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Trapezius flaps for reconstruction of head and neck defects following oncological resection – A systematic review
Accepted Manuscript Trapezius flaps for reconstruction of head and neck defects following oncological resection-a systematic review Conor M. Sugrue, MCh, Grainne Rooney, M.B., B.Ch., B.A.O, Ryan M. Sugrue, MCh PII:
S1010-5182(17)30340-2
DOI:
10.1016/j.jcms.2017.10.001
Reference:
YJCMS 2802
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 14 May 2017 Revised Date:
23 August 2017
Accepted Date: 2 October 2017
Please cite this article as: Sugrue CM, Rooney G, Sugrue RM, Trapezius flaps for reconstruction of head and neck defects following oncological resection-a systematic review, Journal of Cranio-Maxillofacial Surgery (2017), doi: 10.1016/j.jcms.2017.10.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Trapezius flaps for reconstruction of head and neck defects following oncological resection- a systematic review. Conor M Sugrue MCh, Grainne Rooney M.B., B.Ch., B.A.O. Ryan M Sugrue MCh
Corresponding Author Conor M Sugrue
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[email protected]
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Department of Plastic & Reconstructive Surgery, Cork University Hospital, Cork. Ireland
Department of Plastic & Reconstructive Surgery, Cork University Hospital, Cork. Ireland
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+353 (021) 492 2000 +353 (021) 492 2432
Financial disclosures: none Conflicts of interest: none
ACCEPTED MANUSCRIPT Introduction
Head and neck (H&N) cancer is the sixth most common malignancy worldwide, with a reported incidence of 500,000 cases annually (Jemal et al., 2011).
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Surgical resection with subsequent reconstruction is the cornerstone of H&N cancer treatment. The spectrum of composite tissue defects following oncological resection creates challenging reconstructions. Microvascular free tissue transfer (MFTT) is the
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gold standard in reconstruction of H&N defects (Urken et al., 1994), and yet not all patients with H&N cancer are suitable candidates. In such cases, locoregional,
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pedicled flaps offer an alternative reconstructive option.
The trapezius flap is a large, thin, myocutaneous, pedicled flap. The wide arc of rotation and pliable tissue makes this flap ideal for reconstruction of H&N defects. The trapezius flap has been utilized for a range of H&N defects, including posterior
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occiput (Zenga et al., 2015) and intraoral defects (Chen et al., 2008). Inadequate knowledge of the complex vascular supply to this flap has notably limited its clinical application (Sadigh et al., 2014). Improved understanding, through cadaveric studies
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Yang et al., 1998), of the vascular anatomy of the trapezius muscle has coincided with an increase in this flap’s use. However, no studies have systematically
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evaluated the use of the trapezius flap in either primary or salvage settings. Therefore, the aim of this systematic review was to evaluate the operative technique and complications associated with trapezius flap reconstruction of H&N defects after oncological resection.
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ACCEPTED MANUSCRIPT Methodology Search criteria A comprehensive review of articles involving trapezius flaps for H&N reconstruction was performed over a 30-year period (Jan 1985 to Dec 2015).
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Databases SCOPUS, Web of Science, and PubMed were searched using the
following terms: ‘trapezius flap’, ‘trapezius muscle flap’, ‘lower extended trapezius flap’, and ‘pedicled trapezius flap’. To widen the search, the following phases were
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also used: ‘regional flaps in head and neck reconstruction’ and ‘pedicled flaps in
head and neck reconstruction’. Additionally, references in all articles were manually
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searched to identify other articles. Only studies published in the English were included.
Data selection
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All duplicated studies were removed. Initial screening excluded studies that failed to meet the inclusion criteria. Studies were omitted after full text analysis if the trapezius flap was used as a free/perforator/osteomyocutaneous flap or performed in
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two stages. Studies involving trapezius flaps for non-cancer-related H&N
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reconstruction (e.g. burns, chronic wounds, benign tumours) were also excluded. Specific data on these flaps were extracted from studies that included trapezius flaps in a series of different flaps for H&N reconstruction. Case reports, letters to the editor, and review articles were excluded. Studies that failed to include patient and operative information were also excluded, unless near complete data sets were available, in which case these studies were still included. This systematic process is demonstrated in the PRISMA flow diagram (Figure 1).
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ACCEPTED MANUSCRIPT Data extraction Information collected included date of publication, patient demographics, primary or salvage surgery, recipient site, and use of preoperative imaging. Specific data collected on trapezius flaps included direction and size of the skin paddle (width
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and length), and pedicle blood supply. Variations in vascular pedicle to the trapezius muscle were recorded, and flaps were categorised based upon the arterial supply classification system established by Haas (Wei et al., 2014). Type 1 (occipital
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perforator) and type 4 (intercostal perforator) were not included in this review, as they have a limited role in H&N reconstruction. A type 2 flap is based on the
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superficial branch of the transverse cervical artery (TCA), utilizing the middle portion of trapezius muscle fibers. A type 3 trapezius flap uses the lower lateral muscle fibers and is based on the dorsal scapula artery (DSA) (Figure 2). In this review, salvage surgery was defined as a second operation resulting
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from failure of the original reconstruction or local regional recurrence of malignancy. The level of evidence was also determined for each article. Statistical analysis was performed using SPSS (version 23). Data were analyzed using an independent-
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samples t-test and and chi-squared test. Statistical significance was set at p < 0.05.
Results
17 studies met the inclusion criteria, with a total of 157 trapezius flaps. All of
these studies were level IV evidence. The mean number of patients per study was 9.6 (range 2–23).
Patient demographics
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ACCEPTED MANUSCRIPT The mean age of patients undergoing trapezius flap reconstruction following oncological resection of H&N malignancy was 59.7 years, with 70.6% (108/153) of these patients being male. One study (n = 4) was excluded because it did not contain data regarding age or sex of patients. Intraoral defects were the most
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frequent recipient sites, with 74.5% (117/157) of patients undergoing reconstruction of this subunit. Complete analysis of H&N recipient sites is displayed in Table 1.
Squamous cell carcinoma accounted for 93.6% (147/157) of all H&N tumours. The
adenocarcinoma metastatic deposit (n = 2).
