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Guidance for Circumflex Scapular Artery Flap Utilization in Pediatric Reconstruction
Sasha Lasky, Tayla Moshal, Idean Roohani
1Keck School of Medicine, University of Southern California, Los Angeles, CA.
Insights
The circumflex scapular artery (CSA) flap is a versatile option for pediatric reconstruction, offering reliable vascularity and minimal donor site morbidity. Parascapular flaps are recommended for larger defects due to their larger harvestable skin paddle.
Area of Science:
- Plastic Surgery
- Pediatric Reconstruction
- Microsurgery
Background:
- The circumflex scapular artery (CSA) flap system, including scapular, parascapular, and chimeric flaps, is valuable for diverse pediatric reconstructive needs.
- This case series provides insights into CSA flap selection for specific pediatric cases.
- It establishes a framework for choosing between scapular and parascapular skin paddles and highlights technical considerations in pediatric patients.
Purpose of the Study:
- To analyze decision-making processes for CSA flap selection in pediatric reconstruction.
- To develop a framework for choosing between scapular and parascapular skin paddles.
- To emphasize critical technical aspects of CSA flap use in pediatric patients.
Main Methods:
- Retrospective review of pediatric CSA flap reconstructions from 2006-2022.
- Data abstraction included patient demographics, indications, flap characteristics, complications, and operative details.
- Functional donor site morbidity was assessed via physical examination; an unpaired t-test compared scapular and parascapular flap sizes.
Main Results:
- Eleven CSA flaps (6 scapular, 5 parascapular) were successfully used in 10 pediatric patients (ages 2-17).
- Parascapular flaps were significantly larger (156.6 cm²) than scapular flaps (55.8 cm²; P=0.0495).
- A 100% reconstruction success rate was achieved with 27.3% complication rate (venous congestion, wound dehiscence); no shoulder function compromise was reported.
Conclusions:
- The CSA flap system demonstrates versatility, large vessel caliber, wide rotation, reliable anatomy, and minimal donor site morbidity for pediatric reconstruction.
- Key pediatric considerations include vascular mismatch and limited scapular bone stock.
- Parascapular flaps are preferred for larger, complex defects due to their larger skin paddle potential.
Background:
The circumflex scapular artery (CSA) flap system, consisting of scapular, parascapular, and chimeric flaps, is useful for pediatric reconstruction in many anatomical locations. The objectives of this case series are to offer insights into our decision-making process for selecting the CSA flap in particular pediatric reconstructive cases and to establish a framework for choosing a scapular or parascapular skin paddle. We also aim to emphasize important technical considerations of CSA flap utilization in pediatric patients.
Methods:
Pediatric reconstruction with CSA flaps performed at our institution between 2006-2022 was retrospectively reviewed. Patient demographics, indications, flap characteristics, complications, and operative data were abstracted. Functional donor site morbidity was assessed through postoperative physical examinations. Unpaired t test analyzed scapular versus parascapular flap size.
Results:
Eleven CSA flaps were successfully performed in 10 patients (6 scapular and 5 parascapular flaps). Patient ages ranged from 2 to 17 years. Scapular fasciocutaneous free flaps (n = 4) were performed in patients' ages 2-5 years for hand and forearm scar contractures. Two pedicled scapular flaps were performed for a single patient for bilateral axillary hidradenitis suppurativa. The 5 parascapular flaps were performed in patients' ages 2-14 years for calcaneus and forearm avulsion wounds and reconstruction after resection of hidradenitis suppurativa, nevus sebaceous, and Ewing sarcoma. In the sarcoma resection case, a chimeric flap with latissimus dorsi was employed. Average flap size was 101.6 ± 87.3 cm 2 (range: 18-300 cm 2 ). Parascapular flaps were significantly larger than scapular flaps (156.60 ± 105.84 cm 2 vs 55.83 ± 26.97 cm 2 , P = 0.0495). Overall, 3 complications occurred (27.3% of cases) including venous congestion (n = 2) and wound dehiscence (n = 1). There were no reported cases of compromised shoulder function at 1.9 ± 2.5-year follow-up. The successful reconstruction rate for scapular, parascapular, and chimeric flaps was 100%.
Conclusions:
The CSA flap treated a wide variety of indications demonstrating the flap's attributes: large vessel caliber, wide arc of rotation, reliable vascular anatomy, minimal donor site morbidity, and ability to incorporate bone and muscle. Our cases also highlight important pediatric considerations such as vascular mismatch and limited scapular bone stock. We recommend selection of the parascapular over the scapular flap with reconstruction of larger, complex defects given its ability to be harvested with a large skin paddle.
