The Dorsal Scapular Island Flap: An
Alternative for Head, Neck, and Chest
Reconstruction
Claudio Angrigiani, M.D., Daniel Grilli, M.D., Yvonne L. Karanas, M.D., Michael T. Longaker, M.D., and
Sheel Sharma, M.D.
Buenos Aires, Argentina; Stanford, Calif.; and New York, N.Y.
The back has become an increasingly popular donor
site for flaps because it can provide thin, pliable tissue,
with minimal bulk, and the scar can be easily hidden
under clothing. The authors performed a cadaveric and
clinical 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 anatomical
studies in 28 cadavers and clinical experience with 32
cases, it was concluded that the dorsal scapular vessels
provide a reliable blood supply to the skin of the medial
back, making it a versatile flap to use as an island flap. A
flap raised on the dorsal scapular vessels can be harvested
with a long pedicle and can be rotated to reach as far as
the anterior regions of the head, neck, and chest wall.
Delaying and expanding the flap may help to facilitate
venous drainage. The authors recommend the use of this
versatile island pedicle flap as an alternative to microvas-
cular free-tissue transfer for the reconstruction of defects
in the head, neck, and anterior chest. (Plast. Reconstr.
Surg. 111: 67, 2003.)
The trapezius myocutaneous flap and its
modifications have been used to cover defects
of the head and neck.1,2 However, questions
have been raised in the literature regarding the
blood supply to these flaps. Traditionally, it was
thought that branches of the transverse cervi-
cal artery and vein perfuse these flaps. Several
reports, however, have mentioned the contri-
bution of the dorsal scapular artery in perfus-
ing the inferior part of the trapezius muscle
and, hence, the distal part of the lower trape-
zius myocutaneous flap.3,4 It has been sug-
gested that the dorsal scapular artery should be
included in the lower trapezius myocutaneous
From Centario 133, Buenos Aires; the Institute of Reconstructive Plastic Surgery, New York; and the Department of Surgery and Division of
Plastic 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
flap to ensure viability of the distal part of the
flap.5,6 Previous anatomical studies have shown
the dorsal scapular artery to supply the medial
part of the lower back, suggesting that it is one
of the possible sources of blood supply to flaps
harvested in this area.6 – 8 We have found that a
cutaneous flap can be raised on this vessel with
a long vascular pedicle (15 to 16 cm) that can
be rotated to reach as far as the anterior part of
the head and chest wall. During the flap har-
vest, the trapezius muscle can be completely
spared, preserving full shoulder function. The
purpose of this article is to present (1) the
results of an anatomical study performed in 28
cadaveric 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 head
and neck area, and (3) our clinical experience
using this flap in 32 cases.
ANATOMY OF THE DORSAL SCAPULAR ARTERY
The dorsal scapular artery originates from
the subclavian artery as an independent
branch or from the trunk of the transverse
cervical artery. It runs posteriorly and almost
horizontally deep to or through the branches
of the brachial plexus. It then courses under
the trapezius muscle and, more importantly,
under the omohyoid and levator scapulae mus-
cles on top of the rib cage. At the medial angle
of the scapula, it gives off a superficial branch
68
that pierces the rhomboideus muscle and ap-
pears under the deep surface of the trapezius
muscle. This superficial branch runs on the
deep belly of the trapezius muscle, perfusing
that muscle, and giving off one or two cutane-
ous perforators that traverse through the mus-
cle. Our flap is based on this superficial branch
of the dorsal scapular artery. After giving off
the superficial branch, the main trunk of the
dorsal scapular artery becomes the deep
branch of the dorsal scapular artery. It runs
under the medial border of the scapula in the
mass of the rhomboideus muscle up to the tip
of the scapula, which it perfuses. During its
course, the deep branch of the dorsal scapular
artery gives off one or two perforators to the
rhomboideus 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 were
preserved in 10 percent formol solution for
delayed dissection. The preserved specimens
were used for photographic documentation.
The skin was removed and the cutaneous arte-
rial branches of the medial back were mapped
in the subcutaneous tissue. The branches were
FIG. 1. Anatomic location of the cutaneous perforators of the dorsal scapular
artery.
