Comparison of onestage free gracilis muscle flap with two. It has also been used to restore the loss of muscle function in facial pa. The main function of the gracilis muscle is to facilitate hip adduction and to help with knee flexion. The doublemuscle gracilis and sartoriusgracilis myocutaneous flap leas a generous length, ample bulk, and has been transposed easily into the ischial defect. Breast reconstruction usin a transverse upper gracilis tug flap. Double free gracilis muscle transfer after complete brachial. The gracilis muscle or musculocutaneous flap is the flap of choice in functional motor unit transfers. This study aims to evaluate the use of a medial gastrocnemius muscle and or soleus muscle flap as a surgical treatment of the leg bone exposure. Muscle flap surgery wmhs plastic surgery cumberland, md. Traumatic brachial plexus root avulsions are devastating injuries, and are complex and challenging to reconstruct. One of the techniques that have been described consists of constructing a functional microsurgical flap from the gracilis muscle, in order to recover elbow flexion figures 1 and 2. Arterial anatomy of the gracilis muscle as determined by latex injection. Benefits to this technique when compared to use of the myocutaneous gracilis flap. The basic anatomy of the gracilis muscle, especially its extramuscular blood supply and its innervation, has been well and extensively documented and understood in the past magden et al, 2010.
A 57yearoldman with rectal cancer underwent abdominoperineal resection including part of the prostate and seminal vesicle. The gracilis muscle is detached, including its blood vessels and nerve. Jun 12, 2016 the belly of the muscle can be rotated and inserted as a flap between the rectum and adjacent organs during the repair of fistulas, or used as filler for the repair of nonhealing perineal wounds, with the option of harvesting an island of skin from the medial aspect of the thigh as a myocutaneous flap. Gracilis muscular flap for large urethral defect author. The primary function of this muscle is to aid in knee flexion. Free gracilis muscle coverage of forearm and hand soft tissue. Apr 01, 2015 the gracilis muscle is one of the muscles found in the groin. A small portion of this muscle with its blood supply artery and vein and nerve can be transplanted in the face to replace the facial muscles that allow you to smile. Doublemuscle gracilis and sartorius myocutaneous flap. This artery enters the muscle about 10 cm from the pubic symphysis.
For patients requiring two ostomies, robotassisted abdominoperineal resections aprs, and to avoid the morbidity of a vram harvest, the authors have used the gracilis muscle flap to reconstruct the large dead space. The procedure is simple enough for a vascular surgeon, the muscle is reliable in location and blood supply, and the results are satisfactory given the complexity of the problem. The belly of the muscle can be rotated and inserted as a flap between the rectum and adjacent organs during the repair of fistulas, or used as filler for the repair of nonhealing perineal wounds, with the option of harvesting an island of skin from the medial aspect of the thigh as a myocutaneous flap. The reconstruction of large defects after abdominoperineal resections and pelvic exenterations has traditionally been accomplished with vertical rectus myocutaneous flaps vrams. However, muscle flap selection after failure of treatment with other modalities necessitates diagnosis of the etiology of previous failure. Coverage of tissue defects of the lower limbs is a complex problem.
It is easily harvested and provides an excellent neurovascular pedicle. This muscle also assists in knee stabilization and knee rotation. Microsurgical transfer of the gracilis muscle for elbow. A transplanted muscle from the groin gracilis muscle is necessary if one desires to create a natural and spontaneous facial movement. It explains what the reconstruction involves, and what to expect before and after the operation. From march of 2003 until march of 2010, the authors performed a series of 20 patients receiving gracilis flaps for defects in the achilles region alone or in combination with concomitant tendon loss. Gracilis muscle flap is commonly used in reconstructive surgery. It is thin and flattened, broad above, narrow and tapering below. The free gracilis muscle flap in achilles tendon coverage and. The gracilis flap is the first flap to be transferred as a free muscle flap 1. Technique of harvesting the gracilis for free functioning muscle.
The gracilis muscles of 15 formalinfixed adult cadavers 30 cases were dissected with 4. Gracilis muscle flap for urologic reconstruction video. Gracilis free muscle transfer for chronic facial paralysis. It has a type iivascular supply, with the branch of the femoral artery forming a dominant pedicle 8. The muscle is then transplanted to the paralyzed side of the face and connected to a nerve and blood vessel. In the conventional technique of flap harvest, figure 5.
