Transverse splitting of the gracilis muscle free flap: Maximal use of a single muscle

The gracilis muscle, based on the dominant pedicle, has been used extensively for free tissue transfer. Recent studies have described the constant anatomy, ease of dissection, and low donor-site morbidity of the distal segmental gracilis free muscle flap. We present three cases of free distal segmental gracilis muscle transfer. In one case, the gracilis muscle was divided transversely into one proximally based and one distally based free flap and used for coverage of two separate wounds in a patient with bilateral open calcaneal fractures. In two cases, the preserved proximal gracilis was used as a reoperative free flap after failure of the initial distal segmental gracilis free muscle. With recent advances in microsurgery and ever-growing demands for low donor-site morbidity, it is important to ensure each free muscle flap harvested is used efficiently. Use of the free distal segmental gracilis muscle flap maximally uses one muscle while minimizing donor site morbidity and retaining the proximal muscle for future uses.     

应用节段性兔股薄肌肌皮瓣重建阴茎勃起功能的研究

目的 设计应用节段性兔股薄肌肌皮瓣构建再造阴茎、重建勃起功能的动物模型.方法 依据肌亚部原则,近似二等分纵向完全劈开兔股薄肌,以前部肌束作为功能单位和皮瓣血供来源,植入硅胶假体作为支撑,构建阴茎再造的动物模型.应用多道生理信号采集处理系统刺激再造阴茎活动,并同步检测复合肌肉动作电位.结果 通过电刺激兔再造阴茎根部的神经,可使前部肌束收缩,引起阴茎形态的相应改变,当肌束发生强直收缩时,再造阴茎上翘幅度最大,并可维持翘起状态数秒,较满意地模拟了阴茎的勃起动作.结论 应用节段性兔股薄肌肌皮瓣构建的再造阴茎动物模型,较满意地重建了阴茎勃起功能,达到了兼顾改善阴茎外观与保留肌肉收缩功能的要求,具有较好的临床应用前景.     

Reconstruction of large head and neck deformities: Experience with free gracilis muscle and myocutaneous flaps

Microvascular free flaps continue to revolutionize coverage options in head and neck reconstruction. The authors describe their experience with the gracilis free flap and the myocutaneous gracilis free flap with reconstruction of head and neck defects. Eleven patients underwent 12 free tissue transfer to the head and neck region. The reconstruction was performed with the transverse myocutaneous gracilis (TMG) flap (n = 7) and the gracilis muscle flap with skin graft (n = 5). The average patient age was 63.4 years (range, 17–82 years). The indications for this procedure were tumor and haemangioma resections. The average patient follow‐up was 20.7 months (range, 1 month–5.7 years). Total flap survival was 100%. There were no partial flap losses. Primary wound healing occurred in all cases. Recipient site morbidities included one hematoma. In our experience for reconstruction of moderate volume and surface area defects, muscle flaps with skin graft provide a better color match and skin texture relative to myocutaneous or fasciocutaneous flaps. The gracilis muscle free flap is not widely used for head and neck reconstruction but has the potential to give good results. As a filling substance for large cavities, the transverse myocutaneus gracilis flap has many advantages including reliable vascular anatomy, relatively great plasticity and a concealed donor area. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

Further experience with the medial circumflex femoral(GRACILIS) perforator free flap

The microsurgical transfer of the medial groin skin territory previously required this to be part of a transverse-oriented gracilis musculocutaneous free flap. As the concept of muscle perforator flaps has evolved, avoidance of muscle bulk and/or retention of muscle function here is also possible with the careful intramuscular dissection of the gracilis musculocutaneous perforators back to the usual medial circumflex femoral source vessel. This so-called medial circumflex femoral (GRACILIS) [MCF (GRACILIS)] perforator free flap has been successfully used seven times in six patients with minimal complications. The MCF (GRACILIS) muscle perforator flap may well represent the ideal skin flap: no muscle function is sacrificed; a reliable skin territory of large size is available; the dominant vascular pedicle is consistent in location; the flap may be harvested with the patient in a supine position; a combined conjoint flap including the gracilis muscle is optional; closure of the donor site leaves a medial groin scar that can be readily concealed; and flap dissection in this region is already very familiar to most microsurgeons.     

