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Between 1988 and 1992, 80 Brånemark-type implants were inserted in 18 patients during reconstruction of the mandible or maxilla with vascularized iliac crest or scapula grafts with or without additional soft tissue pedicles. In these procedures, nine vascularized bone grafts were combined with a primary insertion of 32 implants and a secondary insertion of 48 implants. Twelve patients are currently wearing the implant-borne dentures. From 32 implants inserted primarily, eight could not be used for prosthodontic rehabilitation because three were lost with a graft, three were left as sleepers, and two demonstrated a lack of osseointegration. None of the implants inserted secondarily in grafts were lost. Primary implant insertion should be performed only in close cooperation with the prosthodontist and in selected cases, for example, in free-end reconstruction of the mandible with a straight graft and where a limited number of implants is needed. Although restoration of masticatory function in patients with head and neck cancer can be achieved, compared with a healthy control group, functional impairments remain. Patients subjectively favor the nonreconstructed side of the mandible or maxilla for chewing. These findings can be correlated with a postoperative follow-up investigation using a miniature force transducer and the T-scan system.

This study was performed to evaluate the utility and safety of catheterizing the right subscapular artery for balloon valvuloplasty of critical aortic stenosis in infants. Twenty-one patients, age 20 days to 17 months, underwent attempted valvuloplasty through the surgically exposed right subscapular artery. Five or 7Fr catheters with balloon diameters of 7 to 10 mm were used. Valvuloplasty was successfully performed using this approach in 11 patients. In 2 other patients, the subscapular artery would not accommodate the balloon angioplasty catheter (7Fr), and the arteriotomy was extended into the axillary artery. In these 13 patients, the peak systolic pressure gradient across the aortic valve was decreased from 85 +/- 23 to 33 +/- 7 mm Hg. Moderate aortic regurgitation developed in 3 patients. In the remaining 8 patients, valvuloplasty could not be performed through the right subscapular artery. In 2 patients, the right subclavian artery was anomalous and led to the descending aorta. In 6 small patients, no catheter could be advanced across the aortic valve. In 1 of these patients, a guidewire perforated a coronary sinus of Valsalva causing death. Overall, valvuloplasty using the right subscapular arterial approach was successful in 13 of 19 infants (68%) with normal right subclavian arteries, including all 10 such patients weighing > or = 5.5 kg. No clinically significant peripheral vascular complications or brachial plexus injuries occurred. Thus, the right subscapular arterial approach is an alternative route to be considered when planning balloon aortic valvuloplasty in infants.

We have treated three patients with avascular osteonecrosis using vascularized scapular bone graft. To predict blood perfusion in both the diseased femoral head and the transferred bone, all the hips were followed up using dynamic magnetic resonance (MR) scans, performed 1 and 7 months after surgery. In the present cases, it was shown that conventional enhanced MR imaging sometimes depicts increased intensity in bone marrow without blood perfusion due to the leakage of gadolinium-DTPA (Gd-DTPA) from the capillaries surrounding the avascular tissue. It was found that Gd-DTPA remaining in the dead bone marrow resulted in a false-positive image. By contrast, the dynamic MR scan evaluated only those images taken before the leakage. This is one of the advantages of the dynamic study, which reflects actual blood flow in the bone. The fast rise in the time-intensity curve following bolus injection of Gd-DTPA indicates that there is fast blood perfusion in the bone. The dynamic MR scan has demonstrated that there is little blood perfusion in the diseased bone 1 month after the operation and that vascular ingrowth from the transferred bone flap proceeds gradually between 1 and 7 months after surgery. These findings indicate that the dynamic MR scan is very useful in demonstrating vascular ingrowth after surgery in avascular necrosis of the femoral head and can be a reliable monitoring technique for anastomotic patency of the vascularized bone flap.

A newly developed technique for cricoid reconstructive surgery is presented and discussed. This method allows us to increase the number of patients presenting with squamous cell carcinoma who may benefit from partial laryngectomy. The method is based on the transfer of a vascularized scapular flap to reconstruct half a resected cricoid. Two alternatives may be used whether anterior laryngectomy preserves the half posterior cricoid and both arytenoids or a hemilateral laryngectomy leaves one arytenoid and half the cricoid. Complementary radiotherapy may be performed after surgery. Satisfactory results are reported from an initial series of three patients.

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 anatomy of the subscapular vein and its tributaries is described. Importantly, the angular branch of the subscapular vein and its almost constant relationship to the thoracodorsal nerve were demonstrated.

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.