PLASTIC AND RECONSTRUCTIVE SURGERY, January 2003
dissected under ⫻4 loupe magnification and
traced 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, superiorly
by a horizontal line drawn at the level of the
superior border of the scapula, and inferiorly
by a horizontal line at the level of the inferior
tip of the scapula.
RESULTS
Anatomical Study
The cutaneous arteries near the spine origi-
nated from the intercostal arteries, one in each
intercostal space. These branches perforated
the spinal muscles and were accompanied by a
cutaneous nerve and an accompanying vein.
The size of these arteries was variable, some
being up to 1.2 mm in diameter. These perfo-
rating branches emerged in the subcutaneous
tissue caudal to their parent artery.
The cutaneous perforating branches in the
superior part of the medial back arose from the
superficial transverse cervical artery and
pierced 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 the
levator scapulae and omohyoid muscles at the
apex of the thorax. Once it reaches the supero-
Vol. 111, No. 1 / DORSAL SCAPULAR ISLAND FLAP
FIG. 2. Anatomy of the dorsal scapular artery.
medial angle of the scapula, it gives off a su-
perficial branch (superficial dorsal scapular ar-
tery), which pierces the rhomboideus muscle
and runs under the deep surface of the inferior
part of the trapezius muscle. This superficial
dorsal scapular artery consistently gives off one
or two cutaneous branches that pierce the
lower trapezius muscle 1 to 2 cm medial to the
lateral border of the muscle. In 16 specimens
there were two perforators, and in 12 cases
there was one perforator. There were no cases
without 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, there
were two perforating cutaneous branches that
each arose from a different branch of the dor-
sal scapular artery.
The other division of the dorsal scapular
artery is called the deep branch of the dorsal
scapular artery. It remains deep to the rhom-
boideus muscle and runs under the medial
border of the scapula. This deep branch gives
off one or two more cutaneous branches, distal
to the origin of the superficial branch. All of
69
these cutaneous branches pierced the rhom-
boideus muscles. In eight cadavers, we found
that the second perforator of the rhomboideus
also pierced the trapezius muscle in a manner
similar 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 the
trapezius muscle. Two other cutaneous
branches originating from the deep branch of
the dorsal scapular artery were observed pierc-
ing the rhomboideus muscle near the medial
border of the scapula: one in the central part
of the medial border of the scapula and the
other near the tip.
In summary, the dorsal scapular artery and
its cutaneous branches were identified in all of
our dissections. There was a consistent arterial
supply to the skin and subcutaneous tissue of
the medial back from the superficial dorsal
scapular artery, either through the trapezius
muscle or around its lateral border. These an-
atomical findings illustrate that it is possible to
raise a cutaneous flap based on the lower tra-
70 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2003

FIG. 3. (Above, left) Posterior view of the back muscles. The center arrow points to one
of the muscular perforators from the superficial branch of the dorsal scapular artery
emerging through the trapezius muscle. (Above, right) The superficial branch of the dorsal
scapular artery is shown emerging from the rhomboideus muscle and running on the
undersurface of the trapezius muscle that has been reflected medially. (Below, left) The
deep branch of the dorsal scapular artery is shown running along the medial border of
the scapula. The rhomboideus muscle has been partially resected from its attachment to
the medial border of the scapula. (Below, right) The dorsal scapular artery runs under the
omohyoid 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 superficial
branches that run on the undersurface of the trapezius muscle that has been partially
reflected.
Vol. 111, No. 1 / DORSAL SCAPULAR ISLAND FLAP
pezius myocutaneous perforator of the dorsal
scapular artery (Fig. 3).
Surgical Technique
The patient is placed in a lateral decubitus
position. The ipsilateral arm is draped free to
permit its mobility during flap harvest.
Flap design. The flap design is centered on a
cutaneous perforator of the dorsal scapular ar-
tery, which is identified preoperatively using a
Doppler probe. This perforator is usually lo-
cated at the intersection of a horizontal line
drawn 6 to 8 cm inferior to the spine of the
scapula with a vertical line drawn 8 to 9 cm
lateral to the midline of the back. A flap as large
as 20 ⫻ 20 cm can be safely harvested on this
perforator. The flap can be oriented in any
direction.
