Nape of The Neck Flap

EDITORIAL COMMENT

When this flap is taken without the underlying trapezius muscle to augment its circulation, it often creates difficulties with the very distal circulation, resulting in the loss of the most important part of the flap.

In 1842, Mutter first described his “autoplasty technique,” using a superiorly based posterolateral neck flap from the shoulder and deltoid region to correct a cicatricial burn contracture of the anterior neck (1). Since then, several variously named, constructed, and applied shoulder neck flaps have been suggested (2, 3, 4, 5, 6, 7, 8, 9).

INDICATIONS

The nape of neck flap has been used to cover a wide variety of defects. In the neck, these include closure of pharyngocutaneous fistulas, replacement of soft tissue lost through excision or slough, pharyngolaryngeal reconstruction, release of contractures, and provision of protective coverage for the great vessels.

Uses on the face or scalp include replacement of excised facial or scalp skin (see Fig. 125.5), repair of through-and-through cheek defects, closure of orocutaneous fistulas (see Fig. 125.4), and coverage along an exposed mandible. Repair of the lower face and mandibular margin is often beyond the range of the forehead flap and somewhat awkward for the deltopectoral flap.

Intraoral applications include palate reconstruction, floor of mouth repair, coverage of lateral oropharyngeal wall defects, and lateral commissure reconstruction. This flap is a particularly useful alternative to the forehead flap in repair of palatal defects, both because of its proximity and also because its bulk provides a very appropriate thickness to the reconstructed palate (see Fig. 125.3).

The advantages of the flap include its high reliability, ease of construction, and constant anatomic basis. The bulk and generous amount of usable flap area are sufficient for large, full-thickness defect replacement with or without the use of other flaps. The donor site is usually beyond neck radiation fields, thus allowing the flap to be used even in heavily irradiated necks. Cosmetically, the texture and color match are good and the donor-site defect, after skin grafting, is acceptable. This compares with the forehead flap and anterior chest wall flap, which usually result in a much more obvious cosmetic deformity, especially in women.

ANATOMY

The blood supply of the nape of the neck flap usually has been described as being based on main branches of the posterior auricular and occipital arteries, implying it to be primarily an arterialized flap in its proximal half, with random supply by means of perforating vessels in its distal half. No significant branches, however, have been found running longitudinally within this flap (10, 11). There is strong evidence that the nape of the neck flap has a random vascular supply by means of perforating vessels (Fig. 125.1). Should the flap be used in its musculocutaneous form, the trapezius musculocutaneous flap, the descending branch of the occipital artery, running deep to the trapezius muscle, then is included in the proximal part of the flap (see Chapter 133).

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