The Dorsal Scapular Island Flap

The Dorsal Scapular Island Flap: AnAlternative for Head, Neck, and ChestReconstructionClaudio Angrigiani, M.D., Daniel Grilli, M.D., Yvonne L. Karanas, M.D., Michael T. Longaker, M.D., andSheel Sharma, M.D.Buenos Aires, Argentina; Stanford, Calif.; and New York, N.Y.

The back has become an increasingly popular donorsite for flaps because it can provide thin, pliable tissue,with minimal bulk, and the scar can be easily hiddenunder clothing. The authors performed a cadaveric andclinical study to evaluate the anatomy of the dorsal scap-ular vessels and their vascular contribution to the skin,fascia, and muscles of the back. On the basis of anatomicalstudies in 28 cadavers and clinical experience with 32cases, it was concluded that the dorsal scapular vesselsprovide a reliable blood supply to the skin of the medialback, making it a versatile flap to use as an island flap. Aflap raised on the dorsal scapular vessels can be harvestedwith a long pedicle and can be rotated to reach as far asthe anterior regions of the head, neck, and chest wall.Delaying and expanding the flap may help to facilitatevenous drainage. The authors recommend the use of thisversatile island pedicle flap as an alternative to microvas-cular free-tissue transfer for the reconstruction of defectsin the head, neck, and anterior chest. (Plast. Reconstr.Surg. 111: 67, 2003.)

The trapezius myocutaneous flap and itsmodifications have been used to cover defectsof the head and neck.1,2 However, questionshave been raised in the literature regarding theblood supply to these flaps. Traditionally, it wasthought that branches of the transverse cervi-cal artery and vein perfuse these flaps. Severalreports, however, have mentioned the contri-bution of the dorsal scapular artery in perfus-ing the inferior part of the trapezius muscleand, hence, the distal part of the lower trape-zius myocutaneous flap.3,4 It has been sug-gested that the dorsal scapular artery should beincluded in the lower trapezius myocutaneous

flap to ensure viability of the distal part of theflap.5,6 Previous anatomical studies have shownthe dorsal scapular artery to supply the medialpart of the lower back, suggesting that it is oneof the possible sources of blood supply to flapsharvested in this area.6–8 We have found that acutaneous flap can be raised on this vessel witha long vascular pedicle (15 to 16 cm) that canbe rotated to reach as far as the anterior part ofthe head and chest wall. During the flap har-vest, the trapezius muscle can be completelyspared, preserving full shoulder function. Thepurpose of this article is to present (1) theresults of an anatomical study performed in 28cadaveric specimens to investigate the cutane-ous branches of the dorsal scapular artery, (2)the surgical technique for raising and transfer-ring an island dorsal scapular flap to the headand neck area, and (3) our clinical experienceusing this flap in 32 cases.

ANATOMY OF THE DORSAL SCAPULAR ARTERY

The dorsal scapular artery originates fromthe subclavian artery as an independentbranch or from the trunk of the transversecervical artery. It runs posteriorly and almosthorizontally deep to or through the branchesof the brachial plexus. It then courses underthe trapezius muscle and, more importantly,under the omohyoid and levator scapulae mus-cles on top of the rib cage. At the medial angleof the scapula, it gives off a superficial branch

From Centario 133, Buenos Aires; the Institute of Reconstructive Plastic Surgery, New York; and the Department of Surgery and Division ofPlastic and Reconstructive Surgery, Stanford University School of Medicine. Received for publication November 26, 2001; revised March 7, 2002.

Presented at the 76th Annual Meeting of the American Association of Plastic Surgeons, in Portland, Oregon, in May of 1997.

DOI: 10.1097/01.PRS.0000037682.59058.6B

67

that pierces the rhomboideus muscle and ap-pears under the deep surface of the trapeziusmuscle. This superficial branch runs on thedeep belly of the trapezius muscle, perfusingthat muscle, and giving off one or two cutane-ous perforators that traverse through the mus-cle. Our flap is based on this superficial branchof the dorsal scapular artery. After giving offthe superficial branch, the main trunk of thedorsal scapular artery becomes the deepbranch of the dorsal scapular artery. It runsunder the medial border of the scapula in themass of the rhomboideus muscle up to the tipof the scapula, which it perfuses. During itscourse, the deep branch of the dorsal scapularartery gives off one or two perforators to therhomboideus muscle (Figs. 1 and 2).

