## 4 Discussion  
The scapular flap was first developed by [PERSON] and [PERSON] in 1982 and has since been recognized as a versatile free flap in head and neck surgery, particularly in cases requiring complex hard and soft tissue reconstruction [11]. Its chimeric potential makes the scapula flap ideal for oromandibular and craniofacial defects, although it has remained underused for decades. The free scapula flap has been increasingly recognized over the past two decades as a viable alternative to the better-known fibula and iliac crest flaps. Anatomically, it is important to specify the chimeric nature of the scapula flap and its vascular tree. As primarily described by [PERSON], a chimeric flap is defined as a combination of regional flaps converging into a single major pedicle. This allows for spatiality between the components of the flap and its various tissues, making it possible to perform complex reconstructions without using multiple flaps [30]. The chimeric scapular flaps are possible thanks to an anatomically constant vascular system widely described in the literature [14; 31]. The \begin{table}
\begin{tabular}{c c c c c c} \hline \hline
**Article** & \begin{tabular}{c} **Scapula** \\ **Flaps (n)** \\ \end{tabular} & \begin{tabular}{c} **Reconstruction** \\ **Site (n)** \\ \end{tabular} & \begin{tabular}{c} **Dental** \\ **Implants (n)** \\ \end{tabular} & \
\begin{tabular}{c} **Failures** \\ **(n)** \\ \end{tabular} &
\begin{tabular}{c} **Survival** \\ **Rate (\%)** \\ \end{tabular} \\ \hline [PERSON] 2023 [26] & 1 & Maxilla (1) & 3 & 0 & 100\% \\ [PERSON] 2024 [23] & 5 & n.s. & 20 & 6 & 70\% \\ [PERSON] 2021 [22] & 22 & Maxilla (9) & 62 & 2 & 96.7\% \\ [PERSON] 2015 [27] & 6 & Mandible (6) & 35 & 0 & 100\% \\ [PERSON] 2016 [28] & 14 & Maxilla (14) & 50 & 0 & 100\% \\ [PERSON] 2002 [24] & 18 & Mandible (18) & 44 & 0 & 100\% \\ [PERSON] 2018 [25] & 1 & Maxilla (1) & 3 & 0 & 100\% \\ [PERSON] 2016 [29] & 7 & [PERSON] (7) & 23 & 0 & 100\% \\ [PERSON] 2019 [6] & 9 & n.s. & 9 & 1 & 88.9\% \\ \hline \hline \end{tabular}
\end{table} 
Table 1: Dental implants on free scapula flaps: summary of the results of the systematic review. n.s. = not specified. subscapularis system originates at the level of the axillary cavity from the homonymous artery. The subscapular artery, after having generated the circumflex artery of the scapula, which is necessary for the setup of the parascapular bone component, continues into the thoracodorsal artery. The latter is fundamental in the setting up of chimeric flaps; with a length varying from 6 to 18 cm, it allows the harvesting of the soft tissue component given by the latissimus dorsi muscle and in 85% of the cases provides the angular branch which, with an average length ranging from 2.5 to 8 cm, leads to the tip of the scapula and is, therefore, to be preserved in cases in which the bony component of the tip of the scapula must be harvested [14; 15]. The latter is generally the most frequently used bone component of scapular chimeric flaps in jaw reconstruction. Its unique usefulness has been demonstrated in frail patients and those with significant comorbidities, such as peripheral atherosclerotic disease, in whom there may be concern about the adequacy of blood supply to the peripheral limbs after flap retrieval [7]. The scientific literature is divided between authors who prefer a simultaneous ablation and the harvest of the flap with the patient in a supine position and authors who prefer an ablation and reconstruction at two different times with the patient in a prone position or in lateral decubitus. In fact, the proximity to the head and neck makes a simultaneous two-team oro-maxillo-facial resection and scapular harvest very challenging, thus inevitably increasing the operation time and with it the peri-operative adverse events. This is particularly important in elderly patients who are often selected for this flap.