Logan Steele
Flap surgery is a subspecialty of plastic and reconstructive surgery. It involves the transfer of tissue from one part of the body to another. Muscle flaps are used to fill dead space and serve as a vascularized graft surface. Pedicled muscle flaps are particularly useful for covering infected wounds or exposed dura. They are also used in breast reconstruction, where they can be used to transfer skin, adipose tissue, and muscles without completely disrupting their blood supply. The benefits of a pedicled myocutaneous flap relate to the bulk of fresh tissue with an independent blood supply.
| Characteristics | Values |
|---|---|
| Definition | A muscle pedicle flap is a type of reconstructive surgery that uses muscle flaps with vascular pedicles to fill dead space and provide a vascularised graft surface. |
| Types | Type I, Type II, Type III, Type IV, Type V |
| Examples | Latissimus dorsi flap, TRAM flap, Abbe flap, Karapandzic flap, Estlander flap |
| Uses | Breast reconstruction, lip reconstruction, covering infected wounds or exposed dura, filling dead space, providing a vascularised graft surface |
| Advantages | Bulk of fresh tissue, independent blood supply, reliable, versatile, reduces complications |
| Disadvantages | Donor site deformity, risk of donor site complications, requires skilled operative team |
| Contraindications | Personal/family history of thrombotic/bleeding events, prior radiation to donor areas, history of surgeries compromising vascular supply, unacceptable disability from muscle sacrifice |
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What You'll Learn
Muscle flap vascular anatomy
Flap surgery is a subspecialty of plastic and reconstructive surgery. A flap is defined as a piece of tissue with a defined blood supply, which differentiates it from a graft, where a piece of tissue is freed from any defined blood supply and replanted into the surrounding tissue. Muscle flaps have vascular supply from named vessels and have a consistent blood supply, making them a good option for many different reconstructions.
There are several patterns of muscle flap vascular anatomy. Type I has one vascular pedicle, Type II has dominant pedicle(s) and minor pedicle(s), Type III has two dominant pedicles, Type IV has segmental vascular pedicles, and Type V has one dominant pedicle and secondary segmental pedicles. An interpolated flap is a type of muscle flap vascular anatomy where the donor site is separated from the recipient site, and the pedicle of the flap must pass above or beneath the tissue to reach the recipient area.
The trapezius flap is a type of muscle flap that has been used for reconstruction of the head and neck, particularly in the case of parotidectomy defects. The trapezius muscle is large, flat, and triangular, with distinct directional fibres. The variability in the description of the trapezius flap has caused confusion in flap elevation, so it is best described in terms of its vascular pedicle. The perforator anatomy of the trapezius muscle has been well documented in recent years, allowing reconstructive surgeons to raise fasciocutaneous flaps without violating the trapezius muscle.
Lip flap surgery is another example of muscle flap vascular anatomy, used to reconstruct defects in the upper or lower lip. The Karapandzic, Abbe, and Estlander flaps are all types of lip flaps that transfer functional orbicularis oris muscle. The Abbe and Estlander flaps are pedicled lip-switch flaps, while the Karapandzic flap is an advancement rotation flap with arterial and nervous supplies.
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Muscle flap surgery
Flaps composed of one type of tissue include skin (cutaneous), fascia, muscle, bone, and visceral (e.g. colon, small intestine, omentum) flaps. Composite flaps include fasciocutaneous (e.g. radial forearm flap), myocutaneous (e.g. transverse rectus abdominis muscle [TRAM] flap), osseocutaneous (e.g. fibula flap), tendocutaneous (e.g. dorsalis pedis flap), and sensory/innervated flaps (e.g. dorsalis pedis flap with deep peroneal nerve).
There are several different types of flap surgery methods, including:
- Local flap - located next to the wound, with one end of the skin remaining attached to preserve the blood supply.
- Regional flap - uses a section of tissue attached by a specific blood vessel.
- Bone/soft tissue flap - used when bone and overlying skin are transported to a new location.
- Musculocutaneous flap (muscle and skin flap) - used when the area to be covered requires more bulk and an increased blood supply.
In free flap surgery, surgeons completely disconnect the flap and its blood vessels from the donor site and reattach them to the recipient site, carefully reconnecting the blood vessels to restore blood flow. Flaps can be taken from almost any part of the body, as long as there is enough healthy tissue and blood supply to keep the flap alive after transfer. Common locations for free and regional flaps include the abdomen, back, thighs, and buttocks.
The risks of flap surgery can be greater than those of other surgeries, as complications can arise at both the donor and recipient sites. These risks include a personal or family history of thrombotic or bleeding events, prior radiation to donor areas, and a history of surgeries that may have compromised the vascular supply of the proposed muscle.
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Pedicled muscle flaps for wounds
Flap surgery is a technique in plastic and reconstructive surgery where tissue with an intact blood supply is lifted from a donor site and moved to a recipient site. Skin flaps are an essential part of a surgeon's toolbox in plastic surgery. Flaps are distinct from grafts, which do not have an intact blood supply and rely on the growth of new blood vessels. Flaps are composed of one type of tissue, including skin (cutaneous), fascia, muscle, bone, and visceral flaps.
Muscle flaps contain a layer of muscle to provide bulk that can fill a deeper defect. If skin coverage is needed, a skin graft can be placed over the top. Muscle flaps are effective in filling dead space and decreasing the bacterial concentration of wounds. They are often used in reconstructive surgery, such as breast reconstruction after mastectomy.
