CLINICAL PAPER

The Lower Trapezius Musculocutaneous Flap for Head and Neck Reconstruction Two Decades of Clinical Experience Kuang-Ling Ou, MD, Yang-Hong Dai, Hsian-Jenn Wang, MD, Tim-Mo Chen, MD, Nian-Tzyy Dai, MD, Shun-Cheng Chang, MD, Shou-Cheng Deng, MD, Yuan-Sheng Tzeng, MD, Chih-Hsing Wang, MD, and Shyi-Gen Chen, MD Background: Microsurgical free f lap has gained the popularity over pedicle f lap nowadays in the reconstruction of head and neck. However, pedicled f laps remain a promising alternative and have a remarkable position in selected patients. This review study aimed to determine the reliability and versatility of the lower trapezius musculocutaneous f lap for reconstructing complex defects in the head and neck. Methods: Between 1993 and 2012, 22 male and 10 female patients underwent a total of 32 lower trapezius f lap reconstructions for complex defects that included neoplasm extirpation (n = 21), radionecrosis (n = 6), dehisced laminectomy (n = 2), pressure sore (n = 2), and necrotizing fasciitis (n = 1). The most common site of defect was the perioral region, followed by the neck, posterior skull, back, temporal region, shoulder, and the upper arm. Flap design was based on the defect size and location, as well as the ability to close the donor site primarily and to preserve muscle function. Outcome has been evaluated by the hospital course, postoperative morbidity, mortality, resultant cosmetics, and function at donor and recipient sites. Results: Stable wound coverage with total flap survival was achieved in 30 (93.75%) patients, 2 patients had partial f lap necrosis which required f lap reinsertion and skin graft coverage. All donor sites were closed primarily. Seroma developed in 2 (6.25%) patients, which were solved by needle aspiration. All muscle function was preserved. Eight patients died of their primary disease. Conclusions: For selected patients who have advanced stage cancer, surgical sequelae after free flap surgery, unable to tolerate microsurgery, or special defect location, pedicled lower trapezius musculocutaneous flap provides efficient and effective reconstruction for complex defects especially in the head and neck. Key Words: trapezius musculocutaneous flap, squamous cell carcinoma, radionecrosis, laminectomy, pressure sore (Ann Plast Surg 2013;71: S48YS54)

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omplex soft tissue defects around the posterior skull, perioral, and neck region represent a difficult area for reconstruction particularly when associated with tumor resection, neck dissection, repeated operations, chemotherapy, or recalcitrant wounds due to radionecrosis or osteomyelitis. The ultimate reconstructive goals are to achieve primary wound healing, protect vital structures, maintain function of donor site, restore function after ablative surgery, and obtain acceptable form for the patients.

Received September 29, 2013, and accepted for publication, after revision, October 6, 2013. From the Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China. Conflicts of interest and sources of funding: none declared. Reprints: Shyi-Gen Chen, MD, Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center No. 325, Sec. 2, Cheng-Kung Rd, Nei-Hu 114, Taipei, Taiwan, Republic of China. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/13/7101-S048 DOI: 10.1097/SAP.0000000000000036

