Vascularized free muscle flaps are indicated for complex reconstruction of:

1. Defects requiring filling of dead space

2. Coverage of exposed vital structures

3. Treatment of osteomyelitis

4. Functional reconstruction of muscle loss or absence in congenital conditions

5. Coverage of exposed orthopedic hardware

The indications are numerous and varied, but most common for reconstruction of
complex defects with exposed vital structures such as bone, tendon, nerve, vein graft or
other major vessels. Often, muscle flaps are used for defects where skin grafting or local
flaps would not adequately address the defect, or where skin grafting or local flaps have
previously failed.

Selection Of Muscle Over Other Types Of Flaps

Muscle flaps are often the first and best choice. However, muscle flap selection after
failure of treatment with other modalities necessitates diagnosis of the etiology of
previous failure. The issues that would negatively impact free flap success should be
assessed. For instance, if a previous lower extremity gastrocnemius flap failed to
adequately treat a complex open tibial wound, the surgeon should ascertain if poor
vascular inflow to the leg compromised muscle perfusion. Similarly, if inadequate
debridement and control of the bed promoted infection and wound recurrence, the bed
should be adequately debrided or controlled before a free flap is performed. Other
factors that may have led to local flap or conservative treatment failure include
inadequate immobilization in the postoperative period, or overly aggressive
dangling/dependency. Both can lead to wound dehiscence and or vascular compromise
and pedicle thrombosis. Of course, multiple other contributors to failure of treatment
such as poorly controlled diabetes, active smoking, immunosuppression, etc. need be
considered.
When underlying treatable conditions that promote failure are corrected or addressed,
the choice of muscle flap over other free flaps depends on surgeon preference and
comfort, pedicle needs, wound dimensions, donor site morbidity, defect location and the
need for future surgical treatment.

Advantages Of Muscle Flaps

Muscle flaps have significant advantages over skin and/or fasciocutaneous flaps. They
have many features that make them well suited to reconstruction of complex wounds.
Muscles are indicated to:
 Obliterate dead space
Increase perfusion and resistance to infection

Provide functional innervated coverage

Cover exposed vital structures

Complex three dimensional wounds can be filled and obliterated with muscle to reduce
the potential of fluid collection/and or dead space that can be susceptible to infection or
bursa formation. Mathes and Chang demonstrated elegantly that muscle has tremendous
infection fighting ability, perhaps because it has increased vascular perfusion in
comparison to fasciocutaneous or skin flaps. This quality makes muscle a good choice for
complex wounds, especially wounds that have been contaminated by long term dressing
changes and or subatmospheric pressure dressings.

Limitations

Selection of a muscle flap is not a substitute for adequate debridement and control of
underlying infection or contamination. Infection or colonization should be controlled
before flap coverage of any kind by appropriate wound management, antibiotic coverage
and treatment of comorbidities if possilbe.
Skin grafting of muscle can be a potential advantage of these flaps, but it can also be a
disadvantage depending on circumstances. A skin paddle may alleviate the need for
grafting if it is harvested with the flap. But it may not be appropriate in some cases. Skin
grafts heal more slowly in the initial post-operative period than skin flaps and this should
be considered. The decreased durability of a skin graft over muscle relative to a skin flap
in the first few weeks after surgery can be a drawback. There are times when a slow
healing or a failed skin graft can interfere with recovery by impeding mobilization and
therapy, and delay secondary surgery such as bone grafting. A slow healing skin graft with
eschar or open areas might delay radiation or chemotherapy.

Bibliography

1. Anthony, J.P., S.J. Mathes, and B.S. Alpert, The muscle flap in the treatment of chronic
lower extremity osteomyelitis: results in patients over 5 years after treatment. Plast
Reconstr Surg, 1991. 88(2): p. 311-8.
2. Briones, R., et al., Single pedicle microvascular transfers of the serratus anterior and
latissimus dorsi muscles in rats. Microsurgery, 1989. 10(4): p. 269-73.

3. Bunkis, J., R.L. Walton, and S.J. Mathes, The rectus abdominis free flap for lower
extremity reconstruction. Ann Plast Surg, 1983. 11(5): p. 373-80.
4. Buntic, R.F. and D. Brooks, Free partial medial rectus muscle flap for closure of
complex extremity wounds. Plast Reconstr Surg, 2005. 116(5): p. 1434-7.

5. Buntic, R.F., et al., The free partial superior latissimus muscle flap: preservation of
donor-site form and function. Plast Reconstr Surg, 2008. 121(5): p. 1659-63.

6. Calderon, W., N. Chang, and S.J. Mathes, Comparison of the effect of bacterial
inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg,
1986. 77(5): p. 785-94.

7. Cetrulo, C.L., Jr., et al., Management of exposed total knee prostheses with
microvascular tissue transfer. Microsurgery, 2008. 28(8): p. 617-22.

8. Chang, K.N., S.J. DeArmond, and H.J. Buncke, Jr., Sensory reinnervation in
microsurgical reconstruction of the heel. Plast Reconstr Surg, 1986. 78(5): p. 652-64.

9. Chang, N. and S.J. Mathes, Comparison of the effect of bacterial inoculation in

musculocutaneous and random-pattern flaps. Plast Reconstr Surg, 1982. 70(1): p. 1-
10.

10. Cordeiro, P.G., R.I. Neves, and D.A. Hidalgo, The role of free tissue transfer following
oncologic resection in the lower extremity. Ann Plast Surg, 1994. 33(1): p. 9-16.

