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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_816_Библиотеки_им_академика_М_И_Перельмана.pdf
10 Cervicodeltopectoral Flap
Fig. 10.3 CDP ap is
highlighted in light blue
incision. Purple incision
marks the expected skin
defect after cancer
resection. The CDP ap
can be based on second
and third intercoastal
spaces (located inferior to
the corresponding rib).
139
raised supercial to the pectoralis major muscle fascia and the deltoid muscle
fascia, while paying attention to avoid sacricing the pectoralis muscle skin ap
in case the ap is needed in the future (skin medial and inferior to the nipple is
left undisturbed). The superolateral chest, axilla, and anterior deltoid skin are
recruited as a skin ap is then mobilized superiorly to meet the posterior neck/
deltoid skin ap. Towel clamps can be used to help oppose the two skin ap
edges that typically end up in a horizontal orientation near the clavicle. However,
it is best to avoid placing the incision directly over the clavicle to minimize the
risk of bone exposure. If there is excessive tension that prohibits primary closure, typically near the deltopectoral groove or at the site of skin ap trifurcation,
either a split thickness or full thickness skin graft may be employed.
8. Two Jackson Pratt (JP) drains are placed into the neck. One JP drain is placed
from the posterior neck/deltoid skin ap to sit along the posterior neck/inferior
neck gutter. A second JP drain is placed through the superolateral chest/axilla/
deltoid skin ap or from the opposite neck skin ap to sit along the anterior neck/
inferior neck gutter. It is best to avoid placing any drain through the CDP ap as
it can negatively affect the blood supply.
140
Fig. 10.4 Ensure adequate
ap reach by checking
from the posteroinferior
corner of the defect (A) to
the second intercoastal
space and attempting to
reach the superoanterior
most point of
reconstruction (A′). This
line marks the axis of
rotation from
posteroinferior corner of
the defect to meet the
superoanterior aspect of
the defect. The second
limb of the CDP ap
(marked as point C) allows
closure of the donor defect
with local tissue
advancement in vast
majority of cases
N. Vahidi et al.
10 Cervicodeltopectoral Flap
Fig. 10.5 Donor site
closure can be achieved by
advancing the posterior
neck/posterior deltoid skin
ap (E) anteroinferiorly
while moving the lateral
chest/axillary skin/anterior
deltoid skin ap (D)
superiorly for the incision
line to line up near the
level of the clavicle. Be
mindful of not disrupting
the pectoralis
myocutaneous muscle ap
site in case of future
reconstruction needs.
141
Fig. 10.6 Maximal wound tension will commonly occur near the trifurcation (C′, D′, and E′) as
well as along the length of the posterior neck/deltoid skin ap and superior chest/anterior deltoid
skin ap (D′, E′). One should expect wound dehiscence, especially at the trifurcation, to avoid
exposure of critical structures in case of lack of SCM.Best practice is to bring the posterior neck
skin aps (E′) anteriorly closer to the clavicle and along the anterior aspect of the deltoid muscle.
If possible, avoid the ap incision coming together along the top aspect of the trapezius and deltoid
(purple line) to minimize wound dehiscence that can occur from the skin aps falling away from
each other due to gravity
142
N. Vahidi et al.
Important Considerations
– The arch of rotation for the DP ap can limit its use in the head and neck region,
but can be increased by dissecting out the perforators and freeing the parasternal
skin with a back cut.
– If the sternocleidomastoid muscle has been sacriced, one must be mindful of
the potential for great vessel exposure in the event of wound dehiscence. In such
a case, consideration should be taken to drape any remnant sternocleidomastoid
muscle over the great vessels for protection. An alternative option is the pectora-
lis major ap to provide proper muscle bulk to sit on top of the great vessels,
especially if postoperative radiation therapy is anticipated.
Important Dimensions
Skin Island Dimensions
– Length: range 10–30cm.
Artery
2nd or 3rd perforating branches of internal mammary artery (dominant)
– Length~1.5cm, diameter~1mm.
1st and 4th perforating branches of internal mammary artery (minor)
– Length~1.5cm, diameter~0.7mm.
Direct cutaneous artery that arises from thoracoacromial system (minor)
– Provides the blood supply to skin lateral to the deltopectoral groove (this area is
not typically included as part of the CDP ap but is typically used for donor site
closure).
Vein
Vena comitans
– Primary vena comitans accompanying artery: length ~1.5 cm,
diameter~2.5mm.
