review

1. Journal Presentation
Dr. Aditi Sharma
M.Ch. Resident

2. Effect of Platelet Rich Plasma versus Saline
Solution as a Preservation Solution for Hair
Transplantation
• Rasha Abdelkader, MD
• Department of Plastic Surgery, Alkasr Allni Hospital, Cairo
University, Cairo, Egypt
• Plast Reconstr Surg Glob Open 2020;8:e2875;
• doi: 10.1097/GOX.0000000000002875;
• Published online 25 June 2020.

3. Introduction
• Androgenetic alopecia (AA) is a genetically determined phenomenon defined
by a gradual hair loss and reduction in normally thick hair follicles. AA affects
up to 30% of men over the age of 30 years and 50% of men over the age of 50
years. It also affects women.
• Platelet-rich plasma (PRP) is created through concentrating platelets found
in whole blood. It can aid in tissue regeneration, bone regeneration, and
wound repair.
• 2–7 PRP treatment have been suggested to promote hair growth, encourage
cell survival and proliferation, and prolong the anagen phase of the hair
cycle

4. • PRP is thought to exert its effects on AA via delivery of concentrated
growth factors to the hair follicle and surrounding area, so it is
recommended in the treatment of AA.
• For many years, several procedures have been used for treating male
pattern baldness. These include punch grafts, strip grafts, scalp flaps,
scalp reductions, and tissue expansion. These techniques tend to take too
many sessions, leaving noticeable scarring and yielding unappealing
results.
• Recently, an autologous alternative has emerged not only for the
intradermal activation of dormant hair follicles but also as an adjuvant
therapy for the follicular unit extraction (FUE) technique.

5. • The plasma rich in growth factors (PRGF) technology is based on the recovery
of a small volume of the patient’s own blood, which is afterward centrifuged
and activated to obtain an autologous formulation enriched in proteins and
growth factors. The use of this approach enhances the organism’s self-
healing ability and promotes tissue renewal, thus providing a therapeutic
option for hair follicle regeneration.
• For patients who require significant hair coverage, follicular unit hair
transplantation and extraction have become the gold standard surgical
methods for providing a natural-looking hairline and the illusion of a headful
hair.

6. METHODS
• This single, prospective, randomized comparative study was conducted at a
private clinic between June 2017 and March 2019. The study was approved
by the ethics committee of the Faculty of Medicine, Cairo University, Egypt
(IRB 257).
• The subjects were 30 patients [27 men and 3 women, aged between 22 and
51 years (average, 34 years)] with AA who underwent an FUE type of hair
transplantation.
• The men were classified according to the Norwood classification (grades 2–
6) and the women according to the Ludwig classification (grades 1–3). All
patients provided informed consent before participating in the study.

7. Inclusion Criteria
• The inclusion criteria were as follows:
• (1) age between 20 and 55 years,
• (2) men with AA and classification of AA into grades 2, 3, 4, 5, or 6
according to the Norwood scale of baldness,
• (3) women with AA and classification of AA into grades 1, 2, or 3
according to the Ludwig scale of baldness,
• (4) men with AA, and
• (5) women with AA.

8. Exclusion Criteria
• The exclusion criteria were as follows:
• (1) age below 20 years or above 55 years,
• (2) classification of AA into grade 1 or 7 according to the Norwood scale
of baldness,
• (3) patients with thyroid disorders,
• (4) patients with bleeding disorders,
• (5) patients with diabetes,
• (6) smokers,
• (7) patients on corticosteroids or immunosuppressive drugs,
• (8) women with diffuse hair thinning, and
• (9) men and women with cicatricial alopecia.

9. Hair Density and Hair Thickness Analysis
• Before treatment, patient’s profile photographs (frontal view, lateral view,
cephalic view, and occipital view) were taken. Furthermore, the hairs were
assessed using a digital trichoscope.
• Trichoscope is a method of hair and scalp evaluation, which can be used for the
diagnosis of certain hair- or scalp-related diseases. Hair and scalp structures can
be visualized at higher magnifications.
• After exclusion of hair or scalp diseases, the trichoscope was used to evaluate
and calculate hair density by measuring the number of hairs in 1/2cm2 area, and
then the total number of available hairs for grafting was calculated. Finally, the
size of the bald area was assessed and the number of hairs needed in this area
was estimated.

