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 entire posterior portion of the flap can then be raised to the level of the muscle, which simplifies exposure of any exiting musculocutaneous perforators. 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. Gracilis tendon graft for static suspension of the midface and perioral region fixed to. Jun 26, 2018 the major blood supply to the gracilis myocutaneous or gracilis muscle flap is derived from the medial femoral circumflex artery. Distal gracilis muscle flap was rotated and fixed by tensionfree suturing to the fistula site. Gracilis muscle definition of gracilis muscle by medical. Muscle conserving free gracilis transfer minigracilis. Review committee for otolaryngology case log coding.
Transverse upper gracilis tug flap johns hopkins hospital. Gracilis muscle flap for urologic reconstruction video. Since gracilis does not result in much functional deficit, closure to the defect and can be. The success of free gracilis muscle transfer to restore. 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 the muscles fibers run vertically downward, ending in a rounded tendon. The free gracilis muscle flap in achilles tendon coverage and. Successful repair was defined as absence of a fistula after reversal of fecal and urinary diversions. Pulling these two ends with strings, the location of. Two venae, one usually slightly larger than the artery. I am quite pleased with myself because i have designed and made it myself.
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. The authors retrospectively analyzed the origin and size of the defect, microsurgical success, and early and late complications. The double muscle gracilis and sartorius gracilis myocutaneous flap leas a generous length, ample bulk, and has been transposed easily into the ischial defect. Not sure of 15734, that is what i thought at first, but all he did was after plastics harvested the gracilis flap and it was separated, dr. The free gracilis muscle flap in achilles tendon coverage an. The authors retrospectively analyzed the origin and size of the defect, microsurgical success, and early and late. The free gracilis muscle flap in achilles tendon coverage.
Generally passes underneath adductor longus and above adductor magnus, and enters fairly close to a right angle to the gracilis muscle. Gracilis muscle free flap transplant facial paralysis institute. Gracilis, tensor fascia lata, vastus lateralis, rectus. Burr down the zygoma to prevent excess flap bulk in the cheek region and partial excision of the buccal fat pad. Jun 24, 2019 the gracilis muscle free flap is generally performed as a 2stage procedure. Microsurgical transfer of the gracilis muscle for elbow. Sep 23, 2016 use of the tug myocutaneous flap for breast reconstruction was first described as a single breast reconstructive case in 1992. Free gracilis muscle transfer is a challenging technique that leads to reproducible and encouraging results, but has vascular failure rate that cannot be ignored. Gracilis muscle free flap transplant facial paralysis. Gracilis free flap for smile reanimation iowa head and neck. Coverage of softtissue defects of various sizes by an easytodo and reliable free musclemyocutaneous flap. There was a subcutaneous tunnel created to allow the flap to pass to the fistula site fig. Muscle disorders and rehabilitation in canine athletes 269 characterized by minimal tissue disruption, lowgrade in. The intent of the procedure is to prevent the cancer from spreading to lymph nodes and other organs of the body.
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. Original article experience with a modified technique of free. Double free gracilis muscle transfer after complete brachial. The gracilis muscle is located in the inner aspect of the thigh. Long term follow up and evaluation of free muscle graft in. The vagina mucosa for the gracilis muscle flap was excised in order to. Gracilis flaps for breast reconstruction plastic surgery key. Gracilis muscle flap is an excellent option to assist perineal wound healing after apr for both rectal cancer and anal cancer with minimal complications at both the donor site and. Gracilis is a commonly used muscle for free tissue transfer for small to mediumsized soft tissue defects.
Athletes may not be aware of the injury until they cool down, and they then complain of soreness. This artery enters the muscle approximately 810 cm below the inguinal ligament. Evolution from the tug to pap flap for breast reconstruction. The use of the gracilis muscle in reconstructive surgery was first described by pickrell in 1952 for rectal sphincter reconstruction. The following case log coding recommendations have been provided in an attempt to establish some degree of uniformity for all otolaryngology residents in terms of the logging of cases into the acgme case log system. This is usually done if patients do not have adequate skin and tissue in the abdomen or buttock region, or have had previous abdominal surgeries that may have interfered. Double free muscle transfer using the gracilis muscles is a potentially effective method. The introduction of radical vulvar surgery and pelvic exenteration in 1950s allowed for the treatment of locally advanced or recurrent cancer with improved survival outcomes.
