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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5208_Библиотеки_им_академика_М_И_Перельмана
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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
t.me/Dr_Mouayyad_AlbtousH
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.
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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
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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.
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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
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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
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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.
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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
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11 Trapezius Flap forHead andNeck Reconstruction
149
Regional Anatomy
Muscles that lie deep to the trapezius muscle include the levator scapulae, the major
and minor rhomboid muscles, and the latissimus dorsi.
Blood Supply: Nomenclature
It is commonly taught that the thyrocervical trunk arises from the subclavian artery
and gives risk to the inferior thyroid artery, the suprascapular artery, and the transverse cervical artery. Nomina Anatomica denes the transverse cervical artery as the
common trunk that gives rise to a supercial and a deep branch. The supercial
branch is also called the supercial cervical artery (SCA), and the deep branch is
also called the dorsal scapular artery (DSA) [1]. However, cadaveric studies have
shown that the origin of the SCA and DSA is variable [1, 7].
While there are many variations in the proximal vascular anatomy of the SCA
and DSA, the distal course of these vessels is constant. Successful ap elevation
with reliable blood supply is possible with the knowledge of the distal course of the
SCA and DSA because their proximal components are not routinely explored during ap elevation.
The DSA is located deep to the levator scapulae and minor rhomboid muscles. In
the vast majority of cases, it passes medial to the levator scapulae. The branch that
supplies the trapezius muscle ap arises between the minor and major rhomboid
muscles at the level of the spine of the scapula. It courses along the under surface of
the trapezius muscles close to the medial border of the scapula in a more lateral
course than the SCA.It is accompanied by the dorsal scalpular nerve.
Flap Nomenclature
The middle part is referred to as the upper trapezius ap, and the lower part is
referred to as the lower trapezius ap [20].
Operative Technique
Preoperative Evaluation
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
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K. B. Wie and W. Wang
previously sacriced. The back and shoulder should be assessed for prior scars and
trauma, which may compromise the vascular supply of anticipated ap designs.
Positioning
Harvest techniques vary depending on the anticipated defect to be reconstructed. In
many cases, if an upper trapezius ap is needed for a periauricular defect, a lazy
lateral decubitus position is enough. In cases where a lower trapezius island myocutaneous ap is utilized, a lateral decubitus position may be necessary. Often a lateral
decubitus position may be useful for both the ablative portion of malignancy involving periauricular areas, radical parotidectomy, and radical excision of the neck. In
these scenarios, the advantage is no position change requirement prior to starting
the reconstructive portion of the case.
Harvest Technique
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 identied. 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 identied, 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.
Lower trapezius ap design should be that at least one-third of the skin paddle
should be overlapping the inferior border of the trapezius muscle.
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