Grady B. Core, Rick Weimar, and N. Bradly Meland
THE TURBO GRACILIS MYOCUTANEOUS FLAP ABSTRACT
The gracilis muscle and musculocutaneous flap, originally described by McCraw,1 has become a widely accepted flap for a variety of uses. Not only is it most notable for coverage of defects in the perineal region 23 and vaginal reconstruction,14 but also as a free flap,5 finding functional applications in facial reanimation,6 as well as forearm flexorplasty.7 In this latter function, Manktelow7 has defined its use. In addition to its advantages, he also has listed flap disadvantages, the most significant of which is the unreliability of the distal skin island, due to the absence of musculocutaneous perforators over the distal one-third of the muscle. The inability to extend the skin island becomes a major disadvantage, if volar wrist skin coverage is missing distally. Manktelow notes that this distal wrist area is exactly where it is most crucial for there to be a good skin coverage, since the muscletendon coaptation must be well protected. Another disadvantage he points out is that, at times, the distal muscle does not perfuse well, requiring that the muscle be shortened and the hand flexor tendons attached more proximally. We felt that an extended gracilis skin island would be possible, if the "turbo" concept, as introduced by Harii,8 could be applied to the distal blood supply of the muscle and anteromedial thigh skin. Harii com-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
While the gracilis muscle flap continues to be used for coverage of selected defects and in specialized applications such as facial reanimation, the lack of reliability of the distal skin component of the gracilis musculocutaneous flap has limited its usefulness. Reliable distal skin and muscle viability are particularly important when the gracilis musculocutaneous free flap is used in forearm flexorplasty. A method for "turbocharging" this flap, to improve distal reliability, is described. The anatomy of 24 human lower extremities was studied, with respect to the arterial supply to the distal gracilis muscle and distal medial thigh skin. A consistent septal branch, originating from the superficial femoral artery proximal to the adductor canal, supplying the distal gracilis muscle as well as the overlying skin, was identified in all extremities. "Turbocharging" via this vessel increases the reliability of both the distal skin island and distal muscle of the gracilis myocutaneous flap and enhances its versatility, when used as either a pedicle or free flap.
bined a latissimus myocutaneous pedicled flap with an extended groin skin island augmented with microvascular anastomosis. The anteromedial thigh skin has been shown to be supplied by septocutaneous perforators, which have also been described as the basis for free fasciocutaneous flaps.9-11 Other authors have demonstrated that these septocutaneous vessels also give rise to muscular branches as well.1213 In order further to define the relationships of the septocutaneous perforators of the anteromedial thigh and the distal gracilis blood supply, the following study was undertaken.
MATERIALS AND METHODS The study was performed by dissecting 24 human lower extremities, of which 16 were fresh tissue and eight were preserved tissue. Injections of the common femoral artery were done using colored latex, and more flap-specific injections were through the dominant distal gracilis pedicle using Microfil. The vascular pedicles from the superficial femoral artery were carefully dissected, with special attention given to the branches to the gracilis, sartorius, and skin of the medial thigh. The classification used to describe the morphol-
From the Sections of Plastic and Reconstructive Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN, the Mayo Clinic, Scottsdale, AZ, and the Maricopa Medical Center, Phoenix, AZ Materials in this paper were presented at the Seventh Annual Meeting, American Society for Reconstructive Microsurgery, Orlando, FL, September, 1991 Reprint requests-. Dr. Rick Weimar, Maricopa Medical Center, 2601 E. Roosevelt, Phoenix, AZ 85008 Accepted for publication February 25, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
267
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 4