Methods prospective evaluation was performed on 20 patients with nonflaccid facial paralysis who underwent free gracilis muscle transfer. The gracilis muscle free flap is generally performed as a 2stage procedure. Then this was laid posterior to the anastomosis and the muscle flap was laid anterior over the suture line and tacked in. It is thin and flattened, broad above, narrow and tapering below.
We prefer the gracilis flap to the sartorius or other groin muscle flaps in the management of complex groin wounds. Urologygracilis flap placement urology coding ask an. It can be harvested with a skin paddle see tug flap. A transplanted muscle from the groin gracilis muscle is necessary if one desires to create a natural and spontaneous facial movement. The gracilis muscle provides a wellvascularized muscular rotation flap and avoids the need for laparotomy. Using the gracilis muscle flap vascular specialist. Obturator nerve runs superiorly and obliquely to gracilis muscle in the same plane as the pedicle.
Muscle flap surgery wmhs plastic surgery cumberland. The cutaneous territory of the gracilis myocutaneous flap was demonstrated by anatomic and injection studies to lie perpendicular to the muscle in its proximal one third, transverse and parallel to the medial groin crease. Muscle conserving free gracilis transfer minigracilis free. Urologygracilis flap placement urology coding ask an expert.
Dissection of the proximal gracilis vascular pedicle proceeds in a dark tunnellike space deep to the adductor longus. The gracilis flap is an exciting alternative to abdominal, back, or buttock. The gracilis muscles of 15 formalinfixed adult cadavers 30 cases were dissected with 4. Gracilis muscle interposition with primary rectal without. The medical files were divided into two groups according to the location of the anastomosis and whether a nerve graft between the donor and recipient of the gracilis muscle was used, as follows. The following case log coding recommendations have been provided in an attempt to establish some degree of uniformity for all otolaryngology residents in terms of the logging of. Doublemuscle gracilis and sartorius myocutaneous flap 43 fig. 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 major blood supply to the gracilis myocutaneous or gracilis muscle flap is derived from the medial femoral circumflex artery. The dissected gracilis muscle flap was 25 cm in length. 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. A surgical video demonstrating the 10 steps of a gracilis muscle flap for treatment of a complex groin wound. Doublemuscle gracilis and sartorius myocutaneous flap. Horton introduction the inner thigh skin and fat based on the transverse upper gracilis tug musculocutaneous flap blood supply provides an autologous donor area with several qualities complementary to microvascular breast reconstruction.
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. The gracilis muscle is commonly used as a flap in microsurgery. Apr 01, 2015 the gracilis muscle is one of the muscles found in the groin. Ok, it was a complete and utter mare doing it as i am quite a technophobe and it was far from simple, even reducing me to tears at one point. Double free gracilis muscle transfer after complete. It starts at the external point of the ischiopubic ramus on the pubic bone and extends down to the upper medial middle shaft of. Gracilis free flap for smile reanimation iowa head and.
The gracilis free muscle flap can be harvested through a well concealed, limited incision in the upper, inner thigh that is covered by shorts and summer wear. However, muscle flap selection after failure of treatment with other modalities necessitates diagnosis of the etiology of previous failure. Blunt dissection proceeds from posterior to anterior until the more distal aspect of the gracilis muscle is found. The gracilis muscle or musculocutaneous flap is the flap of choice in functional motor unit transfers. The reconstruction of large defects after abdominoperineal resections and pelvic exenterations has traditionally been accomplished with vertical rectus myocutaneous flaps vrams. Video presentation 08 rectovaginal fistula repair using a. Gracilis muscle interposition in conjunction with primary rectal repair but without urethral reconstruction is one of the reconstructive surgery options for moderate 2cm to 3cm rectourethral fistulas. In patients with longterm facial paralysis more than 2 years, the native facial muscles are not functional. Discussion the gracilis flap represents the workhorse for reconstruction of the perineal and pelvic defect.
