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The Development of the Medial Circumflex Femoral Artery Perforator (MCFAP) Flap
Abstract
In the quixotic quest for the “ideal” flap, the major attribute of the medial circumflex femoral artery perforator flap is its minimal donor-site deformity even if primary closure is not possible and a skin graft must be used. This source vessel captures the medial groin skin territory, and therefore sometimes has been referred to as the “medial groin” flap. This flap can be moderately large, the donor site easily hidden by clothing, the flap almost always has at least a single relatively large musculocutaneous perforator, and the location of the vascular pedicle has a consistent location already familiar to most microsurgeons. The history and approach specifically in the development of the medial circumflex femoral artery perforator flap is presented here to explain the rationale as to why this donor site deserves consideration in the hierarchy of cutaneous flap selection.
... Анатомічна основа верхнього внутрішнього об'єднаного перфорантного клаптя стегна (ВВОПКС) базується на перфорантах граціоз ного м'яза. Додаткові широкі анастомози утво рюються з перфорантами ПОККА та ГАС [7]. ...
Introduction. Post-burn total or subtotal scar lesions of the skin in the lower limb lead to static-dynamic disorders, lympho-venous outflow disturbances, and increased pressure in the fascia-muscle sheath, the appearance of ulcers in the joints and the disorders of growth of bones and muscles in children.
The aim of the work is to improve the results of surgical treatment of children with post-burn deformities of the thigh in different areas by using extended expanded flaps on the basis of perforator vessels.
Materials and methods. The work is based on a study of 12 patients (10 females and 2 males) aged from 6 to 18 years (average age — 13.0 years). All patients underwent a reconstruction of cicatricial defects with 28 preexpanded thigh flaps were used on the basis of perforator vessels depending on the anatomical site. Flaps were formed from the tissues of the outer, inner and posterior surfaces of the thigh.
Results and discussion. The possibility of the formation of expanded joint flaps in different zones of the thigh on the basis of their own perforator vessels is shown. which made it possible to obtain a sufficient quantity of plastic material with similar tissue features to those of the defect.
Conclusions. The use of joined expanded flaps on the basis of perforator vessels in different parts of the thigh allowed to obtain good ((10(66.7%) and 8(72.7%)) and satisfactory ((5(33.3%) and 3(27.3%)) results of treatment respectively, in the nearest and distant periods.
... There is a segmental arterial supply to the muscle by the external branches of femoral artery and branches of the deep artery of the thighmainly from the medial circumflex femoral artery. Vessels supplying this muscle make it a well pedunculated muscle flap [11,19,20,21,28,33]. ...
Ten human gracilis muscles obtained from adults and ten gracilis muscles collected from human foetuses between the 15th and 21st week of gestation were examined. The results of this preparatory study show that the gracilis muscle in adults is narrow and long - 482 mm on average. The distal tendon of gracilis muscle is long, 294 mm on average. It can be divided into two sections - external part, outside the muscle belly, and internal, intramuscular, part. The latter one is partially covered by muscle fibres and some of it is completely hidden inside the muscle belly, which is on average 76 mm long. Presence of an intramuscular part of the distal tendon was also demonstrated in the foetal material. Moreover, very strong correlations between particular muscle lengths were noted in foetuses.
... The one DIEAP flap selected was so chosen to allow a concomitant cosmetic abdominoplasty, although the flap itself was too bulky. A better choice, if thin enough, is the medial circumflex femoral artery perforator-gracilis flap (also known as the medial groin flap), as the donor defect even if not possible to be closed primarily can always be easily hidden by clothing [8]. Even in the obese individual where a LCFAPvl flap may be awkward, the lower leg may still be thin enough to consider a muscle perforator flap. ...
Adequate soft tissue coverage is imperative after any interventions performed to maximize or preserve hand function. Although this can most simply be achieved by primary closure or a skin graft if possible, often a vascularized flap will be preferable, especially if a later secondary procedure is planned. Even moderately sized skin deficits of the upper extremity, and especially if involving the hand itself, can be better covered using a free tissue transfer. Many reasonable options in this regard are available. Muscle perforator flaps, as a relatively new variant of a fasciocutaneous flap, have unique attributes, including availability, diversity, accessibility, large size, and lengthy vascular pedicle, and since no muscle need be included, donor site function is preserved. As is shown here in a series of nine muscle perforator flaps in eight patients, these represent yet another alternative that should be considered if selection of a free flap is indicated to maintain hand function.
