After Having Skin Graft on Lower Leg Can the Muscle Be Built Up Strong Again
Methodist Debakey Cardiovasc J. 2013 Apr-Jun; nine(2): 95–99.
Musculus Flaps and Their Role in Limb Relieve
Michael Klebuc
a The Methodist Hospital, Houston, Texas
b Weill Cornell Medical School, New York, New York
Zachary Menn
a The Methodist Hospital, Houston, Texas
Abstruse
Muscle flaps take proved to be a valuable and versatile tool in the surgical treatment of the severely compromised lower extremity. Utilized as both local pedicle flaps and free tissue transfers, muscles have been successfully employed to cover complex wounds, manage osteomyelitis, salve infected vascular grafts, treat recalcitrant venous stasis ulcers, preserve amputation levels, and restore motion post-obit compartment syndrome. Free flap pedicles accept as well been used in a flow-through style to create a distal arterial bypass. This article explores the multipurpose role of musculus flaps in limb relieve surgery and their beneficial physiologic characteristics in hostile wound environments.
Keywords: musculus flaps, limb salvage
Introduction
Muscle flaps accept proven to be a valuable, versatile tool for the limb salvage surgeon. Utilized equally both local pedicle flaps and costless tissue transfers, muscles have been employed successfully to cover complex wounds, manage osteomyelitis, save infected vascular grafts, treat recalcitrant venous stasis ulcers, preserve amputation levels, and restore move following compartment syndrome. Free flap pedicles also have been used in a menstruum-through way to create a distal arterial featherbed.
Versatility
Muscle flaps have demonstrated, both clinically and experimentally, a serial of advantages over local skin flaps and fasciocutaneous flaps for the management of complex wounds. The malleability of muscle allows it to effectively obliterate dead space while the dense capillary network facilitates antibody deposition. Additionally, muscle flaps are more than effective than their counterparts in overcoming varying degrees of bacterial colonization and infection. In a canine model, musculus flaps accept demonstrated a rapid, early augmentation of blood menstruation in response to an inoculum, providing greater degrees of bacterial growth inhibition and bacterial emptying than random skin flaps or fasciocutaneous flaps. Musculus flaps likewise have demonstrated more rapid collagen degradation and greater tissue ingrowth.1-iii These advantageous characteristics probable business relationship for their high level of success when used to manage hostile wounds. Regardless of their ability to inhibit bacterial growth, muscle flaps should non be used in an inadequately prepared wound bed. Serial debridement in conjunction with local wound care, antibiotic bead pouches, and negative pressure wound therapy should be employed to decrease contamination and maximize the character of the wound prior to definitive coverage.
Flap Option
The location of the soft tissue defect plays a pivotal role in flap selection. The lower extremity is oft subdivided into proximal, middle, and distal thirds in an effort to guide muscle flap selection. The medial and lateral gastrocnemius muscles are supplied proximally by the sural arteries emanating from the popliteal avenue. The flap hands covers the tibial plateau region, and the musculus's origin on the distal femur tin be released, allowing the attain to be extended to the patella and suprapatellar regions. The soleus muscle flap is the workhorse of the key third of the leg, and its blood supply is derived principally from proximal branches of the posterior tibial artery and peroneal artery. Secondary perfusion is provided by distal branches of the posterior tibial artery. In well-selected patients without significant trauma or vascular disease, information technology is possible to split up the soleus muscle and perform a reverse transposition to cover distal tertiary defects. The groovy bulk of defects in the distal third of the leg, however, are best managed with microsurgical gratis-tissue transfer (free flaps) (Figure 1), although reverse neuro-fasciocutaneous flaps (contrary sural flaps) can provide a reasonable alternative in select patients. The latissimus dorsi, rectus abdominis, gracilis, serratus anterior, and anterolateral thigh with segmental vastus lateralis are frequent donor sites. The flaps can incorporate a peel island or be covered with peel graft as determined by the size and topography of the defect. Blood supply is restored with an arterial and venous microvascular anastomosis, which tin be achieved in an end-to-end or end-to-side fashion, typically using 9-0 nylon under the guidance of an operating microscope or high power loupes. Gratuitous musculus flaps take proved more resistant to the furnishings of cigarette smoking than local peel and fasciocutaneous flaps and have been successfully employed in patients with diabetes and peripheral vascular disease.4
(A, B) Circuitous plantar and dorsal foot wounds with exposed bone and tendon. (C) Reconstruction with split latissimus dorsi free flap and skin graft. (D) Late postoperative follow-upwardly after complimentary muscle flap reconstruction.
