RECONSTRUCTIVE The Trapezius Perforator Flap: An Underused but Versatile Option in the Reconstruction of Local and Distant Soft-Tissue Defects Parviz L. Sadigh, M.B., Ch.B. Li-Ren Chang, M.D. Ching-Hua Hsieh, M.D., Ph.D. Wen-Jui Feng Seng-Feng Jeng, M.D. Kaohsiung, Taiwan
Background: The trapezius myocutaneous flap is an established reconstructive option in head and neck cases The authors present their experience with 10 trapezius perforator flaps, all raised using a freestyle technique of perforator dissection, to successfully reconstruct both local and distant soft-tissue defects. Methods: Ten patients underwent soft-tissue reconstruction using trapezius perforator flaps. After mapping the perforator with a handheld Doppler device at the intersection of a horizontal line drawn 6 to 8 cm inferior to the scapular spine and a vertical line drawn 8 to 9 cm lateral to the midline of the back, perforator flaps were raised in a freestyle fashion, with complete preservation of the trapezius muscle. The flap can be pedicled into local defects or transferred as a free flap. Results: Six flaps were elevated as pedicled flaps and four were transferred as free flaps. Flap size ranged from 6 × 4 cm to 25 × 15 cm. The pedicle length ranged from 4 to 14 cm. The pedicle originated from the dorsal scapular artery. In one case, the authors converted from a pedicled flap to a free flap secondary to insufficient pedicle length. All donor sites were closed directly. The follow-up period ranged from 4 months to 4 years. All of the flaps survived completely with no major complications, and no patients developed any shoulder dysfunction. Conclusions: The trapezius perforator flap is a reliable and versatile reconstructive option that can be used to repair both local and distant soft-tissue defects. The donor-site morbidity is minimal. (Plast. Reconstr. Surg. 134: 449e, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
T
he myocutaneous trapezius flap based on the superficial cervical artery was first described by Nakajima and Fujino in 1984.1 It was then developed by Hyakusoku et al. in 1990 as a skin flap for reconstruction of large neck defects after the release of burn scar contractures.2 A number of authors have since published results using the trapezius as a myocutaneous flap in the setting of salvage head and neck reconstruction.3–9 In these situations, the soft tissues of the back represent an area of the body that has normally been spared from the effects of radiotherapy and previous From the Departments of Plastic Surgery and Management, E-Da Hospital, I-Shou University; and the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital. Received for publication October 19, 2013; accepted February 26, 2014. The first two authors contributed equally to this work. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000430
flap harvest. The relative underuse of the trapezius myocutaneous flap in situations other than in salvage head and neck reconstruction may be because of the fear of impacting on trapezius muscle function or because of an unfamiliar knowledge of the relevant vascular anatomy. In 2003, Angrigiani et al. reported on the use of harvesting lower medial back tissue as an island flap based on the dorsal scapular artery to reconstruct defects of the head, neck, and chest. However, some muscle was included in the flap in all cases.10 With the advent of the perforator flap concept11 and the trend toward the technique of free-style perforator dissection,12–14 with subsequent preservation of donor-site integrity, it has become possible to raise “true”15 trapezius perforator flaps and to preserve total integrity of the trapezius muscle. In this study, we aim to share our Disclosure: The authors have no financial interest to declare in relation to the content of this article.
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Plastic and Reconstructive Surgery • September 2014 experience with the use of 10 trapezius perforator flaps, revisit the relevant surgical anatomy, and discuss the advantages and clinical indications of this flap over its more conventional counterparts. Surgical Anatomy The trapezius muscle takes its origin from the occiput, seventh cervical vertebra, and all thoracic vertebrae, and inserts into the acromion, spine of the scapula, and clavicle. It is innervated by the accessory nerve and functions to raise the shoulder girdle and to assist in shoulder rotation. According to the Mathes and Nahai classification,16 the trapezius muscle has a type 2 vascular supply, with the dominant inflow arising from the transverse cervical artery and with minor pedicles arising from intercostal, circumflex scapular, and occipital perforators. In an anatomical study of 124 cadavers by Haas et al.,17 it was noted that the upper part of the trapezius muscle is supplied by branches of the occipital artery, the middle and lateral parts by the superficial cervical artery, and the lower portion by the dorsal scapular artery. The vascular anatomy of the trapezius muscle and its overlying skin can be confusing because of the various names used to describe similar vessels in this region, and the anatomical variation in which the vessels branch from the subclavian artery. According to the Terminologia Anatomica,18 the transverse cervical artery is defined as the arterial trunk that gives rise to the superficial cervical and dorsal scapular arteries, and although various branching patterns are seen at the origin of this artery with the subclavian, this does not influence the surgical procedure when raising a trapezius perforator flap. What is of importance is the manner in which these vessels descend the back before perforating the trapezius to enter into the subcutaneous tissue. The superficial cervical artery initially runs lateral to the levator scapulae and rhomboid muscles before coursing medially to give a short ascending and long descending branch that runs to the level of the scapular spine. With a caliber greater than 0.7 mm, it always descends superficial to the levator scapulae and the rhomboids and is accompanied by branches of the accessory nerve.8 The dorsal scapular artery, in contrast, runs deep to the levator scapulae and rhomboid minor before a branch pierces the fascia between the rhomboid minor and major to run along the medial border of the scapula (superficial dorsal scapular artery) before appearing under the trapezius muscle. This superficial branch runs on the deep belly of the trapezius, perfusing the muscle and consistently giving off one or two cutaneous
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perforators that pierce the lower trapezius to supply the overlying skin 1 to 2 cm medial to its lateral edge (Fig. 1).10 The average caliber of the dorsal scapular artery is 2.7 mm proximally at its origin and 1.95 mm at the level of the levator scapulae muscle.17 A deep branch of the dorsal scapular artery continues to descend under the rhomboid major, which largely supplies muscular perforators to the rhomboids, but can supply perforators penetrating the overlying trapezius muscle to reach the skin.10
PATIENTS AND METHODS Patients and Dissection Technique Patients selected for trapezius perforator flap reconstruction were those with central upper back defects, those who had exhausted other sites of flap harvest, or those who wanted to avoid the donor-site scarring associated with more conventional flaps. All patients were positioned in the lateral decubitus position with the ipsilateral arm draped free to allow its mobility during flap harvest, before undergoing perforator mapping with hand-held Doppler ultrasound. The cutaneous perforators are usually located at the intersection of a horizontal line drawn 6 to 8 cm inferior to the scapular spine and a vertical line drawn 8 to 9 cm lateral to the midline of the back.10 The flap design is then marked on the back, depending on the size and shape of the defect. An incision is made along the lateral margin of the flap, and dissection proceeds from lateral to medial, superficial to the deep fascia, until the lateral border of the trapezius is encountered. At this point, under loupe magnification, care is taken to identify the perforator(s) piercing the muscle to enter the skin. Meticulous hemostasis is imperative at this stage to avoid blood staining of the tissues and maintain clear visualization of the perforating vessels. When a sizable perforator is identified, dissection then proceeds in a retrograde manner using a deroofing technique. Numerous muscular branches will need to be carefully ligated during the intramuscular dissection and care must be taken to avoid stretching or excessive handling of the vessel. In our experience, the visible pulsation of the perforator throughout its length is the most reliable way of confirming that the vessel is uninjured and safely supplies the overlying skin flap. In our series, the pedicle was skeletonized to the level at which it ascended under the cover of the medial scapular border, as this provided us with an adequate pedicle length
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Fig. 1. Surgical anatomy relevant to the raising of a trapezius perforator flap.
