Advertisement

The Application of Muscular, Myocutaneous, and Fasciocutaneous Flaps as Adjuncts in Complex Refractory Urethral Disorders

  • Leonard N. ZinmanEmail author
  • Jill C. Buckley
Chapter
Part of the Current Clinical Urology book series (CCU)

Abstract

Simple wounds, fistulas, strictures, and tissue loss can be readily managed by appropriate tension-free approximation of unaltered wound edges with or without local random flaps. A number of local and systemic factors, however, transform these readily managed wounds into complex challenging conditions with poor outcome. Size, location, infection, radiation, reoperative hypovascular fibrosis, steroids and immunocompromising drugs, and vascular disease impact on wound care. With the advent of the axial muscle and fascial flaps, regional transpositions of peninsular flaps have dramatically changed our ability to restore the stability of wounds and the rescue of an anatomic region. These tissue transfer techniques have been underutilized in genitourinary reconstruction over the past two decades in the care of refractory radiation and inflammatory and reoperative pathology of the urethra, bladder, rectum, and perineum. This chapter reviews our experience with gracilis, gluteus, rectus abdominis, and Singapore flaps in refractory stricture and fistulas that defy conventional options. Experimental and clinical studies have confirmed the role of muscle surface in wound healing demonstrating superior resistance to bacterial inoculation in the presence of viable muscle, compared to random flaps and altered wound edges. These appropriately selected muscular and fascial flaps separate suture lines, support hypovascular fibrotic wound edges, protect grafts in adverse settings, and fill dead space injuries adjacent to wound. The adjuncts of axial muscular and fascial flaps in challenging complex perineal wound and fistulas closure have had a profound impact on outcome in our experience.