10. • Fields to be analyzed were as follows:
A zone, from hair line to a line 10cm behind it;
C zone, a circle 10cm diameter centered on vertex;
B zone, between A zone and C zone and donor area between both ears.
• A magnification of 100× was used to provide a clear view of hair and scalp.
• During the FUE, 20ml blood was drawn from the median cubital vein, via
venipuncture and then transferred into vacutainer tubes containing acid citrate
dextrose or sodium citrate. A ratio of 1ml of anticoagulant to 7–8ml of whole blood
was maintained. The aspirated blood was gently agitated to thoroughly mix the
anticoagulant with the blood.

11. • The blood was centrifuged using a slow speed (soft spin, 101G) for 5 minutes
to avoid spinning down the platelets so that they remained suspended in the
supernatant plasma.
• The supernatant plasma containing the platelets was transferred into
another sterile tube. The tube was then centrifuged at a higher speed (hard
spin, 280G) for another 5 minutes to obtain a platelet at the bottom of the
tube and a platelet-poor plasma (PPP) at the top.
• The mean platelet count in group 1 was 250 × 109/L, and it was 240 × 109/L
in group 2. In the 15 patients undergoing preservation of grafts in PRP, 2ml of
PRP was added to every 500 grafts by pouring from a syringe; thus, grafts
were kept in activated PRP from the break to the end of the procedure, that
is, for around 3 hours.

12. RESULTS
• In the PRP group, the age of the patients ranged from 27 to 51 years (mean
36 years), and in the saline group, from 22 to 48 years (mean 33 years), with
an SD of 6 in the PRP group and 7 in the saline group.
• Grades of alopecia ranged from 3–6.
• There was no difference in sex distribution between the 2 study groups (P =
0.640).
• There was no significant difference between the 2 groups regarding the
number of transplanted hairs per session (3500–4500 hairs in the saline
group versus 3000–5000 hairs in the PRP group) (P = 0.234). There was no
statistical difference between the 2 study groups regarding hair quantity
pretreatment (cm2 ) or hair thickness

13. • results had significant difference in the yield of follicular units on the
scalp in the experimental group compared with the yield in the control
group (18.7 follicular units per cm2 versus 16.4 follicular units per cm2 ),
and an increase in follicular density of 15.1% among patients who are
treated with saline-preserved hair grafts. A value of P < 0.001 was
considered a significant difference
• hair follicle density reached its peak at 3 months (170.7 ± 37.8; P <
0.001). At 6 months and 1 year, hair density had increased significantly
(196.25 ± 37.7; P < 0.001 and 203.7 ± 39.9; P < 0.001, respectively)
compared with that at the baseline

14. • There was no statistical difference between the 2 groups regarding the
percentage of hair graft uptake at the 1-month follow-up. On the other
hand, there was a significant difference in the percentage of hair graft
uptake post-transplantation in both groups at the 3-, 6-, and 12-month
follow-ups (P < 0.001). There was also a significant difference in hair
thickness at the 1-, 3-, 6-, and 12-month follow-ups.
• Using PRP therapy with FUE increases the success of FUE hair
transplantation. All participants in the PRP group had >75% hair regrowth
after 6 months. They had more rapid improvements in hair density and
skin recovery than those in the non-PRP group.

15. DISCUSSION
• PRP therapy improves the skin milieu of grafted area by cell growth and differentiation,
antiapoptotic activity, and neovascularization, making grafted areas more receptive and fertile
for newly transplanted hair.
• It also helps in providing conducive growth environment for dormant hair follicles, leading to
their activity and appearance of new regained hair as early as 3 months.9 Most studies suggest
that subcutaneous injection of PRP is likely to reduce hair loss and increase hair diameter and
density in patients with AA.10 The literature reports a significant improvement in hair density
and stimulation of growth when follicular units were pretreated with
• PRP before implantation comparable with our results that there was a significant difference in
the yield of follicular units on the scalp in the experimental group compared with the control
group (18.7 follicular units per cm2 versus 16.4 follicular units per cm2 ), which represented an
increase in follicular density of 15.1%.
• Hair loss was reduced with the use of PRP, and at 3 months, it reached normal levels.
• In this study, hair density reached its peak at 3 months (170.7 ± 37.8; P < 0.001). At 6 months
and 1 year, hair density had increased significantly (196.25 ± 37.7; P < 0.001 and 203.7 ± 39.9;
P < 0.001, respectively) compared with that at the baseline. Furthermore, patients were
satisfied with a mean satisfaction rate of 7.1 on a scale of 1–10