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Musculocutaneous f laps, either designed in pedicle or in free transfer, are now available for single-stage reconstruction1,2 for the head and neck. Microvascular free f lap transfer has several advantages, which include multiple potential sites in the body, distant donor tissue, independent blood supply, freedom of design, and versatile compositions of free flaps. Numerous reports pointed out the substantial advantages and achieved good results of primary reconstruction with vascularized free flaps.3,4 However, free flap reconstruction equires special equipment and training, lengthy operation times, multidisciplinary teams, higher cost, and risk of catastrophic complications.5 In addition, for head and neck cancer patients who are frequently treated with chemoradiotherapy, which is often associated with poor local vascular and cellular conditions that may impair the healing process and reduce the tolerance of surgical stress, many of them are ineligible for the free flap reconstruction.2 Therefore, regional flap reconstruction should be attempted in this context. The donor sites ideal for the head and neck reconstruction include supraclavicular artery island flap, the pectoralis major musculocutaneous flap, and lower trapezius musculocutaneous (LTMC) f lap.6Y8 They meet the following requirements: 1-stage reconstruction, feasibility of use, short surgical duration, low complication rate, and functional results. Therefore, pedicled flaps remain to be a promising alternative and have a remarkable position for head and neck reconstruction especially for patients who have advanced stage cancer, surgical sequelae after free f lap surgery, unable to tolerate microsurgery, or special defect location. Selection of flaps for reconstruction of these areas should be based on parameters including flap pliability, pedicle size, and donor-site morbidity. The LTMC flap was initially described by Mathes and Stevenson,1 providing a good option for head and neck cancer reconstruction. Subsequent studies have verified reliability of flap design with an average of 73% successful rates.1,9Y15 This fact, along with the success seen for back, shoulder, and upper arm defects, increases the feasibility of LTMC flap for the upper trunk reconstruction. The purpose of this article was to retrospectively review our 20-year experience of 32 consecutive cases using the vertical trapezius musculocutaneous f lap with emphasis on f lap reliability and effectiveness.

PATIENTS AND METHODS The hospital records of all patients who underwent the LTMC f lap in the head, neck, back, shoulder, and upper arm defects reconstruction at the Tri-Service General Hospital, Taipei, Taiwan, from 1993 to 2012 were analyzed retrospectively. Thirty-two patients were enrolled in the study; 22 were male patients and 10 were female patients. The mean age at time of surgery was 53 years, ranging from 21 to 87 years. Each patient was analyzed for defect etiology, location, size, and potential adverse wound environment from diabetes, cancer, or chronic bone infection. The vertical trapezius f lap data include size, donor, and recipient-site complications. The complications could be divided into major (death related to f lap surgery or f lap loss over 20%) and minor (seroma, wound dehiscence, and Annals of Plastic Surgery

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TABLE 1. Causes of Defects Requiring Flap Coverage Tumor extirpation Radionecrosis with infected wound Pressure sore Dehisced laminectomy Necrotizing fasciitis Total

21 (65.0%) 6 (18.0%) 2 (7.0%) 2 (7.0%) 1 (3.0%) 32 (100%)

partial f lap loss). Outcomes have been determined by the evaluation of hospital course, postoperative morbidity and mortality, and resultant form and function at donor and recipient sites.

Surgical Technique and Harvest Pearls The trapezius muscle was outlined on the day of admission. The f lap surface area and configuration were designed based on the anticipated defect to reconstruct after the ablative procedure was completed. The elliptical skin paddle is located between the medial border of the scapula and vertebral column, and can be harvested as large as 12 cm in width. For maximal arc of rotation, the skin island may extend 10 to 15 cm caudal to the tip of the scapula.10 The patient was placed in either the lateral decubitus position for temporal, facial and oral coverage, or prone position for posterior neck and skull reconstruction. The LTMC flap is based on the descending branch of the transverse cervical artery. Dissection of the flap is commenced inferiorly and laterally toward the medial border of scapula. The fasciocutaneous extension beyond the trapezius muscle should be protected to avoid inadvertent separation from the trapezius muscle. There is no previous delay of the skin paddle. The lateral edge of the muscle is defined and a subtrapezial plane is identified. After the incision around the skin paddle of the flap has been made, it is continued as a vertical incision from the upper limit of the flap toward the posterior triangle of the neck. This vertical incision is approximately at the midpoint between the scapula and the spinous processes of the vertebrae. Perforators from the posterior intercostal arteries and minor pedicles from the dorsal scapular artery are ligated and divided. Beneath the trapezius muscle, the latissimus dorsi muscle and the rhomboid muscles are preserved. Actual identification of the descending branch of the transverse cervical vessels is not required. These vessels are protected by a fascial layer and can usually be seen and always be palpated along the undersurface of the trapezius midway between the medial border of the scapula and vertebral column, superficial to the rhomboideus major, rhomboideus minor, and latissimus dorsi muscles. No incision is made in the skin of the posterior triangle of the neck. Subcutaneous undermining is done for the last 6 to 10 cm of the skin so that the extended lower trapezius island musculocutaneous flap can be tunneled into the head and neck region. Adequate tunnel size is required to avoid compression of the muscle f lap. The superior and lateral fibers of the trapezius muscle are left intact to preserve shoulder function as well the aesthetic appearance of the fold of the neck. The donor-site defect is closed primarily. This f lap would reach the vertex of the skull, the anterior neck, the midface, and the temporal and orbital regions. Regarding the tips and pearls of harvesting, keep in mind that the extension beyond the scapular angle should be within 15 cm because greater extension may cause tenuous f laps. If the dominant transverse cervical artery is found, the branch of the dorsal scapular artery may be ligated between the rhomboid major and minor muscles. If the dorsal scapular artery is dominant, be sure to protect the artery and divide the rhomboid minor muscle on either side of the artery to decrease further tension on the vessels and increase the arch of rotation. What is more, if the transverse cervical artery * 2013 Lippincott Williams & Wilkins

