Free composite myo-osseous flap with serratus anterior and rib: Indications in head and neck reconstruction

Background. Although the microvascular transfer of the serratus/rib myo- osseous composite flap has been previously described, the indications for its use in head and neck reconstruction have not been fully explored. Slender and easily contoured, rib bone offers reconstructive advantages over other bone sources under certain circumstances. The serratus/rib myoosseous flap can provide vascularized muscle, bone, and cartilage; in combination with the latissimus dorsi muscle, the serratus/rib flap provides additional soft- tissue bulk on a single thoracodorsal vascular pedicle unrestricted by orientation requirements of the bone. Many orientations of bone and soft tissue are possible. Methods. We describe, through three illustrative cases, the indications for this flap, which might include bony, cartilaginous, and soft-tissue requirements in the retromolar trigone region, large calvarial defects, and large composite full-thickness cheek and mandibular defects. Conclusions. The serratus/rib composite myo-osseous flap reliably provides vascularized bone of relatively delicate composition which offers advantages in certain reconstructive circumstances. In addition, when combined with latissimus dorsi muscle on a single vascular pedicle, it supplies additional soft-tissue bulk which can be positioned without being constrained by the bone placement. Finally, this is a useful 'backup' supply of vascularized bone when other sources cannot be used due to, for example, inability to use fibula in the face of severe peripheral vascular disease and inability to use lilac crest if this has been previously used as a donor site for nonvascularized free grafts (as in secondary reconstructions).