RESULTS The total number of vascular pedicles to the gracilis, including the proximal pedicle, ranged from three to five. There were two double proximal pedicles. It should be noted that, if the proximal pedicle is dissected back far enough, there are branches coming off it which can be saved as a possible site of anastomosis for a vein graft to the distal pedicle. The 24 lower extremities dissected revealed that there was always a type III pedicle proximal to the entry of the superficial femoral artery into the adductor canal (see Table 2 and Fig. 1). In 23 of the 24 specimens, the pedicle was within 1.5 cm of the entrance and, in one specimen, it was 3 cm proximal, with a smaller, nondominant pedicle between it and the adductor canal entrance. It was the second distal pedicle in 20 cases, third distal pedicle in three cases, and the first distal pedicle in one case; however, its position on the superficial femoral artery was constant in 23 of 24 specimens, within 1.5 cm proximal to the adductor canal. Therefore, with the skin contribution from this type III vessel being technically a septocutaneous perforator, the observation was that the dominant distal gracilis vascular leash arises in common with a major septocutaneous perforator, in a constant pattern at a constant position, despite variation in arterial morphology both proximally and distally along the superficial femoral artery (Fig. 2). We believe this septocutaneous perforator to be the same one described by Baek as the basis for the medial thigh flap,9 and also the same vessel alluded to by Song and colleagues as the "backup" vessel for the anteromedial thigh flap, if the descending innominate branch of the lateral femoral circumflex was too small.10
Table 1. Morphology of Arterial Types Type
268
Structure(s) Supplied
IA IB Ic
Gracilis only Sartorius only Skin only
IIA
Gracilis a n d skin
1IB IIC
Sartorius a n d skin Gracilis a n d sartorius
III
All three structures supplied
Table 2 Specimen 1 2 3 4
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Type FT FT PT PT PT PT PT PT PT PT FT FT FT FT FT FT FT FT FT FT FT FT FT FT
Gracilis Vascular Pedicles Proximal Pedicle
Double Double Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single
Distal Pedicles 1 III III III III 111 III III III III III III III III III III IIB IIB
lie III III III** III IIB
IIB
2 III* III* III* III* III* III* III* III* III* III* 111* III* lie lie lie III* III* III* 111* III* lie III* 111* III*
3 B
II IIB
lie lie III* III* III* lie lie
4 ic ic — — — — — — — — IA IA
ic |C
IC
ic III
III IA
III IIB IIB
111 lie IA
IA
FT, fresh tissue; PT preserved tissue (unable to determine pedicle morphology distal to adductor canal). *, origin within 1.5 cm proximal to adductor canal. **, origin within 3.0 cm proximal to adductor canal.
Injection studies performed through this pedicle revealed not only filling of the entire gracilis muscle, but also filling of a septocutaneous branch which supplied the medial thigh skin (Fig. 3). The skin island used for the injection study was quite large (10 x 30 cm) and could be noted to be filling throughout its distal portion. We feel this lends support to the hypothesis that inflow through both the proximal and distal pedicles can significantly increase the amount of medial thigh skin available. Pedicles distal to the origin of the adductor canal were quite variable as to morphology (see Table 2). There was an association with the saphenous artery in seven of 16 fresh tissue specimens, and there were also direct vessels to the upper thigh skin from the saphenous artery in nine of 16 specimens. Direct contributions from the popliteal to the gracilis (4/16) and the skin (2/16) were also found. Preserved tissue specimens did not always allow for accurate tracing of these small vessels distal to the adductor canal in all specimens; therefore, the data for this region in these specimens were omitted.
CLINICAL APPLICATION The clinical significance of the cadaver findings is that, since there is a consistent type III vessel supply-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
ogy of the arterial contributions to these three structures was the same as that introduced by Giordano,13 except that types I and II were expanded, as seen in Table 1. Results of anatomic findings are summarized in Table 2. Although our emphasis was on the pedicles arising from the superficial femoral artery proximal to the adductor canal, we did attempt to evaluate all gracilis pedicles.
JULY 1992
TURBO GRACILIS/CORE, WEIMAR, MELAND Type III distal pedicle
Sartorius m.
Deep femoral art.
Adductor canal
Figure 2. A, Distal septocutaneous/muscular (type III) pedicle, near entrance of superficial femoral artery in adductor canal. Skin and distal gracilis elevated. B, Distal type III pedicle with muscular and septocutaneous branches.
Fasciocutaneous plexus
Proximal pedicle
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Skin Figure 1. Most common anatomy of distal gracilis pedicles.