Lower Trapezius Musculocutaneous Flap

is not robust enough, use microvascular clamps to this artery and accompanied veins for more than 15 minutes and observe the dermal bleeding to assess the contribution of the dorsal scapular artery to the distal trapezius muscle. This method is especially helpful when there is question about dividing the less robust transverse cervical artery.

RESULTS Thirty-two patients underwent LTMC island flap reconstructions within 2 decades. The 22 male and 10 female patients ranged in age from 21 to 87 years, with a mean age of 53 years at the time of surgery. The most common etiology of defect was tumor extirpation (n = 21) followed by radionecrosis with infected wound (n = 6), dehisced laminectomy (n = 2), pressure sore (n = 2), and necrotizing fasciitis (n = 1) (Table 1). Defect size ranged from 4  4 to 15  10 cm with an average size of 5  12 cm. Perioral region was the most common site of defect (n = 12), followed by lateral neck (n = 6), posterior skull (n = 3), posterior neck (n = 3), back (n = 3), shoulder and scapula (n = 3), temporal area (n = 2), and upper arm (n = 1) (Table 2). The flap design was based on defect size and location, as well as the ability to close the donor site primarily and to preserve muscle function. The average skin island dimensions were 5  12 cm and ranged from 4  4 to 15  10 cm. Postoperative follow-up ranged from 6 to 52 months with a mean of 28.7 months. Eight patients died of their primary disease. Excellent reconstruction with primary healing was achieved in 30 (93.75%) patients. There was no death directly attributable to flap procedures or total flap loss. Two patients had partial f lap necrosis and one of them required flap reinsertion with skin graft coverage. The other one case was treated successfully with conservative wound care. All donor sites were closed primarily. Donor-site morbidity was limited to 2 (6.25%) seromas, which was solved by needle aspiration. Muscle function was maintained in all patients by preserving the continuity of the superior third trapezius muscle and accessory nerve.

CASE REPORTS Case 1 A 65-year-old man presented with a recurrent squamous cell carcinoma of right external ear canal after twice excisions by otologist. Facial nerve was injured during the first time of tumor excision (Fig. 1A). Magnetic resonance imaging showed the tumor involved the ear auricle with a rodent-bite appearance and erosion of temporal bone. Radical excision was performed which included tumor lesion, entire ear auricle apparatus, and tympanomastoid fossa (Fig. 1B). This defect was measured 6  10 cm and was reconstructed with a 6  11-cm vertical trapezius musculocutaneous f lap. He received 5000 cGy conventional once-daily radiotherapy after the wound healed. After a 4-year follow-up period, the wound remained well healed and had no evidence of local recurrence (Fig. 1C). The shoulder function was well preserved (Fig. 1D).

