The trapezius perforator flap: Versatility for locoregional reconstruction

Interpreting Lower Trapezius Musculocutaneous Flap Skin Paddle Perfusion with Indocyanine Green Angiography

Background: The lower trapezius myocutaneous flap (LTF) is a pedicled flap with clinically significant variability of distal skin flap perfusion. Objective: To compare the incidence of partial flap necrosis before and after the institution of routine intraoperative laser-assisted indocyanine green (ICG) angiography. Methods: This is a retrospective review of all LTF performed between November 2021 and July 2022. The outcomes measured in this study are the distance distal to the inferior border of the trapezius muscle with adequate perfusion, and incidence and degree of partial flap necrosis. Results: Sixteen patients met inclusion criteria with a median age of 64.5 years, and a median defect size of 147 cm2. Most patients (11/16) had undergone previous treatment for malignancy. Before utilizing ICG angiography, 40% (2/5) had partial flap necrosis, whereas after utilizing ICG angiography, 9% (1/11) of patients had partial flap necrosis. Seventy-three percent (8/11) of cases who underwent ICG angiography demonstrated a portion of the skin paddle with inadequate perfusion. The range of skin perfusion distal to the inferior border of the trapezius muscle was 0-7 cm (median, 4). Conclusions: The incidence of partial flap necrosis decreased after institution of routine ICG angiography.

Trapezius Perforator Flaps Based on Superficial Cervical Artery and Dorsal Scapular Artery: An Anatomical Study and a Systematic Review of Their Clinical Application

BACKGROUND

The flaps in the trapezius region are routinely elevated as musculocutaneous flaps. The anatomy of trapezius perforators and their clinical application are unclear.

METHODS

The number and distribution of superficial cervical artery perforators (SCAPs) and dorsal scapular artery perforators (DSAPs) were studied on 8 cadavers. The clinical usage of SCAP and DSAP flaps was investigated through a systematic literature review.

RESULTS

A total of 27 SCAPs and 28 DSAPs were found in the 16 hemibacks. The mean calibers of SCAP and DSAP were 0.9 ± 0.2 and 0.8 ± 0.2 mm, respectively. The vascular length to the takeoff of the source artery was 7.3 ± 2.0 cm (range, 4.7-9.7 cm) for SCAPs and was 8.1 ± 2.8 cm (range, 3.2-13.6 cm) for DSAPs. Contour and density heat maps showed that the SCAPs were clustered within approximately 3 to 5 cm above the horizontal line through the medial point of the scapular spine (x-axis) and 5 to 8 cm from the midline (y-axis, P = 0.001) and clustered DSAPs located in approximately 4 to 9 cm below the x-axis and 4 to 10 cm from the y-axis (P = 0.002). Four SCAP and 19 DSAP flaps were found in literature. The mean sizes of SCAP flaps and DSAP flaps were 18.5 × 7.8 and 16.5 × 8.7 cm, respectively.

CONCLUSIONS

Both SCAP and DSAP flaps can be elevated with a relatively long pedicle. The anatomical knowledge of the location of major clusters of perforators contributes to the application of these flaps.

The Dorsal Scapular Artery Perforator Flap: A Complete Muscle-sparing Technique

Cervical and thoracic spine reconstruction can be a difficult area to provide stable soft tissue coverage. Historically, trapezius myocutaneous flaps and trapezius muscle turnover flaps have proven to be reliable and versatile methods for the reconstruction of these areas. However, sequelae such as restriction of shoulder movement have been reported, as well as unsightly “humpback” contour deformities from turnover flap bulk. The use of the trapezius muscle for coverage has evolved to include descriptions of a trapezius perforator flap to address some of the issues of donor site morbidity, as it is described as a muscle-sparing technique. Although described as “muscle-sparing,” these approaches nonetheless involve sacrifice of trapezius muscle overlying the pedicle as that musculature is “deroofed” and divided off the pedicle during dissection. In this article, we present a detailed technical description of our novel technique to the trapezius perforator flap using a dorsal scapular artery flap for spinal reconstruction that is truly, completely muscle-sparing. This technique may prove useful for those patients in which even minimal disruption of trapezius muscle fibers is undesirable.

Propeller and Pre-expanded Propeller Use of a Transversely Oriented Upper Trapezius Perforator Flap in Head and Neck Reconstruction: Clinical Experience and Review of Vascular Anatomy of the Supraspinal Trapezius Muscle

Conventionally, trapezius musculocutaneous flap is raised to harbour perforators located inferior to the scapular spine (i.e. 'lower trapezius flap'). In this clinical study, we aimed to use trapezius perforators located superior to the scapular spine to raise a transversely oriented propeller fasciocutaneous flap based on the superficial cervical artery to reconstruct head and neck defects. Patients with head and neck defects who underwent reconstruction with a propeller trapezius perforator flap between August 2014 and October 2019 were evaluated. Demographic data of the patients, topographic data on defects and the flaps were analysed. A total of 14 patients underwent reconstruction with upper trapezius perforator flap with equal gender distribution. Defects were due to tumour resections, burn contractures and exposed foreign materials; located in occipital, temporal, parietal, midfacial and cervical areas; with sizes ranging between 8 × 7 cm and 22 × 19 cm. Overall patient satisfaction was assessed subjectively using a pre-determined set of questions. The sizes of the flaps ranged between 15 × 8 cm - 20 × 9 cm in non-expanded and 26 × 15 cm - 30 × 16 cm in expanded cases. One flap suffered distal superficial flap loss, which was treated with wound care. Follow up period of the patients ranged between 3 and 40 months with an average of 29 months. Using trapezius perforators located above the scapular spine provides thin transversely oriented propeller flaps to be used in head and neck reconstruction. In our series, this flap is further enhanced by pre-expansion for wider uses, e.g. facial resurfacing and releasing neck contractures.