in all of our cases. Further proximal dissection is difficult and risks damage to the vessel; however, if a longer pedicle length is required, dissection can continue to the superior border of the rhomboid major muscle, followed by ligation of the deep branch of the dorsal scapular artery if an even longer pedicle is required.17 It has also been reported that the rhomboid minor muscle can be divided or the flap even tunneled under the levator scapulae to further increase the arc of rotation to reach defects on the face.17 Once pedicle dissection is complete, the trapezius perforator flap can be transposed into a regional defect or transferred as a free flap using microsurgical techniques (Fig. 2).
RESULTS Between December of 2005 and May of 2013, 10 patients underwent trapezius perforator flap reconstruction at our institution (Table 1). The mean age of the patients was 44.3 years (range, 28 to 55 years) and the harvested skin paddle size ranged from 6 × 4 cm to 25 × 15 cm. Six flaps were used as pedicled flaps to reconstruct a range of defects on the back and neck, whereas four flaps were raised as free flaps to reconstruct defects of back, mandible, and a first-web-space contracture of the hand. In one case (patient 9), the initial plan was to use the trapezius perforator flap as a pedicled flap in the reconstruction of a contralateral back defect. However, because of inadequate pedicle length, we
converted to a free flap. The pedicle length ranged from 4 to 14 cm, with a mean of 7 cm, and all flaps were based on a single perforator of the dorsal scapular artery. A sizable perforator was encountered in all cases (caliber at least 0.5 mm in diameter) and the donor sites were all closed primarily; however, postoperative wound dehiscence necessitating return to the operating room for closure was encountered in patients 3 and 5. All of the flaps survived completely and no patients developed any postoperative shoulder weakness or winging of the scapula during a follow-up period that ranged from 4 months to 4 years. Donor-site scars were all located close to the mid back and as such were not visible to the patients. Indeed, in all cases, the patients reported no functional or cosmetic concerns with regard to the donor site.
CASE REPORTS Case 3 A 46-year-old male worker presented with a large Marjolin ulcer on his upper right back (Fig. 3, above, left). After wide local excision, a 25 × 10-cm pedicled trapezius perforator flap (Fig. 3, above, right) based on a perforator of the superficial branch of the dorsal scapular artery (Fig. 3, below, left) was used for reconstruction. Total preservation of the trapezius muscle was achieved. The donor site was closed primarily; however, postoperative wound dehiscence was encountered, which necessitated a return to the operating room for delayed primary closure 1 week later. The wound healed well and the flap tolerated the subsequent radiotherapy with no complications. No weakness in shoulder abduction was identified at a postoperative follow-up of 36 months (Fig. 3, below, right).
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Fig. 2. Patient in the lateral decubitus position with a trapezius perforator flap raised on a single perforator of the superficial branch of the dorsal scapular artery.
Table 1. Summary of Our Trapezius Perforator Flap Series Age Case (yr) Sex 1 2 3 4 5 6 7 8 9 10
42 30 46 28 55 37 52 50 33 70
M M M F F M M F M M
Diagnosis
Site
Flap Size Pedicle (cm) Length (cm)
Chronic ulcer Nuchal 15 × 7 Dermatofibrosarcoma Back 10 × 8 Marjolin’s ulcer Back 25 × 10 Malignant neurofibromatosis Back 25 × 15 Dermatofibrosarcoma Back 15 × 7 First-web-space contracture Hand 6×4 Osteoradionecrosis Mandible 16 × 8 Osteoradionecrosis Mandible 15 × 6 Dermatofibrosarcoma Back 20 × 6 Osteomyelitis Back 6×4
14 5 7.5 6 6.5 6 7.5 6 7.5 4
Type
Complications
Pedicled None Pedicled None Pedicled Wound dehiscence Pedicled None Pedicled Wound dehiscence Free None Free None Free None Free Conversion to free flap Pedicled None
Follow-Up (mo) 28 15 36 14 13 12 24 36 53 4
M, male; F, female.
Case 6 A 37-year-old man presented with a first-web-space contracture of the right hand. After contracture release, there was a resulting deep defect measuring 6 × 4 cm (Fig. 4, above, left). This defect was successfully reconstructed with a free trapezius perforator flap based on a perforator of the dorsal scapular artery (Fig. 4, above, right), which was anastomosed to the superficial branch of radial artery at the level of the anatomical snuffbox. The flap survived completely, with no complications (Fig. 4, below, left). After one debulking procedure, an excellent functional and cosmetic result was achieved (Fig. 4, below, right).
DISCUSSION A number of studies have reported on the use of the trapezius myocutaneous flap as a pedicled or free flap in the reconstruction of a variety of defects (Table 2).4,8,9,10,17,19,20 However, in the interests of minimizing the donor-site morbidity and
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decreasing flap bulk, we propose that the raising of true trapezius perforator flaps, with the subsequent preservation of trapezius integrity, is a superior and indeed reliable technique. Although some anatomical variations do exist with regard to the vessels that supply the skin overlying the trapezius, by using a free-style technique of perforator dissection, these anatomical inconsistencies can be overcome, and indeed do not impact on one’s ability to harvest this tissue. Raising a skin flap in a free-style method entails perforator localization using a hand-held Doppler probe, followed by perforator identification and retrograde intramuscular dissection until sufficient pedicle length and size have been achieved. This sequence of steps remains unchanged regardless of any variation in the anatomy of the vessels.
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Fig. 3. (Above, left) Large Marjolin ulcer located on the right upper back with left trapezius perforator flap marked. (Above, right) Wide local excision of the Marjolin ulcer with elevation of the trapezius perforator flap. (Below, left) True trapezius perforator flap raised on a single perforator of the dorsal scapular artery. (Below, right) Result at 36-month follow-up demonstrating full range of shoulder movement.
