|Year : 2020 | Volume
| Issue : 4 | Page : 252-254
Role of trapezius turnover flap in complex posterior cervical wounds
Department of Plastic, Reconstructive and Aesthetic Surgery, Balikesir Atatürk City Hospital, Balıkesir, Turkey
|Date of Submission||01-Jan-2020|
|Date of Acceptance||09-Jan-2020|
|Date of Web Publication||28-Sep-2020|
Dr. Bilgen Can
Plastic Reconstructive and Aesthetic Surgery Clinic, Balikesir Ataturk City Hospital, Balıkesir
Source of Support: None, Conflict of Interest: None
The trapezius turnover muscle flap is a very useful and effective solution for complex wounds in the posterior cervical area after neurosurgical interventions. However, it is one of underused flaps in plastic surgery practice. The trapezius flap should be considered as the first choice when regional fasciocutaneous flap options are unavailable after radiotherapy and when patients are unsuitable for long-term microsurgical tissue transfer operations due to their age and general condition. The protection of the upper 1/3rd of the trapezius muscle during elevation of the flap could prevent the development of a drooping shoulder.
Keywords: Muscle, neurosurgical, trapezius, turnover
|How to cite this article:|
Can B. Role of trapezius turnover flap in complex posterior cervical wounds. Turk J Plast Surg 2020;28:252-4
| Introduction|| |
Posterior cervical defects often occur after neurosurgical tumor excisions. The risk of infection in the surgical area after neurosurgical operation is 1%–6%. In addition, the presence of metallic hardware placed in the vertebral column and postsurgical radiotherapy after tumor excision delay wound healing. After neurosurgical interventions, unhealed wounds in the posterior cervical area, development of radionecrosis and osteomyelitis in the vertebrae, and exposed hardware are common. In these types of complex wounds, a trapezius muscle flap should be kept in mind as the first choice with selected patients because of its proximity to the wound, rich blood circulation, increased resistance of local tissue to infection, strong soft-tissue support, and short operation time. In this study, we presented a patient to whom we applied a trapezius turnover flap due to chronic wound and vertebral radionecrosis after tumor excision and radiotherapy in the posterior cervical area. We aimed to reveal that a trapezius turnover flap is an effective and easy solution to a rather complex wound despite its rare use in plastic surgery practice.
| Case Report|| |
A 56-year-old female patient presented to our outpatient clinic with a complaint of an open wound with purulent discharge in the posterior cervical area for 1 year [Figure 1]. In her history, she reported a resection of cervical ependymoma 1½ years ago and that she received six cycles of radiotherapy after the resection. However, after radiotherapy, discharge began appearing at the surgical site. She had undergone antibiotic treatment and local wound care for the last 1 year. In the examination of the patient, three sinuses were extending between the seventh cervical and forth thoracic vertebrae in the posterior cervical area, and purulent discharge from these sinuses was observed. The seventh cervical vertebra's spinous process protruded posteriorly toward the skin and seemed nonvital. Cervical magnetic resonance imaging showed no vertebral osteomyelitis, but some changes in the vertebral and soft tissues due to the surgery. The patient who had no additional health problems and had nothing to be noted in the general physical examination was scheduled for an operation with a trapezius turnover muscle flap and skin graft.
|Figure 1: Posterior spinal wound, with nonvital seventh cervical vertebrae protrusion|
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The patient was operated on with a neurosurgery team. An elliptical excision of the skin was performed. The debridement of unhealthy skin, soft tissue, and spinous processes of the seventh cervical, first and second thoracic vertebrae was performed. The metallic hardware placed for stabilization became exposed after debridement.
The tip of the scapula, medial borders of the scapula, and transverse cervical artery were marked preoperatively. Through a lazy “S” incision made inferior to the defect, muscle fascia has been reached. The skin flaps were elevated to reveal the medial and lateral parts of the muscle. The flap was dissected from the spinous processes and from the latissimus dorsi muscle and elevated from inferior to superior [Figure 2]. When the medial scapula level was reached, care was taken not to separate the muscle from the upper scapula 1/3rd adhesion site, and the superior border of the dissection was determined to be here. The flap was dissected up to the top 1/3rd of the scapula and was turned back 180° like paper and adapted to the defect area [Figure 3]. The skin edges were sutured to the muscle and the remaining defect area was repaired with a full-thickness skin graft.
