The spreaded gracilis flap revisited: Comparing outcomes in lower limb reconstruction

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.

[Reconstruction of posttraumatic deformities and defects]

The reconstruction of posttraumatic defects of bone and soft tissue, as well as residual deformities of the bone is often a lengthy and complicated procedure. Multiple surgical interventions are necessary to reconstruct the affected extremity and restore its functionality. To achieve an optimal result it often takes months or years and requires great patience and compliance of the patient. This treatment should be carried out in centers with the appropriate instrumental and human resources. Since the pathologies are often complex with bony deformities or loss of bone, as well as infections and soft tissue defects, the treatment should be carried out by very experienced surgeons to successfully manage these complex reconstructions. This often requires interdisciplinary cooperation, especially with experienced plastic surgeons. A soft tissue reconstruction for better blood circulation in the exposed bony structures, as well as the bony defects themselves, can be reconstructed at the same time.

Use of the Adductor Magnus Muscle Free Flap for Lower-Extremity Soft Tissue Coverage: An Alternative to the Gracilis Muscle Flap With Unfavorable Vascular Anatomy

BACKGROUND

The gracilis muscle free flap has proven to be a dependable tool for the reconstructive microsurgeon for coverage of small- to medium-sized lower-extremity soft tissue defects because of its reliable anatomy, ease of elevation, and minimal donor site morbidity. We describe our experience with the adductor magnus muscle free flap which we have utilized in cases when confronted with the rare situation in which the dominant vascular pedicle to the gracilis muscle is insufficient or absent.

METHODS

We conducted a retrospective chart review of a single surgeon's experience (EG Melissinos) over an 18-year period of all patients that underwent adductor magnus muscle free flap coverage for lower-extremity soft tissue injuries.

RESULTS

Twenty-four adductor magnus free flaps in 24 patients were performed over an 18-year period (2000-2018). All of the adductor magnus muscle free flaps were performed with the initial intention of gracilis muscle harvest for lower-extremity soft tissue coverage. The most common wound etiology was motor vehicle collisions (8 patients, 33%). All of the adductor magnus free flaps were used for coverage of lower-extremity wounds in the following anatomic locations: distal third (10 patients, 41.7%), ankle (11 patients, 45.8%) and foot (3 patients, 12.5%). All flaps were successful. There were minimal donor site complications. Limb salvage rate was 100%.

CONCLUSIONS

Use of the adductor magnus muscle free flap is a reasonable alternative to the gracilis muscle in cases when unfavorable gracilis vascular anatomy is encountered intraoperatively. It can be easily and safely harvested within the same donor incision and permits reliable coverage of small- to medium-sized lower-extremity soft tissue defects while avoiding the morbidity of a secondary donor site.

The esthetic outcome of lower limb reconstruction

BACKGROUND

In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients' quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction.

OBJECTIVES

This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction.

DATA SOURCES

A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits.

STUDY ELIGIBILITY CRITERIA

All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search.

PARTICIPANTS, AND INTERVENTIONS

One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed.

RESULTS

We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps.

LIMITATIONS

The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed.

CONCLUSIONS

Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.

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.