Trapezius Musculocutaneous Island Flap
W. R. PANJE
The trapezius musculocutaneous flap, as outlined, is supplied by the branches of the transverse cervical artery. It would be difficult for the flap to consistently reach the glabellar area for a secure attachment. A wide area of attachment would allow more effectively for greater circulation than the so-called training technique. This particular method of nasal reconstruction should be considered after other simpler and more effective methods have been discarded.
Surgical reconstruction of a total nasal defect can be effectively accomplished by using the trapezius musculocutaneous extended island flap.
This flap provides the abundant cutaneous tissue required for total nasal reconstruction without the need for delay. It also offers an excellent color match. The procedure can be accomplished in a two-staged operation, leaving a relatively hidden donor site. No external cast immobilization is required in the transfer of this regional flap to the face.
For the first stage of this procedure, an extended trapezius musculocutaneous island flap is developed based on the transverse cervical vessels. The accessory nerve innervation to the remaining trapezius muscle can be preserved. Once the flap is divided prior to insetting, it has, of course, a random-pattern circulation.
FLAP DESIGN AND DIMENSIONS
As with other methods of total nasal reconstruction, the initially reconstructed nose should be 20% to 30% larger than the desired final goal because of shrinkage. A cutaneous segment of flap 16 cm long by 10 cm wide is elevated onto the trapezius muscle carrier, which is 16 × 5 cm.
Initially, a triangular incision (the apex located over the acromion) is made lateral to medial along the clavicle and the anterior border of the trapezius muscle to allow identification of the transverse cervical vessels into the posteroinferior part of the neck. This incision provides access to the lower neck for identification of the posterior belly of the omohyoid muscle (crucial for convenient location of the transverse cervical vessels) and dissection of the trapezius muscle and eleventh nerve. It also allows external delivery of the vascular pedicle from the neck to increase the arc of the flap. In dissecting the transverse cervical vascular pedicle, overzealous exposure of the vessels should be avoided.
The distal cutaneous portion of the flap, dissected caudal to the scapular spine, is tubed onto itself. The end is attached to a cephalic-based half-circle flap developed over the glabella (Fig. 62.1). The length of the half-circle or trapdoor flap should equal the radius of the tubed portion of the flap. The muscle portion of the flap is not rolled onto itself because of bulkiness and the risk of compressing the vascular pedicle.