Nerve
Supraclavicular and intercostal nerves
– Sensory innervation comes from the supraclavicular nerves (C3 and C4) and the
anterolateral intercostal nerves (T2, T3, and T4).
– There is no motor innervation for this ap.
10 Cervicodeltopectoral Flap
143
Cervicodeltopectoral Flap Usage
The CDP ap can be used to reconstruct defects of the face and neck up to the level
of the zygoma. It offers a skin ap with appropriate color and thickness match for
cutaneous cervicofacial defects.
– Reconstruction of facial or neck cutaneous defects.
– Reconstruction of intraoral defects (buccal mucosa, oor of mouth) or pharyn-
geal defects, although there is a higher risk of ap necrosis from salivary expo-
sure. Thus, use of the CDP ap is generally discouraged where there is a potential
for salivary exposure.
Complications
There is an insufcient number of studies reporting complications after CDP ap
usage. Ducic and Smith report that 2 out of 18 patients had partial ap necrosis
which was managed successfully with conservative therapy (0.25% acetic acid
wound dressing changes) [2]. In situations of wound dehiscence, conservative management with secondary healing and local wound care is appropriate in most situations. However, in such situations, it is essential to ensure that there is no risk of
great vessel exposure located deep to the site of dehiscence. Donor site complications include postoperative hematoma, seroma, scarring, or wound dehiscence.
Case Example
1. This patient had a large squamous cell carcinoma involving the inferior cheek
and unilateral neck skin with concern for nodal and deep tissue plane involvement. A 2-cm margin around the cancer is marked out.
2. The anticipated CDP ap harvest with its landmarks is marked out. Again, the
CDP ap is based on the second and third perforators from the internal mammary artery on the ipsilateral second and third intercostal spaces (inferior to the
corresponding ribs). It extends obliquely to include the deltopectoral groove laterally and superiorly along the trapezius muscle border until the inferior margin
of the skin defect is encountered (Fig.10.3).
3. The patient underwent wide local excision of a malignancy resulting in a large
skin defect (17×10cm2) extending from the inferior border of the mandible to
the clavicle and crossing midline. A neck dissection of levels 1–3 with preservation of the sternocleidomastoid muscle (SCM) was performed, with sacrice of
the greater auricular nerve and external jugular vein for oncologic reasons
(Fig.10.4). As the SCM was preserved, the great vessels remained protected.
4. A left-sided CDP ap was designed based off of the second and third perforating
branches of the internal mammary artery. Point A marks the posterior/inferior
most aspect of the defect which will be rotated towards the anterior/superior
144
N. Vahidi et al.
most aspect of the defect (A′). Point B marks the lateral-most aspect of the CDP
ap at the deltoid which will move towards the posterior/superior aspect of the
defect (B′). Point C marks the half-way point along the curvilinear incision from
the third intercostal space to the deltopectoral region. The green line marks the
axis of rotation. Conrmation of adequate ap reach should be conrmed prior
to proceeding with CDP ap incision. In this case, conrmation of adequate
reach from point A to A’ and from B to B′ while following the contour of the
underlying soft tissue was performed. Dissection should not be carried 2–3cm
lateral from the sternum at the second and third intercostal spaces to ensure that
the perforating branches from the internal mammary artery are preserved
(Fig.10.4).
5. After denitive cancer resection, the CDP ap was raised in the subplatysmal
tissue plane immediately supercial to the deltoid and pectoralis muscle fascia
below the level of the clavicle. Point D marks approximately the midpoint along
the remaining chest skin ap, and Point E marks the posterior neck overlying the
trapezius and posterior deltoid skin that will be advanced anteriorly to assist in
closure of the donor site defect (Fig.10.5).
6. The CDP ap is seen to be well healed at the 1-year postoperative visit. Local
tissue advancement was performed allowing for primary closure using the superolateral chest/axilla/anterior deltoid skin ap (D′) and the posterior neck/posterior deltoid skin ap (E’). It is common for wound dehiscence to occur at the site
of trifurcation where points C′, D′, and E’ converge as this area is at risk for
heightened tension. When closing the donor site defect, it is imperative to avoid
applying tension on the CDP ap to optimize perfusion. Thus, skin graft placement can be considered in this location, if excess tension is present (Fig.10.6).
References
1. Bakamijam VY.A two-stage method for pharyngoesophageal reconstruction with a primary
pectoral skin ap. Plast Reconstr Surg. 1965;36:173.
