Soft Tissue/Skin Graft/Muscle Flap Reconstruction:

Soft tissue reconstruction remains one of the most significant challenges for plastic surgeons. A lack of soft tissue can occur due to trauma, congenital diseases. Transplantation of autologous adipose tissue has been used for soft tissue reconstruction for the last century. Current strategies involve tissue transplantation, including composite tissue flaps.

A full-thickness skin graft is generally not considered the ideal replacement for the thick, sebaceous skin of the nasal tip, ala, lower sidewalls, or dorsum. Instead, many clinicians prefer to reconstruct these defects with local or axial composite flaps that incorporate skin, subcutaneous tissue, and fat.

Muscle flaps are often the first and best choice. However, muscle flap selection after failure of treatment with other modalities necessitates diagnosis of the etiology of previous failure. The issues that would negatively impact free flap success should be assessed.  For instance, if a previous lower extremity gastrocnemius flap failed to adequately treat a complex open tibial wound, the surgeon should ascertain if poor vascular inflow to the leg compromised muscle perfusion. Similarly, if inadequate debridement and control of the bed promoted infection and wound recurrence, the bed should be adequately debrided or controlled before a free flap is performed. Other factors that may have led to local flap or conservative treatment failure include inadequate immobilization in the postoperative period, or overly aggressive dangling/dependency. Both can lead to wound dehiscence and or vascular compromise and pedicle thrombosis. Of course, multiple other contributors to failure of treatment such as poorly controlled diabetes, active smoking, immunosuppression, etc. need to be considered.