MATERIALS AND METHODS

Cadaver Dissections

Twenty-eight cadavers were injected with col-ored latex through the ascending aorta. Twen-ty-two cadavers were immediately dissected un-der magnification, and the remaining six werepreserved in 10 percent formol solution fordelayed dissection. The preserved specimenswere used for photographic documentation.The skin was removed and the cutaneous arte-rial branches of the medial back were mappedin the subcutaneous tissue. The branches were

dissected under �4 loupe magnification andtraced to their origins. The medial back is de-fined as the area bound medially by the spine,laterally by a vertical line drawn midway be-tween the spine and the shoulder, superiorlyby a horizontal line drawn at the level of thesuperior border of the scapula, and inferiorlyby a horizontal line at the level of the inferiortip of the scapula.

RESULTS

Anatomical Study

The cutaneous arteries near the spine origi-nated from the intercostal arteries, one in eachintercostal space. These branches perforatedthe spinal muscles and were accompanied by acutaneous nerve and an accompanying vein.The size of these arteries was variable, somebeing up to 1.2 mm in diameter. These perfo-rating branches emerged in the subcutaneoustissue caudal to their parent artery.

The cutaneous perforating branches in thesuperior part of the medial back arose from thesuperficial transverse cervical artery andpierced the trapezius muscle to reach the skin.These are the branches that perfuse the tradi-tional trapezius myocutaneous flap.

The dorsal scapular artery runs deep to thelevator scapulae and omohyoid muscles at theapex of the thorax. Once it reaches the supero-

FIG. 1. Anatomic location of the cutaneous perforators of the dorsal scapularartery.

68 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2003

medial angle of the scapula, it gives off a su-perficial branch (superficial dorsal scapular ar-tery), which pierces the rhomboideus muscleand runs under the deep surface of the inferiorpart of the trapezius muscle. This superficialdorsal scapular artery consistently gives off oneor two cutaneous branches that pierce thelower trapezius muscle 1 to 2 cm medial to thelateral border of the muscle. In 16 specimensthere were two perforators, and in 12 casesthere was one perforator. There were no caseswithout a muscular perforator. In eight cases,there were two cutaneous perforators that orig-inated from a single branch of the dorsal scap-ular artery. In another eight specimens, therewere two perforating cutaneous branches thateach arose from a different branch of the dor-sal scapular artery.

The other division of the dorsal scapularartery is called the deep branch of the dorsalscapular artery. It remains deep to the rhom-boideus muscle and runs under the medialborder of the scapula. This deep branch givesoff one or two more cutaneous branches, distalto the origin of the superficial branch. All of

these cutaneous branches pierced the rhom-boideus muscles. In eight cadavers, we foundthat the second perforator of the rhomboideusalso pierced the trapezius muscle in a mannersimilar to the perforators of the superficial dor-sal scapular artery. In other cases, these cuta-neous branches reached the skin and subcuta-neous tissue directly without penetrating thetrapezius muscle. Two other cutaneousbranches originating from the deep branch ofthe dorsal scapular artery were observed pierc-ing the rhomboideus muscle near the medialborder of the scapula: one in the central partof the medial border of the scapula and theother near the tip.

In summary, the dorsal scapular artery andits cutaneous branches were identified in all ofour dissections. There was a consistent arterialsupply to the skin and subcutaneous tissue ofthe medial back from the superficial dorsalscapular artery, either through the trapeziusmuscle or around its lateral border. These an-atomical findings illustrate that it is possible toraise a cutaneous flap based on the lower tra-

FIG. 2. Anatomy of the dorsal scapular artery.

Vol. 111, No. 1 / DORSAL SCAPULAR ISLAND FLAP 69

FIG. 3. (Above, left) Posterior view of the back muscles. The center arrow points to oneof the muscular perforators from the superficial branch of the dorsal scapular arteryemerging through the trapezius muscle. (Above, right) The superficial branch of the dorsalscapular artery is shown emerging from the rhomboideus muscle and running on theundersurface of the trapezius muscle that has been reflected medially. (Below, left) Thedeep branch of the dorsal scapular artery is shown running along the medial border ofthe scapula. The rhomboideus muscle has been partially resected from its attachment tothe medial border of the scapula. (Below, right) The dorsal scapular artery runs under theomohyoid and levator muscles just on top of the thorax. It is seen branching into the deep(white arrow) and superficial branches (open arrow). In this case, there are two superficialbranches that run on the undersurface of the trapezius muscle that has been partiallyreflected.


pezius myocutaneous perforator of the dorsalscapular artery (Fig. 3).

