PERMUTATIONS OF COMBINED FREE FLAPS USING THE SUBSCAPULAR SYSTEM

Over five dozen permutations of free-flap combinations based on the su bscapular system are possible. Although this has been the most common single flap donor site in the author's overall experience (38.5 percen t), the use of a combined flap has been required in only seven cases, representing only 10 percent of ail free flaps selected from this regi on, indeed implying that their indications are limited. When muscle fl aps per se were specifically desired, the latissimus dorsi and serratu s anterior muscles could be simultaneously transferred, while requirin g only a single microanastomosis to their common subscapular pedicle. Additional advantages of using this most common form, or with other co mbined flaps, are not only augmentation of available surface area for wound coverage, but also disparate sites can be closed individually; m icroanastomoses are easily protected by the second flap; circumferenti al gliding surfaces are provided to minimize tendon adhesions; and dyn amic restoration of multiple paralyzed muscles is achieved, while viol ating but a single donor site.