Recent advances in microvascular surgery have made it possible to reconstruct large skeletal defects with autogenous bone grafts on a vascular pedicle. Experimental studies have demonstrated that vascularized bone grafts have superior blood flow and osteocyte survival when compared with nonvascular grafts. This improves the union rate and allows full incorporation of cortical bone, remodeling, and graft hypertrophy. Clinical experience over the past decade demonstrates that 80% to 90% of these grafts are ultimately successful, allowing limb salvage in complex reconstructive cases. However, the technique is technically demanding, has a relatively high complication rate, and requires prolonged immobilization and rehabilitation. Thus, vascularized bone grafts should only be used when simpler reconstructive techniques are unlikely to succeed.

The value of the scapular crest pedicle bone graft has been clearly established by clinical cases over the ten last years. The crest is compared to cortico-diaphyseal bone because of its properties, which are different from those of other parts of the scapula. The centromedullary space is vascularized by its own vascular system which penetrates the bone at the site of emergence of the cutaneous vessels of the scapular flap. The inferior portion is covered, in children by a voluminous apophysis which remains cartilaginous for a long time. Harvesting difficulties due to vascular and muscular characteristics are described in this paper.

In cases of surgically removed mandibular symphysis malignancies, the bone and mouth floor were reconstructed using osteo-musculo-cutaneous flaps. In our experience, the latter provide the best results. Removed in dorsal decubitus, they allow floor replacement. During the dissection of the tumor site, we also preserve labial and chin structures, which favours a good restoration of phonation and swallowing.

Reports on the use of osteocutaneous free scapular flap transfers have focused primarily on mandible reconstruction. Yet the scapula is a nearly straight bone, and it is also useful in the reconstruction of long bones. We would like to report on 23 patients undergoing osteocutaneous free scapular flap transfers to the lower extremities in whom we obtained extremely satisfactory results. These 23 surgical patients included 10 with pseudoarthrosis with osteomyelitis, 3 with pseudoarthrosis due to trauma, and 5 with osteomyelitis of the lower extremities, as well as 5 with other miscellaneous problems. Surgery was successful in all patients. There was a recurrence of osteomyelitis in 2 patients. In 1 patient, the problem was minor and was treated on an outpatient basis. In the other patient, an infection arose in surgical dead space, and a second operation was required. The level of weight bearing achieved with the osteocutaneous free scapular flap is the same as obtained with a vascularized free fibular graft used for the treatment of pseudoarthrosis. We therefore believe that the osteocutaneous free scapular flap is extremely effective in the treatment of chronic and severe lower leg problems.

This is a retrospective review of our experience with microvascular transfer of scapular and parascapular flaps for the correction of lateral facial contour deficiencies. Twenty-eight patients with congenital (n = 8) and acquired (n = 20) defects were treated with 30 flaps; two patients had bilateral flaps. The etiology of the defects included hemifacial microsomia (n = 2), oblique facial cleft (n = 1), Romberg's hemifacial atrophy (n = 5), neoplasm (n = 4), irradiation (n = 8), trauma (n = 4), tumor excision (n = 4), facial lipodystrophy (n = 2), and silicone granuloma (n = 2). The follow-up evaluation was from 2 to 13 years, with an average of 6 years. Fabrication of a facial moulage was part of the preoperative planning for each patient. These were compound flaps, including skin, deepithelialized skin, fat, fascia, and bone, if necessary. All flaps were constructed with an intact skin paddle for postoperative monitoring. Based on dissections and anatomic findings at operation, several variations in the level of emergence of the circumflex scapular artery from the triangular space and its branching patterns were noted. All flaps survived; changes in the patients' weights were reflected in the flaps. Twelve patients required secondary procedures: excision of skin monitor islands, scar revisions, debulking, or flap resuspension to the malar region. Bone grafts or alloplastic implants were necessary in four patients in whom the malar eminence could not be adequately corrected by transfer of a flap. The deepithelialized scapular/parascapular flap is preferred for correction of large lateral facial defects.

Congenital segmental amputations are difficult to correct. Free interposition bone grafts with growth centers were tried experimentally by many investigators even at the beginning of this century. Attempts at clinical application of this principle, however, were mostly failures. More recently, with the advent of microsurgical techniques, new hope has arisen. In particular, toe transfers in children have confirmed the survival of such growth centers, as these transfers could be found to grow normally [1]. The transfer of vascularized epiphysis with its growth plate has been shown in animal limbs to achieve a rate of growth comparable with the normal site. Originally, two donor sites were used with acceptable results in children. These were the superior epiphysis of the fibula and the iliac crest. So far, in most clinical applications, they have been used as appositional transfers. However, a growth problem occurring at the donor site has proved to be quite crippling.

In 12 cases of surgically removed mandibular symphysis malignancies, the bone and mouth floor were reconstructed using osteo-musculocutaneous flaps from the iliac crest or free osteo-cutaneous scapular flaps. In our experience, the latter provide the best results. Removed in dorsal decubitus, they allow floor replacement. During the dissection of the tumor site, we also preserve labial and clin structures, which favours a good restoration of phonation and swallowing.