Surgical Technique

The patient is placed in a lateral decubitusposition. The ipsilateral arm is draped free topermit its mobility during flap harvest.

Flap design. The flap design is centered on acutaneous perforator of the dorsal scapular ar-tery, which is identified preoperatively using aDoppler probe. This perforator is usually lo-cated at the intersection of a horizontal linedrawn 6 to 8 cm inferior to the spine of thescapula with a vertical line drawn 8 to 9 cmlateral to the midline of the back. A flap as largeas 20 � 20 cm can be safely harvested on thisperforator. The flap can be oriented in anydirection.

Flap elevation. The skin is incised along themargins of the flap. The flap dissection pro-ceeds in a distal to proximal fashion superfi-cial to the deep fascia. On reaching the lateralborder of the trapezius, the cutaneous per-forator is identified. We prefer to elevate the

edge of the trapezius muscle to identify thesuperficial dorsal scapular artery running onits deep surface. This maneuver provides abetter view of the cutaneous perforator orig-inating from the muscular branch. The mus-cular branch can be dissected off the belly ofthe trapezius with blunt dissection. Once thecutaneous perforator is visualized, it is dis-sected including a small piece of the trapeziusmuscle around the perforator (approximately5 � 5 cm). It is possible to raise a “pureperforator” flap isolated on the cutaneousperforator without including any muscle.However, we do not recommend this becausethe muscle at this level is quite thin and in-clusion of a small cuff of muscle does notincrease the volume of the flap significantly.In addition, resecting a small portion of themuscle causes no functional impairment andallows easier dissection of the flap. The flap isnow attached only to the superficial muscularbranch of the dorsal scapular artery, whichcan be visualized penetrating the rhomboi-deus muscles. Dissection then proceeds

FIG. 4. Illustration of the anatomy of the dorsal scapular island flap.


through the rhomboideus muscles to isolatethe deep branch and the common trunk ofthe dorsal scapular artery. The deep branch isidentified and ligated. The angle of the scap-ula is retracted. This maneuver allows betterexposure of the dorsal scapular artery deep tothe scapula and the levator and omohyoidmuscles. At this point, the pedicle appears torun in a “tunnel,” giving off branches to thelevator scapulae and omohyoid muscles andto the rib cage. These branches must be li-gated and transected. Blunt dissection of thesoft tissues enlarges this area to allow the flapto be passed through the tunnel. On reaching

the anterior border of the levator scapulae,the dorsal scapular vein, which may not ac-company the artery, is located with meticu-lous dissection. Dissection stops at the ante-rior border of the trapezius. It is unnecessaryto dissect the artery all the way to its origin.

A second incision is then made in the supra-clavicular area in front of the anterior borderof the trapezius muscle. A subcutaneous tunnelis created with blunt dissection. The flap isthen tunneled through this space and deliv-ered through the supraclavicular incision. Thedonor site is closed primarily. When very largeflaps are required, we recommend dividing the

FIG. 5. A 76-year-old woman with a recurrent basal cell carcinoma of the occipital scalp. (Above, left) Skin and boneinvolvement. (Above, center) Markings of the dorsal scapular island flap. (Above, right) Elevation of the dorsal scapular island flap.(Below, left) The wound and the donor site have healed completely. (Below, right) The patient has regained almost complete rangeof motion in the left shoulder.


levator and omohyoid muscles to facilitate flaptransfer. These muscles are repaired after flaptransfer. In the earlier cases of our series, weroutinely disinserted the trapezius from thescapula. These patients all had persistent diffi-culty with full shoulder elevation postopera-tively. We therefore did not disinsert the trape-zius muscle in our later cases (Fig. 4).

