Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 952e954

CASE REPORT

Transverse cervical artery perforator propeller flapfor reconstruction of supraclavicular defects*

Ulrich Kneser *, Justus P. Beier, Adrian Dragu, Andreas Arkudas,Raymund E. Horch

Department of Plastic and Hand Surgery, University of Erlangen Medical Center, Krankenhausstrasse 12, D-91054 Erlangen,Germany

Received 21 October 2010; accepted 29 October 2010

KEYWORDSPerforator Flap;Propeller Flap;Trapezius;Transverse cervicalartery

* Financial disclosure: None of thinterest to declare in relation to the* Corresponding author. Tel.: þ49 9

85 39327.E-mail address: ulrich.kneser@uk-

1748-6815/$-seefrontmatterª2010Bridoi:10.1016/j.bjps.2010.10.021

Summary Propeller perforator flaps supplied by branches from the transverse cervical arteryallow transport of skin from the back region to supraclavicular defects. This article describesa soft tissue defect following resection of melanoma metastasis that was successfully recon-structed using a propeller flap based on a perforator originating from the anterior part of thecranial trapezius muscle. This technique should be considered as an alternative to commonlyused muscle or myocutanous flaps in selected cases.ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Soft tissue defects at the supraclavicular region oftenrequire coverage by local, distant or free flaps. Whilemyocutaneous flaps such as the pectoralis major or trape-zius flap are widely used, perforator propeller flaps are notconsidered as first line procedure for these indications yet.We present a clinical case where such a flap was used forreconstruction of a large skin and soft tissue defectfollowing excision of a malignant melanoma.

e authors has any financialcontent of this article.131 85 33277; fax: þ49 9131

erlangen.de (U. Kneser).

tishAssociationofPlastic,Reconstruc

Case report

A 61 years old female patient with a history of metastasingmalignant melanoma presented with an unclear and painfulsubcutaneous mass above the left clavicle. One year ago theprimary tumor (Clark level IV, 17 mm thickness, pT4b pN2 (2/8) R0 cMo) had been resected including a significant propor-tion of the pectoralismajormuscle and a dissection of axillarylymph nodes was performed. The defect had been covered bya split thickness skin graft. Upon physical examination a denseand tender soft tissuemass with close relationship to skin andleft clavicle was palpated. Ultrasound and CT scans revealeda 6 cm tumor mass suspect of metastasis with close relation-ship to the subclavian artery and vein. Surgical explorationand en bloc resection of the mass was performed by the

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Transverse cervical artery perforator propeller flap 953

oncologic surgeon leavingbehinda6�6 cmskinand soft tissuedefect with widely exposed clavicle (Figure 1). A subathmo-spheric pressure dressing (VAC, KCI Inc, San Antonio, TX,U.S.A.) was applied. Aetiology of the tumor and clearmarginswere confirmed by the pathologist and after six days plasticsurgical reconstruction was initiated. Flap surgery was per-formed with the patient in the lateral decubitus position.Perforators adjacent to the defect region were identifiedusing a handheld Doppler device and a 16 �7 cm island flapwas planned (Figure 2A). The perforators originating from theventral part of the trapezius muscle were explored viaa limited incision. One dominant perforator originated 2 cmposterior to the anterior margin of the trapezius muscle. Thisperforator was dissected over 5 cm distance (Figure 2B). Theflap was rotated through 180� into the defect and the donorsite was closed directly (Figure 2C). The postoperative coursewas uneventful and the patient was discharged after 8 days.Six weeks later radiotherapy of the supraclavicular andcervical region was initiated and 60 Gy were applied. After 4months the defect was stably healed while some radio-dermatitis was present at the neck region (Figure 3). Range ofmotion of the left shoulder was unrestricted and therewas noevidence of paresis of the trapezius muscle. The patient didnot complain ofweakness in the shoulder joint or restriction inher daily activities.

Discussion

Although the pedicled trapezius muscle or myocutaneousflap has been described several decades ago by many

Figure 1 Defect after tumor resection with exposed clavicle.Arrow indicates skin graft following resection of the primarytumor.

