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Trapezius flap for coverage of the right shoulder. (A) Cutaneous metastasis of breast cancer at the right shoulder. (B) Status after resection. (C) Preparation of the myocutaneous trapezius muscle from caudal to cephalic. (D) Identification of the deep branch of the cervical artery and vein. (E) Transposition of the myocutaneous flap. (F,G) Intraoperative insert of the flap. (H) Postoperative result.
Source publication
After oncological tumor resections at the back, large defects can remain that depending on the size and location may require flap coverage and represent reconstructive challenges to plastic surgeons. Flap selection includes the entire armamentarium of coverage including transposition flaps, perforator flaps, pedicled muscle flaps and free flaps. Mo...
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Objectives
The objective of this article is to review options for regional pedicled reconstruction for large head and neck defects in a salvage setting.
Methods
Relevant regional pedicled flaps were identified and reviewed. Expert opinion and supporting literature were used to summarize and describe the available options.
Results
Specific regiona...
We present a pediatric patient with an ASMT of the wrist with the unique approach of a plastic and reconstructive surgeon to surgical oncologic resection and reconstruction: WLE, ICG and NIRF imaging-assisted SLNB followed by reconstruction with a keystone perforator flap.
Cutaneous xanthogranuloma is a rare benign tumor and both adults and children could be affected. Head and neck area of the human body is the most commonly affected one which often poses a serious reconstructive challenge for the plastic surgeon who is in charge of removing the lesion. We report on a clinical case of an adult female patient who pres...
Citations
... 11 Soft-tissue defects resulting from radiation-induced damage often require reconstructive surgical intervention. 12 Although several reconstructive options exist for posterior trunk defects, 13 they markedly affect the length of hospital stay and overall patient discomfort. In selected cases, well-vascularized coverage and modification of tension forces on the wound might reduce the risk of both postoperative complications and reoperations in patients undergoing total or partial posterior vertebrectomy after tumor excision. ...
Background
Adjuvant radiation therapy following vertebrectomy is a major risk factor for local wound complications such as dehiscence, infection, and skin necrosis. In selected cases, well-vascularized coverage and modification of tension forces on the wound might reduce the risk of postoperative complications and reoperations. We aimed to demonstrate a reduction in general and specific complications in patients undergoing vertebral resection and flap coverage compared with vertebral resection alone.
Methods
We retrospectively analyzed and collected data from patients diagnosed with a tumor involving the spine and requiring a total or partial posterior vertebrectomy between January 2012 and October 2022, referred to a single tertiary-level orthopedic and trauma center. We included only patients in whom primary closure of the wound was possible but judged to be under excessive tension.
Results
A total of 145 patients underwent partial or total vertebrectomy for oncological reasons at our tertiary-level trauma hospital. Among these, 73 patients were eventually included according to the inclusion and exclusion criteria: 53 in the orthopedic group and 20 in the orthoplastic group. Considering only patients undergoing radiation therapy, the orthoplastic group showed significantly lower rates of overall complications (33% versus 69%) than the orthopedic group.
Conclusions
Primary flap coverage, especially in patients receiving RT, reduces the risk of postoperative complications and avoids a second reconstructive operation, consequently reducing patient discomfort, length of hospital stay, and healthcare costs.
... The flap was marked so as to be 2 cm larger than the mapping. Following the incision extending from the posterior axilla to the posterior iliac crest, and the muscle which was classified according to Mathes and Nahai as a class V muscle, making it suitable for use as a flap to cover contralateral or distal defects (16,17) was detached from the inferior edge of the scapula. ...
... Many reconstructive surgeons utilize free flaps as their first-line treatment option, especially for large defects of the trunk. Regional flaps (transposition flaps, perforator flaps, and pedicled muscle flaps) for the repair of trunk defects can be approached through the shoulder girdle, paraspinal region, epigastric axis, or pelvic girdle [14,15]. Pedicled muscle flaps utilize local "like" tissue and preserve the nerve, muscle, and main vasculature, thus reducing the operation and hospitalization time. ...
The keystone design perforator island flap can be utilized in the repair of trunk defects. A systematic review was carried out to identify the complication rates of the use of this flap to treat such defects. The MEDLINE, Embase, Cochrane Library, and PubMed Central databases were searched for articles published between January 2003 and December 2018 that reported the use of keystone design perforator island flaps in the repair of trunk defects. Study selection was conducted in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Eight articles involving a total of 54 flaps satisfied the inclusion criteria. The most frequently reported cause of trunk defects was oncologic resection (64.4%). The overall complication rate was 35.2%, and complications included infection (11.1%), wound dehiscence (7.4%), delayed healing (7.4%), and partial flap loss (1.9%). The keystone design perforator island flap is associated with a high success rate and low technical complexity. Despite minor complications, keystone design flaps could be a preferred choice for trunk reconstruction.
... Classically, pedicled musculocutaneous flaps like latissimus dorsi and trapezius musculocutaneous flaps as well as random pattern fasciocutaneous flaps have been used for reconstruction of back. Muscle flaps have high morbidity due to sacrificing their actions and added problem with these pedicled flaps is, the donor defect needs to be skin grafted, which would be troublesome when patient needs radiotherapy [1] (9.10). ...