The use of the dorsal scapular artery as the pedicle to the trapezius flap was originally described by Tan and Tan in 2000.19 In 2009, the same authors described the use of the extended lower trapezius myocutaneous flap in the reconstruction of shoulder tip defects.21 Although Angrigiani et al. described the flap as the dorsal scapular artery island flap,10 we prefer the term “trapezius perforator flap” because, in the spirit of the free-style perforator philosophy, any skin flap based on a perforating vessel can be raised without necessarily knowing, or being limited by, its nominated parent vessel. In our experience of raising true trapezius perforator flaps, we were able to provide excellent like-for-like tissue for regional back and nuchal defects. The donor sites could be closed primarily and the resultant scars were inconspicuous. We
feel that for central defects of the upper back and cervical spine, a pedicled trapezius flap, raised in the fashion described in this article, provides an unparalleled and reliable reconstructive option. In addition, in those select patients in whom the more conventional sites of free flap harvest have been exhausted, as in cases 7 and 8, the trapezius perforator flap represents a versatile salvage option. Significantly, as reported by Lynch et al. in 2002, an absolute contraindication to a pedicled lower trapezius musculocutaneous flap is previous surgery that has compromised the transverse cervical artery or its origin.20 In these situations, which is not uncommon in salvage head and neck surgery, a trapezius perforator flap can still be relied on because of its collateral supply from the occipital, circumflex scapular, and posterior intercostal vessels.
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Fig. 4. (Above, left) First-web-space contracture of right hand after release. (Above, right) Marking of a trapezius perforator flap after perforator mapping with a hand-held Doppler probe. (Below, left) Immediate postoperative result. (Below, right) Final result after one debulking procedure.
Table 2. Summary of Published Reports Using the Trapezius Myocutaneous/Fasciocutaneous Flap Country
Present study sites, 2014 Tan and Tan, 200919 Hafezi et al., 20089
Taiwan
Present study
10
Singapore
Ann Plast Surg.
3
Iran
Ann Plast Surg.
15
Plast Reconstr Surg.
41
Plast Reconstr Surg.
9
Plast Reconstr Surg.
5
Plast Reconstr Surg.
32
Plast Reconstr Surg.
13
Japan Ogawa et al., 20068 Turkey Uğurlu et al., 20044 Austria Haas et al., 200417 Argentina Angrigiani et al., 200310 United States Lynch et al., 200220
Source
No. of Patients
Reference
Regarding the thickness of the trapezius perforator flap, we found that this was comparable to other fasciocutaneous flaps raised from the back,
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Type of Flap
Pedicle
Perforator flap Dorsal scapular pedicled/free artery Myocutaneous Dorsal scapular pedicled artery Traditional Descending branch fasciocutaneous of superficial cervical artery Myocutaneous Superficial pedicled cervical artery Myocutaneous Superficial pedicled cervical artery Myocutaneous Dorsal scapular pedicled/free artery Myocutaneous Dorsal scapular pedicled artery Myocutaneous Descending branch pedicled of superficial cervical artery
Site of Defect Head, neck, and back and distant Shoulder tip Head and neck Head and neck Head and neck Head and neck Head, neck, and anterior chest Posterior neck and occiput
namely, the parascapular, scapular, and thoracodorsal artery perforator flaps. This can be advantageous in the setting of salvage head and neck
Volume 134, Number 3 • Trapezius Perforator Flap reconstruction, as the relatively thick dermis of the back can help to fill contour defects caused by radiotherapy changes and surgical scarring, and in providing robust cover to hardware used in mandibular fixation. With regard to case 6, the defect of the first web after scar release was very deep, and the trapezius perforator flap provided good bulk to fill this; however, one debulking procedure was indeed required to achieve the final result. In this series, we dissected the superficial branch of the dorsal scapular artery only to the level at which it passed under the medial border of the scapula. In our experience, unless a longer pedicle is desired, attempting to dissect under the scapula is difficult and carries a risk of vessel damage and should be avoided if possible. Indeed, in case 9, we changed our original plan to perform a pedicled trapezius perforator flap to a contralateral back defect after realizing that the pedicle length was inadequate. Rather than continue dissecting under the medial scapular border, we opted to simply transfer the flap as a free flap. No complications were encountered and the donor site was closed directly. This case illustrates that the pedicle length can be unpredictable. Indeed, a disadvantage with freestyle flaps is the inability to accurately predict pedicle length preoperatively. In addition, the possibility of inaccurately mapping a cutaneous perforator or damaging the delicate vessel during the intramuscular dissection exists, and the importance of always having a reliable back-up strategy must be stressed. We recommend always marking two perforating vessels before making the skin incision, as this additional perforator can act as a lifeboat in the event of vessel damage. So what are the advantages of this flap over other flaps that can be raised from the back, namely, the scapular, parascapular, and thoracodorsal
artery perforator flaps? Well, with regard to pedicle length, in our series, we achieved lengths of up to 14 cm. In contrast, the pedicle of the scapular and parascapular flaps is relatively short at 5 to 6 cm.16 Pedicle length with a thoracodorsal artery perforator flap is comparable to that of a trapezius perforator flap; however, the donor scar of a trapezius perforator flap does not encroach onto the flank, unlike that of the thoracodorsal artery perforator flap, and is therefore very easily concealed under clothes even when wearing sleeveless low-cut tops. In addition, when raised as an island pedicle flap, a trapezius perforator flap can reach defects on the occiput, nuchal, and spinal areas, all of which are beyond the arc of rotation of the scapular, parascapular, and thoracodorsal artery perforator flaps. For us, this represents a distinct advantage of this flap, as for these defects a true like-for-like tissue replacement is provided. Moreover, as the trapezius perforator flap is based on perforators of the dorsal scapular artery, it represents a flap option that is independent of the subscapular system. It can be therefore be relied on when the ipsilateral subscapular system is unavailable or unreliable, such as after ipsilateral latissimus dorsi harvest, unlike the scapular, parascapular, and thoracodorsal artery perforator flaps. Furthermore, the trapezius perforator flap can also provide a convenient back-up option in the event of pedicle damage during harvest of a thoracodorsal artery perforator flap, as the trapezius perforators are located within the same surgical field as those of the thoracodorsal artery. The trapezius perforator flap is compared with the scapular, parascapular, and thoracodorsal artery perforator flaps in Table 3. In our opinion, the most significant advantage of using a true trapezius perforator flap when reconstructing a regional or indeed a distant
Table 3. Comparison of the Pedicled Trapezius Perforator, Thoracodorsal Artery Perforator, and Scapular and Parascapular Flaps Flap Pedicle length, cm Pedicle caliber, mm Skin paddle size, cm Donor site Arc of rotation
Trapezius Perforator Flap 7* 1.95§║ 25 × 15 (largest in our series) Direct closure Ipsilateral and contralateral upper back, spinal, nuchal, and occipital regions
TDAP Flap 15† 2.5† 25 × 15¶ Direct closure Ipsilateral flank and axilla
Scapular/Parascapular Flaps 5–6‡ 2.5‡ 20 × 7‡ Direct closure Ipsilateral shoulder, axilla, and lateral thoracic wall
TDAP, thoracodorsal artery perforator. *Mean from our series. †From Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg. 1995;96:1608–1614. ‡From Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy and Technique. New York: Churchill Livingstone; 1997. §Caliber of vessel as measured at level of levator scapulae muscle (2.7 mm at origin as it branches from subclavian). ║From Haas F, Weiglein A, Schwarzl F, Scharnagl E. The lower trapezius musculocutaneous flap from pedicled to free flap: Anatomical basis and clinical applications based on the dorsal scapular artery. Plast Reconstr Surg. 2004;113:1580–1590. ¶From Hwang JH, Lim, SY, Pyon JK, Bang SI, Oh KS, Mun GH. Reliable harvesting of a large thoracodorsal artery perforator flap with emphasis on perforator number and spacing. Plast Reconstr Surg. 2011;128:140e–150e.
