INTRODUCTION
Large defects in the upper region of the back, such as in cases of vertebrae exposure,
pressure ulcers, or those that evolve with dehiscence and exposure of plates or screws,
can require complex closure, as well as in meningeal exposure in high myelomeningoceles.
Conventional treatment may require large flaps with skin grafting in the donor area
and, sometimes, the time necessary for sufficient granulation1.
The trapezius muscle can be divided into three parts: ascending, transverse, and descending,
with irrigation by the occipital, transverse cervical, dorsal scapular, and posterior
intercostal arteries. According to the classification of Mathes & Nahai1, this vascularization is type II based on a dominant pedicle, the transverse cervical
artery (TCA)1.
According to Horch & Stark2, after tumor extirpation, the ideal treatment is early closure, preferably performed
with a muscle flap, which irrigates the defect.
The first trapezius musculocutaneous flap was described by Baek et al., in 1980, with
application to the head and neck, but with vascularization limitations that are still
referred to in other publications1-5.
According to studies by Weiglein et al.3, the dorsal scapular artery (DSA) is important in guaranteeing a larger cutaneous
territory, and its preservation in the trapezius flaps can include it in the Mathes
and Nahai type V classification.
According to Cormack & Lamberty6, the ascending and transverse parts of the muscle are irrigated by the occipital
and transverse cervical arteries with branches piercing the skin that guarantee a
cutaneous territory within the anatomical limits of the muscle. However, in the descending
part, when the cutaneous portion exceeds the inferior angle of the scapula by 5 centimeters,
it suffers and becomes necrotic, as the skin in this region is irrigated by direct
perforators of the DSA which, although it has a larger cutaneous territory, is not
preserved in flaps based on in TCA2,6.
Yang & Morris4 dissected 20 cadavers and described two irrigation patterns for the descending portion
of the trapezius muscle and noted the constancy of the DSA whose cutaneous territory
is described as having dimensions that exceed the limits of that attributed to the
TCA, but they did not establish its limits.
Netterville & Wood5 studied the irrigation of the trapezius muscle and reported the DSA as the dominant
pedicle on 15 sides of 30 dissections, the TCA on 9 sides, and 6 sides the dominance
of both arteries. The authors emphasized the importance of the first in irrigating
the musculocutaneous portion caudal to the inferior angle of the scapula.
Rocha et al.7 studied eight sides by dissection in cadavers and 60 sides by EcoDoppler in volunteers
and found the constancy of the DSA with the two trajectory patterns already described.
They found that both patterns allow mobilization of the flap in a musculocutaneous
composition with a cutaneous territory that goes beyond the limits of the muscle in
its lower third.
Bearing in mind these concepts and the difficulties encountered in cases of defect
in the upper region of the back, the authors planned a trapezius musculocutaneous
flap that, with the preservation of the DSA, would ensure a large cutaneous territory
and allow primary closure of the donor area with mobilization in V-Y.
OBJECTIVE
To treat large defects with bone exposure in the upper region of the back with a trapezius
musculocutaneous flap with a cutaneous territory larger than that recommended in the
literature and close the donor area primarily with V-Y mobilization.
METHOD
The protocol for this study was approved by the Research Ethics Committee of the Faculty
of Medical Sciences of the University of Vale do Sapucaí, under number 169/02, on
August 20, 2002, and the procedures were conducted from 2002 to 2012.
Five successive cases of patients with malignant neoplasia in the upper back (Table 1) underwent diagnostic incisional biopsy.
Table 1 - Patients.
| Sex |
Age in
years
|
Diagnosis |
Defect dimensions
(longitudinal x transverse)
|
| Male |
69 |
Basal cell carcinoma |
8cm x 8cm |
| Female |
80 |
Squamous cell carcinoma |
9cm x 9cm |
| Male |
17 |
Dermatofibrosarcoma Protuberans |
10cm x 16cm |
| Male |
70 |
Basal cell carcinoma |
10cm x 9cm |
| Male |
53 |
Basal cell carcinoma seeded by ornamental tattoo |
10cm x 14cm |
By post-informed consent, they adhered to the protocol and were individually subjected
to tumor extirpation.
The procedures consisted of creating a triangular island of skin and subcutaneous
tissue in the vicinity of the defect and with part of its extension over the trapezius
muscle on the chosen side, preserving the perforators of the lower extremity originating
from the DSA. In each case, the muscle was dissected in its descending part, freed
from its vertebral origins and scapular insertions. The posterior intercostal vessels
were ligated with 4-0 polyglactin 910 thread and divided without the use of thermocautery.
