## 4 Discussion
From the latter point of view, it is important to highlight that scapular bone flap allows early ambulation, also in first post-operative day, resulting in a lighter post-operative patient care management and in a minimization of adverse effects in elderly patients during hospitalization [17]. Various supine and/or semi-lateral decubitus methods have been described in the literature over the years to enable simultaneous ablation and flap harvesting [32]. To follow this purpose, support stands such as the Mayo stand or the Spider limb positioner have also been introduced [33; 34]. Today, the simultaneous one is the preferred approach by the senior authors. From a morbidity perspective, numerous articles have demonstrated its efficacy, reproducibility, and low cost in relation to the donor site [13]. Regarding the latter aspect, from a functional point of view, the authors have already described a significant reduction in the strength and external rotation of the shoulder in the absence of a significant reduction in the quality of life reported by patients [17]. Similarly, [PERSON] et al. evaluated the range of motion of the active shoulder (ROM) and measured the shoulder strength using the Microfe2, demonstrating a significant difference between the operated shoulder and the contralateral healthy one without subjectively impacting the patient's perception [18]. [PERSON] et al. also investigated scapula donor site morbidity, both objectively (using the Costant-Marley test) and subjectively (using the Disability Arm, Shoulder, and Hand (DASH) test). In their case series, no significantly impacting changes in the quality of life of the treated patients were found. In addition, a progressive improvement in shoulder function was demonstrated in tests performed after surgery in a long-term setting. Peri-operatively, the two most frequently reported complications were seroma, which was reported in 16% of the cases in the case series of [PERSON] et al., and post-operative pain, which was easily managed with normal anti-inflammatory painkillers such as paracetamol [16]. In addition, the vascular pedicle appears to be the least affected by atherosclerosis, offering an advantage in smokers, such as most oral cancer patients [14; 35]. Moreover, it allows one to bypass possible problems related to peripheral obliterative arteriopathy diseases, which have smoking and dyslipidemia as their risk factors. Considering that the majority of the cases involve the lower limbs, this may represent a serious issue that needs to be carefully evaluated in patients who are candidates for fibula flap harvesting [36]. The role of atherosclerosis in the iliac crest flap, on the other hand, is still vague and not described in detail in the scientific literature. A further advantage of this flap is the long vascular pedicle, similar to the fibula flap pedicle. Differently from the fibula flap, the scapula one also has the advantage of its possible chimeric harvesting and thus mobility between the hard and soft components of the flap, allowing the treatment of vessel-depleted necks or even the treatment of irradiated patients with invasive recurrences, where salvage surgery is required. As this systematic review has shown, the scapula flap has proved to be versatile in jaw reconstruction as it is used in a proportionally semi-symmetrical manner in both maxillary and mandibular reconstruction. In the latter, 58.0% of the case series reported in this study, despite having limited bone reserve, a composite osteomyocutaneous scapular flap in combination with latissimus dorsi was shown to reduce post-operative fistulae in mandibular reconstructions [29]. Since scapula flaps were used for both maxillary and mandibular reconstructions, it should be noted that the implant failure rate was low in both cases. A peculiarity to consider about the scapular flap compared to other free bone flaps is that related to the concept of 'implantability', which has often been addressed in the literature [19; 27; 37; 38].