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Muscle and myocutaneous flaps are common reconstructive options for patients with acquired traumatic or oncologic defects. While fasciocutaneous and perforator flaps have emerged as elegant reconstructive options for various indications, muscle and myocutaneous flaps remain workhorse flaps, especially in large or infected wounds. Therefore, knowledge of flap anatomy and surgical techniques is paramount for plastic and reconstructive surgeons. This activity reviews muscle and myocutaneous flaps, highlighting the anatomy, technique, pitfalls, and role of the interprofessional team in caring for patients. Objectives: Identify the anatomical structures, indications, and contraindications of muscle and myocutaneous flaps. Describe the technique in regards to muscle and myocutaneous flaps. Review appropriate evaluation of the potential complications and clinical significance of muscle and myocutaneous flaps. Summarize interprofessional team strategies for improving care coordination and communication to advance muscle and myocutaneous flap surgeries and improve outcomes. Access free multiple choice questions on this topic.

The definition of a flap is a piece of tissue with a defined blood supply, which differentiates it from a graft, where a piece of tissue is freed from any defined blood supply and re-planted to be absorbed into the native tissue surrounding it. The first flaps were performed in 600 BC by the ancient Indian physician Sushruta who utilized regional flaps for nasal reconstruction after amputation. Unlike skin grafts, or other grafts, which rely on the vascularity of the recipient wound bed for survival, flaps describe a larger amount of tissue with its own blood supply. Through anatomic studies, improved technology, and wartime injuries, flap reconstruction evolved to address complex traumatic and oncologic defects.[1] Around the 1900s, surgeons in Europe began experimenting with muscle and skin/composite flaps, particularly Sir Harold Gilles, for facial reconstruction in soldiers wounded in World War I. From these local and regional movements of composite tissues, the concept of angiosomes was developed, and anatomical studies began into the blood supply to more superficial muscular and musculocutaneous tissues. Many of these early reconstructive flaps were based on random blood supply and occurred in multiple stages, the so-called "waltzing" flaps, and were very successful. As anatomical and physiological knowledge matured, the blood supply to individual areas of the body was more understood, allowing for transposition of tissue from healthy to wounded areas. Rectus abdominis muscle flaps were used to reinforce hernia repairs and, shortly after, surgeons performed the first latissimus dorsi muscle and myocutaneous flaps in breast reconstruction after mastectomy, representing some of the early efforts at functional and aesthetic reconstructive surgery outside of the arena of war wounds.[2][3] With the evolution of soft-tissue reconstruction, microsurgery, and free-tissue transfer, muscle and myocutaneous flaps have become established workhorse flaps for numerous types of reconstructive surgeries. Although perforator and fasciocutaneous flaps have recently grown in popularity, muscle and myocutaneous flaps have vascular supply from named vessels and have a consistent blood supply, and remain a good option for many different reconstructions. Additionally, muscle flaps are effective in filling dead space and decreasing the bacterial concentration of wounds. They remain an essential part of the reconstructive armamentarium of the modern reconstructive surgeon.[4]

Complications of muscle and myocutaneous flaps include infection, partial or total flap loss, seroma or hematoma of donor and recipient sites, fat necrosis, and wound dehiscence. Specific flaps such as the TRAM flap may lead to hernia or significant abdominal laxity, while latissimus dorsi donor sites are notorious for seroma formation if not adequately drained.[9][10] Even moderately sized hematomas in a confined space can compress the vascular pedicle and lead to total flap failure.Post-operatively, flap patients require monitoring for signs of flap compromise. Muscle flaps that begin to appear gray or bleed poorly with pinprick are ischemic and should go to the operating room immediately for exploration. Myocutaneous flaps have an added benefit of a skin paddle that serves as a monitor for overall flap status. Venous congestion of the skin paddle may appear as a blue hue indicative of venous congestion or thrombosis. Unlike fasciocutaneous flaps, muscle and myocutaneous flaps tolerate ischemia poorly, and any concern for flap ischemia necessitates an expeditious return to the operating room for flap exploration. Depending on the location of muscle or myocutaneous flaps, appropriate positioning measures should be undertaken to ensure vascular pedicles do not become compressed. Extremity flap patients should adhere to a dangle protocol to avoid the devastating effects of venous congestion.

The optimal care for muscle and myocutaneous flap patients involves an experienced microsurgeon, anesthesia, and operating room staff familiar with complexities of flap surgery, nurses attentive to flap monitoring, and a facility with appropriate instrumentation and support. Preoperatively, access to CT angiogram allows for confirmation of recipient vessels and evaluation of proposed flap vascular anatomy in cases of prior surgery. Intraoperatively, communication between the anesthesia and surgical team is vital to minimize hemodynamic fluctuations and maintain paralysis. Surgical-specialty nursing can be of great benefit during the procedure, especially if they have training or experience in flap procedures. Postoperatively, wound-management specialty-trained nurses familiar with managing flap patients are instrumental in quickly identifying flap issues that may require reintervention. With their additional training, they can be more aware of situations that may require intervention and notify the surgeon or managing physician promptly. Likewise, updating other providers, pharmacists, and therapy teams will ensure that appropriate medication and therapy restrictions are in place during the perioperative period. If physical therapy is needed, the PT should keep the entire team abreast of progress and coordinate with the nurse or physician on continued care leading to release from active care. The use of muscular and musculocutaneous flaps in surgical interventions requires the coordination and communication of the entire interprofessional healthcare team so that the patient receives the best possible care leading to optimal results. [Level 5]

Routine post-surgical care is required; this will often include flap checks, wound care, pain management, and dangle protocols, depending on the type of reconstruction performed. Specifics are beyond the scope of this activity.

If the patient had a free tissue transfer, a free flap monitoring protocol is required to increase the chances of salvage if a complication were to occur.  Free flap protocols vary by attending surgeon preference and type of reconstruction performed. Specifics are also beyond the scope of this activity.