruction. The developmentof perforator flaps has to some extent addressed both linesof development by providing a wide range of donor sites,and permitting the harvest of skin, adipose tissue, fascia,and muscle as separate components of the flap.20 Donorsite morbidity in head and neck reconstruction has beenreduced by the anterolateral thigh flap as compared tothe radial forearm flap,27 and the perforator-based forearmflap;28 in breast reconstruction the deep inferior epigastricartery flap has reduced abdominal wall morbidity.29e31

The classification of perforator flaps has become in-creasingly formalised, and remains a source of controversy,but an approach based upon angiosomal knowledge, andthe course of the perforator predominates.20,32,33 Essen-tially a perforator flap is defined as a paddle of skin and

T

D

P

CSA

AM

Os

SF

Figure 9 The pedicle dissection and thinning of the CSAPflap. At the level of the deep fascia overlying the scapular mus-culature ( ) the circumflex scapular artery (CSA) and venaecommitans, and its bi-/trifurcation into ascending (A), de-scending (D), and transverse branches (T) is defined. All threebranches run parallel to the deep fascia, in contrast to the per-forator vessels (P) which are identifiable by their vertical ori-entation as they ascend into the deep layer of subcutaneousadipose tissue ( ). The perforator vessels are carefully dis-sected through this tissue until confirmed to perforate the fas-cial layer that separates the deep, and superficial adiposelayers (Scarpa’s equivalent, SF). The flap can then be incisedaround its margin and raised on the surface of the SF (hatchedline: ) towards the perforators, around which a smallcuff of deep adipose tissue is preserved. Further thinning ofthe superficial adipose tissue ( ) can then be undertaken underloupe magnification using scissors (dashed line: ) ifrequired. The CSA main pedicle is then dissected proximallyas for a traditional dorsal scapular flap preserving or dividingdirect muscular (M), or osseous (Os) branches as necessary.

subcutaneous tissue vascularised by one or more vesselsthat arise from defined main arteries and traversethrough/between deeper structures.20 The flap is namedafter the main artery (e.g. the anterolateral thigh flap25

as the lateral circumflex femoral artery perforator-LCFAPflap). If that vessel traverses muscle, the flap is termeda musculocutaneous perforator flap, and receives a suffixdenoting the muscle traversed (e.g. musculocutaneousLCFA-vl ), if it traverses a septum the flap is called a septalperforator flap (e.g. musculocutaneous LCFA-s). An alterna-tive strategy has more recently been described by Kim34

based upon the course of the perforator, and how far thepedicle is traced and in which direction. Since it is the cir-cumflex scapular artery, and not the perforator, that exitsthe loose intermuscular septum of the omotricipital space,under these definitions the flap described is vascularised bya class III direct perforator,33 and would be termed the ‘cir-cumflex scapular artery perforator’ flap (CSAP-s)20 or ‘cir-cumflex scapular perforator’ flap.34

Anatomical studies have located a total of 374 cutaneousperforators larger than 0.5 mm in the human body,9 andflaps based on only a small number of these have demon-strated their widespread clinical use.23,25,35e38 Flaps basedupon other perforators retain more restricted applica-tions.20,39e43 Each flap has its own balance of anatomicalconsistency, ease of dissection, skin quality, volume, andpatient position in which raising the flap is practicable,but none is a panacea.

In particular, intramuscular dissection adds time andtechnical exactitude to the procedure, and no single flapcan give a range of skin thicknesses depending upon skinpaddle orientation. The options for chimeric flaps, poten-tially incorporating vascularised bone, fascia, and twin/multiple skin paddles for complex defects, are also limitedat present. In contrast the CSAP flap involves no intramus-cular dissection, has a very well localised main pedicle, andthe character of skin raised can be varied by adjusting theorientation of the flap (Fig. 2). Furthermore, as the rela-tively straightforward incorporation of vascularised bone,fascia, and thin skin in case 4 demonstrates, the circumflexscapular axis presents a wide array of chimeric options witheasily defined pedicle lengths. If traced more proximallythe subscapular axis provides the greatest array of anyknown vascular pedicle, and the combination of the CSAPflap with thoracodorsal artery flaps (muscular, perforator,or gliding layer) would provide innumerable chimeric op-tions, including the provision of high quality bone stock.44