16. • . In this study, saline-preserved hair grafts using the FUE technique in group A.
While in group B,PRP-preserved hair grafts, which resulted in a significantly
increased percentage of hair graft uptake in the implanted area after 1 year
(93.3% versus 76.6% in the saline group).
• In 2012, Araki et al reported a significant difference in the number of newly
formed follicles in the area of transplantation when PRP was used (344 ± 27 with
PRP versus 288 ± 35 without PRP). PRP also shortened the time of hair formation
significantly, and the first hairs were observed after 18 days using PRP versus after
20 ± 1 days without PRP.
• Therefore, PRP has a considerable positive effect on the time of hair formation
and the yield of hairs following transplantation. A significant visual difference in
the hair cross-section, but not in hair numbers, was observed with the use of PRP.
• Microscopic findings showed a thickened epithelium, proliferation of collagen
fibers and fibroblasts, and increased vessels around the follicles. The effect of
autologous PRP injections on the affected area of alopecia was studied Three
months after the treatment, the patients presented with clinical improvements in
hair count, hair thickness, hair root strength, and overall alopecia

17. • . In 2016, Mahapatra et alconducted a study involving 177 patients. They
reported significantly increased local hair numbers per square
centimeter after PRP injections, compared with controls (mean
difference, 17.90; 95% confidence interval, 5.84–29.95; P = 0.004).
Similarly, they reported a significantly increased hair thickness cross
section per 10−4 mm2 (mean difference, 0.22; 95% confidence interval,
0.07–0.38; P = 0.005), favoring the PRP group.

18. • study included a small number of participants and a short follow-up period. In this
study, it was demonstrated that pretreatment of hair grafts with PRP can
significantly increase hair thickness after 12 months. Therefore, the use of PRP-
preserved hair grafts is recommended to improve the satisfaction of patients.
• Although additional studies are needed to elucidate the underlying mechanisms by
which PRGF regulates tissue regeneration, the present study demonstrates that
PRGF is able to minimize the postsurgical telogenization of the hair and potentiate
the performance of grafted hairs.
• The fibrin clot not only acts as a protective barrier against environmental factors
but also provides a biologically active scaffold that induces resident cell
proliferation and maintains an optimal integrity of the grafted hair.
• Randomized clinical trials with a higher number of patients and longer follow-up
periods are needed to clarify the suitability of autologous growth factors for hair
transplant treatment

19. The Central Mound Pedicle: A Safe and Effective
Technique for Reduction Mammaplasty
• Michael R. DeLong, M.D.
• From the Division of Plastic and Reconstructive Surgery,
Department of Surgery, University of California, Los Angeles; and
Plastic Surgery Specialists.
• Received for publication August 8, 2019; accepted March 31, 2020
• PRS GLOBAL OPEN

20. • Reduction mammaplasty is a common procedure used by plastic surgeons to
improve quality of life in patients with symptomatic macromastia, or to
restore symmetry in patients with congenital discrepancies or after
unilateral reconstruction.
• Although this is a common procedure, adherence to fundamental plastic
surgery principles is required to remove the excess skin and breast
parenchyma and to reposition the nipple while maintaining adequate
perfusion to all tissues.

21. • Improper technique or overly aggressive resection can result in
necrosis of the nipple, skin, or fat, and can lead to a poor
cosmetic result.
• In addition, the extent of skin excision must be balanced with the
ultimate scar burden on the breast mound and inframammary fold

22. • These considerations have resulted in the development and description of
numerous techniques for performing reduction mammaplasty, categorized by
differing skin pattern reductions and pedicle designs.
• The most commonly used technique is the inferior pedicle with a Wise
incision pattern, preferred by an estimated 70 percent of surgeons.
• The inferior/Wise approach offers the safe excision of large tissue volumes
with predictability and reproducibility. However, some surgeons have
criticized this approach for perceived shortcomings, including squaring of the
breast borders and late pseudoptosis

23. • Many critics of the inferior/Wise approach have adopted the superomedial
pedicle reduction, using either a Wise or vertical incision pattern. Advocates
of this technique believe that the superiorly based pedicle affords longevity
to the final breast mound shape and position by primarily resecting tissue
inferiorly.
• In addition, limiting the skin incision to only a vertical ellipse can reduce the
eventual scar burden for patients. However, although studies have suggested
that the superomedial pedicle can be used safely for larger reductions, some
surgeons are hesitant to use the superomedial technique in gigantomastia
patients with ptosis because of the reliance on a superiorly based blood
supply and potential for nipple ischemia.