Transplantation of the scapular bone vascularized by the thoracodorsal vessels offers some major advantages. This new myo-osseous grafting unit has the longest pedicle of all pedicled bone flaps used until now. It is particularly in difficult cases involving major parts of the maxillofacial region--as after neck dissection and irradiation--or distant regions such as the maxilla that its long pedicle and its anatomical configuration render the scapula an ideal graft.

Thirty-six adult dissections (14 cadaver and 22 operative) demonstrate the constant presence of the angular branch of the thoracodorsal artery as a vascular pedicle to the inferior pole of the scapula. This vessel originated in all cases just proximal or distal to the serratus branch of the thoracodorsal artery and arborized to the periosteum 6 to 9 cm from the bony branch of the circumflex scapular artery. In eight patients, scapular osteocutaneous flaps were raised preserving the angular branch and the circumflex scapular artery and dissecting up to the subscapular vessels. In all cases, bone was independently perfused by the angular branch. In all six cases where the angular branch was the sole supply to bone, technetium-99m scans demonstrated perfusion. Addition of this vascular pedicle to scapula bone allows two separate bone flaps with one microanastomosis and provides a longer arc of rotation between skin supplied by the circumflex scapular artery and bone. Donor-site morbidity was no greater than with the standard scapula flap.

The lower trapezius flap was first described in 1980 based on the transverse cervical artery. The older anatomical literature, however, describes the dorsal scapular artery as a major contributor of blood supply to the skin overlying the lower trapezius fibers. To clarify this, 30 dissections of this vascular region were performed. In 15 of 30 dissections, the dorsal scapular artery was dominant and the distal transverse cervical artery arose from the dorsal scapular. In nine of 30 dissections, the transverse cervical artery was dominant and the distal dorsal scapular artery arose from the transverse cervical. In six of 30 dissections, both proximal arteries were of equal caliber with no distal communication. We describe a surgical technique that makes use of the lower trapezius flap with inclusion of the dorsal scapular artery; this technique greatly extends the usefulness of the lower trapezius flap, while decreasing the morbidity caused by division of the upper portion of the trapezius muscle during flap harvest.

The course of the subscapular artery was studied in 20 rabbits. Its course was constant, giving two branches to the latissimus dorsi muscle after which the vessel sent a branch (S1) that perforated the panniculus carnosus to supply a large territory of skin. In a separate experiment, the contribution of the S1 branch to the viability of the rabbit latissimus dorsi musculocutaneous flap was evaluated. From this experiment it can be concluded that, first, it is possible in a rabbit to elevate a large skin flap based solely on a muscle perforator (S1), which survives completely. Second, in the rabbit latissimus dorsi musculocutaneous flap, S1 is the major blood supply to the skin component. Damage to it severely diminishes skin flap survival, even if the vascular supply to the underlying muscle is completely intact.

Mandibular reconstruction is one of the most challenging fields in plastic and reconstructive surgery. Deficiencies of the mandible occur in congenital anomalies, trauma, oral and mandibular neoplasms and osteoradionecrosis. Conventional reconstructive aids like bone grafting or insertion of a metallic implant often fail in such situations due to poor local blood supply, deficient oral lining, inadequate skin coverage, large mandibular defects, irradiated fields or infected wounds. A free vascularized bone graft of a osteocutaneous flap overcomes the incompetence of conventional mandible reconstruction. It offers not only a desirable length of vascularized bone, but also has an adequate skin lining for oral mucosa and external tissue deficiencies, as well as a "sandwich reconstruction" for the mandible. The results are usually satisfactory in terms of function and aesthetics. Experience in 8 cases with iliac and scapular osteocutaneous free flaps are presented and discussed in this report. We conclude that a vascularized bone graft, especially the iliac crest, provides reliable and contented results for major mandibular reconstruction.

The scapular and parascapular cutaneous branches of the circumflex scapular artery were studied in 28 cadaver sides using red latex dissection or lead oxide radiography. 2 vascular patterns have emerged depending on the dominant artery. The 2 patterns have important anatomical implications in reconstructive surgery.

In order to clarify the vascularization of the pectoralis major muscle by the pectoral branch of the thoracoacromial artery, morphometric investigations and selective injection studies of the vessel were performed. A comparison with the anatomical orientation points clinically used for locating the vessel and its course confirms that the origin of the artery is at a constant spot at half the sternoacromial distance; the main vessel axis, however, deviates considerably from the clinically used acromioxiphoid axis in lateral direction. The lumen of the thoracoacromial artery has a range of more than 150% of the smallest vessel. Atherosclerotic alterations are not the reason for this variety but only an additional handicap for the vessel capacity. Two types of muscle-perforating arteries were found, and the cutaneous area of blood supply was defined.

