A retrospective review of all patients undergoing STFF for head and neck reconstruction at Samsung Medical Center from April 2013 to April 2014 was performed. Data collected included age, sex, defect site, pathology, previous treatment, and time of reconstruction. The patients were divided into two groups (i.e., patients undergoing maxillary reconstruction and those undergoing mandibular reconstruction). The surgical findings, postoperative complications, imaging studies, and medical photographs were also collected in both groups, and all of the patients provided informed consent for the publication of facial photographs.

We examined the surgical findings, including defect type, size of harvested scapular bone and pedicle, recipient vessels, complications, and esthetic outcome.

The maxillectomy defects were classified according to the system developed by Okay et al. [11], and mandibulectomy defects were classified according to the system developed by Deleyiannis et al. [12]. The details of the classifications are presented in Table 1.

The short-term and long-term complications were reviewed from medical charts retrospectively. We examined the complications of donor and reconstruction sites, such as bleeding, fistula, infection, flap failure, and diplopia.

The physician graded the esthetic results from photographs of the patients that were taken 1 month after surgery. Patients estimated their shoulder function during daily activities after the operation.

The patient was placed in the 30° lateral decubitus position with a rolled-up towel under the inferolateral border of the LD. This position allows a two-team approach in selected cases for simultaneous tumor resection and flap harvesting [13]. During the harvest procedure, the shoulder is fully adducted and fixed in position, which rotates the scapula upward and outward, and secures the operating field. After positioning, an S-shaped cutaneous incision is made from the midaxilla along the lateral border of the LD, and towards the scapular tip. The first step involves exposing the dorsal aspect of the LD, mobilizing it from the scapular border and the teres major (Fig. 1A). This procedure should be accomplished first to facilitate pedicle management (Fig. 1B). The vascular pedicle must be manipulated carefully because its course is variable between individuals. The pedicle was identified at the origin of the thoracodorsal artery from the subscapular vessels, and then traced down the course of the thoracodorsal artery until the emerging branches to the serratus anterior, teres major, and angular branch (Fig. 1C). If the parascapular skin is needed for the reconstruction, the circumflex scapular artery should be preserved. Similarly, if any muscular structure is also needed, such as the teres major or serratus anterior, vascular branches to these muscles should be saved. When the pedicle had been fully identified and mobilized, osteotomy of the scapular tip bone was performed according to the defect size (Fig. 1D). The size of the bone should be carefully assessed before osteotomy, because further osteotomy in the scapular tip could lead to flap failure. After flap harvest, the remaining teres major muscle was fixed to the remnant scapular bone to facilitate the recovery of muscle function, and to prevent seroma and hematoma (Fig. 1E). Three holes were drilled in the remaining scapular bone, and the teres major muscle was fixed to the scapular bone via these holes using 3-0 nylon sutures. In all of the patients, primary closure of the donor site was achieved, and a sling was applied to the arm until 1 week postoperatively.

We used 3D midface rapid prototype model (replica) for delicate maxillectomy and reconstruction. The reconstruction plate (Synthes CMF; Synthes, Mississauga, ON, Canada) was prefabricated on a patient-specific rapid prototype model. If orbital reconstruction was needed, titanium mesh (Synthes CMF) was prefabricated using the rapid prototype model (Fig. 2A). The harvested scapular tip bone was placed vertically in the malar area to reconstruct the zygomatic bone and maxilla in all cases. The muscular component was positioned at the palate for reconstruction and obliteration of the defect cavity. The scapular tip bone was fixed at the premaxilla and maxillary process of the zygomatic bone with the titanium plate, and the prefabricated titanium mesh was placed on the bony defect of the orbital rim and stably positioned at the remained surrounding bony structures (Fig. 2B). The flap pedicle was tunneled through the buccal space deep to the facial nerve over the mandible and anastomosed with a single artery and vein. The superior thyroidal artery and internal jugular vein were usually used for revascularization.