Objetivo:
Describir el manejo quirúrgico realizado para la reconstrucción genitoperineal (RGP) en pacientes con secuelas de Gangrena de Fournier (GF).
Materiales y Método:
Corresponde a una serie de casos retrospectiva de pacientes con secuelas de GF a los que se les realizó RGP entre los años 2011 y 2019. Se realizó un análisis descriptivo con las variables de técnica quirúrgica, edad, sexo, comorbilidades, subunidades anatómicas afectadas, origen anatómico de la gangrena de Fournier, número de procedimientos quirúrgicos, procedimiento de colostomía, terapia de presión negativa, Flexi-Seal®, bacterias aisladas, duración de estancia hospitalaria, tipo de procedimientos reconstructivos y complicaciones.
Resultados:
Se realizó RGP a 43 pacientes (81,1% hombres), con un promedio de edad de 59,1 (17-86 años), 72,7% eran diabéticos. El número de subunidades involucradas se asocia directamente y significativamente en relación al número de intervenciones quirúrgicas. Las técnicas utilizadas para la reconstrucción en orden de frecuencia fueron: colgajos (23%), cierre parcial más injerto dermoepidérmico de grosor parcial (IPP) (20%), cierre parcial (16%) e IPP (16%), cierre por segunda intención (10%), colgajo más IPP (7%) y cierre parcial para cierre por segunda intención de zona restante (5%).
Discusión:
La elección de reconstrucción se basa en las características del defecto, es decir, el tamaño, la ubicación y profundidad, así como la disponibilidad de tejido local. De preferencia optar por cierres primarios sin tensión, seguido de colgajos y de IPP.
Conclusión:
La RGP es un desafío para el cirujano plástico. Las técnicas descritas han demostrado ser seguras y reproducibles para el tratamiento quirúrgico de la gangrena de Fournier.
Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.
Over the past decade, muscle perforator flaps have proven their versatility as another important option when a soft tissue flap is essential. Valuable as either local or free flaps, these are no longer a novelty, and are perhaps even becoming a necessity for the mainstream reconstructive surgeon. Prior microsurgical capabilities will unquestionably simplify the transition to harvesting the diminutive vascular pedicle of these flaps, while perhaps shortening the learning curve, but these skills are not imperative. With proper assistance and perseverance, as with any other aspect of surgery, muscle perforator flaps can become a mainstay, if not the preferred method, for soft tissue repairs even in the community hospital where resources tend to be less available.
In this article, the authors review the literature regarding perforator flaps. Musculocutaneous perforator flaps have evolved from musculocutaneous flaps and offer several distinct advantages. By sparing muscle tissue, thus reducing donor site morbidity and functional loss, perforator flaps are indicated for a number of clinical problems. The versatility of the perforator flap makes it ideal for the reconstruction of three-dimensional defects such as breast reconstruction or as a thin flap for resurfacing shallow wounds when bulk is considered a disadvantage. The authors review the historical development of the perforator flap and discuss the advantages and disadvantages of perforator flaps compared with free and pedicled musculocutaneous flaps. The nomenclature traditionally used for perforator flaps is confusing and lacks a standardized anatomic basis. The authors present a method to describe all perforator flaps according to their artery of origin.
The unreliability of the distal skin component of the gracilis myocutaneous free flap has been frequently reported. To improve the reliability of the skin we orientated the cutaneous paddle in a transverse direction in the proximal third of the gracilis muscle, as first described by Yousif et al in 1993. Their anatomical studies showed that cutaneous branches of the dominant proximal pedicle have a pronounced tendency to travel in a transverse direction, supplying the skin anteriorly over the adductor longus and sartorius muscles and extending beyond the posterior margin of the gracilis muscle. We adopted this transverse design and transferred myocutaneous gracilis flaps measuring up to 17 x 9 cm. The transverse gracilis myocutaneous flap was dissected in the subfascial plane to include the peri-gracilis fascia, which preserved the fascial vascular network and thus optimised skin-paddle perfusion. Ten transverse gracilis myocutaneous free flaps were performed over 3 years. Skin paddles ranged in size from 10 x 7 cm (70 cm(2)) to 17 x 9 cm (153 cm(2)) with a mean of 113.4 cm(2). Five defects were located in the head and neck region, three in the lower leg, one in the thigh and one in the thorax. Patients were followed for an average of 16.6 months (range: 6--46 months). Minor complications (donor-site wound dehiscence and flap-wound-edge separation) occurred in four patients;however, all 10 flaps survived and healed with complete cutaneous survival.