TABLE 2. Locations of Defect Requiring Flap Coverage Perioral region Lateral neck Posterior neck Posterior skull Back Shoulder and scapula Temporal region and ear Upper arm Total

12 (37.5%) 6 (18.75%) 3 (9.375%) 3 (9.375%) 3 (9.375%) 2 (6.25%) 2 (6.25%) 1 (3.125%) 32 (100%)

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FIGURE 1. A, A 65-year-old man presented with a recurrent squamous cell carcinoma of right external ear canal after twice excisions by otologists. Note the facial nerve was injured during tumor excision. B, Radical excision was performed and the defect was measured 10  6 cm2. An 11  6-cm2 vertical trapezius musculocutaneous f lap was designed. C, Nine months postoperatively, the wound remains well healed after full course radiotherapy and the patient has no evidence of recurrence. D, The donor site was closed primarily with preserved shoulder function.

Case 2 A 55-year-old man had an initial surgery for a right tonsillar carcinoma in 2000. Composite resection of tonsillar carcinoma and modified radical neck dissection were performed by head and neck surgeon (Fig. 2A), and then was reconstructed with free radioforearm f lap (Fig. 2B). Postoperative radiotherapy was also delivered as adjuvant of this treatment. He was crippled by radionecrosis of mandible combined with orocutaneous fistula and Staphylococcus aureus infection (Fig. 2C). He underwent sequestrectomy and subsequently segmental resection of mandible was implemented combined with antibiotics treatment. The patient presented with an 11  8-cm lesion including a 6  5-cm central bone defect. He refused free osteosseous f lap to restore his mandible. Therefore, we designed a 5  10-cm vertical trapezius musculocutaneous f lap (Fig. 2D) for the intraoral mucosal lining and obliterating the fistula. S50

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The outer surface was skin-grafted. The donor site was closed primarily and the wound healed uneventfully. Wound coverage remained stable during the 3-year follow-up period (Fig. 2E). He retained excellent shoulder contour and function (Fig. 2F).

Case 3 A 21-year-old man presented with a residual dermatofibrosarcoma of the right neck region after 2 episodes of excisions at other institute (Fig. 3A). Enlargement of the right submandibular lymph node about 2  1.5  1.5 cm was also palpated. Radical excision was performed, which included the tumor mass with 3-cm safe margin, previous surgical scar, subcutaneous tissue, and underlying muscle fascia. This defect measured 5  12 cm (Fig. 3B) was reconstructed with a 5  12-cm vertical trapezius musculocutaneous flap (Fig. 3C). The donor site was closed primarily and the wound healed uneventfully. The * 2013 Lippincott Williams & Wilkins

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Lower Trapezius Musculocutaneous Flap

FIGURE 2. A, Composite resection of tonsillar carcinoma and modified radical neck dissection. B, A free radioforearm f lap was harvested for reconstruction. C, Radionecrosis of mandible combined with orocutaneous fistula and Staphylococcus aureus infection was noted. D, A 5  10-cm2 vertical trapezius musculocutaneous f lap was elevated for the intraoral mucosal lining and obliterating the fistula. E, Three-year follow-up. F, Excellent shoulder contour and function retained.

histology of lymph node showed reactive hyperplasia without regional or distant metastasis. Wound coverage remained stable at 1-year follow-up. He retained excellent shoulder contour and function (Fig. 3D).