Although the vascular anatomy of the circumflex scap-ular artery, and dorsal scapular skin has been investigatedin depth,13,15 not least by Nakajima’s group,16,17,45 the per-forator forming the basis of the flap described here has notpreviously been recognised, yet appears to be representedin Fig. 1 of Imanishi’s paper.16 We do not yet have sufficientexperience to fully define the perforator anatomy, or thisflap’s defined safe dimensions when raised full thickness,or thinned, but extremely large perforator flaps havebeen described. The anterolateral thigh, paraumbilical,and thoracodorsal flaps are most notable in this regard,and can be thinned to 2e4 mm thickness.23,35,46,47 Experi-ence of the thin anterolateral thigh flap also suggests thatin perforator flaps the orientation of the skin paddle tothe perforator is relatively unimportant, skin perfusion


being reliably maintained within at least a 9 cm radius inany direction.48,49

The drive to refine surgical outcome, and minimise theneed for secondary procedures resulted in the developmentof primary thinning. Perforator flaps are anatomicallysuited for this since they rely upon the sub-dermal vascularplexus23 for survival (see Kimura and Satoh for anatomicaldiagrams49), and so the parasitic adipose tissue deep tothis layer can safely be excised, as long as the perforator’sterminal arborisations are preserved. A single cadavericstudy has questioned the safety of thinning.50 This has notbeen borne out clinically in our experience of 31 cases, orthe weight of anatomical and clinical literature whichdocuments the technique’s safety,8,21e24,27,46,47,49,50e55

although microdissection42,55 may be less safe.20 The flapdescribed adds another thin flap to the literature, andone in which the character of skin can be adjusted while re-taining the familiarity of one pedicle dissection. An addi-tional benefit is the firm anatomical definition of themain CSA pedicle, and the reliability of its surfacemarkings.

Handheld unidirectional Doppler flowmetry is widelyused to localise perforators for pre-operative flap design,but is demonstrably unreliable when compared to operativefindings, and colour flow, or power Doppler for the antero-lateral thigh and TDAP flaps.56e58 Our experience with thisflap suggests a higher predictive value, the Doppler locationmatching the intraoperative location in all but one case(case 4), in which erroneous interpretation of the signaldid hinder elevation of the flap. As suggested for the supe-rior gluteal artery perforator flap (sGAP),56 this may actu-ally reflect the relatively well defined anatomical limitswithin which the perforator arises, rather than an inherentfeature of the Doppler signal. Our initial findings withpower Doppler are encouraging, but a larger study is re-quired. Additionally, if large radiological/anatomical stud-ies confirm that the perforator arises within as shorta segment of the circumflex scapular system as our earlyfindings suggest, then Doppler location may be unnecessaryif a defensive approach to raising the flap is routinelyemployed.

The duration of follow-up in this clinical series does notpermit conclusions to be drawn about the long-term efficacyof the reconstructive techniques employed, but doesdemonstrate the viability of the CSAP flap, and begins toindicate the breadth of reconstructive possibilities that theflap may provide. Five cases provide insufficient experiencefrom which to definitively describe the most optimalsurgical strategy, but each case has revealed learningpoints, as detailed earlier. Based upon reflection of theseevents, our current surgical strategy is now described.

For optimal exposure, the patient is placed in the lateralposition, although once familiar it should prove possible toraise the flap with the patient supine plus a spinal roll. Thearm is placed on a padded support to maintain the shoulderflexed and abducted, and the scapula protracted. Dopplersignals, and the surface markings of the scapula and CSAconfirmed. An elliptical skin island is then designed with theperforator located near its superior apex (Fig. 1). The angleof the skin paddle will dictate the nature of the dermis in-corporated (if angled laterally from the post-axillary, skin isincorporated for thinner, more flexible skin; if angled

medially, or transversely over the scapula, then thicker,more robust dermis is included).

