Muscle Flaps

Trefor Nodwell MD CM Dr. D. Lalonde, FRCSC Dr. W. Parkhill, FRCSC

Outline

Review
Basic Anatomical and Physiologic Review Reconstructive Goals & Principles Classification Schemes with examples

Muscle Flaps Only

Common Examples
Type/Pattern of Circulation Applications Anatomy and Elevation

Outline

Precautions/Pitfalls

Brief overview of Less Common (but applicable) flaps Discussion

The Basics - Anatomy

Motor nerves are always accompanied by vascular pedicles Pedicles

Dominant can sustain entire muscle on its own Minor maintains only a portion of the muscle Segmental nourishes small segment of the muscle

Allows for a classification scheme

The Basics- Physiology

Arc of Rotation
Standard extent of reach of the muscle based on its dominant pedicle Reverse (distally based) restricted by secondary pedicles

The Basics- Physiology

Choke arteries

Small caliber vessels allowing bidirectional flow

No valves, allows reversal of flow

Oscillating veins

Perforators
Vessels pass through muscle to supply overlying skin Identified preoperatively

The Basics

Balance reconstructive needs and sacrifice of normal function Reconstructive Ladder versus Triangle Defect analysis
Location Size Physical Components

Environment host factors

The basics Goals & 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

The basics Goals & Principles

Function stability of closure, specialized functions.

Hair growth Sensibility Skeletal Support Locomotion (or animation)

Classification

Classification

According to mode of innervation (Taylor)

Type I single unbranched nerve enters muscle. Type II- Single nerve, branches prior to entering. Type III Multiple branches from same nerve trunk. Type IV Multiple branches from different nerve trunks.

Affects suitability for functioning muscle transfer

Classification

Vascular Supply (Mathes and Nahai, PRS, 1981) Type I Single vascular pedicle Type II Dominant pedicle, minor pedicle(s) Type III Dual dominant pedicles Type IV Segmental Pedicles Type V Dominant pedicle with secondary segmental pedicles

Examples Type I

Single Vascular Pedicle

Tensor fascia Lata Gastrocnemius Genioglossus Stylogossus Anconeus

First Dorsal Interosseus Abductor Digiti Minimi (hand) Abductor Pollicis Brevis Vastus Lateralis

Examples Type II

Dominant Vascular Pedicle and Minor Pedicles

Gracilis Trapezius Soleus Rectus femoris

Coracobrachialis Biceps Femoris Triceps SCM Platysma Brachioradialis Abductor digiti minimi (foot)

Examples Type III

Two Dominant Pedicles

Gluteus Maximus Rectus abdominus Serratus Temporalis Pectoralis Minor

Intercostal Orbicularis oris

Examples Type IV

Segmental Pedicles

Sartorius Tibialis Anterior External Oblique Extensor Hallucis Longus Flexor digitorum longus Flexor hallucis longus

Examples Type V

Single Dominant and secondary segmental pedicles.

Latissimus Dorsi Fibula Pectoralis Major Internal oblique

Common Examples

Each reviewed in terms of

Applications Features Location, size, origin, insertion Classification Nerve supply motor and sensory Function Anatomy vascular Arc of rotation Elevation

Tensor Fascia Lata

Tensor Fascia Lata - Type I

Applications- Coverage of lower abdominal wall, perineum, ischium and sacrum. Free flap. Small thin, flat. 5X15cm. Origin ASIS and crest. Behind sartorius Insertion Iliotibial tract of Fascia Lata. Innervation
Superior Gluteal T12 and lateral femoral cutaneous

Tensor Fascia Lata - Type I

Function - flexes and abducts the thigh Vascular Anatomy

Ascending branch lateral circumflex femoral (off Profunda femoris) Pedicle: length 7cm, Diameter 2-3mm

Arc of Rotation
Anterior abdominal wall, groin, perineum Posterior greater trochanter, ischium, perineum, sacrum.