The muscle was elevated from the medial to the lateral margin to allow identification
and preservation of the DSA that penetrates the deep surface (Figures 1 to 20).
Figure 1 - (Case 1): Basal cell carcinoma in the upper region of the back.
Figure 1 - (Case 1): Basal cell carcinoma in the upper region of the back.
Figure 2 - (Case 1): Defect measuring 8 x 8cm with exposure of vertebrae.
Figure 2 - (Case 1): Defect measuring 8 x 8cm with exposure of vertebrae.
Figure 3 - (Case 1): Island of skin and subcutaneous tissue over the lower portion of the left
trapezius muscle.
Figure 3 - (Case 1): Island of skin and subcutaneous tissue over the lower portion of the left
trapezius muscle.
Figure 4 - (Case 1): Muscle reflected and dorsal artery of the scapula preserved. The island
of skin exceeds the dimensions of the muscle and the midline.
Figure 4 - (Case 1): Muscle reflected and dorsal artery of the scapula preserved. The island
of skin exceeds the dimensions of the muscle and the midline.
Figure 5 - (Case 1): Muscle rotation with the transfer of the skin island to the defect. The
arrow indicates the dorsal scapular artery at the pivot of rotation.
Figure 5 - (Case 1): Muscle rotation with the transfer of the skin island to the defect. The
arrow indicates the dorsal scapular artery at the pivot of rotation.
Figure 6 - (Case 1): Flap transferred and donor area closed in VY.
Figure 6 - (Case 1): Flap transferred and donor area closed in VY.
Figure 7 - (Case 2): Basal cell carcinoma in thoracocervical transition.
Figure 7 - (Case 2): Basal cell carcinoma in thoracocervical transition.
Figure 8 - (Case 2): Defect measuring 9 x 9cm with exposure of vertebrae.
Figure 8 - (Case 2): Defect measuring 9 x 9cm with exposure of vertebrae.
Figure 9 - (Case 2): Flap with an island of skin that goes beyond the limits of the muscle. The
arrow indicates the dorsal artery of the scapula penetrating the deep surface of the
muscle.
Figure 9 - (Case 2): Flap with an island of skin that goes beyond the limits of the muscle. The
arrow indicates the dorsal artery of the scapula penetrating the deep surface of the
muscle.
Figure 10 - (Case 2): Flap sutured to the defect and donor area closed in VY.
Figure 10 - (Case 2): Flap sutured to the defect and donor area closed in VY.
Figure 11 - (Case 3): Dermatofibrosarcoma in the upper region of the back.
Figure 11 - (Case 3): Dermatofibrosarcoma in the upper region of the back.
Figure 12 - (Case 3): Defect measuring 10 x16cm with exposure of vertebrae and right.
Figure 12 - (Case 3): Defect measuring 10 x16cm with exposure of vertebrae and right.
Figure 13 - (Case 3): Flap with an island of skin that goes beyond the limits of the muscle and
the midline. The arrow indicates the dorsal artery of the scapula penetrating the
deep surface of the muscle.
Figure 13 - (Case 3): Flap with an island of skin that goes beyond the limits of the muscle and
the midline. The arrow indicates the dorsal artery of the scapula penetrating the
deep surface of the muscle.
Figure 14 - (Case 3): Third postoperative day. Flap sutured to the defect and the donor area closed
in V-Y.
Figure 14 - (Case 3): Third postoperative day. Flap sutured to the defect and the donor area closed
in V-Y.
Figure 15 - (Case 4): Basal cell carcinoma in thoracocervical transition.
Figure 15 - (Case 4): Basal cell carcinoma in thoracocervical transition.
Figure 16 - (Case 4): Defect measuring 10 x 9cm with exposure of vertebrae.
Figure 16 - (Case 4): Defect measuring 10 x 9cm with exposure of vertebrae.
Figure 17 - (Case 4): Third month postoperatively.
Figure 17 - (Case 4): Third month postoperatively.
Figure 18 - (Case 5): Basal cell carcinoma seeded by ornamental tattoo.
Figure 18 - (Case 5): Basal cell carcinoma seeded by ornamental tattoo.