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Plastic and Reconstructive Surgery • September 2014 defect is the total preservation of trapezius integrity. None of our patients developed any shoulder weakness, drooping, or winging of the scapula as a result, and no postoperative seromas were identified. As with all true perforator flaps, the underlying muscle is preserved and as such the donor-site morbidity is kept to a minimum. Along with the principle of replacing like tissue with like tissue, the preservation of donor-site integrity with a minimal, easily concealed scar burden is what we should be striving to achieve in this current era of reconstruction.22
CONCLUSIONS In summary, in our series of 10 trapezius perforator flaps raised to reconstruct a range of softtissue defects, we found the flap reliable and easy to raise and the donor-site morbidity minimal with an easily concealed scar burden. It should be considered for patients undergoing salvage head and neck reconstruction, patients with nuchal or spinal soft-tissue defects of the upper back, and patients who want to avoid the donor-site scarring associated with more conventional flap options. Seng-Feng Jeng, M.D. Department of Plastic Surgery E-Da Hospital No. 1, Yi-Da Road Jiao-Su Village Yan-Chao District Kaohsiung 824, Taiwan [email protected]
REFERENCES 1. Nakajima H, Fujino T. Island fasciocutaneous flaps of dorsal trunk and their application to myocutaneous flap. Keio J Med. 1984;33:59–82. 2. Hyakusoku H, Yoshida H, Okubo M, Hirai T, Fumiiri M. Superficial cervical artery skin flaps. Plast Reconstr Surg. 1990;86:33–38. 3. Hyakusoku H, Takizawa Y, Murakami M, Gao JH, Takekoshi A, Fumiiri M. Versatility of the free or pedicled superficial cervical artery skin flaps in head and neck burns. Burns 1993;19:168–173. 4. Uğurlu K, Ozçelik D, Hüthüt I, Yildiz K, Kilinç L, Baş L. Extended vertical trapezius myocutaneous flap in head and neck reconstruction as a salvage procedure. Plast Reconstr Surg. 2004;114:339–350.
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5. Rosen HM. The extended trapezius musculocutaneous flap for cranio-orbital facial reconstruction. Plast Reconstr Surg. 1985;75:318–327. 6. Demergasso F, Piazza MV. Trapezius myocutaneous flap in reconstructive surgery for head and neck cancer: An original technique. Am J Surg. 1979;138:533–536. 7. Baek SM, Biller HF, Krespi YP, Lawson W. The lower trapezius island myocutaneous flap. Ann Plast Surg. 1980;5:108–114. 8. Ogawa R, Murakami M, Vinh VQ, Hyakusoku H. Clinical and anatomical study of superficial cervical artery flaps: Retrospective study of reconstructions with 41 flaps and the feasibility of harvesting them as perforator flaps. Plast Reconstr Surg. 2006;118:95–101. 9. Hafezi F, Naghibzadeh B, Pegahmehr M, Boddouhi N, Nouhi A. Extended vertical trapezius fasciocutaneous flap (back flap) in face and neck burn scar reconstruction. Ann Plast Surg. 2008;61:441–446. 10. Angrigiani C, Grilli D, Karanas YL, Longaker MT, Sharma S. The dorsal scapular island flap: An alternative for head, neck, and chest reconstruction. Plast Reconstr Surg. 2003;111:67–78. 11. Koshima I, Higaki H, Soeda S. Combined vascularized fibula and peroneal composite-flap transfer for severe heat-press injury of the forearm. Plast Reconstr Surg. 1991;88:338–341. 12. Feng KM, Hsieh CH, Jeng SF. Free-style puzzle flap: The concept of recycling a perforator flap. Plast Reconstr Surg. 2013;131:258–263. 13. Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: A further step forward for perforator flap surgery. Plast Reconstr Surg. 2009;124:e419–426. 14. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg. 2004;114:910–916. 15. Wei FC, Jain V, Suominen S, Chen HC. Confusion among perforator flaps: What is a true perforator flap? Plast Reconstr Surg. 2001;107:874–876. 16. Mathes SJ, Nahai F. Clinical Atlas of Muscle and Musculocutaneous Flaps. St. Louis, Mo: Mosby; 1979. 17. Haas F, Weiglein A, Schwarzl F, Scharnagl E. The lower trapezius musculocutaneous flap from pedicled to free flap: Anatomical basis and clinical applications based on the dorsal scapular artery. Plast Reconstr Surg. 2004;113:1580–1590. 18. Federative Committee on Anatomical Terminology. Terminologia Anatomica: International Anatomical Terminology. Stuttgart: Thieme; 1998. 19. Tan KC, Tan BK. Extended lower trapezius island myocutaneous flap: A fasciomyocutaneous flap based on the dorsal scapular artery. Plast Reconstr Surg. 2000;105:1758–1763. 20. Lynch JR, Hansen JE, Chaffoo R, Seyfer AE. The lower trapezius musculocutaneous flap revisited: Versatile coverage for complicated wounds to the posterior cervical and occipital regions based on the deep branch of the transverse cervical artery. Plast Reconstr Surg. 2002;109:444–450. 21. Rasheed MZ, Tan BK, Tan KC. The extended lower trapezius flap for the reconstruction of shoulder tip defects. Ann Plast Surg. 2009;63:184–187. 22. Jeng SF, Tan NC. Optimizing aesthetic and functional outcomes at donor sites. Chang Gung Med J. 2012;35:219–230.
