Trapezius and Latissimus Dorsi Regional Flaps

History

• 1.

  History of present illness:

  • a.

    The cause of the defect should be determined because it can affect current and future reconstructive needs.

    • 1)

      In defects secondary to benign or malignant tumors, the risk of recurrence and possible need for future reconstruction should be considered. Donor sites that do not limit future reconstructive options are preferred (a supraclavicular flap may compromise future use of a lateral trapezius flap, because both are based on branches of the transverse cervical artery).

    • 2)

      In defects secondary to traumatic injury, the needs of immediate coverage must be weighed against goals of ultimate reconstruction. For example, a pedicled flap reconstruction may provide the most rapid/immediate solution for traumatic defect coverage. However, if a free flap would provide the best long-term results, a free flap may be the preferred reconstructive option despite the added time and complexity associated with this form of reconstruction.

  • b.

    The extent and complexity of the defect requiring reconstruction should be determined.

    • 1)

      Reconstruction ideally replaces lost tissue with tissue of similar texture, thickness, and type. Thus, cutaneous tissue defects are ideally reconstructed with cutaneous tissue of similar color, thickness, and texture.

    • 2)

      A composite defect involving multiple tissue types is ideally reconstructed with equivalent tissue. Thus muscle is replaced with muscle, and bone is replaced with bone. Finding donor tissue matching the needs of the defect may guide a surgeon’s decision when choosing between a regional flap and a free flap.

  • c.

    Current function and future functional needs should be elicited.

    • 1)

      Preoperative swallowing and breathing should be evaluated.

    • 2)

      Possible need for postoperative airway protection (tracheostomy) and nutritional support (nasogastric or gastric feeding tube) should be considered.

• 2.

  Past medical history

  • a.

    Prior treatment in the head and neck region:

    • 1)

      History of surgery in the neck, axilla, and back may affect viability of regional reconstructive options.

    • 2)

      Prior radiation may affect postoperative healing and flap viability.

  • b.

    Medical illnesses may affect flap viability and reconstructive outcomes:

    • 1)

      Diabetes, especially if poorly controlled, can effect healing outcomes and flap viability.

    • 2)

      Peripheral vascular disease may affect flap viability.

    • 3)

      Coagulopathies may affect postoperative bleeding or coagulation.

    • 4)

      Tobacco abuse/nicotine exposure is associated with arterial constriction and vascular insufficiency. This should be avoided in the perioperative period.

  • c.

    Family medical history:

    • 1)

      Coagulopathies may affect postoperative bleeding or coagulation and thus flap viability.

  • d.

    Medications:

    • 1)

      Consider the risks and benefits of discontinuing any drugs that may increase the perioperative risk of bleeding. A hematoma in the postoperative period can affect flap viability.

Physical Examination

• 1.

  Neck examination

  • a.

    The neck should be carefully evaluated for any scars or evidence of prior surgical intervention that the patient may have forgotten to mention during collection of the history of the present illness or past medical history.

• 2.

  Extremity examination

  • a.

    The axilla and extremity on the side considered for flap harvest should be carefully inspected for any evidence of scars suggesting prior surgery.

  • b.

    The range of motion and strength of the extremity on the side selected for flap harvest should be carefully evaluated and documented preoperatively.

• 3.

  Doppler examination

  • a.

    A Doppler examination to identify and trace the vascular pedicle should be performed prior to proceeding with surgery. This can be done in the office or on the day of surgery.

  • b.

    The site of Doppler signals should be marked with a marking pen to facilitate future identification.

Imaging

• 1.

  No dedicated imaging of the neck, axilla, or back is required prior to planning or harvesting trapezius or latissimus dorsi flaps.

Preoperative Preparation

• 1.

  The side to be used for flap harvest should have the upper extremity marked “No Lines and No IVs” in the preoperative area. This extremity will be prepped into the surgical field.

• 2.

  Discontinue any medications that increase the risk of bleeding if medically safe.

Anesthesia

• 1.

  General anesthesia:

  • a.

    Due to the extent of dissection and positioning needs of the surgery, general anesthesia is necessary for the procedure.

  • b.

    Use of a paralytic agent is at the discretion of the surgeon. Some surgeons prefer paralysis during dissection because it relaxes muscles and makes manipulation easier. Others prefer no paralysis to aid in identification of motor nerves during dissection.

Positioning

• 1.

  Lateral decubitus

  • a.

    Facilitates exposure of the back to the midline

  • b.

    Requires placement of the axillary roll and careful positioning to prevent injury of the brachial plexus

• 2.

  Modified lateral decubitus

  • a.

    Adequate exposure can be accomplished with placement of a bump or bean bag. There is less exposure of the back compared to a true lateral decubitus positioning.

  • b.

    Does not require placement of an axillary roll

• 3.

  Prone

  • a.

    Prone positioning may be preferred if trapezius or latissimus dorsi flaps are used to reconstruct the posterior neck or occipital defects.

Perioperative Antibiotic Prophylaxis

• 1.

  As indicated by the primary defect undergoing reconstruction

Monitoring

• 1.

  None necessary

Instruments and Equipment to Have Available

• 1.

  Handheld Doppler

• 2.

  Monopolar and bipolar cautery

• 3.

  Axillary roll

• 4.

  Bean bag

Operative Risks

• 1.

  Bleeding: Development of a hematoma must be carefully monitored because it can cause compression of the vascular pedicle and result in flap compromise.

• 2.

  Infection: Infection at the flap donor site is a relatively low risk, but the area may be contaminated by the defect undergoing reconstruction (especially in cases involving oral or oropharyngeal defects). Antibiotics should be chosen based on the primary site defect and associated risk of infection.

• 3.

  Scarring/cosmetic defect: It may be impossible to close donor sites primarily, and they may require split-thickness skin grafting. When split-thickness skin grafting is used, a less aesthetic donor site appearance will generally result, and a second donor site is created where the graft is harvested.

• 4.

  Flap loss: A significant risk in any flap reconstruction surgery is that of partial or total flap loss. In pedicled flaps, the most common cause of total flap loss is poor pedicle geometry with pedicle compression within a tunnel, kinking, or tension at time of inset. Care must be taken to avoid these situations. Partial flap loss may be due to numerous factors including the patient’s peripheral vascular disease, perioperative hypo- or hypertension, rough handling of the tissue, and excess flap size resulting in random-pattern blood supply to distal flap tissues.

• 5.

  Damage to surrounding structures: During flap harvest and inset involving the trapezius flaps and latissimus dorsi flaps, there are multiple neurovascular structures at risk. The structures at risk include the brachial plexus and the accessory nerve. Damage to the brachial plexus can affect function of the shoulder and upper extremity. Damage to the accessory nerve or destabilization of key trapezius muscular insertions can result in shoulder droop and weakness.

Introduction

The trapezius muscle is a triangular muscle that extends from the occipital skull base, along the spine, to the level of the 10th thoracic vertebrae. It has insertions onto the lateral third of the clavicle, the spine of the scapula, and the acromion. The trapezius muscle is associated with three separate musculocutaneous flaps based on three separate vascular pedicles. These include the superior trapezius flap, the lateral trapezius flap, and the inferior trapezius flap. Because each of these flaps is based upon a unique vascular pedicle, they are considered, designed, and surgically elevated separately.

Superior Trapezius Flap

The superior trapezius musculocutaneous flap is based upon vascular contributions from the paraspinous muscular perforators and from branches of the occipital artery. This flap requires a broad superior base to provide sufficient vascular supply and as such has a limited arc of rotation. Although its limited arc of rotation decreases its applicability, it has the most reliable vascular supply of the trapezius flaps.