Total tongue reconstruction with free functional gracilis muscle transplantation: a technical note and review of the literature

The tongue is one of the most difficult structures of the body to reconstruct if more than 85% to 90% of it has been resected. A functional neotongue requires both soft-tissue bulk and restoration of muscle function. The innervated gracilis muscle flap folded on itself was used to reconstruct a total glossectomy defect. The genioglossus muscle, which makes the greatest contribution to swallowing, and the mylohyoid muscle, which elevates the larynx to prevent aspiration, were simulated with the design and placement of the gracilis muscle. The muscle was placed and secured longitudinally from the remnant of the tongue base and pharynx to the mandible, and then folded on itself and attached to the hyoid bone. The obturator nerve to the gracilis was coapted with the hypoglossal nerve. The patient was able to resume oral feeding without aspiration. Electromyographic results demonstrated reinnervation of the flap with active elevation of the mouth base. The patient died 1 year postoperatively because of recurrence of her disease. This type of design and placement of gracilis muscle transplantation is recommended.     

Multiple-component tissue reconstruction of a complex dorsal foot wound through a single gracilis muscle donor incision

The authors describe the ability of the gracilis muscle to provide multiple tissue components- skin, muscle, nerve, and tendonin the reconstruction of a complex dorsal foot wound resulting from a sarcoma resection. The deficits of skin, deep peroneal nerve, anterior tibialis tendon, and dorsal extensor retinaculum were all reconstructed with the gracilis component flap through one medial thigh incision. This case illustrates two important points: (1) the gracilis flap is tremendously versatile and can serve as the donor for multiple tissue components in complex reconstructions, and (2) donor site morbidity can and should be minimized even in complex reconstructions.     

闭孔动脉跨区供血的长型股薄肌肌皮瓣

目的 为解决由股深动脉分支供血的股薄肌肌皮瓣因血管蒂在股薄肌中上1／3处，致使向骨盆会阴带蒂转移时距离受限的问题，探索该肌皮瓣由闭孔起始部为旋转点向骨盆会阴区域转移的方法。方法 根据闭孔动脉-旋股内侧动脉-股深动脉分支之间存在良好吻合支，设计以闭孔动脉跨区供血的长型股薄肌肌皮瓣转移的方法。这种方法可以切断股深动脉分支，使股薄肌肌皮瓣能够更松弛地转移至骨盆、外阴、耻骨、联合、腹股沟等区域。结果修复骨盆会阴区的畸形和缺损9例，所有肌皮瓣均全部成活，经术后3个月至3年的随诊，效果均满意。结论 闭孔动脉跨区供血的长型股薄肌肌皮瓣，可以作为常规的肌皮瓣在临床应用。     

The accordion gracilis muscle flap: a new design for coverage of recurrent and complicated ischeal pressure sores

Management of patients with large or recurrent pressure ulcerations can be complicated by the lack of available local flap, whether already used or because adjacent lesions make such flap insufficient for complete coverage. In this article, the gracilis muscle was modified to cover large defects without help from its cutaneous territory. Twelve ischeal pressure sores were treated between August 2007 and 2009 with the modified gracilis muscle flap in a single-staged procedure. Five ulcers were recurrent and seven patients have associated pressure ulcers. All reconstructions were successful. Mean patient age was 35 years and nearly all patients had multiple significant comorbidities, including associated ulcers, diabetes and urethrocutaneous fistula. All flaps and donor sites healed uneventfully. There was one complication presented as cellulites at the donor site. Follow-up in some cases extend up to 1·5 years. No recurrence was observed. The accordion gracilis muscle flap is a handy, safe and fast flap for reconstruction of recurrent, difficult ischeal pressure sores.     