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remaining pathology included sarcoma (n = 4), basal cell carcinoma (n = 4), and
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Comparable numbers of patients in this review had trapezius flap reconstruction following primary surgery (79/157) and salvage surgery (78/157). The indications for salvage reconstruction included locoregional tumour recurrence in 82% (64/78) of cases and primary flap reconstruction breakdown in 21% (17/78).
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Among the studied patients, 64.9% (89/137) of patients underwent adjuvant radiotherapy. One study (n = 20) was excluded from this analysis because it failed to
Trapezius flap
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document radiotherapy status.
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All trapezius flaps in this study were myocutaneous flaps with a vertical skin paddle. The mean skin paddle width was 6.84 cm (range 3–15 cm), with a mean length of 11.1 cm (range 4–25 cm). Folded trapezius flap accounted for 22.7% of all flaps, with all of them used to reconstruct intraoral defects. These flaps had a similar average width (6.39 cm) to the standard flap, but a greater mean length of 17.9 cm (range 11–23 cm). In all cases, the vascular pedicle for the flap was based on one or two arterial pedicles. One study (n = 4) was excluded from this particular analysis because it
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ACCEPTED MANUSCRIPT failed to describe the pedicle. The most frequent pedicle used was the superficial branch of the TCA (type 2), accounting for 77.1% (118/153) of flaps. The DSA (type 3) pedicle was used in 22.9% (35/153) of cases. Four patients underwent trapezius flap reconstruction raised on both pedicles. Preoperative identification of these
remaining having Doppler assessment.
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Complications
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pedicles was carried out with computed tomography angiograms in 53.5%, with the
The total complication rate for trapezius flaps in H&N reconstruction was
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15.9% (22/138). Of these complications, 4/22 required a second operation. Two studies did not disclose complications and were not included in this analysis (n = 19). There were 15 flap-related complications in 138 trapezius flaps (10.9%). The most frequent complication was flap necrosis (n = 11). There were fewer donor site
flap loss.
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complications, reported in 5.1% (7/138) of patients (Table 2). There was no reported
A univariate analysis was performed comparing flap-related complications
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with patient demographics and operative techniques. Size of skin paddle, previous radiotherapy, and primary or salvage were not associated with increased risk of
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complications (Table 3).
Discussion
The complex anatomy of the H&N region presents unique technical
challenges for reconstruction. Achieving restoration of function, integrity, and form after oncological resection can be difficult (Chim et al., 2010). Microvascular free tissue transfer (MFTT) is the preferred reconstruction method for H&N defects (Wong et al., 2009), but not all patients are suitable because of locoregional disease
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ACCEPTED MANUSCRIPT and multiple comorbidities (Patel et al., 2010). In these circumstances, regional pedicled flaps, such as myocutaneous trapezius flap, provide an ideal reconstruction alternative. The trapezius flap, first described by Baek (1980) for reconstruction of soft tissue facial defects (Baek et al., 1980), was popularized by Pajnel as a flap for
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H&N reconstruction (Pajnel et al., 1980), and there has been a recent revival in this application (Can et al., 2014). This review has highlighted the reliability of this flap in a cohort of patients in which the majority have undergone adjuvant radiotherapy. The
different recipient sites in the H&N region.
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versatility of the flap is evident too, in providing soft tissue coverage for over 15
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Mathes and Nahai classify the trapezius flap as a type II myocutaneous flap, with one dominant pedicle (superficial branch of the transverse cervical artery or dorsal scapula artery) and minor pedicles (intercostal perforators and occipital artery) (Mathes et al., 1981). The dominant pedicle in the trapezius flap is a cause of much
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debate. Early descriptions of the trapezius flap describe the superficial branch of the TCA as the dominant pedicle (Urken et al., 1991). Cadaveric dissection by Netterville reported a reciprocal relationship between pedicles, confirming the dorsal scapular
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artery (DSA) to be the dominant vessel in 50% of cases, the TCA in 30% of cases,
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with both vessels codominant in 20% (Netterville et al., 1991). Further confusion surrounds the highly variable anatomy and nomenclature of these pedicles (Nichter et al., 1984). In one third of cases, both the TCA and DSA arise from a common trunk, known as the transverse cervical artery, which most frequently arises as a branch of the thyrocervical trunk (Hurley et al., 2014). In other cases, the superficial branch of the TCA arises from the suprascapular artery or directly from the thyrocervical trunk. The DSA most commonly arises from the subclavian artery and then as a combined common trunk with the TCA, as above. Other origins of the DSA
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ACCEPTED MANUSCRIPT include the suprascapular, internal thoracic, and costocervical trunks (Haas et al., 2004). Within the literature, there is significant disparity in descriptions of the trapezius flap, which creates confusion. In an attempt to provide clarity, Haas et al.
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developed a classification system for trapezius flaps based on arterial vascular supply. In our study, 77.1% all flaps were type 2 (superficial branch TCA), with
22.8% type 3 (DSA). Given the superficial nature of the TCA, a type 2 flap tends to
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be a simpler dissection. Dividing the rhomboid muscle to expose the DSA, in a type 3 flap, improves the arc of rotation of the flap. Also, the lower position of the skin
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paddle in a type 3 flap means that a greater flap width can be harvested. There was no difference in flap- or donor-related complications between these two types of trapezius flap. Interestingly, one study (n = 4) raised the trapezius flap on both these pedicles. This is not included in the classification system, so we propose an
2).
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additional classification – type 5 – describing a flap raised on both pedicles (Figure
The trapezius flap was used for salvage reconstruction in half of the patients
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in this cohort. The role of surgery in salvage H&N procedures is controversial
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(Mandapathil et al., 2014), potentially delaying radiotherapy, chemotherapy, and palliative treatment modalities. Significant improvements in quality of life with surgical resection of recurrent H&N tumours, regardless of stage, has been demonstrated (Goodwin et al., 2000). With a need for larger tissue resection in a potentially irradiated field, reconstruction of these salvage defects is particularly difficult. Salvage reconstruction with MFTT is associated with more complications than primary reconstruction with MFTT (Kostrzewa et al., 2010). This is supported by Bozikov et al, who demonstrated a 56% success rate of MFTT in salvage settings
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ACCEPTED MANUSCRIPT compared with primary reconstruction (Bozikov et al., 2004). However, our study revealed no difference in complication rates for trapezius flap performed in primary settings (14.7%) or salvage settings (10.4%) (p = 0.495). This highlights the potential importance of trapezius flaps as an option for reconstruction in patients undergoing
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H&N salvage surgery.
