Pedicled Gracilis Muscle Flap Research Articles

Management of a giant lymphocele following varicose vein surgery: a case report

BackgroundA lymphocele or lymphocyst is formed when lymphatic fluid accumulates in a space, following disruption of lymphatic channels. Here, we report a case of a giant lymphocele in a middle-aged female, who underwent Trendelenburg operation (saphenofemoral junction ligation) for varicose veins of her right lower limb.Case presentationA 48-year-old Pakistani Punjabi female presented to the plastic surgery outpatient department with a history of painful, progressive swelling of the right groin and medial aspect of the right thigh for 4 months. After investigation, it was diagnosed as a giant lymphocele. A pedicled gracilis muscle flap was used to reconstruct and obliterate the cavity. There was no recurrence of the swelling.ConclusionLymphocele is a common complication after extensive vascular surgeries. In the unfortunate case of its development, prompt intervention must be done to prevent its growth and ensuing complications.

(520) The Use of Gracilis Muscle Flap in Radial Forearm Free Flap Phalloplasty to Decrease Urethral Fistula Rate: Initial Outcome

Abstract Introduction `- Chang and Hwang, in 1984, described the technique of Radial Forearm Free Flap Phalloplasty (RFFFP). It is now considered to be the standard surgery for phallic reconstruction. Urethral fistula is the most common complication reported in RFFFP and may reach up to 60-70%. Most commonly, the fistula site is at the anastomosis between the native urethra and the neo-urethra. Objective `- to study the impact of gracilis muscle flap wrapping around the native urethra/neo-urethral anastomosis on decreasing the fistula rate. Methods `- A prospective study was conducted at our urology department, from January 2018 till December 2020. - Patients presenting with a micropenis (Stretched penile length <7 cm) underwent RFFFP with gracilis muscle flap wrapping. - The free-flap was harvested from the non-dominant forearm. Under microscopic guidance, the radial artery was anastomosed with the inferior epigastric artery, the cephalic vein with the great saphenous vein, and the medial and lateral antecubital nerves with the ilio-inguinal and the dorsal penile nerves respectively. - A pedicled gracilis muscle flap was then wrapped around the neo-urethera/native urethral anastomosis to assess its possible role in decreasing the postoperative urinary fistula rate. Results `- Nineteen patients were included in the study with a median age of 26 years (16 - 43) and a BMI of 24 (22-25). The median hospital stay of 14 days (14 - 21) and the median follow-up was 11 months (4 - 13). The median cold ischemia time was 90 mins (70 - 100), estimated blood loss was 500 cc (400 - 500) and operative time was 11 hrs (10 - 12). - A viable phallus was achieved in 13 patients (overall free flap survival 68.4%). - Of the successfully viable phallus cases, 8 cases (42.1%) were complicated by complete disruption of the urethra and the remaining five cases (26.3%) had complete urethral tube. - One case of them developed a fistula at the neo-urethera/native urethral anastomosis, one case had a distal fistula and one case had a ring stricture at the site of anastomosis. - The gracilis muscle flap prevented urethral fistula formation in 4 out of 5 cases (80%) with complete urethral tube. Conclusions `- The use of pedicled garcilis muscle flap wrapping around the neo-urethra/native urethral anastomosis during RFFP might be helpful in reducing the urinary fistulae rates at this site. However, larger comparative studies are needed. Disclosure No

Gracilis Muscle Interposition to Fill the Perianal Dead Space May Decrease Hospital Length of Stay in Fournier's Gangrene.