24. • The central mound pedicle technique, introduced by Balch in 1981, offers many
advantages.
• The central mound relies on a highly vascular glandular pedicle directly from the
chest wall and can be safely used in re-reductions regardless of the pedicle design
used in the prior reduction.
• In addition, the central mound technique allows the surgeon to precisely predict
and modify the base width of the breast mound by shaping the underlying coned
pedicle and draping the skin over the final desired shape.
• By centering the pedicle under the nipple and point of maximal projection, an
aesthetic and anatomical breast contour can be constructed. The preservation of
the directly underlying tissue also may limit the likelihood of damage to the sensory
cutaneous nerves destined for the nipple-areola complex.

25. • This study evaluates multiple decades of patients having
undergone this relatively less common technique to report on
experience with respect to expected safety and efficacy outcomes
for the central mound procedure.

27. Operative Technique
• Preoperative markings are made with the patient in the sitting position,
with a typical Wise-pattern skin reduction design drawn on the patient.
• The expected new nipple-areola complex position is marked at or just
slightly above the Pitanguy point.
• The limbs of the Wise pattern are then marked based on surgeon
preference estimating the final breast size and extent of expected
resection.
• Once in the operating room, an areolar template is used to mark the new
preferred size of the areola.

28. • Incisions are made through skin based on the preoperative Wise-pattern
markings. The skin around the areola and the inferior pole is completely
removed down to the breast capsule.
• Superiorly, medial and lateral skin flaps are created at the junction
between the subcutaneous fat and the breast capsule.
• This plane will vary based on the patient’s body habitus and body fat
percentage. Dissecting in this plane maintains the entire subcutaneous
layer on the skin flap and is usually adequate to maintain adequate
vascular perfusion to the skin flaps

29. • In extremely thin patients, if the surgeon feels that insufficient subcutaneous
tissue is present, or if the capsule is not clearly defined, a rim of breast tissue
measuring a few millimeters can be included on the skin flaps in a more
conservative elevation.
• The desired base width for the patient’s body habitus is determined and the
breast parenchyma is marked with a circle of this diameter centered on the
nipple.
• Parenchymal reduction is conducted circumferentially to create a cone-shaped
breast central mound pedicle, with the apex and resulting point of maximal
projection being the nipple-areola complex. The amount of tissue to resect can
be reliably determined without needing anatomical landmarks by using a circular
template based on the final anticipated base width and resecting tissue outside
of this construct as demonstrated

30. • The usual diameter of the neo–breast mound will vary, again depending on the
patient’s body habitus, breast shape, and desired final breast volume;
however,, in general, as with implant-based breast reconstructions, this
diameter will range anywhere from 11 to 15 cm as a rough estimate. For
surgeons less familiar with the central mound

31. • technique, a more conservative resection can be used with the knowledge that
additional tissue can be resected after a tailor-tacking assessment, as
discussed below.
• In large ptotic breasts, the surgeon will find that, in the supine position, the
notch-to-nipple distance will not be as lengthy as in the sitting position. The
central breast mound can easily be performed on these cases simply because
the vessels will still be present from the central mound originating off of the
chest wall.

32. • A ridge of breast parenchyma is intentionally left at the superior portion of
the dissection cavity in the intrinsic breast mound. This ridge is
approximately 2 to 3 cm in width, spanning the entire width of the upper
quadrants.
• At this time, absorbable sutures are placed, securing the newly shaped
and reduced central breast mound to this superior parenchymal ridge,
creating an internal mastopexy of the entire neo–breast mound. With this
maneuver, the breast mound is supported not only by the skin envelope,
but by the internal parenchymal mastopexy.

33. • The skin flaps are then redraped and tailortacked with staples. The patient’s
back is then elevated on the operating room table to assess symmetry, shape,
and nipple position. Adjustments can be made as necessary.
• If the initial resection based on the desired base width template is felt to be
insufficient, more tissue can be resected from the central mound pedicle in
the areas that still appear inappropriately full or convex.
• This step can be repeated with tailor-tacking to ensure that the final
appearance of the breast is the desired size and shape and that satisfactory
symmetry is achieved.

