Brief Clinical Studies The Journal of Craniofacial Surgery  Volume 26, Number 6, September 2015

10. Park YH, Kim HJ, Park MH. Temporomandibular joint herniation into
the external auditory canal. Laryngoscope 2010;120:2284–2288 Key Words: CSF leak, posterior skull reconstrcution, trapezius
11. Tozoglu U, Caglayan F, Harorli A. Foramen tympanicum or foramen of myocutaneous flap
Huschke: anatomical cone beam CT study. Dentomaxillofac Radiol
2012;41:294–297

S oft-tissue defects in posterior skull can be challenging for

reconstruction. If related to tumor resection, these wound beds
are generally irradiated increasing the risk of cerebrospinal fluid
(CSF) leak.1 In addition, CSF leaks are relatively common in
Use of Pedicled Trapezius posterior fossa surgery because of difficulty in achieving water tight
dural closure.2 A CSF leak into such dead space can result into
Myocutaneous Flap for Posterior pseudomeningocele. In addition, accumulation of CSF or hematoma
in a dead space can result in secondary infections that have a potential
Skull Reconstruction to develop into epidural abscess.3 Such situations may develop into
life-threatening intracranial complications. A myocutaneous flap can
Mansher Singh, MD,
Arturo J. Rios Diaz, MD,y obliterate this cavity and resist CSF leak or hematoma formation. Free
Ryan Cauley, MD,
Timothy R. Smith, MD, PhD,z tissue transfer has emerged as a reliable choice for complex head and
and E.J. Caterson, MD, PhD
neck repair.4 However, locoregional flaps have better matched skin
color and texture, which makes them aesthetically more appealing for
Background: Soft-tissue defects in posterior skull can be challen- reconstruction involving skin defects.4–6 Moreover, most of the
ging for reconstruction. If related to tumor resection, these wound patients with posterior skull tumors have significant comorbidities
beds are generally irradiated and can be difficult from a recipient- and have generally been treated with radiation therapy, which
vessel perspective for a free tissue transfer. Locoregional flaps increases the risks of postoperative complications with free tissue
transfer. Based on these observations, there has been renewed interest
might prove to be important reconstructive option in such patients.
in the usage of locoregional flaps.
There is a very limited data on the usage of pedicled trapezius The pectoralis major myocutaneous flap is considered the
myocutaneous flaps for such defects. ‘‘workhorse’’ flap for head and neck reconstruction.7 Lattisimus
Methods: The authors reviewed existing study for usage of trape- dorsi myocutaneous flap is also used for posterior neck and skull
zius flap for posterior skull repair and used pedicled trapezius reconstruction.8 However, use of these flaps for posterior skull
myocutaneous flaps based on the descending branch of superficial reconstruction requires extensive mobilization. Trapezius muscle
cervical artery (SCA) for reconstruction of posterior skull soft- mycocutaneous flap provides another alternative for reconstruction.
tissue defect in an irradiated and infected wound. Different types of myocutaneous trapezius flaps described in the
Results: Two patients were operated for trapezius myocutaneous flap study include the superior, the lateral island, the vertical, and the
for posterior skull defects complicated by cerebrospinal fluid (CSF) lower island flap.9–12 This flap is easy to harvest, has a large arc of
