Subscapular System Free Flap Using Trimano Fortis Support Arm

Submitted by:

Mannat Sandhu BS
University of South Florida


Mannat Sandhu


The subscapular system is a highly versatile donor site to obtain free tissue for both bony and soft tissue head & neck reconstruction. Traditional methods of harvesting subscapular flaps required intraoperative repositioning of the patient to a lateral decubitus position, which significantly increased the operative time and prevented simultaneous harvesting of the flap. Various surgical teams have described advances on this technique, but these methods are dependent on either added assistants, a secondary sterile Mayo stand, or a somewhat bulky Spider Limb Positioner® placed on the contralateral side of the table from the harvest site. To overcome these limitations, we have introduced the Trimano Fortis limb positioning system in our practice.

Single institution retrospective chart review and analysis of patients between 2020 and 2022 that underwent a subscapular system free flap with use of the Trimano Fortis limb positioning system. Forty-one patients in total were reviewed. Variables regarding age, procedure indications, cancer staging, bony defects, anesthesia time, hospital length of stay, and postoperative complications were recorded.

68% of patients were managed for an active cancer (46% oral cavity primary) with all these staged as with T4a or T4b utilizing the AJCC 8th edition system. Median total anesthesia time was 567 minutes ranging from 456 – 753 minutes depending on the extent of resection and complexity of the surgical defect. Median hospital of stay was seven days. Five patients developed a major surgical site complications including 4 with pharyngocutaneous fistula formation and 1 with culture confirmed wound infection. There was one case of partial free flap failure and no cases of total free flap failure in this series.

At our institution, application of this positioning system is in part responsible for making the subscapular system the preferred reconstruction for mandibulectomy/maxillectomy defects unless a large volume (>10cm) of bone or dental implantation is expected. It has thus allowed us to fully take advantage of the subscapular system, facilitating a two-team approach, decreasing operative times to match that of other bony free flaps, limits the number of required intraoperative assistants, and simplifies flap harvest to ensure consistent perioperative results.


Demonstrate the application and benefits of the Trimano Fortis support arm for subscapular system free flaps in head & neck reconstructive surgery.

Review the methods of patient positioning for subscapular system flap harvest using the Trimano Fortis limb positioner.

Present a series of patients utilizing the described technique.