Gracilis Myocutaneous Flap Research Articles

Extending the use of the gracilis muscle flap in perineal reconstruction surgery

Reconstruction of the perineum is required following oncological resections. Plastic surgical techniques can be used to restore the aesthetics and function of the perineum. The gracilis myocutaneous flap provides a substantial skin paddle, with minimal donor site morbidity. The flap is pedicled on a perforator from the medial circumflex femoral artery, giving it limited reach across the perineum. Tunnelling the flap under the adductor longus muscle may free up more of the arterial pedicle, increasing its reach. On three female cadavers, bilateral gracilis flaps were raised in the standard surgical manner, giving six flaps in total. With the flaps pedicled across the perineum, the distance from the tip of each flap was measured to the anterior superior iliac spine (ASIS). The flaps were then tunnelled under the adductor longus muscle. The distances to the ASIS were measured again. The average pedicle length was greater than 7cm. Tunnelling the flap under the adductor longus muscle increased the reach by more than 4cm on average. Cadaveric dissection has shown that tunnelling of the flap in a novel way increase its reach across the perineum. This additional flexibility improves its use clinically and is of benefit to plastic surgeons operating in perineal reconstruction.

FRI-09 THE CREATION OF THE NEOVAGINA: A HISTORY OF VAGINAL RECONSTRUCTION

INTRODUCTION AND OBJECTIVES: After Realdus Colombus described congenital vaginal agenesis in the 16th century, vaginal reconstruction became of interest to urologists, plastic surgeons, and gynecologists. We will review the evolution of neovaginal reconstruction as it’s indications expanded from treatment of congenital disease, to restoration of normal function following radical surgery and finally to elective gender reassignment surgery. METHODS: A comprehensive literature review (PubMed, Clinical Key) was performed to elucidate relevant historical and clinical information. RESULTS: Early reports of surgical vaginal reconstruction attempted to use the labia majora for vaginoplasty, however the first use of extravaginal tissue came in 1898 when Dr. Abbe described the construction of a neovagina using skin grafts. The technique was largely abandoned until McIndoe refined the procedure in 1938. Although the procedure was successful in over 133 reported cases by 1948, patients developed scarring and subsequent stenosis. Techniques in reconstruction expanded as the indications for neovaginal reconstruction began including patients with large defects following radical pelvic surgery. In the 1950’s Conway and Stark popularized the use of bowel similar to their predecessors at the turn of the century, however this approach proved to be afflicted with complications. The use of regional tissue transposition began with McGraw in 1976 that utilized a gracilis myocutaneous flap. For larger defects following pelvic exenteration, Tobin described the use of a rectus abdominis myocutaneous flap in 1988. Alternatively, in 1974 Davydov described a procedure using peritoneum from the pouch of Douglas to reconstruct upper vaginal defects. A new interest has currently been taken in this procedure as it is now being performed laparoscopically. The vaginal reconstructive techniques described for treating patients with vaginal atresia helped form the foundation for neovaginal construction in male-to-female transgender surgery which became popularized in the late 1960’s. Although penile disassembly and inversion vaginoplasty remains the preferred surgical technique, nongenital flaps and intestinal interposition remain suitable options as primary or revision vaginoplasty. CONCLUSIONS: Techniques in vaginoplasty have evolved since their original descriptions in the turn of the century and their contemporary applications are used for numerous indications.

Surgical therapy of vulvar cancer: how to choose the correct reconstruction?