Tensor Fascia Lata - Type I

Musculocutaneous V-Y advancement Fasciocutaneous Precautions

Distal end less reliable (consider delay) Donor site closure possible thigh compartment syndrome Donor site often requires grafting

Gastrocnemius - Type I

Gastrocnemius - Type I

Applications coverage of inferior thigh, knee, contralateral leg. Location superficial posterior calf. Medial and lateral heads. 20X 8 cm. Origins medial and lateral femoral condyles Insertion calcaneus via Achilles tendon

Gastrocnemius - Type I

Pedicles

Major - Medial and Lateral sural arteries Minor paired anastomotic sural vessels\
Tibial nerve Saphenous (medial), Sural (lateral)

Innervation

Function plantar flexion of the foot.

Gastrocnemius - Type I

Vascular Anatomy - medial and lateral muscles Arc of rotation - Medial

Standard - suprapatellar thigh, knee, upper 1/3 tibia. Extended by 5-8cm Distally based middle third of leg. V- Y advancement to Achilles

Gastrocnemius - Type I

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 nerve superficial to popliteal artery

Gastrocnemius - Type I

Precautions

Preserve soleus

Tourniquet recommended avoid nerve injury Standard flap leaves better scar Preoperative angiography Relative contraindication recent DVT

Gracilis Type II

Gracilis Type II

Applications groin, perineum, abdomen, ischium. Vaginal reconstruction. Facial reanimation. Location medial thigh. Pubis to medial knee
Thin, flat 6X24 cm. Adductor longus and sartorius anteriorly Semimembranosus posteriorly.

Origin Pubic symphysis Insertion Medial Tibial condyle

Gracilis Type II

Innervation
Motor anterior branch of obturator Sensory anterior femoral cutaneous (L2-3).

Function thigh adductor.

Gracilis Type II

Vascular Anatomy Dominant

Ascending branch of medial circumflex femoral. Length 6 cm, Diameter 1.6 mm.

Minor
one or two branches of superficial femoral Length 2 cm, Diameter 0.5 mm

Gracilis Type II

Arc of Rotation
Standard groin perineum vagina, anus and ischium Distal requires delay, arc to knee.

Skin territory
Pubis to junction of middle and lower third between rectus anteriorly and biceps posteriorly. 16X18cm

Gracilis Type II

Flap Elevation
Draw line from Symphysis to medial femoral condyle cut 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

Gracilis Type 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 reconstruction paired flaps

Trapezius Type II

Trapezius Type II

Applications Skull, head and neck, Oral cavity, posterior trunk and shoulder. Mandible facial reanimation. Location large, flat, triangular. Superficial. 34 X 18 cm Origin external occipital protuberance, medial third of sup. nuchal line, ligamentum nuchae, spinous processes of C7 to T12 Insertion lateral third of clavicle, spine of scapula, acromion.

Trapezius Type II

Vascular anatomy Dominant

Transverse 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.

Trapezius Type II

Innervation
Motor CN XI (spinal accessory) Sensory - #rd and 4th cervical nerves, intercostals

Function

Rotates scapula, elevates shoulder during abduction and flexion of arms

Trapezius Type II

Arc of Rotation
Standard Posterior skull, cervical and thoracic vertebral column, midface and neck. Reverse midline of trunk

Skin territory

20 X 8 cm.

Trapezius Type II

Elevation
Mark midline, scapular border, midportion of scapula. 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 flap ascending branch of TCA identified in posterior neck

Trapezius Type II

Vertical Flap

Trapezius Type II

Precautions
Preserve superior fibers Selective ateriography if radiated or radical neck dissection. Use Doppler to identify segmental vessels in reverse flap Shoulder immobilization post op to avoid tension on closure.