Flap elevation. The skin is incised along the
margins of the flap. The flap dissection pro-
ceeds in a distal to proximal fashion superfi-
cial to the deep fascia. On reaching the lateral
border of the trapezius, the cutaneous per-
forator is identified. We prefer to elevate the
FIG. 4. Illustration of the anatomy of the dorsal scapular island flap.
71
edge of the trapezius muscle to identify the
superficial dorsal scapular artery running on
its deep surface. This maneuver provides a
better view of the cutaneous perforator orig-
inating from the muscular branch. The mus-
cular branch can be dissected off the belly of
the trapezius with blunt dissection. Once the
cutaneous perforator is visualized, it is dis-
sected including a small piece of the trapezius
muscle around the perforator (approximately
5 ⫻ 5 cm). It is possible to raise a “pure
perforator” flap isolated on the cutaneous
perforator without including any muscle.
However, we do not recommend this because
the muscle at this level is quite thin and in-
clusion of a small cuff of muscle does not
increase the volume of the flap significantly.
In addition, resecting a small portion of the
muscle causes no functional impairment and
allows easier dissection of the flap. The flap is
now attached only to the superficial muscular
branch of the dorsal scapular artery, which
can be visualized penetrating the rhomboi-
deus muscles. Dissection then proceeds
72
through the rhomboideus muscles to isolate
the deep branch and the common trunk of
the dorsal scapular artery. The deep branch is
identified and ligated. The angle of the scap-
ula is retracted. This maneuver allows better
exposure of the dorsal scapular artery deep to
the scapula and the levator and omohyoid
muscles. At this point, the pedicle appears to
run in a “tunnel,” giving off branches to the
levator scapulae and omohyoid muscles and
to the rib cage. These branches must be li-
gated and transected. Blunt dissection of the
soft tissues enlarges this area to allow the flap
to be passed through the tunnel. On reaching
PLASTIC AND RECONSTRUCTIVE SURGERY, January 2003
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 unnecessary
to 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 border
of the trapezius muscle. A subcutaneous tunnel
is created with blunt dissection. The flap is
then tunneled through this space and deliv-
ered through the supraclavicular incision. The
donor site is closed primarily. When very large
flaps 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 bone
involvement. (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 range
of motion in the left shoulder.
Vol. 111, No. 1 / DORSAL SCAPULAR ISLAND FLAP
levator and omohyoid muscles to facilitate flap
transfer. These muscles are repaired after flap
transfer. In the earlier cases of our series, we
routinely disinserted the trapezius from the
scapula. 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 flaps
are required, the flap is expanded and de-
layed to augment the vascularity of the flap
and improve venous outflow. A vertical inci-
sion is made 3 to 4 cm from the midline of the
back, parallel to the spine. The lower part of
the trapezius is divided about 4 to 5 cm from
the midline. The intercostal musculocutane-
ous perforating arteries and veins are ligated.
The superficial muscular branch of the dorsal
scapular artery is identified at the point where
it pierces the rhomboideus muscles and is
traced distally into the trapezius muscle. A
600-cc rectangular tissue expander is placed
73
under the muscle, with care taken to preserve
this musculocutaneous branch. The muscle is
sutured back and the incision is closed in
layers. 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 to
reconstruct soft-tissue defects of the head and
neck, shoulder, and anterior chest wall in 32
patients. The average age at surgery was 42
years (range, 6 to 77 years). There were 20
male and 12 female patients. The smallest flap
used was 6 ⫻ 8 cm and the largest was 30 ⫻ 26
cm. The operative procedure lasted an average
of 2.6 hours (range, 1.7 to 4.3 hours). The
average 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 dorsal
scapular island flap (above, center). Elevation of the flap (above, right). The patient has a healed wound and diminished chest wall
contracture postoperatively (below, left). The donor site has healed and the patient has regained full range of motion (below, right).
74
for a flap survival rate of 91 percent. Two flap
failures were attributed to technical errors
early in our series. A third flap was lost be-
cause of venous insufficiency despite careful
dissection. One additional flap developed ve-
nous insufficiency intraoperatively. It was sal-
vaged by anastomosing a flap vein to the
external jugular vein. Therefore, all flap fail-
ures were caused by venous insufficiency (9
percent). Partial flap loss occurred in two
cases (6 percent). Notably, each of these
flaps was greater than 25 cm in length. Do-
nor-site complications included wound de-
hiscence in four cases (12.5 percent). Two of
these were encountered in the preexpanded
flaps. All of these wounds healed by second-
ary intention without surgical intervention.
