The lower trapezius musculocutaneous flap revisited: versatile coverage for complicated wounds to the posterior cervical and occipital regions based on the deep branch of the transverse cervical artery

The clinical role of the lower trapezius musculocutaneous flap varies within the literature. Many describe its use in the reconstruction of the lateral neck and facial regions, but very few refer to its use in the posterior cervical and occipital regions. Different vascular pedicles have also been described and effectively used. A retrospective analysis was conducted, reviewing the authors' experience with 13 patients who suffered complex open wounds to the posterior cervical and occipital regions that were treated with a lower trapezius muscle or musculocutaneous flap. All flaps were based on the deep branch of the transverse cervical artery. This pedicle was used to support a relatively large skin segment over the distal portion of the lower trapezius muscle, a margin that, in the authors' experience, extends at least 1 cm beyond the muscular margin. Postoperatively, patients were evaluated based on complications, residual shoulder function, and aesthetic outcome. In addition to the clinical study, cadaveric dissection of the trapezius muscle was conducted on 22 specimens, and the vascular anatomy was confirmed by direct visualization. The authors' experience indicates that the lower trapezius musculocutaneous flap, when based on the deep branch of the transverse cervical artery, provides a reliable alternative for the reconstruction of complicated wounds in the posterior cervical and occipital regions, with the added capability of providing richly vascularized tissue to compromised wounds as far cephalad as the vertex of the skull.     

One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.     

Reconstruction of soft-tissue defects using serratus anterior adipofascial free flap

The serratus anterior muscle has been suggested as a versatile and reliable flap for reconstruction of head and neck and extremity injuries. The adipofascial layer overlying the serratus anterior muscle is the anatomic layer, which is supplied by the same branch of thoracodorsal artery. Even though great progress has occurred in the prevention of postoperative adhesion of extremity injuries, the problem has not been completely solved and is still of special importance in complex injuries. Between March of 1995 and February of 1996, seven patients underwent reconstructive operation as a result of soft-tissue defects of the upper or lower extremities or the scalp. We transferred free adipofascial tissue overlying the serratus anterior muscle in three patients and both serratus anterior muscle and adipofascial tissue in four patients. A free adipofascial flap overlying serratus anterior muscle was transferred when a gliding surface was required, owing to the exposure of tendons and neurovascular structures. The average duration from operation to follow-up examination was 8 months (from 4 to 16 months). The results of the operations were satisfactory in functional and cosmetic aspects. This kind of flap was very effective in reconstruction of soft-tissue defects and gliding surfaces for these reasons: easy dissection, the capability of obtaining a long vascular pedicle, large-sized flap, composite flap including muscle or rib, and the fact that there was no serious functional or cosmetic deficit at the donor site.     

The lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and clinical applications based on the dorsal scapular artery

The pedicled lower trapezius musculocutaneous flap is a standard flap in head and neck reconstruction. A review of the literature showed that there is no uniform nomenclature for the branches of the subclavian artery and the vessels supplying the trapezius muscle and that the different opinions on the vessels supplying this flap lead to confusion and technical problems when this flap is harvested. This article attempts to clarify the anatomical nomenclature, to describe exactly how the flap is planned and harvested, and to discuss the clinical relevance of this flap as an island or free flap. The authors dissected both sides of the neck in 124 cadavers to examine the variations of the subclavian artery and its branches, the vessel diameter at different levels, the course of the pedicle, the arc of rotation, and the variation of the segmental intercostal branches to the lower part of the trapezius muscle. Clinically, the flap was used in five cases as an island skin and island muscle flap and once as a free flap. The anatomical findings and clinical applications proved that there is a constant and dependable blood supply through the dorsal scapular artery (synonym for the deep branch of the transverse cervical artery in the case of a common trunk with the superficial cervical artery) as the main vessel. Harvesting an island flap or a free flap is technically demanding but possible. Planning the skin island far distally permitted a very long pedicle and wide arc of rotation. The lower part of the trapezius muscle alone could be classified as a type V muscle according to Mathes and Nahai because of its potential use as a turnover flap supplied by segmental intercostal perforators. The lower trapezius flap is a thin and pliable musculocutaneous flap with a very long constant pedicle and minor donor-site morbidity, permitting safe flap elevation and the possibility of free-tissue transfer.     

