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Objective: An evidence regarding which bony flap for reconstruction of mandibular defects following tumour resection is associated with the highest survival rate is still lacking. This network meta-analysis (NMA) aimed to guide surgeons selecting which vascularized osseous flap is associated with the highest survival rate for mandibular reconstruction., Methods: From inception to March 2021, PubMed, Embase, Scopus, and Cochrane library were searched to identify the eligible studies. The outcome variable was the flap survival rate. The Bayesian NMA accompanied by a random effect model and 95% credible intervals (CrI) was calculated., Results: Twenty-two studies with a total of 1513 patients, comparing four osseous flaps namely fibula free flap (FFF), deep circumferential iliac artery flap (DCIA), scapula flap, and osteocutaneous radial forearm flap (ORFF) were included. The respective survival rates of FFF, DCIA, Scapula, and ORFF were 94.50%, 93.12%, 97%, and 95.95%. The NMA failed to show a statistically significant difference between all comparators (FFF versus DCIA (Odd ratio, 1.8; CrI, 0.58,5.0); FFF versus ORFF (Odd ratio, 0.57; CrI, 0.077; 2.9); FFF versus scapula flap (Odd ratio, 0.25; CrI, 0.026; 1.5); DCIA versus ORFF (Odd ratio, 0.32; CrI, 0.037; 2.1); DCIA versus scapula flap (Odd ratio, 0.14; CrI, 0.015; 1.1) and ORFF versus scapula flap (Odd ratio, 2.3; CrI, 0.16; 34))., Conclusion: Within the limitations of the current NMA, FFF, DCIA, Scapula, and ORFF showed a comparable survival rate for mandibular reconstruction. Although the scapula flap reported the highest survival rate compared to other osseous flaps for mandibular reconstruction; however, the decision making when choosing an osseous flap should be based on many factors rather than simply flap survival rate., Competing Interests: The authors reported no conflicts of interest related to this study.

Objective: The aim of our paper is to present a rare variation of the suprascapular vein, its incidence and clinical significance., Case Report: A rare case of a double suprascapular vein was observed in a digitalized human cadaver on Anatomage Table 5.0. The vein divided into two branches, one passing over the transverse scapular ligament, while the other one coursed underneath the ligament, inside the notch., Conclusion: This variation has major clinical importance as it is associated with the appearance of Suprascapular nerve entrapment syndrome., (Copyright © 2019 by Academy of Sciences and Arts of Bosnia and Herzegovina.)

Introduction: Whether secondary to trauma, infection or tumor invasion, a complex reconstruction procedure is required after proximal humerus resection. Among the reconstruction options, there are few published reports of a vascularized scapular pillar graft being used. The goal of our study was to describe the surgical technique for shoulder arthrodesis using a vascularized scapular pillar based on an anatomical study of this graft., Materials and Methods: This anatomical and surgical study involved both shoulders from seven separate cadavers (14 shoulders). Two shoulders were used for trials. Four shoulders were injected with latex to describe the vascularization of the composite scapular pillar graft. Five fresh shoulders were then used to define the optimal orientation of the osteotomy and rotation of the scapular pillar. Each vascularization element was then isolated and measured. The shoulder arthrodesis procedure using a composite scapular pillar graft was performed on three shoulders in order to describe the steps of this procedure., Results: The angular branch of the thoracodorsal artery was 8.25±1.5 cm long and reached the lateral angle of the scapula 1.6±1.1 cm above its antero-inferior edge. The mean length of the circumflex scapular artery was 5.25±1 cm with 3 cm separating the inferior edge of the glenoid and the end of the artery in question. Optimal graft positioning was achieved with a glenoid osteotomy of the pillar that was horizontal in the frontal plane and angled 20° downward and forward in the sagittal plane. This resulted in the pillar being turned 240° medially (internal rotation)., Discussion: The latex injection study confirmed that the scapular pillar always has two vascularization sources: circumflex scapular artery and angular branch of the thoracodorsal artery. While there are anatomical variations, the scapular pillar shares its vascularization with the latissimus dorsi and teres major muscles. It can be preserved when transferring the graft for reconstruction. Our anatomical description of shoulder arthrodesis using this composite graft allows surgeons to anticipate potential technical and anatomical problems that could be encountered during this complex surgical procedure., (Copyright © 2019. Published by Elsevier Masson SAS.)

