A defect-oriented decision framework for circumflex scapular artery-based flaps: Insights from a 20-year single-centre clinical experience.

BACKGROUND: Circumflex scapular artery (CSA)-based flaps are reliable reconstructive options; however, systematic analyzes of their diverse pedicled applications remain limited. We evaluated a 20-year clinical experience and proposed a post hoc, defect-oriented institutional decision framework to guide flap selection and transfer patterns. METHODS: A retrospective analysis was conducted in patients who underwent reconstruction with pedicled CSA-based flaps between September 2005 and October 2025. Patient demographics, defect characteristics, flap types, transfer patterns, and surgical outcomes were analyzed. RESULTS: The cohort comprised 80 patients with a mean defect area of 203.4 cm2, and 83 flaps were performed. Three transfer patterns were applied according to the anatomical requirements: traditional island flaps without traversing the triangular space (n = 63) for back, upper extremity, and latissimus dorsi myocutaneous flap donor-site defects; traditional island flaps transferred through the triangular space (n = 6) for anterior axillary and chest wall defects; and propeller flaps (n = 14) to reduce pedicle tension when sufficient intervening tissue was present. The largest harvested flap measured 720 cm2. Complications, primarily related to vascular compromise and partial flap loss, occurred in 9 cases. In axillary reconstruction, shoulder range of motion improved by 65.6 ± 24.1° (P < 0.001). CONCLUSIONS: CSA-based flaps offer substantial versatility for regional reconstruction. The post hoc institutional decision framework integrates clinical experience in selecting transfer patterns with the observed complications and may serve as a practical reference for reconstructive planning.