Area enlargement of the gracilis muscle flap through microscopically aided intramuscular dissection: ideas and innovations

To Shrink or Not to Shrink? An Objective Assessment of Free Gracilis Muscle Volume Change in Lower-Extremity Defect Reconstruction

Background: The use of free gracilis muscle flaps in reconstructive surgery of the lower leg is common practice to cover defects. However, there is still a lack of understanding of the morphometric changes that occur in the transferred muscle and area of interest over time, particularly the characteristic volume decrease that is observed over the course of the first year. This study aimed to assess volume changes in patients with free gracilis muscle flap reconstruction following infection, trauma, or malignancies of the lower extremity. Methods: Three-dimensional surface imaging was performed intraoperatively after 2 weeks, 6 months, and 12 months with the Vectra H2 system. A total of 31 patients were included in this study and analyzed. Results: There was an average volume increase of 146.67 ± 29.66% 2 weeks after reconstruction. Compared to this volume increase, there was a reduction of 108.44 ± 13.62% after 12 months (p < 0.05). Overall, we found a shrinkage to 85.53 ± 20.14% of the intraoperative baseline volume after 12 months. Conclusions: The use of non-invasive 3D surface imaging is a valuable tool for volume monitoring after free flap reconstruction of the lower extremity. The free gracilis muscle flap undergoes different phases of volume change over the first year, with the greatest influence on overall change being the development and decongestion of edema. Precise initial surgical tailoring is crucial for optimal long-term functional and cosmetic results.

Mid-term Clinical Outcome of Microvascular Gracilis Muscle Flaps for Defects of the Hand

PURPOSE

Gracilis muscle flaps are useful to cover defects of the hand. However, there are currently no studies describing outcome measurements after covering soft tissue defects using free flaps in the hand.

AIM

To analyze mid-term results of gracilis muscle flap coverage for defects on the hand, with regard to functional and esthetic integrity.

METHODS

16 patients aged 44.3 (range 20-70) years were re-examined after a mean follow-up of 23.6 (range 2-77) months. Mean defect size was 124 (range 52-300) cm2 located palmar (n = 9), dorsal (n = 6), or radial (n = 1). All flaps were performed as microvascular muscle flaps, covered by split thickness skin graft.

RESULTS

Flaps survived in 15 patients. 6 patients required reoperations. Reasons for revisions were venous anastomosis failure with total flap loss (n = 1) requiring a second gracilis muscle flap; necrosis at the tip of the flap (n = 1) with renewed split thickness skin cover. A surplus of the flap (n = 2) required flap thinning and scar corrections were performed in 2 patients. Mean grip strength was 25% (range 33.3-96.4%) compared to the contralateral side and mean patient-reported satisfaction 1.4 (range 1-3) (1 = excellent; 4 = poor).

CONCLUSIONS

Gracilis muscle flaps showed a survival rate of 94%. Patients showed good clinical outcomes with acceptable wrist movements and grip strength as well as high reported satisfaction rates. Compared to fasciocutaneous free flaps, pliability and thinness especially on the palmar aspect of the hand are advantageous. Hence, covering large defects of the hand with a gracilis muscle flap can be a very satisfactory procedure.

LEVEL OF EVIDENCE

IV observational.

Medial fascia lata perforator flap: Anatomical basis and clinical application as a pedicled or free flap

Adipofascial flaps have proven to be an excellent tool for multipurpose reconstruction as free or pedicled flaps. The anatomical studies in this field are now focused on improving esthetics in reconstruction while maintaining a minimal donor site morbidity. An anatomical cadaver study has been carried out to investigate the medial thigh region as a potential donor site for adipofascial flaps. Eighteen thighs from fresh cadavers were dissected and a new territory with autonomous vascular supply was defined through vascular injection, anatomical dissection, transillumination, and angiography. Cutaneous access was made in a "T" shape. The fascia harvests had to be centered on the adductor longus and gracilis muscles bearing in mind the position of the flap pedicle. The fascial flap was isolated from adductor longus and gracilis muscles and isolated on his pedicle (medial circumflex femoral artery). After our anatomical study, we used the flap in 2 clinical cases. The results of our anatomical study and clinical cases confirmed the suitability and reliability of a new flap: the "Medial Fascia Lata Flap." Flap size ranged from 20 to 25 cm and has the advantage of preserving the functionality of the thigh muscles. The study showed that the "Medial Fascia Lata Flap" is easy to harvest, and the resulting scar is concealed. In consideration of its suitability, reliability and aesthetical advantages, it could be proposed as a good option in selected cases.

Gracilis free flap in head and neck reconstruction beyond facial palsy reanimation

INTRODUCTION

The gracilis muscle free flap has gained popularity in head and neck reconstruction due to minimal donor-site morbidity, reliable vascular pedicle, strong muscular component, and possibility to perform nerve coaptation. However, almost all the existing evidence in the literature is related to its use for facial palsy reanimation. The aim of this study was therefore to review and provide a comprehensive summary of all the possible indications and outcomes of this versatile free flap in head neck reconstructive surgery.