Soleus Type II

Soleus Type II

Applications coverage of middle third +/- lower third of leg Location

large, broad, bipennate, deep to gastroc. Medial and lateral bellies. Fused proximally. 8X28 cm (Flap dimensions 7-12 cm) Lateral posterior head and body of fibula Medial middle third of medial border of tibia Calcaneus via Achilles tendon

Origin

Insertion

Soleus Type II

Innervation

Motor posterior tibial and medial popliteal nerves

Function- plantar flexion of the foot

Soleus Type 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 1-2 cm, diameter 1-2 mm) medial belly Proximal two branches of peroneal artery (Length 1-2 cm, diameter 1-2 mm) lateral belly 3-4 segmental branches of posterior tibial (L 1-1.5 cm, D 0.5 1mm)

Minor

Soleus Type II

Arc of rotation Standard middle third of tibia Distal distal third of tibia, based on minor pedicles. (Distal hemisoleus, more reliable)

Soleus Type II

Elevation Landmarks medial border of tibia, fibula laterally. Extends below gastrocs and plantaris. Pedicle
Deep surface (Post tib medial, peroneal laterally) Minor segmentals distal medial border

Soleus Type II

Standard Flap

Medial incision, transposed laterally.

Lateral approach Hemisoleus medial and lateral. Pedicle length cannot be extended

Soleus Type II

Precautions
Congenital adhesions Distally based lateral hemisoleus has less reach than medial.

Gluteus Maximus Type III

Gluteus Maximus Type III

Applications Sacrum , Ischium, Trochanter, breast reconstruction. Location large, quadrilateral, most superficial. 24X24 cm Origin gluteal line of ilium and sacrum Insertion Greater tuberosity of femur, iliotibial band.

Gluteus Maximus Type III

Vascular Anatomy Dominant

Superior gluteal artery (Length 3 cm, diameter 2.5 mm) Inferior Gluteal artery (Length 3 cm, diameter 2.5 mm) First perforator of Profunda femoris (L 5 cm, D 1.5mm) Intermuscular branches of lateral circumflex femoral (length 1 cm, diameter, 0,6 mm)

Minor

Gluteus Maximus Type III

Innervation
Motor inferior gluteal nerve (L5 to S1-2) via sciatic foramen at level of piriformis Sensory Posterior divisions of L1-3 laterally, S1-3 medially)

Function

Extends and laterally rotates the thigh

Gluteus Maximus Type III

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

Gluteus Maximus Type III

Elevation Easily identified Standard flap Superior half cover sacrum Inferior half cover ischium

Gluteus Maximus Type III

Donor closure

Recommended, V-Y advancement may facilitate this.

Precautions
Not expendable Denervation atrophy Piriformis key to division of midportion Sciatic nerve inferior flap

Rectus Abdominus Type III

Rectus Abdominus Type III

Applications Thorax, abdomen, perineum, Breast, head and neck upper and lower extremities. Location vertical, costal margin to pubis, long flat, three tendinous intersections.. Length 25X6 cm. Origin crest of pubis, symphysis Insertion 5th to 7th ribs

Rectus Abdominus Type III

Innervation
Motor segmental 7th to 12th intercostal nerves Sensory 7th to 12th intercostal nerves

Function

Flexes vertebral column, tenses abdominal wall.

Rectus Abdominus Type III

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

Rectus Abdominus Type III

Arc of rotation Standard two

Superior epigastric Anterior thorax Inferior epigastric Groin Perineum and inferior trunk

Skin territory
Vertical standard or island Transverse ipsilateral or TRAM

Rectus Abdominus Type III

Elevation Landmarks costal margins to pubic ramus Easily palpable Leg raising maneuver Standard muscle flap numerous modifications Donor closure
Critical to prevent herniation Avoid tension on pedicle base

Rectus Abdominus Type III

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.

Serratus Anterior Type III

Serratus Anterior Type III

Applications head and neck, Thorax, axilla, posterior trunk, breast reconstruction and free tissue transfer Thin, broad, multidigitated. 15X20cm. Origin outer surface upper nine ribs Insertion ventral surface of medial border of scapula.

Serratus Anterior Type III

Innervation
Motor Long thoracic N. (C5-7 roots) Sensory T2-4 segmental intercostals

Function pulls medial border of scapula anteriorly. Prevents winging.