The complication rate for trapezius flap reconstruction (15.9%) is comparable to, if not lower than, other forms of H&N flap reconstruction. In a review of over 300
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free flaps for a variety of H&N defects, Bianchi et al. highlighted a major complication (return to theatre) rate of 15.1%, and a reported flap loss of 4% (Bianchi et al., 2009).
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The pectoralis major flap is an alternative pedicled flap for H&N defects in patients not suitable for MFTT. Yet when compared with trapezius flaps, pectoralis major flaps have a greater reported complication rate, which also includes flap loss (Vartanin et al., 2004). Furthermore, the choice of donor site for this flap can lead to
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significant chest wall disfigurement and a postoperative weakness in shoulder abduction (Refos et al., 2016). The trapezius flap donor site located in the mid-back is inconspicuous, with minimal effect on the muscle function postoperatively (Ou et
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al., 2013). Another pedicled flap for H&N reconstruction is the supraclavicular artery
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island flap (SCAIF). When reconstructing through-and-through defects of the cheek, Chen used a combination trapezius flap and SCAIF (Chen et al., 2012). However, SCAIF is significantly limited by the length of its pedicle (Kokot et al., 2013), reducing its versatility for H&N reconstruction. MFTT is the gold standard for complex reconstruction of intraoral defects (Schusterman et al., 1994). Of the patients in this review who underwent trapezius flap reconstruction for intraoral defects, the majority were salvage reconstructions following locoregional tumour recurrence. These patients presented a reconstructive
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ACCEPTED MANUSCRIPT challenge, given that the majority had primary MFTT with adjuvant radiotherapy. While the trapezius flap is not the reconstructive mainstay for intraoral defects, the use of this flap in the above cohort of patients demonstrates its reliability and versatility for reconstruction of H&N defects.
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There are several limitations to this review. Slightly more than half of the
studies (8/17) and patients (92/157) in this review are from the same institution. This could possibly introduce a bias, reflecting a single institution’s surgical practice of
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preferring trapezius flaps. The quality of the research from this institution mirrors the other studies in the review – single-centre retrospective case series equating to level
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IV evidence. Although this is on the lower end of the scale, it does emulate the level of evidence in otolaryngology (Wasserman et al., 2006) and plastic surgery (Sinno et al., 2011) research. Ideally, higher levels of evidence (i.e. case-controlled studies or randomized control trials) are needed, but ethical approval can be difficult to obtain.
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Notably, no studies focused on quality of life or patient-reported outcomes after reconstruction, so, as a result, such data could not be included in this systematic review. Patient-reported outcomes are an important variable, and must be included
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in future studies on trapezius flaps. This systematic review was designed to include
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studies on trapezius flaps between 1985 and 2015. However, studies prior to 1997 failed to include extractable data, omitting important patient- and flap-related information. Also, these studies failed to reveal associated complications, making them not suitable for inclusion in this review. Though studies were excluded by this process, this improved the overall consistency of the data in this systematic review. The key strength of this review centers around the strict inclusion criteria – i.e. only patients undergoing reconstruction following oncological resection. This established homogeneity within this study cohort, reducing the risk of any
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ACCEPTED MANUSCRIPT confounding variables. Another strength of this study was the involvement of both primary and salvage reconstructions. This enabled a complete overview of the
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trapezius flap, thus improving the clinical significance of this paper.
Conclusion
The trapezius flap is a reliable and versatile myocutaneous flap for both primary and
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salvage surgery reconstruction of H&N defects. Larger skin paddle size, different pedicle selection, primary vs salvage reconstruction, and previous radiotherapy were
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not identified as risk factors for complications. Clinical application of a universal classification system for trapezius flaps is paramount, as this would alleviate confusion and potentially increase use of these flaps as a suitable alternative for
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patients not fit for microvascular free tissue transfer.
References
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1. Baek S, Biller H, Krespi Y, Lawson W. The lower trapezius island myocutaneous flap. Annals of plastic surgery 5: 108–114, 1980.
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2. Bozikov K, Arnez ZM. Factors predicting free flap complications in head and neck reconstruction. J Plast Reconstr Aesthet Surg 59: 737–742, 2006.
3. Bianchi B, Copelli C, Ferrari S et al. Free flaps: outcomes and complications in head and neck reconstruction. J Craniomaxillofac Surg 37: 438–442, 2009.
4. Can A, Orgill DP, Dietmar Ulrich JO, Mureau MAM. The myocutaneous trapezius flap revisited: a treatment algorithm for optimal surgical outcomes based on 43 flap reconstructions. J Plast Reconstr Aesthet Surg 67: 1669– 1679, 2014.
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ACCEPTED MANUSCRIPT 5. Chen W, Yang Z, Li J, Huang Z. Reconstruction of the tongue using an extended vertical lower trapezius island myocutaneous flap after removal of advanced tongue cancer. Br J Oral Maxillofac Surg 46: 379–382, 2008. 6. Chen WL, Yang ZH, Zhang DM, et al. Reconstruction of major full cheek
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defects with combined extensive pedicled supraclavicular fasciocutaneous island flaps and extended vertical lower trapezius island myocutaneous flaps after ablation of advanced oral cancer. J Oral Maxillofac Surg 70: 1224–1231,
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2012
7. Chim H, Salgado C, Seselgyte R, Wei F-C, Mardini S. Principles of head and
24: 148–154, 2010.
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neck reconstruction: an algorithm to guide flap selection. Semin Plast Surg
8. Goodwin WJ Jr. Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: when do the ends justify the
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means? Laryngoscope 110: 1–18, 2000.
9. Haas F, Weiglein A, Schwarzl F, Scharnagl E. The lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and
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clinical applications based on the dorsal scapular artery. Plast Reconstr Surg
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113: 1580–1590, 2004.