Soft tissue sarcomas can occur anywhere in the body. In the back, they pose a significant problem due to their large size. Surgery is the main stay of treatment for soft tissue sarcoma management. However, removal of such tumors results in large soft tissue defects. Skin grafts can resurface large defects, but skin grafts have their own limitations and can delay initiation of radiotherapy. Providing a stable soft tissue cover which can withstand post-op radiotherapy is desirable. Single flap cannot cover large defects. We report one such technique where two antero-lateral thigh free flaps were connected in series for the first time as “chain flaps” for large defect coverage. Six months follow-up showed no complications following radiotherapy. We recommend this technique to cover large size defects which are not amenable to cover via single flap, for optimal outcome.
... T he reconstruction of the posterior trunk offers special challenges to plastic surgeons, given the relative shortage of elasticity and wide extent as well as a deficiency of potential microsurgical recipient vessels. [1][2][3] Soft tissue defects of posterior trunk may occur from removal of malignant skin or soft tissue tumors, infection, trauma, spine surgery, radiation ulcers, and congenital malformations. [4][5][6] Defects of the posterior trunk often involve hardware exposure, infection of bone, and poor healing wounds as a result of radiation therapy or bedsores. ...
... For larger wounds, free flaps may be required, but isolating a reliable recipient pedicle can be challenging. [1][2][3] To overcome the limitation in obtaining a suitable recipient vessel, the use of free flaps implemented with arteriovenous loops and interposition grafts has been reported along with a remarkable increase in risk of complications. 9,10 The application of perforator flaps has expanded the horizons of plastic surgery and has gained a prominent role in posterior trunk reconstruction, because this anatomical region provides abundant perforators. ...
... Free flaps can be advocated as an alternative, although isolating reliable recipient vessels can be difficult. [1][2][3][4] More recent techniques proposed the application of perforators and the perforasome concept. [14][15][16][17][18][19] The rational of using perforators to elevate a flap was first proposed by Taylor and Palmer, 14 after their studies on angiosomes. ...
Background:
Closure of extensive defects of posterior trunk can be challenging for reconstructive surgeons owing to the need of a large bulk of well-vascularized tissue to resurface the skin and the exposed hardware and to fill the dead spaces. We hypothesized that elevating multiple perforators flaps in various patterns would allow for reconstruction of large posterior trunk defects with tension-free primary closure and minimal donor site morbidity.
Patients and methods:
Between January 2013 and December 2016, 23 patients with large posterior trunk defects underwent reconstruction with a multiple freestyle perforator flaps approach. We experimented a freestyle perforator-based reconstruction, which consists of designing a sequence of flaps, able to adequately fit the defects, allowing for tensionless primary closure.
Results:
The average age of patients was 60.2 years (range, 18-80 years). A total number of 62 perforator flaps was performed, with an average of 2.6 flaps per patient. We were able to successfully cover defects up to 27 × 29 cm. A single perforator was used in 58 flaps, whereas more than 1 perforator was applied in 4 flaps. In all cases, the donor sites were closed primarily, and patients healed uneventfully. Six patients underwent radiotherapy after surgery, but no complication occurred.
Conclusions:
In this series of extensive defects of the posterior trunk, a tension-free closure was achieved by distributing the tension to multiple freestyle perforator flaps, supplying sufficient volume of tissue and reliable vascularization. This approach can be a valid tool in facing reconstruction of large and complicated defects of the posterior trunk.
... Reconstruction of soft-tissue defects of the posterior trunk can constitute a challenge for plastic surgeons. Reliable axial pattern flaps for local tissue transfer and recipient vessels for microsurgical reconstruction are scant [9] , the wound is often deep and with irregular three-dimensional contour [10] . Inadequate amounts of soft tissue can lead to contracture during the healing process, compromising trunk and upper extremity function. ...
... Nevertheless, the dorsal trunk hosts several muscles that may be transferred as pedicled flaps such as the latissimus dorsi or the trapezius. Moreover, in selected cases free flaps with vein graft or loops may be used [5][6][7][8][9][10][11] . ...
... Its dominant vascular pedicle is the thoracodorsal artery, which is part of the scapular vascular system, whereas the non-dominant pedicles origin from intercostal and lumbar arteries. It is therefore a class V muscle according to the popular classification of Mathes and Nahai [16] ; thus, survival of the flap may also be based on the non-dominant pedicles [17] , which would allow utilization of this flap as a "reverse" flap in order to cover contralateral or more caudal defects [9] . ...
Surgical resection of soft tissue sarcoma of the trunk can result in large defects requiring complex reconstruction for coverage of vital neurovascular structures and tissue defect. Large defects of the back could be reconstructed with multiple random pattern or local pedicled flaps. We present the case of a 48-year-old patient with a locally advanced dermatofibrosarcoma protuberans of the back. Wide local excision of the lesion was performed. The soft tissue defect measured 22 cm × 20 cm × 4 cm and was reconstructed with bilateral reverse latissimus dorsi myocutaneous (RLDM) flap. Each RLDM flap measured 24 cm × 10 cm. The donor site on the back was closed directly on both sides. The patient recovered well and the two flaps healed uneventfully. Twelve months after surgery the patient is disease-free. The use of a RLDM flap in mid-back reconstructions provided wide well-vascularized soft tissue, minimized risk of infection, and maximized back coverage. This flap is an excellent choice for reconstruction of large defects of the mid-back.
