Gracilis Free Flap Research Articles

Transforming growth factor-beta receptor-II up-regulation during wound healing in previously irradiated graft beds in vivo.

Wound healing disorders may often present in patients with head and neck cancer after surgical interventions, particularly in preirradiated tissue. Inflammatory changes and the expression of cytokines can lead to induction of fibrosis. The isoforms of the transforming growth factor beta (TGFbeta1-3) play a key role for this process. It has been shown that radiation treatment associated fibrosis is induced by TGFbeta1 and TGFbeta2, although the influence of radiation on the expression of the TGFbeta receptor-II (TGFbetaR-II) involved in the signal transduction of TGFbeta remains elusive. The objective of this in vivo study was to analyze the expression profile of TGFbetaR-II in the graft bed and in the transition area between graft and graft bed after surgery with and without prior radiation treatment to compare with the expression profiles of activated TGFbeta1 and latency-associated peptide. A total of 48 Wistar rats (male, weight 300-500 g) were used in the study. Eighteen rats were irradiated in the neck region (3 x 10 Gy) without transplantation. A free myocutaneous gracilis flap was transplanted in 30 rats, of which 16 animals were preirradiated in the neck region (3 x 10 Gy) and 14 animals were not irradiated at all. Tissue samples were taken postoperatively from the transition area between the graft and the graft bed and from the graft bed itself after 3, 7, 14, and 28 days. Tissue samples were taken from the irradiated neck region and the non-irradiated groin region 0, 4, 7, 11, 14, and 28 days after the end of the exposure. The expression of TGFbetaR-II, activated TGFbeta1 and latency-associated peptide was analyzed immunohistochemically both qualitatively and quantitatively (labeling index). The success rate for graft healing was 75% in the previously irradiated group with 30 Gy, and 86% in the non-irradiated group. Following radiation alone a significantly (p = 0.04) increased TGFbetaR-II expression in the neck was revealed 2-4 weeks following irradiation compared to non-irradiated skin. Whereas only minor differences in TGFbetaR-II expression were observed following surgery between the groups with and without prior radiation in the transition area between the graft and the graft bed, the group undergoing prior radiation and subsequent grafting showed significantly increased expression in the bed compared to the non-preirradiated group with a maximum on postoperative day 7 (week 1, p = 0.003; week 2-4, p < 0.001). In irradiated tissues the up-regulation of TGFbetaR-II expression correlated with an increase of activated TGFbeta1 and latency-associated peptide expression compared to non-irradiated tissues. After irradiation, a significantly increased TGFbetaR-II expression was identified in the irradiated graft bed, which may be the reason for delayed reepithelialization and fibrosis. Exogenous blocking or TGFbetaR-II inhibitors could therefore represent a new therapeutic approach for improving wound healing after preoperative radiotherapy.

Medial thigh lift free flap for autologous breast augmentation after bariatric surgery.

Massive weight loss following bariatric surgery frequently results in body contour deformities like ptotic and hypoplastic breasts, redundant abdominal tissue and loose skin especially in the medial thigh area. This redundant tissue can be used for breast augmentation in the case of hypertrophic ptotic breasts. In 3 patients who underwent a vertical banded gastroplasty and consecutively lost more than 60% of their body weight, a breast augmentation with a transverse gracilis myocutaneous free flap was performed. Bilateral myocutaneous gracilis free flap breast augmentation resulted in an esthetic, pleasing result, with additional correction of the redundant skin from the medial thigh region. Autologous breast augmentation with a simultaneous medial thigh lift can be performed safely, after successful weight loss following bariatric surgery.

Vascularization of the area between free grafts and irradiatedgraft beds in the neck in rats

Inflammatory lesions of the vascular endothelium after preoperative radiotherapy often cause healing-delayed healing of free flaps in the irradiated graft bed. We investigated changes in neovascularization in the transition area between grafted tissues and irradiated tissues of the graft bed. We irradiated the neck(30 and 50Gy total dose) in 102 Wistar rats and then grafted a free myocutaneous gracilis flap to the irradiated region of the neck 4 weeks later. We examined histologically the tissues of the graft, the transition area between the graft and the irradiated graft b<$>ed, and the graft bed. In contrast to control rats, the tissues in the irradiated animals showed a qualitatively reduced and a more irregular capillary distribution, with substantial fibrosis in the irradiated graft bed. We also found significant differences in vascularization and mean capillary lumen in the transitional zone between graft and graft bed in the irradiated rats compared with controls (P = 0.004 and P < 0.001, respectively). Both number and diameter of capillaries were reduced in the irradiated graft bed tissue. The graft failed to improve vascularization in the transitional zone between graft and irradiated tissue, so we conclude that it is the vascularization status of the bed tissue rather than that of the transplant tissue that is the limiting factor for graft healing.

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.

The combination of posterior scalping flap and gracilis free flap for mid-face reconstruction

A variety of donor sites have been reported for the restoration of mid-face cutaneous defects; however, the limited availability of tissue of similar color and texture to that of native facial skin greatly limits reconstructive options. Similarly, resection of the underlying mimetic musculature during the primary ablation compounds this reconstructive challenge, resulting in both a cosmetic and a functional deformity. The combination of the posterior scalping flap for cutaneous resurfacing, and microvascular transfer and reinnervation of the gracilis free flap for dynamic facial reanimation, offers a reconstructive alternative for extensive soft tissue defects of the mid-face.