Nine patients underwent disinsertion of the
trapezius muscle. Four of these patients (44
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 shown
intraoperatively (below).
PLASTIC AND RECONSTRUCTIVE SURGERY, January 2003
percent) had a moderate restriction in shoul-
der motion 2 years postoperatively. The
other five patients had minimal restriction of
their shoulder function. None of the patients
in whom the trapezius, omohyoid, and leva-
tor scapulae muscles were disinserted and
reinserted regained complete range of mo-
tion of the shoulder. Eleven patients under-
went division of the omohyoid and levator
scapulae muscles without disinsertion of the
trapezius muscle. All of these patients had a
temporary limitation in shoulder movement.
In the remaining 12 cases, in which neither
the trapezius nor the omohyoid and levator
muscles were divided, the patients regained
full shoulder function in the immediate post-
operative period. We therefore do not rec-
ommend dividing the trapezius muscle for
flap mobilization.
Vol. 111, No. 1 / DORSAL SCAPULAR ISLAND FLAP
CASE REPORTS
Case 1
A 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 been
surgically resected 3 years previously. A radical resection of
the tumor resulted in a defect 30 ⫻ 26 cm in size, with
exposure of the dura mater after almost complete resection
of the occipital bone. A 30-cm ⫻ 26-cm dorsal scapular flap
was harvested and transferred to the defect. The medial
insertion of the trapezius muscle was divided temporarily
to facilitate flap transfer. The omohyoid and levator scap-
ulae muscles were not divided. The donor site was closed
primarily. The shoulder was immobilized for 3 weeks, and
the flap healed uneventfully. The patient regained almost
full range of motion in the shoulder by 2 months after
surgery (Fig. 5).
Case 2
A 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 scapular
island flap was expanded as previously described to minimize
the problem of venous insufficiency. In the second stage, the
contracture was excised. With the patient in a prone position,
a 28-cm ⫻ 14-cm flap was harvested. A cuff of trapezius muscle
around the superficial branch of the dorsal scapular artery
was included in the flap. The flap was tunneled under the
trapezius, omohyoid, and levator scapulae muscles and was
exteriorized through a skin incision on the anterior border
of the trapezius muscle. The donor site was closed primar-
ily. The flap was then transferred to the defect on the
anterior chest wall. The distal 2 cm of the flap suffered
superficial necrosis, which healed by secondary intention
in 2 weeks. The patient began active range-of-motion ex-
ercises of the shoulder 3 weeks postoperatively and re-
FIG. 8. Postoperative result showing improved neck contour and motion. (Left) An-
terior view; (right) lateral view.
75
gained full range of shoulder movement. There were no
donor-site complications (Fig. 6).
Case 3
A 32-year-old woman developed a recurrent neck contrac-
ture after treatment of a postburn contracture of her anterior
neck. A delayed dorsal scapular island flap was planned to
cover the anterior neck as an aesthetic unit. The flap was
preexpanded to the desired size. A 32-cm ⫻ 12-cm dorsal
scapular island flap was designed to conform to the size of the
anterior neck aesthetic unit. The flap was harvested in the
usual 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. The
flap was inset into the defect and healed uneventfully. The
patient regained full function within 2 weeks after surgery. A
partial dehiscence of the donor site healed by secondary
intention. We recommended an additional procedure to thin
the flap to achieve a better cosmetic result. However, the
patient was happy with the outcome and refused additional
surgery (Figs. 7 and 8).