DISCUSSION There has been a dramatic evolution of head and neck reconstructive surgery during the past 4 decades. The development of microvascular free tissue transfer provides a wide array of tissue options to reconstruct complicated head and neck defect. Various free flaps can be used not only for soft tissue coverage but also for functional rehabilitation such as sensation, lubrication, and osteointegration. However, for some patients with advanced stage of cancer, intolerability to microsurgery, special location, and failed previous free flap, pedicle f lap is a good salvage procedure. Table 3 summarizes some common regional flaps for reconstruction of head and neck defects.6,16Y24 Available choices in posterior head and neck reconstruction included latissimus dorsi flap, pectoralis flap, and trapezius flap.25Y27 The latissimus dorsi f lap requires an extensive dissection, and functional preservation is not feasible although the arc of rotation is similar to the vertical trapezius design. The pectoralis major flap is limited by insufficient arc of rotation to the posterior skull, neck, and upper facial regions. Microvascular flap transplantation will also allow singlestage reconstruction. However, suitable receptor vessels are frequently confined to the anterior neck and the higher morbidity potential are relatively contraindicated for the older age group and critical ill patients. It is a f lat, triangular muscle that originates from the occipital * 2013 Lippincott Williams & Wilkins

protuberance superior to the nuchal line and the spinous processes of all cervical spines and the seventh through twelfth thoracic vertebrae. Its fibers then course laterally to insert on the lateral third of the clavicle, the acromion, and the medial end of scapular spine. The function of the trapezius muscle is to suspend and stabilize the shoulder girdle and to assist in elevating and rotating the shoulder. The motor innervation of the trapezius is provided by the accessory nerve, whereas the sensory supply is provided by third and fourth cervical nerves. According to the classification define by Mathes and Nahai,28 the trapezius muscle has a type 2 vascular distribution with major and additional minor vascular pedicels. The dominant feeding artery is the transverse cervical artery with minor contribution from the occipital artery and posterior intercostal artery. Clinically, 3 distinct musculocutaneous segments, the superior, the lateral island, and the vertical island flap, can be harvested from the trapezius muscle and its overlying skin to reconstruct a wide variety of head and neck defects.8Y10,13Y15,29Y34 Among the 3 segments, the superior and lateral trapezius musculocutaneous f laps have limited use because of limited arc of rotation35; the donor-site defect requires a skin graft for closure, and potential loss of eleventh nerve function. Therefore, the superior and lateral islands of the trapezius muscle are better to be left intact to preserve the posterior fold of the neck and minimize the functional and aesthetic deformity. The vertical trapezius musculocutaneous f lap described by Mathes and Stevenson1 is chief ly based on the transverse cervical artery, which enters the deep surface of the muscle at the base of the www.annalsplasticsurgery.com

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FIGURE 3. A, A 21-year-old man had residual dermatofibrosarcoma of the right neck region. B, Radical excision was performed and this defect was measured 5  12 cm2. C, A 5  12-cm2 vertical trapezius musculocutaneous f lap was elevated for reconstruction. D, Wound coverage remained stable at 1-year follow-up and excellent shoulder contour and function was retained.

neck. This pedicle may originate either from the thyrocervical trunk or directly from the second or third part of the subclavian artery. The dual blood supply of the distal part of this f lap with the dorsal scapular artery and the deep branch of the transverse cervical artery is unique. The transverse cervical artery is the main arterial supply, although the dorsal scapular artery often may be the dominant vessel.8 Anastomosis is observed between the arterial system of the transverse cervical artery and the dorsal scapular artery at the junction of the middle and lower thirds of the trapezius muscle. Frequently, the superficial branch arises directly from the thyrocervical trunk and is thus named the superficial cervical artery. In this event, the deep descending branch arises directly from the subclavian artery

and is named the dorsal scapular artery, providing the dominant blood supply to the lower trapezius composite f lap. Except for defects superior to the occiput, the distance of superior dissection required for an adequate arc of rotation is usually several centimeters above the scapula. Actual identification of the descending branch of the transverse artery is not necessary. However, its minor pedicles, muscular perforating branch from the dorsal scapular artery, and segmental branches from the posterior intercostal arteries are frequently divided to obtain adequate muscle arc of rotation for coverage of skull and cervical defects.36 Many advantages of the vertical trapezius musculocutaneous f lap have been described.2,13,15 Immediate reconstruction is possible

