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Tissue coverage for exposed vascular reconstructions (grafts)
Published in Sachinder Singh Hans, Mark F. Conrad, Vascular and Endovascular Complications, 2021
Kaitlyn Rountree, Vikram Reddy, Sachinder Singh Hans
The gracilis muscle is a long, slender muscle seated superficially on the inner thigh. It functions as an adductor of the thigh, and assists with flexion of the knee and hip. It receives segmental blood supply from the medial circumflex femoral artery (a branch of the deep femoral artery), usually encountered about 10 cm inferior from its origin at the pubic symphysis, and innervation from the obturator nerve. The gracilis muscle flap has long been a work horse of reconstructive surgery in both pedicle and free flap form. Its proximity to the groin makes it a valuable option for native tissue coverage in vascular patients with complicated groin wounds with little residual morbidity. Likewise, its blood supply does not rely on the SFA, which is commonly occluded or compromised in vascular patients with arterial occlusive disease.
Perineal Hernia
Published in Jeff Garner, Dominic Slade, Manual of Complex Abdominal Wall Reconstruction, 2020
A review of myocutaneous flap reconstruction of the perineum after APER included 36 studies; 19 studies (385 patients) considered patients who underwent RAM flaps with excellent healing rates during the various follow-up periods.22 A total of 33 flaps out of 300 underwent total or partial necrosis and 21/272 patients suffered a perineal wound infection, 19/270 developed an abdominal wall hernia but only two perineal hernias were identified in follow-up. A comparison of 35 VRAM reconstructions against a control group of 76 patients with direct primary closure reported lower rates of perineal wound infection and dehiscence with a reduced rate of abdominal wall morbidity including hernia at nearly 4 years of follow-up.27 Gracilis flaps showed excellent healing with only 8/85 partial or complete flap loss, whereas there were only 4 partial flap losses in 61 gluteal flaps. In general, complication rates were lower with flap closure than primary closure.
Advanced autologous tissue flaps for whole breast reconstruction
Published in Steven J. Kronowitz, John R. Benson, Maurizio B. Nava, Oncoplastic and Reconstructive Management of the Breast, 2020
Steven J. Kronowitz, John R. Benson, Maurizio B. Nava
The gracilis muscle lies medially beneath the fascia lata of the thigh. It arises from the ischiopubic ramus and inserts as the middle component of the pes anserinus on the medial tibial tuberosity. The muscle belly of the gracilis lies posterior to the adductor longus and sartorius muscles and anterior to the hamstrings (Figure 23.6.1).
10-Year single center experience in lower limb reconstruction with free muscle flaps – factors influencing complications in 266 consecutive cases
Published in Journal of Plastic Surgery and Hand Surgery, 2023
Inga S. Besmens, Florian S. Frueh, Christina Gehrke, Sophie Knipper, Pietro Giovanoli, Maurizio Calcagni
Fifth, the use of LD flaps presented a statistically significant predictor for the need for revision surgery. The LD flap has a very constant anatomy [21] and we do not presume that raising of the flap can be considered a reason for a higher complication rate in these patients. The risk of total flap loss is usually quoted between 5.3% [22] and 13% [4]. Since generally larger defects with more extensive underlying trauma or infection need to be covered by a larger muscle flap, this may be the explanation for the increased risk for revision surgery. In a large flap, we sometimes experience partial flap loss distal to a watershed line. This phenomena is specifically true for the latissimus dorsi free flap, a type 5 flap according to Mathes and Nahai with multiple minor segmental pedicles. Moreover, one could assume that the majority of donor site complications would be found in the larger latissimus dorsi donor site. Indeed, in our study, 10 of the 17 donor site complications registered were found in latissimus cases. The absolute survival rate of gracilis and latissimus dorsi flap however are similar Franco et al. report a single surgeon experience with gracilis flaps to the leg with a success rate of 92% [23] while Knobloch et al. report on overall free latissimus dorsi flap survival of 95% [24]. Having the data from our study in mind, we recommend using a gracilis muscle flap instead of a latissimus dorsi flap whenever possible. When used correctly, the gracilis flap can be easily used to cover large defects (<100 cm2) [25].
Impact of patients’ gender on microvascular lower extremity reconstruction
Published in Journal of Plastic Surgery and Hand Surgery, 2022
Nicholas Moellhoff, P. Niclas Broer, Paul I. Heidekrueger, Milomir Ninkovic, Denis Ehrl
The data presented within this manuscript show no significant differences between the two groups of patients regarding the rate of major complications, including total flap loss and partial flap loss >10%, or surgical revision surgeries. Comparable literature on gender-related outcome of lower extremity free flap reconstruction is scarce and limited by small patient populations. While Wong et al. based their analysis on a total of 778 free flaps, only 36 of these were lower extremity reconstructions [28]. In accordance with our results, their study showed no association of flap failure with gender. Sanati-Mehrizy et al. included a subgroup of 127 extremity free flaps in their study and also reported no gender-related risk [20]. Conversely, in head and neck reconstructions, female gender is considered an independent risk factor for free tissue transfer, however, based on a limited number of only 94 flaps [19]. Gender has been evaluated as a risk factor in lower extremity reconstructions using perforator-based propeller flaps and free-style flaps [21,22], showing no significant differences between male and female patients and thus complying with our results. Recently, Yang et al. published risk factors for ALT flap failure in 128 lower-limb reconstructions and found no significant differences related to patients’ sex [29]. Accordingly, when analyzing all ALT- and gracilis muscle flaps separately, we observed no differences regarding the rate of major and minor surgical complications as well as of total and partial flap loss between male and female patients.
Isolating the Superficial Peroneal Nerve Motor Branch to the Peroneus Longus Muscle with Concentric Stimulation during Diagnostic Motor Nerve Biopsy
Published in The Neurodiagnostic Journal, 2022
Ashley Rosenberg, Rachel Pruitt, Sami Saba, Justin W. Silverstein, Randy S. D’Amico
Motor nerve biopsy is a frequent final diagnostic tool to distinguish motor neuropathy from motor neuron disease and may be performed with associated muscle biopsy to diagnose myopathy in patients with focal or diffuse motor weakness. Accurate diagnosis is critical as treatment with immunoglobulin can be effective in select motor neuropathies (Latov et al. 1988; Pestronk et al. 1988). Biopsy of the gracilis muscle and obturator nerve, and the pronator teres muscle and the motor branch of the median nerve supplying it, have been described for diagnosis in suspected lower or upper extremity disease processes, respectively (Berman et al. 1985; Corbo et al. 1997; Dy et al. 2012; Kinoshita et al. 2014). Recently, a technique to biopsy the motor branch to the peroneus longus muscle was described as adequate and sufficient to enable diagnosis in patients with suspected motor neuropathy (D’Amico and Winfree 2017). We describe our techniques for intraoperative neuromonitoring for preservation of motor function during this approach which, to-date have not been described.