DISCUSSION
The vascular anatomy of the skin of the back
remains confusing because of the different
terms used to describe the many vessels that
perfuse this area. Classic anatomists have re-
ferred to the dorsal scapular artery by many
different names.9,10 Adachi called it the de-
scending branch of the transverse cervical ar-
tery. He observed that this branch divides into
two minor branches: one medial and one lat-
eral.11 Cruveilhier named this same branch the
scapular branch of the posterior scapular ar-
76
tery.12 Salmon referred to the dorsal scapular
artery as the descending branch or spinal
branch of the posterior scapular artery. Ac-
cording to Salmon’s description, the posterior
scapular artery divides into two branches: the
ascending branch, which is the main vascular
pedicle of the trapezius muscle, and the de-
scending branch.13,14 The term “dorsal scapular
artery” was introduced by Hulke to replace the
terms “deep branch of the transverse cervical
artery” and “descending scapular artery,” fol-
lowing the criteria of the International Ana-
tomical Nomenclature Committee, which pro-
posed that “structures closely related
topographically shall, as far as possible, have
similar names.”15 According to the Nomina Ana-
tomica,16 the transverse cervical artery gives rise
to a superficial branch and a deep branch. If
these branches originate separately, the super-
ficial branch is called the superficial cervical
artery (arteria cervicalis superficialis) and the
deep branch is called the dorsal scapular artery
(arteria dorsalis scapulae). Although the ori-
gins of the transverse cervical and the dorsal
scapular artery are variable, it is accepted that
the distal distribution of these arteries follows a
consistent pattern.4
Daseler and Anson described the dorsal
scapular artery originating as a direct branch of
the subclavian artery and the superficial trans-
verse cervical artery arising directly from the
thyrocervical trunk.17 They referred to the dor-
sal scapular artery as the transverse cervical
artery, and they named the artery to the trape-
zius muscle the superficial transverse cervical
artery. Thompson found that the dorsal scap-
ular artery most often originated as a branch
from the thyrocervical trunk, whereas Röhlich
observed it as a direct branch of the subclavian
artery.18,19
The transverse cervical artery perfuses the
trapezius muscle. Before entering this muscle,
the artery divides into two branches: an ascend-
ing and a descending branch, which run in the
deep surface of the trapezius muscle. If the
transverse cervical artery has a common origin
with the dorsal scapular artery, the common
trunk is called the transverse cervical artery,
and its superficial branch, which perfuses the
trapezius muscle, is known as the superficial
cervical artery or superficial transverse cervical
artery. The deep branch of the transverse cer-
vical artery is then called the dorsal scapular
artery. It is important to distinguish the term
“descending branch of the transverse cervical
PLASTIC AND RECONSTRUCTIVE SURGERY, January 2003
artery” from the “descending branch of the
superficial branch of the transverse cervical
artery.” The first term is synonymous with the
dorsal scapular artery. The second term de-
scribes the division of the superficial branch of
the transverse cervical artery, which supplies
the lower trapezius musculocutaneous flap.
The superficial branch of the transverse cervi-
cal artery is superficial to the levator scapulae
and omohyoid muscles and descends along the
deep surface of the trapezius muscle.
The relationship between the lower trape-
zius musculocutaneous flap and the dorsal
scapular artery flap is not clearly defined in the
literature. 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 the
descending branch of the superficial transverse
cervical artery nourishes this flap. Inclusion of
the dorsal scapular artery in the classic lower
trapezius musculocutaneous flap, suggested by
some authors, is unclear. If such a flap is to be
transferred to the face or the anterior neck, the
only way to preserve the dorsal scapular artery
is to divide the omohyoid and the levator scap-
ulae muscles. There is no mention of this in
their surgical technique.8
It is generally believed that the underlying
muscle can nourish the overlying skin and sub-
cutaneous tissue directly. However, it has been
proved that the skin and subcutaneous tissue
are perfused by cutaneous vessels that may or
may not perforate the underlying muscles. In
the latter case, the vessels perfuse the skin and
subcutaneous tissue independently from the
muscle. In the case of the back, it may be
inaccurate to consider the skin and subcutane-
ous tissue as the “angiosome” of the trapezius
muscle vascular pedicle. In fact, the medial
back skin and subcutaneous tissue can derive
their blood supply from several different sourc-
es: the intercostal vessels, the superficial cir-
cumflex scapular vessels, and the cutaneous
perforators from the pedicles of the trapezius
and the dorsal scapular vessels. The dorsal
scapular artery contributes to the vascularity of
this area in two different ways: (1) musculocu-
taneous perforator(s) through the lower part
of the trapezius, and (2) musculocutaneous
perforator(s) through the rhomboideus mus-
cle alone that do not pierce the trapezius mus-
cle. Based on our anatomical dissections, we
believe that the dorsal scapular vessels provide
Vol. 111, No. 1 / DORSAL SCAPULAR ISLAND FLAP
a reliable blood supply to this territory and
allow it to be raised as an island flap. We do
not, however, believe that this pedicle is the
sole blood supply to this territory.