... Their ability to obliterate dead space, enhance local perfusion, and facilitate collagen deposition apportions flap reconstruction with a pivotal role along with thorough debridement and antimicrobial therapy in the management of complex postoperative wounds. A regional approach based on location, size, blood supply, and donor site morbidity can be utilized to facilitate flap selection and enhance the potential for successful wound healing [2,3]. ...
Innovations in oncology, perioperative patient management, and spinal stabilization, which typically include the use of spinal instrumentation, have widened the spectrum of patients deemed suitable candidates for spinal surgery. Spinal defects are frequently encountered after resection of primary tumors or metastases within the vertebral bone. A variety of local flaps, pedicled flaps, and free tissue transfers have been described in the literature as options for soft tissue reconstruction of the posterior trunk. These methods encompass numerous fasciocutaneous as well as myocutaneous flaps. This chapter aims to review recent reports and provide systematic guidance for reconstructive surgeons taking care of patients who require either simultaneous prophylactic coverage or delayed soft tissue reconstruction of such defects. The recommended operative techniques can be stratified in two different manners: either by anatomical region on the back (C1–T7, T7–L1, or L1–S5) or by complexity and efficacy (primary, secondary, tertiary). Larger defects may necessitate combinations of flaps for successful reconstructions, while infected wounds require additional antibiotic treatment. Typically, the instrumentation inserted by the orthopedic surgeon can be salvaged with these approaches while subsequently reducing the risk of neurological injury to the patient. An array of different scenarios and techniques are presented and discussed.
... The onset of free-style dissection perforator flaps has warranted the possibility of raising proper perforator flaps without compromising the trapezius muscle role. 4 The main vascular supply of the trapezius muscle arises from the transverse cervical artery (TCA), with minor contributions from intercostal, circumflex scapular and occipital perforators. The dorsal scapular artery (DSA) is the deep branch of the TCA; it courses beneath the levator scapulae and rhomboid minor muscles before a branch perforates the fascia between the rhomboid minor and major to run along the medial border of the scapula (superficial dorsal scapular artery) before emerging under the trapezius muscle. ...
The use of free flaps is considered the “gold standard” for reconstruction of head and neck defects. Locoregional flaps allows a better aesthetic result compared to free flaps, whenever there's an external skin defect. However the use of free flaps is not always adequate in the presence of preoperative comorbidities or previous surgeries. Since the description of the trapezius myocutaneous flap in the 1980's, many authors have published the results of the applicability of this flap in head and neck salvage reconstructive surgery. Nonetheless, the concern with trapezius muscle function remains an important issue. The onset of free-style dissection perforator flaps has attenuated this problem. The authors present a case of a 68 year old man with a posterior cervical wound after a cervical spine trauma, who underwent multiple spine surgeries, successfully treated with an island muscle-sparing trapezius flap. All the details of the dissection technique are outlined. The authors found the trapezius perforator flap to be a reliable and accessible to raise flap with a negligible donor-site morbidity. This flap can be used for occiput, nuchal and spinal areas injuries without the local morbidity related to other flap options.
Introduction: Soft tissue sarcomas (STS) in the extremities require complex treatment involving limb-sparing surgery with adjuvant therapy. The treatment involves tumor resection with wide margins along with additional radiation and/ or chemotherapy. In addition to tumor resection, an important aspect is the reconstruction of the resulting soft tissue defect. For extensive reconstructive procedures in the upper extremities, literature suggests the use of free or pedicled flaps. In the shoulder region, due to its complex regional anatomy, selecting an appropriate flap is the surgical imperative. Recently, there has been significant interest in the use of the pedicled trapezius musculocutaneous flap, which offers certain advantages over other flaps. Case report: A female patient (31 years old) with STS in the left shoulder region, was surgically treated three times. The first surgery involved an intralesional procedure - R2 resection when a pleomorphic dermal sarcoma was diagnosed. After five months, a recurrence of the disease was detected based on magnetic resonance imaging (MRI) findings at the site of the surgical scar. Tumor resection was performed, and the soft tissue defect was covered with a free Thiersch partial-thickness skin graft. Histopathological analysis revealed a high-grade leiomyosarcoma. Two months after the second surgery, MRI findings confirmed a recurrence of the disease. Wide tumor resection was conducted, and the soft tissue defect was covered with a pedicled lower trapezius musculocutaneous flap. Conclusion: The literature lacks studies describing the outcomes of the use of trapezius flaps in the reconstruction of defects in the shoulder region following STS resection. Additionally, there is no unanimous official opinion on the resection margin width that is considered safe. The treatment outcome of our patient indicates the significant potential and advantages of the trapezius flap, as compared to other flaps of that region.
