Proper counseling of the patient is essential in preparation for trapezius reconstruc­tion. In cases of large defect reconstruction requiring a large amount of trapezius muscle and skin transfer, patients must be warned of associated shoulder morbidity and the likely need for postoperative physiotherapy and rehabilitation. History of prior neck dissection is in itself not a contraindication of this ap and does not nec­essarily preclude use of a trapezius ap even when the transverse cervical artery was

The lateral aspect of the designed skin paddle is typically incised rst. When per­forming an upper trapezius ap, following incision, blunt dissection is carried out until the lateral border of the upper trapezius is identied. A simple way to consis­tently identify the lateral border of the trapezius is to rst identify the upper border of the latissimus dorsi muscle with its muscle bers in a horizontal orientation. This can then be traced medially until the more vertically oriented muscle bers of the trapezius are encountered. Care is taken to avoid dissecting between the plane of the skin paddle and trapezius muscle owing to risk of injury of the musculocutaneous perforators. Once the lateral border is identied, blunt dissection is carried out under the trapezius muscle until it is dissected off of the underlying soft tissue. Care should be taken during this step as the transverse cervical artery contributions can be encountered deep to the trapezius muscle as it enters. In the event an island ap is utilized, this vessel must be preserved as it is the sole vascular supply for the skin paddle. In cases where a transposition ap is planned, the vessel can be ligated as the vascular supply is based off the superior trapezius and intercostal perforators. Once the trapezius muscle is well dissected off the underlying soft tissues, the infe­rior skin paddle or skin ap incision is then made as the skin is ensured to be posi­tioned on the trapezius muscle. Rapid division of the trapezius muscle close to the spine of the scapula can then be performed to free the ap and allow adequate arc of rotation. The ap is then transposed to the defect and inset. The donor site is closed primarily with undermining of the surrounding skin and layered closure is per­formed with placement of a fenestrated drain via a separate incision.

The ideal defect for an upper trapezius ap is an infra-auricular, or posterior supe­rior neck defect. Flaps can be designed along the upper back in both island and transposition fashion. The lateral border of the trapezius muscle is palpated above the spine of the scapula. The designed ap can be medially based off the intercostal perforators or laterally based off the transverse cervical artery, if the arch of rotation is enough.

A lower trapezius myocutaneous ap can be designed with the benet of a very long pedicle by tracing the dorsal scapular or transverse cervical vessels up to the origin point in the neck anteriorly. This can afford a ap pedicle of up to 25–30cm in some cases. The trapezius free ap remains described in few case reports in the literature and has not achieved widespread use. Typically free tissue transfer use of the trape­zius myocutaneous ap is limited in the head and neck owing to its wide reach as a pedicle ap. Alternative free aps such as the latissimus dorsi provide the additional reach to areas such as the scalp with a similarly long pedicle length as well as supe­rior muscle area coverage compared to the trapezius and are likely the reason why the trapezius ap remains largely a pedicled ap in most clinical scenarios.

In situations where the spinal accessory nerve is intact, patients should be coun­seled on the possibility of shoulder weakness and need for physiotherapy to assist in ipsilateral shoulder abduction. To avoid functional impairments, a smaller cuff of trapezius muscle can be harvested with a skin paddle with perforator dissection. The small size of the perforators through the trapezius does make this technically chal­lenging and risky.

There are several advantages to using the trapezius ap as discussed above in terms of reach. The trapezius ap is viable in complex, salvage head and neck cases in that it does not require recipient vessels and is outside of the irradiated eld. Additionally, a large skin island can be harvested; the muscle is thin and thus very pliable. While we discussed the limitations of reach of the trapezius ap, overall it has a very long pedicle length and wide arc of rotation making it a suitable reconstructive option for a wide range of defects [19, 22].

techniques can be utilized to assess the perfusion of the distal skin paddle after ap elevation, particularly when the distal portion covers vital structures such as the great vessels.

The trapezius ap is a well-described myocutaneous ap that is versatile and reli­able. Its arch of rotation makes it an obvious choice for lateral face, periauricular, lower scalp, and posterolateral neck defects. The dorsal scapular and transverse cervical artery supply the lower trapezius ap, while upper trapezius aps can be based off the transverse cervical artery and occipital and intercostal perforators. Complication rates are comparable to other regional aps, and donor-site cosmesis is improved in female patients when compared to other workhorse aps such as the pectoralis major ap.