Keywords

Necrotizing Fasciitis Muscle Flap Rectus Sheath Urethral Stricture Gluteus Maximus 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Zinman L. Muscle-assisted full thickness skin graft urethroplasty. In: McAninch JW, editor. Traumatic and reconstructive urology. Philadelphia: Saunders; 1996. p. 623–30.Google Scholar
  2. 2.
    Zinman L. Myocutaneous and fasciocutaneous flaps in complex urethral reconstruction. Urol Clin North Am. 2002;29:443–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Roehrborn CG, McConnell JD. Analysis for factors contributing to the success or failure of 1-stage urethroplasty for urethral stricture disease. J Urol. 1994;151:69–74.Google Scholar
  4. 4.
    Morey AF, McAninch JW. When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Br J Urol. 1996;48:194–8.Google Scholar
  5. 5.
    Venn SN, Mundy AR. Early experience with the use of buccal mucosal grafts in adult bulbar urethroplasty. Br J Urol. 1998;81:738–40.PubMedCrossRefGoogle Scholar
  6. 6.
    Meland NB, Arnold PG, Weiss HC. Management of the recalcitrant total hip arthroplasty wound. Plast Reconstr Surg. 1991;88:681–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Asaadi M, Murray KA, Russell RC, et al. Experimental evaluation of free-tissue transfer to promote healing of infected wounds in dogs. Ann Plast Surg. 1986;17:6–12.PubMedCrossRefGoogle Scholar
  8. 8.
    Giordano PA, Abbes M, Pequignot JB. Gracilis blood supply: anatomical and clinical re-evaluation. Br J Plast Surg. 1990;43:266–72.PubMedCrossRefGoogle Scholar
  9. 9.
    Morris SF, Yang D. Gracilis muscle: arterial and neural basis for subdivision. Ann Plast Surg. 1999;42:630–3.PubMedCrossRefGoogle Scholar
  10. 10.
    Chen SH, Hentz V, Wei F, Chen Y. Short gracilis myocutaneous flaps for vulvoperineal and inguinal reconstruction. Plast Reconstr Surg. 1995;95:372.PubMedCrossRefGoogle Scholar
  11. 11.
    Soper JT, Larson D, Hunter VJ, Berchusk A, Clark-Person DP. Short gracilis myocutaneous flaps for vulvovaginal reconstruction after radical pelvic surgery. Obstet Gynecol. 1989;74:823.PubMedGoogle Scholar
  12. 12.
    Demming C. Transplantation of the gracilis muscle for incontinence of urine. J Am Med Assoc. 1926;86(12):822–5.CrossRefGoogle Scholar
  13. 13.
    Garlock JH. The cure of intractable vesicovaginal fistula by the use of pedicled muscle flap. Surg Gynecol Obstet. 1923;47:533.Google Scholar
  14. 14.
    Erol OO. The transformation of a free skin graft into a vascularized pedicle flap. Plast Reconstr Surg. 1976;58:470–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Zinman L. Muscle and myocutaneous grafts in urologic surgery. In: Libertino JA, editor. Pediatric and adult reconstructive urologic surgery. Baltimore: Williams and Wilkins; 1987. p. 567–97.Google Scholar
  16. 16.
    Hallock GG. Skin recycling following neovascularization using the rat musculocutaneous flap model. Plast Reconstr Surg. 1991;88:673–80.PubMedCrossRefGoogle Scholar
  17. 17.
    Woods JE, Beart RW. Reconstruction of non-healing perineal wounds with gracilis muscle flaps. Ann Plast Surg. 1983;11:513–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Whetzel T, Lechman AN. The gracilis myofasciocutaneous flap: vascular anatomy and clinical application. Plast Reconstr Surg. 1997;99:1642.PubMedCrossRefGoogle Scholar
  19. 19.
    Reddy VR, Stevenson TR, Whetzel TP. 10 year experience with gracilis myofasciocutaneous flap. Plast Reconstr Surg. 2006;117:635.PubMedCrossRefGoogle Scholar
  20. 20.
    Chuang DC, Mardini S, Lin SH, Chen HC. Free proximal gracilis muscle and its skin paddle compound flap transplantation for complex fascial paralysis. Plast Reconstr Surg. 2004;113:126.PubMedCrossRefGoogle Scholar
  21. 21.
    Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal thigh flaps. A preliminary report. Plast Reconstr Surg. 1989;83:701–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Zinman L. Perineal artery axial fasciocutaneous flap in urethral reconstruction. Atlas Urol Clin N Am. 1997;5:91–107.Google Scholar
  23. 23.
    Tzarnas CD, Raezer DM, Castillo OA. A unique fasciocutaneous flap for posterior urethral repair. Urology. 1994;43:379–81.PubMedCrossRefGoogle Scholar
  24. 24.
    Ramirez OM, Swartz WM, Futrell JW. The gluteus maximus muscle: experimental and clinical considerations relevant to reconstruction in ambulatory patients. Br J Plast Surg. 1987;10:1–10.CrossRefGoogle Scholar
  25. 25.
    Stevenson TR, Pollack RA, Rohrich RJ, Vanderkolk CA. The gluteus maximus musculocutaneous island flap; refinements in design and application. Plast Reconstr Surg. 1987;79:761–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Mathes SJ, Bostwick J. A rectus abdominis myocutaneous flap to reconstruct the abdominal wall defects. Br J Plast Surg. 1977;30:285CrossRefGoogle Scholar
  27. 27.
    Taylor GI, Corlett RJ, Boyd JB. The versatile deep inferior epigastric (inferior rectus abdominis) flap. Br J Plast Surg. 1984;37:330.PubMedCrossRefGoogle Scholar
  28. 28.
    Lee MJ, Darmanian GA. The oblique rectus abdominis musculocutaneous flap: revisited clinical application. Plast Reconstruct Surg. 2004;114:367–73.CrossRefGoogle Scholar
  29. 29.
    McMenamin DM, Clemts D, et al. Rectus abdomimis myocutaneous flaps for perineal recsonstruction. Ann R Coll Surg Engl. 2011;93:375–81.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Color Atlas of Anatomy. Rohen JW, Yocochi C (eds). Igaku Shoin Medical Pub, New York, 1993.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of UrologyLahey ClinicBurlingtonUSA
  2. 2.Department of UrologyUniversity of California – San DiegoSan DiegoUSA

Personalised recommendations