2. Ducic Y, Smith JE. The cervicodeltopectoral ap for single-stage resurfacing of anterolat-
eral defects of the face and neck. Arch Facial Plast Surg. 2003;5(2):197–201. https://doi.
org/10.1001/archfaci.5.2.197.
Trapezius Flap forHead andNeck
Reconstruction
KathrynBradburnWie andWeitaoWang
Introduction
The trapezius muscle ap can be used in primary and salvage settings to reconstruct
a wide range of head and neck defects. Multiple variations of the trapezius muscle
ap have been reported in the literature. These include multiple musculocutaneous
aps, osteocutaneous ap, free ap, and perforator ap.
Review of the literature is challenging due to lack of uniform and clinically
applicable ap descriptions. Furthermore, early reports of trapezius ap complications related to poor vascularization raised concern about the reliability of the blood
supply. Cadaveric studies and standardized nomenclature have advanced our collective understanding of the vascular anatomy. Successful harvest of trapezius muscle
aps with reliable blood supply is possible with knowledge of the complex vascular
supply. Table11.1 provides the various terms used in the literature to describe the
ap modications and vascular anatomy along with the nomenclature that will be
used throughout this chapter.
In this chapter, we will review the history and development of the trapezius ap,
discuss the relevant anatomy, and review the various modications of the ap with
case presentations. The ap types will be dened by their supplying arteries using
the nomenclature proposed by Haas and Weiglein [14].
11
K. B. Wie · W. Wang (*)
Department of Otolaryngology Head and Neck Surgery, University of Rochester,
Rochester, NY, USA
e-mail: Kathryn_wie@urmc.rochester.edu; Weitao_wang@urmc.rochester.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_11
145
146
Table 11.1 Flap nomenclature and anatomic description
Muscle bers, artery
Middle/transverse
supercial cervical
artery (SCA)
Inferior/ascending
DSA
***Dorsal scapular artery
Nomenclature in literature
Type 2: Trapezius ap based
on SCA.Middle transverse
bers included
Upper musculocutaneous
(myocutaneous) trapezius ap
Trapezius myocutaneous ap Supercial
Lateral island trapezius
musculocutaneous
(myocutaneous) ap
Extended trapezius
musculocutaneous ap
Vertical trapezius
musculocutaneous ap
Type 3: Trapezius ap based
on DSA.Inferior (ascending)
muscle bers
Lower trapezius
musculocutaneous
(myocutaneous) ap
Extended lower trapezius
myocutaneous ap
Extended lower trapezius
island myocutaneous ap
Extended vertical lower
trapezius island myocutaneous
ap
Pear-shaped lower trapezius
ap
Vertical island myocutaneous
trapezius ap
K. B. Wie and W. Wang
Pedicle artery in
literature
SCA Haas [1]
*** Nettervile [4]
transverse cervical
artery
Transverse cervical
artery
Descending branch
of TCA
Descending branch
of TCA
DSA Haas [1]
*** Weiglein [7]
Descending branch
of the transverse
cervical artery
DSA Tan [10]
Transverse cervical
artery
DSA Hamilton
*** Lee [13]
Authors
Demergasso, [2]
Panje [3]
Netterville [4]
Rosen [5]
Papadopoulos
[6]
Lynch [8]
Ou [9]
Haas [1]
Yoon
Zheng
Chen [11]
Huang [12]
History
We will rst review the development of the ap in clinical practice and then discuss
the relevant anatomy, and how the terminology used to describe the trapezius ap
has evolved over time.
In 1979, Demergasso and Piazza were the rst to describe the trapezius musculocutaneous and osteomyocutaneous aps. Their work demonstrated the versatility of
the ap in head and neck reconstruction, using it to reconstruct large defects in the
oral cavity, oropharynx, hypopharynx, and skin of the head and neck. Their aps
11 Trapezius Flap forHead andNeck Reconstruction
147
were pedicled on the supercial cervical artery, which they called the supercial
transverse cervical vessels [2]. In 1980, Panje further described the anatomic basis of
the same ap, referencing uorescein perfusion studies performed by McGregor and
Morgan which showed that the upper third of the trapezius muscle is supplied by
transverse cervical artery. His work further promoted the trapezius ap as a safe and
effective reconstructive option [3]. The vascular territories and physiologic basis of
the ap were further elucidated by experimental studies [15, 16]. Baek etal. were the
rst to publish on a lower trapezius ap, which he described as the lower trapezius
island ap with blood supply primarily from the transverse cervical artery. His work
showed that the ap was a reliable reconstructive option for facial defects. In the following years, there were reports of ap complications specically due to poor vascularity of the distal portion of the ap. Previous experimental studies identied the
dorsal scapular artery (DSA) as a major portion of the blood supply to the lower part
of the trapezius muscle and the overlying skin [17]. For that reason, in 1991,
Netterville and Wood reinvestigated the blood supply to the lower trapezius muscle
bers by dissecting 15 cadavers. They found the dominant vessel to the lower trapezius muscle to be DSA in 50%, transverse cervical artery (TCA) in 30%, and codominance of DSA and TCA in 20%. The lack of clarity regarding the vascular
anatomy led to further cadaveric studies that will be discussed below [1, 18].