Background: The trapezius myocutaneous flap is an established reconstructive option in head and neck cases The authors present their experience with 10 trapezius perforator flaps, all raised using a freestyle technique of perforator dissection, to successfully reconstruct both local and distant soft-tissue defects. Methods: Ten patients underwent soft-tissue reconstruction using trapezius perforator flaps. After mapping the perforator with a handheld Doppler device at the intersection of a horizontal line drawn 6 to 8 cm inferior to the scapular spine and a vertical line drawn 8 to 9 cm lateral to the midline of the back, perforator flaps were raised in a freestyle fashion, with complete preservation of the trapezius muscle. The flap can be pedicled into local defects or transferred as a free flap. Results: Six flaps were elevated as pedicled flaps and four were transferred as free flaps. Flap size ranged from 6 × 4 cm to 25 × 15 cm. The pedicle length ranged from 4 to 14 cm. The pedicle originated from the dorsal scapular artery. In one case, the authors converted from a pedicled flap to a free flap secondary to insufficient pedicle length. All donor sites were closed directly. The follow-up period ranged from 4 months to 4 years. All of the flaps survived completely with no major complications, and no patients developed any shoulder dysfunction. Conclusions: The trapezius perforator flap is a reliable and versatile reconstructive option that can be used to repair both local and distant soft-tissue defects. The donor-site morbidity is minimal. (Plast. Reconstr. Surg. 134: 449e, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
T
he myocutaneous trapezius flap based on the superficial cervical artery was first described by Nakajima and Fujino in 1984.1 It was then developed by Hyakusoku et al. in 1990 as a skin flap for reconstruction of large neck defects after the release of burn scar contractures.2 A number of authors have since published results using the trapezius as a myocutaneous flap in the setting of salvage head and neck reconstruction.3–9 In these situations, the soft tissues of the back represent an area of the body that has normally been spared from the effects of radiotherapy and previous From the Departments of Plastic Surgery and Management, E-Da Hospital, I-Shou University; and the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital. Received for publication October 19, 2013; accepted February 26, 2014. The first two authors contributed equally to this work. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000430
flap harvest. The relative underuse of the trapezius myocutaneous flap in situations other than in salvage head and neck reconstruction may be because of the fear of impacting on trapezius muscle function or because of an unfamiliar knowledge of the relevant vascular anatomy. In 2003, Angrigiani et al. reported on the use of harvesting lower medial back tissue as an island flap based on the dorsal scapular artery to reconstruct defects of the head, neck, and chest. However, some muscle was included in the flap in all cases.10 With the advent of the perforator flap concept11 and the trend toward the technique of free-style perforator dissection,12–14 with subsequent preservation of donor-site integrity, it has become possible to raise “true”15 trapezius perforator flaps and to preserve total integrity of the trapezius muscle. In this study, we aim to share our Disclosure: The authors have no financial interest to declare in relation to the content of this article.
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Plastic and Reconstructive Surgery • September 2014 experience with the use of 10 trapezius perforator flaps, revisit the relevant surgical anatomy, and discuss the advantages and clinical indications of this flap over its more conventional counterparts. Surgical Anatomy The trapezius muscle takes its origin from the occiput, seventh cervical vertebra, and all thoracic vertebrae, and inserts into the acromion, spine of the scapula, and clavicle. It is innervated by the accessory nerve and functions to raise the shoulder girdle and to assist in shoulder rotation. According to the Mathes and Nahai classification,16 the trapezius muscle has a type 2 vascular supply, with the dominant inflow arising from the transverse cervical artery and with minor pedicles arising from intercostal, circumflex scapular, and occipital perforators. In an anatomical study of 124 cadavers by Haas et al.,17 it was noted that the upper part of the trapezius muscle is supplied by branches of the occipital artery, the middle and lateral parts by the superficial cervical artery, and the lower portion by the dorsal scapular artery. The vascular anatomy of the trapezius muscle and its overlying skin can be confusing because of the various names used to describe similar vessels in this region, and the anatomical variation in which the vessels branch from the subclavian artery. According to the Terminologia Anatomica,18 the transverse cervical artery is defined as the arterial trunk that gives rise to the superficial cervical and dorsal scapular arteries, and although various branching patterns are seen at the origin of this artery with the subclavian, this does not influence the surgical procedure when raising a trapezius perforator flap. What is of importance is the manner in which these vessels descend the back before perforating the trapezius to enter into the subcutaneous tissue. The superficial cervical artery initially runs lateral to the levator scapulae and rhomboid muscles before coursing medially to give a short ascending and long descending branch that runs to the level of the scapular spine. With a caliber greater than 0.7 mm, it always descends superficial to the levator scapulae and the rhomboids and is accompanied by branches of the accessory nerve.8 The dorsal scapular artery, in contrast, runs deep to the levator scapulae and rhomboid minor before a branch pierces the fascia between the rhomboid minor and major to run along the medial border of the scapula (superficial dorsal scapular artery) before appearing under the trapezius muscle. This superficial branch runs on the deep belly of the trapezius, perfusing the muscle and consistently giving off one or two cutaneous
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perforators that pierce the lower trapezius to supply the overlying skin 1 to 2 cm medial to its lateral edge (Fig. 1).10 The average caliber of the dorsal scapular artery is 2.7 mm proximally at its origin and 1.95 mm at the level of the levator scapulae muscle.17 A deep branch of the dorsal scapular artery continues to descend under the rhomboid major, which largely supplies muscular perforators to the rhomboids, but can supply perforators penetrating the overlying trapezius muscle to reach the skin.10
PATIENTS AND METHODS Patients and Dissection Technique Patients selected for trapezius perforator flap reconstruction were those with central upper back defects, those who had exhausted other sites of flap harvest, or those who wanted to avoid the donor-site scarring associated with more conventional flaps. All patients were positioned in the lateral decubitus position with the ipsilateral arm draped free to allow its mobility during flap harvest, before undergoing perforator mapping with hand-held Doppler ultrasound. The cutaneous perforators are usually located at the intersection of a horizontal line drawn 6 to 8 cm inferior to the scapular spine and a vertical line drawn 8 to 9 cm lateral to the midline of the back.10 The flap design is then marked on the back, depending on the size and shape of the defect. An incision is made along the lateral margin of the flap, and dissection proceeds from lateral to medial, superficial to the deep fascia, until the lateral border of the trapezius is encountered. At this point, under loupe magnification, care is taken to identify the perforator(s) piercing the muscle to enter the skin. Meticulous hemostasis is imperative at this stage to avoid blood staining of the tissues and maintain clear visualization of the perforating vessels. When a sizable perforator is identified, dissection then proceeds in a retrograde manner using a deroofing technique. Numerous muscular branches will need to be carefully ligated during the intramuscular dissection and care must be taken to avoid stretching or excessive handling of the vessel. In our experience, the visible pulsation of the perforator throughout its length is the most reliable way of confirming that the vessel is uninjured and safely supplies the overlying skin flap. In our series, the pedicle was skeletonized to the level at which it ascended under the cover of the medial scapular border, as this provided us with an adequate pedicle length
Volume 134, Number 3 • Trapezius Perforator Flap
Fig. 1. Surgical anatomy relevant to the raising of a trapezius perforator flap.