MATERIALS AND METHODS

A systematic review of the literature was conducted including articles from 1970 to 2019. All articles were examined and described.

RESULTS

Twenty-seven papers published between 1994 and 2019 were identified for analysis. The evidence highlights the use of the gracilis muscle free flap for parotid, forehead and midface defects, oral tongue, oral sphincter, lower and upper lip, cheek, and oral commissure defects, among others, as the most common defects reconstructed.

CONCLUSION

This flap represents an easy to harvest and versatile free flap with low donor-site morbidity and multiple proven uses in head & neck reconstruction. We therefore encourage reconstructive surgeons to include this flap in their armoury, either as a first or as a second-line option.

Anatomical and topographical features of the gracilis muscle of the thigh from the position of using it for autotransplantation

Autotransplantation of a free flap of the gracilis muscle is currently actively used in reconstructive surgery for persistent prosoplegia, injuries of the brachial plexus, for plastic closure of defects in the upper lip, and in the treatment of pelvic sepsis. This study provides important information about the anatomical features of the gracilis muscle and its neurovascular bundle, which are highly variable. The study of the anatomical and topographic features of this fine thigh muscle was carried out on a sectional study of 25 corpses of both sexes, 50 lower limbs. The present study demonstrates that the median value of the total length of m. Gracilis, the length of its muscular part, as well as the length of the tendon were 452.25 (439.7; 462.0); 225.3(208.1;239.0); 230.5 (213.0; 244.4) mm, respectively. The number of vascular pedicles included in m. Gracilis, ranged from 1 to 5. In 86% of the cases, the deep femoral artery formed the dominant vascular pedicle, and in 14% of cases, it was the medial circumflex artery. Small secondary vascular pedicles originated from the descending genicular artery or the anterior branch of the obturator arter: from the basin of the internal iliac artery. The length of the main feeding artery varied from 76 to 134 mm, the median value was 100.5(90;110) mm, and its diameter ranged from 1.4 to 2.1 mm (M = 1.9(1.8;2, 0) mm. The innervation of the fine muscle of the thigh was carried out by the anterior branch of the obturator nerve, which in 82% of the cases was represented by a single trunk; less often a loose type of structure was observed. The proper nerve was located at a distance of 108.5 (96; 117) mm from the origin of the muscle; its diameter was 2.1 (1.9; 2.2) mm. Knowledge of the topographic and anatomical relationships of the neurovascular bundle with the surrounding formations, variants of its individual anatomical variability are the key to successful reconstructive surgery.

[Case report of frontobasal reconstruction and volume augmentation using a free gracilis muscle flap and autologous fat grafting: utilising the free flap as a scaffold for fat transplantation]

This case report shows the interdisciplinary treatment of a 28-year-old woman suffering from a pronounced frontal volume defect after severe craniocerebral trauma. The combination of cranioplasty using a polymethylmethacrylate (PMMA) implant, free gracilis muscle flap transfer for soft tissue coverage and serial autologous fat grafting into the muscle flap for subsequent contouring enabled both an adequate and aesthetic reconstruction. This example demonstrates the feasibility of treating increasingly complex composite defects in a multidisciplinary setting, when plastic surgeons are involved.

Scalp Reconstruction after Malignant Tumor Resection: An Analysis and Algorithm

Background  An oncologic tumor resection of the scalp can result in complex wounds that result in challenging scalp reconstructions. This study aimed to evaluate the outcomes of microvascular-based scalp reconstructions (MSR) in oncologic patients and to propose an algorithmic treatment approach. Methods  Within a 5-year period, 38 patients having undergone 41 MSR (15 anterolateral thigh (ALT), 15 gracilis muscle (GM), and 11 latissimus dorsi muscle (LDM) flaps) after extensive scalp tumor resections fulfilled inclusion criteria for this study. Results  Malignant skin disease included superficial and/or deep infiltration of the calvarium in 26 and combined intracranial infiltration in 12 patients. In case of bone replacement (24 patients), MSR was done concomitant, otherwise MSR was performed after pathological confirmation of tumor-free margins. LDM flaps were used in cases with defect sizes of 400 to 1250cm ² , whereas ALT- and GM flaps were chosen for defects ranging from 40 to 350cm ² . The average length of the pedicle was comparable in ALT- and LDM flaps and longer than in GM flaps. Total flap loss with need for revision surgery and minor donor site morbidity occurred in four and three patients, respectively. Conclusion  Microsurgical reconstruction of moderate-to-extensive scalp defects remains a reliable method with overall low risks and satisfactory aesthetic results, while, according to our experience, muscle flaps show the best functional and aesthetic results. However, in cases of central scalp defects and in situations when a long vascular pedicle of the flap is important, the ALT flap seems to be the best solution.