Previous publications have documented the
feasibility and utility of “perforator” flaps. The
skin island of the musculocutaneous flap can
be perfused by the cutaneous perforators of
the underlying muscle without actually in-
cluding the muscle in the flap. This spares
the muscle so that its function is preserved
and the bulk of the flap is reduced.20 –22 The
dorsal scapular island flap can be raised as a
true perforator flap; however, the dissection
becomes more tedious and time-consuming.
By including a small cuff of muscle around
the perforator, the dissection becomes easier
and quicker. In our series, only a small piece
of the lower trapezius muscle around the
perforator was harvested. The main func-
tional portion of the muscle was completely
spared; therefore, shoulder motion was
preserved.
Four of our initial cases (12 percent) suf-
fered venous insufficiency resulting in partial
or total flap loss. Technical errors accounted
for two of these cases, in which the main vein
was inadvertently divided. Despite careful
dissection and complete preservation of the
main venous outflow, adequate venous drain-
age could not be obtained in the other two
cases. One of these flaps was salvaged by
anastomosing another vein from the flap to a
recipient vein in the neck. We consider this a
complication caused by insufficient venous
return. As was described in the anatomical
findings, there is venous drainage of this area
through the intercostal veins near the mid-
line of the back. These perforating veins are
divided during the elevation of the flap. We
believe that these veins may represent a sub-
stantial source of venous drainage for this
flap.23 Ligation of these veins may result in
insufficient venous drainage, especially in
large flaps. Therefore, in the most recent
cases of our series, we preferred to delay the
flap by ligating the intercostal venous system
3 weeks before transferring the flap. As part
of this delay procedure, the flap was also
expanded. Almost complete flap survival was
consistently observed in the delayed flaps.
Based on our anatomical and clinical stud-
ies, we conclude that the dorsal scapular vessels
provide a reliable blood supply to the skin of
the medial back, making it a versatile flap to
77
use as an island flap. By delaying and expand-
ing the flap, we were able to overcome the
problem of inadequate venous drainage of the
flap. Although the majority of large head and
neck defects are reconstructed with microsur-
gical tissue transfer, this flap is a good alterna-
tive for such defects while avoiding the need
for microsurgery with its associated complica-
tions. This flap provides an excellent func-
tional and cosmetic result and minimal donor-
site morbidity. We highly recommend delaying
and expanding the flap when using it to recon-
struct large defects on the face and anterior
neck.
Claudio Angrigiani, M.D.
Centenario 133
Buenos Aires 1405
Argentina
claudioan@fibertel.com.ar
ACKNOWLEDGMENT
All illustrations are the original work of Shirley Kuikman
Kantoff. 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. The
lower trapezius island myocutaneous flap. Ann. Plast.
Surg. 5: 108, 1980.
3. Netterville, J. L., and Wood D. E. The lower trapezius
flap. Arch. Otolaryngol. Head Neck Surg. 117: 73, 1991.
4. Weiglein, A. H., Haas, P., and Pierer, G. Anatomic basis
of 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 musculocutaneous
flap in head and neck reconstruction: Potential pit-
falls. Head Neck Surg. 7: 129, 1984.
6. Cormack, G. C., and Lamberty, B. G. H. The Arterial
Anatomy 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 trapezius
island musculocutaneous flap: A fasciomyocutaneous
flap 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: Oxford
University 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.
78
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 the
subclavian 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
PLASTIC AND RECONSTRUCTIVE SURGERY, January 2003
of Collective Investigation of the Anatomical Society
of Great Britain and Ireland for the year 1890 –1891.
J. Anat. Physiol. 26: 77, 1891.
20. Koshima, I., and Soeda, S. Inferior epigastric artery skin
flaps 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 dorsi
musculocutaneous flap without muscle. Plast. Reconstr.
Surg. 96: 1608, 1995.
23. Goodwin, J. W., and Rosenberg, G. J. Venous drainage
of the lateral trapezius musculocutaneous island. Arch.
Otolaryngol. Head Neck Surg. 108: 411, 1982.