Figure 2 A: Perforators were mapped out using a handheldDoppler device. B: The flap with completely dissected perfo-rator prior to rotation into the defect. C: The flap is adequatelyperfused directly after of surgery. The donor sits is closeddirectly.

different authors, its vascular anatomy has been subject ofongoing controversies. This flap is frequently used for defectreconstruction in head and neck surgery.1,2 Recently, a studyby Haas et al. clarified the anatomy of the so called lowertrapezius muscle flap which is constantly supplied by thedorsal scapular artery (synonym for the deep branch of thetransverse cervical artery).3 The isolated superior trapeziusmuscle is considered as less reliable and is based on theparaspinous perforating branches of the intercostal vessels.4

Mizerny et al. performed an anatomical study usingmethylene blue dye injection into the transverse cervical

Figure 3 Four months postoperatively, the defect iscompletely healed. There is a small area of radiodermatitis atthe lateral neck following radiotherapy.

954 U. Kneser et al.

artery. They were able to demonstrate reliable perfusion ofa supraclavicular and upper back skin territory via thispedicle.5 The supraclavicular island flap (SIF), a fasciocuta-neous flap based on the supraclavicular artery which origi-nates from the transverse cervical artery, has been widelyused for reconstruction in the head and neck region.6e8

Recently, Cordova et al published a detailed study onperforator flaps from the supraclavicular region.9 However,these flaps included skin anterior to the trapezius muscle. Aseries of superficial cervical artery flaps has been publishedin 2006 by Ogawa et al.10 They demonstrated that the upperpart of the trapeziusmuscle and the overlying skin is suppliedby a superficial branch from the transverse cervical artery.The flap has been mainly used for release of postburn scarcontractures but also for tumor reconstruction. However,while Ogawa et al. preserved a muscle cuff around theperforator vessels, we performed a complete dissection ofthe perforator that allowed us to rotate the flap by 180�. Alsothe orientation of the flap was different (perpendicular tothe longitudinal axis) in the presented case.

In the presented case the pectoralis major flap was notapplicable due to the former resection of the primary tumor.Although the arc of rotation of the myocutaneous trapeziusflap might even reach to the supraclavicular region, thisprocedure would have required extensive mobilisation anddissection of the trapeziusmuscle. The use of the skin paddleoverlying the anterior trapezius muscle based on a single

perforator as a propeller flap allows a wide arc of rotation.The procedure is straightforward and safe and should beconsidered as alternative therapeutic option for recon-struction of supraclavicular skin defects. In the presentedcase the donor site was closed directly and donor sitemorbidity was negligible. However, due to the knowninconstant anatomy of this region detailed anatomic studieswith a focus on number and position of perforators piercingthrough the anterior trapezius muscle are necessary beforethis flap can be recommended as a standard procedure forreconstruction of supraclavicular defects.

References

1. Horch RE, Stark GB. The contralateral bilobed trapezius myo-cutaneous flap for closure of large defects of the dorsal neckpermitting primary donor site closure. Head Neck 2000;22:513e9.

2. Baek SM, Biller HF, Krespi YP, et al. The lower trapezius islandmyocutaneous flap. Ann Plast Surg 1980;5:108e14.

3. Haas F, Weiglein A, Schwarzl F, et al. The lower trapeziusmusculocutaneous flap from pedicled to free flap: anatomicalbasis and clinical applications based on the dorsal scapularartery. Plast Reconstr Surg 2004;113:1580e90.

4. Aviv JE, Urken ML, Lawson W, et al. The superior trapeziusmyocutaneous flap in head and neck reconstruction. ArchOtolaryngol Head Neck Surg 1992;118:702e6.

5. Mizerny BR, Lessard ML, Black MJ. Transverse cervical arteryfasciocutaneous free flap for head and neck reconstruction:initial anatomic and dye studies. Otolaryngol Head Neck Surg1995;113:564e8.

6. Pallua N, Machens HG, Rennekampff O, et al. The fasciocuta-neous supraclavicular artery island flap for releasing postburnmentosternal contractures. Plast Reconstr Surg 1997;99:1878e84 [discussion 85e6].

7. Vinh VQ, Van Anh T, Ogawa R, et al. Anatomical and clinicalstudies of the supraclavicular flap: analysis of 103 flaps used toreconstruct neck scar contractures. Plast Reconstr Surg 2009;123:1471e80.

8. Lamberty BG. The supra-clavicular axial patterned flap. Br JPlast Surg 1979;32:207e12.

9. Cordova A, Pirrello R, D’Arpa S, et al. Vascular anatomy of thesupraclavicular area revisited: feasibility of the free supra-clavicular perforator flap. Plast Reconstr Surg 2008;122:1399e409.

10. Ogawa R, Murakami M, Vinh VQ, et al. Clinical and anatomicalstudy of superficial cervical artery flaps: retrospective study ofreconstructions with 41 flaps and the feasibility of harvestingthem as perforator flaps. Plast Reconstr Surg 2006;118:95e101.