The dorsal thoracic fascia: anatomic significance with clinical applications in reconstructive microsurgery

The anatomic distribution and potential arterial flow patterns of the circumflex scapular artery were investigated by Microfil injection. These studies demonstrated that the circumflex scapular artery lies within the dorsal thoracic fascia, which plays a significant role in the circulation of the overlying skin and subcutaneous tissue. We conclude that scapular/parascapular flaps are fasciocutaneous flaps, the dorsal thoracic fascia can be transferred as a free flap without its overlying skin and subcutaneous tissue, and intercommunication exists between the myocutaneous perforators of the latissimus dorsi myocutaneous flap and the vascular plexus of the dorsal thoracic fascia. We present microvascular cases in which the vascular properties of the dorsal thoracic fascia facilitated wound closure with free fascia flaps or expanded cutaneous or myocutaneous flaps.     

Clinical and basic research on occipito-cervico-dorsal flaps: including a study of the anatomical territories of dorsal trunk vessels

The authors have carried out a clinical study of all the patients who underwent reconstructions with occipito-cervico-dorsal flaps in their department between 1994 and 2003 and analyzed the outcomes of the surgery. The reconstructed areas ranged from the cheek to the anterior chest. Twenty-eight cases underwent reconstruction with microvascular augmented occipito-cervico-dorsal flaps, and four were reconstructed with single pedicle occipito-cervico-dorsal flaps. In five cases, distal partial necrosis was observed. The largest flap size was 43 x 23 cm (5 x 5-cm pedicle). In the microvascular augmented occipito-cervico-dorsal flaps, the circumflex scapular artery and veins were used in 28 cases, and dorsal intercostal perforators were used together with circumflex scapular artery and veins in five cases. The follow-up term was between 1 and 8 years. Neck scar contractures were released in all cases, and good results were obtained not only functionally but also aesthetically. In an anatomical study, the authors used 20 preserved cadavers and took angiograms of the dorsal region. Five cadavers were used to confirm the territory of each of the vessels that have close relations to the occipito-cervico-dorsal flap (the occipital artery, transverse cervical artery, circumflex scapular artery, and dorsal intercostal perforator artery). Each anatomical territory was clearly seen and its area identified.     

The bipedicled osteocutaneous scapula flap: a new subscapular system free flap

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 use of scapular and parascapular flaps for cheek reconstruction.

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.     

Rotator cuff muscle function and its relation to scapular morphology in apes

It is widely held that many differences among primate species in scapular morphology can be functionally related to differing demands on the shoulder associated with particular locomotor habits. This perspective is largely based on broad scale studies, while more narrow comparisons of scapular form often fail to follow predictions based on inferred differences in shoulder function. For example, the ratio of supraspinous fossa/infraspinous fossa size in apes is commonly viewed as an indicator of the importance of overhead use of the forelimb, yet paradoxically, the African apes, the most terrestrial of the great apes, have higher scapular fossa ratios than the more suspensory orangutan. The recent discovery of several nearly complete early hominin scapular specimens, and their apparent morphological affinities to scapulae of orangutans and gorillas rather than chimpanzees, has led to renewed interest in the comparative analysis of human and extant ape scapular form. To facilitate the functional interpretation of differences in ape scapulae, particularly in regard to relative scapular fossa size, we used electromyography (EMG) to document the activity patterns in all four rotator cuff muscles in orangutans and gibbons, comparing the results with previously published data for chimpanzees.     

Structures passing through the triangular space of the human upper limb

Structures passing through the triangular space of the human upper limb have been studied in 50 upper limbs from 25 cadavers. In all the specimens used in this study, a branch of the circumflex scapular artery with an accompanying vein was found to pass through this space.     

Reconstruction of a complex defect of the hand with two distinct segments of the scapula and a scapular fascial flap transferred as a single transplant.