Illig et al evaluated outcomes and prognostic factors in patients who underwent a combined gratuitous tissue transfer and distal vascular bypass to manage otherwise nonreconstructible infrainguinal arterial occlusive affliction with associated advanced tissue necrosis.five Post-obit wound debridement, ischemia was managed past an infrainguinal bypass with the distal anastomosis achieved below the knee in the majority of patients. The microvascular arterial anastomosis was fabricated to the bypass graft in most patients. The patient group had multiple comorbidities including diabetes mellitus, advanced historic period, cease-stage renal affliction (ESRD), and osteomyelitis. All patients would have required a minimum of a below-knee amputation (BKA) if no intervention was initiated. Utilizing debridement in conjunction with arterial featherbed and a free muscle flap coverage, a 57% limb relieve rate and 65% rate of meaningful ambulation was accomplished during the 5-year follow-upward. The study also provides important insight regarding which patients may non benefit from this type of reconstruction. Individuals with diabetes and ESRD requiring dialysis fared poorly, and serious consideration regarding primary amputation should be given to this subpopulation.
Flow-Through Flaps
In the presence of distal vascular disease, select complimentary-tissue transfers can be employed in a period-through manner to provide simultaneous soft tissue reconstruction and enhance limb perfusion. The subscapular arterial system tin can provide an arterial autograft for distal bypass forth with associated segments of serratus anterior or latissimus dorsi muscle with or without a skin island.6 Similarly, the descending branch of the lateral circumflex femoral artery tin be combined with pare, fascia, and vastus lateralis muscle segments and employed equally a menstruation-through flap. The radial avenue flow-through flap provides a thin pare island and is well suited for defects of the pes and ankle region (Figure 2).7 An additional benefit of the flow-through flaps is their positive influence on bypass graft menses. Anastomosis of a complimentary flap to a distal bypass produces a subtract in distal resistance, thereby increasing catamenia. This effect was confirmed in a prospective hemodynamic study conducted by Lorenzetti et al., who demonstrated a 50% increase in flow when free-tissue transfers where continued to infrapopliteal bypass grafts.8 The enhanced flow bodes well for the long-term patency of the distal bypass.
(A) Class IIIC open ankle fracture with vascular compromise. (B) Arteriogram showing three-vessel injury with limited collateral menstruum to the human foot. (C) Radial forearm free flap in situ. (D) Late postoperative follow up of radial forearm menses through free flap. (E) Late magnetic resonance angiogram (MRA) demonstrating a patent radial artery perfusing the human foot via a distal anastomosis to the dorsal pedis artery.
Amputation
All-encompassing soft tissue necrosis and irreversible vascular affliction will necessitate amputation in some individuals. For these patients, free muscle flaps can play an important office in the preservation of more distal amputation levels (Figure three). Indirect calorimetry has been used to report oxygen consumption and the energy cost associated with airing at different amputation levels. Ambulation with a unilateral BKA requires approximately 9% more oxygen consumption than an unimpaired private. Oxygen consumption rises to 49% above the base line for individuals with a unilateral in a higher place-knee amputation.nine The extensive metabolic demand contributes to the low prosthetic utilization rates in patients with to a higher place-articulatio genus versus below-knee amputations. Gratuitous-tissue transfers take been successfully used to restore the soft-tissue envelope in short, guillotine-mode below-knee amputations, maintaining the more functional amputation level.10
(A) Short beneath-knee amputation (BKA) stump with unstable soft tissue. (B) Operative markings: muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flap. (C) Resurfaced BKA stump. (D) Long-term follow-up with preserved BKA level.
Chronic Ulcers
Gratuitous muscle flaps have also been used successfully to treat recurrent chronic venous ulcers that have failed conventional therapy. The treatment includes broad local excision of lipodermatosclerotic tissue and replacement with a healthy, well-perfused gratuitous-tissue transfer with a vascular pedicle that contains multiple competent microvenous valves. Importing a competent venous segment improves regional venous hemodynamics. This was demonstrated by Dunn et al., who used photoplethysmography to evaluate venous filling times in free-flap reconstructions of chronic venous ulcers.11 They found significant immediate and long-term increases in flap venous refilling times every bit compared to the preoperative values. Clinically, no recurrent ulceration or flap breakup was identified at the 24-month follow-up. Weinzweig et al. also described a ten-year feel using free muscle flaps to reconstruct 24 recalcitrant venous stasis ulcers.12 Later on a mean follow-upwardly of 58 months, no recurrent ulcers were identified in the flap territory; even so, three patients developed new ulcers on the same leg.