Two options for perforator flaps in the flank donor site: latissimus dorsi and thoracodorsal perforator flaps

Two types of perforators, septocutaneous and musculocutaneous, are found in the same donor site of the flank area, and two perforator flaps based on each perforator are clinically available. Therefore, it is necessary to distinguish them from one another using different nomenclatures. Accordingly, the perforator flap based on a musculocutaneous perforator is named according to the name of the muscle perforated, the latissimus dorsi perforator flap, and the perforator flap based on a septocutaneous perforator, located between the serratus anterior and latissimus dorsi muscles, is named according to the name of the proximal vessel, the thoracodorsal perforator flap. In this series of 42 latissimus dorsi perforator flaps, flap size ranged from 5 x 3 cm to 20 x 15 cm, and two complications were observed: a marginal necrosis in an extremely large flap (26 x 12 cm) and a failure caused by infection. The thoracodorsal perforator flap was used in 14 cases, including two cases of chimeric composition. Flap size ranged from 4.5 x 3.5 to 18 x 15 cm, with no complications. In the two patterns of perforator flap that the author used, initial temporary flap congestion was observed in five latissimus dorsi perforator flap cases and two thoracodorsal perforator flap cases, when the flap was designed as a large flap or a less reliable perforator was selected. However, the congestion was not serious enough to cause flap necrosis. Several techniques, such as T anastomosis or inclusion of an additional perforator or a small portion of muscle, are recommended to prevent the initial flap congestion, especially when an unreliable perforator is inevitably used or when a flap larger than 20 cm long is required. A small portion of the muscle was included in six cases, when an unduly large or improperly long flap was planned. All of the flaps were successful and ranged from 22 x 7 to 15 x 28 cm, except for one case of distal flap necrosis in an extraordinarily large flap measuring 34 x 10 cm. Diverse selection of the perforator flap is one of the great advantages of the flank donor site, providing it with wider availability and more versatile composition for reconstruction or resurfacing.     

A new extended external oblique musculocutaneous flap for reconstruction of large chest-wall defects

A new extended external oblique musculocutaneous flap utilized in the reconstruction of chest-wall defects is described. The flap is drawn as a V-Y rotation flap on the ipsilateral abdominal wall. It is laterally based, and its pedicle coincides with the five lowest costal insertions of the external oblique. The flap extends above the transiliac line, from the posterior axillary line to the linea alba, and includes the dynamic territory of the external oblique muscle. Vascular supply is provided by the musculocutaneous perforating arteries of the intercostal vessels and their subcutaneous branches. The flap is raised medially and includes the anterior sheath of the rectus. Undermining continues between the external and the internal oblique muscles as far as the posterior axillary line. The donor site on the abdominal wall is reinforced by the plication of the internal oblique sheath. This flap was used in 13 patients with major anterior chest-wall excisional defects. The mean chest-wall defect was about 390 cm2. Marginal necrosis with distal skin loss was observed in one patient. All other flaps healed without complications. The extended external oblique musculocutaneous flap differs from other external oblique flaps already described in several aspects that allow it to obtain better functional and aesthetic results.     

The vascular territories of the superior epigastric and the deep inferior epigastric systems

The vascular territories of the superior and the deep inferior epigastric arteries were investigated by dye injection, dissection, and barium radiographic studies. By these means it was established that the deep inferior epigastric artery was more significant than the superior epigastric artery in supplying the skin of the anterior abdominal wall. Segmental branches of the deep epigastric system pass upward and outward into the neurovascular plane of the lateral abdominal wall, where they anastomose with the terminal branches of the lower six intercostal arteries and the ascending branch of the deep circumflex iliac artery. The anastomoses consist of multiple narrow "choke" vessels. Similar connections are seen between the superior and the deep inferior epigastric arteries within the rectus abdominis muscle well above the level of the umbilicus. Many perforating arteries emerge through the anterior rectus sheath, but the highest concentration of major perforators is in the paraumbilical area. These vessels are terminal branches of the deep inferior epigastric artery. They feed into a subcutaneous vascular network that radiates from the umbilicus like the spokes of a wheel. Once again, choke connections exist with adjacent territories: inferiorly with the superficial inferior epigastric artery, inferolaterally with the superficial circumflex iliac artery, and superiorly with the superficial superior epigastric artery. The dominant connections, however, are superolaterally with the lateral cutaneous branches of the intercostal arteries. For breast reconstruction, it would appear that prior ligation of the deep inferior epigastric artery would be of advantage when elevating the lower abdominal skin on a superiorly based rectus abdominis musculocutaneous flap. The vascularity of this flap would be further increased by positioning some part of the skin paddle over the dense pack of large paraumbilical perforators. Based on these anatomic studies, the relative merits of the superior and deep inferior epigastric arteries with respect to local and distant tissue transfer using various elements of the abdominal wall are discussed in detail.     

Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps

The skin fascial flap is now recognized as a reliable flap for use in reconstructive surgery. The fasciocutaneous flap has been advocated for coverage of chronic infected wounds after debridement as an alternative to the musculocutaneous flap. Previous experimental and clinical studies have demonstrated the superior resistance of the musculocutaneous flap as compared to the random-pattern flap to bacterial inoculation. A canine model is presented for comparison of the effect of bacterial inoculation in fasciocutaneous and musculocutaneous flaps of similar dimensions. The area of skin necrosis secondary to bacterial inoculation was similar in these two flap types despite greater blood flow and skin oxygen in the fasciocutaneous flap. In a study of closed wound spaces formed by the deep surface of these two flap types, a greater degree of inhibition and elimination of bacterial growth and more collagen deposition are observed in the musculocutaneous wound space than in the fasciocutaneous flap.     

Skin recycling following neovascularization using the rat musculocutaneous flap model.

The recycling of a skin territory as part of a musculocutaneous flap despite prior division of existing musculocutaneous perforators or vice versa within an axial cutaneous flap using skin from a previous musculocutaneous flap may sometimes be done safely if an adequate time period has been allotted to permit sufficient neovascularization from adjacent tissues. In order to test this clinically observed phenomenon, a musculocutaneous flap model based on perforators from the rat rectus abdominis muscle was developed and observed to have complete reliability. Groups of five Sprague-Dawley rats each were sequentially utilized to prove that by a single week following creation of a rectus abdominis musculocutaneous flap adequate peripheral neovascularization would evolve to permit total viability of secondary axial epigastric cutaneous flaps incorporating the same skin that initially was the cutaneous portion of the muscle flap. The converse was also confirmed possible, again using sequential groups of five rats each, in that by 2 weeks the skin of an initial abdominal cutaneous flap could instead be safely transposed and nourished as part of a rectus abdominis musculocutaneous flap. The proposition concerning the reliable reuse of identical skin territories as part of disparate metachronous flap configurations appears to be valid.     

Vastus medialis myocutaneous and myocutaneous-tendinous composite flaps

This report describes a new myocutaneous territory and introduces a new myocutaneous flap based on the vastus medialis muscle. Dissection, arterial dye perfusion, and specimen angiography of 32 fresh cadaver legs defined a vastus medialis myocutaneous territory directly overlying the muscle and also defined a segment of quadriceps femoris tendon vascularized by the muscle. This vascular unit provides a myocutaneous flap for closure of anterior knee defects. This flap can also be designed as a composite myocutaneous-tendinous flap by inclusion of the vascularized quadriceps femoris tendon segment, which allows reconstruction of missing patellar tendon segments. The distal advancement flap design with retention of motor innervation preserves vastus medialis contribution to knee extension. Clinical applications of vastus medialis myocutaneous and myocutaneous-tendinous flaps are illustrated by their use in three patients with knee defects and patellar tendon losses. The potential value of vascularized tendon (versus vascular free tendon grafts) for patellar tendon reconstruction is discussed.     

Differential activation of parts of the serratus anterior muscle during push-up variations on stable and unstable bases of support

No studies have examined the effects of an unstable surface on push-up and push-up plus exercises in terms of the two parts of the serratus anterior muscle. We hypothesized that the lower part of the serratus anterior would have greater activity with an unstable surface, which requires stabilizing the scapular position. The present study was performed to investigate the intramuscular differences between parts of the serratus anterior muscle during push-up and push-up plus exercises. Twelve healthy subjects were included in the study. The upper and lower parts of the serratus anterior and upper and lower parts of the trapezius were investigated by surface EMG during four types of exercise. Repeated one-way ANOVA was used for statistical analyses. Maintaining the push-up plus phase caused significant increases in EMG activity of the upper serratus anterior compared with the push-up ascending phase on both of stable and unstable bases (P < 0.05). The lower serratus anterior showed increased activation on an unstable surface, which required more joint stability than did the stable base. Upper trapezius/upper serratus anterior ratio was significantly lower in the PUP than in the PUA phase with both stable and unstable bases of support (P < 0.05).Further studies are required to investigate the intramuscular variation in activation of the serratus anterior during exercises for rehabilitation.     

