[Surgical designs and clinical effects of pedicled transfer of extended lower trapezius musculocutaneous flap in repairing massive wounds in the shoulder and back].

Abstract

Objective: To explore the surgical designs and clinical effects of pedicled transfer of extended lower trapezius musculocutaneous flap (e-LTMF) in repairing massive wounds in the shoulder and back. Methods: This study was a retrospective case series study. From January 2009 to April 2023, 41 patients with massive wounds in the shoulder and back who met the inclusion criteria were admitted to Plastic Surgery Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College, including 26 males and 15 females, aged 4 to 83 years. The surgical design was selected according to the nature of the wound and surgical timing. The 15 patients repaired with the conventional e-LTMF were included in conventional group, the 15 patients repaired with the modified e-LTMF incorporating a distal segment of the latissimus dorsi muscle were included in modified group, and the 11 patients repaired with the pre-expanded e-LTMF were included in pre-expanded group. The wound areas ranged from 7 cm×5 cm to 21 cm×12 cm and the harvested musculocutaneous flap areas ranged from 7 cm×5 cm to 33 cm×10 cm in patients in conventional group. The wound areas ranged from 16 cm×8 cm to 28 cm×18 cm and the harvested musculocutaneous flap areas ranged from 25 cm×8 cm to 40 cm×12 cm in patients in modified group. The wound areas ranged from 12 cm×8 cm to 36 cm×12 cm and the harvested musculocutaneous flap areas ranged from 22 cm×8 cm to 35 cm×15 cm in patients in pre-expanded group. The musculocutaneous flaps were transferred to the recipient sites in a fashion of propeller rotation or as an island flap through a subcutaneous tunnel. The donor site wounds were repaired by direct suture, local flap transfer, or skin grafting. After surgery, the survival of musculocutaneous flaps was observed, the complete survival rate and the necrosis rate of musculocutaneous flaps were calculated, and the management and outcome of the necrotic musculocutaneous flaps were recorded. During follow-up, the appearance and texture of the musculocutaneous flaps, the recovery of the affected upper limb and the shoulder and back at recipient sites, the tumor recurrence in patients with tumors, and the wound healing at donor sites were observed. Results: After surgery, among the 41 patients, the musculocutaneous flaps survived completely in 38 patients, with a complete survival rate of musculocutaneous flaps of 92.7% (with a 95% CI of 80.6% to 97.5%). The necrosis of the musculocutaneous flaps occurred in 3 patients, with a necrosis rate of musculocutaneous flaps of 7.3% (with a 95% CI of 2.5% to 19.4%). Among them, total necrosis of the musculocutaneous flaps occurred in one patient in conventional group, whose wound healed after skin grafting. Distal necrosis of the musculocutaneous flap occurred in two patients in modified group, whose wounds both healed after dressing changes. During the follow-up of 1 to 48 months after surgery, the color and texture of the musculocutaneous flaps were similar to those of the normal skin surrounding the recipient sites, no obvious limitation was observed in the motion of the affected upper limb or the shoulder and back at recipient sites, and no tumor recurrence was observed in patients with tumors. The wounds at donor sites all healed well. Conclusions: Three surgical designs of e-LTMF can be used to repair massive wounds of varying complexity in the shoulder and back, achieving good outcomes in postoperative musculocutaneous flap survival, appearance and texture, recovery of the affected upper limb and the shoulder and back at recipient sites, and donor site wound healing. Among them, the conventional e-LTMF can be used for repairing simple skin and soft tissue defects, the modified e-LTMF incorporating a distal segment of the latissimus dorsi muscle can be used for repairing complex wounds complicated by exposure of critical structures, wound infection, or dead-space formation, and the pre-expanded e-LTMF can be used for elective reconstruction of wounds requiring larger musculocutaneous flap coverage.