Muscle Flaps Flashcards
Mathes and Nahai Classification
Based on muscle vascular supply
Type 1 - 1 vascular pedicle
Type 2 - 1 dominant and 1 minor (most common)
Type 3 - 2 dominant pedicles (allows muscle to be split)
Type 4 - segmental vascular pedicle (most ltd role)
Type 5 - 1 dominant with secondary segmental pedicle (dom near insertion and segmental near origin) - can raise on either ie. reverse LD
Examples of Type 1 Muscle flaps
Gastroc* TFL* VL* First DIO APB Anconeus Genioglossus Hyoglossus Styloglossus Colon Jejunum
Examples of Type 2 Muscle Flaps
Gracilis* Soleus* RF* Biceps femoris Vastus Medialis BR* ADM FDMB FCU Peroneus Longus Peroneus Brevis Platysma Abductor Hallucis SCM Trapezius* Triceps Coracobrachialis
Examples of Type 3 Muscle Flaps
PIGROST P - PecMinor I - Intercostal G - Glut Max R - RA O - Orbicularis Oris S - Serratus Anterior T - Temporalis
Omentum
Examples of Type 4 Muscle Flaps
FFEEETS F - FDL F - FHL E - EDL E - EHL E - External Oblique T - tibialis ant S - sartorius
Examples of Type 5 Muscle Flaps
LIP
L - LD*
I - Internal Oblique
P - Pec Major*
Define - arc of rotation
What determines this?
Arc of rotation:
“reach of flap” or area it covers when raised on pedicle
Determined by:
- extent of elevation of muscle
- location of dominant pedicle in relation to origin and insertion
- # of vascular pedicles
What are choke arteries?
What are oscillating veins?
What are perforators?
Choke arteries:
Small caliber vessels allowing bidirectional flow
Oscillating veins:
No valves - allow reversal of flow
Perforators:
Vesels passing through muscle to supply overlying skin
What is the Mathes classification for vascular supply to the skin?
Type A - direct cutaneous vessels
Type B - fasciocutaneous perforators (thin, narrow muscles ie. sartorius and biceps femoris)
Type C - musculocutaneous perforators (broad, flat muscles)
How to increase survival of muscle flap?
- delay procedure
- avoid distal skin paddles
- define perforators and max. inlc of them
What muscle flap types should you be cautious with when dividing?
TYpe 2 and 4 - minor and segmental pedicles - may jeopardize skin paddle
What are indications for muscle flaps?
- Massive defects
- Ischemic wounds (irradiated, chronic ulcers)
- Obliteration of dead space
- Compond wounds (composite flaps)
- Contaminated wounds (after debridement - well vascularized tissue to decrease bactrerial load)
- Functional sensorimotor flaps (facial reanimation, UE recon)
Advantages of muscle flaps?
- Reliable and sp vascular pedicles
- Bulk
- Pedicle outside of zone of injury
- Resistance to infection
- Possibility of functional restoration
- Malleable
- Different sizes
- Can combined with skin paddle (closure/cosmesis)
Disadvantages of muscle flaps?
- Potential functional deficit at donor site
- Possible unaesthetic appearance at donor site (scars, contour)
- Excess bulk
- Variable/unpredictable degrees of muscle atrophy (~50% of bulk)
Common complications of flaps (local, donor and systemic)?
Local
- flap loss
- epidermal slough
- wound dehiscence
- infection
- hematoma/seroma
Donor
- scar/deformity
- loss of function
- infection
- hematoma/seroma
Systemic
- anaesthetic complications
- DVT/PE
- atelectasis/ pneumonia
- MI
What is the pedicle for the TRAM/VRAM flap?
Origin and insertion of RA?
Pedicle - DIEA or SEA; VCs
O = pubic symphysis
I = costal cartilages 5-7 and xiphoid
How to raise TRAM flap?
Mark in standing position - 7 cm above introitus, midline and ASIS - upper incisons high enough to catch periumbilical perforators
PInch to close when supine
Dissection:
1. Sup incisions - bevel up
2. Dissect abdo flap to costal margin (tunnel if pedicled)
3. Flex bed - make sure you can close - incise inf/ly
4. Raise non-TRAM side (suprafascial to midline)
5. Incise ant rectus fascia (leave 1 cm cuff med and lat)
6. Dissect muscle circumferentially
7. If pedicled, incise sup or inf depending on use - if sup ID and clip DIEA - split ant rectus fascia sup to flap and circumferentially dissect it out
8. If free - dissect out pedicle into groin until VC join and become 1 v. - incise muscle sup and inf
What portion of the LD muscle flap is reliable?
