{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,2]],"date-time":"2026-10-02T15:24:49Z","timestamp":1790954689054,"version":"4.1.0"},"reference-count":47,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2025,5,8]],"date-time":"2025-05-08T00:00:00Z","timestamp":1746662400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: This systematic review and meta-analysis evaluates the surgical, functional, and aesthetic outcomes of scapular free flaps in maxillary reconstruction. The primary objective is to assess early surgical complications, fistula formation, donor site morbidity, dental restoration, normal dietary intake, aesthetic compromise, and eye-related issues. Secondary objectives include total free flap necrosis, the need for revision procedures, and functional performance of the upper limb. Methods: A systematic review was conducted following the PRISMA guidelines. Eligible studies were identified by searching PubMed\/MEDLINE, Cochrane Library, Scopus, and Google Scholar, with the last search conducted on 10th February 2025. Inclusion criteria were studies reporting on patients undergoing maxillary reconstruction with scapular free flaps, and which provided data on at least one of the primary or secondary outcomes. A single-arm meta-analysis was performed to assess the outcomes of scapular free flap reconstruction. The risk of bias was assessed using the Newcastle\u2013Ottawa Quality Assessment Scale, with two independent reviewers performing the assessment. Results: From an initial search of 310 articles, 6 studies were included in the qualitative and quantitative synthesis, encompassing 231 patients with a mean age of 52.9 years (95% CI 44.9\u201360.8). Early general surgical complications occurred in 24% (95% CI 13\u201340) of patients, while 12% (95% CI 4\u201331) experienced fistula formation. Donor site morbidity was reported in 10% (95% CI 6\u201317) of cases, with a mean DASH score of 10.49, indicating low upper limb impairment. Dental rehabilitation was achieved in 56% (95% CI 42\u201370), and 52% (95% CI 31\u201372) of patients resumed a normal diet. Aesthetic compromise was observed in 27% (95% CI 9\u201358), and 36% (95% CI 28\u201344) reported eye-related issues. Conclusions: Scapular free flap is a reliable option for maxillary reconstruction with favourable outcomes, particularly in complex composite defects requiring both bone and soft tissue reconstruction. However, the evidence is limited by risk of bias, significant heterogeneity, and imprecision due to the small number of studies and participants. Larger, more robust trials are needed to confirm these findings.<\/jats:p>","DOI":"10.3390\/jcm14103278","type":"journal-article","created":{"date-parts":[[2025,5,8]],"date-time":"2025-05-08T07:41:47Z","timestamp":1746690107000},"page":"3278","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Advancing Maxillary Reconstruction: A Systematic Review and Meta-Analysis of the Evolving Role of the Scapular Free Flap"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3947-8733","authenticated-orcid":false,"given":"Giovanni","family":"Salzano","sequence":"first","affiliation":[{"name":"Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Via Pansini 5, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-8717-7121","authenticated-orcid":false,"given":"Veronica","family":"Scocca","sequence":"additional","affiliation":[{"name":"Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Via Pansini 5, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8421-0328","authenticated-orcid":false,"given":"Stefania","family":"Troise","sequence":"additional","affiliation":[{"name":"Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Via Pansini 5, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7905-0531","authenticated-orcid":false,"given":"Vincenzo","family":"Abbate","sequence":"additional","affiliation":[{"name":"Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Via Pansini 5, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3326-4825","authenticated-orcid":false,"given":"Paola","family":"Bonavolont\u00e0","sequence":"additional","affiliation":[{"name":"Maxillofacial Surgery Unit, Department of Clinical and Surgical Medicine, University Federico II, Via Pansini 5, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7789-145X","authenticated-orcid":false,"given":"Luigi Angelo","family":"Vaira","sequence":"additional","affiliation":[{"name":"Maxillofacial Surgery Operative Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alfonso","family":"Scarpa","sequence":"additional","affiliation":[{"name":"Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Salerno, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0845-0845","authenticated-orcid":false,"given":"Jerome