2026 Poster Presentations
P232: THE SERRATUS ANTERIOR MICROVASCULAR FREE FLAP FOR SKULL BASE AND CALVARIAL RECONSTRUCTION
Mark D DeLacure, MD; The Cleveland Clinic
The serratus anterior microvascular free flap is an underutilized reconstructive option for complex defects of the scalp, calvarium, orbit, and skull base regions. It offers a fast, reliable, easily dissected, long, pedicle anatomy of satisfactory caliber, which can be harvested simultaneously in the supine position, and is thus amenable to the reconstruction of many defects of the region, in both acute and late contexts.
This flap has been used by the author in over a dozen cases over several decades in inflammatory/infectious (refractory mucor sinoorbital infection, infected, nonviable bone flaps, exposed implant hardware, alloplastic cranioplasty (for seizure grid placement, intracranial vascular decompression and evacuation, tumor excision), and benign (NF, Meningioma) and malignant (intracranial and cutaneous carcinomas of scalp) neoplastic contexts.
A commonly held, but inaccurate, misperception is that the scapular winging disability will invariably result from use of this donor site, though by harvesting only the lower 3-4 slips of the muscle, functional disability is avoided. This will be demonstrated in postoperative vdeos. The thoracic donor site also allows harvesting an STSG from the margins of the back incision, by advancing and directly closing the site after excising the harvested graft site, obviating the need for a sceond lower extremity donor site. Dead space reductive closing techniques have resulted in no donor site hematomas or fluid collections. Use of the serratus flap does not preclude use of the larger latissimus flap in the future. Alternatively, pedicle lengthening may be accomplished by including the latissiumus pedicle, avoiding in some cases need for interposition vein grafts. In aggregate, misperceptions have resulted in the historical and continued underapplication of this flap option.
The skin grafted muscle flap atrophies rapidly over the first 2-3 months and assumes a neoanatomical thickness and appearance that has never required revision in over a dozen cases. The construct is particularly useful in orbital reconstruction. As such, this free flap should be among first line choices for microvascular reoconstruction of scalp, calvarial (with titanium mesh construct) skull base, and orbital defects of various origin.