rotation, is well vascularized, and is more pliable than both latti-
leakage and epidural abscess. There was no recipient or donor-site
simus dorsi and pectoralis major flap. In addition, it can provide
complication at a mean follow-up of 12.5 months. Neither of the bulk to the soft-tissue defect and can be extended with the use of a
2 patients had any functional deficits for the entire duration of the tissue expander.13
follow-up. Although this flap was able to help in controlling the CSF We present a set of 2 patients with posterior skull soft-tissue
leakage in the first patient, it successfully healed the cavity generated defects who were successfully treated with trapezius myocutaneous
from epidural abscess drainage in the second patient. flap. Through this series, we aim to establish trapezius myocuta-
Conclusion: The large angle of rotation coupled with the ability to neous flap as an alternative option for posterior skull soft-tissue
complete the procedure without repositioning the patients makes defects. It can be successfully used in a setting of radiation,
trapezius myocutaneous flap an attractive option for posterior skull infection, and other conditions which impact wound healing.
reconstruction. In our limited experience, the pedicled trapezius
flaps are a reliable alternative as they are well vascularized and able METHODS
to obliterate the soft-tissue defect completely. The recipient site Two patients with soft-tissue defect in the posterior skull underwent
healed completely in infected as well as irradiated wound beds. trapezius myocutaneous flap placement. The hospital records of
In addition, the donor site can be primarily closed with minimal both the patients were reviewed, and patient characteristics, oper-
ative details, and follow-up data were recorded.
donor-associated complication.
Trapezius Muscle and Surgical Technique
The anatomy of the trapezius muscle has been extensively
From the *Division of Plastic Surgery, Department of Surgery, Brigham
and Women’s Hospital; yCenter for Surgery and Public Health, Depart- described in the study.14,15 It originates from the medial third of
ment of Surgery, Brigham and Women’s Hospital; and zDepartment of the superior nuchal line of the occipital bone, the external occipital
Neurosurgery, Brigham and Women’s Hospital, Boston MA. protuberance, the ligamentum nuchae, the spinous process of the
Received March 5, 2015. seventh cervical vertebrae, and all the thoracic vertebrae and inserts
Accepted for publication June 28, 2015. into the lateral third of the clavicle, the medial border of the
Address correspondence and reprint requests to Edward J. Caterson, MD, acromion, and the entire length of the scapular spine. It is a
PhD, Division of Plastic Surgery, Brigham and Women’s Hospital, triangular shaped thin and large muscle, which assists in raising
Harvard Medical School, 75 Francis Street, Boston, MA 02115; and rotating the shoulder. The nerve supply to this muscle comes
E-mail: ecaterson@partners.org from accessory nerve.
The authors report no conflicts of interest.
Copyright # 2015 by Mutaz B. Habal, MD The main blood supply of the trapezius muscle and the overlying
ISSN: 1049-2275 skin is from the superficial and deep branches of the transverse
DOI: 10.1097/SCS.0000000000002033 cervical artery (TCA), which is generally a branch of the

