The Clipped Wings of "Jatayu"- A Double Set of Bilateral Sequential Bipedicled Flaps to Primarily Close the Secondary Defects on the Back Following the Harvest of a Trapezius Myo-cutaneous Flap.

We report an innovative technique for closure of a large secondary donor-site defect (in a post-electric-burn primary defect in cervico-occipital area, reconstructed with Trapezius myo-cutaneous flap) by using a double set of sequential bilateral bipedicled flaps which resembled "Jatayu", the holy bird with clipped wings as per the epic "Ramayana".

Vertical musculocutaneous trapezius flap for the closure of postpneumonectomy empyema.

OBJECTIVE: The aim of the study was to present our experience with the vertical musculocutaneous trapezius (VMCT) flap and highlight its utility in the thoracic wall reconstruction in patients with bronchopleural fistula (BPF). MATERIALS AND METHODS: We present a five case series of patients with long-standing cavities and BPF. The VMCT flap was used, and a direct pathway into the defect was made through a separate posterior thoracotomy shortening the distance between the flap and the defect. RESULTS: In 80% of the cases, the flap succeeded in solving the fistula and filling the defect, quality of life improved, and the need for oxygen decreased. CONCLUSIONS: Management of open window thoracostomy is challenging. Debridement, thoracoplasty, and flap coverage are the mainstream of their treatment, but these patients have scarce available muscle. The VMCT flap represents the major non-affected musculocutaneous unit in the thoracic area after lung surgery. Its dermal component offers a rigid matrix to form a seal over the bronchial stump. Its muscular component adds a good amount of vascularized tissue. No functional impairment has been described after its use.

OBJETIVO: Exponer nuestra experiencia con el colgajo vertical de trapecio y destacar su utilidad en la reconstrucción de la pared torácica en pacientes con fístulas broncopleurales. MATERIAL Y MÉTODOS: Presentamos una serie de cinco pacientes con cavidades y fístulas broncopleurales de larga evolución. Utilizamos el colgajo musculocutáneo vertical de Trapecio, con un redireccionamiento del mismo a través de una ventana costal que permite acortar la distancia entre el colgajo y el defecto. RESULTADOS: La fístula y el defecto fueron solucionados en el 80% de los casos. La calidad de vida mejoró y las necesidades de oxígeno disminuyeron. CONCLUSIONES: El manejo de las toracotomías es un reto. El desbridamiento, toracoplastia y cobertura con colgajo son los pilares de su tratamiento, pero estos pacientes tienen escasa disponibilidad muscular. El colgajo musculocutáneo vertical de Trapecio representa la mayor unidad intacta musculocutánea en el tórax tras cirugía pulmonar. Su componente dérmico ofrece una matriz rígida para sellar el muñón bronquial, su componente muscular añade una gran cantidad de tejido vascularizado. No se han descrito déficits funcionales tras su uso.

Combined Pedicled Trapezius Flap With Negative Pressure Wound Therapy for Treating a Traumatic Chest Wall Defect With Intrathoracic Infection.

Background: Traumatic chest wall defect normally involves severe tissue damage and easily develops into intrathoracic infection. The challenge for doctors is to control the infection and reconstruct the chest wall defect. However, not much experience has been reported on how to control the intrathoracic infection and reconstruct the chest wall defect when the most commonly used muscle flaps are damaged. Methods: We present a case of a 46-year-old male patient who sustained a traumatic amputation of the right upper extremity in a forklift accident. The scapula and clavicle were partially amputated. The right lung was exposed to the outside and finally developed into intrathoracic infection. The intrathoracic infection was successfully controlled by applying negative pressure wound therapy, followed with reconstruction using a pedicled trapezius flap. Results: The patient resumed normal life after the surgery. No complications had developed at the 2-year follow-up. The respiratory function of the patient was barely affected, but the trapezius flap moved when the patient breathed. Conclusions: This case report demonstrates the effectiveness of negative pressure wound therapy in controlling intrathoracic infection after a traumatic chest wall defect as well as the possibility of applying trapezius muscle flap to reconstruct the chest defect when the commonly used muscle flaps are not available.

Reconstruction of a massive defect of the neck after a scorpion sting: A case report.