ObjectiveTo create a comprehensive algorithmic approach to reconstruction after vulvar cancer ablative surgery, which includes both traditional and perforator flaps, evaluating anatomical subunits and shape of the defect.MethodsWe retrospectively reviewed 80 cases of reconstruction after vulvar cancer ablative surgery, performed between June 2006 and January 2016, transferring 101 flaps. We registered the possibility to achieve the complete wound closure, even in presence of very complex defects, and the postoperative complications. On the basis of these experience, analyzing the choices made and considering the complications, we developed an algorithm to help with the selection of the flap in vulvoperineal reconstruction after oncologic ablative surgery for vulvar cancer.ResultsWe employed eight types of different flaps, including 54 traditional fasciocutaneous V-Y flaps, 23 rectus abdominis myocutaneous flaps, 11 anterolateral thigh flaps, three V-Y gracilis myocutaneous flaps, three free style perforators V-Y flaps from the inner thigh, two Limberg flaps, two lotus flaps, two deep inferior epigastric artery perforator flap, and one superficial circumflex iliac artery perforator flap. The structures most frequently involved in resection were vulva, perineum, mons pubis, groins, vagina, urethra and, more rarely, rectum, bladder, and lower abdominal wall.ConclusionThe algorithm we implemented can be a useful tool to help flap selection. The key points in the decision-making process are: anatomical subunits to be covered, overall shape and symmetry of the defect and some patient features such as skin laxity or previous radiotherapy. Perforator flaps, when feasible, must be considered standard in vulvoperineal reconstruction, although in some cases traditional flaps remain the best choice.

Outcome of vulvar reconstruction in patients with advanced and recurrent vulvar malignancies.

BackgroundThe use of flaps in vulvar cancer-related reconstruction has been increasing, but few studies have evaluated the outcome and quality of life of patients after this surgery. The purpose of this study was to evaluate the outcomes of vulvar reconstruction using musculocutaneous/skin flaps in patients with advanced and recurrent vulvar malignancies.MethodsPatients with vulvar malignancies who underwent vulvar reconstruction using different types of flaps were retrospectively reviewed. Patient outcomes were evaluated with a focus on quality of life and prognosis.ResultsThirty-six patients were enrolled, 58.33 % of them used anterolateral thigh flap (ALT), 16.67 % of them used pudendal thigh flap (PTF), 11.11 % of them used deep omferior epigastric perforator (DIEP) and gracilis myocutaneous flap were used in 2.78 % of the patients, the other 11.11 % patients used two types of flaps. Eleven patients (30.56 %) developed complications, including 5 patients (13.89 %) with partial necrosis, 5 (13.89 %) with minimal wound dehiscence and 1 (2.78 %) with flap cellulitis. All patients who developed partial necrosis (13.89 %) underwent reoperation. The mean verbal rating scale score was 1.44 before reconstruction and 0.17 after surgery (P < 0.0001). The mean performance status was 1.67 before surgery and improved to 0.31 after surgery (P < 0.0001). The median overall follow-up time after vulvar reconstruction was 9 months. Twenty-one patients (58.3 %) developed recurrence at a median interval of 5 months after vulvar reconstruction. After a median follow-up time of 14 months, 41.7 % of the patients were living and disease-free. The 5-year survival of the 36 patients was 53.8 %.ConclusionSoft tissue reconstruction in patients undergoing resection of advanced/recurrent vulvar malignances is associated with a low rate of postoperative complications, decreased pain, and improved functional status. Although the recurrence rate in this patient population is high, a reasonable proportion of patients who undergo resection for advanced/recurrent vulvar cancer and reconstructive surgery appear to benefit.

Hyperbaric Sub-Normothermic Ex-Vivo Perfusion Delays the Onset of Acute Rejection in a Porcine VCA Model

INTRODUCTION: Vascularized composite allotransplantation (VCA) offers superior functional recovery following devastating maxillofacial and upper limb injuries compared to traditional reconstructive techniques. Here, we evaluate the efficacy of a novel sub-normothermic (SN) ex-vivo perfusion strategy using hyper-oxygenated University of Wisconsin (UW) solution to mitigate reperfusion injury (RI) and the onset of acute rejection in a porcine VCA model.1 Minimizing RI by optimizing allograft preservation strategies could improve early VCA outcomes, and reduce dose, frequency, and duration of immunosuppression. MATERIALS AND METHODS: Heterotopic gracilis myocutaneous flap transplants were performed into the necks of Yorkshire swine recipients, mismatched for one swine leucocyte antigen. Group 1 (controls, n=8) received allotransplants without additional flap treatment. Group 2 (experimental, n=8) flaps were perfused ex-vivo with hyper-oxygenated UW for five hours at 20ºC in a hyperbaric chamber at 3 atm before transplantation. Without systemic immunosuppression, flaps were monitored daily for clinical evidence of rejection and biopsied for immunohistopathological analysis. Serum was sampled for markers of immune injury secondary to RI. RESULTS: Control flaps experienced Banff2 Grade 1 rejection at a mean of 6.4 days (SD=0.52), and Grade 4 rejection at a mean of 10.5 days (SD=2.6). The experimental flaps showed a statistically significant delay in the onset of Grade 1 rejection at 13.7 days (SD=0.52, p<0.05). At the experiment’s conclusion (Day 15), 75% of the experimental flaps showed no evidence of Grade 4 rejection. CONCLUSION: Hyperbaric SN perfusion significantly delays the onset of acute rejection in the absence of systemic immunosuppression. This technology has potential utility in the field of solid organ transplantation and VCA, and could expand the donor pool dramatically. Furthermore, ex-vivo normalization of tissue physiology may reduce antigen presentation and acute rejection phenomena in allotransplantation.