Compartment Syndrome
The benefit of free muscle flaps far exceeds their ability to provide stable soft-tissue coverage. In cases of irreversible compartment syndrome, neurotized costless musculus flaps have been successfully used to restore motor part. Lin et al. reported their experience using complimentary-operation muscle flaps to care for post-traumatic defects in the lower extremity that included cases of neglected compartment syndrome. They utilized the rectus femoris muscle to re-constitute ankle plantar flexion and the gracilis to restore ankle dorsi flexion. Acceptable outcomes were achieved in ten of 15 patients.xiii We have establish functional gratis muscle flaps to be a valuable tool in individuals who have express options for traditional tendon transfers.
Chronic Osteomyelitis
The benign physiologic characteristics of muscle flaps take been previously discussed; however, in few situations are they more advantageous than for the treatment of chronic osteomyelitis. Customary handling protocols include bony sequestrectomy and serial debridement with application of an antibiotic bead pouch along with a six-week form of culture-specific intravenous antibiotics. Once a clean wound with visible punctate bony bleeding is achieved, local or free muscle flaps are used to obliterate expressionless space and ameliorate the local wound surround. Utilizing a like treatment protocol, Anthony et al. reported a 96% success rate in 34 patients with a mean follow-upward of vii.four years.14 While the above treatment strategy tin prove very effective, patients should exist cautioned that chronic osteomyelitis is better thought of as being managed or suppressed and not eradicated, every bit tardily recurrences are not exceptional.
Graft Infections
Vascular surgeons may discover that muscle flaps take the greatest utility when used for managing periprosthetic graft infections. Although the number of graft infections is generally depression (1-6%), they are associated with significant rates of limb loss (30-50%) and mortality (25-75%).15 Debridement, graft preservation, and muscle flap coverage have been used every bit an culling to graft removal and extra-anatomic featherbed. Meland and Arnold, in their classic paper, describe the role of musculus flaps in the management of 24 periprosthetic graft infections.fifteen The infected grafts were treated with extensive debridement followed by muscle flap coverage and postoperative wound irrigation with a povidone-iodine solution delivered through implanted catheters. Systemic intravenous antibiotics were too employed. Ofttimes used donor sites include the sartorius, rectus femoris, and rectus abdominis. Although not advocated in this study, the gracilis and omentum are additional sources of well-vascularized soft tissue. Utilizing this treatment strategy, a 66% limb save charge per unit was achieved over a mean follow-up of 41 months.
In our reconstructive surgery establish at The Methodist Hospital, this protocol has been modified, yielding even college rates of graft preservation and limb salvage. The closed-suction irrigation system has been abased in favor of antibiotic-impregnated beads. Polymethyl methacrylate bone cement is combined with powdered vancomycin and tobramycin and fashioned into pocket-sized beads secured on a heavy nonabsorable suture. When implanted within the wound, the beads offload their antibiotic payload, achieving local concentrations exceeding 100 times the mean inhibitory concentration. These supraphysiologic antibiotic concentrations accept proved active against biofilms while being associated with express systemic absorption, fugitive potential ototoxicity and nephrotoxicity.16 Serial debridement and antibiotic bead exchange is undertaken until a make clean civilisation-negative wound has been obtained (Figure 4A). The antibody chaplet are removed and the graft covered with a local muscle flap (Effigy 4B-D). Utilizing this treatment protocol in conjunction with 6 weeks of civilisation-specific intravenous antibiotics, we have achieved a 96% long-term limb relieve charge per unit.17
(A) Infected prosthetic vascular graft treated with antibiotic impregnated chaplet. (B) Elevated sartorius musculus flap. (C) Vascular graft enshrouded past musculus flap. (D) Long-term follow-upward with graft preservation.
Conclusion
In conclusion, both pedicle and gratuitous muscle flaps savour intrinsic biologic advantages over local pare and fasciocutaneous flaps, making them a powerful, multipurpose tool in the armamentarium of the limb save surgeon.
Funding Argument
Funding/Support: The authors have no funding disclosures.
Footnotes
Conflict of Involvement Disclosure: All authors have completed and submitted the Methodist DeBakey Cardiovascular Journal Conflict of Interest Statement and none were reported.
References
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3693523/
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