Flap design and preliminary clinical experience of the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

XIE Tingjun ,  LIU Yuanbo , HAN Tinglu , ZHU Shan , ZANG Mengqing , CHEN Bo , LI Shanshan

Scar Comprehensive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100144, P.R.China;

Corresponding author：

LIU Yuanbo, Email: ybpumc@sina.com

Keywords：

Lower trapezius musculocutaneous flap; latissimus dorsi muscle; defect repair

DOI：

10.7507/1002-1892.202009114

Video：

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Objective To explore the reliability and effectiveness of soft tissue defect reconstruction using the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle.Methods Between December 2014 and December 2019, 13 patients underwent the reconstruction of soft tissue defects in various sites using the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle. There were 10 males and 3 females, with an average age of 52.1 years (range, 29-83 years). Twelve wounds were resulted from resection of various malignant tumor, including 6 cases of head and neck tumors, 5 cases of shoulder and back tumors, 1 case of chest and back tumors. Among the 12 cases, 4 cases were complicated with wound infection and bone exposure, 1 case with skull defect and cerebral dura exposure, and 1 case with wound infection, skull necrosis, and cerebrospinal fluid leakage. One case was injured in a traffic accident, which resulted in infection wound in the back and shoulder and bone exposure. The sizes of the defect and musculocutaneous flap ranged from 11 cm×7 cm to 23 cm×15 cm and 25 cm×8 cm to 40 cm×14 cm, respectively. According to the spatial relationship between the donor and recipient sites, propeller flaps (8 cases) or percutaneous tunnel island flaps (5 cases) were used to transfer the myocutaneous flap to the recipient area to repair the wound. The donor site was directly closed and sutured in 9 cases, and those with excessive tension were repaired with free skin grafts in 2 cases or transferred flaps in 2 cases.Results After the operation, necrosis of the distal 4-cm of the musculocutaneous flap occurred in 2 cases. After debridement, the resultant wounds were reconstructed using a local flap and a posterior intercostal artery perforator flap, respectively. The remaining 11 myocutaneous flaps survived completely without arteries and veins crisis. The wounds in the donor and recipient areas healed by first intention. All the patients were followed up 1 to 48 months (mean, 7.4 months). The color and texture of the flap were good. During the follow-up, 1 patient underwent tumor resection again due to tumor recurrence, and 1 patient with a scalp hemangiosarcoma died due to unexplained thoracic hemorrhage. Tumor recurrence was not found in the remaining patients. The musculocutaneous flap coverage was stable and the infection was controlled.Conclusion The lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle can be an alternation option to reconstruct refractory wounds with exposure of vital structures and organs and infection.

Citation： XIE Tingjun, LIU Yuanbo, HAN Tinglu, ZHU Shan, ZANG Mengqing, CHEN Bo, LI Shanshan. Flap design and preliminary clinical experience of the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(3): 349-355. doi: 10.7507/1002-1892.202009114 Copy