The treatment of Fournier's gangrene (FG) includes aggressive debridement of the affected necrotic area, broad-spectrum antibiotic therapy, and reconstructive procedures, respectively. One of the main reasons of unfavorable outcomes in FG surgery is that the dead space occurs in the perianal region because of destruction of fascias and soft tissues. In this study, we aimed to evaluate the results of gracilis muscle flap transposition to fill the FG-associated perianal dead spaces. Patients treated for FG-associated dead spaces in their perianal region between the years 2017 and 2021 were included in the study. The patients who underwent the pedicled gracilis muscle flap surgery were included in group 1, whereas group 2 consisted of the patients with no additional surgical procedure for dead spaces but only the reconstruction of the soft tissue defects. Demographic data (age, sex), comorbid diseases, localization and length of perianal dead space, and management method for the soft tissue defects and complications were noted. The length of hospital stay and discharge day after surgery were also recorded. In group 1, the mean duration of hospital stay was 23.5 ± 5.0 (range, 14-48) days, whereas the mean period between the surgery and discharge was 5.1 ± 2.2 (range, 3-12) days. These numbers were 31 ± 8.3 (range, 19-58) days and 12.7 ± 6.1 (range, 7-22) days in group 2, respectively. Statistical comparison of the periods between the surgery and discharge was found to be significantly different ( P = 0.022). The duration of hospital stay was also shorter in the patients with gracilis muscle flap ( P = 0.039). Perianal dead spaces accompanying many of the patients with FG provide appropriate conditions for bacterial colonization. Filling these pouches by the gracilis muscle flap prevented the progression of infection and enabled the patients to return to their normal life earlier.

70 - Adynamic gracilis urethral myoplasty with a pedicled gracilis muscle flap wrapped around bulbar urethra: Surgical treatment options for the management of severe male acquired urinary incontinence.

70 - Adynamic gracilis urethral myoplasty with a pedicled gracilis muscle flap wrapped around bulbar urethra: Surgical treatment options for the management of severe male acquired urinary incontinence.

The outcome of gracilis muscle flap wrapping around the neourethra-native urethral anastomosis after radial forearm free flap phalloplasty on the incidence of fistula formation

ABSTRACT Introduction The radial artery-based free-flap phalloplasty (RFFP) is accompanied by high rates of fistula formation and urological complications. We thought to investigate the impact of pedicled gracilis muscle flap wrapping around the urethral anastomosis on the occurrence of fistula at the neourethra-native urethral junction. Materials and Methods Prospective study was conducted at the urology department of Cairo University Hospitals. Patients presenting with micropenis (stretched penile length ≤7 cm) underwent RFFP. The RFF was harvested from the non-dominant forearm after ensuring of good collateral supply to the hand. All patients underwent RFFP with pedicled gracilis muscle flap wrapping. Under microscopic guidance, the radial artery was anastomosed with the inferior epigastric artery, the cephalic vein with the great saphenous vein and the medial and the lateral ante-brachial nerves with the ilioinguinal nerve and the dorsal penile nerve, respectively. Data were reviewed for demographics and perioperative outcomes. Results Nineteen patients were included in the study with a median follow up of 11 months (3, 22). Median age of 26 yrs (16, 43), hospital stay was 7 days (7, 30) and. Indications for RFFP were: micropenis (40%), post-surgery crippled penis (25%), amputated penis (20%), aphallia (5%), epispadias (5%) and gender dysphoria (5%). Median ischemia time was 88 mins (60, 120), ebl was 600 cc (300, 2000) and operative time 11 hrs (8, 14). Intraoperative complications were a case of transection of the radial artery during graft harvesting, failure to tubularize the graft and significant blood loss during vaginectomy. Overall success rate was 70%. 5 cases had a complete success, only one case had a fistula at the neo-uretheral native urethral anastomosis, one patient had a distal fistula and another patient had a ring stricture at site of anastomosis. 8 cases were complicated by complete disruption of the urethra. 6 cases were complicated by total graft loss (2 cases due to arterial causes and 4 cases due to venous congestion). No donor site morbidity was noted. During follow up patients reported shortness in the mean length of the phallus was 2.1cms. All patients reported recovery of both general and erogenous sensations in the neo-phallus. The recovery of the general sensation (tactile stimulation and two-point discriminations) ranged between 2 to 4 weeks post-operatively while recovery of the erogenous sensation occurred between 8 to 16 weeks. Conclusion The use of pedicled garcilis flap during RFFP resulted in a fistulae rate of 20%. Disclosure Work supported by industry: no.