Surgical Repair Involving Tissue Flap Transplantation with Vascular Pedicle in Treating Refractory Pressure Ulcers Around Hip and Sacral Region

Objective: To explore the therapeutic methods on surgical repair of refractory pressure ulcers around hip and sacral region, and to conclude the focuses of the surgical treatment. Materials and Methods: From January 2007 to December 2013, tissue flap transport with vascular pedicle was applied to repair 77 cases refractory pressure ulcers (96 wounds) around hip sacral region, with the patients aging from 21 to 82. For the positions of the 96 wounds, 34 wounds were on the sacrococcygeal region, 21 in femoral major trochanteric portion, and 41 on the ischial tuberosity. The size of smallest pressure ulcer was 1cm×2cm, and the biggest was 12×16cm, all were accompanied by infections with different degrees. Among all the cases, 38 wounds were repaired by gluteus maximus myocutaneous flaps, 11 wounds were repaired by gracilis myocutaneous flaps, and 12 wounds were repaired by long end of musculus biceps femoris myocutaneous flaps; 34 wounds repaired by fasciocutaneous flaps, including 10 wounds by posterior fasciocutaneous flaps; and 5 cases were healed by hip disarticulation and repaired by bone musculocutaneous flaps. Results: 75 of the 77 patients were healed after the operation, while 2 failed to be healed because of their old age and poor nutritional status. According to the follow-ups, 4 of the healed patients with pressure ulcers on ischial tuberosities relapsed 1 year after the operation, and were thoroughly healed by second operation of biceps femoris myocutaneous flaps transport; the transplanted myocutaneous flaps of other cases all survived and no recurrence of pressure ulcers happened, that the surgical treatment received satisfactory results. Conclusion: Combining the supportive therapeutics of nutritional support and control of the infections, surgical treatment of tissue flap transport with vascular pedicle could reach satisfactory results for repair refractory pressure ulcers around hip and sacral region. Keywords: Follow-up, refractory pressure ulcers, surgical repair, therapy, tissue flap with vascular pedicle.

Double transverse myocutaneous gracilis free flaps for unilateral breast reconstruction.

In cases were the deep inferior epigastric perforator flap (DIEP flap) is not available and unilateral transverse myocutaneous gracilis flap (TMG flap) is not sufficient for breast reconstruction, we perform double TMG flaps as a reconstructive method. In this report, we present our results of the use of double TMG free-flap-transfer for unilateral breast reconstruction. Between August 2004 and June 2012 we performed 58 TMG flaps in 29 patients for unilateral breast reconstruction. Patient data were analyzed and operative outcome (operation time, complication rate and aesthetic results) were investigated. Aesthetic outcome was evaluated retrospectively via photo documentation by an independent plastic surgeon. The results were classified in;unsatisfactory, satisfactory, good and very good. The average operating time was 6 hours 55 minutes (295 - 650 minutes). Of 58 TMG flaps, 57 (98.3%) were successful. Thrombosis occurred in seven (12%) cases (1 arterial, 6 venous). Flap salvage was successful in six cases and flap failure occurred in one (1.7%) case. The results of 25 patients were graded as good and very good. Three patients showed satisfying and one patient unsatisfying results. Double TMG flaps in unilateral breast reconstruction could lead to good operative results. This method further expands the range of options with autologous tissue in reconstructive breast surgery. © 2015 Wiley Periodicals, Inc. Microsurgery 36:539-545, 2016.