1.	Liu Y, Zang M, Wu L, et al. Improving the versatility of the latissimus dorsi myocutaneous flap using the perforator propeller flap concept. Ann Plast Surg, 2020, 84(6): 689-696.
2.	Yoon JS, Oh J, Chung MS, et al. The island-type pedicled TRAM flap: Improvement of the aesthetic outcomes of breast reconstruction. J Plast Reconstr Aesthet Surg, 2020, 73(6): 1060-1067.
3.	Baek SM, Biller HF, Krespi YP, et al. The lower trapezius island myocutaneous flap. Ann Plast Surg, 1980, 5(2): 108-114.
4.	Tan KC, Tan BK. Extended lower trapezius island myocutaneous flap: a fasciomyocutaneous flap based on the dorsal scapular artery. Plast Reconstr Surg, 2000, 105(5): 1758-1763.
5.	Raguse JD, Czabanka M, Voss JO, et al. The lower trapezius island myocutaneous flap in tunnelled technique to cover complicated tissue defects located between the craniocervical and cervicothoracic junction following spinal surgery. J Craniomaxillofac Surg, 2016, 44(8): 969-972.
6.	Haas F, Weiglein A, Schwarzl F, et al. The lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and clinical applications based on the dorsal scapular artery. Plast Reconstr Surg, 2004, 113(6): 1580-1590.
7.	Atiyeh BS, Hamdan AM, Nassar SI, et al. Vascularized fascial patch for repair of suboccipital dural defect. Ann Plast Surg, 1996, 37(4): 422-427.
8.	Chen WL, Yang ZH, Huang ZQ, et al. Craniofacial resection and reconstruction in patients with recurrent cancer involving the craniomaxillofacial region. J Oral Maxillofac Surg, 2017, 75(3): 622-631.
9.	Eshima I, Mathes SJ, Paty P. Comparison of the intracellular bacterial killing activity of leukocytes in musculocutaneous and random-pattern flaps. Plast Reconstr Surg, 1990, 86(3): 541-547.
10.	Guerra AB, Gill PS, Trahan CG, et al. Comparison of bacterial inoculation and transcutaneous oxygen tension in the rabbit S1 perforator and latissimus dorsi musculocutaneous flaps. J Reconstr Microsurg, 2005, 21(2): 137-143.
11.	Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg, 1987, 40(2): 113-141.
12.	Cormack GC, Lamberty BG. Cadaver studies of correlation between vessel size and anatomical territory of cutaneous supply. Br J Plast Surg, 1986, 39(3): 300-306.
13.	Taylor GI, Corlett RJ, Dhar SC, et al. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg, 2011, 127(4): 1447-1459.
14.	Salmon M. Arteries of the muscles of the trunk//Taylor GI, Razaboni RM, eds. Arteries of the muscles of the extremities and the trunk. St. Louis: Quality Medical Publishing, 1994: 117-119.
15.	Taylor GI, Chubb DP, Ashton MW. True and ‘choke’ anastomoses between perforator angiosomes: part Ⅰ. anatomical location. Plast Reconstr Surg, 2013, 132(6): 1447-1456.
16.	Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined. Plast Reconstr Surg, 2012, 129(5): 1043-1048.
17.	Hébert PC, McDonald BJ, Tinmouth A. Clinical consequences of anemia and red cell transfusion in the critically ill. Crit Care Clin, 2004, 20(2): 225-235.
18.	Hill JB, Patel A, Del Corral GA, et al. Preoperative anemia predicts thrombosis and free flap failure in microvascular reconstruction. Ann Plast Surg, 2012, 69(4): 364-367.
19.	Rosen HM. The extended trapezius musculocutaneous flap for cranio-orbital facial reconstruction. Plast Reconstr Surg, 1985, 75(3): 318-327.
20.	Netterville JL, Wood DE. The lower trapezius flap. Vascular anatomy and surgical technique. Arch Otolaryngol Head Neck Surg, 1991, 117(1): 73-76.
21.	Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg, 1981, 67(2): 177-187.
22.	Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg, 1981, 67(5): 637-641.
23.	Adams WP, Lipschitz AH, Ansari M, et al. Functional donor site morbidity following latissimus dorsi muscle flap transfer. Ann Plast Surg, 2004, 53(1): 6-11.
24.	Sowa Y, Morihara T, Kushida R, et al. Long-term prospective assessment of shoulder function after breast reconstruction involving a latissimus dorsi muscle flap transfer and postoperative radiotherapy. Breast Cancer, 2017, 24(3): 362-368.
25.	Theeuwes HP, Gosselink MP, Bruynzeel H, et al. An anatomical study of the length of the neural pedicle after the bifurcation of the thoracodorsal nerve: implications for innervated free partial latissimus dorsi flaps. Plast Reconstr Surg, 2011, 127(1): 210-214.
26.	Ding Y, Cao DS, Huang X, et al. Segmental latissimus dorsi free flap attempting to preserve function at the donor site: Anatomical and clinical experiences. J Reconstr Microsurg, 2017, 33(4): 268-274.