34. • Once the result appears acceptable, the patient is returned to the
supine position and the incisions are closed after hemostasis is
ensured.
• A closed-suction drain may be used if desired.
• Finally, a new areolar defect is created at a desired distance from
the inframammary fold and the underlying nipple-areola complex
is delivered and the skin is closed with absorbable sutures.

35. Results
A total of 325 patients were identified for inclusion (227
bilateral and 98 unilateral; 552 breasts).
The average patient age was 46 years, and the average body
mass index was 27.4 kg/m2 .
Thirteen patients reported actively smoking, and 54 patients
were former smokers.
Among the bilateral macromastia patients, the average operative
time was 3 hours 34 minutes, and average breast tissue removed was
533 g from the right and 560 g from the left.
Among all patients, average followup was 169 days.

37. • Ninety-six bilateral macromastia patients (42.3 percent) completed the BREAST-Q
Reduction/ Mastopexy questions on a Likert scale ranging from 1 to 5.
• The following changes in average symptom frequency were observed
postoperatively: shoulder pain, 3.40 to 1.41 (of 5) (p < 0.001); neck pain, 2.94 to
1.63 (p < 0.001); painful shoulder grooving, 3.78 to 1.57 (p < 0.001); rashes under
breasts, 2.08 to 1.09 (p < 0.001); and back pain, 3.27 to 1.64 (p < 0.001).
• Nipple sensation was also reduced from 3.53 to 3.05 (p < 0.001). Patients were
also satisfied with breast appearance in clothes, 1.48 to 3.70 (of 4) (p < 0.001);
breast size match to their body habitus, 1.46 to 3.70 (p < 0.001); breast size, 1.39
to 3.61; (p < 0.001); breast shape in a bra, 1.91 to 3.64 (p < 0.001); comfort of bra
fit, 1.53 to 3.59; (p < 0.001); how breasts hang, 1.38 to 3.70 (p < 0.001); and how
normal breasts appeared postoperatively, 1.57 to 3.60 (p < 0.001).

38. DISCUSSION
• The central breast mound reduction technique has the advantage of
being supplied from multiple sources.
• Because the base of the mound is never violated, some have called this
technique the “maximally vascular central breast mound reduction,” as
perforators from the internal mammary, intercostal, thoracoacromial,
and perhaps some branches from the lateral thoracic arteries can
contribute to the central mound vascular supply.
• The maximally vascularized pedicle enables the central mound
technique to be used for all appropriate breast reduction candidates.
• There are no specific contraindications for this approach other than
general contraindications for reduction mammaplasty.

39. • Conceptually, the central breast mound reduction technique has the
following significant advantages:
1. Wide skin undermining, which allows redraping of the overlying skin
envelope in a much more controlled and tension-free fashion.
2. Circumferential resection of the large and ptotic breast parenchyma in
a dome-shaped fashion.
3. Creation of an internal parenchymal mastopexy by securing the upper
pole of the new breast mound to the upper glandular ridge or pectoralis
major fascia.
4. Tension-free closure of skin flaps. Because the skin flaps do not bear the
primary burden of supporting the new breast mound, the scars should in
theory be less prone to hypertrophic scar formation.

40. • Regarding the effectiveness of the central mound technique, we
observed substantial and statistically significant improvements in all
symptom and appearance questions from the BREASTQ
Reduction/Mastopexy module, asked on a Likert scale ranging from 1 to
5, among macromastia patients.
• On average, patients reported reduced or relieved symptoms along with
an enhanced and harmonized appearance. Unfortunately, these data are
limited by susceptibility to recall bias because preoperative values were
acquired postoperatively during the retrospective review. They are also
not directly comparable to other studies, which reported aggregate
scores of a total of 100.

41. • Patient satisfaction was similarly reflected in the very low revision
rates of 4.9 percent for scar revision and 0.9 percent for revision
of the reduction itself, although these rates may be
underestimates because patients may undergo revisions at a
different center if they are truly unhappy with their results.

42. • The centralization of the pedicle underneath the final nipple position has
additional theoretical advantages that are more difficult to measure. By
minimally disrupting the underlying breast parenchyma, lactation is likely to be
less impaired compared to other techniques.
• The preservation of a cone of breast tissue directly underneath the nipple also
allows the placement of the nipple-areola complex at the point of maximal
projection, which may be partially responsible for the high satisfaction scores
observed in our patient population.
• The reliance on a central, maximally vascularized pedicle also allows the central
mound technique to be used safely in patients undergoing re-reduction with
unknown prior pedicle, or patients with a history of radiation therapy. Ultimately,
our evaluation of the central mound technique in 552 breasts demonstrates
reassuring safety and effectiveness outcomes.