e532 # 2015 Mutaz B. Habal, MD

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 26, Number 6, September 2015 Brief Clinical Studies

hemangioma and complex watertight dural closure using alloderm

patch. Postoperatively, the patient reported spontaneous copious
amount of clear fluid drainage from the inferior aspect of his wound,
which was consistent with pseudomeningocele on CT scan. He was
taken back to the operating room for decompression of his pseu-
domenigocele and was found to have 3 points of clear leakage from
the allograft, which was sutured with 4-0 Nurulon. His pseudome-
ningocele persisted postoperatively despite lumbar drainage and
FIGURE 1. Anatomy and vascular supply of trapezius muscle. The flap in our
was therefore operated for a VP shunt placement. However, within
series was raised on the descending branch of the superficial cervical artery. next few weeks, he was readmitted with reports of fluid ‘‘gushing’’
from his suboccipital craniotomy incision. Given his continued
wound leakage, it was decided to take him back to the operating
thyrocervical trunk (Fig. 1). Most of the myocutaneous trapezius room for wound exploration and definitive closure. A large amount
flap are raised on these 2 dominant flaps: the superficial branch of of CSF was evacuated from his pseudomeningocele. The prior
TCA (SCA) and the deep branch of TCA (DSA)16 The SCA gives alloderm patch had thinned out with a number of openings resulting
rise to an ascending and a descending branch, which can be in CSF leakage. It was replaced with a new alloderm patch, and a
individually used to raise the trapezius flap. The minor pedicles, watertight closure was confirmed with valsalva maneuver. The
such as the occipital artery and the intercostals perforators, are plastic surgery team was consulted to help with closure of his
uncommonly used for trapezius flap elevation.14 wound. As the patient had a longstanding cavity in a radiated field,
We decided to use the descending branch of the superficial it was decided to use a myocutananeous trapezius flap to obliterate
cervical artery for our myocutaneous trapezius flap. As the acces- the cavity. The skin paddle, which was 6 cm  14 cm, was marked
sory nerve mainly traverses through the upper trapezius muscle, preoperatively, and a trapezius flap was raised based upon the
there is minimal to no risk of nerve injury with this technique as it descending branch of superficial cervical artery. A large portion on
raises the lower half of the trapezius muscle. In addition, the whole the distal flap was de-epithelialized and was tucked against the skull
procedure can be done in a prone position so that there is no need for base and posterior cervical spine to bolster the alloderm repair
repositioning the patient for posterior skull reconstruction. The skin resulting in a transposition flap for wound closure. Postoperatively,
island is outlined after localizing the vascular pedicle with a the patient reaccumulated a 6 cm  6 cm CSF collection necessitat-
Doppler (Fig. 2A). The course of SCA is followed under the anterior ing another trip to the operating room. No definite leak was
border of the trapezius muscle. Once the descending branch is observed in the dural alloderm patch after multiple valsalva man-
identified, the pedicle is freed completely and the vertical skin euvers, and it was determined that the patient has an occult CSF
island is elevated (Fig. 2B). The myocutaneous trapezius flap is then leakage. It was decided to separate the cutaneous portion of the flap
elevated (Fig. 2C) and the donor site is closed primarily (Fig. 2D). from the trapezius muscle flap and use this as a 2-layered closure.
The muscle portion of the trapezius flap was inset by parachuting it
RESULTS down into the skull base along the paraspinal muscles. A Blake
drain was placed inferior to the trapezius flap, and a lumbar drain
Two patients underwent the abovementioned procedure for soft-
was also placed in the pseudomeningocele. Two weeks postopera-
tissue defect in the posterior skull. In both the patients, the flap
tively, the patient presented to the clinic with leakage of CSF around
healed completely and was able to effectively obliterate the soft-
the Blake drain. Given the known occult CSF leak and continued
tissue defect. There was no flap-related or donor-site complication
CSF leakage, it was decided to internalize the lumbar drain, and a
in either of the patients at a mean follow-up of 12.5 months. Neither
lumbar peritoneal shunt was placed for definitive management of
of the 2 patients had any functional deficits for the entire duration of
his CSF leakage. His trapezius flap was completely intact during
the follow-up.
this time without any concern for wound dehiscence. On his 6-week
follow-up appointment, his trapezius flap and the donor sites had
Patient 1 healed completely without any bogginess associated with recurrent
The patient was a 57-year-old male with a history of brainstem CSF leak (Fig. 3A). It was determined that that the trapezius flap
heamngioblastoma who was operated for subtotal suboccipital was doing an effective job at blocking any further built up of CSF.
craniectomy and C1 laminectomy in 2007 followed by radiation The patient’s remainder clinical course was unremarkable from
for residual tumor and VP shunt placement. Unfortunately, his reconstructive standpoint, but his magnetic resonance imaging
clinical course was complicated by meningitis, which required (MRI) showed an increase in the size of his tumor around 6 months
shunt removal. In 2012, he developed new neurologic symptoms after the flap procedure. As he was an extremely poor surgical
in the form of upper extremity numbness and was found to have candidate, alternative options were sought and he was started on
tumor recurrence for which he required reresection of his Pazopanib therapy with plans for restaging MRI. However, his
tumor continued to progress slowly on this therapy and the patient
was placed under hospice care. During his last clinical visit, he was

FIGURE 2. Trapezius flap: A, outline of skin island after localization of the

vascular pedicle with a Doppler; B, isolation of vascular pedicle and elevating
the skin island; C, elevation of myocutaneous trapezius flap; and D, primary FIGURE 3. Completely healed donor and recipient site in patient 1 (A) and in
closure of the donor site. Patient 2 (B).

