Permutations of combined free flaps using the subscapular system.

Over five dozen permutations of free-flap combinations based on the subscapular system are possible. Although this has been the most common single flap donor site in the author's overall experience (38.5 percent), the use of a combined flap has been required in only seven cases, representing only 10 percent of all free flaps selected from this region, indeed implying that their indications are limited. When muscle flaps per se were specifically desired, the latissimus dorsi and serratus anterior muscles could be simultaneously transferred, while requiring only a single microanastomosis to their common subscapular pedicle. Additional advantages of using this most common form, or with other combined flaps, are not only augmentation of available surface area for wound coverage, but also disparate sites can be closed individually: microanastomoses are easily protected by the second flap; circumferential gliding surfaces are provided to minimize tendon adhesions; and dynamic restoration of multiple paralyzed muscles is achieved, while violating but a single donor site.