1. Liu Y, Zang M, Wu L, et al. Improving the versatility of the latissimus dorsi myocutaneous flap using the perforator propeller flap concept. Ann Plast Surg, 2020, 84(6): 689-696.
2. Yoon JS, Oh J, Chung MS, et al. The island-type pedicled TRAM flap: Improvement of the aesthetic outcomes of breast reconstruction. J Plast Reconstr Aesthet Surg, 2020, 73(6): 1060-1067.
3. Baek SM, Biller HF, Krespi YP, et al. The lower trapezius island myocutaneous flap. Ann Plast Surg, 1980, 5(2): 108-114.
4. Tan KC, Tan BK. Extended lower trapezius island myocutaneous flap: a fasciomyocutaneous flap based on the dorsal scapular artery. Plast Reconstr Surg, 2000, 105(5): 1758-1763.
5. Raguse JD, Czabanka M, Voss JO, et al. The lower trapezius island myocutaneous flap in tunnelled technique to cover complicated tissue defects located between the craniocervical and cervicothoracic junction following spinal surgery. J Craniomaxillofac Surg, 2016, 44(8): 969-972.
6. Haas F, Weiglein A, Schwarzl F, et al. The lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and clinical applications based on the dorsal scapular artery. Plast Reconstr Surg, 2004, 113(6): 1580-1590.
7. Atiyeh BS, Hamdan AM, Nassar SI, et al. Vascularized fascial patch for repair of suboccipital dural defect. Ann Plast Surg, 1996, 37(4): 422-427.
8. Chen WL, Yang ZH, Huang ZQ, et al. Craniofacial resection and reconstruction in patients with recurrent cancer involving the craniomaxillofacial region. J Oral Maxillofac Surg, 2017, 75(3): 622-631.
9. Eshima I, Mathes SJ, Paty P. Comparison of the intracellular bacterial killing activity of leukocytes in musculocutaneous and random-pattern flaps. Plast Reconstr Surg, 1990, 86(3): 541-547.
10. Guerra AB, Gill PS, Trahan CG, et al. Comparison of bacterial inoculation and transcutaneous oxygen tension in the rabbit S1 perforator and latissimus dorsi musculocutaneous flaps. J Reconstr Microsurg, 2005, 21(2): 137-143.
11. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg, 1987, 40(2): 113-141.
12. Cormack GC, Lamberty BG. Cadaver studies of correlation between vessel size and anatomical territory of cutaneous supply. Br J Plast Surg, 1986, 39(3): 300-306.
13. Taylor GI, Corlett RJ, Dhar SC, et al. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg, 2011, 127(4): 1447-1459.
14. Salmon M. Arteries of the muscles of the trunk//Taylor GI, Razaboni RM, eds. Arteries of the muscles of the extremities and the trunk. St. Louis: Quality Medical Publishing, 1994: 117-119.
15. Taylor GI, Chubb DP, Ashton MW. True and ‘choke’ anastomoses between perforator angiosomes: part Ⅰ. anatomical location. Plast Reconstr Surg, 2013, 132(6): 1447-1456.
16. Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined. Plast Reconstr Surg, 2012, 129(5): 1043-1048.
17. Hébert PC, McDonald BJ, Tinmouth A. Clinical consequences of anemia and red cell transfusion in the critically ill. Crit Care Clin, 2004, 20(2): 225-235.
18. Hill JB, Patel A, Del Corral GA, et al. Preoperative anemia predicts thrombosis and free flap failure in microvascular reconstruction. Ann Plast Surg, 2012, 69(4): 364-367.
19. Rosen HM. The extended trapezius musculocutaneous flap for cranio-orbital facial reconstruction. Plast Reconstr Surg, 1985, 75(3): 318-327.
20. Netterville JL, Wood DE. The lower trapezius flap. Vascular anatomy and surgical technique. Arch Otolaryngol Head Neck Surg, 1991, 117(1): 73-76.
21. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg, 1981, 67(2): 177-187.
22. Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg, 1981, 67(5): 637-641.
23. Adams WP, Lipschitz AH, Ansari M, et al. Functional donor site morbidity following latissimus dorsi muscle flap transfer. Ann Plast Surg, 2004, 53(1): 6-11.
24. Sowa Y, Morihara T, Kushida R, et al. Long-term prospective assessment of shoulder function after breast reconstruction involving a latissimus dorsi muscle flap transfer and postoperative radiotherapy. Breast Cancer, 2017, 24(3): 362-368.
25. Theeuwes HP, Gosselink MP, Bruynzeel H, et al. An anatomical study of the length of the neural pedicle after the bifurcation of the thoracodorsal nerve: implications for innervated free partial latissimus dorsi flaps. Plast Reconstr Surg, 2011, 127(1): 210-214.
26. Ding Y, Cao DS, Huang X, et al. Segmental latissimus dorsi free flap attempting to preserve function at the donor site: Anatomical and clinical experiences. J Reconstr Microsurg, 2017, 33(4): 268-274.

Chinese Journal of Reparative and Reconstructive Surgery

Flap design and preliminary clinical experience of the lower trapezius musculocutaneous flap carrying a portion of the latissimus dorsi muscle

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