Preexpanded delayed flap. When large flapsare required, the flap is expanded and de-layed to augment the vascularity of the flapand improve venous outflow. A vertical inci-sion is made 3 to 4 cm from the midline of theback, parallel to the spine. The lower part ofthe trapezius is divided about 4 to 5 cm fromthe midline. The intercostal musculocutane-ous perforating arteries and veins are ligated.The superficial muscular branch of the dorsalscapular artery is identified at the point whereit pierces the rhomboideus muscles and istraced distally into the trapezius muscle. A600-cc rectangular tissue expander is placed

under the muscle, with care taken to preservethis musculocutaneous branch. The muscle issutured back and the incision is closed inlayers. We do not routinely drain this space.Serial expansion is performed until the de-sired degree of expansion has been achieved.The flap is then harvested in the manner de-scribed above.

Clinical Experience

The dorsal scapular artery flap was used toreconstruct soft-tissue defects of the head andneck, shoulder, and anterior chest wall in 32patients. The average age at surgery was 42years (range, 6 to 77 years). There were 20male and 12 female patients. The smallest flapused was 6 � 8 cm and the largest was 30 � 26cm. The operative procedure lasted an averageof 2.6 hours (range, 1.7 to 4.3 hours). Theaverage hospital inpatient stay was 6.7 days.

Twenty-nine of the 32 flaps were successful,

FIG. 6. A 16-year-old boy with a severe burn scar contracture of the chest wall (above, left). Expansion and delay of the dorsalscapular island flap (above, center). Elevation of the flap (above, right). The patient has a healed wound and diminished chest wallcontracture postoperatively (below, left). The donor site has healed and the patient has regained full range of motion (below, right).


for a flap survival rate of 91 percent. Two flapfailures were attributed to technical errorsearly in our series. A third flap was lost be-cause of venous insufficiency despite carefuldissection. One additional flap developed ve-nous insufficiency intraoperatively. It was sal-vaged by anastomosing a flap vein to theexternal jugular vein. Therefore, all flap fail-ures were caused by venous insufficiency (9percent). Partial flap loss occurred in twocases (6 percent). Notably, each of theseflaps was greater than 25 cm in length. Do-nor-site complications included wound de-hiscence in four cases (12.5 percent). Two ofthese were encountered in the preexpandedflaps. All of these wounds healed by second-ary intention without surgical intervention.Nine patients underwent disinsertion of thetrapezius muscle. Four of these patients (44

percent) had a moderate restriction in shoul-der motion 2 years postoperatively. Theother five patients had minimal restriction oftheir shoulder function. None of the patientsin whom the trapezius, omohyoid, and leva-tor scapulae muscles were disinserted andreinserted regained complete range of mo-tion of the shoulder. Eleven patients under-went division of the omohyoid and levatorscapulae muscles without disinsertion of thetrapezius muscle. All of these patients had atemporary limitation in shoulder movement.In the remaining 12 cases, in which neitherthe trapezius nor the omohyoid and levatormuscles were divided, the patients regainedfull shoulder function in the immediate post-operative period. We therefore do not rec-ommend dividing the trapezius muscle forflap mobilization.

FIG. 7. A 32-year-old woman with a burn scar contracture of the neck. (Above, left) anterior view; (above, center) lateral view.Surgical markings for the dorsal scapular island flap after expansion and delay (above, right). Donor site and flap shownintraoperatively (below).


CASE REPORTS

Case 1A 76-year-old woman presented for treatment of a recur-

rent basal cell carcinoma in the occipital region of the scalp.The cancer had been present for over 5 years and had beensurgically resected 3 years previously. A radical resection ofthe tumor resulted in a defect 30 � 26 cm in size, withexposure of the dura mater after almost complete resectionof the occipital bone. A 30-cm � 26-cm dorsal scapular flapwas harvested and transferred to the defect. The medialinsertion of the trapezius muscle was divided temporarilyto facilitate flap transfer. The omohyoid and levator scap-ulae muscles were not divided. The donor site was closedprimarily. The shoulder was immobilized for 3 weeks, andthe flap healed uneventfully. The patient regained almostfull range of motion in the shoulder by 2 months aftersurgery (Fig. 5).