10. Hurley M, Tomasik Z, Heller S, Isbrandt R, Stevens T, Olivieri M. Variations in the transverse cervical artery (543.6). The FASEB Journal 28: 543–546, 2014.
11. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA: A Cancer Journal for Clinicians 61: 69–90, 2011. 12. Kokot N, Mazhar K, Reder LS, Peng GL, Sinha UK. The supraclavicular artery island flap in head and neck reconstruction. JAMA Otolaryngol Head Neck Surg 139: 1247, 2013.
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ACCEPTED MANUSCRIPT 13. Kostrzewa JP, Lancaster WP, Iseli TA, et al. Outcomes of salvage surgery with free flap reconstruction for recurrent oral and oropharyngeal cancer. Laryngoscope 120: 267–272, 2010. 14. Mandapathil M, Roessler M, Werner JA et al. Salvage surgery for head and
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neck squamous cell carcinoma. Eur Arch Otorhinolaryngol 271: 1845, 2014. 15. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles:
experimental and clinical correlation. Plast Reconstr Surg 67: 177–187, 1981.
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16. Netterville JL, Wood DE. The lower trapezius flap. Vascular anatomy and surgical technique. Arch Otolaryngol Head Neck Surg 117: 73–76, 1991
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17. Nichter L, Morgan R, Harman D, Horowitz J, Edlich R. The trapezius musculocutaneous flap in head and neck reconstruction: potential pitfalls. Head Neck Surg. 1984;7: 129–34, 1984.
18. Ou K-L., Dai Y-H., Wang H-J., Chen T-M. et al. The lower trapezius
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musculocutaneous flap for head and neck reconstruction: two decades of clinical experience. Ann Plast Surg 71: S48–S54, 2013. 19. Panje WR. Myocutaneous trapezius flap. Head Neck Surg 2: 206–212, 1980.
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20. Patel RS, McCluskey SA, Goldstein DP, et al. Clinicopathologic and
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therapeutic risk factors for perioperative complications and prolonged hospital stay in free flap reconstruction of the head and neck. Head & Neck 32: 1345– 1353, 2010.
21. Refos JW, Witte BI, de Goede CJ, de Bree R. Shoulder morbidity after pectoralis major flap reconstruction. Head Neck 38: 1221–1228, 2016. 22. Sadigh PL, Chang L-R, Hsieh C-H, Feng W-J, Jeng S-F. The trapezius perforator flap. Plast Reconstr Surg 134: 449–456, 2014. 23. Schusterman MA, Miller MJ, Reece GP, et al. A single center’s experience
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ACCEPTED MANUSCRIPT with 308 free flaps for repair of head and neck cancer defects. Plast Reconstr Surg 93: 472–478, 1994. 24. Sinno H, Neel OF, Lutfy J, et al. Level of evidence in plastic surgery research. Plast Reconstr Surg 127: 974–980, 2011
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25. Urken ML, Weinberg H, Buchbinder D, et al. Microvascular free flaps in head and neck reconstruction: report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg 120: 633–640, 1994.
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26. Urken ML, Naidu RK, Lawson W, Biller HF. The lower trapezius island
musculocutaneous flap revisited. Report of 45 cases and a unifying concept of
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the vascular supply. Arch Otolaryngol Head Neck Surg 117: 502–511, 1991. 27. Vartanin JG, Carvalho AL, Carvalho SM, et al. Pectoralis major and other myofascial/myocutaneous flaps in head & neck cancer reconstruction: experience with 437 cases at single institution. Head Neck 26: 1018–1023,
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2004.
28. Wasserman JM, Wynn R, Bash TS, Rosenfeld RM. Levels of evidence in otolaryngology journals. Otolaryngol Head Neck Surg 134: 717–723, 2006.
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29. Wei F-C, Mardini S. Flaps and Reconstructive Surgery, Chapter 21, page 257.
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Edinburgh: Elsevier Health Sciences, 2014. 30. Wong C-H, Wei F-C. Microsurgical free flap in head and neck reconstruction. Head & Neck 32: 1236–1245, 2009.
31. Yang D, Morris SF. Trapezius muscle: anatomic basis for flap design. Ann Plast Surg 41: 52–57, 1998. 32. Zenga J, Sharon J, Santiago P, et al. Lower trapezius flap for reconstruction of posterior scalp and neck defects after complex occipital-cervical surgeries. Journal of Neurological Surgery Part B: Skull Base 76: 397–408, 2015.
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Figure legends Figure 1
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PRISMA flow diagram
Figure 2
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Schematic representation of trapezius muscle blood supply, with a corresponding skin paddle local based upon the Haas classification system for trapezius flaps. *Type 5 (type 2 + type 3) is not included in the Haas classification, but is a new type of flap proposed by us.