Original research article an anatomical study of gracilis. Muscle and my ocutaneous flaps in the treatment of pressure sores wheatley, m. Its location in the medial thigh permits the use of a twoteam approach with one team for flap harvest and one team for preparation of the recipient site. The double muscle gracilis and sartorius gracilis myocutaneous flap leas a generous length, ample bulk, and has been transposed easily into the ischial defect. Original article experience with a modified technique of free. Disadvantages include small muscle volume bulk, poor reliability of. In 1990, obrien was the first to report the use of the gracilis free flap for singlestage facial reanimation. Gracilis muscle has a class 2 vascular pedicle, with a dominant vascular pedicle. The gracilis myocutaneous flap is favoured by many reconstructive surgeons. The gracilis muscle free flap is generally performed as a 2stage procedure. A surgical video demonstrating the 10 steps of a gracilis muscle flap for treatment of a complex groin wound.
Use of a gracilis myocutaneous flap for reconstruction of a. It is reported that the gracilis muscle can be used as a pedicle flap and a free microsurgical flap in skin reconstruction of dogs and cats 4,5,8. Early results with use of gracilis muscle flap coverage of infected groin wounds after vascular surgery mark d. Extended approach to the vascular pedicle of the gracilis. Experience with a modified technique of free gracilis transfer. A harvest of gracilis muscle from the medial thigh. Multivector gracilis muscle flap viable for facial reanimation.
An algorithmic approach to perineal reconstruction. This muscle originates from the external point of the pubic bone and goes all the way down the midshaft of the tibia. Original article experience with a modified technique of. The average duration of simultaneous apr and gracilis flap reconstruction was 235. In reconstructive techniques, the use of the composite gracilis skin flap may be complicated by a total or partial necrosis of the cutaneous paddle. Extended approach to the vascular pedicle of the gracilis muscle flap. Gracilis muscle transposition for iatrogenic rectourethral. The gracilis musculocutaneous flap as a method of closure. Muscle flap surgery a mastectomy is a necessary, yet often times traumatic, surgery that removes one or both breasts of a woman who has cancerous tumors. Use of local muscle flaps to cover leg bone exposures. The mean time of the initial contraction of the muscle flap in the onestage group 5. After the primary tumor was resected and the recipient vessels prepared the pedicle was separated and the.
Other substances have been recommended as variations on the technique. Two venae, one usually slightly larger than the artery. Limited exposure technique for harvesting the whole muscle. It starts at the external point of the ischiopubic ramus on the pubic bone and extends down to the upper medial middle shaft of. It involves using a bit of muscle from another body part and using it like some sort of packing. Latissimus dorsi type v elevation standard muscle flap posterior axillary incision 510cm pedicle in posterior axilla deep to muscle. It arises by a thin aponeurosis from the anterior margins of the lower half of the symphysis pubis and the upper half of the pubic arch. Doublemuscle gracilis and sartorius myocutaneous flap 43 fig. Pdf perineal reconstruction after abdominoperineal. Urologygracilis flap placement cherie posted thu 05th of november, 2015 14. The muscle was oriented longitudinally between the anterior part of the mandible and the hyoid bone. Based on the pudendal vessels, the gracilis muscle of the medial thigh can be harvested as a muscleonly or myocutaneous flap.
With the application of a previously described technique for an extended approach to the lateral arm free flap, the authors describe a novel technique that improves observation and thus facilitates dissection of the proximal gracilis vascular pedicle. The gracilis muscleonly flap is relatively rapid and easy to perform with. Gracilis vessels from the medial femoral circumflex system. For patients requiring two ostomies, robotassisted abdominoperineal resections aprs, and to avoid the morbidity of a vram harvest, the authors have used the gracilis muscle flap to reconstruct the large. Sep 02, 20 a surgical video demonstrating the 10 steps of a gracilis muscle flap for treatment of a complex groin wound.
Tongue reconstruction with the gracilis myocutaneous free flap. Additional minor perforators originate proximally from the obturator artery and may supply a short gracilis flap. Successful repair was defined as absence of a fistula after reversal of fecal and urinary diversions. D the gracilis muscle free flap measuring 17 a 7 cm. We avoid joining the perineal and thigh incisions to prevent future. The gracilis muscle is a long, thin muscle located in the medial thigh fig.
Centro europeo cirugia colorrectal valencia 1,563 views. Dissection of the proximal gracilis vascular pedicle proceeds in a dark tunnellike space deep to the adductor longus. E the muscle is inset according to resting muscle tension and sutured to the upper lips remaining orbicularis muscle to form a sphincter. The transverse upper gracilis muscle is located in the inner thigh. Doi et al 5 described the possibility of making this transfer, and its results have been reproduced in several centers with a mean success rate of between 65 and. The major blood supply to the gracilis myocutaneous or gracilis muscle flap is derived from the medial femoral circumflex artery.
