SLR - June 2021 - Ashley A. Mariano

The Essential Local Muscle Flaps for Lower Extremity Reconstruction 

Reference: Atia A, Vernon R, Pyfer BJ, Shammas RL, Hollenbeck ST. The Essential Local Muscle Flaps for Lower Extremity Reconstruction. J Reconstr Microsurg. 2021 Jan;37(1):89-96. doi: 10.1055/s-0040-1709480. Epub 2020 Apr 17. PMID: 32303104.

Level of Evidence: Level V

Scientific Literature Review 

Reviewed By: Ashley A. Mariano, DPM 
Residency Program: Beaumont Wayne Hospital, Wayne, MI 

Podiatric Relevance: Lower extremity reconstruction provides its challenges for podiatric surgeons. Defects of the lower limb can result from trauma, tumors or chronic diseases like diabetes. In the diabetic population, the use of local muscle flaps is a viable and alternative option to amputation and can preserve limb function. Muscle flaps have been shown to be an effective treatment for complex wound closure and to prevent limb amputation. This literature review aims to guide the reconstructive surgeon on when to consider local muscle flaps and how to ensure suitable and durable coverage for lower limb defects.

Methods: A literature review using PubMed was performed to identify flaps that can be used in lower extremity reconstruction. The review focused on common local muscle flaps and classified them based on anatomical region.  

Results: Common muscle flaps used in lower extremity reconstruction can be divided by anatomical region (thigh, knee and tibia and foot and ankle). Within each category multiple muscles have been identified that cover a defect in the corresponding zone of injury. There are several principles of muscle flaps to be considered during the evaluation of a lower extremity wound including vascular anatomy, arc of rotation, tunneling and loss of muscle function. Muscle flaps are traditionally classified based on the vascular supply. The Mathes and Nahai classification is useful to help preserve blood supply during dissection and understand the rotation of the muscle to the defect. Compared with the thigh, a soft tissue defect within the knee and leg creates a challenge for reconstruction due to less redundant soft tissues and functional muscles. Local muscle flaps within the foot and ankle are small but ideal to cover defects in the distal third of the leg, heel, Achilles and foot with minimal functional deficient. Postoperative management of local muscle flaps are equally important to selection of flaps for reconstruction. One must monitor the flap for viability to ensure there is adequate perfusion and restrict mobility to avoid tension. Secondary procedures will often be required including skin graft, bone graft and use of hardware. 

Conclusions: Muscle flaps are a viable option to cover soft tissue defects; however, multiple variables must be considered prior to flap selection including zone of injury, extent of defect and donor-site morbidity. This article provides a summary of local muscle flap options that can provide a reconstructive plan to manage soft-tissue defects, while minimizing donor-site morbidity and leading to improved patient outcomes. 

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