To repair multiple defects of the metacarpal bones in combination with skin defects, a combined scapular free flap on a single vascular pedicle--the subscapular artery and the accompanying veins--can be used successfully. This flap includes two distinct bone segments of the lateral border of the scapula and a scapular fascial flap. Because of its long and mobile vascular pedicle, such a transplant can be used for one-stage reconstruction of the first and other metacarpal bones of the long fingers of the hand. The scapular fascial flap included in the transplant provides good functional and aesthetic results in combined injury of the skin of the hand.     

The vascular anatomy and dissection of the free scapular flap

This article refers to the author's personal experience with a new scapular flap based on the dissection of 35 cadavers. In total, 70 free flaps were dissected. Its main advantages are the following: constancy of vascular anatomy; adequate size, length, and diameter of its vascular pedicle (which is formed by the cutaneous scapular artery and two veins); easy surgical dissection; primary closure of the donor site; and limited scar. However, this technique is not recommended in cases in which a large loss of substance is to be replaced. The first successful surgical application of the microsurgical scapular flap was performed in Paris in October of 1979.     

Extended lower trapezius island myocutaneous flap: a fasciomyocutaneous flap based on the dorsal scapular artery

The lower trapezius island myocutaneous flap is a useful flap in head and neck reconstruction. It is thin and pliable and can reach defects in most areas of the head and neck. Its usefulness in head and neck reconstruction has often been limited or discouraged by reports of significant failure rates. In this study, the vascular anatomy and clinical use of the extended lower trapezius myocutaneous flap based solely on the dorsal scapular artery system are elucidated, and experience gained performing 20 flaps over the past 5 years by using the extended lower trapezius myocutaneous flap is reported. The vascular anatomy of the dorsal scapular artery system is reviewed in 13 fresh cadaveric dissections by using methylene blue, latex injection studies, and radiologic examination.     

Modified 3D scapular kinematic patterns for activities of daily living in painful shoulders with restricted mobility: a comparison with contralateral unaffected shoulders

There is a lack of studies of 3D scapular kinematic patterns for patients with shoulder conditions comparing affected and contralateral nonaffected shoulders during self-care activities of daily living (ADL). In this study, we compared 48 patients - 11 with glenohumeral osteoarthritis (GHOA), 20 with frozen shoulder (FS) and 17 with rotator cuff tendinopathies (RCT) - as they performed two ADL: hair combing and back washing. 3D scapular rotations and humerothoracic elevation (HTE) of the affected and contralateral nonaffected shoulders were recorded with use of a 6 degrees-of-freedom electromagnetic device. The HTE of affected and nonaffected shoulders were compared for each pathology group at rest and at the HTE used to perform the ADL: 30°, 45° and 60° of HTE for hair combing, and 30° of HT elevation for back washing. For hair combing, mean peak HTE was significantly lower for affected than nonaffected shoulders. Mean scapular lateral rotation was significantly greater at each HTE degree for GHOA and RCT groups, and mean scapular posterior tilt was significantly lower at 30° of HTE for the FS group. For back washing, mean peak HTE was lower for affected than nonaffected shoulders for the FS group only. Mean scapular medial rotation was significantly lower at 30° of HTE for the RCT group. 3D scapular kinematics appear to be specific to the shoulder pathology and to the task studied. Specific scapular kinematic patterns must be considered for appropriate therapeutic management.     

Use of circumflex scapular vessels as a recipient pedicle for autologous breast reconstruction: a report of 40 consecutive cases