Medial thigh fasciocutaneous element
Superficial fem. a. (superimposed)
Proximal pedicle filling retrograde
270
JULY 1992
ing the distal gracilis muscle, as well as the overlying skin, this pedicle can be utilized to expand the capabilities of the gracilis myocutaneous flap. CASE REPORT. A 21-year-old male was referred to the Plastic Surgery Service with complete loss of his forearm flexor musculature, secondary to a compartment syndrome. His flexor tendons had been debrided up to the wrist level, and traumatic lacerations to his dorsal forearm rendered tendon transfers impractical. In addition, he also had loss of skin coverage over the distal volar wrist (Fig. 4). A forearm flexorplasty utilizing a free gracilis myocutaneous flap with an extended skin island was performed (Fig. 5). The basic technique as described by Manktelow7 was utilized for positioning and inset of the muscle. Neural coaptation was to the anterior interosseous nerve, and the proximal vascular anastomosis was from a muscular branch of the ulnar artery to the proximal gracilis pedicle. After inflow was established, the distal muscle and skin paddle appeared ischemic. A reverse vein graft was then interposed from a branch off the proximal pedicle to the distal gracilis pedicle (Fig. 6), and the ischemia resolved in both muscle and
Figure 3. A, Injection studies of "turbo gracilis" through distal type III pedicle. B, Diagrammatic representation of Figure 3A.
skin. A shorter vein graft to this pedicle, directly off a more distal artery, was not performed, since the radial and ulnar arteries at this level were encased under fibrotic wound base. No additional venous outflow conduit was necessary, as there was no appearance of distal venous congestion. The extended skin paddle was then used to cover the muscle-tendon coaptation easily (Fig. 7). Postoperatively, the patient did well and has continued to have excellent coverage (Fig. 8), good muscle viability and, at two months postsurgery, was starting to have evidence of reinnervation. Donor-site morbidity was not a problem, with the incision extended distally over the lower leg for vein-graft harvesting (Fig. 9). Arteriography at two months also shows patency of the vein graft (Fig. 10).
DISCUSSION Although the turbo gracilis myocutaneous flap has not been described previously, it is based not only on McCraw's description of the original gracilis flap,1 but also on various techniques taken from other pre-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 4
Figure 4. A, Volar arm defect. B, Dorsal injuries to arm.
Figure 5. Flexorplasty. Note distal skin island draped behind hand.
B
271
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
TURBO GRACILIS/CORE, WEIMAR, MELAND
JULY 1992
Figure 6. Vein graft (VG) to distal pedicle seen just above distal median nerve.
Figure 7. TWo months postoperative. Note distal skin coverage over area of muscle-tendon coaptation.
272
Figure 8. Donor site at two weeks.
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 4
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
TURBO GRACIUS/CORE, WEIMAR, MELAND
Figure 9. Arteriogram showing patent vein graft (VG) at two months postoperative.
viously described methods. Orticochea in 1972 described a musculocutaneous flap method as a "heroic substitute for the method of delay."14 The flap he used, although no description was given of its vascular anatomy, appears to be very similar to the distal portion of our flap, and also appears to be based on the same septocutaneous vessel later described by Baek.9 Vasconez gives credence to this in his comment on Baek's article.15 Baek's description of the medial thigh flap clearly delineates anatomic relationships. It is apparent that the pedicle to the medial thigh flap is the same vessel which we found consistently arising just proximal to
Figure 10. Combined skin islands of gracilis and medial thigh flaps.
the adductor canal. Vasconez15 also states that his own cadaver dissections confirm Baek's descriptions. However, Baek did not describe the constant association of this septocutaneous vessel with a distal branch to the gracilis and sartorius, which we noted. Although others have described an association between the distal gracilis pedicle and a branch to the skin, the recognition that this branch is, indeed, the vessel supplying the medial thigh flap has never been noted.13 For all practical purposes, the skin island of the turbo gracilis myocutaneous flap is simply a combination of the standard gracilis skin island and the medial thigh flap skin island (Fig. 11). Presumably, therefore,
273
JULY 1992
Figure 11. Example of free flap with overlying extended skin island.
