In this episode of Plastics in Practice, we break down one of the most enduring debates in reconstructive microsurgery: Muscle vs. Fasciocutaneous (FC) flaps for lower limb trauma. For decades, residents were taught that muscle was mandatory for open fractures and osteomyelitis due to its superior vascularity and dead-space obliteration. But does the modern evidence support this?

We analyze landmark papers including the massive retrospective review by Yazar et al. and the controlled osteomyelitis study by Salgado et al., which suggest clinical equivalence between the two tissue types. We also dive into the biological nuances reviewed by Chan et al., highlighting why muscle might still hold the edge in specific scenarios—and how chimeric flaps offer a "best of both worlds" solution.

Key Takeaways for Residents:

• Debridement is King: The single most critical factor for success is not the tissue type, but the adequacy of the debridement.

• Clinical Equivalence: For distal third and ankle defects, FC flaps show statistically equivalent rates of flap survival, infection, and union compared to muscle flaps.

• The Practical Edge: FC flaps offer superior aesthetics, less donor morbidity, and are easier to re-elevate for secondary orthopedic procedures (hardware removal/bone grafting).

• Biological Nuance: Muscle tissue retains biological superiority (osteogenic potential and antimicrobial properties) for deep, complex, 3D dead spaces.

• The Chimeric Solution: Consider chimeric flaps (e.g., ALT + Vastus Lateralis) to combine biological dead-space filling with cutaneous coverage.

Citations:

1. Yazar S, Lin CH, Lin YT, et al. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle open tibial fractures. Plast Reconstr Surg. 2006;117(7):2468-2475. doi:10.1097/01.prs.0000224304.56885.c2

2. Salgado CJ, Mardini S, Jamali AA, et al. Muscle versus nonmuscle flaps in the reconstruction of chronic osteomyelitis defects. Plast Reconstr Surg. 2006;118(6):1401-1411. doi:10.1097/01.prs.0000239579.37760.92

3. Chan JK, Harry L, Williams G, Nanchahal J. Soft-tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps. Plast Reconstr Surg. 2012;130(2):284e-295e. doi:10.1097/PRS.0b013e3182589e63

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