VP3: Pelvic Reconstruction After Large Sacral Chordoma Resection Using Acellular Dermal Matrix and Double Pedicled Gracilis Muscle Flap Combined with Gluteal Fasciocutaneous Rotation Flap

INTRODUCTION: Sacral chordomas are rare, malignant primary bone tumors. Surgical resection with wide margins, combined or not with radiotherapy, is the only effective treatment with near 50% remission at 10 years. Surgery results in large three dimensional defects, as total or subtotal sacrectomy is often required. The treatment is challenging and requires a multidisciplinary approach. Several reconstructive approaches have been described, classically including rectus abdominis or gluteus musculocutaneus flap and omental flap. We aim at presenting an innovative method of pelvic floor reconstruction using acellular dermal matrix and double pedicled Gracilis muscle flap combined with gluteal fasciocutaneous rotation flap. MATERIALS AND METHODS: We report the case of a 70 yo patient affected by locally invasive sacral chordoma. The oncological treatment included neuronavigation-assisted subtotal sacrectomy with en bloc resection at the level of S1-S2 intervertebral disc and laparoscopic abdomino-perineal amputation with terminal colostomy. After the R0 resection was confirmed, pelvic floor was reconstructed with an acellular dermal matrix and a double-breasted pedicled muscle Gracilis flap to avoid herniation of the abdominal cavity organs. The overlying soft tissue defect was reconstructed with an unilateral gluteal fasciocutaneous rotation flap partially deepitelialized to fill the dead space. The donor sites were closed directly. RESULTS: No surgical complications were observed, with flaps and donor sites healing uneventfully. After 3 days in intermediate intensive care and 22 days in plastic surgery department, he was transferred to rehabilitation center. Walking was reassumed after 2 weeks, sitting after 4 weeks. Satisfying outcomes both functionally and cosmetically for both patient and surgeons were observed at 3 months follow-up. CONCLUSION: Large sacral defect can successfully be reconstructed with double pedicled muscle Gracilis flap combined with gluteal rotation flap. The association with acellular dermal matrix is recommended to avoid abdominal cavity organs herniation. The oncological, functional results at 3 months are satisfying with minimal donor site morbidity. Presentation Type

Scrotal reconstruction with pedicled gracilis muscle flap following Fournier\u2019s gangrene: a case report and literature review

BackgroundFournier’s gangrene is an acute soft tissue necrotizing infection involving the perineum and the external genitalia which can result in a major loss of the scrotal wall with exposure of the testicles. Reconstruction of such major defect is quite challenging; the use of pedicled gracilis muscle flap helps to create an aesthetically acceptable scrotum with minimal donor site morbidity.Case presentationWe described the case of a 60-year-old man with a large scrotal loss from Fournier’s gangrene following bladder outlet obstruction and perineal abscess. He had multiple debridement and reconstruction with pedicled left gracilis muscle flap with a good aesthetic and functional post-operative outcome. The major challenge encountered was the loss of the skin graft as a result of the retraction of the muscle flap due to too early ambulation; this can thus be avoided by adequate pre-operative counseling and enforcing bed rest.ConclusionsThe use of gracilis muscle flap in the reconstruction of large scrotal defect described in this report has the additional advantage of creating a pliable and soft feel like that of the original scrotum with minimal donor site morbidity.

A surgical challenge: reconstruction of post Fournier’s gangrene large penoscrotal defects with pedicled Gracilis muscle flap

A surgical challenge: reconstruction of post Fournier’s gangrene large penoscrotal defects with pedicled Gracilis muscle flap

Reconstruction of a Wide Defect in the Prostatic Urethra after Abdomino-Perineal Amputation Using Buccal Mucosa Free Graft and Pedicled Gracilis Muscle Flap

Lesions with significant substance loss in the prostatic segment of the urethra can represent a reconstructive challenge, especially when peripheral tissues are damaged or poor-vascularized. We present an infrequent clinical case in which a prostatic urethral defect of 2.6cm in length following abdomino-perineal amputation was repaired using a free buccal mucosa graft which was stabilized with a muscular gracilis flap. Complementing the buccal mucosa graft with a well-vascularised support the stability of the graft could be enhanced and the rates of fistula or strictures reduced.