TABLE 3. Common Regional Flaps for Reconstruction of Head/Neck Defects Regional Flap for Head/Neck* Buccal flap Nasolabial and melolabial flaps Platysma flap Sternocleidomastoid myocutaneous flap Supraclavicular Pectoralis major myocutaneous flap Internal mammary artery perforator flap Trapezius myocutaneous flap Latissimus dorsi myocutaneous flap

Examples of Reconstruction Oronasal mucosa Tongue, lips, lower eyelids, cheeks Ear, cheek, lip, oropharynx, hypopharynx, neck Head, neck defects, esophageal perforation Head, oral cavity, neck The floor of mouth, orbits Pharynx, trachea, anterior neck Lateral neck, external face, posterolateral scalp Large scalp, mandible, facial skeleton, oral cavity, oropharynx

*The f laps were listed in cephalocaudal and ventrodorsal anatomical order.

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without delay procedure even in extensive defects. The muscle function can be preserved by maintaining continuity of the superior muscle fibers between the occipital skull and lateral third of the clavicle and acromion. Those patients in whom the trapezius muscle was denervated before transfer suffered no additional morbidity. In our series, there was no any shoulder weakness or dysfunction. Restriction of shoulder abduction was observed in 3 patients with electric burn injury and pressure sores over the shoulder and scapula that required adequate debridement and partial osteotomy to obtain clean wound bed. Functional recovery was achieved after physical therapy. However, there are some limitations for this flap. If there is prior injury or sacrifice of the proximal transverse cervical artery in the neck, the adoption of alternative flap should be considered although a separate dorsal scapular artery remains intact. During the operation, the patient is required to be positioned in lateral decubitus position. Therefore, if the patients experience leg injuries or arthritis, this position may exacerbate these problems. Other minor limitations may include relative superiority for flaps to reconstruct certain head and neck defects such as the oral cavity and regions beyond the reach of the flap. The pedicle of this flap has an adequate length, allowing a wide arc of rotation which will reach to cranio-orbital region.37 The f lap may be used to cover the defects of upper parieto-occipital skull, neck, temporal, perioral region, shoulder, and axilla without difficulties. The skin island of this flap can be designed transversely, obliquely, or vertically. Vertical orientation of the skin island is preferred for large distant defects because a wider arc of 180 degree rotation is required. The superior margin of the skin island is commonly located at the middle portion of the scapula and may extend inferiorly to a point midway between the posterior iliac spine and inferior tip of scapula. Generally, the flap is passed through a tunnel superficial to the superior trapezius muscle and beneath neck skin to reach the posterior skull and neck defects. Adequate tunnel size is required to avoid compression of the muscle flap. The donor site of all patients can be closed primarily. The donor-site scar located on the posterior back is more acceptable for the female patients because a chest flap, such as a pectoralis musculocutaneous flap, generally results in visible scar in proximity to the breast and alteration of breast contour. Bilateral vertical trapezius musculocutaneous flaps may be designed as advancement f laps for extensive cervical-thoracic vertebral defect. This design has been successfully used in 2 patients in this series. However, there lies an absolute contraindication before the f lap can be designed: previous surgical procedures that compromise the transverse cervical artery, or its origin, have been the only absolute contraindication for use of the vertical trapezius f lap. The complications of the vertical trapezius musculocutaneous f lap could be divided into major (death related to f lap surgery or f lap loss over 20%) or minor (seroma, wound dehiscence, and partial f lap loss). Mathes and Stevenson,1 Baek et al,11 Seyfer,13 and Rosen37 reported minimal major complication rates (range, 0%Y17%). However, Chandrasekhar et al9 reported a 35% complication rate (14% major and 21% minor), Cummings et al10 reported a 57% complication rate (21% major and 36% minor). Compared with these articles, our primary healing rate was excellent (no major complication), but the minor complication rates still high (10% for f lap and 10% for donor site). The hematoma developed in 1 patient induced partial f lap necrosis is due to aggressive debridement of necrotic bone and soft tissue, which could be prevented by meticulous hemostasis and proper drainage. The seroma requiring needle aspiration occurred in 1 patient might be associated with the extensive dissection of the large f lap design and inadequate drainage.