274
although not proven clinically, the limits of the distal turbo gracilis skin island would be the same as those described for the medial thigh flap. That gives us the capability to extend the skin flap well over the distal tendinous portion of the gracilis muscle. It should also be noted that the artery to the skin island always arose in common with a branch to the gracilis in our series, but other authors have described the distal gracilis pedicle without a skin contribution in as many as 15 percent of the cases.13 Although this artery was present consistently in both our series and Baek's, and was always sufficiently large enough for microvascular anastomosis (0.8 to 2.0 mm in diameter), the fundamental principle here should not be lost: that is, there are always septocutaneous perforators present in the medial thigh area and these can be identified preoperatively with a Doppler probe.16 Quite likely, any of these can be utilized, not only as the basis for a free fasciocutaneous flap,9-'1 but also as a pedicle for supplying this same skin area, when it is still attached to the more proximal skin overlying the gracilis. Although this latter statement has not been proven clinically, it is certainly reasonable. Based on the consistency of location of the type III septocutaneous/muscular vessel noted in our dissections, we recommend this as the vessel of choice when an extended gracilis skin island is needed. The proper orientation of the skin island has recently been redesigned to a more transverse orientation,17 but the myocutaneous perforators present in the proximal portion of the muscle should still provide for a longitudinally-oriented skin island, as long as it does not extend too far distally. Therefore, the skin island which we have designed, that extends the standard skin island, should still be a viable concept. The latissimus dorsi myocutaneous flap has also been recommended for forearm flexorplasty, when a large cuta-
neous defect is present. However, this muscle unit has required multiple reoperations to facilitate finger flexion.18 The "turbo-charged" gracilis myocutaneous unit would seem to be a more logical choice for this problem, since the muscle has been shown to supply excellent function as a finger flexor.
CONCLUSIONS We have presented evidence from 24 cadaver lower-extremity dissections, demonstrating the feasibility of extending the gracilis skin island, using the "turbo-charge" principle of vein grafting to a distal pedicle. The septocutaneous perforator supplying the skin over the distal one-third on the medial thigh was consistently associated with a distal gracilis pedicle, both originating in common from the superficial femoral artery just proximal to the adductor canal. This concept was applied successfully in one clinical case of forearm flexorplasty, where distal, volar wrist skin was missing; the extended skin paddle easily covered the area.
REFERENCES McCraw IB, Massey FM, Shanklin KD, et al: Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg 58:176, 1976 Bartholdsen L, Hulten L: Repair of persistent perineal sinuses by means of a pedicle flap of musculus gracilis. Scand I Plast Reconstr Surg 9:74, 1975 Bostwick I, Hill HL, Nahai F: Repairs in the lower abdomen, groin, or perineum with myocutaneous or omental flaps. Plast Reconstr Surg 63:186, 1979 Dibbell DG: Dynamic correction of intractable vaginal prolapse. Ann Plast Surg 2:254, 1979 Mathes SI, Nahai F, Vasconez LO: Myocutaneous free flap trans-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 4
TURBO GRACILIS/CORE, WEIMAR, MELAND
12
13. 14. 15. 16.
17. 18.
Giordano PA, Abbes M, Pequignot )P: Gracilis blood supply: Anatomical and clinical re-evaluation. Br I Plast Surg 43: 266, 1990 Orticochea M: The musculocutaneous flap method: An immediate and heroic substitute of the method of delay. Br I Plast Surg 25:106, 1972 Vasconez L: Discussion: Baek S: Two new cutaneous free flaps: The medial and lateral thigh flaps. Plast Reconstr Surg 71: 364, 1983 Taylor GI, Doyle M, McCarten G: The Doppler probe for planning flaps: An anatomical study and clinical applications. Br I Plast Surg 43:1, 1990 Yousif NJ, Yezhong Y: Analysis of cutaneous perfusion: An aid to lower extremity reconstruction. Clin Plast Surg 18:559, 1991 Favero K, Wood MB, Meland NB: Innervated latissimus dorsi free muscle transfer for the restoration of finger flexion. Presented at the Annual Meeting, Midwestern Association of Plastic Surgery, Chicago, IL, June, 1990
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
10.
