Reusing the workhorse: Outcomes after secondary inset of paraspinous muscle flaps

Paraspinous muscle flaps are the workhorse for midline spinal coverage. If additional spine surgery is required, these flaps can be elevated and re-inset. In this setting, a hostile wound environment may compromise flap integrity, raising the question of whether flap re-inset is sufficient or if additional vascularized tissue would be preferable. We compared outcomes of patients undergoing re-elevation and inset of previously performed paraspinous flaps with those undergoing primary paraspinous flaps.

A retrospective review was performed on patients undergoing spinal surgery with paraspinous flap closure between 2021 and 2025. Demographics, comorbidities, and postoperative outcomes were compared between the patients undergoing primary flap versus repeat flap closure.

A total of 96 patients were identified: 81 (84.4%) underwent a primary paraspinous muscle flap procedure alone and 15 (15.6%) underwent re-inset of paraspinous flaps during return to operating room. Baseline demographics and comorbidities were similar between the cohorts (p > 0.05). The revision cohort had more prior spinal operations before their initial flap compared to those requiring only a single paraspinous flap (2.0 ± 1.3 versus 1.16 ± 1.74, p = 0.04). Healing without further intervention occurred in 92.6% of primary flap patients versus 66.7% of revision patients (p < 0.01).

Re-raising and re-insetting paraspinous flaps is technically feasible and achieves durable closure in several patients; however, outcomes are inferior compared to primary use of these flaps. Although flap re-advancement may suffice in some cases, surgeons should maintain a low threshold to introduce additional vascularized tissue, particularly in multiply operated spines.