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The use of myocutandous flaps can increase the possibilities for construction in many cases by bringing in new blood supply to avascular areas by furnishing additional bulk for filling defects or covering bone grafts or other deep repairs, and sometimes by making longer flaps viable. Also, the need for delay procedures is decreased and sometimes avoided. In this paper we define the vascular territories of 13 clinical myocutaneous flaps, and we describe possible uses of them. Three illustrative clinical cases are presented, in which repairs were done with these flaps. The future uses of these flaps challenge the imagination. Knowledge about them may significantly alter the traditional approaches to flap designs and repairs.
The definition, history, experimental background, surgical technique, and clinical applications of compound gracilis myocutaneous flaps are presented. This flap has been our method of choice for neo-vaginal reconstruction after radical pelvic surgery.
Through detailed anatomical study and latex injection of 24 cadaver legs, the blood supply to the skin overlying the gracilis muscle was examined. The proximal pedicle entered the gracilis muscle 10 +/- 2 cm below the pubic tubercle. The dissections identified both septocutaneous and musculocutaneous perforators from the proximal gracilis pedicle. These branches had a pronounced tendency to travel in a transverse direction, supplying the cutaneous territory over the adductor longus and sartorius anteriorly and extending for > 5 cm beyond the posterior margin of the gracilis muscle. This information led to a "new" transverse design of the gracilis musculocutaneous flap, such that the vascular perforators are invariably included in the cutaneous portion of the flap. In contrast, the traditional design, because of skin mobility, may allow elevation outside the skin territory of the muscle perforators.
In a review of 20 gracilis flaps in 18 patients, variations in flap viability have been found. In response to these findings, a detailed anatomical study was performed in 15 fresh cadavers. Selective dye injections evaluated the limits of the skin paddle depending on the dominant pedicle. Most of the musculocutaneous perforators were in the upper two-thirds of the gracilis. In one selected application the main blood supply to the skin was recognised to be proximal. Despite the variations in viability, the flap proved to be a versatile and totally adequate tool.
A musculo-cutaneous flap is described which can provide immediate cover to soft tissue defects particularly of the lower leg. When accurately designed and carefully dissected, the rich blood supply of such flaps ensures not only survival of the skin but control of any infection around areas of denuded bone or tendon.
The case described meets the basic criteria of success in a direct flap transfer: complete survival without preliminary delay operations, hair growth, minimal shrinkage and edema. From these, plus a confirmatory arteriogram, one can only conclude that this case is the first successful distant skin island flap transfer by microvascular anastomoses to be reported in man.
The width of the gracilis muscle was measured before and after removal of the epimysium in 10 fresh cadavers. The average extent of muscle widening achieved by epimysium removal was over 100% (mean 112.6%; standard deviation 11.9%). This extended muscle flap enabled us to cover successfully even large soft tissue defects measuring up to 300 cm2. In 27 consecutive patients, soft tissue defects of the lower leg with exposed bone have been repaired by free tissue transfer of a gracilis muscle flap, covered with split skin grafts. The advantages of the gracilis muscle flap were the low donor site morbidity with almost no recognisable functional loss, the easy surgical access, the thin and flat shape of the muscle, and its adequate size after excision of the epimysium. Reconstruction with a gracilis muscle flap resulted in an inconspicuous, stable, and flat contour of the lower leg. The entire length of the vascular pedicle of the gracilis muscle was easily harvested in our patients by routinely dissecting the pedicle on both sides of the adductor longus muscle.