43. • This data provide a benchmark in a large series of patients to
establish the expected complication rates and efficacy results.
• Further rigorous evaluation will be required to understand the
relative benefits or disadvantages compared to other techniques.

44. CONCLUSIONS
• The central mound reduction mammaplasty technique offers a
relatively safe and effective method for treating patients with
symptomatic macromastia or breast asymmetry.
• Theoretical benefits for this technique include versatile
reduction, preservation of nipple sensation, reliable nipple
perfusion in re-reduction patients, and sustained results with
internal mastopexy.
• Further research is needed to robustly assess the relative
performance compared to alternative reduction techniques.

45. Role of Trapezius Turnover Flap in Complex
Posterior Cervical Wounds
• Bilgen Can
• Department of Plastic, Reconstructive and Aesthetic Surgery,
Balikesir Atatürk City Hospital, Balıkesir, Turkey
• Turk J Plast Surg 2020;28:252-4

46. Introduction
• Posterior cervical defects often occur after neurosurgical tumor excisions.
• The risk of infection in the surgical area after neurosurgical operation is 1%–6%.
• In addition, the presence of metallic hardware placed in the vertebral column
and postsurgical radiotherapy after tumor excision delay wound healing.
• After neurosurgical interventions, unhealed wounds in the posterior cervical
area, development of radionecrosis and osteomyelitis in the vertebrae, and
exposed hardware are common.
• In these types of complex wounds, a trapezius muscle flap should be kept in
mind as the first choice with selected patients because of its proximity to the
wound, rich blood circulation, increased resistance of local tissue to infection,
strong soft-tissue support, and short operation time.

47. • In this study, the author presented a patient to whom they
applied a trapezius turnover flap due to chronic wound and
vertebral radionecrosis after tumor excision and radiotherapy in
the posterior cervical area.
• they aimed to reveal that a trapezius turnover flap is an effective
and easy solution to a rather complex wound despite its rare use
in plastic surgery practice

48. Case Report
• A 56-year-old female patient presented to our
outpatient clinic with a complaint of an open wound
with purulent discharge in the posterior cervical
area for 1 year .
• In her history, she reported a resection of cervical
ependymoma 1½ years ago and that she received six
cycles of radiotherapy after the resection.
• However, after radiotherapy, discharge began
appearing at the surgical site. She had undergone
antibiotic treatment and local wound care for the
last 1 year.

49. • In the examination of the patient, three sinuses were extending between
the seventh cervical and forth thoracic vertebrae in the posterior cervical
area, and purulent discharge from these sinuses was observed.
• The seventh cervical vertebra’s spinous process protruded posteriorly
toward the skin and seemed nonvital. Cervical magnetic resonance
imaging showed no vertebral osteomyelitis, but some changes in the
vertebral and soft tissues due to the surgery.
• The patient who had no additional health problems and had nothing to
be noted in the general physical examination was scheduled for an
operation with a trapezius turnover muscle flap and skin graft.

50. Surgical technique
• The patient was operated on with a neurosurgery team.
• An elliptical excision of the skin was performed.
• The debridement of unhealthy skin, soft tissue, and spinous processes of the
seventh cervical, first and second thoracic vertebrae was performed.
• The metallic hardware placed for stabilization became exposed after
debridement. The tip of the scapula, medial borders of the scapula, and
transverse cervical artery were marked preoperatively.
• Through a lazy “S” incision made inferior to the defect, muscle fascia has been
reached. The skin flaps were elevated to reveal the medial and lateral parts of
the muscle.

51. • The flap was dissected from the spinous processes and from the latissimus dorsi
muscle and elevated from inferior to superior [Figure 2].
• When the medial scapula level was reached, care was taken not to separate the
muscle from the upper scapula 1/3rd adhesion site, and the superior border of
the dissection was determined to be here. The flap was dissected up to the top
1/3rd of the scapula and was turned back 180° like paper and adapted to the
defect area [Figure 3].
• The skin edges were sutured to the muscle and the remaining defect area was
repaired with a full-thickness skin graft.
• The patient was followed up on with an elastic bandage application to the flap
donor site for 3 weeks.
• After 3 months of follow-up, no problems were found at the wound site and the
flap donor site [Figure 4].