R.","family":"Lechien","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology and Head and Neck Surgery, Division of Laryngology and Broncho-Esophagology, UMONS Research Institute for Health Sciences and Technology, EpiCURA Hospital, University of Mons, 7301 Mons, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gianluca","family":"De Fazio","sequence":"additional","affiliation":[{"name":"Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Via Pansini 5, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6463-5118","authenticated-orcid":false,"given":"Emanuele","family":"Carraturo","sequence":"additional","affiliation":[{"name":"Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Via Pansini 5, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6479-6130","authenticated-orcid":false,"given":"Giovanni","family":"Dell\u2019Aversana Orabona","sequence":"additional","affiliation":[{"name":"Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University Federico II, Via Pansini 5, 80131 Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,5,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1001","DOI":"10.1016\/S1470-2045(10)70113-3","article-title":"Reconstruction of the maxilla and midface: Introducing a new classification","volume":"11","author":"Brown","year":"2010","journal-title":"Lancet Oncol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1097\/MOO.0b013e328304b426","article-title":"Reconstruction of the midface and maxilla","volume":"16","author":"Dalgorf","year":"2008","journal-title":"Curr. Opin. Otolaryngol. Head Neck Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1016\/S1470-2045(06)70616-7","article-title":"Developments in reconstruction of midface and maxilla","volume":"7","author":"Futran","year":"2006","journal-title":"Lancet Oncol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1016\/j.coms.2013.01.004","article-title":"Maxillary reconstruction","volume":"25","author":"Lenox","year":"2013","journal-title":"Oral. Maxillofac. Surg. Clin. North Am."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"398","DOI":"10.1016\/j.joms.2012.04.035","article-title":"Reconstruction of orbitomaxillary defects","volume":"71","author":"Yetzer","year":"2013","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1001\/archfaci.2010.18","article-title":"Reconstruction of the mandible and the maxilla: The evolution of surgical technique","volume":"12","author":"Genden","year":"2010","journal-title":"Arch. Facial Plast. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1016\/j.tripleo.2010.03.042","article-title":"Maxillary reconstruction using microvascular free flaps","volume":"111","author":"Loeffelbein","year":"2011","journal-title":"Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endodontology"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2706","DOI":"10.1016\/j.joms.2010.01.008","article-title":"Iliac crest free flap for maxillary reconstruction","volume":"68","author":"Bianchi","year":"2010","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1055\/s-0030-1263066","article-title":"Perforator flaps in head and neck reconstruction","volume":"24","author":"Chana","year":"2010","journal-title":"Semin. Plast. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1177\/1457496918772365","article-title":"Clinical comparison of scapular, fibular, and iliac crest osseal free flaps in maxillofacial reconstructions","volume":"108","author":"Wilkman","year":"2019","journal-title":"Scand. J. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1097\/00005537-199802000-00010","article-title":"An algorithm for maxillectomy defect reconstruction","volume":"108","author":"Davison","year":"1998","journal-title":"Laryngoscope"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Clark, J.R., Vesely, M., and Gilbert, R. Scapular angle osteomyogenous flap in postmaxillectomy reconstruction: Defect, reconstruction, shoulder function, and harvest technique. Head Neck, 2007.","DOI":"10.1002\/hed.20649"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1130","DOI":"10.1001\/archoto.2011.187","article-title":"Maxillary reconstruction with the scapular angle osteomyogenous free flap","volume":"137","author":"Miles","year":"2011","journal-title":"Arch. Otolaryngol. Head Neck Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1159\/000016663","article-title":"The anatomy of the angular branch of the thoracodorsal artery","volume":"164","author":"Seitz","year":"1999","journal-title":"Cells Tissues Organs"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"104468","DOI":"10.1016\/j.oraloncology.2019.104468","article-title":"Reconstruction of maxillectomy and midfacial defects using latissimus dorsi-scapular free flaps in a comprehensive cancer center","volume":"99","author":"Veyrat","year":"2019","journal-title":"Oral Oncol."