Rationale: Isolated metastasis to the hand bones is very rare. Only seven cases of metastasis to the trapezium have been reported. To the best of our knowledge, this is the first report of a single metastasis to the trapezium from a gastric adenocarcinoma., Patient Concerns: A 62-year-old man presented with pain and massive swelling in the right carpometacarpal joint of the thumb., Diagnoses: The patient was diagnosed with trapezial metastasis of advanced gastric adenocarcinoma., Interventions: The patient underwent systemic chemotherapy with cisplatin and S-1, radiotherapy to the metastatic bone, and treatment with denosumab. One year later, the huge metastatic tumor was resected, and the hand was reconstructed using vascularized scapular bone., Outcomes: Eighteen months postoperatively, the patient was satisfied with the appearance of the reconstructed hand and was able to use his right thumb in activities of daily living., Lessons: Although rare, metastasis to the trapezium should be considered in patients with persistent and progressive thumb CMC joint pain., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Tears of the glenoid labrum are common after dislocation of the glenohumeral joint. The outcome for healing or surgical reconstruction of the glenoid labrum relies on the extent of its vascularization. This study aims to evaluate the glenoid labrum blood supply and to determine its regional vascularity., Materials and Methods: A total of 140 shoulders (30 male and 40 female cadavers) were examined: mean age 81.5 years, range 53-101 years. All blood vessels around the glenohumeral joint were dissected and recorded. Ten specimens with the glenoid labrum and fibrous capsule attached were randomly selected and detached at the glenoid neck and subjected to decalcification. Sections (10-20 μm) were cut through the whole thickness of each specimen from the centre of the glenoid fossa perpendicular to the glenoid labrum at 12 radii corresponding to a clock face superimposed on the glenoid. Sections were stained using haematoxylin and eosin and then examined., Results: The blood supply to the glenoid labrum is by direct branches from the second part of the axillary artery, subscapular, circumflex scapular and anterior circumflex humeral and posterior circumflex humeral arteries, as well as branches of muscular arteries supplying the surrounding muscles., Conclusion: This study shows that the glenoid labrum has a rich blood supply suggesting that, regardless of the types of the glenoid labrum lesions or their management, an excellent outcome for glenoid labrum healing and joint stability is possible. The observations also suggest that the blood supply to the glenoid labrum is sufficient, enabling its reattachment.

Anatomic variations of axillary artery branches are commonly encountered during radiological investigation and surgical operations. Their existence can confuse interpretation of radiological results and lead to undesired complications during surgery. In this report authors describe a rare case of a subscapular arterial trunk that gave origin to thoracodorsal, circumflex scapular, posterior humeral circumflex, and lateral thoracic artery. Such a variation might cause undesired sequelae during trauma management and a variety of common flap harvesting operations including latissimus dorsi, scapular and parascapular flaps. Furthermore it presents embryological interest as it gives insight to embryologic development of axillary area.

Objective: To explore a surgical model of utilizing consecutive free scapular flap and adjacent pedicled flap transfer for repairing massive soft tissue defects on the dorsum of the hand while minimizing the donor site morbidity., Methods: Six patients with massive soft tissue injuries on the opisthenar and forearm were treated with free scapular flaps. Afterwards, a pedicled flap adjacent to the donor site was transferred to cover the donor site defect by direct closure., Results: All six free scapular flaps survived without signs of infection. Three adjacent pedicled flaps presented minor signs of insufficient blood flow on the distal apex, which resolved after six weeks with only conservative therapy. All the incisions healed without other complications. At six-month follow-up, the patients regained full shoulder function., Conclusion: With the assistance of an adjacent pedicled flap, the scapular flap is a highly applicable approach in repairing massive soft tissue defects in the opisthenar. It can achieve positive outcomes in both reconstructive and aesthetic aspects.