For a maximally defensive approach that preserves thetraditional dorsal scapular flaps as lifeboat options, the flapshould be incised first along its superolateral border (Fig. 1,solid line). The incision is deepened vertically on to the un-derlying musculature (preserving any perforating vesselsencountered at this stage). Teres minor and major are iden-tified and followed medially into the omotricipital space,bordered on its third side by the long head of triceps, withinwhich the CSA is identified. This is then followed distallyuntil its largest perforator is identified exiting the superfi-cial surface of the CSA, or its bifurcating main branches,and ascending into the sub-dermal plexus. Finally, thedesign of the flap is confirmed (Fig. 1, dashed lines), itsperipheral margins incised, and the flap raised at the levelof the fascial plane separating the deep and superficial ad-ipose layers (Scarpa’s equivalent; Fig. 9). The pedicle dis-section is completed, noting that the perforating arterymay not be directly apposed to the largest draining vein,which is commonly a few millimetres distant as the vesselstraverse the upper superficial fascia, in keeping with Ima-nishi’s findings.16,17 The perforator’s arborisations into thesub-dermal vascular plexus must be preserved and thinningcan safely be carried out centripetally using scissors under2.5e3.5� loupe magnification as far as the small, denselyadherent fat lobules that lie within millimetres of thedermis over the majority of the flap (Fig. 9). The descend-ing, transverse, and osseous branches of the main CSA ped-icle can then be divided, or raised as chimeric constituents,and the main pedicle dissected back to its subscapular ori-gin as required.

An alternative surgical strategy is to design a vertical/laterally angulated skin paddle around the CSA surfacemarking, and perforator Doppler signal. The flap is thenincised along its medial border, deepening the incision untilthe transverse branch of the circumflex scapular artery(CSA) is identified. This can be followed proximally to thepoint of origin of the vertical and transverse branches, andthe CSA itself. Dissection proceeds until the cutaneousperforator vessel can be clearly identified arising fromthe superficial aspect of one of these three vessels. Theperforator can then be carefully dissected free, and theprocedure continued as described above.

When approaching a novel flap, in particular, it isreassuring to have a salvage strategy that avoids inflictinga second donor site upon the patient, and with the CSAPflap two such options exist should no perforator be located,or should iatrogenic injury to it occur. For coverage ofdefects where flap thickness is less critical one can revertto a traditional dorsal scapular flap based upon either thetransverse or descending branch of the CSA as appropriate.Similarly for coverage of defects where a thin flap isessential, one could revert to a scapular or parascapularfascial flap covered by skin graft, although quality of skin-cover would be reduced.

In summary, we present a new perforator flap raised withthe circumflex scapular vessels as the main pedicle, andthereby possessing easily defined surface markings, goodpedicle length, and larger diameter vessels. This flap avoidsthe technical exactitude and time of an intramusculardissection, while retaining all the potential for thinning of


other perforator flaps. The character of the dermis can beadjusted by varying the orientation of the skin paddle, andmultiple chimeric options are possible. The flap has appli-cations as both a pedicled and free tissue transfer, butrequires larger anatomical, radiological, and clinical studiesto clearly define its potential dimensions, safety and use.

Acknowledgements

In all clinical cases surgery was led by Mr Stuart Watson,Consultant Plastic Surgeon in the Canniesburn Unit, towhom the authors are indebted for permission to publishhis clinical work, and for his guidance during the evolutionof this flap and preparation of this paper. The authors alsoacknowledge the Department of Medical Illustration atGlasgow Royal Infirmary for its assistance in the preparationof clinical illustrations. Funding was provided by theStephen Forrest Charitable Trust.

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The thin circumflex scapular artery perforator flap