fer: Anatomical and experimental considerations. Plast Reconstr Surg 62:162, 1978 Harii K, Ohmori K, Torii S: Free gracilis muscle transplantation with microneurovascular anastomosis for the treatment of facial paralysis. Plast Reconstr Surg 57:133, 1976 Manktelow R, McKee NH: Free muscle transplantation to provide active finger flexion. J Hand Surg 3:416, 1978 Harii K, Iwoya T, Kawaguchi N: Combination myocutaneous flap and microvascular free flap. Plast Reconstr Surg 68:710, 1981 Baek S: Two new cutaneous free flaps: The medial and lateral thigh flaps. Plast Reconstr Surg 71:354, 1983 Song YG, Chen GZ, Song YL: The free thigh flap: A new free flap concept based on the septocutaneous artery. Br) Plast Surg 37:149, 1984 Hayashi A, Maruyama Y: The medial genicular artery flap. Ann Plast Surg 25:174, 1990 Cormack GC, Lamberty BGH: The blood supply of thigh skin. Plast Reconstr Surg 75:342, 1985
275
THE TURBO GRACILIS MYOCUTANEOUS FLAP ABSTRACT
The gracilis muscle and musculocutaneous flap, originally described by McCraw,1 has become a widely accepted flap for a variety of uses. Not only is it most notable for coverage of defects in the perineal region 23 and vaginal reconstruction,14 but also as a free flap,5 finding functional applications in facial reanimation,6 as well as forearm flexorplasty.7 In this latter function, Manktelow7 has defined its use. In addition to its advantages, he also has listed flap disadvantages, the most significant of which is the unreliability of the distal skin island, due to the absence of musculocutaneous perforators over the distal one-third of the muscle. The inability to extend the skin island becomes a major disadvantage, if volar wrist skin coverage is missing distally. Manktelow notes that this distal wrist area is exactly where it is most crucial for there to be a good skin coverage, since the muscletendon coaptation must be well protected. Another disadvantage he points out is that, at times, the distal muscle does not perfuse well, requiring that the muscle be shortened and the hand flexor tendons attached more proximally. We felt that an extended gracilis skin island would be possible, if the "turbo" concept, as introduced by Harii,8 could be applied to the distal blood supply of the muscle and anteromedial thigh skin. Harii com-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
While the gracilis muscle flap continues to be used for coverage of selected defects and in specialized applications such as facial reanimation, the lack of reliability of the distal skin component of the gracilis musculocutaneous flap has limited its usefulness. Reliable distal skin and muscle viability are particularly important when the gracilis musculocutaneous free flap is used in forearm flexorplasty. A method for "turbocharging" this flap, to improve distal reliability, is described. The anatomy of 24 human lower extremities was studied, with respect to the arterial supply to the distal gracilis muscle and distal medial thigh skin. A consistent septal branch, originating from the superficial femoral artery proximal to the adductor canal, supplying the distal gracilis muscle as well as the overlying skin, was identified in all extremities. "Turbocharging" via this vessel increases the reliability of both the distal skin island and distal muscle of the gracilis myocutaneous flap and enhances its versatility, when used as either a pedicle or free flap.
bined a latissimus myocutaneous pedicled flap with an extended groin skin island augmented with microvascular anastomosis. The anteromedial thigh skin has been shown to be supplied by septocutaneous perforators, which have also been described as the basis for free fasciocutaneous flaps.9-11 Other authors have demonstrated that these septocutaneous vessels also give rise to muscular branches as well.1213 In order further to define the relationships of the septocutaneous perforators of the anteromedial thigh and the distal gracilis blood supply, the following study was undertaken.
MATERIALS AND METHODS The study was performed by dissecting 24 human lower extremities, of which 16 were fresh tissue and eight were preserved tissue. Injections of the common femoral artery were done using colored latex, and more flap-specific injections were through the dominant distal gracilis pedicle using Microfil. The vascular pedicles from the superficial femoral artery were carefully dissected, with special attention given to the branches to the gracilis, sartorius, and skin of the medial thigh. The classification used to describe the morphol-
From the Sections of Plastic and Reconstructive Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN, the Mayo Clinic, Scottsdale, AZ, and the Maricopa Medical Center, Phoenix, AZ Materials in this paper were presented at the Seventh Annual Meeting, American Society for Reconstructive Microsurgery, Orlando, FL, September, 1991 Reprint requests-. Dr. Rick Weimar, Maricopa Medical Center, 2601 E. Roosevelt, Phoenix, AZ 85008 Accepted for publication February 25, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