Warfarin is widely used. Spontaneous bleeding is one of the complications of warfarin treatment. A 70-year-old man was admitted to the emergency room with right back pain. There was no history of trauma. He was using warfarin following a bypass graft. The patient's vital signs were stable. On physical examination, swelling at the level of the right scapula was detected. Laboratory findings showed that the international normalised ratio (INR) was ↑↑ (a very high reading) (1.47 1 month previously). There was no melena on rectal examination. A chest CT was performed to differentiate the swelling of the right scapula. Warfarin was stopped and vitamin K was administered. Fresh frozen plasma was initiated and the patient was hospitalised to the cardiovascular surgical service. The fact that use of warfarin in the elderly may increase the risk of spontaneous bleeding should be especially kept in mind.

During dissection of a 75-year-old Caucasian female cadaver, a trifid superior transverse scapular ligament (STSL) was found. The suprascapular nerve and vessels ran inferior to the STSL though the suprascapular notch. Measurements of the structures of the suprascapular region were taken using two complementary but independent methods: a classical method using an electronic digimatic calliper and a new one based on an analysis of digital photographic documentation of the STSL. The knowledge of anatomic variations of the STSL is important because this structure is the most commonly recognised possible predisposing factor of suprascapular nerve entrapment and can be helpful in diagnosis and surgical and arthroscopic treatment of this pathology.

Objectives: The purpose of our study was to evaluate the results of the reconstruction of the lower extremity defects with free flaps based on the subscapular artery., Methods: Between January, 1998 and December, 2008, 51 patients (mean age 26 years; 16 female and 35 male) presenting with a lower extremity defect underwent a reconstructive surgery with flaps based on the subscapular vascular system. Thirty-seven percent of the defects were located in the crus, 19% in the sole, 16% in the heel, and 14% in the dorsum of the foot. Eighty and a half percent of the patients had traffic-accident-related and 13.5% had burn-related tissue defects., Results: Fifty-three percent of the patients presenting with lower extremity defects underwent reconstruction with latissimus dorsi muscle flaps, 21% with free serratus muscle and/or fascia flaps, 14% with free parascapular fasciocutaneous flaps, and 12% with free combined latissimus muscle and serratus muscle and/or fascia flaps. Anastomoses of 80% of the patients were performed on their posterior tibial artery and accompanying veins and/or foot dorsal veins. End-to-end anastomosis was performed on 14 patients, while 35 patients received end-to-side anastomosis. Six patients were treated with cross free flaps, of which 4 received cross latissimus, 1 cross serratus, and 1 cross combined serratus and latissimus flaps. End-to-side anastomoses were performed on these patients on the cross-leg tibialis posterior artery. The cross-leg anastomosis was freed 4 weeks later. In the early period, venous occlusion was observed in 4 patients and arterial and venous occlusion was present in 1 patient. New anastomoses were performed in these patients. Partial necrosis was observed in 2 patients. The average follow-up period was 61 months. Pressure-related late ulcerative lesions developed in 4 patients. The lesions of these patients were repaired by debridement and primary suturing or partial thickness skin grafts., Conclusion: The subscapular vascular system based flaps have an optimal vascularity once they are prepared with adequate pedicles, causing minimal donor site morbidity. These flaps are a safe and effective alternative in lower extremity reconstruction. On the other hand, in the absence of appropriate recipient vessels, single or combined cross-leg free flaps may provide successful repair.