The use of the circumflex scapular pedicle as a recipient vessel for breast reconstruction in a series of 40 consecutive cases in 37 patients is reported. There were 3 bilateral reconstructions and 34 unilateral reconstructions. Twenty-one cases were immediate reconstructions, and 19 cases were secondary reconstructions. The diameter of the artery varied from 1.5 mm to 3 mm and systematically matched with the diameter of the epigastric artery. The artery was a branch of the subscapular system in 82.5 percent of cases (33 of 40). In 17.5 percent of cases (7 of 40), the artery was a direct branch of the axillary artery. The length of available pedicle between the axillary vessel and the distal part where it can be divided (on its division between scapular and parascapular artery) was of 76 +/- 13 mm for the artery and 72 +/- 12 mm for the vein. The vein was unique in 77.5 percent of cases. The diameter was similar to the artery diameter when unique. There was a dual venous system in 21 of 40 cases (52.5 percent) but in 15 cases (37.5 percent), one of the two veins was dominant. In the seven cases for which the veins were dual and of equivalent diameter, the epigastric veins were also dual and allowed a second anastomosis. Clinically, the anastomosis was always possible on the artery. In one case of reconstruction after Halstedt mastectomy, no vein could be found, because all the veins had been ligated previously. One venous thrombosis (2.5 percent) and one arterial thrombosis were experienced. Both were treated by revised anastomoses and did not compromise late results. The circumflex scapular pedicle is a reliable and simple recipient site for breast reconstruction. It allows a unique site of dissection in immediate reconstruction and avoids division of the thoracodorsal pedicle. The technique is now used exclusively at this institution.     

Ontogeny of the hominoid scapula: The influence of locomotion on morphology

Primate shoulder morphology has been linked with locomotor habits, oftentimes irrespective of phylogenetic heritage. Among hominoids, juvenile African apes are known to climb more frequently than adults, while orangutans and gibbons maintain an arboreal lifestyle throughout ontogeny. This study examined if these ontogenetic locomotor differences carry a morphological signal, which should be evident in the scapulae of chimpanzees and gorillas but absent in taxa that do not display ontogenetic behavioral shifts. The scapular morphology of five hominoid primates and one catarrhine outgroup was examined throughout ontogeny to evaluate if scapular traits linked with arboreal activities are modified in response to ontogenetic behavioral shifts away from climbing. Specifically, the following questions were addressed: 1) which scapular characteristics distinguish taxa with different locomotor habits; and 2) do these traits show associated changes during development in taxa known to modify their behavioral patterns? Several traits characterized suspensory taxa from nonsuspensory forms, such as cranially oriented glenohumeral joints, obliquely oriented scapular spines, relatively narrow infraspinous fossae, and inferolaterally expanded subscapularis fossae. The relative shape of the dorsal scapular fossae changed in Pan, Gorilla, and also Macaca in line with predictions based on reported ontogenetic changes in locomotor behavior. These morphological changes were mostly distinct from those seen in Pongo, Hylobates, and Homo and imply a unique developmental pattern, possibly related to ontogenetic locomotor shifts. Accordingly, features that sorted taxa by locomotor habits and changed in concert with ontogenetic behavioral patterns should be particularly useful for reconstructing the locomotor habits of fossil forms. Am J Phys Anthropol 152:239–260, 2013. © 2013 Wiley Periodicals, Inc.     

Vasculature of the parotoid glands of four species of toads (bufonidae: bufo)

The parotoid glands of toads (Bufonidae) consist of large aggregations of granular glands located between the otic region of the skull and the scapular region. To determine the circulatory pattern of these glands, we perfused the vascular systems of Bufo alvarius, B. marinus, B. terrestris, and B. valliceps with either India ink or Microfil, a fine latex. The perfused glands were studied by gross dissection, microscopic examination, and histology. The vascular patterns of the parotoid glands were compared to the arrangement of vessels in the dorsal skin of Rana sphenocephala (Ranidae), a frog that lacks parotoid glands. The parotoid glands of the four species of toads are supplied with blood by the lateral and dorsal cutaneous arteries and are drained by one or more branches of the internal jugular vein. The dorsal cutaneous artery supplies most of the blood to the parotoid glands in B. terrestris and B. valliceps. In B. alvarius and B. marinus, both the lateral and dorsal cutaneous arteries serve major roles in the blood supply of the glands. These patterns of blood flow have not been described previously for parotoid glands and conflict with earlier accounts for B. alvarius and B. marinus. The arteries and veins associated with the parotoid glands of toads are present in R. sphenocephala, but are arranged differently. In R. sphenocephala, the lateral cutaneous artery supplies the dorsal and lateral skin posterior to the shoulder region, whereas the dorsal cutaneous artery supplies the skin of the shoulder region. In toads, both the lateral and dorsal cutaneous arteries supply the skin of the shoulder region and ramify into subcutaneous capillaries that surround the secretory units of the parotoid glands. Extensive vasculature presumably is important for delivering cholesterol and other precursor molecules to the parotoid glands, where those compounds are converted into toxins.     