Chest-wall reconstruction by contralateral latissimus dorsi musculocutaneous flap

Reconstruction of chest wall and axilla are performed in 11 patients using a contralateral latissimus dorsi musculocutaneous flap. The entire lattisimus dorsi muscle, including the fascial portion, safely carried an island of skin from the area of the lumbodorsal fascia to the contralateral axilla. The flap was transposed to the defect through a tunnel between the pectoralis major and minor muscles. Most patients who needed reconstruction of the chest wall and axilla had compromised ipsilateral vasculature that prohibited its use in a pedicled flap but had an intact contralateral chest wall, axilla, and thoracodorsal vessels. Therefore, this procedure was performed easily in comparison with a free flap or pedicled omental flap. This is a new, valuable application for the versatile latissimus dorsi musculocutaneous flap.     

More experience with the "reverse" latissimus dorsi musculocutaneous flap: precise location of blood supply

Our work demonstrates that the "reverse" latissimus dorsi musculocutaneous flap has a predictable and consistent blood supply. A major portion of the muscle can be nourished by the dorsal perforating branches of the ninth, tenth, and eleventh intercostal vessels. The skin island based on the "reverse" latissimus dorsi muscle can be as large as 8 X 20 cm. This is confirmed by anatomic dissections and clinical cases. Knowledge of the blood supply facilitates elevation of the flap and extends its utility.     

A combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles

Although a free vascularized iliac bone graft has been successfully used for the reconstruction of large bone defects, there is a serious problem of how to repair in one stage patients having a large bone defect with a very wide skin defect. A free combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles seems to be one of the most suitable methods for patients having large defects of both bone and skin. Based on our patient, the main advantage of this flap is the extreme width of the skin territory. The pedicle vessels are large and long, and the donor scar can be made in an unexposed area. This flap should be considered for use in one-stage reconstructions of large defects of both bone and skin in the leg region.     

Clinical applications of the posterior rectus sheath-peritoneal free flap

Soft-tissue injuries involving the dorsum of the hand and foot continue to pose complex reconstructive challenges in terms of function and contour. Requirements for coverage include thin, vascularized tissue that supports skin grafts and at the same time provides a gliding surface for tendon excursion. This article reports the authors' clinical experience with the free posterior rectus sheath-peritoneal flap foil dorsal coverage in three patients. Two patients required dorsal hand coverage; one following acute trauma and another for delayed reconstruction 1 year after near hand replantation. A third patient required dorsal foot coverage for exposed tendons resulting from skin loss secondary to vasculitis. In all three patients, the flap was harvested through a paramedian incision at the lateral border of the anterior rectus sheath. After opening the anterior rectus sheath, the rectus muscle was elevated off of the posterior rectus sheath and peritoneum. When elevating the muscle, the attachments of the inferior epigastric vessels to the posterior rectus sheath and peritoneum were preserved while ligating any branches of these vessels to the muscle. Segmental intercostal innervation to the muscle was preserved. The deep inferior epigastric vessels were then dissected to their origin to maximize pedicle length and diameter. The maximum dimension of the flaps harvested for the selected cases was 16 X 8 cm. The anterior rectus sheath was closed primarily with non-absorbable suture. Mean follow-up was 1 year, and all flaps survived with excellent contour and good function in all three patients. Complications included a postoperative ileus in one patient, which resolved after 5 days with nasogastric tube decompression.     

Normalization procedures using maximum voluntary isometric contractions for the serratus anterior and trapezius muscles during surface EMG analysis.

The serratus anterior and trapezius muscles are considered to be the only upward rotators of the scapula and are very important for normal shoulder function. A variety of methods have been used to produce a maximum voluntary isometric contraction (MVIC) of these muscles for normalization of EMG data. The purpose of this study was to quantify the surface EMG activity of the serratus anterior muscle and the upper, middle, and lower parts of the trapezius during 9 manual muscle tests performed with maximum effort in 30 subjects. It was found that no one muscle test produced a MVIC for all individuals. Therefore, to perform normalization within each subject, it is suggested that the 2 or 3 tests identified in this study that produce high levels of EMG activity for each muscle be performed. The scapular protraction muscle test that is often used to normalize data for the serratus anterior muscle produced relatively low levels of EMG activity and was not found to be an optimal test. Muscle tests in which an attempt was made to de-rotate the scapula from an upwardly rotated position produced much higher levels of EMG activity in the serratus anterior muscle.     

