Muscle Flaps

7/27/2019 Muscle Flaps

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Muscle Flaps

Trefor Nodwell MD CM

Dr. D. Lalonde, FRCSCDr. W. Parkhill, FRCSC


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Outline

Review Basic Anatomical and Physiologic Review

Reconstructive Goals & Principles

Classification Schemes with examples

Muscle Flaps Only Common Examples

Type/Pattern of CirculationApplications

Anatomy and Elevation


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Outline

Precautions/Pitfalls

Brief overview of Less Common (but applicable)flaps

Discussion


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The Basics - Anatomy

Motor nerves are always accompanied byvascular pedicles

Pedicles

Dominantcan sustain entire muscle on its own

Minormaintains only a portion of the muscle

Segmentalnourishes small segment of the muscle

Allows for a classification scheme


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The Basics- Physiology

Arc of Rotation

Standard

extent of reach of the muscle based onits dominant pedicle

Reverse (distally based)restricted by secondarypedicles


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The Basics- Physiology

Choke arteries

Small caliber vessels allowing bidirectional flow

Oscillating veins No valves, allows reversal of flow

Perforators

Vessels pass through muscle to supply overlying skin Identified preoperatively


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The Basics

Balance reconstructive needs and sacrifice ofnormal function

Reconstructive Ladder versus Triangle

Defect analysis

Location

Size

Physical Components

Environmenthost factors


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The basicsGoals & Principles

Safety - successful wound coverage

Identify and protect pedicle

Conservative skin territories

Tension- at pedicle or inset site

Form- normal shape or contour

Restoration at defect

Preservation at donor site


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The basicsGoals & Principles

Functionstability of closure, specializedfunctions.

Hair growth

Sensibility

Skeletal Support

Locomotion (or animation)


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Classification


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Classification

According to mode of innervation (Taylor) Type Isingle unbranched nerve enters muscle.

Type II- Single nerve, branches prior to entering. Type IIIMultiple branches from same nerve trunk.

Type IVMultiple branches from different nerve trunks.

Affects suitability for functioning muscle transfer


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Classification

Vascular Supply(Mathes and Nahai, PRS, 1981)

Type ISingle vascular pedicle

Type II

Dominant pedicle, minor pedicle(s) Type IIIDual dominant pedicles

Type IVSegmental Pedicles

Type VDominant pedicle with secondary segmental pedicles


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ExamplesType I

Single Vascular Pedicle

Tensor fascia Lata

Gastrocnemius

Genioglossus Stylogossus

Anconeus

First Dorsal Interosseus

Abductor Digiti Minimi(hand)

Abductor Pollicis Brevis Vastus Lateralis


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ExamplesType II

Dominant VascularPedicle and MinorPedicles

Gracilis Trapezius

Soleus

Rectus femoris

Coracobrachialis

Biceps Femoris

Triceps

SCM Platysma

Brachioradialis

Abductor digiti minimi

(foot)


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ExamplesType III

Two Dominant Pedicles

Gluteus Maximus

Rectus abdominus

Serratus Temporalis

Pectoralis Minor

Intercostal

Orbicularis oris


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ExamplesType IV

Segmental Pedicles

Sartorius

Tibialis Anterior

External Oblique Extensor Hallucis Longus

Flexor digitorum longus

Flexor hallucis longus


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ExamplesType V

Single Dominant andsecondary segmentalpedicles.

Latissimus Dorsi Fibula

Pectoralis Major

Internal oblique


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Common Examples

Each reviewed in terms ofApplications

FeaturesLocation, size, origin, insertion

Classification Nerve supplymotor and sensory

Function

Anatomy

vascularArc of rotation

Elevation


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Tensor Fascia Lata


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Tensor Fascia Lata - Type I

Applications- Coverage of lower abdominal wall,perineum, ischium and sacrum. Free flap.

Small thin, flat. 5X15cm.

OriginASIS and crest. Behind sartorius

InsertionIliotibial tract of Fascia Lata.

Innervation Superior Gluteal

T12 and lateral femoral cutaneous


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Function - flexes and abducts the thigh

Vascular AnatomyAscending branch lateral circumflex femoral (off

Profunda femoris) Pedicle: length7cm, Diameter 2-3mm

Arc of Rotation

Anterior

abdominal wall, groin, perineum Posteriorgreater trochanter, ischium, perineum,

sacrum.


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Musculocutaneous

V-Y advancement

Fasciocutaneous Precautions

Distal end less reliable (consider delay)

Donor site closure

possible thigh compartmentsyndrome

Donor site often requires grafting


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Gastrocnemius - Type I


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Applicationscoverage of inferior thigh, knee,contralateral leg.