Serratus Anterior Type III

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.

Serratus Anterior Type III

Arc of rotation Standard - chest wall, shoulder, axilla, back. Extended divide one of the two pedicles. Combined Serratus-Latissimus dorsi flap.

Serratus Anterior Type III

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 pec Thoracodorsal 6 cm lateral and below LT pedicle

Serratus Anterior Type III

Identify lower 3-4 slips (on TD pedicle) Identify Nerves

Lateral thoracic superficially, at 6th rib with TD pedicle Long Thoracic

Divide vessels to latissimus. Donor site closed primarily.

Serratus Anterior Type III

Precautions
Identify thoracodorsal pedicle early to speed dissection Prevent winging 3-4 segments, prevent denervation. Tunneling potential for vascular compromise.

Latissimus Dorsi Type V

Latissimus Dorsi Type V

Applications among the most varied Location large flat, triangular, postero-inferior trunk. Deep to trapezius. 25X35cm. Origin aponeurosis to thoraco lumbar fascia, T7-12 spinous processes, sacrum, post iliac crest Insertion scapular tip. Intertubercular groove of humerous.

Latissimus Dorsi Type V

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)

Latissimus Dorsi Type V

Innervation
Motor Thoracodorsal (C6-8) enters with dominant pedicle Sensory Lateral intercostal cutaneous nerves (divided)

Function adducts, extends and rotates the humorous

Latissimus Dorsi Type V

Arc of Rotation Standard

Axis at posterior axilla Posterior neck, occiput, parietal skull. Anterior hemi thorax, sternum, mid face, upper abdomen.

Extended

5-10 cm more

Reverse off segmentals

Latissimus Dorsi Type V

Elevation -Standard muscle flap Posterior axillary incision 5-10cm Pedicle in posterior axilla deep to muscle. 1015 cm below insertion. Proceed from inferior/medial to superior/lateral Divide insertion only after pedicle is isolated Donor site closure direct 5-7cm.

Latissimus Dorsi Type V

Precautions
Relative contraindication contra-lateral shoulder girdle is paralyzed Denervated muscle is difficult to dissect Do not divide branch to serratus until subscapularthoracodorsal system is identified. Adhesions with serratus Identify segmental vessels prior to reverse transposition.

Pectoralis Major Type V

Pectoralis Major Type V

Applications Coverage, Reconstruction, Functional transfer, Free flap. Location flat, fan shaped. 15X23 cm. Origin Medial clavicle, anterior sternum, upper seven costal cartilages, ext. oblique aponeurosis. Insertion Lateral lip of bicipital groove.

Pectoralis Major Type V

Vascular Anatomy Dominant

Pectoral branch of Thoracoacromial artery (L 4cm. D 2-2.5 mm) Pectoral branch of lateral thoracic (L 3-4 cm, D 1-2 mm)

Minor

Minor Segmental

Internal mammary perforators (L 1-2 cm, D 1-2mm) Intercostal perforators, 5-7th (L 1-2 cm, D <0.5mm)

Pectoralis Major Type V

Innervation Motor
Lateral (Superior) Pectoral nerve deep surface near dominant pedicle. Medial (Inferior) Pectoral nerve via pec minor to posterolateral pec major.

Sensory

2-7th intercostal nerves

Function arm adduction and medial rotation.

Pectoralis Major Type V

Arc of rotation Standard

Head and neck, sternal defects 3-5 cm Inferior orbital rim, intrathoracic cavity

Extended

Reverse (turn over)

Sternum and mediastinum

Pectoralis Major Type V

Elevation

Standard (Thoraco acromial pedicle)

Midline incision elevate skin flaps then muscle

Identify pedicle deep surface, junction of middle and lateral thirds of clavicle. Minor pedicles cauterized.

Incise origin island muscle flap

Pectoralis Major Type V

Precautions
Less reliable as vascularized bone flap (5th-6th rib) Bulky in head and neck reconstruction Donor deformity (loss of axillary fold) minimized with segmental transpositions.