A 26-year-old man sustained a scapulothoracic dissociation (STD) as a result of severe shoulder girdle trauma. In this recently described syndrome, multiple fractures of the upper extremity and closed disruption of the scapula from the thorax are combined with damage to the local neurovascular structures. The occurrence of blunt subclavian arterial injury and STD indicates the possibility of severe brachial plexus lesions.

The radiographic anatomy of the IMAs is described based on bilateral selective arteriography in 100 patients with coronary artery disease. The right and left IMAs were identical in caliber in their mid portions in 94% of cases. Fifteen percent of the IMAs measured less than 2 mm in luminal diameter at the level of the fourth costal cartilage. The side branches showed a great deal of variability and asymmetry in their origin and distribution. The understanding of the radiographic anatomy of the IMA and its branches is helpful in preoperative appraisal and is crucial for postoperative evaluation of the IMA grafts.

Reinvestigation of the configuration of the human thyrocervical trunk revealed, that in the presently investigated specimens the dorsal scapular artery is a direct branch of the subclavian artery in approximately 75% of the cases, whereas in the remaining 25% it is derived from the thyrocervical trunk, either directly or via the transverse cervical artery (Nomina anatomica 1977). The internal thoracic artery participates in the thyrocervical trunk in more than 10% of the observed cases. Thus, both dorsal scapular and internal thoracic artery have to be considered as facultative branches of the thyrocervical trunk. According to our results, the subclavian artery must be considered as the most common site of origin of the dorsal scapular artery. This vessel may be replaced by another artery in about one fourth of the cases. A survey of studies on the origin of the dorsal scapular artery clearly demonstrates that it is not warranted to give an overall numerical proportion for the main modes of branching. As yet no satisfactory explanation for the high degree of variability of these subclavian branches has been given. Especially the widely held notion of differences related to race, which is based on Adachi's (1928) work, has turned out to be invalid. Interpretation of variability may rather be based, as a general concept, on the late acquisition of a thyrocervical trunk in phylogeny as well as in ontogeny.

Microfil injections in 8 cadavers and clinical experience with 26 patients have demonstrated a reliable blood supply to the lateral border of the scapula based on branches of the circumflex scapular artery. This tissue has been used successfully for reconstruction of a variety of defects resulting from maxillectomy and mandibular defects from cancer and benign tumor excisions. Advantages of this tissue over previous reconstructive methods include the ability to design multiple cutaneous panels on a separate vascular pedicle from the bone flap allowing improvement in three-dimensional spatial relationships for complex mandibular and maxillary reconstructions. The lateral border of the scapula provides up to 14 cm of thick, straight corticocancellous bone that can be osteotomized where desired. The thin blade of the scapula provides optimum tissues for palate and orbital floor reconstruction. There have been no flap failures and minimal donor-site complications.

The anterior mandible defect following cancer excision presents a formidable reconstructive challenge. A trapezius osteomyocutaneous island flap based on the transverse cervical vessels is described which allows immediate reconstruction of the entire defect. The various classes of bone flaps retaining an intact vascular pedicle are discussed. The osseous extension of the trapezius island flap appears to be adequate perfused. The anatomy involved and the orthopedic sequelae of using flap are discussed.

A rare case of avascular necrosis of the glenoid is presented. This process should be considered in the differential diagnosis of shoulder pain and radiologic lesions of the glenoid. In this patient anti-inflammatory medications and exercise resulted in resolution of the symptoms. A good prognosis is expected in this non weight bearing joint.

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.

The use of the trapezius osteomusculocutaneous island flap for mandibular reconstruction was first described in the American literature by Panje and Cutting in 1980. Since that initial description, we have utilized this composite flap to reconstruct the lower jaw in 24 patients. Approximately 85% of the cases were done for anterior arch defects and/or osteoradionecrosis. With an overall success rate of 87%, this surgical technique offers an especially useful method for immediate reconstruction of the lower jaw.

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.

The parascapular flap is a new, reliable and thin flap with a constant anatomy of the vascular pedicle. The flap can be taken with the lateral border of the scapula or used in combination with the latissimus dorsi muscle. Primary closure of the donor site can be achieved with a flap size up to 30 X 15 cm. The various applications of the parascapular flap are discussed and the results of four patients are presented.

A case is presented where certain branches of the right subclavian artery had unusual origins. The thyrocervical trunk was missing, the transverse cervical artery occupying its place. The inferior thyroid artery arose from the common carotid, and the suprascapular from the dorsal scapular artery. Pertinent literature on the suprascapular artery is reviewed.