The microvascular anastomotic coupler for venous anastomoses in free flap breast reconstruction improves outcomes.

Venous couplers are ubiquitous around the world and are a useful tool for the reconstructive microsurgeon. A systematic review of coupler performance studies demonstrated a thrombosis rate range of 0% to 3%, whilst the average time of using the device is 5 minutes. There is sparse published data on cost analysis and the impact of operator experience on the anastomotic coupler device success. Improvements in outcomes other than time benefits have also not been shown. This study aims to address these deficiencies in the literature. A retrospective clinical study was undertaken, aiming to compare equivalent groups of patients that had free flap surgery with venous micro-anastomoses with those that had sutured anastomoses. The cohort comprised all patients undergoing microsurgical breast reconstruction at the St Andrew's Centre for Plastic Surgery & Burns from January 2009 to December 2014. Between January 2010 to December 2014, 1,064 patients underwent 1,206 free flap breast reconstructions. The average age of patients was 50 years. Seventy percent of patients underwent mastectomy and immediate reconstruction during this period with the remaining 30% having a delayed reconstruction. The 1,206 free flaps comprised of 83 transverse myocutaneous gracilis (TMG) flaps, and 1,123 deep inferior epigastric artery perforator (DIEP) flaps. In total the coupler was used in 319 flaps, 26% of the cohort. There was a statistically significant clinical benefit in using the anastomotic coupler for venous anastomosis. Overall, the return to theatre rate was 12.69% whilst the overall flap loss rate was 0.75%. The overall coupler failure rate was significantly less at 1.4% whilst sutured vein failure rate was 3.57% (P=0.001). The anastomotic coupler for venous anastomosis in free flap surgery is associated with reduced operating times, reduced take-backs to theatre and cost benefits. This is the first study to demonstrate clear clinical benefits to anastomotic couplers, and suggests that these may be the gold standard for venous microanastomosis. With increasing experience with their use and technological advances, these outcomes may continue to improve.

Vascular Variations of the Transverse Upper Gracilis Flap in Consideration for Breast Reconstruction

The transverse upper gracilis (TUG) myocutaneous flap has served as an alternative to abdominally based autologous breast reconstruction since its introduction by Yousif et al in 1992. The reliability of the overlying skin paddle of the gracilis myocutaneous flap depends on the perforator anatomy as well as the vascular pedicle. Although much attention recently has been given to variations in the septocutaneous as well as myocutaneous perforators, we believe that relevant variations in pedicle anatomy have been underappreciated. We would like to report our experience with pedicle variability. A retrospective review of records was performed on patients undergoing a TUG flap for autologous breast reconstruction from July 2006 and November 2011 by a single surgeon (L.C.W.). A total of 36 TUG flaps were performed on 24 patients. Twelve patients underwent bilateral simultaneous TUG reconstruction, and 12 patients underwent unilateral TUG reconstruction. Pedicle variability was found in 6 (17%) of 36 dissections. In 5.5% of dissections, there was a split pedicle and 11% were found to have a double main pedicle. There was 1 partial flap loss that resulted in a failed breast reconstruction. Four limbs had some degree of resultant lymphedema as a consequence of flap harvest. Although still a viable alternative to abdominally based autologous reconstruction, we find that the variability of the main pedicle has been quite underestimated in earlier reports. We also present a logical algorithm for flap dissection when the microsurgeon encounters such aberrancies.

Donor-site morbidity following harvest of the transverse myocutaneous gracilis flap for breast reconstruction.