Proximal 70%
What is the pedicle to the LD flap?
Thoracodorsal a and VCs (reverse flap - thoracolumbar perfs)
n = thoracodorsal nerve
How to plan the pedicled LD flap for breast recon?
- Measure mastectomy scar length - skin paddle a couple of cm longer
- Ellipse 10 cm for primary closure
- Use sponge and plan in reverse (dome of axilla = pivot point)
- Landmarks - midline, scapula tip, PSIS, post axillary line
How to perform dissection of LD flap?
- Incise skin paddle and raise skin off of LD fascia to all 3 borders
- ID ant border and raise off of serratus down to inf attchs - transect without breaching thoracolumbar fascia
- Elevate inf to sup
- Release from trap in midline and come over rhomboids and scapula
- Ligate branch to serratus and follow muscle up to axilla (protect pedicle on underside of LD)
- Make tunnel to defect and transfer flap
- 2 drains in back, 1 in breast
- Quilting sutures in back and 3 layer closure
- Inset flap by turning 180 degrees to point lower muscle into upper pole of breast
Other blood supplies to the LD flap?
Common complication post LD harvest?
- Segmental perforators (thoracolumbar)
- Reverse flow through serratus branch
Complication - winging of scapula (ID and preseve long thoracic nerve)
Traingular space?
Teres minor, Teres major and LH of Triceps
Contains circumflex scapular vessels
What is the pedicle of the TFL muscle flap?
Where does it enter?
What is the origin and insertion of the TFL?
Pedicle: ascending branch of LCFA and VC; n= sup gluteal
7-12 cm inferior to ASIS
O: iliac crest (ASIS)
I: IT band (fascia lata) - 5 cm below GT
What are the uses of the TFL flap?
TRochanteric pressure ulcers and abdo wall recon
TFL Flap planning?
Landmarks: ASIS to Lat patella (ant border of flap); post border = axis of femur
Max 6 cm width to close primarily
Distal 1/3 unreliable - can extend to 6-8cm above lateral femoral condyle
V-Y = best for trochanteric ulcer
Large rotation flap = #2 for GT ulcer
Transposition flap = another option
How to elevate TFL flap?
- Incise skin and fascia - raise in subfascial plane (fascia lata and IT tract)
- 12 cm below ASIS start looking for pedicle (between RF and VL)
- Once ID transpose, advance or rotate into defect
- Can take portion of iliac crest for boney recon
What is the pedicle for the gracilis flap?
What is its Origin and insertion?
Pedicle: Ascending branch of MCFA and VC
minor: Branches of SFA
n: motor branch of anterior branch of obturator
O: Pubis and inf ramus
I: Upper surface of tibia below condyle
PLanning for gracilis muscle flap?
Axis - insertion in pubic tubercle to tibial tuberosity
Pedicle enters 10 cm from pubic tubercle and obturator n is 2 cm sup to this
Distal extent = 6-8 cm above knee
Inicision placed over sup 10 cm of muscle (keep long saphenous v ant - it crosses the muscle)
How to raise a gracilis flap?
Muscle or musculocut flap
- Skin paddle - longitidunal (extend to junction of distal and middle 1/3) vs transverse (TUG - extend 4-5cm on either side of flap)
- Dissect with mets along edge to seperate from Add Longus
- Pedicle enters from beneath Add Longus and travels superficial to Add Magnus
- Id pedicle and obturator n and protect (n comes in sup/ly at a 45 degree angle to NVB)
- Circumferentially isolate muscle
- Incise distally over insertion to take whole muscle (raise from inf to sup)
What are indications for gracilis flap?
Small defects LE Pubis, groin, perineum Abdo, ischium Recon - genitalia, anus Breast recon (bilateral TUG) Functional muscle flaps - facial reanimation, UE recon
What is the pedicle of the gastroc flap?
What is the origin and insertion of this flap?
Pedicle: Sural a and VC
n - sural n
O: Med and Lat femoral condyle
I: Achilles tendon
How to raise a gastroc flap?