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Franchi, A., Perozzo, F.A.G., Tiengo, C., Walber, J., Parisato, A., Jandali, A.R., and Jung, F. (2025). SCIP\/SIEA and PAP: The new workhorse flaps in soft tissue reconstruction for all body regions. J. Clin. Med., 14.","DOI":"10.3390\/jcm14030921"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"602","DOI":"10.1002\/(SICI)1097-0274(199606)29:6<602::AID-AJIM4>3.0.CO;2-L","article-title":"The Upper Extremity Collaborative Group (UECG). Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand)","volume":"29","author":"Hudak","year":"1996","journal-title":"Am. J. Ind. Med."},{"key":"ref_19","unstructured":"Wells, G.A., Shea, B., O\u2019Connell, D., Peterson, J., Welch, V., Losos, M., and Tugwell, P. (2025, May 03). The Newcastle\u2013Ottawa Scale (NOS) for Assessing the Quality of Non-Randomized Studies in Meta-Analysis. Available online: https:\/\/www.ohri.ca\/programs\/clinical_epidemiology\/oxford.asp."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1311","DOI":"10.1016\/j.ijom.2009.07.005","article-title":"Maxillary reconstruction using a bipedicled osteocutaneous scapula flap","volume":"38","author":"Yoshioka","year":"2009","journal-title":"Int. J. Oral Maxillofac. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1002\/hed.2880120502","article-title":"Reconstruction of complex maxillectomy defects with the scapular-free flap","volume":"12","author":"Granick","year":"1990","journal-title":"Head Neck"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1016\/j.ijom.2023.10.207","article-title":"Maxillary reconstruction with a scapula tip free flap and immediate implantation using virtual surgical planning and computer-aided design\/computer-aided manufacturing technology","volume":"52","author":"Maier","year":"2024","journal-title":"Int. J. Oral Maxillofac. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1042","DOI":"10.1016\/j.ijom.2011.07.061","article-title":"Scapular free flap for maxillary reconstruction","volume":"40","author":"Leporati","year":"2011","journal-title":"Int. J. Oral Maxillofac. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1002\/micr.30700","article-title":"Maxillary reconstruction with scapular tip chimeric free flap","volume":"41","author":"Ferri","year":"2021","journal-title":"Microsurgery"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1016\/j.bjps.2024.05.042","article-title":"Maxillary reconstruction with horizontally oriented scapular tip free flap: Outcomes in orbital support and palate closure","volume":"95","author":"Pereira","year":"2024","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"21","DOI":"10.2340\/jphs.v60.42699","article-title":"An evaluation of the scapular osseous free flap in maxillary reconstruction using the FACE-Q Head and Neck Cancer Module for patient-reported outcome measures","volume":"60","author":"Becker","year":"2025","journal-title":"J. Plast. Surg. Hand Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"352","DOI":"10.1067\/mpr.2001.119524","article-title":"Prosthodontic guidelines for surgical reconstruction of the maxilla: A classification system of defects","volume":"86","author":"Okay","year":"2001","journal-title":"J. Prosthet. Dent."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1097\/SLA.0b013e3181b13ca2","article-title":"The Clavien-Dindo classification of surgical complications: Five-year experience","volume":"250","author":"Clavien","year":"2009","journal-title":"Ann Surg"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1124","DOI":"10.1016\/j.jcms.2017.05.006","article-title":"Outcomes of multimodal management for sinonasal squamous cell carcinoma","volume":"45","author":"Blanchard","year":"2017","journal-title":"J. Craniomaxillofac. Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1288\/00005537-198604000-00018","article-title":"Hard palate reconstruction in maxillectomy","volume":"96","author":"Gillespie","year":"1986","journal-title":"Laryngoscope"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1053\/joms.2003.50044","article-title":"Health-related quality of life after maxillectomy: A comparison between prosthetic obturation and free flap","volume":"61","author":"Rogers","year":"2003","journal-title":"Br. J. Oral. Maxillofac. Surg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"808","DOI":"10.1002\/hed.20026","article-title":"Reconstruction of the hard palate using the radial forearm free flap: Indications and outcomes","volume":"26","author":"Genden","year":"2004","journal-title":"Head Neck"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1097\/00000637-198003000-00002","article-title":"Tongue flaps and the closing of large fistulas of the hard palate","volume":"4","author":"Carreirao","year":"1980","journal-title":"Ann. Plast. Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1097\/00000637-198302000-00014","article-title":"Palatal defect reconstruction with hinged nasal septum flap","volume":"10","author":"Borges","year":"1983","journal-title":"Ann. Plast. Surg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"147","DOI":"10.3109\/00016487609120874","article-title":"A new method for strengthening palatal closure defects of the hard palate","volume":"82","author":"Biorklund","year":"1976","journal-title":"Acta Otolaryngol."},{"key":"ref_36","first-page":"477","article-title":"Immediate reconstruction of the hard palate following maxillectomy for carcinoma","volume":"60","author":"Lissaois","year":"1975","journal-title":"Int. Surg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1067","DOI":"10.1016\/0278-2391(91)90141-8","article-title":"Temporalis myofascial flap for maxillofacial reconstruction","volume":"49","author":"Colmenero","year":"1991","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"440","DOI":"10.1097\/00006534-198104000-00004","article-title":"Primary reconstruction after total or extended total maxillectomy for maxillary cancer","volume":"67","author":"Konno","year":"1981","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1002\/hed.26933","article-title":"The Zygomatic Implant Perforated (ZIP) flap reconstructive technique for the management of low-level maxillary malignancy\u2014Clinical & patient related outcomes on 35 consecutively treated patients","volume":"44","author":"Butterworth","year":"2021","journal-title":"Head Neck."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1002\/micr.1920090214","article-title":"Immediate microvascular reconstruction of combined palatal and midfacial defects using soft tissue only","volume":"9","author":"Shestak","year":"1988","journal-title":"Microsurgery"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1001\/archotol.128.2.161","article-title":"Midface reconstruction with the fibula free flap","volume":"128","author":"Futran","year":"2002","journal-title":"Arch. Otolaryngol. Head Neck Surg."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1002\/hed.20927","article-title":"Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction","volume":"31","author":"Yu","year":"2009","journal-title":"Head Neck"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"208","DOI":"10.2106\/00004623-200202000-00007","article-title":"The American Academy of Orthopaedic Surgeons outcomes instruments\u2014Normative values from the general population","volume":"84","author":"Hunsaker","year":"2002","journal-title":"J. Bone Joint. Surg. Am."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1055\/s-0033-1343777","article-title":"Orbital floor reconstruction with free flaps after maxillectomy","volume":"6","author":"Sampathirao","year":"2013","journal-title":"Craniomaxillofac. Trauma Reconstr."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"242","DOI":"10.1002\/hed.20736","article-title":"Management of the orbit in malignant sinonasal tumors","volume":"30","author":"Ferlito","year":"2008","journal-title":"Head Neck"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"752","DOI":"10.1002\/micr.30201","article-title":"Reconstruction of midface defects with the osteocutaneous radial forearm flap: Evaluation of long-term outcomes including patient-reported quality of life","volume":"37","author":"Connolly","year":"2017","journal-title":"Microsurgery"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1002\/cncr.31900","article-title":"Leveraging patient-reported outcomes data to inform oncology clinical decision making: Introducing the FACE-Q Head and Neck Cancer Module","volume":"125","author":"Cracchiolo","year":"2019","journal-title":"Cancer"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/10\/3278\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:29:29Z","timestamp":1760030969000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/10\/3278"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,8]]},"references-count":47,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2025,5]]}},"alternative-id":["jcm14103278"],"URL":"https:\/\/doi.org\/10.3390\/jcm14103278","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,5,8]]}}}