# 2015 Mutaz B. Habal, MD e533

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies The Journal of Craniofacial Surgery  Volume 26, Number 6, September 2015

23 months out from his trapezius flap procedure without any DISCUSSION
complications. The purpose of this study was to establish the trapezius myocuta-
neous flap as a reconstructive option for soft-tissue defect in
posterior skull area. Such defects are generally secondary to tumor
Patient 2 resection, which generally requires radiation. Irradiated wound bed
The patient was a 60-year-old male who was diagnosed with a and other coorbidities, generally present in these patients, would
nonfunctioning pituitary adenoma in 2001 and underwent a trans- increase the postoperative complication rates of free tissue transfer.
sphenoidal resection. During his work-up, he was found to have a In addition, distant tissue transfer would not have similar skin color
left cerebellar epidermoid mass that was followed over several and texture as the locoregional flaps.6 Free tissue transfer would
years with serial imaging. Owing to an increase in the size of the require extended operative time exposing the patients to the com-
epidermoid tumor, which was essentially filling the entire left plications of general anesthesia. Among locoregional flaps, pector-
posterior fossa and compressing the cerebellum, a left suboccipital alis major and lattisimus dorsi-based myocutaneous flaps are
craniectomy with titanium plate was performed in 2008. In Decem- considered ‘‘workhorse’’ flaps for head and neck reconstruction.7,8
ber 2012, he started noticing drainage on his pillowcases, mostly at Pectoralis major-based flap is the first choice regional flap in head
the nighttime while lying down. The drainage from the scalp was and neck surgery as it is easy to harvest and does not require
not concerning for CSF leak based in its appearance. The patient repositioning for anterior reconstruction. However, use of pec-
also noticed left ear tinnitus, fullness, and decreased left-sided toralis major flap might require repositioning of the patient for
hearing since his epidermoid tumor resection. A brain MRI in June posterior skull reconstruction. In addition, it would be aestheti-
2013 demonstrated a large nonenhancing mass in the left posterior cally unpleasing in women, and the amount of skin may be
fossa that seemed to track extracranially through the titanium mesh limited due to mobility of the breast on the underlying pectoralis
with areas of small puckered sites in the scalp at the site drainage. musculature.17 There is also a possibility of secondary contrac-
The findings were thought to represent either a recurrence of ture of the pedicle or gravitational displacement with time.7
epidermoid mass or a chronic infection in the epidural space. Lattisimus dorsi muscle flap will require extensive mobilization
The pituitary area appeared unremarkable without any evidence to reach the posterior skull, and function preservation might not
of recurrence. It was determined that the caustic contents of the be possible in some cases.
epidermoid cyst might be responsible for poor healing along the site Trapezius myocutaneous flap has a large arc of rotation and is
of titanium mesh attached to the scalp and could also result in scalp more pliable than both lattisimus dorsi and pectoralis major flaps.18
wound dehiscence resulting in drainage. As the patient did not have As the upper portion of the muscle contains the spinal accessory
any concern for rhinorrhea or CSF leak and was nontoxic in nerve, which provides innervation to the entire muscle, the well-
appearance, it was decided to perform a wound exploration in an vascularized lower portion of the trapezius muscle is considered a
elective fashion. He was followed conservatively for over a year dispensable unit. Use of the highly vascularized lower portion of
with malodorous yellowish drainage from 2 spots on his scalp along the muscle serves to prevent the motor function of the muscle while
the suboccipital craniotomy incision. He also reported further providing an excellent reconstructive option. Trapezius muscle