Vascularization of the myocutaneous latissimus dorsi flap. Injection study on the thoracodorsal artery

This study reports on investigations of the thoracodorsal artery by injection studies. This artery has a long proximal extramuscular course before it enters the muscle. A consistent neurovascular hilum was found at a considerably constant location on the inferior muscle surface, 2-3 cm medial to its lateral edge and about 5 cm distal to the inferior scapular border. A constant branching pattern of the thoracodorsal artery into a lateral and a medial vessel stem was found. A high number of muscle-perforating arteries from a dense network in the cutaneous and subcutaneous layer. The thoracodorsal artery supplies the whole cutaneous area adjacent to the latissimus dorsi muscle plus a streak of about 2 cm at the medial and distal muscle borders. The presented anatomical landmarks are useful for locating the neurovascular hilum, and the intramuscular course of the thoracodorsal artery for exploration of the vessel by Doppler sonography or dissection. The length of the pedicle and the relatively big vessel gauge are good anatomical markers for the free transfer of a latissimus dorsi flap.     

EMG of serratus anterior and trapezius in the chimpanzee: scapular rotators revisited.

The importance of arm-raising has been a major consideration in the functional interpretation of differences in shoulder morphology among species of nonhuman primates. Among the characters that have been associated with enhancement of the arm-raising mechanism in hominoid primates are the relative enlargement of cranial trapezius and caudal serratus anterior, as the main scapular rotators, as well as changes in scapular morphology associated with their improved leverage for scapular rotation. Yet in an EMG study of cranial trapezius and caudal serratus anterior function in the great apes, Tuttle and Basmajian (Yrbk. Phys. Anthropol. 20:491-497, 1977) found these muscles to be essentially inactive during arm-raising. Although Tuttle and Basmajian suggest that the cranial orientation of the glenoid fossa in apes has reduced the demand for scapular rotation during arm-raising, subsequent EMG studies on other primate species suggest that these muscles do play a significant role in arm motion during active locomotion. This paper presents a reexamination of muscle recruitment patterns for trapezius and caudal serratus anterior in the chimpanzee. All but the lowest parts of caudal serratus anterior were found to be highly active during arm-raising motions, justifying earlier morphological interpretations of differences in caudal serratus anterior development. The lowest digitations of this muscle, while inactive during arm-raising, displayed significant activity during suspensory postures and locomotion, presumably to control the tendency of the scapula to shift cranially relative to the rib cage. Cranial trapezius did not appear to be involved in arm-raising; instead, its recruitment was closely tied to head position.     

Arterial T and Y grafts.

Presented is the use of an autogenous arterial T graft for the salvage of a thrombosed arterial end-to-side anastomosis. The T-graft concept also offers the possibility of replacing a segment of artery in patients with arterial vessel wall defects, stenosis, obliteration, or disease during free latissimus dorsi or scapular flap transfer. The arterial T graft is harvested from the axilla and consists of segments of the subscapular, circumflex scapular, and thoracodorsal arteries. The large diameter of these vessels offers a good match with the arteries of the lower leg and forearm. The arterial Y graft consists of the same arteries and is used as an interpositional graft to revascularize two distal vessels from one proximal vessel.     