Microsurgical Forehead Reconstruction

Reconstruction of the forehead remains challenging. Especially in cases of large or even complete forehead defects, local flaps and skin grafting may not be an option, necessitating free flap coverage. The aim of this retrospective case series was to develop an algorithmic surgical approach as well as to evaluate surgical and aesthetic outcomes of microvascular-based forehead reconstructions, using gracilis muscle or anterolateral thigh flaps in 15 cases. The mean size of the defects was 84.6 (range: 25-160, ±44.1) cm, all with significant area of bone exposure. The free flap reconstructions included 7 gracilis muscle flaps, covered with 1.2-mm-thick unmeshed split-thickness skin grafts, and 8 anterolateral thigh flaps with a mean size of the free flaps of 160 (range: 56-300, ±78.6) cm. In all patients, wound healing at the donor site was uneventful. Minor complications occurred in 3 patients and required small revision procedures. This case series demonstrates that microsurgical reconstruction of multiple entities of forehead defects poses a reliable method, especially in large and complex defects. In our opinion, given low risks for major complications and superior aesthetic results, the gracilis muscle flap covered with unmeshed split-thickness skin graft is ideally suited to reconstruct the forehead and should be one of first choices.

Microsurgical Reconstruction of Extensive Oncological Scalp Defects

Although most small to medium defects of the scalp can be covered by local flaps, large defects or complicating factors, such as a history of radiotherapy, often require a microsurgical reconstruction. Several factors need to be considered in such procedures. A sufficient preoperative planning is based on adequate imaging of the malignancy and a multi-disciplinary concept. Several flaps are available for such reconstructions, of which the latissimus dorsi and anterior-lateral thigh flaps are the most commonly used ones. In very large defects, combined flaps, such as a parascapular/latissimus dorsi flaps, can be highly useful or necessary. The most commonly used recipient vessels for microsurgical scalp reconstructions are the superficial temporal vessels, but various other feasible choices exist. If the concomitant veins are not sufficient, the jugular veins represent a safe back-up alternative but require a vessel interposition or long pedicle. Post-operative care and patient positioning can be difficult in these patients but can be facilitated by various devices. Overall, microsurgical reconstruction of large scalp defects is a feasible undertaking if the mentioned key factors are taken into account.

Fascial Release of the Pectoralis Major: A Technique Used in Pectoralis Major Muscle Closure of the Mediastinum in Cases of Mediastinitis

BACKGROUND

The authors' goal was to demonstrate a technique of gaining added width from the right pectoralis major muscle flap through muscle fascia release, with the hope of attaining sturdier, tension-free dead space closure of the debrided mediastinum in cases of mediastinitis.

METHODS

The authors measured the preincisional and postincisional widths of the right pectoralis major flap following release of the fascia in nine patients who underwent mediastinal reconstruction using pectoralis major muscle flaps from 2002 to 2004 at the Detroit Medical Center.

RESULTS

The average width of the nine muscles was 16.3 +/- 1.7 cm before fascia release and 22.1 +/- 1.3 cm after release. The average increase in width was 5.8 +/- 1.3 cm, with a 95 percent confidence interval of 4.8 to 6.8 cm. A value of p < 0.0001 indicated that this increase in width was statistically significant. After fascial release, the width of the muscles increased by an average of 26.1 percent, with a 95 percent confidence interval of 21.6 to 30.6 percent.

CONCLUSIONS

The authors present a new technique that can be used to gain additional width from the right pectoralis major muscle in cases of mediastinal reconstruction using the pectoralis major muscle flap. With the added 26 percent of width obtained from the right pectoralis major muscle with fascia release, the authors contend that a sturdier and tension-free closure of the mediastinal dead space can be obtained, further expanding the indications for use of the pectoralis major muscle flap as the sole closure modality in even the most complicated cases of mediastinitis.

Gracilis muscle flap for aesthetic reconstruction in the head and neck region

Microsurgical tissue transfer has constantly improved the therapeutic options for reconstruction in the head and neck region, but the ideal flap has yet to be found. The purpose of this study is to discuss the aesthetic potential of the free gracilis muscle flap in difficult head and neck reconstruction. We report our experience with the free gracilis muscle flap in seven patients who underwent reconstruction in the head and neck region for a variety of indications. In all seven patients, the transplanted muscle flaps healed well, with no flap loss. Postoperative complications consisted of skin-graft loss in one patient requiring a second split-thickness skin graft. Donor-site morbidity was minimal in all patients. For difficult reconstruction in the head and neck region, the free gracilis muscle flap offers a number of advantages, including reliable vascular anatomy, relatively great plasticity, and a concealed donor area. Thus this type of flap offers a valuable option whenever an aesthetically pleasing result is sought.