Advancing Maxillary Reconstruction: A Systematic Review and Meta-Analysis of the Evolving Role of the Scapular Free Flap

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-Ottawa 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 44.9-60.8). Early general surgical complications occurred in 24% (95% CI 13-40) of patients, while 12% (95% CI 4-31) experienced fistula formation. Donor site morbidity was reported in 10% (95% CI 6-17) of cases, with a mean DASH score of 10.49, indicating low upper limb impairment. Dental rehabilitation was achieved in 56% (95% CI 42-70), and 52% (95% CI 31-72) of patients resumed a normal diet. Aesthetic compromise was observed in 27% (95% CI 9-58), and 36% (95% CI 28-44) 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.