The gracilis flap revisited

The gracilis muscle or myocutaneous flap is a Mathes and Nahai neurovascular flap type II. It can be used either as a pedicled flap, or as a free flap. Since 1983, 21 gracilis muscle flaps were used in 19 patients at this department; 15 were pedicled while six were free flaps. Two pedicled flaps were lost, possibly due to an intraoperative spasm of the feeding artery. The indications for using the gracilis muscle are discussed, and the results with an average follow-up of more than a decade are presented. Received: 6 December 1999 / Accepted: 7 June 2000     

Pedicled flaps in the treatment of nonhealing perineal wounds

INTRODUCTION: A persistent sinus is an annoying complication following proctectomy. We examined the experience of a single colorectal surgeon in treating this condition using pedicled flaps. METHODS: Case note review of all patients undergoing gracilis muscle transposition, Rectus abdominis muscle flap or omental flap for persistent perineal sinus. RESULTS: Seventeen patients were identified: seven had gracilis muscle transposition, eight had omental transposition and two had a rectus abdominis flap. 13/17 patients who underwent a flap had a persistent sinus following proctectomy for Inflammatory bowel disease. Four patients who had a gracilis muscle transposition achieved healing. Seven out of eight patients had good results with omental transposition. One patient did well after a rectus abdominis flap. CONCLUSIONS: A gracilis transposition is a relatively simple operation with minimal morbidity useful for superficial sinuses not requiring a muscle bulk. A rectus abdominis flap is a more complex specialized procedure with better results especially in dealing with larger cavities but it may compromise future stoma sites. Omentoplasty has excellent results, but is only available in some patients.     

Use of a free gracilis flap for coverage of medium size defects over the ankle and foot

We report the use of a free gracilis flap in six cases of medium size tissue loss over the ankle and foot. All the procedures were done under spinal or epidural block. A muscle flap was used twice and a musculocutaneous flap four times. The skin paddle was reliable in three cases for evaluation of the vascularity of the musculocutaneous flaps, but in one case there was necrosis of 70% of the surface. In three cases the fatty skin paddle was removed at two weeks and the entire muscle surface was mesh skin grafted. The advantages of the use of a gracilis flap are easy dissection and low donor site morbidity. This flat and thin muscle is well-suited for medium size defects from 8-15 cm. The length of the pedicle could be extended to 8 cm by dissecting it as far as the profunda femoris vessels.     

Endoscopic harvest of four muscle flaps: safe and effective techniques

The recent explosion of endoscopic techniques in plastic surgery has led to the successful harvest of a number of useful muscle flaps. The gracilis, rectus femoris, external oblique, and gastrocnemius muscles can all be harvested safely and reproducibly using endoscopic techniques. The aim of this study was to identify a safe and effective technique for endoscopic muscle flap harvest. Harvesting the gracilis muscle as a free flap and the gastrocnemius as a pedicle flap lends themselves best to the use of endoscopic techniques.     

Use of a free gracilis flap for coverage of medium size defects over the ankle and foot.

We report the use of a free gracilis flap in six cases of medium size tissue loss over the ankle and foot. All the procedures were done under spinal or epidural block. A muscle flap was used twice and a musculocutaneous flap four times. The skin paddle was reliable in three cases for evaluation of the vascularity of the musculocutaneous flaps, but in one case there was necrosis of 70% of the surface. In three cases the fatty skin paddle was removed at two weeks and the entire muscle surface was mesh skin grafted. The advantages of the use of a gracilis flap are easy dissection and low donor site morbidity. This flat and thin muscle is well-suited for medium size defects from 8-15 cm. The length of the pedicle could be extended to 8 cm by dissecting it as far as the profunda femoris vessels.     

Muscle flap mass preservation with end-to-side neurorrhaphy: an experimental study

The authors examined the preservation of rat gracilis muscle flap mass after motor and sensory end-to-side neurorrhaphy. The rat gracilis muscle flap model was designed based on a previous study. Twenty-four Sprague-Dawley rats were divided into three groups. In Group 1 (n = 8), the flap was denervated by transecting the obturator nerve. In Group 2 (n = 8), the flap was reinnervated by coapting the proximal saphenous nerve to the distal obturator nerve. In Group 3 (n = 8), the flap was reinnervated by coapting the motor branch of the femoral nerve to the distal stump of the obturator nerve. At 6 months postoperatively, the gracilis muscle flaps were examined, harvested, and weighed individually. Results showed that the flaps with motor nerve reinnervation retained good bulk, with a weight of 634.0 +/- 65.1 gm, which was statistically significantly higher than the denervated group (457.5 +/- 125.3 gm, p < 0.01). However, muscle mass preservation in the sensory reinnervated group (606.9 +/- 209.1 gm) was not significantly different, compared to the denervated group. Histology revealed atrophic changes in the denervated group, compared to the sensory and motor-reinnervated groups. The authors concluded that muscle mass can be preserved by end-to-side nerve repair. Motor nerve reinnervation is able to better arrest atrophic changes of the muscle flaps.     