Reconstruction of Upper Extremity Function in Brachial Plexopathy Using Double Free Gracilis Flaps

Reconstruction of Upper Extremity Function in Brachial Plexopathy Using Double Free Gracilis Flaps

Electrically Stimulated Free-Flap Graciloplasty for Urinary Sphincter Reconstruction: A New Surgical Procedure

In electrically stimulated (dynamic) graciloplasty for urinary incontinence, the gracilis muscle is transposed into the pelvis, and the distal part is used to reconstruct a neosphincter. Clinical outcomes using this technique have been disappointing due to stricture of the urethra caused by ischemia in the distal part of the gracilis and limited gracilis length available for neosphincter construction. Furthermore, the urethra is twisted by the contracting gracilis, rather than circumferentially squeezed. The purpose of the present study was to test the anatomical and functional feasibility of a new surgical approach to reconstruct a urinary sphincter, using the gracilis muscle as a free flap. In 12 human cadavers, the anatomical feasibility for creating a neosphincter by using the gracilis free flap was determined. In all cases, transfer of the gracilis muscle into the pelvis as a free flap (with the nerve intact) was feasible, and ample muscle was available to construct a neosphincter around the bladder neck. Gracilis neosphincter function was studied in seven dogs. The left gracilis muscle was subjected to transfer into the pelvis as an innervated free flap to create a neosphincter around the urethra. The right (control) gracilis muscle was lifted as a single pedicle flap, remained in situ, and was wrapped around a stent to mimic the urethra. Function (expressed as peak pressure generation and fatigue rate) and surface perfusion were determined for all gracilis muscles. In each dog, both sides were compared using the paired Student's t test for statistical analysis, and no significant difference was measured for the two groups. In conclusion, an innervated gracilis free flap can be used to create a neosphincter around the bladder neck. In an acute study in dogs, function and perfusion of the innervated gracilis free flap are not compromised.

Paralisia facial. Técnicas de reconstrução neuro-muscular.

Several surgical procedures have been proposed through the years for the treatment of facial paralysis. The multiplicity and diversity of techniques portray the complexity and challenge represented by this pathology. Two basic dynamic options are available: -Reconstruction of nerve continuity through direct micro suture, with interposition grafts or nerve transpositions. -Regional muscular transposition, most often using the temporalis. Facial reanimation with the temporalis transfer has withstood the test of time and still is a reference technique. In a few weeks, good results can be obtained with a single and rather simple surgical procedure. Functional free flaps have been used with increasing frequency in the last two decades, most often combining a cross-facial nerve graft followed by a gracilis free flap nine months later. With this method there is a potential for restoration of spontaneous facial mimetic function. Apparently there is a limit in microsurgical technique and expertise beyond which there is no clear improvement in nerve regeneration. Current research is now actively studying and identifying nerve growth factors and pharmacological agents that might have an important and complementary role in the near future.

The gracilis free flap revisited: a review of 25 cases of transfer to traumatic extremity wounds.

Trauma to the extremities often results in a complex bony and soft-tissue injury requiring free flap reconstruction. Muscles from various body sites have been used in extremity reconstruction since the early 1970s. The gracilis muscle is usually not considered the first choice for free flap reconstruction of these defects. It is usually relegated to small defects or used to reanimate the face. Our purpose is to present our experience with the gracilis muscle as a first-choice flap in reconstruction of traumatic extremity defects. A retrospective review of all gracilis muscle free flap transfers for traumatic extremity wounds between 1988 and 1995 at the Naval Medical Center Portsmouth was performed. Twenty-five patients age 20 to 71 years (mean, 29.7 years) underwent 26 free flaps to the lower leg, ankle, foot, or forearm to cover traumatic wounds. Defects ranged in size from 3 x 3 cm (9 cm2) to 13 x 18 cm (234 cm2), with a mean of 75.5 cm2. There were no flap losses and all wounds healed. Nine patients experienced 11 complications, which consisted of minor wound separation (16%), wound infection (12%), partial or complete loss of split-thickness skin graft (8%), thrombosis of graft with successful revascularization (4%), and nonunion of an underlying fracture (4%). Our overall success rate for gracilis free flap reconstruction of traumatic wounds is 100%. The gracilis free muscle flap has become our first option for tissue coverage in traumatized extremities. It leaves minimal functional defect limited to the side of the primary injury and provides a good cosmetic result. It can cover large defects when the epimysium is cut, and allows an epidural block to be performed for sympathectomy effect and pain control in the affected extremity during the immediate postoperative period.

The gracilis free flap for reconstruction of parotidectomy defects

Total parotidectomy causes a significant postoperative concave deformity in the retromandibular, preauricular, and infra-auricular regions of the face; many patients are concerned about this defect. Frey's syndrome (gustatory sweating) is also a well-recognized postoperative entity following parotid surgery. The incidence of Frey's syndrome ranges from 10–90%, depending on the type and complexity of the investigation used to diagnose it [5, 11]. Numerous methods have been described to correct these problems. Patients requiring total parotidectomy were recently offered the option of immediate reconstruction of the contour defect with microvascular transfer of a tailored gracilis muscle flap. Four patients are included in this preliminary series; all are extremely satisfied with the postoperative result. The defect following total parotidectomy can be reconstructed immediately with gratifying cosmetic results, a hidden donor site scar, and to date no operative morbidity.

A modified free gracilis flap in the rat.

We present in this paper the use of a combined neurovascularized 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.