A patient-specific 3D facial bone rapid prototype model was made, and the reconstruction plate was prebent on this model preoperatively in a manner similar to maxillary reconstruction (Fig. 2C). The mandibulectomy involved oral cavity mucosa with or without skin defect. The scapular tip bone was placed at the mandibular defect, and the muscle could be positioned at the oral cavity mucosal defect (Fig. 2D). In cases requiring facial skin resection, the skin was harvested as a chimeric flap to cover the skin defect. After positioning the flap, a prefabricated reconstruction plate was used for fixation of the scapular bone at the remaining mandible.

The clinical data are summarized in Table 2. Eight patients underwent reconstruction via Weber-Fergusson incision with Lynch extension (4 males, 4 females; median age, 51 years; range, 41 to 66 years). The scapular tip bone was used for malar reconstruction (vertically inset at the anterior maxillary wall) in all of the cases. Two patients had class Ib f, two had class II f, two had class III, one had class III fz, and one patient had class Ib f defects. The distribution of pathological subtypes was as follows: squamous cell carcinoma, n=2; adenoid cystic carcinoma, n=3; adenocarcinoma, n=1; chondrosarcoma, n=1; melanoma, n=1. Case No. 1 received concurrent chemoradiotherapy previously, and case No. 2-6 had no previous treatment before surgery. Case No. 1-6 simultaneously underwent wide tumor excision and reconstruction. Case No. 7 and 8 underwent delayed reconstruction with confirmation of no evidence of tumor recurrence for 5 years.

The reconstruction data are listed in Table 3. The median size of the scapular tip bone was 4.5 cm (long axis; range, 3.9 to 5.0 cm)×1.5 cm (short axis; range, 1.0 to 2.5 cm). The median pedicle length was 10.8 cm (range, 8.2 to 13 cm), and there was no need for vein grafting in revascularization of the flap in any of the patients. Six patients had orbital floor defects (subclass f defect) that were reconstructed with titanium mesh. The LD muscles were used in all cases for reconstruction of the maxillary cavity or hard palate. The superior thyroidal artery and internal jugular vein were used for revascularization in six cases, the superficial temporal artery and vein were used in one case, and the facial artery and lingual vein were used in one case.

Two patients (cases No. 1 and 8) suffered from diplopia postoperatively, case No. 1 was corrected by orbital floor reconstruction with another titanium mesh, and case No. 8 underwent medial canthopexy. Case No. 4 had flap failure and underwent revision surgery with a contralateral STFF. Case No. 7 developed oroantral fistula postoperatively despite curettage and suturing of the fistula several times, and was finally treated with an anterolateral thigh free flap.

Esthetic outcomes 1 month after reconstruction were excellent in three cases, good in two cases, and fair in three cases. The oral cavity defects that were reconstructed with a muscle flap usually achieved complete mucosalization within 2 months after surgery. Medical photographs of case No. 1 are shown in Fig. 3.

The reconstruction data are summarized in Table 4. Nine patients underwent mandibular reconstruction via the lower cheek approach with or without lip splitting (6 males, 3 females; median age, 54.2 years; range, 34 to 79 years). The distribution of pathological subtypes was as follows: squamous cell carcinoma, n=7; osteosarcoma, n=1; chondrosarcoma, n=1. Three patients had retromolar trigone cancer, two had buccal cancer, two had mandible bone tumor, and one had gingiva cancer. Seven patients underwent salvage surgery, and two patients had no history of prior treatment. All of the patients simultaneously underwent wide tumor excision and reconstruction.

The reconstruction data are summarized in Table 5. Three patients (case No. 1, 2, 4) suffered from oral cavity mucosal dehiscence and bone exposure. Case No. 1 required repair operation only, and the others responded well to conservative management. All of the patients had successful free flap reconstruction without failure. Esthetic outcomes 1 month after reconstruction were considered excellent in four cases, good in two cases, and fair in three cases. Similar to maxillary reconstruction, the reconstructed oral cavity defects healed within 2 months after surgery. Medical photographs of case No. 15 are presented in Fig. 4.

There were no donor site complications, such as infection, hematoma, or dehiscence, in any case in the present series. All patients except case 4 showed recovery of shoulder function after 1 month without restriction of daily activities. Case No. 4 underwent bilateral scapular tip harvest because of flap failure, and had difficulties in internal rotation of both upper extremities.