Muscle Flaps

1
Muscle Flaps

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

2
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

3
Outline

• Precautions/Pitfalls
• Brief overview of Less Common (but applicable)
  flaps
• Discussion

4
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

5
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

6
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

7
The Basics

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

8
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

9
The basics Goals Principles

• Function stability of closure, specialized
  functions.
• Hair growth
• Sensibility
• Skeletal Support
• Locomotion (or animation)

10
Classification
11
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

12
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

13
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

14
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)

15
Examples Type III

• Two Dominant Pedicles
• Gluteus Maximus
• Rectus abdominus
• Serratus
• Temporalis
• Pectoralis Minor

• Intercostal
• Orbicularis oris

16
Examples Type IV

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

17
Examples Type V

• Single Dominant and secondary segmental pedicles.
• Latissimus Dorsi
• Fibula
• Pectoralis Major
• Internal oblique

18
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

19
Tensor Fascia Lata
20
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

21
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.

22
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

23
Gastrocnemius - Type I
24
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

25
Gastrocnemius - Type I

• Pedicles
• Major - Medial and Lateral sural arteries
• Minor paired anastomotic sural vessels\
• Innervation
• Tibial nerve
• Saphenous (medial), Sural (lateral)
• Function plantar flexion of the foot.

26
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

27
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

28
Gastrocnemius - Type I

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

29
Gracilis Type II
30
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

31
Gracilis Type II

• Innervation
• Motor anterior branch of obturator
• Sensory anterior femoral cutaneous (L2-3).
• Function thigh adductor.

32
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

33
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

34
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

35
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

36
Trapezius Type II
37
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.

38
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.

39
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

40
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.

41
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

42
Trapezius Type II

• Vertical Flap

43
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.

44
Soleus Type II
45
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)
• Origin
• Lateral posterior head and body of fibula
• Medial middle third of medial border of tibia
• Insertion
• Calcaneus via Achilles tendon

46
Soleus Type II

• Innervation
• Motor posterior tibial and medial popliteal
  nerves
• Function- plantar flexion of the foot

47
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
• Minor
• 3-4 segmental branches of posterior tibial (L
  1-1.5 cm, D 0.5 1mm)

48
Soleus Type II

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

49
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

50
Soleus Type II

• Standard Flap
• Medial incision, transposed laterally.
• Lateral approach
• Hemisoleus medial and lateral.
• Pedicle length cannot be extended

51
Soleus Type II

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

52
Gluteus Maximus Type III
53
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.

54
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)
• Minor
• First perforator of Profunda femoris (L 5 cm, D
  1.5mm)
• Intermuscular branches of lateral circumflex
  femoral (length 1 cm, diameter, 0,6 mm)

55
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

56
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

57
Gluteus Maximus Type III

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

58
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

59
Rectus Abdominus Type III
60
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

61
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.

62
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

63
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

64
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

65
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.

66
Serratus Anterior Type III
67
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.

68
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.

69
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.

70
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.

71
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

72
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.

73
Serratus Anterior Type III

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

74
Latissimus Dorsi Type V
75
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.

76
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)

77
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

78
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

79
Latissimus Dorsi Type V

• Elevation -Standard muscle flap
• Posterior axillary incision 5-10cm
• Pedicle in 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 closure direct 5-7cm.

80
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
  subscapular-thoracodorsal system is identified.
• Adhesions with serratus
• Identify segmental vessels prior to reverse
  transposition.

81
Pectoralis Major Type V
82
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.

83
Pectoralis Major Type V

• 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
  lt0.5mm)

84
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.

85
Pectoralis Major Type V

• Arc of rotation
• Standard
• Head and neck, sternal defects
• Extended
• 3-5 cm Inferior orbital rim, intrathoracic
  cavity
• Reverse (turn over)
• Sternum and mediastinum

86
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

87
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.