Use of a Split Pedicled Gracilis Muscle Flap in Robotic-assisted Vaginectomy and Urethral Lengthening for Phalloplasty

Use of a Split Pedicled Gracilis Muscle Flap in Robotic-assisted Vaginectomy and Urethral Lengthening for Phalloplasty

A CASE OF PELVIC FRACTURE URETHRAL INJURY REPAIRED BY FOURTH URETHROPLASTY

Pelvic fracture urethral injury (PFUI) is relatively rare injury, and delayed urethroplasty is the gold standard for its repair. Because a failed urethroplasty results in increased scarring and reduced length of the available urethral segment, the salvage urethroplasty is a urologic challenge. We herein report the case of male patient with PFUI who could be salvaged after three failed urethroplasties. A 22-year-old male who had received a PFUI when he was 4 years old was referred for salvage urethroplasty after two perineal anastomotic urethroplasties and one transpubic urethroplasty had failed, leaving him unable to void and forced to keep having a suprapubic tube placed. The meatus was iatrogenically obliterated due to repeated treatments. Through an incision from the scrotum and right side of the root of the penis to the lower abdomen, the anterior urethra was circumferentially mobilized and transected at the distal urethral stump. The proximal urethral end was identified by palpitation with a metallic sound inserted through the suprapubic tube tract. The covering fibrotic scar tissue was completely removed and 8 anastomotic 4-0 polydioxanone sutures were placed to reapproximate the urethral mucosa. A pedicled gracilis muscle flap was created and wrapped around the anastomosis site and intrapelvic segment of the mobilized anterior urethra. A urethrogram 8 months after urethroplasty showed a wide caliber at the anastomosis site and a ventral midline meatotomy was subsequently performed. He is currently free from any instruments and can void well without the need for further intervention.

Reconstruction of gluteal deformities: a systematic review and experience of four cases

Background: The reconstruction of gluteal deformities remains a major challenge. The aim of this article is to provide a systematic review of the literature concerned, and to present a case series with representative defects from various zones.Methods: A review of the literature was performed using PubMed, EMBASE, and The Cochrane Library, in accordance with the PRISMA statement. Quality of evidence was rated according to GRADE. Patients with various buttock deformities were included and, depending on the defect, the reconstructive techniques applied consisted of lipoinjection, local fasciocutaneous flap, or pedicled gracilis muscle flap. Complications, patient’s pain assessment, impairment in everyday-life activities, aesthetic outcome, objective assessment of sensitivity, and recurrence were considered.Results: A total of 498 records were identified in the literature search. Of those, 12 studies met the PICOS (participants, interventions, comparators, outcomes, and study design) criteria. Overall, 41 patients were analysed, the evidence of which was of low quality. In this study, four patients (three female and one male) with a mean age of 44 ± 15 years were operated on between 2010–2014. The mean operation time was 83 ± 30 minutes. One patient required revision due to persistent seroma and recurrence, and one patient required neurolysis and gracilis denervation due to neuroma and scarring. After a mean follow-up of 40 ± 21 months, the results were functionally and cosmetically satisfactory.Conclusions: Reconstruction of buttock deformities using an integrated approach can lead to a long-lasting, functionally and aesthetically satisfactory result. However, evidence is limited due to the lack of good-quality studies.

Editorial Comment

Despite surgical advances, iatrogenic and post-traumatic stress urinary incontinence (SUI) in men continues to be a significant health burden on the individual patient and society. In this report, researchers describe the outcomes of adynamic graciloplasty for the treatment of male SUI. 1 Guo H. Sa Y. Xu Y. et al. Adynamic graciloplasty with a pedicled gracilis muscle flap wrapped around bulbar urethra for treatment of male acquired urinary incontinence. Urology. 2016; 91: 210-216 Google Scholar Essentially, they harvested the gracilis muscle maintaining its proximal pedicle, transferred it to the perineum where it was wrapped around the bulbar urethra, and then passed the distal end back to the thigh where it was sutured back to itself. The goal was to achieve a urethral pressure of between 80 and 90 cm H2O. Ultimately, the results in those with mild to moderate SUI were good. A number of patients had hematomas or pain but these problems all resolved. As highlighted by the authors, there were study and patient factors that may limit the applicability of their data to other populations.