in all of our cases. Further proximal dissection is difficult and risks damage to the vessel; however, if a longer pedicle length is required, dissection can continue to the superior border of the rhomboid major muscle, followed by ligation of the deep branch of the dorsal scapular artery if an even longer pedicle is required.17 It has also been reported that the rhomboid minor muscle can be divided or the flap even tunneled under the levator scapulae to further increase the arc of rotation to reach defects on the face.17 Once pedicle dissection is complete, the trapezius perforator flap can be transposed into a regional defect or transferred as a free flap using microsurgical techniques (Fig. 2).
RESULTS Between December of 2005 and May of 2013, 10 patients underwent trapezius perforator flap reconstruction at our institution (Table 1). The mean age of the patients was 44.3 years (range, 28 to 55 years) and the harvested skin paddle size ranged from 6 × 4 cm to 25 × 15 cm. Six flaps were used as pedicled flaps to reconstruct a range of defects on the back and neck, whereas four flaps were raised as free flaps to reconstruct defects of back, mandible, and a first-web-space contracture of the hand. In one case (patient 9), the initial plan was to use the trapezius perforator flap as a pedicled flap in the reconstruction of a contralateral back defect. However, because of inadequate pedicle length, we
converted to a free flap. The pedicle length ranged from 4 to 14 cm, with a mean of 7 cm, and all flaps were based on a single perforator of the dorsal scapular artery. A sizable perforator was encountered in all cases (caliber at least 0.5 mm in diameter) and the donor sites were all closed primarily; however, postoperative wound dehiscence necessitating return to the operating room for closure was encountered in patients 3 and 5. All of the flaps survived completely and no patients developed any postoperative shoulder weakness or winging of the scapula during a follow-up period that ranged from 4 months to 4 years. Donor-site scars were all located close to the mid back and as such were not visible to the patients. Indeed, in all cases, the patients reported no functional or cosmetic concerns with regard to the donor site.
CASE REPORTS Case 3 A 46-year-old male worker presented with a large Marjolin ulcer on his upper right back (Fig. 3, above, left). After wide local excision, a 25 × 10-cm pedicled trapezius perforator flap (Fig. 3, above, right) based on a perforator of the superficial branch of the dorsal scapular artery (Fig. 3, below, left) was used for reconstruction. Total preservation of the trapezius muscle was achieved. The donor site was closed primarily; however, postoperative wound dehiscence was encountered, which necessitated a return to the operating room for delayed primary closure 1 week later. The wound healed well and the flap tolerated the subsequent radiotherapy with no complications. No weakness in shoulder abduction was identified at a postoperative follow-up of 36 months (Fig. 3, below, right).
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Fig. 2. Patient in the lateral decubitus position with a trapezius perforator flap raised on a single perforator of the superficial branch of the dorsal scapular artery.
Table 1. Summary of Our Trapezius Perforator Flap Series Age Case (yr) Sex 1 2 3 4 5 6 7 8 9 10
42 30 46 28 55 37 52 50 33 70
M M M F F M M F M M
Diagnosis
Site
Flap Size Pedicle (cm) Length (cm)
Chronic ulcer Nuchal 15 × 7 Dermatofibrosarcoma Back 10 × 8 Marjolin’s ulcer Back 25 × 10 Malignant neurofibromatosis Back 25 × 15 Dermatofibrosarcoma Back 15 × 7 First-web-space contracture Hand 6×4 Osteoradionecrosis Mandible 16 × 8 Osteoradionecrosis Mandible 15 × 6 Dermatofibrosarcoma Back 20 × 6 Osteomyelitis Back 6×4
14 5 7.5 6 6.5 6 7.5 6 7.5 4
Type
Complications
Pedicled None Pedicled None Pedicled Wound dehiscence Pedicled None Pedicled Wound dehiscence Free None Free None Free None Free Conversion to free flap Pedicled None
Follow-Up (mo) 28 15 36 14 13 12 24 36 53 4
M, male; F, female.
Case 6 A 37-year-old man presented with a first-web-space contracture of the right hand. After contracture release, there was a resulting deep defect measuring 6 × 4 cm (Fig. 4, above, left). This defect was successfully reconstructed with a free trapezius perforator flap based on a perforator of the dorsal scapular artery (Fig. 4, above, right), which was anastomosed to the superficial branch of radial artery at the level of the anatomical snuffbox. The flap survived completely, with no complications (Fig. 4, below, left). After one debulking procedure, an excellent functional and cosmetic result was achieved (Fig. 4, below, right).
DISCUSSION A number of studies have reported on the use of the trapezius myocutaneous flap as a pedicled or free flap in the reconstruction of a variety of defects (Table 2).4,8,9,10,17,19,20 However, in the interests of minimizing the donor-site morbidity and
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decreasing flap bulk, we propose that the raising of true trapezius perforator flaps, with the subsequent preservation of trapezius integrity, is a superior and indeed reliable technique. Although some anatomical variations do exist with regard to the vessels that supply the skin overlying the trapezius, by using a free-style technique of perforator dissection, these anatomical inconsistencies can be overcome, and indeed do not impact on one’s ability to harvest this tissue. Raising a skin flap in a free-style method entails perforator localization using a hand-held Doppler probe, followed by perforator identification and retrograde intramuscular dissection until sufficient pedicle length and size have been achieved. This sequence of steps remains unchanged regardless of any variation in the anatomy of the vessels.
Volume 134, Number 3 • Trapezius Perforator Flap
Fig. 3. (Above, left) Large Marjolin ulcer located on the right upper back with left trapezius perforator flap marked. (Above, right) Wide local excision of the Marjolin ulcer with elevation of the trapezius perforator flap. (Below, left) True trapezius perforator flap raised on a single perforator of the dorsal scapular artery. (Below, right) Result at 36-month follow-up demonstrating full range of shoulder movement.