The transverse myocutaneous gracilis flap provides adequate autologous tissue for breast reconstruction from the high thigh region, but flap harvest may affect the patient's activities of daily living, sexuality, and quality of life. The authors evaluated the reconstruction outcome, postoperative donor-site complications, and quality-of-life outcomes. All patients who underwent transverse myocutaneous gracilis breast reconstruction performed by the senior author (M.H.) since 2007 were included in the study. Patient files were reviewed, and a questionnaire was used to assess patient satisfaction. Forty-nine transverse myocutaneous gracilis flaps were performed in 36 patients for breast reconstruction. Total flap necrosis occurred in two flaps (4 percent). Additional fat grafting was required in 61 percent of flaps, and donor-site complications occurred in 59 percent of patients. Wound dehiscence and infection were the most commonly encountered donor-site complications. However, by harvesting less skin and gracilis muscle, there was a statistically significant (p<0.001) lower complication rate in the last 16 patients. Twenty-two patients with at least 6 months of follow-up were included in the questionnaire study. Eighteen returned questionnaires. Most patients were happy to very happy with their result and could go about their activities of daily living. There was no statistically significant correlation between the independent variables (e.g., age, body mass index, and radiotherapy) and the dependent variables (e.g., breast satisfaction, sexuality, and donor-site morbidity). There was a statistically significant difference regarding donor-site satisfaction when comparing patients with and without donor-site complications (p=0.01). Although fat grafting was often required, patients were happy with the result of their transverse myocutaneous gracilis breast reconstruction. Donor-site complications correspondence inversely to patient satisfaction. Therapeutic, IV.

The success of rectus and gracilis muscle flaps in the treatment of chronic pelvic sepsis and persistent perineal sinus: a systematic review.

Chronic pelvic sepsis is a challenging problem, which may require muscle flaps to fill the pelvic cavity. The aim of this systematic review was to determine the relative success of rectus and gracilis flaps used for this purpose. A systematic review was conducted to identify papers that reported the outcome of rectus or gracilis myocutaneous flaps in the treatment of persistent perineal sinuses or chronic pelvic sepsis. Reports of muscle flaps used for reconstruction or treatment of fistula in the absence of chronic sepsis were excluded. A successful outcome was defined as complete perineal healing within 12 months of surgery. The review identified 19 studies reporting the outcome of 73 rectus and 87 gracilis flaps. Their respective success was 84% and 64%. Heterogeneity of the underlying cases did not allow for direct comparison of the flaps. Full healing of the flaps was generally achieved within 3 months. Donor site morbidity was minimal. The surgical treatment of chronic pelvic sepsis should be tailored to the individual, but the rectus flap has a reasonable success rate with little morbidity.

Autologous breast reconstruction with the transverse myocutaneous gracilis flap: aesthetic improvements with tissue expansion before free flap transfer

The transverse myocutaneous gracilis (TMG) flap provides an alternative to commonly used free flaps from the lower abdomen and buttocks for breast reconstruction. Excellent aesthetic results can be achieved in primary breast reconstruction after subcutaneous and skin-sparing mastectomy. However, in delayed breast reconstruction after mastectomy, an obvious skin island and conspicuous scars often compromise the final appearance. A two-stage approach with tissue expansion of the skin followed by free deepithelialised TMG flap reconstruction avoids these disadvantages and leads to improved aesthetic results. We treated two patients who asked for an autologous breast reconstruction after mastectomy due to primary breast cancer. Reconstruction with lower abdominal tissue was not feasible in one patient because of a previous abdominoplasty and in the other because of insufficient lower abdominal tissue. Both patients declined an implant-based breast reconstruction as well as a procedure using a flap from the buttock, favouring reconstruction with autologous tissue from the superior inner thigh. In the first stage, a tissue expander was inserted endoscopically assisted via a transaxillary approach. The expander was gradually filled over a 3-month period and finally replaced by a free deepithelialised TMG flap. The postoperative period was uneventful in both patients. We achieved satisfying results in both patients with good breast symmetry and uniform colour of the breast skin. Disadvantages and limitations of traditional one-stage breast reconstructions by free TMG flaps can be avoided by this two-stage approach. This reconstructive procedure leads to inconspicuous scars and a matching skin colour of both breasts.

Hydrogen Sulfide Mitigates Reperfusion Injury in a Porcine Model of Vascularized Composite Autotransplantation