CONCLUSIONS In conclusion, the vertical trapezius musculocutaneous f lap has demonstrated excellent reconstruction for the head and neck defects. The advantages of this f lap are (1) thinness, (2) large f lap * 2013 Lippincott Williams & Wilkins

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size, (3) wide arc rotation, (4) reliable circulation, (5) direct donorsite closure, (6) muscle function preservation, and (7) low complication rate. Certain unfavorable disadvantages are seroma formation due to extensive dissection and partial f lap loss due to uncertain circulation of skin island f lap extension. These can be minimized by meticulous hemostasis, quilt suture, or suctioned drain placement. Also, it should be kept in mind not to extend the skin island by 15 cm below the tip of scapula. REFERENCES 1. Mathes SJ, Stevenson TR. Reconstruction of posterior neck and skull with vertical trapezius musculocutaneous flap. Am J Surg. 1988;156:248Y251. 2. Yoon SK, Song SH, Kang N, et al. Reconstruction of the head and neck region using lower trapezius musculocutaneous flaps. Arch Plast Surg. 2012; 39:626Y630. 3. Ensat F, Schubert H, Hladik M, et al. Soft tissue reconstruction in the extremities and the head and neck area using the anterolateral thigh free flap. Oper Orthop Traumatol. 2013;25:176Y184. 4. Fakhry N, Chamorey E, Michel J, et al. Salvage circular laryngopharyngectomy and radial forearm free flap for recurrent hypopharyngeal cancer. Laryngoscope. 2013;123:910Y915. 5. Baker SR. Microvascular free flaps in soft-tissue augmentation of the head and neck. Arch Otolaryngol Head Neck Surg. 1986;112:733Y737. 6. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg. 1979;63:73Y81. 7. El-Marakby HH. The reliability of pectoralis major myocutaneous flap in head and neck reconstruction. J Egypt Natl Cancer Inst. 2006;18:41Y50. 8. Netterville JL, Wood DE. The lower trapezius flap. Vascular anatomy and surgical technique. Arch Otolaryngol Head Neck Surg. 1991;117:73Y76. 9. Chandrasekhar B, Terz JJ, Kokal WA, et al. The inferior trapezius musculocutaneous flap in head and neck reconstruction. Ann Plast Surg. 1988;21:201Y209. 10. Cummings CW, Eisele DW, Coltrera MD. Lower trapezius myocutaneous island flap. Arch Otolaryngol Head Neck Surg. 1989;115:1181Y1185. 11. Baek SM, Biller HF, Krespi YP, et al. The lower trapezius island myocutaneous flap. Ann Plast Surg. 1980;5:108Y114. 12. Zachrisson BU. JCO/interviews Dr. Bjorn U. Zachrisson on iatrogenic damage in orthodontic treatment (part 2). Interview by Sidney Brandt. J Clin Orthod. 1978;12:208Y220. 13. Seyfer AE. The lower trapezius flap for recalcitrant wounds of the posterior skull and spine. Ann Plast Surg. 1988;20:414Y418. 14. Netterville JL, Panje WR, Maves MD, et al. The trapezius myocutaneous flap. Dependability and limitations. Arch Otolaryngol Head Neck Surg. 1987; 113:271Y281. 15. Urken ML, Naidu RK, Lawson W, et al. The lower trapezius island musculocutaneous flap revisited. Report of 45 cases and a unifying concept of the vascular supply. Arch Otolaryngol Head Neck Surg. 1991;117:502Y511. 16. Bozola AR, Gasques JA, Carriquiry CE, et al. The buccinator musculomucosal flap: anatomic study and clinical application. Plast Reconstr Surg. 1989;84:250Y257. 17. Charles GA, Hamaker RC, Singer MI, et al. Sternocleidomastoid myocutaneous flap. Laryngoscope. 1987;97:970Y974. 18. Chiu ES, Liu PH, Friedlander PL, et al. Supraclavicular artery island flap for head and neck oncologic reconstruction: indications, complications, and outcomes. Plast Reconstr Surg. 2009;124:115Y123. 19. Futrell JW, Johns ME, Edgerton MT, et al. Platysma myocutaneous flap for intraoral reconstruction. Am J Surg. 1978;136:504Y507. 20. Iyer NG, Clark JR, Ashford BG, et al. Internal mammary artery perforator flap for head and neck reconstruction. ANZ J Surg. 2009;79:799Y803. 21. Martin D, Pascal JF, Baudet J, et al. The submental island flap: a new donor site. Anatomy and clinical applications as a free or pedicled flap. Plast Reconstr Surg. 1993;92:867Y873. 22. Maves MD, Panje WR, Shagets FW, et al. Extended latissimus dorsi myocutaneous flap reconstruction of major head and neck defects. Otolaryngol Head Neck Surg. 1984;92:551Y558. 23. Napolitano M, Mast BA, et al. The nasolabial flap revisited as an adjunct to floor-of-mouth reconstruction. Ann Plast Surg. 2001;46:265Y268. 24. Varghese BT, Sebastian P, Cherian T, et al. Nasolabial flaps in oral reconstruction: an analysis of 224 cases. Br J Plast Surg. 2001;54:499Y503.

