Poster Design & Printing by Genigraphics® - 800.790.4001
LOWER TRAPEZIUS ISLAND MYOCUTANEOUS FLAP RECONSTRUCTION OF A
LARGE NECK DEFECT IN AN INFANT
Andrew Scott, MD; Anish Parekh, MD; Mark Vecchiotti, MD; Miriam
O’Leary, MDDepartment of Otolaryngology – Head and Neck Surgery;
Tufts Medical Center – Floating Hospital for Children
Boston MA
INTRODUCTION
CASE REPORTCONCLUSIONS
DISCUSSION
REFERENCES
ABSTRACT
CONTACT
Anish ParekhTufts Medical CenterEmail:
[email protected]
While there is an increasing body of literature documenting the
safe and effective use of free tissue transfer in the pediatric age
group, there is little published on the use of regional
myocutaneous flaps for reconstruction of larger ablative defects.
Prior reports center on the use of pectoralis major myocutaneous
flap reconstruction for sternotomy defects but to our knowledge,
techniques for reconstruction of large neck defects have not been
described. We report on the use of a lower island trapezius
myocutaneous flap to reconstruct a large posterior neck and occiput
wound in an 18 month old child. The case is described in detail and
the literature reviewed. In this case, the use of a regional
myocutaneous flap allowed for reliable transfer of a relatively
large volume of skin and soft tissue, providing coverage of the
internal jugular vein and spinal accessory nerve as well as
limiting the likelihood of debilitating scar contracture.
The lower island trapezius myocutaneous flap was first described
by Baek in 1979. The descending aspect of the superficial branch of
the transverse cervical artery supplies the flap and the venous
outflow is provided by the transverse cervical vein. Advantages of
this flap include long pedicle length, pliability, an inconspicuous
donor site, and a potentially large volume of moveable tissue
including skin and soft tissue bulk. Morbidity from the donor site
includes seroma formation and limited shoulder function; distal
flap necrosis can occur within the skin paddle. In this case we
chose the lower island trapezius flap because of its bulk and
reputation for allowing reliable transfer of a large skin paddle.
Its proximity to our defect and limited donor site morbidity was
also appealing. Although there was venous congestion and partial
skin paddle breakdown in the initial postoperative period, the
patient ultimately had an excellent functional result with an
acceptable postoperative appearance, especially in regards to
contour of the posterior neck (Figure 3).
TB was an ex-23 week premature infant with acquired subglottic
stenosis. At 17 months of age he underwent a single stage expansion
laryngotracheoplasty with costal cartilage. His post-operative
course was complicated by formation of granulation tissue requiring
prolonged use of systemic steroids to maintain airway patency.
Several weeks postoperatively, he developed a rapidly expanding
area of ecchymosis and edema over the right occipital scalp and was
ultimately diagnosed with necrotizing fasciitis. The patient was
taken to the operating room for radical excision of infected skin,
modified radical neck dissection of level IIB, level V, and
occipital nodes with preservation of the internal jugular vein and
the spinal accessory nerve (Figure 1). This resulted in a large
defect, which was left open and serially debrided until resolution
of infection. A 9cm x 5cm defect remained over the posterior right
neck and occipital scalp. Because of concerns for development of
scar contracture the patient underwent a lower island trapezius
myocutaneous flap reconstruction to close the defect (Figure 2).
His postoperative course was notable for venous congestion of the
distal skin flap, and this was treated with leeches. Approximately,
3 weeks after reconstructive surgery, the patient was healed; at 3
months the scars were beginning to fade and contour correction was
adequate (Figure 3).
Regional flap reconstruction of neck wounds is rarely performed
in the pediatric age group. In cases of large ablative defects,
when free tissue transfer is not possible or insufficient for the
reconstructive needs of the patient, regional flap reconstruction
may be performed. We describe the use of a lower island trapezius
myocutaneousflap in a young child, which allowed for reliable
transfer of a large volume of skin and soft tissue for
reconstruction of a large posterior neck wound. It would stand to
reason that many of the donor site morbidities seen in older
patients, especially in regards to functional deficits, in fact
might be minimized in children. In general, young children are able
to compensate for functional impairments effectively over time. It
is plausible that regional flap reconstruction of ablative head and
neck defects in children can be accomplished with a degree of
success similar to that seen in adult patients.
Ablative defects in the head and neck may be reconstructed
through a variety of approaches, with more invasive and complex
procedures reserved for scenarios in which healing by secondary
intention or skin grafting would not be appropriate. Microvascular
free tissue transfer has been described in the pediatric
population. However, reconstruction of large ablative defects with
free flaps is not always possible, due to the percentage of body
surface area lost and degree of donor site morbidity among other
factors.
Regional flaps are still widely used for head and neck
reconstruction in adults but are rarely performed in infants and
children. The pectoralis major flap has been reported for the
reconstruction of pediatric sternotomy wound dehiscence following
infection. To our knowledge, there have been no reports of regional
flap reconstruction for head and neck defects in children. We
describe the use of a lower island trapezius myocutaneous flap for
reconstruction of a large, posterior neck defect in a toddler.
1. Upton et al. Pediatric free-tissue transfer. Plastic and
Reconstructive Surgery (2009) vol. 124 (6 Suppl) pp. e313-26.
2. Grant et al. Muscle flap reconstruction of pediatric
poststernotomy wound infections. Ann Plast Surg (1997) vol. 38 (4)
pp. 365-70.
3. Baek et al. The lower trapezius island myocutaneous flap. Ann
Plast Surg (1980) vol. 5 (2) pp. 108-14.
4. Netterville and Wood. The lower trapezius flap. Vascular
anatomy and surgical technique. Arch Otolaryngol Head Neck Surg
(1991) vol. 117 (1) pp. 73-6.
5. Urken et al. The lower trapezius island musculocutaneous flap
revisited. Report of 45 cases and a unifying concept of the
vascular supply. Arch Otolaryngol Head Neck Surg (1991) vol. 117
(5) pp. 502-11.
6. Cummings et al. Lower trapezius myocutaneous island flap.
Arch Otolaryngol Head Neck Surg (1989) vol. 115 (10) pp.
1181-5.
7. Netterville et al. The trapezius myocutaneous flap.
Dependability and limitations. Arch Otolaryngol Head Neck Surg
(1987) vol. 113 (3) pp. 271-81.
*
Figure 3: three months post-operative
Figure 1: spinal accessory n. (white arrow); splenius capitis
and levator scapulae m. (asterisk)
Figure 2: lower island trapezius myocutaneous flap