The vasculature of the peroneal tissue transfer

Peroneal vascularized composite-tissue transfer has many useful applications and advantages. An anatomic study of the peroneal artery and vein and their branches was carried out on 80 adult cadaver legs. The number of cutaneous branches averaged 4.8 +/- 1.4 per leg. The length of the cutaneous branches averaged 5.4 +/- 1.5 cm. The external diameters of cutaneous branches at the skin distribution site were 0.6 +/- 0.2 mm for the artery and 0.8 +/- 0.3 mm for the vein. The communicating branches were branched at anterior or posterior tibial vessels 6.1 +/- 2.4 cm proximal to the lateral malleolus. The range of rotation of the island flap when transposed proximally was 14.3 +/- 3.3 cm proximal from the head of the fibula, and when transposed distally, the range of rotation was 16.9 +/- 5.3 cm distally.     

Peripheral neovascularization of muscle and musculocutaneous flaps in the pig.

Late loss of free muscle flaps following surgical or accidental trauma to the dominant vascular pedicle has been reported. In this study, time-dependent ligation of the dominant vascular pedicle was undertaken in denervated latissimus dorsi musculocutaneous or muscle-only island flaps in the pig. Muscle flaps were covered with a skin graft, and silicon rubber sheets were inserted between the flaps and their bases to simulate a poorly vascularized bed. Hemodynamic and viability studies were then performed using intravenous fluorescein (skin viability), tetrazolium blue (muscle viability), and radiolabeled 15-micron microspheres (capillary blood flow). Blood flow did not change in acutely raised musculocutaneous flaps (n = 10) but was significantly elevated in acutely raised muscle-only flaps (n = 10), suggesting that the skin paddle may steal blood flow from the underlying muscle in musculocutaneous flaps. Peripheral neovascularization at 1 day to 8 weeks was assessed (n = 30). Viability increased during the first week of revascularization and was not different in musculocutaneous and muscle-only flaps. Revascularization of muscle-only flaps was enhanced compared with musculocutaneous flaps in the 2- to 8-week period.     

Blood supply to osteocutaneous free fibula flap and peroneus longus muscle: prospective anatomic study and clinical applications.

From January of 1998 to December of 1999, a total of 24 fibula free flaps in 24 patients were evaluated in a prospective clinical study. Once the perforators were identified, they were dissected toward the parent vessel and labeled according to type. The soleus and flexor hallucis longus muscles of the fibula were dissected, and the proximal part of the pedicle was reached. Subsequently, the configuration of all muscular branches to the peroneus muscle was studied. The types of skin perforators of the peroneal artery were noted as septocutaneous, musculocutaneous, or septomusculocutaneous. A total of 86 perforators were identified in 24 legs. The average number of perforators per leg was 3.58 +/- 0.71. Among them, 22 were musculocutaneous, 31 were septomusculocutaneous, and were 33 septocutaneous. The septocutaneous branches were significantly more distal than the musculocutaneous and septomusculocutaneous perforators. Eight perforators were identified 25 cm distal from the fibular head and six were identified at 15 cm. Five perforators were then identified at each distance of 8, 12, 19, and 22 cm distal from the fibular head. The total number of muscular branches to the peroneus longus was 62, with an average of 2.58 +/- 0.45. Most muscular branches were found between 8 and 16 cm distal to the fibular head. Nine branches were identified at 13 cm distal to the fibular head, eight at 9 cm, and seven at 12 cm. The number of dominant branches with the largest diameter was seven at 13 cm distal from the fibular head, five at 12 cm, five at 16 cm, and two at 11 cm. In summary, when designing an osteocutaneous free fibula flap 10 to 20 cm from the fibular head, it is recommended that a soleus and flexor hallucis longus muscle cuff be included to incorporate these perforators. In contrast, when designing a flap 20 to 30 cm from the fibular head, it is possible to elevate the flap without incorporating the soleus or flexor hallucis muscles.     

Applied anatomy of the anterolateral femoral flap

A study of the source of the blood supply to the anterolateral femoral flap was carried out on 42 lower limbs of adult cadavers (among them 35 cadavers with injection of red latex and 1 with india ink into the arteries and 6 vascular cast specimens), and the surface locations of the vascular pedicle were detected on 50 healthy adults. It was found that the descending branch of the lateral circumflex femoral vessel was an ideal axial vessel. There are constant perforating branches of the myocutaneous artery or cutaneous branches from the intermuscular space to the anterolateral femoral skin. The area extends about 12 x 30 cm. Within the flap, the anterior branch of the anterolateral cutaneous nerve of the high is located. This flap has been widely used for free transplantation in China since 1983 with satisfactory results.