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25. Quillen CG, Shearin JC Jr, Georgiade NG, et al. Use of the latissimus dorsi myocutaneous island flap for reconstruction in the head and neck area: case report. Plast Reconstr Surg. 1978;62:113Y117. 26. Rudes M, Bilic M, Jurlina M, et al. Pectoralis major myocutaneous flap in the reconstructive surgery of the head and neckVour experience. Coll Antropol. 2012;36(suppl 2):137Y142. 27. Rapis T, Zanakis SN, Letsa IF, et al. Basal cell carcinoma of the posterior neck, reconstructed with lower trapezius island musculocutaneous flap. Case report in an unusual site of occurrence. J BUON. 2003;8:397Y401. 28. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981;67:177Y187. 29. Bertotti JA. Trapezius-musculocutaneous island flap in the repair of major head and neck cancer. Plast Reconstr Surg. 1980;65:16Y21. 30. Conley J. Use of composite flaps containing bone for major repairs in the head and neck. Plast Reconstr Surg. 1972;49:522Y526. 31. Panje WR. Myocutaneous trapezius flap. Head Neck Surg. 1980;2:206Y212.

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32. Aviv JE, Urken ML, Lawson W, et al. The superior trapezius myocutaneous flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1992;118:702Y706. 33. Demergasso F, Piazza MV, et al. Trapezius myocutaneous flap in reconstructive surgery for head and neck cancer: an original technique. Am J Surg. 1979; 138:533Y536. 34. Guillamondegui OM, Larson DL, et al. The lateral trapezius musculocutaneous flap: its use in head and neck reconstruction. Plast Reconstr Surg. 1981; 67:143Y150. 35. Ferbeyre-Binelfa L. Lattissimus dorsi myocutaneous flap in head and neck surgery. Cir Cir. 2010;78:485Y491. 36. Haas F, Pierer G, Weiglein A, et al. The lower trapezius muscle island flap. Anatomic principles and clinical relevance. Handchir Mikrochir Plast Chir. 1999;31:15Y20. 37. Rosen HM. The extended trapezius musculocutaneous flap for cranio-orbital facial reconstruction. Plast Reconstr Surg. 1985;75:318Y327.

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The lower trapezius musculocutaneous flap for head and neck reconstruction: two decades of clinical experience.

Microsurgical free flap has gained the popularity over pedicle flap nowadays in the reconstruction of head and neck. However, pedicled flaps remain a ...
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