54. Discussion
• The trapezius musculocutaneous flap is an underused flap in the plastic surgery
practice.
• However, in posterior cervical defects, it should be considered as the first choice
in case of infection, exposed metallic hardware, and no chance of local
fasciocutaneous flap due to radiotherapy.
• It is also a valuable option for patients who cannot tolerate long and major
reconstructive surgery due to advanced age and tumor surgery. The trapezius
muscle is one of the largest muscles in the body.
• It is separated into three sections as per function and the direction of the
muscle fibers. The sections are superior (descending), middle (transverse), and
inferior (ascending).

55. • The superior part starts from the spinous process of the seventh cervical
vertebra, the external occipital protuberance, and the ligamentum
nuchae. Fibers proceed downward and laterally from this origin and are
inserted into the posterior border of the lateral third of the clavicle.
• The middle section origins from the spinous processes of seventh
cervical vertebrae and first three thoracic vertebrae just to insert into
the medial margin of the acromion and the superior lip of the posterior
border of the spine of the scapula.
• The inferior part starts from the spinous processes of the remaining
thoracic vertebrae. It then proceeds upward and laterally to converge
near the scapula and end in an aponeurosis.

56. • The trapezius muscle has two primary functions: first, the movement of the scapula when the
spinal segments are stable; second, the movement of the spine when the scapula is stable.
• It is innervated by the eleventh cranial nerve (the accessory nerve, CN XI). When the spinal
accessory nerve is disrupted, it produces shoulder drooping or limited arm rotation.
• In the classification of Mathes and Nahai, the trapezius muscle flap has a Type-II pattern of
circulation. Its dominant vascular supplies come from transverse cervical artery.
• The transverse cervical artery arises from the thyrocervical trunk or directly from the second
or the third part of subclavian artery and passes through the posterior triangle of the neck to
the anterior border of the levator scapulae muscle, where it divides into deep and superficial
branches.
• The upper part of the trapezius muscle is supplied by branches of the occipital artery; the
middle and lateral parts are supplied mainly by the superficial cervical artery, and the lower
part is supplied by the dorsal scapular artery and medially segmental perforators of posterior
intercostal arteries.
• In the clinical practice, there is a conceptual confusion about the vessels supplying the
trapezius muscle.

57. • The branches of the subclavian artery supplying the posterior neck and posterior
trunk have been named by different names in various studies. In addition to this,
it has been shown that along with the transverse cervical artery, the dorsal
scapular artery is also the dominant pedicle of the trapezius muscle.
• The presence of arterial anatomic differences between the East Asian and
Caucasian communities leads to these conceptual confusions; thus, more
detailed anatomical studies are needed.
• The muscle flaps are better than fasciocutaneous flaps in terms of covering
infected areas and radiation wounds with exposed metallic hardware.
• Other local muscle flaps that can be used in the posterior trunk are the
paraspinous muscle flap and the latissimus dorsi muscle flap.

58. • In this patient, the paraspinous muscle flap was not an option
bacause the paraspinous muscles were injured during tumor
surgery. The latissimus dorsi muscle flap requires a difficult and
precise dissection.
• It was also difficult to access the superior cervical region, so it
was not a viable option for our patient.

59. • In addition, the trapezius flap was applied as a muscle flap instead of a
musculocutaneous flap. Because the radiodermatitis was observed in a large
area on the back made the skin island circulation in doubt, an isolated muscle
flap was preferred.
• During the preoperative period, the scapular position was proper and the
shoulder rotations were adequate, suggesting that the pedicle of the trapezius
muscle was intact. However, the pulse of the transverse cervical artery was
traced with a hand Doppler.
• In the patients with total neck dissection, if transverse cervical artery
integrity is suspicious, arteriography can be done. Dropping of the shoulder
and the development of seroma at the donor site are the major complications
expected after the surgery

60. • These complications were not observed in this patient owing to
protection of the upper 1/3rd of the trapezius muscle and the use
of elastic bandage at the donor site for 3 weeks.
• As a result, the trapezius muscle turnover flap is a workhorse flap
which should be considered as the first choice in posterior cervical
spine surgeries and complex wounds with infection and exposed
metallic hardware.