Outcomes of Scapula vs. Fibula Free Flaps in Head and Neck Reconstruction

Plastic and Reconstructive Surgery, May 2025

Key Takeaways:

• The scapular flap offers a reliable alternative to the fibular flap in mandibular/maxillary reconstruction with comparable outcomes.

  • Scapular flaps required fewer osteotomies and resulted in better donor-site outcomes.

• The addition of a muscle flap reduced complications.

Objective

To compare surgical outcomes, donor-site morbidity, and quality of life between angular artery-based scapular flaps and fibular flaps for head and neck osseous reconstruction.

Methods

Retrospective analysis (n=120, 2016–2022) at two Swedish university hospitals. Surgical outcomes, osteotomies, soft tissue use, donor-site morbidity (DASH - Hand/Shoulder evaluation, SEFAS - Foot/Ankle evaluation), and patient QoL (FACE-Q) were assessed.

Results

• 58 scapular flaps

  • 26 used for mandible, 32 used for maxilla

• 62 fibula flaps

  • 60 used for mandible, 2 used for maxilla

• Scapular flaps required significantly fewer osteotomies for lateral mandibular defects.

• LD muscle use in scapular flaps significantly reduced complications like fistulas and nonunion (P=0.039).

• Donor-site morbidity was lower in the scapula group (P=0.001).

• No significant difference in QoL scores.

Complication	Scapula (n=58)	Fibula (n=62)	P
Flap failure	1	4	0.36
Soft tissue partial necrosis	4	3	0.71
with exposed bone/plate	4	0	0.05
Fistula	6	4	0.51
Nonunion	1	1	0.5
ORN	4	1	0.19
Donor site complication	1	9	0.01
Medical/Respiratory complication	6	1	0.04
Facial appearance (FACE-Q)	68 +/- 23	60 +/- 21	0.767
Eating/Drinking (FACE-Q)	54 +/- 22	60 +/- 20	0.113

Conclusion

Scapular flaps are effective alternatives to fibular flaps, with comparable function and superior donor-site morbidity. The chimeric nature allows for the easy addition of a muscle flap, which can help mitigate surgical complications

Strengths and Limitations

• Strengths: Multicenter design, matched defect types, validated PROMs.

• Limitations: Retrospective, shorter follow-up in scapula group.

Future Directions

Further prospective studies evaluating long-term functional and aesthetic outcomes are warranted.

Clinical Relevance

Scapular flaps are a viable primary option for selected mandibular and maxillary reconstructions.