Dominic Stone
The parascapular flap is a surgical technique that provides a large area of pliable and thin tissue for forearm coverage. It is based on the descending branch of the circumflex scapular artery, which nourishes the parascapular flap as it travels through the triangular space. This procedure is often used for facial reconstruction, particularly in lip reconstruction, where it is important to maintain oral competence and preserve the gingival-labial sulcus. The parascapular flap can also be used to cover large defect areas and can be combined with other flaps, such as the scapular flap, for additional coverage. The scapula, a large flat bone that serves as a critical site of muscle attachment, is stabilized and moved through dynamic muscle function, with the periscapular muscles playing a key role in its movement and stabilization.
| Characteristics | Values |
|---|---|
| Definition | The parascapular flap is a large, hairless skin paddle with a well-hidden scar. |
| Blood supply | Descending branch of the circumflex scapular artery |
| Use | Forearm coverage, dorsal hand coverage, hand reconstruction, releasing contractures around the axillary region, and coverage of upper extremity defects |
| Surgery position | Patient is placed in the lateral decubitus position on a beanbag. Alternatively, the prone position can be used if a posterior wound must be resurfaced. |
| Muscles involved | Upper and lower trapezius, levator scapulae, rhomboid major, serratus anterior, infraspinatus, teres major, teres minor |
| Innervation | Motor innervation is through cranial nerve 11, the spinal accessory nerve. The dorsal scapular nerve (C5) provides innervation for the rhomboid minor and major. |
| Related conditions | Rotator cuff tears, shoulder impingement, shoulder pain, shoulder rehabilitation, shoulder instability, glenohumeral instability |
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What You'll Learn
The parascapular flap
During the procedure, the patient is placed in the lateral decubitus position on a beanbag. The prone position can be used if a posterior wound must be resurfaced, but this is more difficult as arm positioning cannot be adjusted as easily. The ipsilateral arm is left free and included in the operative scrub. A stockinet around the arm and a well-padded pillow help to rest the arm during surgery. The flap is outlined so that the apex lies over the triangular space, with the incision marked using the scapula as a guide. The superior flap includes the triangular space within its border so that the pedicle vessel is captured. The flap is elevated from inferior to superior, in the areolar fascial layer just above the thick muscular fascia of the back. The infraspinous fascia overlying the infraspinatus muscle and the teres major fascia overlying the teres major are particularly thick. If the flap is elevated deep to this muscular fascia, the dissection can become confusing and difficult around the pedicle.
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Parascapular muscle activities in patients with rotator cuff tears
The parascapular muscles are those that are attached to the scapula, a large, flat bone that forms a critical site of muscle attachment. The scapula shows signs of ossification by the 5th week of embryonic development.
Rotator cuff tears are a common shoulder disease among middle-aged and elderly people. The prevalence of tears has been reported to be at least 10% in the 50s and increases to over 30% in the 80s. Most patients with rotator cuff tears suffer from severe shoulder pain, particularly during arm elevation. However, some rotator cuff tears are asymptomatic, indicating that the existence of a rotator cuff tear is not necessarily a cause of pain.
A study was conducted to compare the differences in kinematics and muscle activities of scapular rotation among patients with symptomatic and asymptomatic tears and healthy individuals. Twenty-three patients with rotator cuff tears and 9 healthy individuals participated in the study. The patients were divided into symptomatic (13 patients) and asymptomatic (10 patients) groups based on a visual analog scale (VAS) of 0-100 mm, with a VAS score of ≥20 mm for the symptomatic group and a score of <20 mm for the asymptomatic group. The study found that scapular upward rotation was significantly less in the symptomatic group (9.4° ± 5.6°) compared to the asymptomatic group (15.7° ± 6.0°). The activity of the levator scapulae was significantly higher in the symptomatic group compared to the asymptomatic and healthy groups at 90° of arm elevation. Additionally, the activity of the upper trapezius was significantly higher in the symptomatic group compared to the healthy group at 120° of arm elevation.
These results suggest that patients with symptomatic rotator cuff tears exhibit less scapular upward rotation and higher activity of the levator scapulae at 90° of arm elevation compared to patients with asymptomatic tears and healthy individuals. The study also hypothesized that symptomatic patients would demonstrate less scapular upward rotation and higher activities of the scapular upward and downward rotators compared to asymptomatic patients and healthy individuals. However, the differences in kinematics and muscle activities between symptomatic and asymptomatic tears are still not entirely clear and require further investigation.
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The role of the parascapular muscles in scapular retraction, elevation and posterior tilting
The parascapular muscles play a crucial role in scapular retraction, elevation, and posterior tilting, contributing to the complex movement patterns of the scapula. The scapula, or shoulder blade, is a large, flat bone that provides a critical site for muscle attachment. Its mobility allows for a wide range of movements, including protraction, retraction, elevation, depression, anterior/posterior tilt, and internal/external rotation.