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ACCEPTED MANUSCRIPT Table 1 H&N recipient sites for trapezius flap
Recipient site
(n = 157)
Posterior neck Occiput Scalp
7 6 3
Ear Temple Parotid Cheek
7 5 7 5
Intraoral
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Face
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Skull
49 21 15 10
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Tongue Buccal mucosa Mandible Floor of mouth Pharyngeal/laryngeal Palate Gingiva Retromolar triangle
8 8 5 1
ACCEPTED MANUSCRIPT Table 2 Complication rates and need for return to OR for trapezius flaps
Return to OR
Flap necrosis Infection Hematoma Fistula Total
2 (1.4) 15/138 (10.9%)
Wound dehiscence Seroma Total
6 (4.3) 1 (0.7) 7/138 (5.1)
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Donor
11 (8.0) 1 (0.7) 1 (0.7)
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Flap
0 1 1
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Number (%)
1 3
0 1 1
ACCEPTED MANUSCRIPT Table 3
Univariate analysis of risk factors for complications associated with trapezius flap reconstruction
XRT
5
0.736
6.64 12.4
7.04 11.9
0.452 0.742
7 9
0.495
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Salvage Primary
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Procedure type
Width Height
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43
No Size of paddle (cm)
67 61
p-value 0.389 0.924
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Pedicle
Skull Face Intraoral 2 3 Both Yes
Complications (n = 22) 61.4 68.70% 3 0 14 13 3 0 11
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Age Sex (male) Subunits
No complications (n = 116) 58.4 69.90% 13 11 103 103 17 4 78
0.316
0.682
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ACCEPTED MANUSCRIPT
S1010-5182(17)30340-2
DOI:
10.1016/j.jcms.2017.10.001
Reference:
YJCMS 2802
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 14 May 2017 Revised Date:
23 August 2017
Accepted Date: 2 October 2017
Please cite this article as: Sugrue CM, Rooney G, Sugrue RM, Trapezius flaps for reconstruction of head and neck defects following oncological resection-a systematic review, Journal of Cranio-Maxillofacial Surgery (2017), doi: 10.1016/j.jcms.2017.10.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Trapezius flaps for reconstruction of head and neck defects following oncological resection- a systematic review. Conor M Sugrue MCh, Grainne Rooney M.B., B.Ch., B.A.O. Ryan M Sugrue MCh
Corresponding Author Conor M Sugrue
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[email protected]
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Department of Plastic & Reconstructive Surgery, Cork University Hospital, Cork. Ireland
Department of Plastic & Reconstructive Surgery, Cork University Hospital, Cork. Ireland
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+353 (021) 492 2000 +353 (021) 492 2432
Financial disclosures: none Conflicts of interest: none
ACCEPTED MANUSCRIPT Introduction
Head and neck (H&N) cancer is the sixth most common malignancy worldwide, with a reported incidence of 500,000 cases annually (Jemal et al., 2011).
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Surgical resection with subsequent reconstruction is the cornerstone of H&N cancer treatment. The spectrum of composite tissue defects following oncological resection creates challenging reconstructions. Microvascular free tissue transfer (MFTT) is the
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gold standard in reconstruction of H&N defects (Urken et al., 1994), and yet not all patients with H&N cancer are suitable candidates. In such cases, locoregional,
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pedicled flaps offer an alternative reconstructive option.
The trapezius flap is a large, thin, myocutaneous, pedicled flap. The wide arc of rotation and pliable tissue makes this flap ideal for reconstruction of H&N defects. The trapezius flap has been utilized for a range of H&N defects, including posterior
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occiput (Zenga et al., 2015) and intraoral defects (Chen et al., 2008). Inadequate knowledge of the complex vascular supply to this flap has notably limited its clinical application (Sadigh et al., 2014). Improved understanding, through cadaveric studies
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Yang et al., 1998), of the vascular anatomy of the trapezius muscle has coincided with an increase in this flap’s use. However, no studies have systematically
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evaluated the use of the trapezius flap in either primary or salvage settings. Therefore, the aim of this systematic review was to evaluate the operative technique and complications associated with trapezius flap reconstruction of H&N defects after oncological resection.
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ACCEPTED MANUSCRIPT Methodology Search criteria A comprehensive review of articles involving trapezius flaps for H&N reconstruction was performed over a 30-year period (Jan 1985 to Dec 2015).
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Databases SCOPUS, Web of Science, and PubMed were searched using the
following terms: ‘trapezius flap’, ‘trapezius muscle flap’, ‘lower extended trapezius flap’, and ‘pedicled trapezius flap’. To widen the search, the following phases were
SC
also used: ‘regional flaps in head and neck reconstruction’ and ‘pedicled flaps in
head and neck reconstruction’. Additionally, references in all articles were manually
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searched to identify other articles. Only studies published in the English were included.
Data selection
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All duplicated studies were removed. Initial screening excluded studies that failed to meet the inclusion criteria. Studies were omitted after full text analysis if the trapezius flap was used as a free/perforator/osteomyocutaneous flap or performed in
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two stages. Studies involving trapezius flaps for non-cancer-related H&N
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reconstruction (e.g. burns, chronic wounds, benign tumours) were also excluded. Specific data on these flaps were extracted from studies that included trapezius flaps in a series of different flaps for H&N reconstruction. Case reports, letters to the editor, and review articles were excluded. Studies that failed to include patient and operative information were also excluded, unless near complete data sets were available, in which case these studies were still included. This systematic process is demonstrated in the PRISMA flow diagram (Figure 1).
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ACCEPTED MANUSCRIPT Data extraction Information collected included date of publication, patient demographics, primary or salvage surgery, recipient site, and use of preoperative imaging. Specific data collected on trapezius flaps included direction and size of the skin paddle (width
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and length), and pedicle blood supply. Variations in vascular pedicle to the trapezius muscle were recorded, and flaps were categorised based upon the arterial supply classification system established by Haas (Wei et al., 2014). Type 1 (occipital
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perforator) and type 4 (intercostal perforator) were not included in this review, as they have a limited role in H&N reconstruction. A type 2 flap is based on the
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superficial branch of the transverse cervical artery (TCA), utilizing the middle portion of trapezius muscle fibers. A type 3 trapezius flap uses the lower lateral muscle fibers and is based on the dorsal scapula artery (DSA) (Figure 2). In this review, salvage surgery was defined as a second operation resulting
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from failure of the original reconstruction or local regional recurrence of malignancy. The level of evidence was also determined for each article. Statistical analysis was performed using SPSS (version 23). Data were analyzed using an independent-
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samples t-test and and chi-squared test. Statistical significance was set at p < 0.05.
Results
17 studies met the inclusion criteria, with a total of 157 trapezius flaps. All of
these studies were level IV evidence. The mean number of patients per study was 9.6 (range 2–23).
Patient demographics
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ACCEPTED MANUSCRIPT The mean age of patients undergoing trapezius flap reconstruction following oncological resection of H&N malignancy was 59.7 years, with 70.6% (108/153) of these patients being male. One study (n = 4) was excluded because it did not contain data regarding age or sex of patients. Intraoral defects were the most
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frequent recipient sites, with 74.5% (117/157) of patients undergoing reconstruction of this subunit. Complete analysis of H&N recipient sites is displayed in Table 1.
Squamous cell carcinoma accounted for 93.6% (147/157) of all H&N tumours. The
adenocarcinoma metastatic deposit (n = 2).