The use of the dorsal scapular artery as the pedicle to the trapezius flap was originally described by Tan and Tan in 2000.19 In 2009, the same authors described the use of the extended lower trapezius myocutaneous flap in the reconstruction of shoulder tip defects.21 Although Angrigiani et al. described the flap as the dorsal scapular artery island flap,10 we prefer the term “trapezius perforator flap” because, in the spirit of the free-style perforator philosophy, any skin flap based on a perforating vessel can be raised without necessarily knowing, or being limited by, its nominated parent vessel. In our experience of raising true trapezius perforator flaps, we were able to provide excellent like-for-like tissue for regional back and nuchal defects. The donor sites could be closed primarily and the resultant scars were inconspicuous. We
feel that for central defects of the upper back and cervical spine, a pedicled trapezius flap, raised in the fashion described in this article, provides an unparalleled and reliable reconstructive option. In addition, in those select patients in whom the more conventional sites of free flap harvest have been exhausted, as in cases 7 and 8, the trapezius perforator flap represents a versatile salvage option. Significantly, as reported by Lynch et al. in 2002, an absolute contraindication to a pedicled lower trapezius musculocutaneous flap is previous surgery that has compromised the transverse cervical artery or its origin.20 In these situations, which is not uncommon in salvage head and neck surgery, a trapezius perforator flap can still be relied on because of its collateral supply from the occipital, circumflex scapular, and posterior intercostal vessels.
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Fig. 4. (Above, left) First-web-space contracture of right hand after release. (Above, right) Marking of a trapezius perforator flap after perforator mapping with a hand-held Doppler probe. (Below, left) Immediate postoperative result. (Below, right) Final result after one debulking procedure.
Table 2. Summary of Published Reports Using the Trapezius Myocutaneous/Fasciocutaneous Flap Country
Present study sites, 2014 Tan and Tan, 200919 Hafezi et al., 20089
Taiwan
Present study
10
Singapore
Ann Plast Surg.
3
Iran
Ann Plast Surg.
15
Plast Reconstr Surg.
41
Plast Reconstr Surg.
9
Plast Reconstr Surg.
5
Plast Reconstr Surg.
32
Plast Reconstr Surg.
13
Japan Ogawa et al., 20068 Turkey Uğurlu et al., 20044 Austria Haas et al., 200417 Argentina Angrigiani et al., 200310 United States Lynch et al., 200220
Source
No. of Patients
Reference
Regarding the thickness of the trapezius perforator flap, we found that this was comparable to other fasciocutaneous flaps raised from the back,
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Type of Flap
Pedicle
Perforator flap Dorsal scapular pedicled/free artery Myocutaneous Dorsal scapular pedicled artery Traditional Descending branch fasciocutaneous of superficial cervical artery Myocutaneous Superficial pedicled cervical artery Myocutaneous Superficial pedicled cervical artery Myocutaneous Dorsal scapular pedicled/free artery Myocutaneous Dorsal scapular pedicled artery Myocutaneous Descending branch pedicled of superficial cervical artery
Site of Defect Head, neck, and back and distant Shoulder tip Head and neck Head and neck Head and neck Head and neck Head, neck, and anterior chest Posterior neck and occiput
namely, the parascapular, scapular, and thoracodorsal artery perforator flaps. This can be advantageous in the setting of salvage head and neck
Volume 134, Number 3 • Trapezius Perforator Flap reconstruction, as the relatively thick dermis of the back can help to fill contour defects caused by radiotherapy changes and surgical scarring, and in providing robust cover to hardware used in mandibular fixation. With regard to case 6, the defect of the first web after scar release was very deep, and the trapezius perforator flap provided good bulk to fill this; however, one debulking procedure was indeed required to achieve the final result. In this series, we dissected the superficial branch of the dorsal scapular artery only to the level at which it passed under the medial border of the scapula. In our experience, unless a longer pedicle is desired, attempting to dissect under the scapula is difficult and carries a risk of vessel damage and should be avoided if possible. Indeed, in case 9, we changed our original plan to perform a pedicled trapezius perforator flap to a contralateral back defect after realizing that the pedicle length was inadequate. Rather than continue dissecting under the medial scapular border, we opted to simply transfer the flap as a free flap. No complications were encountered and the donor site was closed directly. This case illustrates that the pedicle length can be unpredictable. Indeed, a disadvantage with freestyle flaps is the inability to accurately predict pedicle length preoperatively. In addition, the possibility of inaccurately mapping a cutaneous perforator or damaging the delicate vessel during the intramuscular dissection exists, and the importance of always having a reliable back-up strategy must be stressed. We recommend always marking two perforating vessels before making the skin incision, as this additional perforator can act as a lifeboat in the event of vessel damage. So what are the advantages of this flap over other flaps that can be raised from the back, namely, the scapular, parascapular, and thoracodorsal
artery perforator flaps? Well, with regard to pedicle length, in our series, we achieved lengths of up to 14 cm. In contrast, the pedicle of the scapular and parascapular flaps is relatively short at 5 to 6 cm.16 Pedicle length with a thoracodorsal artery perforator flap is comparable to that of a trapezius perforator flap; however, the donor scar of a trapezius perforator flap does not encroach onto the flank, unlike that of the thoracodorsal artery perforator flap, and is therefore very easily concealed under clothes even when wearing sleeveless low-cut tops. In addition, when raised as an island pedicle flap, a trapezius perforator flap can reach defects on the occiput, nuchal, and spinal areas, all of which are beyond the arc of rotation of the scapular, parascapular, and thoracodorsal artery perforator flaps. For us, this represents a distinct advantage of this flap, as for these defects a true like-for-like tissue replacement is provided. Moreover, as the trapezius perforator flap is based on perforators of the dorsal scapular artery, it represents a flap option that is independent of the subscapular system. It can be therefore be relied on when the ipsilateral subscapular system is unavailable or unreliable, such as after ipsilateral latissimus dorsi harvest, unlike the scapular, parascapular, and thoracodorsal artery perforator flaps. Furthermore, the trapezius perforator flap can also provide a convenient back-up option in the event of pedicle damage during harvest of a thoracodorsal artery perforator flap, as the trapezius perforators are located within the same surgical field as those of the thoracodorsal artery. The trapezius perforator flap is compared with the scapular, parascapular, and thoracodorsal artery perforator flaps in Table 3. In our opinion, the most significant advantage of using a true trapezius perforator flap when reconstructing a regional or indeed a distant
Table 3. Comparison of the Pedicled Trapezius Perforator, Thoracodorsal Artery Perforator, and Scapular and Parascapular Flaps Flap Pedicle length, cm Pedicle caliber, mm Skin paddle size, cm Donor site Arc of rotation
Trapezius Perforator Flap 7* 1.95§║ 25 × 15 (largest in our series) Direct closure Ipsilateral and contralateral upper back, spinal, nuchal, and occipital regions
TDAP Flap 15† 2.5† 25 × 15¶ Direct closure Ipsilateral flank and axilla
Scapular/Parascapular Flaps 5–6‡ 2.5‡ 20 × 7‡ Direct closure Ipsilateral shoulder, axilla, and lateral thoracic wall
TDAP, thoracodorsal artery perforator. *Mean from our series. †From Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg. 1995;96:1608–1614. ‡From Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy and Technique. New York: Churchill Livingstone; 1997. §Caliber of vessel as measured at level of levator scapulae muscle (2.7 mm at origin as it branches from subclavian). ║From Haas F, Weiglein A, Schwarzl F, Scharnagl E. The lower trapezius musculocutaneous flap from pedicled to free flap: Anatomical basis and clinical applications based on the dorsal scapular artery. Plast Reconstr Surg. 2004;113:1580–1590. ¶From Hwang JH, Lim, SY, Pyon JK, Bang SI, Oh KS, Mun GH. Reliable harvesting of a large thoracodorsal artery perforator flap with emphasis on perforator number and spacing. Plast Reconstr Surg. 2011;128:140e–150e.