267
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 4
RESULTS The total number of vascular pedicles to the gracilis, including the proximal pedicle, ranged from three to five. There were two double proximal pedicles. It should be noted that, if the proximal pedicle is dissected back far enough, there are branches coming off it which can be saved as a possible site of anastomosis for a vein graft to the distal pedicle. The 24 lower extremities dissected revealed that there was always a type III pedicle proximal to the entry of the superficial femoral artery into the adductor canal (see Table 2 and Fig. 1). In 23 of the 24 specimens, the pedicle was within 1.5 cm of the entrance and, in one specimen, it was 3 cm proximal, with a smaller, nondominant pedicle between it and the adductor canal entrance. It was the second distal pedicle in 20 cases, third distal pedicle in three cases, and the first distal pedicle in one case; however, its position on the superficial femoral artery was constant in 23 of 24 specimens, within 1.5 cm proximal to the adductor canal. Therefore, with the skin contribution from this type III vessel being technically a septocutaneous perforator, the observation was that the dominant distal gracilis vascular leash arises in common with a major septocutaneous perforator, in a constant pattern at a constant position, despite variation in arterial morphology both proximally and distally along the superficial femoral artery (Fig. 2). We believe this septocutaneous perforator to be the same one described by Baek as the basis for the medial thigh flap,9 and also the same vessel alluded to by Song and colleagues as the "backup" vessel for the anteromedial thigh flap, if the descending innominate branch of the lateral femoral circumflex was too small.10
Table 1. Morphology of Arterial Types Type
268
Structure(s) Supplied
IA IB Ic
Gracilis only Sartorius only Skin only
IIA
Gracilis a n d skin
1IB IIC
Sartorius a n d skin Gracilis a n d sartorius
III
All three structures supplied
Table 2 Specimen 1 2 3 4
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Type FT FT PT PT PT PT PT PT PT PT FT FT FT FT FT FT FT FT FT FT FT FT FT FT
Gracilis Vascular Pedicles Proximal Pedicle
Double Double Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single Single
Distal Pedicles 1 III III III III 111 III III III III III III III III III III IIB IIB
lie III III III** III IIB
IIB
2 III* III* III* III* III* III* III* III* III* III* 111* III* lie lie lie III* III* III* 111* III* lie III* 111* III*
3 B
II IIB
lie lie III* III* III* lie lie
4 ic ic — — — — — — — — IA IA
ic |C
IC
ic III
III IA
III IIB IIB
111 lie IA
IA
FT, fresh tissue; PT preserved tissue (unable to determine pedicle morphology distal to adductor canal). *, origin within 1.5 cm proximal to adductor canal. **, origin within 3.0 cm proximal to adductor canal.
Injection studies performed through this pedicle revealed not only filling of the entire gracilis muscle, but also filling of a septocutaneous branch which supplied the medial thigh skin (Fig. 3). The skin island used for the injection study was quite large (10 x 30 cm) and could be noted to be filling throughout its distal portion. We feel this lends support to the hypothesis that inflow through both the proximal and distal pedicles can significantly increase the amount of medial thigh skin available. Pedicles distal to the origin of the adductor canal were quite variable as to morphology (see Table 2). There was an association with the saphenous artery in seven of 16 fresh tissue specimens, and there were also direct vessels to the upper thigh skin from the saphenous artery in nine of 16 specimens. Direct contributions from the popliteal to the gracilis (4/16) and the skin (2/16) were also found. Preserved tissue specimens did not always allow for accurate tracing of these small vessels distal to the adductor canal in all specimens; therefore, the data for this region in these specimens were omitted.
CLINICAL APPLICATION The clinical significance of the cadaver findings is that, since there is a consistent type III vessel supply-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
ogy of the arterial contributions to these three structures was the same as that introduced by Giordano,13 except that types I and II were expanded, as seen in Table 1. Results of anatomic findings are summarized in Table 2. Although our emphasis was on the pedicles arising from the superficial femoral artery proximal to the adductor canal, we did attempt to evaluate all gracilis pedicles.
JULY 1992
TURBO GRACILIS/CORE, WEIMAR, MELAND Type III distal pedicle
Sartorius m.
Deep femoral art.
Adductor canal
Figure 2. A, Distal septocutaneous/muscular (type III) pedicle, near entrance of superficial femoral artery in adductor canal. Skin and distal gracilis elevated. B, Distal type III pedicle with muscular and septocutaneous branches.
Fasciocutaneous plexus
Proximal pedicle
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Skin Figure 1. Most common anatomy of distal gracilis pedicles.
