Flaps: Muscle and Musculocutaneous

Excerpt

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. 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. 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.