Jun 26, 2018 the major blood supply to the gracilis myocutaneous or gracilis muscle flap is derived from the medial femoral circumflex artery. Currently, this seems to be the best method by which to restore smiling to patients paralysed for a long. The gracilis muscle is located in the inner aspect of the thigh. The gracilis muscle is easily accessible on the medial aspect of the thigh and. Early results with use of gracilis muscle flap coverage of. We report the use of gracilis muscle to repair a large urethral defect. Jan 23, 2019 the gracilis muscle is found in the groin. The one option is to have a gracilis muscle flap operation. Once the gracilis muscle is transplanted to the paralyzed side of the face, it must be connected to a new nerve so that it may move the paralyzed side of the face. This fact sheet is for women who are having a breast reconstruction using a tug flap, or are considering having a tug flap reconstruction. Various techniques of harvesting the free gracilis flap have been described. Double muscle gracilis and sartorius myocutaneous flap 43 fig.
Minimally invasive endoscopic technique of harvesting free. Video presentation 08 rectovaginal fistula repair using a. Gracilis is a commonly used muscle for free tissue transfer for small to mediumsized soft tissue defects. The ratio of contraction of the affected side compared to the normal side was similar in both groups. One attempt to merge the advantages of both procedures is gracilis transplantation accompanied by double innervation using the ipsilateral masseteric nerve to ensure contractile power and the contralateral facial nerve to trigger spontaneous smiling18, 19 fig.
The usefulness of the gracilis flap in large pelvic and perineal defects is considered limited because of the smaller mass of the muscle, the technical difficulty designing the skin island, and the high rate of associated complications in a study by soper and colleagues, 68 the. Anatomic basis of medical, surgical, and radiological anatomy. According to the classification of mathes and nahai, it presents a type ii blood supply, allowing it to be transferred on its artery derived from the medial circumflex femoral artery. Using the gracilis muscle flap vascular specialist. The gracilis muscle or musculocutaneous flap has been the donor muscle. Gracilis muscle free flap transplant facial paralysis institute. In patients with longterm facial paralysis more than 2 years, the native facial muscles are not functional.
The muscle extends from the pubic bone and goes to the tibia. The anterior limit is on an axis joining the pubic tubercle to the adduc. It can be harvested with a skin paddle see tug flap. Yuichiro yoshioka, shigeaki moriura, hiroshi yuba, atsushi hirano, ryohei hattori subject. Atlas of muscle and musculocutaneous flaps globalhelp. The gracilis is less bulky than other muscle flaps and even some fasciocutaneous flaps, such as the scapula or lateral arm in larger patients, although it cannot be used as a sensate flap. The issues that would negatively impact free flap success should be assessed. The free gracilis muscle flap in achilles tendon coverage an. Our study was aimed to describe the vascular anatomy of the gracilis muscle and the related skin, in order to have a better understanding of the skins blood supply, and to help in determining a safer cutaneous paddle during transfer. Muscle contracture can occur at any site in the body, but there is a recognised condition involving contracture of the gracilis muscle in dogs.
Methods we conducted a retrospective analysis by active search of medical records of all patients submitted to mobilization of flaps of soleus and gastrocnemius muscles or both to cover the exposure. Double free gracilis muscle transfer after complete brachial plexus injury. Based on the pudendal vessels, the gracilis muscle of the medial thigh can be harvested as a muscle only or myocutaneous flap. Double free muscle transfer using the gracilis muscles is a potentially effective method. Jun 24, 2019 the gracilis muscle free flap is generally performed as a 2stage procedure. The gracilis muscle is an excellent source for filling small and mediumsized soft tissue defects, especially in the lower extremity 26. We prefer the gracilis flap to the sartorius or other groin muscle flaps in the management of complex groin wounds. Proceed from inferiormedial to superiorlateral divide insertion only after pedicle is. Gracilis muscle definition of gracilis muscle by medical. Various other jobs of this muscle are to assist in knee rotation as well as aid in the stabilization of the knee. Reconstruction of large perineal and pelvic wounds using.
Urologygracilis flap placement urology coding ask an expert. The video demonstrates creation of a gracilis muscle flap for use in urethral and perineal reconstruction. Since gracilis does not result in much functional deficit, closure to the defect and can be. Ramirez, gloria salvo, in principles of gynecologic oncology surgery, 2018. The muscle is less reliable as a musculocutaneous flap, since the vascular supply of the skin overlying the gracilis muscle is quite variable. Surgical treatment has been reported to result in dramatic improvement in 100% of cases immediately postoperatively but there is. Kibbe, john hijjawi, gregory ara dumanian corresponding author for this work.
This artery enters the muscle approximately 810 cm below the inguinal ligament. The gracilis muscle is commonly used as a flap in microsurgery. The intent of the procedure is to prevent the cancer from spreading to lymph nodes and other organs of the body. The authors retrospectively analyzed the origin and size of the defect, microsurgical success, and early and late complications. The proximally based gracilis muscle and muscu locutaneous flaps. Muscle conserving free gracilis transfer minigracilis free.
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