Case 2A 16-year-old boy had a severe burn scar contracture of the

anterior chest wall that limited his chest wall movement.Because a large flap would be required, the dorsal scapularisland flap was expanded as previously described to minimizethe problem of venous insufficiency. In the second stage, thecontracture was excised. With the patient in a prone position,a 28-cm � 14-cm flap was harvested. A cuff of trapezius musclearound the superficial branch of the dorsal scapular arterywas included in the flap. The flap was tunneled under thetrapezius, omohyoid, and levator scapulae muscles and wasexteriorized through a skin incision on the anterior borderof the trapezius muscle. The donor site was closed primar-ily. The flap was then transferred to the defect on theanterior chest wall. The distal 2 cm of the flap sufferedsuperficial necrosis, which healed by secondary intentionin 2 weeks. The patient began active range-of-motion ex-ercises of the shoulder 3 weeks postoperatively and re-

gained full range of shoulder movement. There were nodonor-site complications (Fig. 6).

Case 3A 32-year-old woman developed a recurrent neck contrac-

ture after treatment of a postburn contracture of her anteriorneck. A delayed dorsal scapular island flap was planned tocover the anterior neck as an aesthetic unit. The flap waspreexpanded to the desired size. A 32-cm � 12-cm dorsalscapular island flap was designed to conform to the size of theanterior neck aesthetic unit. The flap was harvested in theusual manner and was tunneled under the trapezius, omo-hyoid, and levator muscles. The donor site was closed pri-marily. The patient was then repositioned in the supine po-sition, and the anterior neck contracture was excised. Theflap was inset into the defect and healed uneventfully. Thepatient regained full function within 2 weeks after surgery. Apartial dehiscence of the donor site healed by secondaryintention. We recommended an additional procedure to thinthe flap to achieve a better cosmetic result. However, thepatient was happy with the outcome and refused additionalsurgery (Figs. 7 and 8).

DISCUSSION

The vascular anatomy of the skin of the backremains confusing because of the differentterms used to describe the many vessels thatperfuse this area. Classic anatomists have re-ferred to the dorsal scapular artery by manydifferent names.9,10 Adachi called it the de-scending branch of the transverse cervical ar-tery. He observed that this branch divides intotwo minor branches: one medial and one lat-eral.11 Cruveilhier named this same branch thescapular branch of the posterior scapular ar-

FIG. 8. Postoperative result showing improved neck contour and motion. (Left) An-terior view; (right) lateral view.


tery.12 Salmon referred to the dorsal scapularartery as the descending branch or spinalbranch of the posterior scapular artery. Ac-cording to Salmon’s description, the posteriorscapular artery divides into two branches: theascending branch, which is the main vascularpedicle of the trapezius muscle, and the de-scending branch.13,14 The term “dorsal scapularartery” was introduced by Hulke to replace theterms “deep branch of the transverse cervicalartery” and “descending scapular artery,” fol-lowing the criteria of the International Ana-tomical Nomenclature Committee, which pro-posed that “structures closely relatedtopographically shall, as far as possible, havesimilar names.”15 According to the Nomina Ana-tomica,16 the transverse cervical artery gives riseto a superficial branch and a deep branch. Ifthese branches originate separately, the super-ficial branch is called the superficial cervicalartery (arteria cervicalis superficialis) and thedeep branch is called the dorsal scapular artery(arteria dorsalis scapulae). Although the ori-gins of the transverse cervical and the dorsalscapular artery are variable, it is accepted thatthe distal distribution of these arteries follows aconsistent pattern.4

Daseler and Anson described the dorsalscapular artery originating as a direct branch ofthe subclavian artery and the superficial trans-verse cervical artery arising directly from thethyrocervical trunk.17 They referred to the dor-sal scapular artery as the transverse cervicalartery, and they named the artery to the trape-zius muscle the superficial transverse cervicalartery. Thompson found that the dorsal scap-ular artery most often originated as a branchfrom the thyrocervical trunk, whereas Röhlichobserved it as a direct branch of the subclavianartery.18,19

The transverse cervical artery perfuses thetrapezius muscle. Before entering this muscle,the artery divides into two branches: an ascend-ing and a descending branch, which run in thedeep surface of the trapezius muscle. If thetransverse cervical artery has a common originwith the dorsal scapular artery, the commontrunk is called the transverse cervical artery,and its superficial branch, which perfuses thetrapezius muscle, is known as the superficialcervical artery or superficial transverse cervicalartery. The deep branch of the transverse cer-vical artery is then called the dorsal scapularartery. It is important to distinguish the term“descending branch of the transverse cervical

artery” from the “descending branch of thesuperficial branch of the transverse cervicalartery.” The first term is synonymous with thedorsal scapular artery. The second term de-scribes the division of the superficial branch ofthe transverse cervical artery, which suppliesthe lower trapezius musculocutaneous flap.The superficial branch of the transverse cervi-cal artery is superficial to the levator scapulaeand omohyoid muscles and descends along thedeep surface of the trapezius muscle.