Introduction: Cutaneous traumas from scorpion sting envenomation are rare in European countries. Regarding Greece, Euscorpius sicanus' complex is the most widespread scorpion species. The venom of these small dark brown arthropods, which shelter in woods, usually provokes local cutaneous symptoms: erythema, edema, cellulitis, urticarial plaques, ulcers and rarely skin necrosis. We present a case of a massive soft tissue defect of the neck due to a scorpion sting managed by a Plastic Surgery Department in Greece. Case report: In March 2020, a 60 year-old lumberjack was referred to our Clinic due to a neck wound resulting from Euscorpius cf. sicanus sting. After multiple surgical debridements in combination with negative pressure wound therapy healthy tissue was achieved. Reconstruction followed using a 7cmX15cm vertical island trapezius musculocutaneous flap based on the dorsal scapular artery and rotated to cover the defect. The trapezius flap, donor site and graft healed well and resulted in satisfying contouring at the one-year follow-up. Conclusion: This case report is the first presenting Plastic Surgery reconstructive techniques for a massive neck defect after a Euscorpius cf. sicanus scorpion sting. Major complications of such stings need to be managed drastically for the optimum patient's outcome.

Revisiting the Trapezius Flap as a Reconstructive Option for Cervico-Occipital and Thoracic Spine Regions.

Introduction Reconstruction of complex soft tissue defects around the cervico-occipital and thoracic spine regions is a challenging task. We want to share our experience with trapezius flap for the reconstruction of these complex cases. Materials and Methods A retrospective analysis of patients who underwent reconstruction using trapezius flaps from January 2016 to June 2019 was performed. The indications, technique, complications, and outcomes were analyzed and presented. Results Six patients (three males and three females, >10 years of age) underwent seven reconstructions using trapezius flaps (one of the patients underwent reconstruction using a bilateral trapezius flap). Trapezius flap was used to resurface the parieto-occipital ( n = 2), cervico-occipital ( n = 2), cervicothoracic ( n = 1), and thoracic ( n = 1) regions. All flaps showed successful outcomes; one patient had wound dehiscence, and one patient had partial skin graft loss. Conclusion Trapezius flap is a reliable and good alternative to free flaps for the coverage of complex cervical-occipital and upper thoracic soft tissue defects.

Use of a folded extended vertical lower trapezius island myocutaneous flap to repair large pharyngocutaneous fistulae developing after salvage total laryngectomy.

The purpose of this study was to evaluate the outcomes of surgery involving the use of folded trapezius flaps to repair large pharyngocutaneous fistulae (PCFs) developing after salvage total laryngectomy. Folded extended vertical lower trapezius island myocutaneous flaps (TIMFs) were created to repair large PCFs that developed after salvage total laryngectomy in eight patients. The maximum fistula dimension was 4.5×3.0cm and the minimum was 2.0×1.8cm. The skin paddle of the extended vertical TIMF ranged from 5cm to 9cm in width and 10cm to 23cm in length. The inner lining ranged from 3cm×3cm to 6cm×6cm in dimension and the outer lining from 6cm×5cm to 16cm×9cm. The folded flaps provided both inner mucosa and outer lining. All flaps survived. No fistula recurrence or stricture developed. After 6-24months of follow-up, six patients showed no evidence of disease, one was alive with disease, and one had died of local recurrence at 20months. The folded flap was very reliable and is well-suited for repairing large PCFs, even early large PCFs and those featuring carotid artery rupture.

Combined bilobed trapezius myocutaneous and scapula osteomyocutaneous flaps for the restoration of through-and-through defects of the mandible following salvage surgery for recurrent head and neck tumours.

This study was performed to evaluate the outcomes of combined bilobed trapezius myocutaneous and scapula osteomyocutaneous flaps for the restoration of through-and-through defects of the mandible. The subjects were six patients with recurrent malignant tumours who underwent salvage surgeries and reconstruction with combined flaps based on the transverse cervical vessels (TCVs). All patients had combined bone (four type H, one type LCL, and one type C) and extensive soft tissue defects (through-and-through defects) following salvage surgery. All tumours were removed and the complex defects restored successfully. Two patients experienced minor complications: one minor intraoral flap failure and one case of wound dehiscence at the donor site. The appearance of the face and neck was satisfactory or acceptable in all patients. No patient showed severely limited range of motion of the upper limb. The patients were followed up for 10 to 18months. One patient was living with no evidence of disease. The use of combined bilobed trapezius myocutaneous and scapula osteomyocutaneous flaps based on the TCVs may be an effective approach for the restoration of through-and-through defects of the mandible and may provide satisfactory or acceptable functional and aesthetic outcomes following salvage surgery for advanced head and neck tumours.

Monophasic synovial sarcoma of posterior pharyngeal wall: a rare case report with unique reconstruction using lateral trapezius flap.