|Figure 2: Trapezius muscle elevated from inferior to superior (author's own digital artwork)|
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The patient was followed up on with an elastic bandage application to the flap donor site for 3 weeks. After 3 months of follow-up, no problems were found at the wound site and the flap donor site [Figure 4].
| Discussion|| |
The trapezius musculocutaneous flap is an underused flap in the plastic surgery practice. However, in posterior cervical defects, it should be considered as the first choice in case of infection, exposed metallic hardware, and no chance of local fasciocutaneous flap due to radiotherapy. It is also a valuable option for patients who cannot tolerate long and major reconstructive surgery due to advanced age and tumor surgery.
The trapezius muscle is one of the largest muscles in the body. It is separated into three sections as per function and the direction of the muscle fibers. The sections are superior (descending), middle (transverse), and inferior (ascending). The superior part starts from the spinous process of the seventh cervical vertebra, the external occipital protuberance, and the ligamentum nuchae. Fibers proceed downward and laterally from this origin and are inserted into the posterior border of the lateral third of the clavicle. The middle section origins from the spinous processes of seventh cervical vertebrae and first three thoracic vertebrae just to insert into the medial margin of the acromion and the superior lip of the posterior border of the spine of the scapula. The inferior part starts from the spinous processes of the remaining thoracic vertebrae. It then proceeds upward and laterally to converge near the scapula and end in an aponeurosis. The trapezius muscle has two primary functions: first, the movement of the scapula when the spinal segments are stable; second, the movement of the spine when the scapula is stable. It is innervated by the eleventh cranial nerve (the accessory nerve, CN XI). When the spinal accessory nerve is disrupted, it produces shoulder drooping or limited arm rotation.
In the classification of Mathes and Nahai, the trapezius muscle flap has a Type-II pattern of circulation. Its dominant vascular supplies come from transverse cervical artery. The transverse cervical artery arises from the thyrocervical trunk or directly from the second or the third part of subclavian artery and passes through the posterior triangle of the neck to the anterior border of the levator scapulae muscle, where it divides into deep and superficial branches. The upper part of the trapezius muscle is supplied by branches of the occipital artery; the middle and lateral parts are supplied mainly by the superficial cervical artery, and the lower part is supplied by the dorsal scapular artery and medially segmental perforators of posterior intercostal arteries.
In the clinical practice, there is a conceptual confusion about the vessels supplying the trapezius muscle. The branches of the subclavian artery supplying the posterior neck and posterior trunk have been named by different names in various studies. In addition to this, it has been shown that along with the transverse cervical artery, the dorsal scapular artery is also the dominant pedicle of the trapezius muscle. The presence of arterial anatomic differences between the East Asian and Caucasian communities leads to these conceptual confusions; thus, more detailed anatomical studies are needed.
The muscle flaps are better than fasciocutaneous flaps in terms of covering infected areas and radiation wounds with exposed metallic hardware. Other local muscle flaps that can be used in the posterior trunk are the paraspinous muscle flap and the latissimus dorsi muscle flap. In our patient, the paraspinous muscle flap was not an option bacause the paraspinous muscles were injured during tumor surgery. The latissimus dorsi muscle flap requires a difficult and precise dissection. It was also difficult to access the superior cervical region, so it was not a viable option for our patient.
In addition, the trapezius flap was applied as a muscle flap instead of a musculocutaneous flap. Because the radiodermatitis was observed in a large area on the back made the skin island circulation in doubt, an isolated muscle flap was preferred.
During the preoperative period, the scapular position was proper and the shoulder rotations were adequate, suggesting that the pedicle of the trapezius muscle was intact. However, the pulse of the transverse cervical artery was traced with a hand Doppler. In the patients with total neck dissection, if transvers cervical artery integrity is suspicious, arteriography can be done.
Dropping of the shoulder and the development of seroma at the donor site are the major complications expected after the surgery., These complications were not observed in our patient owing to protection of the upper 1/3rd of the trapezius muscle and the use of elastic bandage at the donor site for 3 weeks.
As a result, the trapezius muscle turnover flap is a workhorse flap which should be considered as the first choice in posterior cervical spine surgeries and complex wounds with infection and exposed metallic hardware.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]