Gracilis muscle neosphincter for treating urinary incontinence.

The purpose of this study was to test the anatomical and functional feasibility of using a gracilis muscle free flap to create a urinary sphincter. Anatomical studies were performed in 12 human cadavers and short-term (n = 7) and long-term (n = 8) functional studies were performed in dogs. In the short-term functional studies, the left gracilis muscle was transferred into the pelvis and wrapped around the urethra and the right gracilis muscle was wrapped around a stent. A cuff electrode was placed on the muscle's nerve pedicle and used to stimulate the neosphincter while peak pressure, fatigue rate, and perfusion measurements were performed. In the long-term functional studies, intramuscular electrodes were inserted into the neosphincter to stimulate the flap. The flaps were wrapped around the urethra and dogs were followed for 16 weeks, during which time urodynamic measurements were performed. Our anatomical studies demonstrated that the gracilis muscle free flap could be transferred into the pelvis to create a urinary neosphincter. Our short-term functional study demonstrated that gracilis muscle free-flap function and perfusion were not compromised by transfer. In our long-term functional study, all neosphincters provided bladder outlet resistance pressures consistent with continence. Our anatomical, short-term, and long-term functional studies indicate that a gracilis muscle free-flap neosphincter is an effective procedure for treating urinary incontinence.     

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.     

The gracilis (medial circumflex femoral) perforator flap: a medial groin free flap?

The superior medial thigh skin territory has previously been successfully transferred as a free flap as part of a gracilis musculocutaneous flap. However, muscle bulk can be avoided and its function preserved by instead retaining only the musculocutaneous perforators arising from the gracilis pedicle like in a true perforator flap. A clinical example of this new perforator flap is described as the gracilis (medial circumflex femoral) perforator flap. This could become an ideal skin flap because no muscle is included, a well-defined segment of skin can be reliably harvested, closure of the donor site leaves a scar in the groin that can be readily concealed, and its dominant vascular pedicle is consistent in location and already familiar to most reconstructive surgeons.     

Rectovaginal fistula repair using a gracilis muscle flap

Introduction and hypothesis

This video demonstrates a technique for using a pedicled gracilis muscle flap to repair rectovaginal fistula.

Methods

We present the case of a 48-year-old woman diagnosed with rectal cancer 2 years earlier. She underwent neoadjuvant chemoradiation followed by ultralow anterior resection. Six weeks after surgery, a fistula was identified at the anastomotic site. Preoperative planning with urogynecology, plastic surgery, and colon and rectal surgery teams deemed a pedicled gracilis muscle flap to be the best approach for this patient due to the rich blood supply and the patient’s prior history of pelvic irradiation. The gracilis muscle is suitable due to the proximity of its vascular pedicle to the perineum, length, and minimal functional donor-site morbidity. We discuss techniques used to interpose a gracilis muscle flap between the rectum and vagina to repair a rectovaginal fistula.

Conclusion

Using the gracilis muscle is a viable option for repairing rectovaginal fistulas, especially in the setting of prior pelvic radiation. A multispecialty approach may be beneficial in complex cases to determine the optimal approach for repair.

     

A modified free gracilis flap in the rat

We present in this paper the use of a combined neurovas-cularized flap of gracilis muscle and inguinal skin in the rat with the femoral vessels and obturator nerve serving as the pedicles. The epigastric, saphenous, and muscular branch vessels arising from the femoral vessels were preserved, and a portion of adductor magnus muscle was included in the flap to protect the delicate muscle vessels at their origins. The inguinal skin and muscle flap both had independent blood supplies, thus, separate assessment of muscle and skin rejection was possible in the single transplanted “packet.” The muscle flap with the reconnected motor nerve regained contractile ability upon nerve stimulation within 30 days after the iso-transplantation. The results suggest that the modified gracilis myocutaneous flap provides an ideal model for transplantation research. © 1994 Wiley-Liss, Inc.