The gracilis muscle is commonly utilized by reconstructive surgeons in a variety of applications as a pedicled muscle or musculocutaneous flap, and as a free tissue transfer for soft-tissue coverage or as a functioning muscle transfer. The muscle anatomy has been well documented in the past. The aim of the present study was to study comprehensively the intramuscular neurovascular anatomy as it relates to segmental neurovascular functioning muscle transfer. The study was carried out in a series of 14 human cadavers. Each cadaver was injected with a lead oxide, gelatin, and water solution through the femoral arteries (200 ml per kilogram). The overall length of the musculotendinous unit was 44 +/- 2 cm, and the tendon comprised up to 6 +/- 2 cm of the length. The main arterial supply to the muscle entered 10 +/- 1 cm from the attachment to the body and inferior ramus of the pubis (diameter, 1.5-2.5 mm). The distal portion of the muscle was supplied by one to three small arterial branches of the superficial femoral artery. Venous drainage was noted to be through paired venae comitantes. The motor nerve arises from the obturator nerve and enters the muscle in association with the major vascular pedicle. The nerve then splits within the muscle and runs longitudinally in two or three major branches within the muscle parallel to the arterial branches and muscle fibers. The neurovascular anatomy of the gracilis muscle was found to be remarkably consistent from specimen to specimen, varying only in the length of the muscle and tendon, and the number of minor pedicles supplying the distal portion of the muscle. This study confirms the suitability of the gracilis for segmental functional muscle transfer.
Skin flaps from the medial aspect of the thigh have traditionally been based on the gracilis musculocutaneous unit. This article presents anatomic studies and clinical experience with a new flap from the medial and posterior aspects of the thigh based on the proximal musculocutaneous perforator of the adductor magnus muscle and its venae comitantes. This cutaneous artery represents the termination of the first medial branch of the profunda femoris artery and is consistently large enough in caliber to support much larger skin flaps than the gracilis musculocutaneous flap. In all 20 cadaver dissections, the proximal cutaneous perforator of the adductor magnus muscle was present and measured between 0.8 and 1.1 mm in diameter, making it one of the largest skin perforators in the entire body. Based on this anatomic observation, skin flaps as large as 30 x 23 cm from the medial and posterior aspects of the thigh were successfully transferred. Adductor flaps were used in 25 patients. On one patient the flap was lost, in one the flap demonstrated partial survival, and in 23 patients the flaps survived completely. The flap was designed as a pedicle island flap in 14 patients and as a free flap in 11. When isolating the vascular pedicle for free tissue transfer, the cutaneous artery is dissected from the surrounding adductor magnus muscle and no muscle is included in the flap. Using this maneuver, a pedicle length of approximately 8 cm is isolated. In addition to ample length, the artery has a diameter of approximately 2 mm at its origin from the profunda femoris artery. The adductor flap provides an alternative method for flap design in the posteromedial thigh. Because of the large pedicle and the vast cutaneous territory that it reliably supplies, the authors believe that the adductor flap is the most versatile and dependable method for transferring flaps from the posteromedial thigh region.
The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients at Chang Gung Memorial Hospital. Four hundred eighty-four anterolateral thigh flaps were used for head and neck region recontruction in 475 patients, 58 flaps were used for upper extremity reconstruction in 58 patients, 121 flaps were used for lower extremity reconstruction in 119 patients, and nine flaps were used for trunk reconstruction in nine patients. Of the 672 flaps used in total, a majority (439) were musculocutaneous perforator flaps. Sixty-five were septocutaneous vessel flaps. Of these 504 flaps, 350 were fasciocutaneous and 154 were cutaneous flaps. Of the remaining 168 flaps, 95 were musculocutaneous flaps, 63 were chimeric flaps, and the remaining ten were composite musculocutaneous perforator flaps with the tensor fasciae latae. Total flap failure occurred in 12 patients (1.79 percent of the flaps) and partial failure occurred in 17 patients (2.53 percent of the flaps). Of the 12 flaps that failed completely, five were reconstructed with second anterolateral thigh flaps, four with pedicled flaps, one with a free radial forearm flap, one with skin grafting, and one with primary closure. Of the 17 flaps that failed partially, three were reconstructed with anterolateral thigh flaps, one with a free radial forearm flap, five with pedicled flaps, and eight with primary suture, skin grafting, and conservative methods. In this large series, a consistent anatomy of the main pedicle of the anterolateral thigh flap was observed. In cutaneous and fasciocutaneous flaps, the skin vessels (musculocutaneous perforators or septocutaneous vessels) were found and followed until they reached the main pedicle, regardless of the anatomic position. There were only six cases in this series in which no skin vessels were identified during the harvesting of cutaneous or fasciocutaneous anterolateral thigh flaps. In 87.1 percent of the cutaneous or fasciocutaneous flaps, the skin vessels were found to be musculocutaneous perforators; in 12.9 percent, they were found as septocutaneous vessels. The anterolateral thigh flap is a reliable flap that supplies a large area of skin. This flap can be harvested irrespective of whether the skin vessels are septocutaneous or musculocutaneous. It is a versatile soft-tissue flap in which thickness and volume can be adjusted for the extent of the defect, and it can replace most soft-tissue free flaps in most clinical situations.