Synovial sarcoma is a rare entity to be encountered in the head and neck region and is always a challenge in terms of diagnosis, treatment planning and reconstruction of the surgical defect. In our case, we faced a similar challenge for diagnosis and also have ventured for lateral trapezius flap as a new reconstructive option for such bulky tumour defects. We hereby present a 25-year old male patient with monophasic synovial sarcoma of posterior pharyngeal wall. The radiological and clinicopathological features along with various diagnostic tests and treatment options are discussed.

Extended vertical lower trapezius island myocutaneous flap versus pectoralis major myocutaneous flap for reconstruction in recurrent oral and oropharyngeal cancer.

BACKGROUND: The purpose of this study was to compare the use of an extended vertical lower trapezius island myocutaneous flap (TIMF) and a pectoralis major myocutaneous flap (PMMF). METHODS: A total of 39 patients with advanced recurrent oral and oropharyngeal squamous cell carcinoma (SCC) underwent salvage surgery followed by placement of either an extended lower vertical TIMF or PMMF for reconstruction. Twenty-one patients received extended lower vertical TIMFs, whereas 18 received PMMFs. RESULTS: The pedicle length of the TIMF was longer than that of the PMMF, and the skin paddle of the TIMF was both wider and longer than the PMMF. No major complication developed in any of the patients. The TIMF group experienced a lower rate of minor flap failure than did the PMMF group. CONCLUSION: Use of an extended vertical lower TIMF, which has a longer pedicle flap and a larger skin paddle than a PMMF, is optimal for reconstruction of major defects. © 2015 Wiley Periodicals, Inc. Head Neck 38: E159-E164, 2016.

Retalho miocutâneo inferior pediculado do músculo trapézio nas reconstruções após cirurgias oncológicas de cabeça e pescoço, e tórax / Lower trapezius myocutaneous pedicle flap in head, neck, and chest reconstructions after cancer surgeries

INTRODUÇÃO: Revisão da literatura sobre o retalho miocutâneo inferior do músculo trapézio, apresentando suas vantagens, técnica cirúrgica e complicações. MÉTODOS: Estudo de 19 casos tratados no INCA, através de técnica específica, e comparação dos dados com a literatura internacional. RESULTADOS: Todas as reconstruções atingiram seus objetivos, com correção dos defeitos em partes moles e pele. O efeito estético foi considerado bom pelos pacientes e pela equipe médica. Foi observada uma taxa de 21% de complicações. Não houve necrose ou infecção nos retalhos. Em relação às funções, 89,5% apresentaram função motora preservada e 10,5%, déficit funcional por acometimento tumoral do nervo acessório. CONCLUSÃO: A despeito do aprimoramento contínuo das técnicas microcirúrgicas, os retalhos miocutâneos pediculados ainda encontram indicações nas reconstruções após ressecções oncológicas alargadas. O retalho miocutâneo inferior do músculo trapézio é uma alternativa segura e aplicável para as reconstruções de partes moles das regiões cervicais lateral e posterior, da região lateral da cabeça, da região do ombro e para as regiões paraespinhal superior e paraescapulares.

INTRODUCTION: In this article, we present a literature review on the lower myocutaneous trapezius flap, and report its advantages, surgical technique, and complications. METHODS: We studied 19 patients treated at INCA with a specific technique, and compared the outcomes with those reported in the international literature. RESULTS: All reconstructions achieved the procedural objectives, and the defects of soft tissues and skin were repaired. The aesthetic outcome was considered satisfactory by the patients and medical staff. The rate of complications was 21%. No necrosis or signs of infection were detected in the flaps. Concerning the functions, 89.5% of patients preserved their motor function, whereas reduced functional movements were observed in 10.5% of the patients due to tumor invasion to the accessory nerve. CONCLUSIONS: Despite the continuous advancements in microsurgical techniques, pedicle myocutaneous flaps are still indicated for reconstruction procedures after extended cancer resections. The use of the lower trapezius myocutaneous flap is safe and represents a suitable option for the reconstruction of soft tissues of the lateral and posterior cervical regions, side of the head, shoulder, and upper paravertebral and parascapular regions.

The supraclavicular artery island and trapezius myocutaneous flaps in head and neck reconstruction.

The supraclavicular artery island flap can be readily used to reconstruct defects within the neck, parotid, lateral temporal region, and lower third of the face. Benefits of the supraclavicular flap include good color and texture match, an ease of harvest, and minimal donor site morbidity; there is also no significant post-operative monitoring required. The trapezius muscle serves as a source for multiple myocutaneous flaps of which most are considered to be salvage flaps among head and neck reconstructive surgeons.

