Muscle Versus Skin or Perforator Flaps for Extremity Salvage: Is There a Difference?

Background:  Evolving management of combat-related extremity injuries has resulted in increased limb salvage opportunities.  The nearly decade long Iraq and Afghanistan Wars have also presented military surgeons with soft tissue coverage challenges in patients who often have multiple injuries which can limit options for availability of known reconstructive workhorse flaps.  The purpose of this study is to investigate our collective experience and compare outcomes for muscle and skin based flaps.

Methods:  A multicenter retrospective review of injured Servicemembers treated for extremity injuries from 2003 through 2012 was completed.  Data collected included location and flap type.  Outcomes measured included complications such as infection and total or partial flap loss, extremity complications, and failed limb salvage. 

Results:  Over the last decade, 346 flap procedures (213 pedicle, 133 free) were performed on 187 lower and 129 upper extremities (30 extremities underwent multiple procedures).  Patients were mostly males, aged 17-63, with a mean injury severity score (ISS) of 18.  A total of 98% of patients were followed with average follow-up of 26 months. 

Flap Options
Muscle		Skin/Perforator		Other
	n(%)		n(%)		n(%)
Total	196(57)	Total	143(41)	Total	7(2)
Free	63(32)	Free	65(45)	Free	5(1.5)
Latissimus	44(70)	Anterolateral thigh (ALT)	31(48)	Pedicle	2(0.5)
Rectus	12(19)	Lateral arm	15(23)
Serratus	3(5)	Scapular	13(20)
Pedicle	133(68)	Pedicle	78(55)
Gastrocnemius	63(47)	Sural	21(27)
Soleus	35(26)	Groin	17(22)
Latissimus	19(14)	Radial forearm	8(10)

 

Complications
	Muscle		Skin/Perforator
	n	%	n	%	P-value
Total	46	13	34	10	0.524
Flap Failure	25	7	11	3	0.093
Soft tissue Infection	26	8	12	3	0.108
Osteomyelitis	21	6	19	5	0.288
Amputation	33	10	13	4	0.027

Conclusion:  In nearly a decade of war trauma, our multicenter group has performed a high volume of complex extremity reconstructions.  We present a broad range of flap options to provide adequate coverage in extremity salvage and will discuss our institutional algorithms for optimal flap selection in our patient population.  Complication rates did not significantly differ between the muscle and skin/perforator-based flap groups.  Each of these flap categories has utility in our patients, but each must be carefully considered prior to transfer based on reconstructive and rehabilitation goals of our war wounded.