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Background: The scapular free flap has increasingly gained popularity as an alternative to the fibular free flap in osseous head and neck reconstruction. The authors evaluated its use in maxillomandibular reconstruction and examined surgical and patient outcomes.

Methods: Osseous head and neck defects reconstructed with an angular artery-based scapular flap or fibular flap from 2016 to 2022 at 2 Swedish university hospitals were evaluated for their intraoperative execution (osseous and soft-tissue combinations) and postoperative outcomes. Facial quality of life (QoL) was assessed using the FACE-Q Head and Neck Cancer module. Donor-site morbidity was assessed using the Disabilities of the Arm, Hand, and Shoulder (DASH) and Self-Evaluated Foot and Ankle Score (SEFAS) questionnaires for scapular- and fibular-reconstructed cases, respectively.

Results: A total of 120 patients were recruited, 86 with mandibular reconstructions (26 scapulas, 60 fibulas) and 34 with maxillary reconstructions (32 scapulas, 2 fibulas). The concave scapula facilitated fewer osteotomies for curved reconstructions, particularly for lateral mandibular defects (P = 0.039). Intraoral lining was primarily achieved with muscle accompanying the scapula and skin accompanying the fibula. Using the latissimus dorsi muscle instead of only teres major decreased fistulas, plate/bone exposure, and nonunions (P = 0.039) in scapular reconstructions. Both flaps demonstrated comparable facial QoL, but the scapula presented superior donor-site outcomes (P = 0.001). Donor limb outcomes were unaffected by harvesting the latissimus dorsi with the scapula (P = 0.64) or by resuturing the detached muscles to the remaining scapula (P = 0.35).

Conclusion: The scapular free flap can be advantageous in osseous head and neck reconstructions, enabling nonosteotomized and chimeric reconstructions without compromising surgical outcomes or QoL.