Adynamic Graciloplasty With a Pedicled Gracilis Muscle Flap Wrapped Around Bulbar Urethra for Treatment of Male Acquired Urinary Incontinence

To evaluate the efficacy of adynamic gracilis urethral myoplasty with a pedicled gracilis muscle flap wrapped around bulbar urethra for treatment of male acquired urinary incontinence. Twenty-four patients with acquired urinary incontinence (8 after radical prostatectomy, 7 after transurethral resection of the prostate, and 9 after posterior urethroplasty) were included in our study. Eighteen of these patients (75.0%) had mild to moderate urinary incontinence, and 6 (25.0%) had severe urinary incontinence. All patients received adynamic gracilis urethral myoplasty with a pedicled gracilis muscle flap wrapped around bulbar urethra and had a close follow-up. The mean postoperative maximum urethral pressure after the gracilis muscle wrapped around bulbar urethra was significantly higher than that of the preoperative measurements (P <.05). After a mean follow-up of 31.5 months (6-64 months), 18 patients were cured, 4 patients improved, and 2 patients were considered failures. The total cure rate was 75.0% (18 of 24). Five out of 6 patients with severe incontinence did not have a great success. A pedicled gracilis muscle flap wrapped around bulbar urethra can raise the urethral pressure. Adynamic graciloplasty with a pedicled gracilis muscle flap wrapped around bulbar urethra is a safe and effective surgical option in the treatment of male patients with mild to moderate incontinence, but is not suitable for severe incontinence.

Rectovaginal Fistula Repair using a Gracilis Muscle Flap

Introduction and hypothesis This video demonstrates a technique for using a pedicled gracilis muscle flap to repair rectovaginal fistula.

The distally pedicled gracilis flap for salvage of complex knee wounds

IntroductionSoft tissue defects around the knee joint resulting from trauma or because of wound breakdown after total knee arthroplasty present a challenge in a group of patients that often suffer from other co-morbidities. A pedicled gastrocnemius muscle flap remains a workhorse for this kind of wound. However, where the defect lies in the supero-lateral aspect of the proximal knee area, an alternative solution is required. The distally based pedicled gracilis flap has been described as an option for these cases where free-tissue transfer may not be an option and the pedicled gastrocnemius is not sufficient or has already been used. The purpose of this review is to evaluate the usefulness of this flap in the nine cases in which we have utilized it in our unit. MethodsNine patients underwent reconstruction of complex proximal knee wound defects with a distally based pedicled gracilis muscle flap. The mean age was 62 years (range 23–83). Five patients had wound breakdown following total-knee arthroplasty (TKR) and four patients had wound complications after road traffic accidents (RTA). Three of the nine flaps were delayed. ResultsEight of the nine patients had successful salvage of the knee with the use of the distally based gracilis flap. Although four of the flaps suffered partial loss, this did not compromise the joint salvage. The patients were moderately satisfied with the reconstruction and achieved a mean range of movement of 75° (±12°). ConclusionThe distally based pedicled gracilis flap can be a salvage solution for complex soft tissue defects with exposed knee joint, patella or proximal part of knee or exposed knee prosthesis in cases where a pedicled gastrocnemius muscle is inadequate or the patient is not suitable for a free flap.Evidence Level IV.