The free gracilis perforator flap is an alternative possibility for autologous breast reconstruction, if previous abdominal operations preclude this donor site, or if there is atypical distribution of fat tissue. The perforator flap is based on the main pedicle of the gracilis muscle. The muscle itself and its innervation can be completely preserved, if the angiosome of this vascular pedicle offers sufficient tissue. In skinny patients however it may be necessary to include the neighbouring angiosome of the second gracilis pedicle by means of the intramuscular anastomosis between both pedicles. In such a case a thin muscle strip with the joining vessel must be included in the flap. The bulk of the gracilis muscle and its motor nerve can, however, still be preserved. Breast reconstruction with this technique was successfully performed on six patients (two bilateral). It is a good alternative to a reconstruction with gluteal, or anteromedial, or lateral thigh perforator flaps.
In this article, the authors review the literature regarding perforator flaps. Musculocutaneous perforator flaps have evolved from musculocutaneous flaps and offer several distinct advantages. By sparing muscle tissue, thus reducing donor site morbidity and functional loss, perforator flaps are indicated for a number of clinical problems. The versatility of the perforator flap makes it ideal for the reconstruction of three-dimensional defects such as breast reconstruction or as a thin flap for resurfacing shallow wounds when bulk is considered a disadvantage. The authors review the historical development of the perforator flap and discuss the advantages and disadvantages of perforator flaps compared with free and pedicled musculocutaneous flaps. The nomenclature traditionally used for perforator flaps is confusing and lacks a standardized anatomic basis. The authors present a method to describe all perforator flaps according to their artery of origin.
The most critical factor to predict viability for any muscle perforator flap is an adequate circulation. Therefore, it is advantageous during preoperative planning to have the capability to localize the requisite cutaneous perforator. Color duplex imaging fulfills this requirement and permits the identification of additional characteristics, including caliber, course, and flow velocity of essential perforators and any source vessel. Nevertheless, with the current state of technology, Doppler sonography remains a more rapid, convenient, and simpler method for perforator localization.
The medial circumflex femoral(GRACILIS) perforator free flap has been previously used to capture the superior medial thigh skin territory. This can also be valuable as a local flap, especially for adjacent groin wounds that are not uncommon after vascular interventions. Uncomplicated healing without vascular compromise was achieved using this as a local flap in 4 recent cases. Because the gracilis muscular branches can be independently dissected from the musculocutaneous perforators, the muscle itself can be separately included to form a combined conjoint flap, where the muscle is specifically only used to wrap around and protect any exposed vascular structures while the cutaneous component simplifies skin wound closure. The axis of rotation of the medial circumflex femoral perforator local flap extends throughout the groin region and potentially to the lateral thigh. This is an ideal local perforator flap because the source pedicle has a consistent location already well known to most plastic surgeons, the boundaries of the potential skin territory are reliable and well defined, and the scar from closure of the donor site within the medial groin can be readily concealed by clothing.