The relationship between the lower trape-zius musculocutaneous flap and the dorsalscapular artery flap is not clearly defined in theliterature. The original article by Baek et al.that describes the lower trapezius island myo-cutaneous flap has no mention of the contri-bution of the dorsal scapular artery to the per-fusion of this flap.2 We believe that thedescending branch of the superficial transversecervical artery nourishes this flap. Inclusion ofthe dorsal scapular artery in the classic lowertrapezius musculocutaneous flap, suggested bysome authors, is unclear. If such a flap is to betransferred to the face or the anterior neck, theonly way to preserve the dorsal scapular arteryis to divide the omohyoid and the levator scap-ulae muscles. There is no mention of this intheir surgical technique.8

It is generally believed that the underlyingmuscle can nourish the overlying skin and sub-cutaneous tissue directly. However, it has beenproved that the skin and subcutaneous tissueare perfused by cutaneous vessels that may ormay not perforate the underlying muscles. Inthe latter case, the vessels perfuse the skin andsubcutaneous tissue independently from themuscle. In the case of the back, it may beinaccurate to consider the skin and subcutane-ous tissue as the “angiosome” of the trapeziusmuscle vascular pedicle. In fact, the medialback skin and subcutaneous tissue can derivetheir blood supply from several different sourc-es: the intercostal vessels, the superficial cir-cumflex scapular vessels, and the cutaneousperforators from the pedicles of the trapeziusand the dorsal scapular vessels. The dorsalscapular artery contributes to the vascularity ofthis area in two different ways: (1) musculocu-taneous perforator(s) through the lower partof the trapezius, and (2) musculocutaneousperforator(s) through the rhomboideus mus-cle alone that do not pierce the trapezius mus-cle. Based on our anatomical dissections, webelieve that the dorsal scapular vessels provide


a reliable blood supply to this territory andallow it to be raised as an island flap. We donot, however, believe that this pedicle is thesole blood supply to this territory.

Previous publications have documented thefeasibility and utility of “perforator” flaps. Theskin island of the musculocutaneous flap canbe perfused by the cutaneous perforators ofthe underlying muscle without actually in-cluding the muscle in the flap. This sparesthe muscle so that its function is preservedand the bulk of the flap is reduced.20 –22 Thedorsal scapular island flap can be raised as atrue perforator flap; however, the dissectionbecomes more tedious and time-consuming.By including a small cuff of muscle aroundthe perforator, the dissection becomes easierand quicker. In our series, only a small pieceof the lower trapezius muscle around theperforator was harvested. The main func-tional portion of the muscle was completelyspared; therefore, shoulder motion waspreserved.

Four of our initial cases (12 percent) suf-fered venous insufficiency resulting in partialor total flap loss. Technical errors accountedfor two of these cases, in which the main veinwas inadvertently divided. Despite carefuldissection and complete preservation of themain venous outflow, adequate venous drain-age could not be obtained in the other twocases. One of these flaps was salvaged byanastomosing another vein from the flap to arecipient vein in the neck. We consider this acomplication caused by insufficient venousreturn. As was described in the anatomicalfindings, there is venous drainage of this areathrough the intercostal veins near the mid-line of the back. These perforating veins aredivided during the elevation of the flap. Webelieve that these veins may represent a sub-stantial source of venous drainage for thisflap.23 Ligation of these veins may result ininsufficient venous drainage, especially inlarge flaps. Therefore, in the most recentcases of our series, we preferred to delay theflap by ligating the intercostal venous system3 weeks before transferring the flap. As partof this delay procedure, the flap was alsoexpanded. Almost complete flap survival wasconsistently observed in the delayed flaps.

Based on our anatomical and clinical stud-ies, we conclude that the dorsal scapular vesselsprovide a reliable blood supply to the skin ofthe medial back, making it a versatile flap to

use as an island flap. By delaying and expand-ing the flap, we were able to overcome theproblem of inadequate venous drainage of theflap. Although the majority of large head andneck defects are reconstructed with microsur-gical tissue transfer, this flap is a good alterna-tive for such defects while avoiding the needfor microsurgery with its associated complica-tions. This flap provides an excellent func-tional and cosmetic result and minimal donor-site morbidity. We highly recommend delayingand expanding the flap when using it to recon-struct large defects on the face and anteriorneck.