The trapezius muscle, which originates from the vertebrae and attaches to the lateral clavicle, acromion, and spine of the scapula, is responsible for upward rotation and elevation in its upper fibres, retraction in its middle fibres, and upward rotation and depression in its lower fibres. The lower trapezius fibres may also contribute to the posterior tilt and external rotation of the scapula during arm elevation. The trapezius muscle is innervated by the spinal accessory nerve, enabling these movements.
The rhomboid muscles, divided into major and minor portions, also play a significant role in scapular retraction. The rhomboid minor originates from the spinous processes of the cervical and thoracic vertebrae, inserting at the medial border of the scapula. The rhomboid major, on the other hand, originates from the thoracic vertebrae and inserts along the posterior aspect of the medial border of the scapula. This arrangement allows the rhomboid muscles to contribute to scapular stability and retraction, or the backward rotation of the scapula towards the vertebral column. The dorsal scapular nerve provides innervation to these muscles.
The serratus anterior, composed of three divisions originating from the ribs, is crucial for stabilizing the scapula during elevation and pulling it forward and around the thoracic cage. It is involved in protraction, or the forward movement of the scapula, which is essential for activities such as pushing or punching. Three-dimensional studies have revealed that the serratus anterior contributes to scapular upward rotation, posterior tilt, and external rotation during arm elevation.
Overall, the parascapular muscles, including the trapezius, rhomboids, and serratus anterior, work together to enable scapular retraction, elevation, and posterior tilting. Their coordinated movements provide stability, mobility, and strength to the scapula, facilitating various functional movements of the shoulder and arm.
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The parascapular branch of the circumflex scapular artery
The circumflex scapular artery is a branch of the subscapular artery, which in turn originates from the axillary artery. The circumflex scapular artery is the largest terminal branch of the subscapular artery. It courses through the posterior aspect of the shoulder, within the infraspinous fossa of the scapula.
The circumflex scapular artery supplies several muscles of the shoulder and arm, such as the deltoid, teres minor, and triceps brachii. It also supplies blood to the glenohumeral joint and two small cutaneous areas partially overlying the scapula. The circumflex scapular artery gives off several muscular, cutaneous, and articular branches.
The circumflex scapular artery has two main branches, the horizontal and vertical (descending) branches, which supply the scapular and parascapular flaps, respectively. The parascapular branch is also referred to as the vertical branch. The parascapular flap is supplied by a descending branch of the circumflex scapular artery. This branch forms the basis of the parascapular flap.
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Parascapular muscles and shoulder pain
The scapula, or shoulder blade, is a triangular bone in the upper back that forms the socket of the shoulder joint. It is surrounded and supported by a complex system of muscles that work together to move the arm. These muscles are referred to as parascapular muscles.
Parascapular muscles include the upper and lower trapezius, rhomboid minor and major, serratus anterior, and levator scapulae. The trapezius muscles are often associated separately, with the upper trapezius involved in scapular elevation and the lower trapezius involved in scapular retraction and posterior tilting. The rhomboids and serratus anterior are also involved in scapular retraction, with the rhomboids providing scapular elevation and depression. The levator scapulae is involved in scapular upward rotation.
Injury or conditions affecting the parascapular muscles can lead to scapular dyskinesis, which is characterised by weakness or tightness in these muscles, altering the position and motion of the scapula. This can result in difficulty moving the arm, particularly during overhead activities. Shoulder pain is a common symptom of scapular dyskinesis, and it can be caused by various conditions such as rotator cuff tears, muscle weakness, or tightness.
To diagnose the cause of shoulder pain, doctors may perform a physical examination, including visual observation, manual muscle testing, and corrective maneuvers such as the scapular assistance test. Treatment options typically involve non-surgical methods such as nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy exercises aimed at strengthening and stretching the muscles around the scapula to improve its position and motion. Surgery may be considered if patients continue to experience significant pain and loss of motion even after completing a rehab program.
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Frequently asked questions
The parascapular muscles are those that function in scapular retraction, elevation, and posterior tilting. These include the upper and lower trapezius muscles, the rhomboids, and the serratus anterior.
The parascapular muscles are important for stabilising the scapula and allowing it to move through a range of motions, such as upward rotation, posterior tilting, and external rotation.
The scapular and parascapular muscles have similar functions, but the parascapular muscles are specifically associated with the scapula, which is a large flat bone that serves as a critical site of muscle attachment.
The parascapular muscles are important for shoulder function and stability. Altered scapular motion and muscle activity have been linked to the development of rotator cuff tears and shoulder impingement.
A parascapular flap is a surgical technique that uses the parascapular muscle and blood supply to cover large defect areas. It is often used in plastic surgery and can be combined with other flaps, such as the latissimus dorsi or serratus muscle, for additional coverage.