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remaining pathology included sarcoma (n = 4), basal cell carcinoma (n = 4), and
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Comparable numbers of patients in this review had trapezius flap reconstruction following primary surgery (79/157) and salvage surgery (78/157). The indications for salvage reconstruction included locoregional tumour recurrence in 82% (64/78) of cases and primary flap reconstruction breakdown in 21% (17/78).
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Among the studied patients, 64.9% (89/137) of patients underwent adjuvant radiotherapy. One study (n = 20) was excluded from this analysis because it failed to
Trapezius flap
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document radiotherapy status.
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All trapezius flaps in this study were myocutaneous flaps with a vertical skin paddle. The mean skin paddle width was 6.84 cm (range 3–15 cm), with a mean length of 11.1 cm (range 4–25 cm). Folded trapezius flap accounted for 22.7% of all flaps, with all of them used to reconstruct intraoral defects. These flaps had a similar average width (6.39 cm) to the standard flap, but a greater mean length of 17.9 cm (range 11–23 cm). In all cases, the vascular pedicle for the flap was based on one or two arterial pedicles. One study (n = 4) was excluded from this particular analysis because it
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ACCEPTED MANUSCRIPT failed to describe the pedicle. The most frequent pedicle used was the superficial branch of the TCA (type 2), accounting for 77.1% (118/153) of flaps. The DSA (type 3) pedicle was used in 22.9% (35/153) of cases. Four patients underwent trapezius flap reconstruction raised on both pedicles. Preoperative identification of these
remaining having Doppler assessment.
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Complications
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pedicles was carried out with computed tomography angiograms in 53.5%, with the
The total complication rate for trapezius flaps in H&N reconstruction was
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15.9% (22/138). Of these complications, 4/22 required a second operation. Two studies did not disclose complications and were not included in this analysis (n = 19). There were 15 flap-related complications in 138 trapezius flaps (10.9%). The most frequent complication was flap necrosis (n = 11). There were fewer donor site
flap loss.
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complications, reported in 5.1% (7/138) of patients (Table 2). There was no reported
A univariate analysis was performed comparing flap-related complications
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with patient demographics and operative techniques. Size of skin paddle, previous radiotherapy, and primary or salvage were not associated with increased risk of
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complications (Table 3).
Discussion
The complex anatomy of the H&N region presents unique technical
challenges for reconstruction. Achieving restoration of function, integrity, and form after oncological resection can be difficult (Chim et al., 2010). Microvascular free tissue transfer (MFTT) is the preferred reconstruction method for H&N defects (Wong et al., 2009), but not all patients are suitable because of locoregional disease
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ACCEPTED MANUSCRIPT and multiple comorbidities (Patel et al., 2010). In these circumstances, regional pedicled flaps, such as myocutaneous trapezius flap, provide an ideal reconstruction alternative. The trapezius flap, first described by Baek (1980) for reconstruction of soft tissue facial defects (Baek et al., 1980), was popularized by Pajnel as a flap for
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H&N reconstruction (Pajnel et al., 1980), and there has been a recent revival in this application (Can et al., 2014). This review has highlighted the reliability of this flap in a cohort of patients in which the majority have undergone adjuvant radiotherapy. The
different recipient sites in the H&N region.
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versatility of the flap is evident too, in providing soft tissue coverage for over 15
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Mathes and Nahai classify the trapezius flap as a type II myocutaneous flap, with one dominant pedicle (superficial branch of the transverse cervical artery or dorsal scapula artery) and minor pedicles (intercostal perforators and occipital artery) (Mathes et al., 1981). The dominant pedicle in the trapezius flap is a cause of much
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debate. Early descriptions of the trapezius flap describe the superficial branch of the TCA as the dominant pedicle (Urken et al., 1991). Cadaveric dissection by Netterville reported a reciprocal relationship between pedicles, confirming the dorsal scapular
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artery (DSA) to be the dominant vessel in 50% of cases, the TCA in 30% of cases,
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with both vessels codominant in 20% (Netterville et al., 1991). Further confusion surrounds the highly variable anatomy and nomenclature of these pedicles (Nichter et al., 1984). In one third of cases, both the TCA and DSA arise from a common trunk, known as the transverse cervical artery, which most frequently arises as a branch of the thyrocervical trunk (Hurley et al., 2014). In other cases, the superficial branch of the TCA arises from the suprascapular artery or directly from the thyrocervical trunk. The DSA most commonly arises from the subclavian artery and then as a combined common trunk with the TCA, as above. Other origins of the DSA
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ACCEPTED MANUSCRIPT include the suprascapular, internal thoracic, and costocervical trunks (Haas et al., 2004). Within the literature, there is significant disparity in descriptions of the trapezius flap, which creates confusion. In an attempt to provide clarity, Haas et al.
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developed a classification system for trapezius flaps based on arterial vascular supply. In our study, 77.1% all flaps were type 2 (superficial branch TCA), with
22.8% type 3 (DSA). Given the superficial nature of the TCA, a type 2 flap tends to
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be a simpler dissection. Dividing the rhomboid muscle to expose the DSA, in a type 3 flap, improves the arc of rotation of the flap. Also, the lower position of the skin
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paddle in a type 3 flap means that a greater flap width can be harvested. There was no difference in flap- or donor-related complications between these two types of trapezius flap. Interestingly, one study (n = 4) raised the trapezius flap on both these pedicles. This is not included in the classification system, so we propose an
2).
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additional classification – type 5 – describing a flap raised on both pedicles (Figure
The trapezius flap was used for salvage reconstruction in half of the patients
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in this cohort. The role of surgery in salvage H&N procedures is controversial
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(Mandapathil et al., 2014), potentially delaying radiotherapy, chemotherapy, and palliative treatment modalities. Significant improvements in quality of life with surgical resection of recurrent H&N tumours, regardless of stage, has been demonstrated (Goodwin et al., 2000). With a need for larger tissue resection in a potentially irradiated field, reconstruction of these salvage defects is particularly difficult. Salvage reconstruction with MFTT is associated with more complications than primary reconstruction with MFTT (Kostrzewa et al., 2010). This is supported by Bozikov et al, who demonstrated a 56% success rate of MFTT in salvage settings
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ACCEPTED MANUSCRIPT compared with primary reconstruction (Bozikov et al., 2004). However, our study revealed no difference in complication rates for trapezius flap performed in primary settings (14.7%) or salvage settings (10.4%) (p = 0.495). This highlights the potential importance of trapezius flaps as an option for reconstruction in patients undergoing
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H&N salvage surgery.