Scapulothoracic kinematic pattern in the shoulder pain and scapular dyskinesis: A principal component analysis approach

The relationship between shoulder pain and scapular dyskinesis (SDK) is unclear. Differences between groups with and without SDK have been demonstrated, focusing on the amount of scapular motion at specific degrees of humeral elevation. However, this approach does not consider the temporal information and shape of the scapular motion temporal series. Principal Component Analysis (PCA) may clarify this variability and advance current understanding of ‘abnormal’ movement patterns. This study aimed to evaluate the scapular kinematics in patients with shoulder pain and in asymptomatic participants with and without SDK using PCA. Data were collected in 98 participants separated in four groups: Pain + SDK (n = 24), Pain (n = 25), No Pain + SDK (n = 24), and No Pain (n = 25). Scapulothoracic kinematic data were measured with an electromagnetic tracking device during arm elevation and lowering phases. PCA and analysis of variance were used to compare the groups. The No Pain + SDK group had a progressive increasing in anterior tilt over the elevation phase compared to the Pain (effect size = 0.79) and No Pain (effect size = 0.80) groups. During the arm-lowering, the Pain + SDK group had a progressive increasing in anterior tilt over this phase in comparison to the No Pain + SDK group (effect size = 0.68). Therefore, PCA demonstrated differences in the scapular anterior tilt related to SDK and shoulder pain. The presence of SDK revealed a scapular pattern with progressive increasing in anterior tilt over the elevation phase. However, during the arm-lowering phase, asymptomatic participants with SDK changed their motion pattern, unlike the symptomatic group, reinforcing the suggested association between scapular modifications and shoulder symptoms.     

Musculoskeletal scapular correlates of plantigrade and acrobatic positional activities in Papio cynocephalus anubis and Macaca fascicularis

This study investigates several musculoskeletal scapular correlates of quadrupedal behavior in predominantly plantigrade, Papio cynocephalus anubis and acrobatic, less plantigrade, Macaca fascicularis. Positional behaviors differ in these two primates reflecting the amount of time spent emphasizing one or the other of these captive behavioral regimes. Stresses associated with particular patterns of behavior result in different scapular morphologies. Papio exhibits a significantly broader scapula with a more dorsoventrally curved blade accompanying an enlarged teres major muscle. The supraspinous fossa is wider in Papio, while the infraspinous/teres major attachment is wider in Macaca. Angular measurements reflect the breadth dimension of the various fossae. These results utilize two species of primates to extend a methodology developed in previous studies and to suggest that a predictable interdependence occurs between scapular dimensions and certain behavioral activities.     

Tracking the scapula using the scapula locator with and without feedback from pressure-sensors: A comparative study

BackgroundThe scapula locator method has associated intra-observer and inter-observer errors caused by the dependency on the observer to locate the scapular landmarks. The potential effect of the pressures applied by the observer on the measured scapular kinematics when this method is used has also been overlooked so far. The aim of this study was to investigate the effect of using feedback on the pressures applied on the scapula using the locator on the intra-observer and inter-observer reliabilities of the method as well as on the kinematics obtained using this method.MethodsThree observers tracked the scapular motion of the dominant shoulder of each subject using the locator with no reference to pressure-feedback for three trials of bilateral elevation in the scapular plane and using the locator with pressure-feedback for three other trials. Variations between the measurements obtained were used to calculate the intra-observer errors and variations between the measurements obtained by the three observers for the same subject were used to calculate inter-observer errors. Repeated-measures ANOVA tests were used to look at differences between the two methods in terms of intra-observer and inter-observer errors and scapular kinematics.FindingsUsing pressure-feedback reduced the intra-observer errors but had no effect on the inter-observer errors. Different scapular kinematics was measured using the two methods.InterpretationsPressure-feedback improves the reliability of the scapula locator method. Differences in the scapular kinematics suggest that unregulated pressures have an effect on the physiological scapular motion.