The transverse upper gracilis (TUG) flap is a free musculocutaneous (type II) flap consisting of a segment of the proximal gracilis muscle and a 25x10 cm skin paddle oriented transversely. The vascular pedicle of the TUG flap is the ascending branch of the medial circumflex femoral artery with two venae comitantes. The pedicle length is 6 cm and the diameter of the artery is 1.6 mm. In the year 2002, seven patients had breast reconstruction by the free TUG flap. There were three primary and four secondary reconstructions. Five flaps totally survived, two flaps were lost (in the same patient).TUG flap is indicated in women who seek primary autologous reconstruction after a skin sparing mastectomy, have small or moderately large breasts, do not accept scars on the abdomen, back or gluteal region, who are large in hips and thighs and want a thigh lift. The vascular pedicle although short, permits easy anastomosis of matching vessel diameters to the internal mammary vessels. The main possible complication, other than thrombosis at the anastomosis, is wound dehiscence on the thigh with secondary wound healing. This can happen when the flap is wider than 10 cm.
The conjoint medial circumflex femoral perforator-gracilis muscle free flap can simultaneously incorporate the superomedial thigh skin territory and the underlying gracilis muscle. Gracilis musculocutaneous branches that sustain the perforator flap can be independently dissected from discrete muscle branches. Although the branches originate from the same dominant source pedicle to the gracilis muscle, this maneuver allows the separate insetting of each component as desired. This combination flap has been successfully used for wound coverage in four clinical cases, with only minor difficulties. Because of a favorable anatomical anomaly, in one case the perforator flap and corresponding muscle flap could be transferred to different extremities from a single donor site. This perforator flap could be considered an ideal skin flap, because the defined skin territory is reliable, harvesting can be performed with the patient supine, the vascular pedicle has a consistent location well known to plastic surgeons, and any donor-site scars in the medial groin can be readily concealed.
Gracilis functioning free-muscle transplantation for the correction of pure facial paralysis has been a preferred method used by many reconstructive microsurgeons. However, for complex facial paralysis, the deficits include facial paralysis along with soft-tissue, mucosa, and/or skin defects. No adequate solution has been proposed. Treatment requests in those patients are not only for facial reanimation but also for correction of the defects. Of 161 patients with facial paralysis treated with gracilis functioning free-muscle transplantation from 1986 to 2002, eight patients (5 percent) presented with complex deficits requiring not only facial reanimation but also aesthetic correction of tissue defects. The tissue defects included an intraoral defect created following contracture release (one patient), infra-auricular radiation dermatitis with contour depression (one patient), temporal depression following a temporalis muscle-fascia transfer (one patient), ear deformity (two patients), and infra-auricular atrophic tissue with contour depression (three patients). A compound flap, consisting of a gracilis muscle with its overlying skin paddle separated into two components, was transferred for simultaneous correction of both problems. The blood supply to the gracilis and to the skin paddle originated from the same source vessel and therefore required the anastomosis of only one set of vessels. The versatility of this compound flap allows for a wide arc of rotation of the skin paddle around the muscle. All flaps were transferred successfully without complications. Satisfactory results of facial reanimation were recorded in five patients after all stages were completed. The remaining three patients are undergoing physical therapy and waiting for revision of the skin paddle.
The transverse myocutaneous gracilis free flap with a transverse orientation of the skin paddle in the proximal third of the medial thigh region allows the taking, in selected patients, of a moderate amount of tissue for autologous breast reconstruction. The donor-site morbidity is similar to that of a classic medial thigh lift. The indication for this flap in autologous breast reconstruction and the surgical technique will be discussed in this article. From August of 2002 to March of 2003, 10 patients underwent autologous breast reconstruction with 12 transverse myocutaneous gracilis free flaps. The patients' ages ranged from 26 to 48 years (median, 40 years). Of those, two BRCA-positive women received bilateral breast reconstructions after prophylactic skin-sparing mastectomy, and eight patients received immediate breast reconstruction after skin-sparing mastectomy in early-stage breast cancer. Mean follow-up of the 10 patients was 5 months (range, 1 to 9 months). We had no free-flap failure. Four patients had small areas of ischemic skin necrosis related to very thin preparation of the skin envelope after skin-sparing mastectomy without altering the final aesthetic results. Cosmetic evaluation of the reconstructed breasts and thigh donor site by two plastic surgeons showed good results in nine patients and fair results in one patient. There was no functional donor-site morbidity caused by harvesting the gracilis flap. The transverse myocutaneous gracilis flap is a valuable alternative for immediate autologous breast reconstruction after skin-sparing mastectomy in patients with small and medium-sized breasts and inadequate soft-tissue bulk at the lower abdomen and gluteal region.