Accidental radiation exposure leading to non-healing ulcers

Two patients with accidental radiation injury presented at the Sir Ganga Ram Hospital. The first patient, a 41-year-old male, presented with a large necrotic patch on his right gluteal region, which was debrided. Due to the progressive nature of the injury, he developed further necrosis and a non-healing ulcer over the right gluteal region, which was further debrided and covered with a tensor fascia lata flap. Further necrosis over the ischial region was debrided and covered with a pedicled gracilis muscle flap, following which he again required debridement and flap cover for the residual area, which then finally healed. The second patient had a history of radiation exposure followed by a non-healing ulcer on right arm. He was managed by debridement and flap coverage in a single sitting. These two cases suggest that wide excision, thorough debridement and coverage with vascularised tissue are effective in treating radiation ulcers and emphasise that all radiation sources and their management should be strictly controlled.

Female Bladder Exstrophy: Report of 2 Unique Cases and Review of the Literature

Bladder exstrophy is a rare lower urinary tract malformation that occurs less frequently in women than in men. We report 2 cases of bladder exstrophy occurring in women. One patient was an adult with congenital bladder exstrophy; the patient's bladder wall flap was used to reconstruct the neourethra after the bladder was closed using a conventional procedure. The other patient experienced lower abdominal trauma that led to widespread loss of skin and subcutaneous tissue, exposing the bladder in the lower abdominal wall. In this patient, a pedicled gracilis muscle flap was used to close the abdominal wall after the closure of the bladder. To our knowledge, the first is the fifth reported case of bladder exstrophy in an adult woman and the latter is the first reported case of bladder exstrophy caused by trauma. Both patients showed good outcomes after undergoing surgical treatment.

Gracilis muscle flap with a tissue-engineered lining for experimental bladder wall reconstruction.

To assess a pedicled gracilis muscle flap pre-laminated with autologous, in vitro-expanded urothelial cells to reconstruct an entire supratrigonal bladder-wall defect in rats. A gracilis muscle flap was harvested from 36 male Wistar rats, transposed into the abdomen and wrapped around a silicon-block space holder. Urothelial cells were harvested and expanded ex vivo. Cells were then suspended in fibrin glue and seeded into the gracilis muscle pocket. One week later this pre-laminated flap was transposed into a surgically created supratrigonal bladder-wall defect. All animals underwent such a pre-laminated gracilis flap bladder reconstruction and were categorized into three experimental groups. All surviving animals with urothelial-culture pre-laminated gracilis flap bladder reconstruction were killed 12 weeks (group 1) later. Control rats had gracilis flaps with no cell seeding and treated only with fibrin glue (group 2) or a standard culture medium (group 3) before reconstruction. Specimens stained with haematoxylin and eosin, and a specific immunohistochemical staining (AE1 and AE3-anti-cytokeratin monoclonal antibody stain) showed a continuous, multilayered functioning urothelial lining along the transposed pre-laminated gracilis flap in group 1. All animals in group 1 with an intact urothelial lining on the gracilis muscle survived, in contrast to most animals in groups 2 and 3, where eight and all 12 animals died, respectively. The surviving four animals in group 2 had no detectable urothelial lining. CONCLUSION Successful urinary reconstruction requires a contractile neo-reservoir resistant to resorption over time and a stable, protective urothelial lining. A gracilis muscle flap can be seeded with autologous cultured urothelial cells suspended in fibrin glue. This pre-laminated flap can be safely transposed on its pedicle and be successfully integrated into the remaining bladder wall, with a urothelial lining and the potential to contract. Further studies in larger animals, with a urodynamic assessment, are warranted to determine if this type of bladder-wall replacement technique is suitable for urinary reconstruction in humans.

Rheumatism; a national pro-problem.

The patient is a 45-year-old man diagnosed with Fournier’s gangrene and underwent treatment for septic shock, broad-spectrum antibiotic therapy and extensive surgical debridement of perineum, including total scrotectomy, ischiorectal fossa, abdomen and left superior thigh and flank. The patient required multiple staged complex reconstruction of the scrotum utilising prelaminated superior medial thigh flaps with use of dermal matrix, split-thickness skin grafting and pedicled gracilis muscle flap for coverage of the ischiorectal wound. The patient had full recovery and followed up 1 year postoperatively. This report discusses our technique for total scrotal reconstruction and provides review of surgical reconstructive techniques for wounds due to Fournier’s gangrene.