British Journal ofPlastic Surgery (1981), 34, 334-337 0 The Trustees of British Association of Plastic Surgeons

0007-1226/81/0194-0334 $02.00

The use of lower trapezius myocutaneous island flaps in head and neck reconstruction

YOHKO YOSHIMURA, YU MARUYAMA and SETSUO TAKEUCHI

Department of Plastic and Reconstructive Surgery, Keio University School of Medicine and the Department of Surgery, Toho University School of Medicine, Tokyo, Japan

Summary-The lower portion of the trapezius muscle can be designed as an island myocutaneous flap and has certain advantages when compared with the more familiar upper trapezius myocutaneous flap.

Several authors have reported the use of trapezius myocutaneous flaps usually based on the upper portion of the trapezius muscle: McGraw et al. (1979); Lamberty (1979); Mathes and Nahai (1979); Bertotti (1980). We have previously reported the use of the lower portion of the trapezius muscle as a myocutaneous flap in head and neck reconstruction (Maruyama et al., 1981) and now wish to report its adaptation as an island flap in two patients.

Case 1

A man aged 28 had been severely burnt at the age of 3 and developed gross hypertrophic scarring over the left side of the face, angle of jaw and mastoid region. From 1972 onwards he had undergone repeated reconstructive procedures to deal with this disfiguring scarring but without much success (Fig. 1). Extensive hypertrophic scarring elsewhere on his body severely limited the choice of skin donor sites. In view of his obvious tendency to form hypertrophic and keloidal scars it was decided to choose a technique of repair that would import adequate flap cover and allow the donor site to be closed by primary suture rather than a split-skin graft.

To fulfill these requirements we decided to use a lower trapezius myocutaneous flap (Fig. 2). After wide excision of all the hypertrophic scar the trapezius flap was elevated from its distal end. The perforating vessels from the rhomboid muscle were ligated. The feeding vessels to the required skin segment were identified and traced proximally with a minimal amount of muscle as far as the bifurcation of the transverse cervical artery. From this point a tunnel was made under the upper portion of the trapezius muscle upwards through which the island flap was brought into the excisional defect (Fig. 3). The donor site defect was closed by primary suture (Fig. 4). The postoperative course was uneventful (Fig. 5).

C.ase 2

A man aged 75 presented with ulceration on a scar Fig. 1 (Case 1) Preoperative view to show recurrent keloidal over the occipital region following a burn sustained scarring over the angle of the jaw and mastoid region.

334

LOWER TRAPEZIUS MYOCUTANEOUS ISLAND FLAPS IN HEAD AND NECK RECONSTRUCTION 335

Fig. 2 (Case I) Design of the lower trapezius island flap

when he was three years old. At operation in 1979 histological examination of a frozen section revealed a squamous cell carcinoma and an immediate wide resection of the lesion was carried out, the defect being covered with a split-skin graft. Within six months of this operation a recurrence of the ulcer was noted at the centre of the grafted area, along with another separate ulcer in the grafted area (Fig. 6). Biopsy of both lesions confirmed the diagnosis of squamous cell carcinoma. At operation a wide resection was performed including the outer layer of the occipital bone and a lower trapezius island flap was transferred to the defect in exactly the same way as described in the first case (Fig. 7). The donor site was closed primarily. The postoperative course (Fig. 8).

was uneventful

Discussion

The value of the upper trapezius myocutaneous

flap was described by McGraw et al. (1979) and

Fig. 3 (Case I) The island flap has been transferred through a tunnel into the neck defect.

Fig. 4 (Case 1) Donor site closed by primary suture.

336 BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 5 (Case 1) Two weeks after operation to show flap in position.

more recently, Bertotti (1980) described its use as an island flap. However the disadvantages of the upper trapezius myocutaneous flap are that the donor area is contiguous with the excisional defect and that the donor site can rarely be closed primarily, often requiring a skin graft. By contrast the donor site of the lower tranezius

I

Fig. 7 (Case 2) Design of the island flap and the intended

occipital region. Fig. 8 (Case 2) The island flap in position live days later.

LOWER TRAPEZIUS MYOCUTANEOUS ISLAND FLAPS IN HEAD AND NECK RECONSTRUCTION 337

myocutaneous flap can usually be closed by primary suture and the scar is hidden from view.

Compared with the latissimus dorsi myocutaneous flap the lower trapezius has its pivot point at the shoulder so that its range of transfer is wider in the head and neck area. Furthermore. the nerve supply to the trapezius muscle is provided by three branches so that preservation of motor function in the upper and middle portions is possible.

If the lower trapezius myocutaneous flap is designed as an island flap the range of transfer is increased, no: dog ears are produced and the repair can be carried out in one stage.

References

Bertotti, J. A. ( 198Oj. Trapezius-musculocutaneous island flap in the repair of major head and neck cancer. Plasric tirrrf Reconstructice Surgery, 65, 16.

Lamberty, B. G. H. (1979). The supra-clavicular axial patterned flap. British Journul of Plastic Surgery, 32, 207.

Maruyama, Y., Nakajima, H., Fujino, T. and Koda, E. (1981). The definition of cutaneous vascular territories over

the back using selective angiography and the intra-arterial injection of Prostaglandin E 1: Some observations on the use of the lower trapezius myocutaneous flap. B~iri.41 Journal q{Pkcsric Surgery 34, 157.

Mathes, S. J. and Nahai, F. (1979). Clinical atlas of muscle and musculocutaneous flaps. St. Louis, C.V. Mosby Company.

McGraw, J. B., Magee, W. P. and Kalwaic. H. (1979). Uses of the trapezius and sternomastoid myocutaneous flaps in head and neck reconstruction. Plastic arui Rrrwwtructict~ Surpv:‘. 63, 19.

The Authors

Yohko Yoshimura, MD, Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo.

Yu Maruyama, MD, Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo.

Setsuo Takeuchi, MD, Department of Surgery, Toho University School of Medicine, Tokyo.

Requests for reprints to: Dr Yohko Yoshimura, Department of Plastic and Reconstructive Surgery, School of Medicine, Keio University. 35. Shinanomachi Shinjuku-ku. Tokyo 160, Japan.