Medial thigh fasciocutaneous element
Superficial fem. a. (superimposed)
Proximal pedicle filling retrograde
270
JULY 1992
ing the distal gracilis muscle, as well as the overlying skin, this pedicle can be utilized to expand the capabilities of the gracilis myocutaneous flap. CASE REPORT. A 21-year-old male was referred to the Plastic Surgery Service with complete loss of his forearm flexor musculature, secondary to a compartment syndrome. His flexor tendons had been debrided up to the wrist level, and traumatic lacerations to his dorsal forearm rendered tendon transfers impractical. In addition, he also had loss of skin coverage over the distal volar wrist (Fig. 4). A forearm flexorplasty utilizing a free gracilis myocutaneous flap with an extended skin island was performed (Fig. 5). The basic technique as described by Manktelow7 was utilized for positioning and inset of the muscle. Neural coaptation was to the anterior interosseous nerve, and the proximal vascular anastomosis was from a muscular branch of the ulnar artery to the proximal gracilis pedicle. After inflow was established, the distal muscle and skin paddle appeared ischemic. A reverse vein graft was then interposed from a branch off the proximal pedicle to the distal gracilis pedicle (Fig. 6), and the ischemia resolved in both muscle and
Figure 3. A, Injection studies of "turbo gracilis" through distal type III pedicle. B, Diagrammatic representation of Figure 3A.
skin. A shorter vein graft to this pedicle, directly off a more distal artery, was not performed, since the radial and ulnar arteries at this level were encased under fibrotic wound base. No additional venous outflow conduit was necessary, as there was no appearance of distal venous congestion. The extended skin paddle was then used to cover the muscle-tendon coaptation easily (Fig. 7). Postoperatively, the patient did well and has continued to have excellent coverage (Fig. 8), good muscle viability and, at two months postsurgery, was starting to have evidence of reinnervation. Donor-site morbidity was not a problem, with the incision extended distally over the lower leg for vein-graft harvesting (Fig. 9). Arteriography at two months also shows patency of the vein graft (Fig. 10).
DISCUSSION Although the turbo gracilis myocutaneous flap has not been described previously, it is based not only on McCraw's description of the original gracilis flap,1 but also on various techniques taken from other pre-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 4
Figure 4. A, Volar arm defect. B, Dorsal injuries to arm.
Figure 5. Flexorplasty. Note distal skin island draped behind hand.
B
271
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
TURBO GRACILIS/CORE, WEIMAR, MELAND
JULY 1992
Figure 6. Vein graft (VG) to distal pedicle seen just above distal median nerve.
Figure 7. TWo months postoperative. Note distal skin coverage over area of muscle-tendon coaptation.
272
Figure 8. Donor site at two weeks.
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 4
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
TURBO GRACIUS/CORE, WEIMAR, MELAND
Figure 9. Arteriogram showing patent vein graft (VG) at two months postoperative.
viously described methods. Orticochea in 1972 described a musculocutaneous flap method as a "heroic substitute for the method of delay."14 The flap he used, although no description was given of its vascular anatomy, appears to be very similar to the distal portion of our flap, and also appears to be based on the same septocutaneous vessel later described by Baek.9 Vasconez gives credence to this in his comment on Baek's article.15 Baek's description of the medial thigh flap clearly delineates anatomic relationships. It is apparent that the pedicle to the medial thigh flap is the same vessel which we found consistently arising just proximal to
Figure 10. Combined skin islands of gracilis and medial thigh flaps.
the adductor canal. Vasconez15 also states that his own cadaver dissections confirm Baek's descriptions. However, Baek did not describe the constant association of this septocutaneous vessel with a distal branch to the gracilis and sartorius, which we noted. Although others have described an association between the distal gracilis pedicle and a branch to the skin, the recognition that this branch is, indeed, the vessel supplying the medial thigh flap has never been noted.13 For all practical purposes, the skin island of the turbo gracilis myocutaneous flap is simply a combination of the standard gracilis skin island and the medial thigh flap skin island (Fig. 11). Presumably, therefore,
273
JULY 1992
Figure 11. Example of free flap with overlying extended skin island.