decrease in his left-sided hearing along with increased tinnitus flap enables posterior skull reconstruction in prone position with-
and fullness during this time period. A follow-up MRI demonstrated out the need to reposition the patient. The donor site can be
interval development of epidural air in the resection cavity and primarily closed, and there is minimal donor-site-associated mor-
development of 2 fistulous tracks extending from the epidermoid bidities with this flap.
tumor to the scalp. In addition, the imaging showed hair within Trapezius flap has been described in the study for head and neck
the extradural cavity suggesting communication with the mastoid reconstruction,16–24 but there are only few reports of its usage for
air cells. On examination, the patient had 2 areas along his left posterior skull reconstruction.25–27 The complication rate varies
suboccipital incision with dried and crusted fluid. Based on these from 0% to 57% in the study with most of the studies showing a
findings, the patient was planned for wound exploration and closure complication rate <20%.16–24 A recently published study by Can
with a trapezius rotational flap. The previous incision was reopened, et al17 demonstrated 35% complication rates in a series of 43
and the fistulous tracts were excised along with 4 cm  2 cm section consecutive patients operated for myocutaneous trapezius flap.
of flap that had 2 areas of hypergranulation tissue where the chronic Nine patients (21%) had recipient-site-related complications, but
infection had indurated through the scalp itself. The skin flap was only 1 patient had a complete flap failure. Only 1 out of the 43
carefully undermined revealing the cranial defect and the titanium patients required flap for posterior skull reconstruction. In our
plate, which was covered with exuberant granulomatous tissue series, there was no donor or recipient-site complication at a mean
beneath which was obvious pus. The plate was removed and pus follow-up of 12.5 months.
was cultured. The pus was odiferous and was quite extensive in its Our study shows that the trapezius flaps can be effectively used
range through the suboccipital region. It was thoroughly removed, for reconstruction of CSF leakage in the posterior skull. Among
and the bone edges of the previous craniectomy were freshened. The pedicled myocutaneous flap, pectoralis major has been described in
mastoid areas were exposed and there was no open mastoid air cell, 1 case report for CSF leakage,28 but there has been no report of
but several air cells were exposed with their mucous membranes trapezius flap being used for this indication. Our second patient
evident. With all of the pus removed and careful irrigation of the demonstrated complete healing of myocutnaeous flap in a patient
wound cavity, it was decided to obliterate this dead space with the with epidural abscess. There is another case report of 2 patients with
fascial and muscle extensions of the trapezius flap. The fashioned epidural abscess who had complete recovery after debridement of
flap extended distal to the insertion of the muscle to have a the abscess cavity and obliterating the dead space with trapezius
fasciocutaneous tongue that would be depepithelialized and tucked myocutaneous flap.27
down into the mastoid air spaces. The flap was then raised on its Trapezius myocutaneous flap is a very safe and reliable option
vascular pedicle, turned 1808 and inset to effectively obliterate the for posterior skull reconstruction, especially in a setting of hostile
dead space. Postoperatively, the patient had uncomplicated recov- host environment such as infection or radiation. There is limited
ery, and his flap and the donor site have completely healed data related to reconstruction with this technique. With this study,
(Fig. 3B). The trapezius flap has effectively prevented any wound we hope to establish trapezius myocutaneous flap as an alternative
leakage secondary to fistulous tracks from chronic infection. option for posterior skull reconstruction.