Locationsuperficial posterior calf. Medial andlateral heads. 20X 8 cm.

Originsmedial and lateral femoral condyles

Insertioncalcaneus via Achilles tendon


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Pedicles Major - Medial and

Lateral sural arteries

Minorpaired

anastomotic sural vessels\

Innervation Tibial nerve

Saphenous (medial), Sural

(lateral)

Functionplantarflexion of the foot.


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Vascular Anatomy - medial and lateral muscles

Arc of rotation - Medial

Standard - suprapatellar thigh, knee, upper 1/3 tibia.

Extendedby 5-8cm

Distally basedmiddle third of leg.

V- Y advancement to Achilles


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Skin territories

Vertical and transverse islands. 10 X 23 cm

Elevation Supine or lateral decubitus position. Stocking seam incision

Pedicles in popliteal fossa entering deep surface, near

origins superior to popliteal crease Popliteal vein and tibial nervesuperficial to

popliteal artery


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Precautions

Preserve soleus

Tourniquet recommendedavoid nerve injury

Standard flap leaves better scar

Preoperative angiography

Relative contraindication

recent DVT


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GracilisType II


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GracilisType II

Applications

groin, perineum, abdomen,ischium. Vaginal reconstruction. Facialreanimation.

Location

medial thigh. Pubis to medial kneeThin, flat 6X24 cm.

Adductor longus and sartorius anteriorly

Semimembranosus posteriorly. OriginPubic symphysis

InsertionMedial Tibial condyle


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GracilisType II

Innervation

Motoranterior branch of obturator

Sensoryanterior femoral cutaneous (L2-3).

Function

thigh adductor.


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GracilisType II

Vascular Anatomy

Dominant

Ascending branch of medial circumflex femoral.

Length6 cm, Diameter1.6 mm.

Minor

one or two branches of superficial femoral

Length2 cm, Diameter0.5 mm


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GracilisType II

Arc of Rotation

Standardgroin perineum vagina, anus and ischium

Distalrequires delay, arc to knee.

Skin territory

Pubis to junction of middle and lower third betweenrectus anteriorly and biceps posteriorly.

16X18cm


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GracilisType II

Flap Elevation Draw line from Symphysis to medial femoral

condylecut 3cm posterior to this.

Pedicle location

10cm inferior to pubic tubercle.Retract the adductor longus to expose.

Muscle superficial to adductor magnus

Medial to adductor longus

Anterior to semimembranosus


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GracilisType II

Precautions

Selective arteriography if prior vascular surgery

Confirm skin island position often

Special case-

Functional muscle transplant

Mark muscle resting length with sutures prior to

disinsertion Dissect out obturator nerve

Vaginal reconstructionpaired flaps


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TrapeziusType II


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TrapeziusType II

Applications

Skull, head and neck, Oral cavity,posterior trunk and shoulder. Mandible facialreanimation.

Location

large, flat, triangular. Superficial. 34 X 18 cm Originexternal occipital protuberance, medial third of

sup. nuchal line, ligamentum nuchae, spinous processesof C7 to T12

Insertionlateral third of clavicle, spine of scapula,acromion.


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TrapeziusType II

Vascular anatomy

DominantTransverse cervical artery

Length 4 cm, diameter 1.8 mm

Minor Branch of Occipital artery

Length 3 cm, diameter 1mm Dorsal Scapular artery

Length 4 cm, diameter 1.6mm.


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TrapeziusType II

Innervation

MotorCN XI (spinal accessory)

Sensory - #rd and 4th cervical nerves, intercostals

Function

Rotates scapula, elevates shoulder during abductionand flexion of arms


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TrapeziusType II

Arc of Rotation

StandardPosterior skull, cervical and thoracicvertebral column, midface and neck.

Reverse

midline of trunk

Skin territory

20 X 8 cm.


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TrapeziusType II

Elevation

Mark midline, scapular border, midportion ofscapula. Midpoint between scapular tip and PSIS

Position prone or lateral decubitus

Pedicle

Vertical flap - vertical component TCA. Deep surface of

middle fibers, over superior rhomboid Lateral flapascending branch of TCA identified in

posterior neck


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TrapeziusType II

Vertical Flap


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TrapeziusType II

Precautions

Preserve superior fibers

Selective ateriography if radiated or radical neck

dissection.

Use Doppler to identify segmental vessels in reverseflap

Shoulder immobilization post op to avoid tension onclosure.