- Supine position - leg externally rotated and knee slightly flexed with thigh tourniquet
- Incision - midcalf ~2cm behing medial tibial border (curvilinear) - to sup popliteal fossa (avoid saphenous v and sural n)
- Raise skin flaps - transect midline raphe between med and lat heads
- Develop plane between medial head and soleus (blunt dissection) - protect pedicle, n
- Divide distal tendon and reflect (take small tendon cuff so that easier to sew to)
- Can increase arc or rotation bu releasing origin +/- checkerboarding epimysiumon post surface
- Cover with STSG; close + drain
List flaps to cover H&N
- scalp
- neck
- face
Scalp (>30%):
regional - temporalis
distant - trap (occipital) and pec major (mastoid and temporal)
free: LD and STSG
Neck :
regional - platysma, SCM
distant - pec major, trap
Face:
regional - temporalis, platysma
distant - pec major
free - facial reanimation - gracilis***, LD, RA
List muscle flaps for breast recon?
Regional - Serratus, PMinor, PMajor (implants)
Distant - LD, TRAM
Free - Glut Max, RA, VL (overlying ALT), TFL (MC), TUG (gracilis)
List muscle flaps to cover mediastinum?
Regional - PMajor
Distant - LD, RA**
Free - LD
List muscle flaps to cover chest wall?
Regional - PMajor, LD, Serr
Distant - RA
Free - RA, LD
List muscle flaps to cover the Back?
Regional - Trap (C-spine, upper thoracic), LD (mid-thoracic, lower thoracic, lumbar), glut max (lumbosacral), paraspinous musculature (deep central midline wounds)
Free - RA, LD
List muscle flaps to cover the abdomen?
Regional - RA, EO
Distant - TFL, LD, RF
Free - LD, TFL, RF
List muscle flaps for groin/perineal coverage?
Regional - sartorius, RA (VRAM), RF, gracilis, TFL, VM, VL, glut max
Free - LD
List muscle flaps to cover the LE?
Regional - gastroc, soleus
Free - LD, gracilis, sartorius, RA
Describe key features of sartorius flap?
O: ASIS I: medial tibial condyle Pedicle - 5-6 segmental vessels off SFA N - Branch femoral n Landmarks - ASIS to medial tibial condyle - pedicle at pubic tubercle level Unreliable skin paddle Covers - groin, femoral vessels and knee
Describe key features of RF flap?
O: Iliac spine I: patella N- femoral n Pedicle - LCFA (enters prox 1/3) Vertical incision ant mid thigh - skin btwn sartorius and TFL Reliable over prox 2/3 Causes knee ext weakness Covers - abdo, groin, perineum, ischium, trochanter Abdo recon; Free flap
Describe key features of a glut max flap?
O: Gluteal line ilium and sacrum
I: Greater tuberosity of femur and IT band
n - inf gluteal n
Pedicle: inf and sup gluteal a
Landmarks: Line from PSIS to GT - SGA exits prox 1/3
Skin paddle: any part overlying muscle
Cover: ischium, sacrum
Hip instability if entire muscle taken in amb pt
What nerve at risk during elevation of lat gastroc flap?
Peroneal nerve
What are key features of Soleus flap?
O: post upper 1/3 of fibula + popliteal line on post tibia
I: Achilles tendon
N: branches of tibial n
Pedicle - Post tibial a (med head), Peroneal a (lat head) - minor: post tibial a branches
Can elevate from med or lat (decr arc of rotation when raised from lat
Landmarks: post to tibia from inf to tibial condyle to above med malleolus
Covers tibia (middle 1/3)
Do not take any achilles with it or else will destabilize
Key features of PMajor Flap?
O: Med 1/2 clavicle, ant 1/2 sternum + ribs 2-6
I: bicipital groove of humerus
N: lat (upper) and med (lower) pectoral
Pedicle: thoracoacromial a - minor - Perfs IMA and ICs, pec branch lat thoracic a
Landmarks: clavicle, ant axillary line, sternal border + 6th rib
Pedicle = jnctn of middle 1/3 and lat 1/3 clavicle to xiphoid (runs med/ly along a line drawn from acromion to xiphisternum)
Paddle - entire skin over muscle (2 - sternocostal or clavicle)
Covers: breast implant, ant chest, sternum, axilla, neck
Recon: H&N, esophagus
Free - functional muscle
Will reach midline without release of insertion
Turnover an option for sternum
Key features of Serr Ant Flap?
O: Outer surface of 1-9 ribs
I: Costal surface of vertebral border of scapula
N: Long thoracic n
Pedicle: Long thoracic a (slips 1-4) & Branch of TD a (slips 5-8)
Incision: vertical incision in midaxillary line
Paddle: Btwn pec major and LD (vertical)
Cover: chest wall, neck. axilla, breast implant
Recon: breast
Loss of lower slips = winging
Only use for ant chest wall if LD absent
What is the pedicle for the trapezius flap?
Major: trans cerviacl a
Minor: occipital a, circumflex scapular, IC perfs