11. Doi, K., et al., Reinnervated free muscle transplantation for extremity
reconstruction. Plast Reconstr Surg, 1993. 91(5): p. 872-83.

12. Gayle, L.B., et al., Treatment of chronic osteomyelitis of the lower extremities with
debridement and microvascular muscle transfer. Clin Plast Surg, 1992. 19(4): p. 895-
903.

13. Mathes, S.J., B.S. Alpert, and N. Chang, Use of the muscle flap in chronic
osteomyelitis: experimental and clinical correlation. Plast Reconstr Surg, 1982. 69(5):
p. 815-29.

14. Mathes, S.J., The muscle flap for management of osteomyelitis. N Engl J Med, 1982.
306(5): p. 294-5.

15. Ong, Y.S. and L.S. Levin, Lower limb salvage in trauma. Plast Reconstr Surg, 2010.
125(2): p. 582-8.

16. Sasmor, M.T., et al., Vascular resistance considerations in free-tissue transfer. J

Reconstr Microsurg, 1992. 8(3): p. 195-200.

17. Takayanagi, S. and T. Tsukie, Free serratus anterior muscle and myocutaneous
flaps. Ann Plast Surg, 1982. 8(4): p. 277-83.

18. Weinzweig, N. and J. Schuler, Free tissue transfer in treatment of the recalcitrant
chronic venous ulcer. Ann Plast Surg, 1997. 38(6): p. 611-9.

19. Weinzweig, N., et al., Lower-limb salvage in a patient with recalcitrant venous
ulcerations. J Reconstr Microsurg, 1997. 13(6): p. 431-7.
 20. Whitney, T.M., et al., The serratus anterior free-muscle flap: experience with 100
consecutive cases. Plast Reconstr Surg, 1990. 86(3): p. 481-90; discussion 491.

Copyright 2001-2016 Rudolf Buntic ~ Rudy Buntic, MD.

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Vascularized Muscle Flaps

Vascularized free muscle flaps are indicated for complex reconstruction of:
1. Defects requiring filling of dead space
2. Coverage of exposed vital structures

3. Treatment of osteomyelitis

4. Functional reconstruction of muscle loss or absence in congenital conditions

5. Coverage of exposed orthopedic hardware

The indications are numerous and varied, but most common for reconstruction of
complex defects with exposed vital structures such as bone, tendon, nerve, vein graft
or other major vessels. Often, muscle flaps are used for defects where skin grafting or
local flaps would not adequately address the defect, or where skin grafting or local
flaps have previously failed.

Selection of Muscle over Other Types of Flaps

Muscle flaps are often the first and best choice. However, muscle flap selection after
failure of treatment with other modalities necessitates diagnosis of the etiology of
previous failure. The issues that would negatively impact free flap success should be
assessed. For instance, if a previous lower extremity gastrocnemius flap failed to
adequately treat a complex open tibial wound, the surgeon should ascertain if poor
vascular inflow to the leg compromised muscle perfusion. Similarly, if inadequate
debridement and control of the bed promoted infection and wound recurrence, the
bed should be adequately debrided or controlled before a free flap is performed.
Other factors that may have led to local flap or conservative treatment failure include
inadequate immobilization in the postoperative period, or overly aggressive
dangling/dependency. Both can lead to wound dehiscence and or vascular
compromise and pedicle thrombosis. Of course, multiple other contributors to failure
of treatment such as poorly controlled diabetes, active smoking,
immunosuppression, etc. need be considered.
 When underlying treatable conditions that promote failure are corrected or
addressed, the choice of muscle flap over other free flaps depends on surgeon
preference and comfort, pedicle needs, wound dimensions, donor site morbidity,
defect location and the need for future surgical treatment.

Advantages of Muscle Flaps

Muscle flaps have significant advantages over skin and/or fasciocutaneous flaps. They
have many features that make them well suited to reconstruction of complex
wounds. Muscles are indicated to:
Obliterate dead space
Increase perfusion and resistance to infection

Provide functional innervated coverage

Cover exposed vital structures

Complex three dimensional wounds can be filled and obliterated with muscle to
reduce the potential of fluid collection/and or dead space that can be susceptible to
infection or bursa formation. Mathes and Chang demonstrated elegantly that muscle
has tremendous infection fighting ability, perhaps because it has increased vascular
perfusion in comparison to fasciocutaneous or skin flaps. This quality makes muscle a
good choice for complex wounds, especially wounds that have been contaminated by
long term dressing changes and or subatmospheric pressure dressings.

Limitations
Selection of a muscle flap is not a substitute for adequate debridement and control
of underlying infection or contamination. Infection or colonization should be
controlled before flap coverage of any kind by appropriate wound management,
antibiotic coverage and treatment of comorbidities if possilbe.
Skin grafting of muscle can be a potential advantage of these flaps, but it can also be
a disadvantage depending on circumstances. A skin paddle may alleviate the need for
grafting if it is harvested with the flap. But it may not be appropriate in some cases.
Skin grafts heal more slowly in the initial post-operative period than skin flaps and
this should be considered. The decreased durability of a skin graft over muscle
relative to a skin flap in the first few weeks after surgery can be a drawback. There
are times when a slow healing or a failed skin graft can interfere with recovery by
impeding mobilization and therapy, and delay secondary surgery such as bone
grafting. A slow healing skin graft with eschar or open areas might delay radiation or
chemotherapy.