Devastating extremity injuries are prevalent but often survivable on the modern battlefield. These complex injuries require advanced methods of reconstruction, involving prolonged ischemic periods and reperfusion injury. Using our group's validated porcine model of gracilis myocutaneous flap transplantation, this study demonstrates that an interim perfusion of hydrogen sulfide (H2S) mitigates the effects of reperfusion injury in the setting of delayed restoration of blood flow. A gracilis myocutaneous flap (200-400 g; surface area, 250 cm²) was procured from the hind limb of a Yorkshire swine (70-90 kg, n=16). The right external carotid artery and the internal jugular vein are the recipient axis. Group 1 (control, n = 6) underwent delayed anastomosis with a 3-hour ischemic period. Group 2 (n=10) underwent a similar delayed anastomosis with an interim perfusion of H2S during the ischemic period. The animals survived for 14 days. Systemic biomarker assays for skeletal muscle tissue injury (creatine kinase, lactate dehydrogenase, and aspartate transaminase) and proinflammatory markers (tumor necrosis factor α and interleukin 6) provide assessment of reperfusion injury at the cellular level. The control animals (3 hours of ischemia with an interim perfusion of heparinized saline) demonstrated increased levels of injury biomarkers and proinflammatory cytokines compared with the animals receiving H2S infusion and identical ischemic interval. The control flaps had a mean creatine kinase level of 280³×10 U/L (±80×10³), compared with the H2S group, which had a mean of 99×10³ U/L (±14×10³; P=0.0007 at postoperative day 2). lactate dehydrogenase levels (mean) were 26×10³ U/L (±8×10³) versus 9×10³ U/L (±3×10³; P=0.0004) and aspartate transaminase levels (mean) were 1651 U/L (±324) versus (873 U/L [±279]; P=0.0013) for the control and treatment groups, respectively. Similarly, an intergroup difference in IL-6 was found, although not statistically significant. Tumor necrosis factor α levels (mean) were 93 pg/mL (±14) versus 39 pg/mL (±4; P=0.0013) for the control and treatment groups, respectively. This study demonstrated the mitigating properties of H2S on reperfusion injury. Interim perfusion with H2S resulted in diminution of ischemia-dependent biomarkers after 3 hours of ischemia. Follow-up studies will translate these findings as an evolving method for reconstructing previously unreconstructable injuries.

Establishing donor specific tolerance in vascularized composite allotransplantation via local enrichment of endogenous regulatory T cells (TRAN3P.865)

Abstract Vascularized composite allotransplantation (VCA)—encompassing transplantation of hands/limbs and face is an emerging field with potential to restore the appearance and function of damaged tissue. Clinically, the process of rejection is suppressed via systemic immunosuppression, which is associated with a host of deleterious side effects. An alternative approach to prevent rejection is to harness the homeostatic mechanisms intrinsic to the immune system. To this end our group has recently developed controlled release microparticle (MP) systems capable of enriching Tregs at given location via synthetic cell constructs referred to as Expansion MP. Accordingly, we hypothesized that Treg enriching systems that release key cytokines, and immunosuppressive agents, can promote long term graft survival in preclinical VCA models. Following fabrication, Expansion MP was tested in an allogeneic rat hind limb transplant model and then in a swine gracilis myocutaneous flap allotransplant model. Following subcutaneous injection of microparticles, rodent hind limbs survived indefinitely (&amp;gt;200 days) and swine allografts survived until the end of the study period (4 weeks) with no signs of rejection. Secondary skin grafts and MLRs in both models demonstrate that ExpansionMP treatment appears to confer donor specific tolerance to recipients. Given these promising results, we believe this technology has the potential to dramatically impact the field of VCA and reconstructive transplantation.

Pelvic reconstruction with pedicled thigh flaps: indications, surgical techniques, and postoperative imaging.

This article will describe and illustrate the relevant anatomy and surgical techniques used in pelvic reconstruction using regional pedicled thigh flaps, which is often necessary in oncologic surgeries. Examples of normal postoperative imaging and common complications that can accompany pelvic reconstruction with anterolateral, gracilis myocutaneous, and posterior thigh fasciocutaneous flaps will be provided. Pelvic reconstruction using regional pedicled thigh flaps is often needed with extirpative oncologic surgeries to eliminate dead space, provide pelvic organ support, restore form and function, and introduce vascularized tissue to promote wound healing. Radiologists need to be aware of the normal postoperative appearance of these flaps so that the flaps are not mistaken for residual or recurrent disease and so that residual or recurrent disease can be identified and treated.