Figure 19 - (Case 5): 10 x 14cm defect with removal of the transverse portion of the trapezius
muscle and the transverse cervical artery (TCA), preserving only the dorsal scapular
artery (DSA).
Figure 19 - (Case 5): 10 x 14cm defect with removal of the transverse portion of the trapezius
muscle and the transverse cervical artery (TCA), preserving only the dorsal scapular
artery (DSA).
Figure 20 - (Case 5): Fourth post-operative week.
Figure 20 - (Case 5): Fourth post-operative week.
The flaps were transferred by rotating the muscle to promote, in a pendulum movement,
the advancement of the skin island towards the defect and closure in V-Y. The detachments
were drained with continuous suction for three days.
RESULTS
All specimens were studied and showed tumor-free margins.
There were no complications related to anesthesia or the surgical procedure, except
for the occurrence of seroma, which was detected and drained on an outpatient basis
in the second week after surgery in the first two cases, despite the use of the drain.
The skin stitches were removed between the 10th and 15th days.
In all the five cases, the flaps evolved without suffering and were sufficient to
treat large defects (Table 1).
DISCUSSION
The pedicles were easily identified in the two anatomical patterns of the DSA and
preserved1,3,4.
Preservation of the DSA did not hinder the rotation arc of the flap, since the flaps
were designed distally to the defects and mobilized in the cephalic direction, approaching
the origin of the vessels2,4-7.
In all cases, the cutaneous territory exceeded the longitudinal and transverse limits,
unlike the discouraging recommendations described in the literature as characteristics
of TCA-based flaps. Viability was demonstrated well beyond the 5cm caudal to the tip
of the scapula and the dimensions of the trapezius muscle and even beyond the midline
of the back2,4,6,7.
The extension of the cutaneous territory obtained with the preservation of the DSA
allowed the creation of the skin island with an elongated shape, convenient for V-Y
closure, attenuating the tension in the donor area and the dimensions of the pedicle
allowed the mobilization of the island for defects up to the fourth cervical vertebra
and above the spine of the scapula (Figures 8, 9, 10, 18, 19, 20).
The V-Y flap has the virtue of transferring a large area of skin and treating the
donor area simultaneously, by redistributing the skin island, unlike transposition
flaps, usually made with the trapezius muscle.
The motor innervation, via the XI cranial nerve, of the ascending portion of the muscle
was preserved and maintained the scapular elevation movement in all cases.
CONCLUSION
The islanded trapezius musculocutaneous flap based on DSA is safe and can be transferred
in V-Y with primary closure of the donor area in cases of defect with bone exposure
in the upper back region.
REFERENCES
1. Mathes SJ, Nahai F. Reconstructive surgery: principles, anatomy and technique. 1st
ed. New York: Churchill Livingstone; 1997. p. 651-77.
2. Horch RE, Stark GB. The contralateral bilobed trapezius myocutaneous flap for closure
of large defects of the dorsal neck permitting primary donor site closure. Head Neck.
2000;22(5):513-9.
3. Weiglein AH, Haas F, Pierer G. Anatomic basis of the lower trapezius musculocutaneous
flap. Surg Radiol Anat. 1996;18(4):257-61.
4. Yang D, Morris SF. Trapezius muscle: anatomic basis for flap design. Ann Plast Surg.
1998;41(1):52-7.
5. Netterville JL, Wood DE. The lower trapezius flap. Vascular anatomy and surgical technique.
Arch Otolaryngol Head Neck Surg. 1991;117(1):73-6.
6. Cormack GC, Lamberty BGH. The arterial anatomy of skin flaps. 2nd ed. New York: Churchill
Livingstone; 1994. p. 324.
7. Rocha JLBS, Paiva GR, Rocha LCS. A artéria dorsal da escápula no terço inferior do
músculo trapézio. Rev Bras Cir Plást. 2021;36(2):151-5.
1. Fundação Hospitalar do Acre, Programa de Reabilitação e Assistência aos Fissurados da Face, Rio Branco, AC, Brazil
2. Clínica Paiva e Rocha, Pouso Alegre, MG Brazil
Corresponding author: João Lorenzo Bidart Sampaio Rocha Av. Alberto de Barros Cobra, 717, Pouso Alegre, MG, Brazil. Zip code: 37553-459, E-mail:
joaolorenzorocha@gmail.com
Article received: July 16, 2023.
Article accepted: February 4, 2024.
Conflicts of interest: none.