Second salvage surgery with extended vertical lower trapezius island myocutaneous flap reconstruction for advanced re-recurrent oral and oropharyngeal squamous cell carcinoma.

The purpose of this study was to evaluate the outcomes of second salvage surgery with extended vertical lower trapezius island myocutaneous flap (TIMF) reconstruction for patients with re-recurrent oral cavity and oropharyngeal squamous cell carcinoma (SCC). The subjects were 23 patients with advanced re-recurrent oral and oropharyngeal SCC undergoing second salvage surgery and reconstruction with a TIMF. A TIMF with a skin paddle measuring 6cm×7cm to 10cm×22cm was used to reconstruct the major defects. Three patients experienced minor complications: minor flap failure (n=1), wound dehiscence at the donor site (n=1), and an orocutaneous fistula (n=1). The patients were followed for 3-72 months. Fifteen patients were alive with no evidence of disease, two were alive with disease, and six died of local recurrence or distant metastases. Second salvage surgery remains an effective treatment modality for select patients with advanced re-recurrent oral and oropharyngeal SCCs, and the extended vertical lower TIMF is a large, simple, and reliable flap for reconstructing the major defect following second salvage surgery.

Reconstruction of through-and-through oral cavity defects with folded extended vertical lower trapezius island myocutaneous flap.

Reconstruction of through-and-through defects of the head and neck is a challenge. In this clinical study we assessed the feasibility of the folded, extended, vertical, lower trapezius island myocutaneous flap (TIMF) for the reconstruction of 16 large through-and-through defects of the oral cavity, which were reconstructed after resection of oral cancer. The skin paddle was 5-7 cm wide and 11-20 cm long. The folded flap provides both inner and outer linings for through-and-through defects, and all the flaps survived. The appearance of the head and neck was acceptable, and oral function was satisfactory. The folded extended vertical lower TIMF is a large, simple, and reliable flap that is preferred for the reconstruction of large through-and-through defects after resection of oral carcinoma.

Reconstruction of complex shoulder defect in a case of subclavian artery thrombosis.

We report a case of a 24-year-old man with complex shoulder defect on the right side following a road traffic accident. The patient was found to have a subclavian artery thrombosis in its second part with good collaterals ensuring limb viability. Free-flap reconstruction was not possible because of lack of recipient vascular pedicle nearby. Pedicled flaps routinely used for this area such as pectoralis major and latissimus dorsi myocutaneous flaps could not be used as their vascular pedicles arise from the second and third parts of the axillary artery distal to the subclavian artery thrombosis. The best option we could think was the trapezius myocutaneous flap as its vascular pedicle arises from the first part of the subclavian artery proximal to the thrombosis. This article further establishes the importance of knowing the vascular supply of flaps before their clinical application. In this case the trapezius flap acts as a lifeboat for coverage of the complex shoulder defect as its vascular supply is proximal to the site of subclavian artery thrombosis.

A huge infiltrating squamous cell carcinoma of the neck 46 years after radiotherapy of a haemangioma.

BACKGROUND: There is a higher risk for malignant tumours in patients who underwent any kind of radiotherapy. MAIN OBSERVATIONS: An 87-year-old patient with an extended squamous cell carcinoma of the neck was referred to our hospital. The large ulcerated tumour showed a deep infiltration of the para-vertebral muscles and the spinal processes C6-C7. The tumour was known since about six years and appeared about 46 years after low-dose radiotherapy of a cervical haemangioma of the neck in 1961. The large dimension of the tumour leaded to a radical surgical removal and a sufficient fast reconstruction strategy. The extended defect was covered by a pedicled lower musculocutaneous trapezius flap. No postoperative complications like partial necrosis, infection or movement disorders of the shoulder or a shoulder drop syndrome were seen. Ten weeks after the operation the patient showed a good functional and aesthetic result with no limitation of arm mobility. Two and a half years after radical intended surgery the patient was still alive and showed no recurrence of the tumour. CONCLUSIONS: In conclusion there is a need for a life-time lasting dermatological supervision in patients with a history of radiotherapy in the past, because the handling of patients with such an enlarged tumour is complicated.

Intraoral reconstruction using local and regional flaps.

Choosing a pedicled flap to reconstruct an intraoral defect depends on the size and the anatomic position of the tissue defect. The goals are to restore form and function and minimize donor site morbidity. Regional pedicled flaps available for intraoral reconstruction are the buccal fat pad flap, facial artery musculomucosal flap, platysma, pectoralis major, temporalis muscle flap, and trapezius flaps. We give a concise illustration of anatomy, our harvesting technique, indications, and eventual pitfalls for each of the six flaps.