Interesting case for the aspn newsletter peripheral nerve. Request pdf the free gracilis muscle flap in achilles tendon coverage and reconstruction the achilles tendon area is a delicate one, and therefore. The video demonstrates creation of a gracilis muscle flap for use in urethral and perineal reconstruction. There may be no obvious swelling or pain on palpation. In 1990, obrien was the first to report the use of the gracilis. Limited exposure technique for harvesting the whole muscle. A relatively new option for interposition between the rectum and the urethra or the vagina without body tissue flaps may involve the use of biologic meshes. After measuring the length of the muscle which is needed for the recipient site, exactly the same length of gracilis muscle combined with over. Sep 25, 2012 urinary and fecal diversion is the firststep operation. Double muscle gracilis and sartorius myocutaneous flap 43 fig. 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. Free gracilis muscle transfer to restore elbow flexion in. Extended approach to the vascular pedicle of the gracilis. When compared to published results, our series provides similar results to primary suturing performed within 6 months for cases of complete paralysis and within 12 months for cases of.
Request pdf comparison of spontaneous sensory recovery of noninnervated anteromedial thigh flap, latissimus dorsi flap, and gracilis muscle flap in lower extremity reconstruction. A small segment can be used in the face and attached to a crossfacial nerve graft or hypoglossal nerve. Muscle flap surgery wmhs plastic surgery cumberland, md. Original article experience with a modified technique of. Pdf perineal reconstruction after abdominoperineal. Endoscopic harvest of gracilis muscle flap for reconstruction.
Mark wallis, whose mountjoy orion damaged a gracilis muscle when trailing the field in the essex vase final, reported ayamzaman relatively unscathed after a nastylooking incident in a 400m open but the prolific winner will now be put away for the year meaning his final tally of open wins is. Request pdf the free gracilis muscle flap in achilles tendon coverage and reconstruction the achilles tendon area is a delicate one, and therefore numerous publications describe methods of. Urinary and fecal diversion is the firststep operation. The transverse upper gracilis tug flap uses tissue from the inner upper thigh near the natural groin crease, as well as the gracilis muscle, to create breast tissue. Double free gracilis muscle transfer after complete brachial plexus injury. In the conventional technique of flap harvest, figure 5.
The gracilis muscle is a thin, flat muscle situated along the inner thigh and is preferred for several functional and cosmetic reasons. An implant is then placed behind this flap and in front of the chest. A gracilis muscle flap, including its tendon, was elevated using a medial thigh incision, with a supplementary incision over the medial aspect of the tibial tuberosity. Gracilis muscle transposition for iatrogenic rectourethral. Internal urethrotomy is a procedure for postoperative urethral strictures of 1. The muscle is placed and sutured to the chest wall. Additional minor perforators originate proximally from the obturator artery and may supply a short gracilis flap.
Mark wallis, whose mountjoy orion damaged a gracilis muscle when trailing the field in the essex vase final, reported ayamzaman relatively unscathed after a nastylooking incident in a 400m open but the prolific winner will now be put away for the year meaning his final tally of open wins is 21. Functional free muscle flap facial paralysis surgery. Multivector gracilis muscle flap viable for facial reanimation. Poor softtissue conditions or lesions on both thighs. This flap is released from the back, passed through a tunnel that is made underneath the axilla and into the anterior chest to fill the mastectomy defect site. This muscle is very special because it can be transplanted to the face with its nerve, artery, and vein. In 1990, obrien was the first to report the use of the gracilis free flap for singlestage facial reanimation. Sep 02, 20 a surgical video demonstrating the 10 steps of a gracilis muscle flap for treatment of a complex groin wound. Flap dissection was performed in the usual fashion, with care taken to safeguard the great saphenous vein proximally and the saphenous nerve distally. 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 vessels from the medial femoral circumflex system. Review committee for otolaryngology case log coding recommendations. The doublemuscle gracilis and sartoriusgracilis myocutaneous flap leas a generous length, ample bulk, and has been transposed easily into the ischial defect. Farhadi a,b a department of plastic and reconstructive surgery, guys and st thomas hospital.
Generally will enter muscle about 8 cm from the pubic tubercle. 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. The issues that would negatively impact free flap success should be assessed.
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