Axillary artery is one of the most important arteries of the upper limb, which is a continua- tion of the subclavian artery. It begins at the lateral border of the first rib and ends at the inferior border of the teres major where it becomes the brachial artery. Axillary artery has six important branches included: 1) Superior thoracic artery 2) Thoracoacromial artery 3) Lateral thoracic artery 4) Subscapular artery 5) Posterior circumflex humeral artery 6) Anterior circumflex humeral artery. Subscapular artery arises from the third part of axillary artery normally and then divides into cir- cumflex scapular artery that extremely enters the triangular space. The other branch of subscapular artery, the thoracodorsal artery, accompanies thracodorsal nerve to lateral border of scapula and supplies and innervates that region. In this case the subscapular artery was absent in both sides and instead of that the circumflex scapular artery was directly derived from axillary artery and the thoracodorsal artery is separated from circumflex scapular artery as a thin and short branch, too. It seemed that the lateral thoracic artery, which was thicker than its normal condition, supplied the muscles of the lateral part of scapula and the thoracodorsal muscle. Other branches of the axillary artery demonstrated without any abnormally. Since axillary artery has the highest rate of rapture and damage coming after the popliteal artery, knowing the variations is important and essential for surgeons, radiologist and anatomist.

The motive for this research was the use of the muscles of the scapular region in transposition, transplantation and reparative surgery and the need for more detailed knowledge of the blood supply to these muscles. In addition, the subscapular arterial tree may be used as a source of microvascular grafts to replace damaged or diseased portions of arteries, particularly in the hand and forearm. The research was conducted on 60 sides of corpses of adults of both sexes. It was noticed that the subscapular artery was present in 96.7% of cases and originated laterally to the pectoralis minor muscle in 76.7% of cases. The average calibre was 5.0 mm, and in 73.2% of cases it measured between 4.0 and 5.9 mm. The average length was 18.0 mm, ranging from 10.0 to 29.9 mm (76.7%). It presented in its course important relations with the axillary nerve (69%) and with the radial nerve (82.8%). Its branches were collateral (subscapular muscle - 61.3%) and terminal (except for the circumflex scapular artery), leading to the following muscles: serratus anterior (43.9%), latissimus dorsi (27.6%), and subscapular (23.3%). The thoracodorsal artery, one of the terminal branches, most frequently showed a calibre of between 2.0 and 3.9 mm (70.3%), collateral branches in 85.0%, was mainly distributed to the subscapular muscle (36.7%) and to the serratus anterior muscle (29.0%) and had terminal branches to the following muscles: latissimus dorsi (44.1%), serratus anterior (40.5%) and the subscapular (12.5%). The serratus anterior muscle received one branch in 39.5% and two branches in 41.9%, while the latissimus dorsi muscle received one branch in 66.7% and two branches in 23.1%.

Anatomical variations of the transverse cervical and suprascapular arteries are common. We report an adult male cadaver found to harbour an unusual variation of the right course of these two arteries. The transverse cervical artery arose independently from the first segment of the subclavian artery and passed deep to the anterior scalene muscle, a course which, to our knowledge, has not been reported before. Simultaneously, the ipsilateral suprascapular artery arose from the third segment of the subclavian artery and travelled posteriorly with the suprascapular nerve deep to the suprascapular ligament. We believe this is the first report of such a simultaneous occurrence.

A rare variation in the arterial pattern was found in the right arm of an 87-year-old male cadaver in a student dissection practice. In this case, the superficial brachial and superficial subscapular arteries coexisted in the absence of the normal brachial artery (A. brachialis profunda). After branching off a large-sized superficial subscapular artery, the axillary artery did not penetrate the brachial plexus and gave rise to a superficial brachial artery, which arose from the axillary artery at the point between the ansa pectoralis and ansa mediana, and descended ventral to the median nerve branching off the profunda brachii and superior and inferior ulnar collateral arteries. The superficial brachial artery finally divided into the radial and ulnar arteries in the cubital fossa. The superficial subscapular artery passed inferior and dorsal to the medial cord of the brachial plexus, giving off the lateral thoracic artery, and then branched off into the thoracodorsal, circumflex scapular and posterior circumflex humeral arteries. Thus the main nerves of the brachial plexus were sandwiched between the superficial brachial artery and the superficial subscapular artery system. The morphological and clinical significance of this variant are discussed.