The complication rate for trapezius flap reconstruction (15.9%) is comparable to, if not lower than, other forms of H&N flap reconstruction. In a review of over 300
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free flaps for a variety of H&N defects, Bianchi et al. highlighted a major complication (return to theatre) rate of 15.1%, and a reported flap loss of 4% (Bianchi et al., 2009).
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The pectoralis major flap is an alternative pedicled flap for H&N defects in patients not suitable for MFTT. Yet when compared with trapezius flaps, pectoralis major flaps have a greater reported complication rate, which also includes flap loss (Vartanin et al., 2004). Furthermore, the choice of donor site for this flap can lead to
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significant chest wall disfigurement and a postoperative weakness in shoulder abduction (Refos et al., 2016). The trapezius flap donor site located in the mid-back is inconspicuous, with minimal effect on the muscle function postoperatively (Ou et
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al., 2013). Another pedicled flap for H&N reconstruction is the supraclavicular artery
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island flap (SCAIF). When reconstructing through-and-through defects of the cheek, Chen used a combination trapezius flap and SCAIF (Chen et al., 2012). However, SCAIF is significantly limited by the length of its pedicle (Kokot et al., 2013), reducing its versatility for H&N reconstruction. MFTT is the gold standard for complex reconstruction of intraoral defects (Schusterman et al., 1994). Of the patients in this review who underwent trapezius flap reconstruction for intraoral defects, the majority were salvage reconstructions following locoregional tumour recurrence. These patients presented a reconstructive
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ACCEPTED MANUSCRIPT challenge, given that the majority had primary MFTT with adjuvant radiotherapy. While the trapezius flap is not the reconstructive mainstay for intraoral defects, the use of this flap in the above cohort of patients demonstrates its reliability and versatility for reconstruction of H&N defects.
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There are several limitations to this review. Slightly more than half of the
studies (8/17) and patients (92/157) in this review are from the same institution. This could possibly introduce a bias, reflecting a single institution’s surgical practice of
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preferring trapezius flaps. The quality of the research from this institution mirrors the other studies in the review – single-centre retrospective case series equating to level
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IV evidence. Although this is on the lower end of the scale, it does emulate the level of evidence in otolaryngology (Wasserman et al., 2006) and plastic surgery (Sinno et al., 2011) research. Ideally, higher levels of evidence (i.e. case-controlled studies or randomized control trials) are needed, but ethical approval can be difficult to obtain.
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Notably, no studies focused on quality of life or patient-reported outcomes after reconstruction, so, as a result, such data could not be included in this systematic review. Patient-reported outcomes are an important variable, and must be included
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in future studies on trapezius flaps. This systematic review was designed to include
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studies on trapezius flaps between 1985 and 2015. However, studies prior to 1997 failed to include extractable data, omitting important patient- and flap-related information. Also, these studies failed to reveal associated complications, making them not suitable for inclusion in this review. Though studies were excluded by this process, this improved the overall consistency of the data in this systematic review. The key strength of this review centers around the strict inclusion criteria – i.e. only patients undergoing reconstruction following oncological resection. This established homogeneity within this study cohort, reducing the risk of any
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ACCEPTED MANUSCRIPT confounding variables. Another strength of this study was the involvement of both primary and salvage reconstructions. This enabled a complete overview of the
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trapezius flap, thus improving the clinical significance of this paper.
Conclusion
The trapezius flap is a reliable and versatile myocutaneous flap for both primary and
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salvage surgery reconstruction of H&N defects. Larger skin paddle size, different pedicle selection, primary vs salvage reconstruction, and previous radiotherapy were
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not identified as risk factors for complications. Clinical application of a universal classification system for trapezius flaps is paramount, as this would alleviate confusion and potentially increase use of these flaps as a suitable alternative for
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patients not fit for microvascular free tissue transfer.
References
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1. Baek S, Biller H, Krespi Y, Lawson W. The lower trapezius island myocutaneous flap. Annals of plastic surgery 5: 108–114, 1980.
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2. Bozikov K, Arnez ZM. Factors predicting free flap complications in head and neck reconstruction. J Plast Reconstr Aesthet Surg 59: 737–742, 2006.
3. Bianchi B, Copelli C, Ferrari S et al. Free flaps: outcomes and complications in head and neck reconstruction. J Craniomaxillofac Surg 37: 438–442, 2009.
4. Can A, Orgill DP, Dietmar Ulrich JO, Mureau MAM. The myocutaneous trapezius flap revisited: a treatment algorithm for optimal surgical outcomes based on 43 flap reconstructions. J Plast Reconstr Aesthet Surg 67: 1669– 1679, 2014.
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ACCEPTED MANUSCRIPT 5. Chen W, Yang Z, Li J, Huang Z. Reconstruction of the tongue using an extended vertical lower trapezius island myocutaneous flap after removal of advanced tongue cancer. Br J Oral Maxillofac Surg 46: 379–382, 2008. 6. Chen WL, Yang ZH, Zhang DM, et al. Reconstruction of major full cheek
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defects with combined extensive pedicled supraclavicular fasciocutaneous island flaps and extended vertical lower trapezius island myocutaneous flaps after ablation of advanced oral cancer. J Oral Maxillofac Surg 70: 1224–1231,
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2012
7. Chim H, Salgado C, Seselgyte R, Wei F-C, Mardini S. Principles of head and
24: 148–154, 2010.
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neck reconstruction: an algorithm to guide flap selection. Semin Plast Surg
8. Goodwin WJ Jr. Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: when do the ends justify the
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means? Laryngoscope 110: 1–18, 2000.
9. Haas F, Weiglein A, Schwarzl F, Scharnagl E. The lower trapezius musculocutaneous flap from pedicled to free flap: anatomical basis and
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clinical applications based on the dorsal scapular artery. Plast Reconstr Surg
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113: 1580–1590, 2004.