Computed Tomographic Angiography Imaging and Clinical Implications of Internal Mammary Artery Perforator Vessels as Recipient Vessels in Autologous Breast Reconstruction

The internal mammary artery (IMA) is the standard recipient vessel for autologous breast reconstruction. To save the IMA for bypass surgery, to keep flap pedicles short, and to allow better flap positioning, the IMA perforators were used. Forty-six flaps for immediate breast reconstructions were performed in 39 patients. In the first 22 patients, the decision to use the perforators was clinically based. In the second group of 17 patients, all patients received a thoracic computed tomographic angiography (CTA) to determine the perforators. In 13 flaps (6 deep inferior epigastric artery perforator, 3 superficial inferior epigastric artery, and 4 transverse myocutaneous gracilis), the perforators were used as recipient vessels. Of these flaps, 5 were anastomosed to perforators before the CTA was applied and 8 after the CTA was established. The CTA revealed the IMA and the perforators in detail. In immediate reconstructions, the IMA perforators can be used as recipient vessels. They allow better flap positioning for superficial inferior epigastric artery and transverse myocutaneous gracilis flaps in particular; moreover, it decreases donor site and recipient site morbidity. After introducing the CTA, the perforators were used more frequently for anastomosis.

Use of a gracilis myocutaneous flap for reconstruction of perineal defect in a dog -Case report

A male Beagle dog was referred with a perineal wound after perineal herniorrhaphy. Open wound management was performed, using wet-to-dry contact dressing with daily debridement and lavage for 7 days. The wound was reconstructed with an island gracilis myocutaneous flap (GMCF). The wound healed without any complications, while limb and pelvic function were uncompromised. Based on the outcome of the present case, it is proposed that transposition of the GMCF can be an effective alternative for reconstruction of soft tissue defects in the perineal area.

Single-Stage Reconstruction of Extensive Defects after Fournier's Gangrene with an Exposed Iliac Crest and Testes

Fournier's gangrene (FG) is an acute necrotizing fasciitis that involves the skin and subcutaneous tissue on the scrotum, perineum, and abdominal wall [1]. It is a potentially fatal disease, with a reported mortality rate between 3% and 67% [2]. Broad-spectrum antibiotics, aggressive fluid therapy, and early surgical debridement are essential for the management of FG [3]. After primary treatment, FG may produce tissue defects of various sizes that need reconstructive procedures. We experienced a case of extensive defects involving the bilateral groin, pubic area, and scrotum after FG, for which we performed single-stage reconstruction using bilateral pedicled anterolateral thigh (ALT) flaps and gracilis myocutaneous flaps.

Breast and Chest Wall Reconstruction with the Transverse Musculocutaneous Gracilis Flap in Poland Syndrome

Poland syndrome is a complex chest wall deformity with unilateral hypoplasia of the breast and pectoralis muscle, with a missing anterior axillary fold in its most common form. The authors report their combined experience and technique with the transverse myocutaneous gracilis flap to reconstruct the chest wall and breast either alone or simultaneously. Between June of 2004 and July of 2010, 11 patients (two male patients) were operated on and 14 flaps were transplanted. The authors found that the transverse myocutaneous gracilis flap proved to be a very valuable microsurgical alternative for reconstructing the chest wall and female breast in Poland syndrome with autologous tissue. The flap provides the surgeon maximal freedom of flap insetting for optimal symmetry together with a very inconspicuous donor site regardless of unilateral or bilateral harvesting.

The Fleur-de-Lis Upper Gracilis Flap for Breast Reconstruction

We evaluated a fleur-de-lis design for the gracilis myocutaneous flap to improve flap volume for breast reconstruction. Thirty-one flaps were used in 17 consecutive patients undergoing the procedure for either thin body habitus (23 flaps) or prior abdominal surgery (8 flaps). The flap success rate was 100%. The fleur-de-lis flap provided proportionate breast reconstructions in all patients. Complications included 6 (19.3%) donor-site dehiscence and 4 (12.9%) episodes of cellulitis. Applying a negative pressure dressing to the donor site (n=26) significantly reduced the initially high dehiscence rate to 7.7% (P<0.01). There was no incidence of lower extremity edema or sensory loss. The fleur-de-lis gracilis flap can be performed with a low flap related complication rate and acceptable donor-site morbidity. Because of its standardized flap design, improved volume, and favorable breast shaping, it may allow autologous breast reconstruction to be offered to a greater number of patients.