An anatomic study was performed to analyse the proximal perforator vessels of the gracilis musculocutaneous flap. Twenty-three cadaver legs preserved by the method of Thiel were carefully dissected 24h after the proximal vascular pedicle was injected with a red silicone mass. Nine additional cadaver legs were injected with ink, to visualise the skin area supplied by the proximal perforators, respectively, clarified by a modified Spalteholz technique to demonstrate the anatomic course of the perforators. A considerable variation in numbers and localisation of proximal cutaneous perforators was found. One to four perforators were seen within an area of 6 x 6 cm(2) at the entrance of the main pedicle into the proximal gracilis muscle. Their external diameter ranged from 0.5 to 1.0 mm. The ink-injections showed an oval shaped angiosome with a mean surface of 88 cm(2) at the level of the proximal gracilis pedicle. We conclude from this anatomic study, that a cutaneous flap based on the medial circumflex femoral gracilis perforators can be harvested by experienced hands bearing in mind the unpredictable perforator-anatomy.
Another perforator flap, the gracilis perforator flap, has recently been added to the armamentarium of reconstructive surgeons. A detailed study of the anatomy of this flap was undertaken in this study. Forty-seven dissections were performed in cadavers and clinical cases of gracilis muscle harvesting for various reconstructive reasons. According to our findings, at least one musculocutaneous perforator of large calibre was found in the majority of the dissections performed (87%), emanating from the proximal third of gracilis. All the perforators were located within a radius of 7 cm from the point of entrance of the gracilis main vascular pedicle. In their majority, they emanated proximal to that point (83%) from the middle part (anteroposterior axis) of the muscle (62%). The intramuscular course of the perforators was easily followed and few muscular branches were encountered, before they joined the main vascular pedicle. A sensory branch of the anterior obturator nerve, accompanying the perforators, was occasionally found (29%). Finally, a superficial vein, branch of the greater saphenous, was always found within the skin territory of the flap in all dissections performed in cadavers.
[corrected] The aim of this study was to establish the anatomic basis of the conjoint medial circumflex femoral perforator and gracilis muscle flap and to expand the use of this flap in complex facial paralysis reconstruction.
An anatomic study was initially undertaken to record the existence, consistency, and diameter of musculocutaneous perforators emanating from the proximal third of the gracilis muscle to provide blood supply to the overlying fascia, subcutaneous fat, and skin. In a total of 20 clinical cases of gracilis muscle harvesting, the aforementioned anatomical data were recorded during flap dissection. At least one musculocutaneus perforator, consisting of one artery and two accompanying veins (vein caliber > 0.3 mm) was found in 95 percent of cases.
The anatomical study was followed by successful use of the conjoint flap for reconstruction of longstanding facial palsy accompanied by a soft-tissue defect of the cheek. In the first stage, cross-face nerve grafting was performed. In the second stage, free transfer of the conjoint flap, consisting of the proximal third of the gracilis muscle and the overlying subcutaneous fat, was performed to the face. The only connection between the two components of the conjoint flap was one musculocutaneous perforator. When the flap was inset, the muscle was used for facial reanimation and partial obliteration of the soft-tissue defect, while the subcutaneous fat was used to obliterate the rest of the defect.
The proposed technique ensured symmetry of the face, on both rest and animation, and obliteration of the cheek deformity.
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.
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.
The gracilis myofasciocutaneous flap
- Tp Whetzel
- Lechtman
Whetzel TP, Lechtman AN. The gracilis myofasciocutaneous flap. Plast Reconstr Surg 1997;99:1642–1652
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1230 South Cedar Crest Boulevard Perforator Flaps; Guest Editor
- M D Hallock
Hallock, M.D., 1230 South Cedar Crest Boulevard, Suite 306,
Allentown, PA 18103.
Perforator Flaps; Guest Editor, Aldona Spiegel, M.D.