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SoleusType II


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SoleusType II

Applications

coverage of middle third +/- lower thirdof leg

Location large, broad, bipennate, deep to gastroc. Medial and lateral

bellies. Fused proximally. 8X28 cm (Flap dimensions 7-12 cm)

Origin Lateral posterior head and body of fibula

Medial middle third of medial border of tibia Insertion

Calcaneus via Achilles tendon


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SoleusType II

Innervation

Motorposterior tibial and medial popliteal nerves

Function- plantar flexion of the foot


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SoleusType II

Vascular Anatomy

Dominant Proximal two branches of popliteal artery (Length 0.5-1 cm,

diameter 1-1.5mm)

Proximal two branches of posterior tibial artery (Length 1-2cm, diameter 1-2 mm) medial belly

Proximal two branches of peroneal artery (Length 1-2 cm,diameter 1-2 mm) lateral belly

Minor 3-4 segmental branches of posterior tibial (L 1-1.5 cm, D 0.5

1mm)


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SoleusType II

Arc of rotation

Standardmiddle third of tibia

Distaldistal third of tibia, based on minorpedicles. (Distal hemisoleus, more reliable)


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SoleusType II

Elevation

Landmarksmedial border of tibia, fibulalaterally. Extends below gastrocs and plantaris.

Pedicle

Deep surface (Post tib medial, peroneal laterally)

Minor segmentalsdistal medial border


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SoleusType II

Standard Flap

Medial incision, transposed laterally.

Lateral approach

Hemisoleusmedial and lateral.

Pedicle length cannot be extended


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SoleusType II

Precautions

Congenital adhesions

Distally based lateral hemisoleus has less reach than

medial.


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Gluteus MaximusType III


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Applications

Sacrum , Ischium, Trochanter,breast reconstruction.

Locationlarge, quadrilateral, most superficial.

24X24 cm

Origingluteal line of ilium and sacrum

InsertionGreater tuberosity of femur, iliotibialband.


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Vascular Anatomy

Dominant

Superior gluteal artery (Length 3 cm, diameter 2.5 mm)

Inferior Gluteal artery (Length 3 cm, diameter 2.5 mm) Minor

First perforator of Profunda femoris (L 5 cm, D 1.5mm)

Intermuscular branches of lateral circumflex femoral (length1 cm, diameter, 0,6 mm)


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Innervation

Motorinferior gluteal nerve (L5 to S1-2) via sciaticforamen at level of piriformis

Sensory

Posterior divisions of L1-3 laterally, S1-3medially)

Function

Extends and laterally rotates the thigh


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Arc of Rotation

Standard

Axis edge of sacrum

Covers sacrum and ipsilateral ischium

Reverse (Inferior half)

Divide origin and inferior pedicle

To posterior lateral thigh

Segmental transposition


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Elevation

Easily identified

Standard flap

Superior halfcover sacrum

Inferior halfcover ischium


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Donor closure

Recommended, V-Y advancement may facilitate this.

Precautions

Not expendable

Denervation atrophy

Piriformiskey to division of midportion

Sciatic nerve

inferior flap


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Rectus AbdominusType III


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Applications

Thorax, abdomen, perineum,Breast, head and neck upper and lowerextremities.

Location

vertical, costal margin to pubis, longflat, three tendinous intersections.. Length 25X6cm.

Origin

crest of pubis, symphysis

Insertion5th to 7th ribs


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Innervation

Motorsegmental 7th to 12th intercostal nerves

Sensory7th to 12th intercostal nerves

Function

Flexes vertebral column, tenses abdominal wall.


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Vascular anatomy

Dominant

Superior epigastric (L 2cm, D 1.8 mm)

Inferior epigastric (L 5 cm, D 2.5 mm)

Minor

Subcostal and 6-7 intercostal arteries


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Arc of rotation

Standardtwo

Superior epigastricAnterior thorax

Inferior epigastric

Groin Perineum and inferiortrunk

Skin territory

Vertical standard or island

Transverse ipsilateral or TRAM


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Elevation

Landmarkscostal margins to pubic ramus

Easily palpable

Leg raising maneuver

Standard muscle flapnumerous modifications

Donor closure Critical to prevent herniation

Avoid tension on pedicle base


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Precautions

Previous abdominal surgery - Kocher, Pfannenstiel

Prior LIMA/RIMA surgery

Segmental flap elevation may not preserve function

Marlex mesh reinforcement

Direct donor site closure preferred.


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Serratus AnteriorType III


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Applications

head and neck, Thorax, axilla,posterior trunk, breast reconstruction and freetissue transfer

Thin, broad, multidigitated. 15X20cm.

Originouter surface upper nine ribs

Insertionventral surface of medial border ofscapula.