274
although not proven clinically, the limits of the distal turbo gracilis skin island would be the same as those described for the medial thigh flap. That gives us the capability to extend the skin flap well over the distal tendinous portion of the gracilis muscle. It should also be noted that the artery to the skin island always arose in common with a branch to the gracilis in our series, but other authors have described the distal gracilis pedicle without a skin contribution in as many as 15 percent of the cases.13 Although this artery was present consistently in both our series and Baek's, and was always sufficiently large enough for microvascular anastomosis (0.8 to 2.0 mm in diameter), the fundamental principle here should not be lost: that is, there are always septocutaneous perforators present in the medial thigh area and these can be identified preoperatively with a Doppler probe.16 Quite likely, any of these can be utilized, not only as the basis for a free fasciocutaneous flap,9-'1 but also as a pedicle for supplying this same skin area, when it is still attached to the more proximal skin overlying the gracilis. Although this latter statement has not been proven clinically, it is certainly reasonable. Based on the consistency of location of the type III septocutaneous/muscular vessel noted in our dissections, we recommend this as the vessel of choice when an extended gracilis skin island is needed. The proper orientation of the skin island has recently been redesigned to a more transverse orientation,17 but the myocutaneous perforators present in the proximal portion of the muscle should still provide for a longitudinally-oriented skin island, as long as it does not extend too far distally. Therefore, the skin island which we have designed, that extends the standard skin island, should still be a viable concept. The latissimus dorsi myocutaneous flap has also been recommended for forearm flexorplasty, when a large cuta-
neous defect is present. However, this muscle unit has required multiple reoperations to facilitate finger flexion.18 The "turbo-charged" gracilis myocutaneous unit would seem to be a more logical choice for this problem, since the muscle has been shown to supply excellent function as a finger flexor.
CONCLUSIONS We have presented evidence from 24 cadaver lower-extremity dissections, demonstrating the feasibility of extending the gracilis skin island, using the "turbo-charge" principle of vein grafting to a distal pedicle. The septocutaneous perforator supplying the skin over the distal one-third on the medial thigh was consistently associated with a distal gracilis pedicle, both originating in common from the superficial femoral artery just proximal to the adductor canal. This concept was applied successfully in one clinical case of forearm flexorplasty, where distal, volar wrist skin was missing; the extended skin paddle easily covered the area.
REFERENCES McCraw IB, Massey FM, Shanklin KD, et al: Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg 58:176, 1976 Bartholdsen L, Hulten L: Repair of persistent perineal sinuses by means of a pedicle flap of musculus gracilis. Scand I Plast Reconstr Surg 9:74, 1975 Bostwick I, Hill HL, Nahai F: Repairs in the lower abdomen, groin, or perineum with myocutaneous or omental flaps. Plast Reconstr Surg 63:186, 1979 Dibbell DG: Dynamic correction of intractable vaginal prolapse. Ann Plast Surg 2:254, 1979 Mathes SI, Nahai F, Vasconez LO: Myocutaneous free flap trans-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 4
TURBO GRACILIS/CORE, WEIMAR, MELAND
12
13. 14. 15. 16.
17. 18.
Giordano PA, Abbes M, Pequignot )P: Gracilis blood supply: Anatomical and clinical re-evaluation. Br I Plast Surg 43: 266, 1990 Orticochea M: The musculocutaneous flap method: An immediate and heroic substitute of the method of delay. Br I Plast Surg 25:106, 1972 Vasconez L: Discussion: Baek S: Two new cutaneous free flaps: The medial and lateral thigh flaps. Plast Reconstr Surg 71: 364, 1983 Taylor GI, Doyle M, McCarten G: The Doppler probe for planning flaps: An anatomical study and clinical applications. Br I Plast Surg 43:1, 1990 Yousif NJ, Yezhong Y: Analysis of cutaneous perfusion: An aid to lower extremity reconstruction. Clin Plast Surg 18:559, 1991 Favero K, Wood MB, Meland NB: Innervated latissimus dorsi free muscle transfer for the restoration of finger flexion. Presented at the Annual Meeting, Midwestern Association of Plastic Surgery, Chicago, IL, June, 1990
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
10.
fer: Anatomical and experimental considerations. Plast Reconstr Surg 62:162, 1978 Harii K, Ohmori K, Torii S: Free gracilis muscle transplantation with microneurovascular anastomosis for the treatment of facial paralysis. Plast Reconstr Surg 57:133, 1976 Manktelow R, McKee NH: Free muscle transplantation to provide active finger flexion. J Hand Surg 3:416, 1978 Harii K, Iwoya T, Kawaguchi N: Combination myocutaneous flap and microvascular free flap. Plast Reconstr Surg 68:710, 1981 Baek S: Two new cutaneous free flaps: The medial and lateral thigh flaps. Plast Reconstr Surg 71:354, 1983 Song YG, Chen GZ, Song YL: The free thigh flap: A new free flap concept based on the septocutaneous artery. Br) Plast Surg 37:149, 1984 Hayashi A, Maruyama Y: The medial genicular artery flap. Ann Plast Surg 25:174, 1990 Cormack GC, Lamberty BGH: The blood supply of thigh skin. Plast Reconstr Surg 75:342, 1985
275