Additional publications reporting various modications and names of the ap
led to further confusion about the anatomic basis of the ap and the vascular supply.
Recent publications by Haas etal., Yang etal., and many others have claried the
vascular territories of the trapezius muscle and the nomenclature of the vascular
supply [1, 18]. Successful utilization of the trapezius ap depends on a thorough
understanding of the variations in the vascular anatomy that they have identied.
Relevant Anatomy [and Nomenclature]
The Trapezius Muscle
The trapezius muscle is a large, at, triangular muscle that stabilizes and moves the
scapula and elevates the shoulder. There are three parts of the trapezius muscle, and
each has distinct directional bers: upper/descending, middle/transverse, and lower/
ascending. The trapezius muscle originates from the external occipital protuberance
and the medial third of the superior nuchal line down the ligamentum nuchae and
the spinous process of the seventh cervical and all thoracic vertebrae. The upper part
of the muscle attaches to the lateral third of the clavicle and the middle part attaches
to the acromion, while the bers of the lower part of the muscle converge to form an
aponeurosis that inserts on the medial tubercle of the scapular spine [4, 19, 20].
The muscle bers of the upper/superior part of the muscle travel obliquely,
downward, and laterally. As a result, this is frequently referred to as the descending
part of the muscle. The upper part originates at the base of skull along the medial
third of the superior nuchal line of the occipital bone, external occipital protuberance, ligamentum nuchae, and spinous process of the seventh cervical vertebra.
148
K. B. Wie and W. Wang
These bers then descend to attach to the lateral third of the clavicle. The primary
function of the upper muscle bers is to elevate the scapula.
The bers of the middle part of the trapezius muscle pass transversely, and as
such this part of the muscle is frequently referred to as the transverse part. This part
of the muscle originates from the spinous processes of the rst through fth thoracic
vertebrae and attaches to the acromion. The function of the middle part is to adduct
and retract the scapula.
Lastly, the bers of the lower part of the trapezius muscle pass obliquely, upward
and laterally from the spinous processes of the sixth through twelfth thoracic vertebrae and attach to the medial aspect of the spine of the scapula. This aspect of the
muscle is frequently referred to as the ascending part. It functions to depress the
scapula [4, 19, 20]. The middle (transverse) and lower (ascending) parts are the
most frequently used in reconstruction [1]. Table 11.2 lists the trapezius muscle
anatomy, attachments, function, and blood supply.
The spinal accessory nerve (cranial nerve 11) provides motor innervation to the
trapezius muscle. The nerve enters near the junction between the middle and lower
bers. The blood supply to the trapezius muscle is via the occipital artery and direct
or indirect branches of the subclavian artery. The vascular anatomy has been extensively investigated and is described in detail below [4].
Table 11.2 Description of trapezius muscle
Muscle
“Portion”
Upper/
superior
Middle Transverse Spinous processes
Lower/
inferior
a
Some publications refer to SCA as supercial branch of the transverse cervical artery and DSA as
the deep branch of the transverse cervical artery in early publications
Fiber
direction Origin Attachment Function
Oblique,
downward
and laterally
Oblique,
upward and
laterally
Medial third of
the superior
nuchal line of the
occipital bone
External occipital
protuberance
Ligamentum
nuchae
Spinous process
of C7
of T1–T5
Spinous processes
of T6–T12
Lateral third
of the clavicle
Acromion Adduct/
Medial
tubercle of the
spine of the
scapula
Elevate
scapula
retract
scapula
Depress
scapula
Blood supply
Occipital artery
Supercial
branch of the
transverse
cervical artery
a
(SCA)
Dorsal scapular
artery (DSA)
Minor
intercostal
perforators
a