Claudio Angrigiani, M.D.Centenario 133Buenos Aires [email protected]

ACKNOWLEDGMENT

All illustrations are the original work of Shirley KuikmanKantoff. We gratefully acknowledge her support.

REFERENCES

1. Demergasso, F., and Piazza, M. V. Trapezius myocuta-neous flap in reconstruction of head and neck cancer:An original technique. Am. J. Surg. 138: 533, 1979.

2. Baek, S., Biller, H. F., Krespi, Y. P., and Lawson, W. Thelower trapezius island myocutaneous flap. Ann. Plast.Surg. 5: 108, 1980.

3. Netterville, J. L., and Wood D. E. The lower trapeziusflap. Arch. Otolaryngol. Head Neck Surg. 117: 73, 1991.

4. Weiglein, A. H., Haas, P., and Pierer, G. Anatomic basisof the lower trapezius musculocutaneous flap. Surg.Radiol. Anat. 18: 257, 1996.

5. Nichter, L. S., Morgan, R. F., Harman, D. M., Horovitz,J., and Edlich, R. F. The trapezius musculocutaneousflap in head and neck reconstruction: Potential pit-falls. Head Neck Surg. 7: 129, 1984.

6. Cormack, G. C., and Lamberty, B. G. H. The ArterialAnatomy of Skin Flaps. New York: Churchill Livingstone,1994.

7. Haas, F., Pierer, G., Weiglein, A., Moshammer, H.,Schwarzl, F., and Scharnagl, E. Der untere M. tra-pezius-Insellapen: Anatomische Grundlagen und kli-nische Relevanz. Handchir. Mikrochir. Plast. Chir. 31:15, 1999.

8. Tan, K. C., and Tan, B. K. Extended lower trapeziusisland musculocutaneous flap: A fasciomyocutaneousflap based on the dorsal scapular artery. Plast. Reconstr.Surg. 105: 1758, 2000.

9. Testut, L. Traité d’Anatomie Descriptive. Paris: Masson,1906.

10. Cunningham, D. Textbook of Anatomy. New York: OxfordUniversity Press, 1951.

11. Adachi, B. Das Arteriensystem der Japaner. Kyoto: Ma-zuren, 1928.

12. Cruveilhier, C. Traité d’Anatomie Descriptive, 5th Ed. Par-is: Masson, 1887.


13. Salmon, M. Les Arteres des Muscles du Tronc. Paris: Mas-son, 1933.

14. Poirier, P. Traite d’Anatomie Humaine. Paris: Masson,1897.

15. Hulke, D. P. A study of the transverse cervical and dor-sal scapular arteries. Anat. Rec. 103: 233, 1958.

16. Subcommittees of the International Anatomica Nomen-clature Committee. Nomina Anatomica, 6th Ed. Ed-inburgh/New York: Churchill Livingstone, 1989.

17. Daseler, E. H., and Anson, B. J. Surgical anatomy of thesubclavian artery and its branches. Surg. Gynecol. Obstet.108: 149, 1959.

18. Röhlich, K. Uber die arteria transversa colli des Men-schen. Anat. Anz. 79: 37, 193.

19. Thompson, A. Second annual report of the Committee

of Collective Investigation of the Anatomical Societyof Great Britain and Ireland for the year 1890–1891.J. Anat. Physiol. 26: 77, 1891.

20. Koshima, I., and Soeda, S. Inferior epigastric artery skinflaps without rectus abdominis muscle. Br. J. Plast.Surg. 42: 645, 1989.

21. Allen, R., and Tucker, C. Superior gluteal artery per-forator free flap for breast reconstruction. Plast. Re-constr. Surg. 95: 1207, 1995.

22. Angrigiani, C., Grilli, D., and Siebert, J. Latissimus dorsimusculocutaneous flap without muscle. Plast. Reconstr.Surg. 96: 1608, 1995.

23. Goodwin, J. W., and Rosenberg, G. J. Venous drainageof the lateral trapezius musculocutaneous island. Arch.Otolaryngol. Head Neck Surg. 108: 411, 1982.


The Dorsal Scapular Island Flap

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