Composite tissue defect of the mandible following the surgical resection of head and neck neoplasma or osteoradionecrosis causes functional and cosmetic disorders. Mandibular reconstruction is, therefore, necessary to obtain satisfactory results. The introduction of microvascular surgery has made it possible to transfer various types of vascularized bone grafts and this technique is considered one of the most reliable procedures for mandibular reconstruction. Recently it has been reported that an osteocutaneous scapular flap is useful for mandibular reconstruction. We have performed, over the last 2.5 years, 13 mandibular reconstructions using a vascularized osteocutaneous scapular free flap, and successful results have been achieved. The features of this flap are as follows: 1) it provides a consistent blood supply to the bone and the skin and has a constant vascular pedicle; 2) since the skin island and bone flap have separate pedicles, three-dimensional reconstructions are facilitated; 3) if needed, two skin flaps can be elevated; 4) the skin island is not so bulky; 5) the lateral border of the scapula provides highly vascularized bone of thick cortical density and osteotomies are safely performed; 6) using an angular branch based on thracodorsal artery, a bi-pedicled scapula bone can be raised and two completely vascularized bone segments can be transferred with a single pedicle. Thus, a vascularized osteocutaneous scapular flap has proven very useful for complex mandibular reconstructions.

The vascular anatomy of the cutaneous branches of the circumflex scapular artery and their communications with perforators supplying adjacent territories are described, based on dissections of 20 scapular regions. The cutaneous branches of the circumflex scapular artery are distributed in three areas by the ascending, horizontal and descending branches. The existence of the ascending branch was constant, confirming the reliability of the ascending scapular flap.

The precise vascular territory and the variations of the acromio-thoracic axis were investigated in a series of 60 fresh cadavers and 50 formalin fixed specimens using dissection, ink injection and barium radiographic studies. The sternocostal portion and the clavicular head of the pectoralis major were found to have virtually independent vascular and nerve supplies. The pectoral artery supplied the former, whereas the deltoid artery nourished the latter. The dominant supply from the pectoral artery to the rib cage was found to enter around the fourth rib in the mid clavicular line. This supply is associated with a previously undescribed origin of the pectoralis major muscle in this region. The supply to the sternum was determined as indirect via the captured territory of the internal mammary system. The dominant supply to the skin from the pectoral artery arose laterally along the free lower border of the muscle as fasciocutaneous branches. The deltoid artery supplies the skin over the shoulder by numerous small branches which emerge from the intramuscular septa of the deltoid muscle. In addition a large axial artery was noted. In most cases this arose from the deltoid artery or its acromial branch and coursed laterally. It is noteworthy that the majority of skin paddles of the pectoralis major myocutaneous flap currently used in clinical practice are designed medially and inferiorly around the perimeter of the muscle and onto the rectus sheath. In these situations such flaps are not supplied directly by the pectoral artery. In fact, they are supplied indirectly by cutaneous branches belonging to the internal mammary/superior epigastric system which are captured by arterial connections with the pectoral artery. These occur predominantly in the pectoralis major muscle. Suggestions, based on these anatomical studies, are offered to improve the versatility and safety of flaps designed in this area.

Twenty-eight immature dogs, divided into three groups, have been studied to determine the possibilities of pedicled epiphyseal transplantation from a rarely used donor site area, the scapula. One group of 8 immature dogs were studied anatomically using India ink and Batson's compound injection methods. We identified the vascular pattern of the diaphyseal portion of the graft, consisting of the lateral crest or border of the scapula. In two groups of 10 immature dogs, this area was used as a pedicled island graft to rebuild the semiresected or totally resected proximal humerus. There were marked differences between these two groups on the basis of morphologic, histologic, histochemical and electron microscopic aspects of the samples. Preservation of normal growth appeared to be directly related to the compressive forces applied to the graft. Preservation of the cartilage was also related to the biomechanical situation; fibrocartilage and signs of arthrosis were noted 1 year after the operation in several animals whose humeri had been fully subjected to normal stresses. Both the diaphyseal and epiphyseal areas had increased one- to fivefold in volume, but longitudinal growth was markedly deficient.