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Plastic and Reconstructive Surgery • September 2014 defect is the total preservation of trapezius integrity. None of our patients developed any shoulder weakness, drooping, or winging of the scapula as a result, and no postoperative seromas were identified. As with all true perforator flaps, the underlying muscle is preserved and as such the donor-site morbidity is kept to a minimum. Along with the principle of replacing like tissue with like tissue, the preservation of donor-site integrity with a minimal, easily concealed scar burden is what we should be striving to achieve in this current era of reconstruction.22
CONCLUSIONS In summary, in our series of 10 trapezius perforator flaps raised to reconstruct a range of softtissue defects, we found the flap reliable and easy to raise and the donor-site morbidity minimal with an easily concealed scar burden. It should be considered for patients undergoing salvage head and neck reconstruction, patients with nuchal or spinal soft-tissue defects of the upper back, and patients who want to avoid the donor-site scarring associated with more conventional flap options. Seng-Feng Jeng, M.D. Department of Plastic Surgery E-Da Hospital No. 1, Yi-Da Road Jiao-Su Village Yan-Chao District Kaohsiung 824, Taiwan [email protected]
REFERENCES 1. Nakajima H, Fujino T. Island fasciocutaneous flaps of dorsal trunk and their application to myocutaneous flap. Keio J Med. 1984;33:59–82. 2. Hyakusoku H, Yoshida H, Okubo M, Hirai T, Fumiiri M. Superficial cervical artery skin flaps. Plast Reconstr Surg. 1990;86:33–38. 3. Hyakusoku H, Takizawa Y, Murakami M, Gao JH, Takekoshi A, Fumiiri M. Versatility of the free or pedicled superficial cervical artery skin flaps in head and neck burns. Burns 1993;19:168–173. 4. Uğurlu K, Ozçelik D, Hüthüt I, Yildiz K, Kilinç L, Baş L. Extended vertical trapezius myocutaneous flap in head and neck reconstruction as a salvage procedure. Plast Reconstr Surg. 2004;114:339–350.
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5. Rosen HM. The extended trapezius musculocutaneous flap for cranio-orbital facial reconstruction. Plast Reconstr Surg. 1985;75:318–327. 6. Demergasso F, Piazza MV. Trapezius myocutaneous flap in reconstructive surgery for head and neck cancer: An original technique. Am J Surg. 1979;138:533–536. 7. Baek SM, Biller HF, Krespi YP, Lawson W. The lower trapezius island myocutaneous flap. Ann Plast Surg. 1980;5:108–114. 8. Ogawa R, Murakami M, Vinh VQ, Hyakusoku H. Clinical and anatomical study of superficial cervical artery flaps: Retrospective study of reconstructions with 41 flaps and the feasibility of harvesting them as perforator flaps. Plast Reconstr Surg. 2006;118:95–101. 9. Hafezi F, Naghibzadeh B, Pegahmehr M, Boddouhi N, Nouhi A. Extended vertical trapezius fasciocutaneous flap (back flap) in face and neck burn scar reconstruction. Ann Plast Surg. 2008;61:441–446. 10. Angrigiani C, Grilli D, Karanas YL, Longaker MT, Sharma S. The dorsal scapular island flap: An alternative for head, neck, and chest reconstruction. Plast Reconstr Surg. 2003;111:67–78. 11. Koshima I, Higaki H, Soeda S. Combined vascularized fibula and peroneal composite-flap transfer for severe heat-press injury of the forearm. Plast Reconstr Surg. 1991;88:338–341. 12. Feng KM, Hsieh CH, Jeng SF. Free-style puzzle flap: The concept of recycling a perforator flap. Plast Reconstr Surg. 2013;131:258–263. 13. Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: A further step forward for perforator flap surgery. Plast Reconstr Surg. 2009;124:e419–426. 14. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg. 2004;114:910–916. 15. Wei FC, Jain V, Suominen S, Chen HC. Confusion among perforator flaps: What is a true perforator flap? Plast Reconstr Surg. 2001;107:874–876. 16. Mathes SJ, Nahai F. Clinical Atlas of Muscle and Musculocutaneous Flaps. St. Louis, Mo: Mosby; 1979. 17. Haas F, Weiglein A, Schwarzl F, Scharnagl E. The lower trapezius musculocutaneous flap from pedicled to free flap: Anatomical basis and clinical applications based on the dorsal scapular artery. Plast Reconstr Surg. 2004;113:1580–1590. 18. Federative Committee on Anatomical Terminology. Terminologia Anatomica: International Anatomical Terminology. Stuttgart: Thieme; 1998. 19. Tan KC, Tan BK. Extended lower trapezius island myocutaneous flap: A fasciomyocutaneous flap based on the dorsal scapular artery. Plast Reconstr Surg. 2000;105:1758–1763. 20. Lynch JR, Hansen JE, Chaffoo R, Seyfer AE. The lower trapezius musculocutaneous flap revisited: Versatile coverage for complicated wounds to the posterior cervical and occipital regions based on the deep branch of the transverse cervical artery. Plast Reconstr Surg. 2002;109:444–450. 21. Rasheed MZ, Tan BK, Tan KC. The extended lower trapezius flap for the reconstruction of shoulder tip defects. Ann Plast Surg. 2009;63:184–187. 22. Jeng SF, Tan NC. Optimizing aesthetic and functional outcomes at donor sites. Chang Gung Med J. 2012;35:219–230.