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Innervation

MotorLong thoracic N. (C5-7 roots)

SensoryT2-4 segmental intercostals

Function

pulls medial border of scapulaanteriorly. Prevents winging.


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Vascular anatomy

Dominant

Lateral thoracic (L 6-8 cm, D 2-2.5 mm)

Branches of Thoracodorsal (L 6-8 cm, D 2-2.5 mm)enters posterior to Lat. Thoracic.


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Arc of rotation

Standard - chest wall, shoulder, axilla, back.

Extendeddivide one of the two pedicles.

Combined Serratus-Latissimus dorsi flap.


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Elevation - Standard

Mark Lat. dorsi and Pec. major

Scapular tip

Elevate skin flaps anteriorly and posteriorly

Pedicles

Lateral Thoracic

upper 3-5 slips, deep to pecThoracodorsal6 cm lateral and below LT pedicle


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Identify lower 3-4 slips (on TD pedicle)

Identify Nerves

Lateral thoracicsuperficially, at 6th rib with TD

pedicle

Long Thoracic

Divide vessels to latissimus.

Donor site closed primarily.


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Precautions

Identify thoracodorsal pedicle early to speeddissection

Prevent winging

3-4 segments, preventdenervation.

Tunnelingpotential for vascular compromise.


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Latissimus DorsiType V


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Applications

among the most varied

Locationlarge flat, triangular, postero-inferiortrunk. Deep to trapezius. 25X35cm.

Origin

aponeurosis to thoraco lumbar fascia,T7-12 spinous processes, sacrum, post iliac crest

Insertionscapular tip. Intertubercular groove

of humerous.


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Vascular anatomy

Dominant

Thoraco dorsal artery (L 8 cm, D 2.5mm)

Secondary Segmental

Lateral Row (L2-3cm, D 2.5 mm)

Medial Row (L 1-2 cm, D 0.5 mm)


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Innervation

MotorThoracodorsal (C6-8)enters withdominant pedicle

Sensory

Lateral intercostal cutaneous nerves(divided)

Functionadducts, extends and rotates the

humorous


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Arc of Rotation Standard

Axis at posterior axilla

Posterior

neck, occiput, parietal skull.Anteriorhemi thorax, sternum, mid face, upper

abdomen.

Extended 5-10 cm more

Reverseoff segmentals

T


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Elevation -Standard muscle flap

Posterior axillary incision 5-10cm

Pediclein posterior axilla deep to muscle. 10-15 cm below insertion.

Proceed from inferior/medial to superior/lateral

Divide insertion only after pedicle is isolated

Donor site closuredirect 5-7cm.

L i i D i T V


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Precautions

Relative contraindication contra-lateral shouldergirdle is paralyzed

Denervated muscle is difficult to dissect Do not divide branch to serratus until subscapular-

thoracodorsal system is identified.

Adhesions with serratus Identify segmental vessels prior to reverse

transposition.

P li M j T V


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Pectoralis MajorType V

P li M j T V


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Applications Coverage, Reconstruction,Functional transfer, Free flap.

Locationflat, fan shaped. 15X23 cm.

Origin

Medial clavicle, anterior sternum, upperseven costal cartilages, ext. oblique aponeurosis.

InsertionLateral lip of bicipital groove.

P li M j T V


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Vascular Anatomy

Dominant

Pectoral branch of Thoracoacromial artery (L 4cm. D 2-2.5

mm) Minor

Pectoral branch of lateral thoracic (L 3-4 cm, D 1-2 mm)

Minor Segmental

Internal mammary perforators (L 1-2 cm, D 1-2mm)

Intercostal perforators, 5-7th (L 1-2 cm, D


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Innervation Motor

Lateral (Superior) Pectoral nerve deep surface near

dominant pedicle. Medial (Inferior) Pectoral nervevia pec minor to

posterolateral pec major.

Sensory 2-7th intercostal nerves

Functionarm adduction and medial rotation.

P li M j T V


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Arc of rotation

Standard

Head and neck, sternal defects

Extended

3-5 cmInferior orbital rim, intrathoracic cavity

Reverse (turn over)

Sternum and mediastinum

P li M j T V


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Elevation Standard (Thoraco acromial pedicle)

Midline incision elevate skin flaps then muscle

Identify pedicle

deep surface, junction of middleand lateral thirds of clavicle.

Minor pedicles cauterized.

Incise origin

island muscle flap

P li M j T V


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Precautions Less reliable as vascularized bone flap (5th-6th rib)

Bulky in head and neck reconstruction

Donor deformity (loss of axillary fold)

minimizedwith segmental transpositions.

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