e534 # 2015 Mutaz B. Habal, MD

Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 26, Number 6, September 2015 Brief Clinical Studies

CONCLUSION 18. Uğurlu K, Ozçelik D, Hüthüt I, et al. Extended vertical trapezius

The large angle of rotation coupled with the ability to complete the myocutaneous flap in head and neck reconstruction as a salvage
procedure without repositioning the patients makes trapezius myo- procedure. Plast Reconstr Surg 2004;114:339–350
19. Aviv JE, Urken ML, Lawson W, et al. The superior trapezius
cutaneous flap an attractive option for posterior skull reconstruc- myocutaneous flap in head and neck reconstruction. Arch
tion. In our limited experience, the pedicled trapezius flaps are a Otolaryngol Head Neck Surg 1992;118:702–706
reliable alternative as they are well vascularized and they are able to 20. Netterville JL, Panje WR, Maves MD. The trapezius myocutaneous
completely obliterate the soft-tissue defect. The evidence provided flap. Dependability and limitations. Arch Otolaryngol Head Neck Surg
shows that the recipient site can heal completely despite an infected 1987;113:271–281
and irradiated wound bed. In addition, the donor site can be 21. Cummings CW, Eisele DW, Coltrera MD. Lower trapezius
primarily closed with minimal complication. Finally, using our myocutaneous island flap. Arch Otolaryngol Head Neck Surg
technique the accessory nerve and the motor function of the muscle 1989;115:1181–1185
can be preserved by using the highly vascularized lower portion of 22. Chen WL, Zhang B, Wang JG, et al. Reconstruction of large defects of
the neck using an extended vertical lower trapezius island
the muscle.
myocutaneous flap following salvage surgery for neck recurrence of oral
carcinoma. J Plast Reconstr Aesthet Surg 2011;64:319–322
REFERENCES 23. Chen WL, Li J, Yang Z, et al. Extended vertical lower trapezius island
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reconstruction: a review and clinical case series of 152 vascularized after salvage surgeryfor recurrent oral carcinoma. J Oral Maxillofac
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cerebrospinal fluid leak. Neurosurg Focus 2014;37:E4 24. Chen WL, Deng YF, Peng GG, et al. Extended vertical lower trapezius
2. Magliulo G, Sepe C, Varacalli S, et al. Cerebrospinal fluid leak island myocutaneous flap for reconstruction of cranio-maxillofacial
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1998;27:258–262 25. Mathes SJ, Stevenson TR. Reconstruction of posterior neck and skull
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Salmonella enteritidis abscess following glioblastoma resection: case
26. Lynch JR, Hansen JE, Chaffoo R, et al. The lower trapezius
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musculocutaneous flap revisited: versatile coverage for complicated
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complications after surgery and radiotherapy for head and neck cancer: branch of the transverse cervical artery. Plast Reconstr Surg
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Reconstr Surg 2005;115:1077–1086 major myocutaneous flap. Plast Reconstr Surg 2011;128:17e–18e
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including transection of thoracoacromial vessels: does the flap remain
dependent on its dominant pedicle? J Plast Reconstr Aesthet Surg
2011;64:323–328 Accurate Evaluation of Cone-
8. Maves MD, Panje WR, Shagets FW. Extended latissimus dorsi
myocutaneous flap reconstruction of major head and neck defects. Beam Computed Tomography
Otolaryngol Head Neck Surg 1984;92:551–558
9. Demergasso F, Piazza MV. Trapezius myocutaneous flap in to Volumetrically Assess Bone
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Am J Surg 1979;138:533–536 Grafting in Alveolar Cleft
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myocutaneous flap. Ann Plast Surg 1980;5:108–114 Patients
11. Tan KC, Tan BK. Extended lower trapezius island myocutaneous flap: a Wei-na Zhou, MD,
y Yan-bin Xu, MD,
z
fasciomyocutaneous flap based on the dorsal scapular artery. Plast Hong-bing Jiang, PhD,
§ Linzhong Wan, MD,
§ and
Reconstr Surg 2000;105:1758–1763
Yi-fei Du, MD
§
12. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles:


experimental and clinical correlation. Plast Reconstr Surg 1981;67: From the Jiangsu Key Laboratory of Oral Diseases; yOrofacial Pain and
177–187 TMD Research Unit, Institute of Stomatology, Affiliated Hospital of
13. Ulrich D, Fuchs P, Pallua N. Preexpanded vertical trapezius Stomatology; zThe Research Institute of Stomatology, The Second
musculocutaneous flap for reconstruction of a severe neck contracture Clinical Department, School of Stomatology; and §The Research Insti-
after burn injury. J Burn Care Res 2008;29:386–389 tute of Stomatology, Department of Oral and Maxillofacial Surgery,
14. Haas F, Weiglein AH. Trapezius flap. In: Wei FC, Mardini S, eds. Flaps School of Stomatology, Nanjing Medical University, Nanjing, China.
and reconstructive surgery. Philadelphia: Saunders; 2009:249–269 Received February 9, 2015.
15. Yang D, Morris SF. Trapezius muscle: anatomic basis for flap design. Accepted for publication June 28, 2015.
Ann Plast Surgl 1998;41:52–57 Address correspondence and reprint requests to Yi-fei Du, MD, The
Research Institute of Stomatology, Department of Oral and Maxillo-
16. Can A, Orgill DP, Dietmar Ulrich JO, et al. The myocutaneous trapezius facial Surgery, School of Stomatology, Nanjing Medical University, 136
flap revisited: a treatment algorithm for optimal surgical outcomes Hanzhong Road, Nanjing 210029, China;
based on 43 flap reconstructions. J Plast Reconstr Aesthet Surg E-mail: danxiangren2006@163.com
2014;67:1669–1679 The authors report no conflicts of interest.
17. Dinner MI, Guyuron B, Labandter HP. The lower trapezius Copyright # 2015 by Mutaz B. Habal, MD
myocutaneous flap for head and neck reconstruction. Head Neck Surg ISSN: 1049-2275
1983;6:613–617 DOI: 10.1097/SCS.0000000000002034

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