Pedicled flaps remain attached to the donor site via a pedicle that contains the blood supply, while in a free flap, the vessels are cut and anastomosed to another blood supply. The Abbe and Estlander flaps are examples of pedicled flaps, used to reconstruct defects in the lip. The Karapandzic flap is another example of a pedicled flap, used to repair contracted scars from previous reconstructive attempts on the lower lip.
There are risks associated with flap surgery, including infection, wound breakdown, fluid accumulation, bleeding, damage to nearby structures, and scarring. The most notable risk is flap death, where the flap loses its blood supply. Negative-pressure wound therapy (NPWT) has been used to manage open wounds and immobilize skin grafts over pedicled muscle flaps, with some success in improving wound healing and flap viability.
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Contraindications for muscle flaps
Absolute Contraindications:
- Severe systemic disease: Patients with severe systemic diseases, such as advanced-stage cancer, uncontrolled metabolic disorders, or severe cardiovascular disease, may not be suitable candidates for muscle flap surgery. This is because the procedure requires a certain level of physiological reserve and the ability to withstand the associated surgical stress. The risk of complications and the potential benefit of the procedure should be carefully weighed in such cases.
- Active infection: The presence of an active infection is an absolute contraindication to muscle flap surgery. Infection at the recipient or donor site can lead to significant complications, including flap necrosis, wound breakdown, and systemic spread of the infection. Proper infection control and timing of the surgery are crucial to ensuring successful outcomes.
- Poor vascularity: Muscle flaps rely on a healthy blood supply for survival. Patients with peripheral vascular disease, atherosclerosis, or other conditions that compromise blood flow may not have sufficient vascularity to support a muscle flap. Assessing vascular health and ensuring adequate perfusion are critical in the decision-making process.
Relative Contraindications:
- Previous radiation therapy: Prior radiation exposure to the donor site or the surrounding area can impact the viability of the muscle flap. Radiation can cause fibrosis, vascular damage, and decreased tissue flexibility, all of which may affect flap survival. A careful assessment of the extent and timing of previous radiation therapy is necessary to determine the feasibility of a muscle flap procedure.
- Smoking: Smoking has detrimental effects on wound healing and vascular health. Patients who are active smokers have a higher risk of flap necrosis, wound dehiscence, and other complications. While it may not be an absolute contraindication, smoking cessation is strongly recommended before and after muscle flap surgery to optimize outcomes.
- Malnutrition: Proper nutrition is essential for wound healing and tissue regeneration. Patients who are malnourished may have impaired wound healing capabilities, which can compromise the success of a muscle flap procedure. Optimizing nutritional status and addressing any underlying nutritional deficiencies prior to surgery are recommended.
It is important to note that the presence of a contraindication does not necessarily preclude a patient from undergoing muscle flap surgery. Each case should be assessed individually, and the benefits and risks should be carefully considered in the context of the patient's overall health and the specific surgical goals.
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Muscle flap donor sites
One commonly used donor site for muscle flaps is the thigh. Different sections of the thigh offer distinct advantages and are suitable for various types of reconstruction. The anterolateral thigh (ALT) flap, for instance, is a popular choice for breast reconstruction and covering vascular bypass grafts in the groin. The ALT flap is easily dissected and can be tunnelled under the rectus femoris muscle to reach the graft site. The gracilis muscle, located in the medial thigh, is another frequently used donor site, especially for smaller breasts, as it helps pull the legs inward and has a well-hidden scar. Other thigh muscle flaps include the rectus femoris, vastus lateralis, and tensor fascia lata flaps.
The radial forearm is another donor site for muscle flaps, particularly in head and neck reconstruction. The radial artery supplies blood to the hand, and the radial forearm flap is suitable for patients with radial artery dominance. For patients with ulnar artery dominance, the ulnar artery perforator (UAP) flap may be preferable. The UAP flap is thin and pliable, making it ideal for certain cancer defects requiring thin tissue for reconstruction, such as partial glossectomy or floor of mouth reconstruction.
In breast reconstruction, when abdominal tissue is not suitable or unavailable, the latissimus dorsi muscle, or the muscle next to the shoulder blade, can be used as a donor site. The flap tissue, muscle, and skin are tunnelled around from the back of the body to the front and placed at the mastectomy site. However, this procedure may require the additional placement of an implant to match the size of the other breast.
Overall, the selection of a muscle flap donor site requires careful consideration of the patient's unique needs and circumstances. Successful reconstruction demands a thorough understanding of anatomy, thoughtful analysis of the defect, and skilled soft tissue-handling techniques.
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Frequently asked questions
A muscle pedicle flap is a type of tissue flap composed of muscle tissue. Tissue flaps are used in plastic and reconstructive surgery to fill dead space and serve as a vascularised graft surface.
There are five types of muscle flap vascular anatomy: Type I (one vascular pedicle), Type II (dominant and minor pedicles), Type III (two dominant pedicles), Type IV (segmental vascular pedicles), and Type V (one dominant pedicle and secondary segmental pedicles).
Muscle pedicle flaps can be used to cover infected wounds or exposed dura. They provide a bulk of fresh tissue with an independent blood supply, which can be useful in areas with poor vascularity.