10. Hurley M, Tomasik Z, Heller S, Isbrandt R, Stevens T, Olivieri M. Variations in the transverse cervical artery (543.6). The FASEB Journal 28: 543–546, 2014.
11. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA: A Cancer Journal for Clinicians 61: 69–90, 2011. 12. Kokot N, Mazhar K, Reder LS, Peng GL, Sinha UK. The supraclavicular artery island flap in head and neck reconstruction. JAMA Otolaryngol Head Neck Surg 139: 1247, 2013.
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ACCEPTED MANUSCRIPT 13. Kostrzewa JP, Lancaster WP, Iseli TA, et al. Outcomes of salvage surgery with free flap reconstruction for recurrent oral and oropharyngeal cancer. Laryngoscope 120: 267–272, 2010. 14. Mandapathil M, Roessler M, Werner JA et al. Salvage surgery for head and
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neck squamous cell carcinoma. Eur Arch Otorhinolaryngol 271: 1845, 2014. 15. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles:
experimental and clinical correlation. Plast Reconstr Surg 67: 177–187, 1981.
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16. Netterville JL, Wood DE. The lower trapezius flap. Vascular anatomy and surgical technique. Arch Otolaryngol Head Neck Surg 117: 73–76, 1991
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17. Nichter L, Morgan R, Harman D, Horowitz J, Edlich R. The trapezius musculocutaneous flap in head and neck reconstruction: potential pitfalls. Head Neck Surg. 1984;7: 129–34, 1984.
18. Ou K-L., Dai Y-H., Wang H-J., Chen T-M. et al. The lower trapezius
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musculocutaneous flap for head and neck reconstruction: two decades of clinical experience. Ann Plast Surg 71: S48–S54, 2013. 19. Panje WR. Myocutaneous trapezius flap. Head Neck Surg 2: 206–212, 1980.
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20. Patel RS, McCluskey SA, Goldstein DP, et al. Clinicopathologic and
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therapeutic risk factors for perioperative complications and prolonged hospital stay in free flap reconstruction of the head and neck. Head & Neck 32: 1345– 1353, 2010.
21. Refos JW, Witte BI, de Goede CJ, de Bree R. Shoulder morbidity after pectoralis major flap reconstruction. Head Neck 38: 1221–1228, 2016. 22. Sadigh PL, Chang L-R, Hsieh C-H, Feng W-J, Jeng S-F. The trapezius perforator flap. Plast Reconstr Surg 134: 449–456, 2014. 23. Schusterman MA, Miller MJ, Reece GP, et al. A single center’s experience
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ACCEPTED MANUSCRIPT with 308 free flaps for repair of head and neck cancer defects. Plast Reconstr Surg 93: 472–478, 1994. 24. Sinno H, Neel OF, Lutfy J, et al. Level of evidence in plastic surgery research. Plast Reconstr Surg 127: 974–980, 2011
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25. Urken ML, Weinberg H, Buchbinder D, et al. Microvascular free flaps in head and neck reconstruction: report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg 120: 633–640, 1994.
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26. Urken ML, Naidu RK, Lawson W, Biller HF. The lower trapezius island
musculocutaneous flap revisited. Report of 45 cases and a unifying concept of
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the vascular supply. Arch Otolaryngol Head Neck Surg 117: 502–511, 1991. 27. Vartanin JG, Carvalho AL, Carvalho SM, et al. Pectoralis major and other myofascial/myocutaneous flaps in head & neck cancer reconstruction: experience with 437 cases at single institution. Head Neck 26: 1018–1023,
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2004.
28. Wasserman JM, Wynn R, Bash TS, Rosenfeld RM. Levels of evidence in otolaryngology journals. Otolaryngol Head Neck Surg 134: 717–723, 2006.
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29. Wei F-C, Mardini S. Flaps and Reconstructive Surgery, Chapter 21, page 257.
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Edinburgh: Elsevier Health Sciences, 2014. 30. Wong C-H, Wei F-C. Microsurgical free flap in head and neck reconstruction. Head & Neck 32: 1236–1245, 2009.
31. Yang D, Morris SF. Trapezius muscle: anatomic basis for flap design. Ann Plast Surg 41: 52–57, 1998. 32. Zenga J, Sharon J, Santiago P, et al. Lower trapezius flap for reconstruction of posterior scalp and neck defects after complex occipital-cervical surgeries. Journal of Neurological Surgery Part B: Skull Base 76: 397–408, 2015.
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Figure legends Figure 1
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PRISMA flow diagram
Figure 2
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Schematic representation of trapezius muscle blood supply, with a corresponding skin paddle local based upon the Haas classification system for trapezius flaps. *Type 5 (type 2 + type 3) is not included in the Haas classification, but is a new type of flap proposed by us.
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ACCEPTED MANUSCRIPT Table 1 H&N recipient sites for trapezius flap
Recipient site
(n = 157)
Posterior neck Occiput Scalp
7 6 3
Ear Temple Parotid Cheek
7 5 7 5
Intraoral
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Face
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Skull
49 21 15 10
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Tongue Buccal mucosa Mandible Floor of mouth Pharyngeal/laryngeal Palate Gingiva Retromolar triangle
8 8 5 1
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Return to OR
Flap necrosis Infection Hematoma Fistula Total
2 (1.4) 15/138 (10.9%)
Wound dehiscence Seroma Total
6 (4.3) 1 (0.7) 7/138 (5.1)
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Donor
11 (8.0) 1 (0.7) 1 (0.7)
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Flap
0 1 1
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Number (%)
1 3
0 1 1
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Univariate analysis of risk factors for complications associated with trapezius flap reconstruction
XRT
5
0.736
6.64 12.4
7.04 11.9
0.452 0.742
7 9
0.495
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Salvage Primary
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Procedure type
Width Height
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43
No Size of paddle (cm)
67 61
p-value 0.389 0.924
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Pedicle
Skull Face Intraoral 2 3 Both Yes
Complications (n = 22) 61.4 68.70% 3 0 14 13 3 0 11
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Age Sex (male) Subunits
No complications (n = 116) 58.4 69.90% 13 11 103 103 17 4 78
0.316
0.682
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