Floor plan - 2013 Annual Meeting - American Association for Hand ...

Complex Perineal and Groin Wound Reconstruction Using the Extended Dissection
Technique of the Gracilis Flap
Institution where the work was prepared: Georgetown University Hospital, Washington, DC, USA
Joseph H. Dayan, MD; Patrick Curry; Chris E. Attinger, MD; Ivica Ducic, MD, PhD; Georgetown University Hospital
BACKGROUND:
The purpose of this paper is to review the applications of the extended dissection technique of the gracilis flap in a high risk patient
population with complex wounds requiring more coverage than a standard gracilis flap may provide. To our knowledge, this is the first
study applying the extended dissection technique as described by Hasen, et al, to pedicled gracilis flaps.
METHODS:
A chart review conducted from 2003 to 2006 identified 19 consecutive patients as having undergone an extended gracilis dissection.
The technical details of this procedure are described.
RESULTS:
All reconstructions were successful. There was one complication presenting as a late infection at the donor site. Mean patient age was
66 years old and nearly all patients had multiple significant comorbidities including diabetes, peripheral vascular disease, and/or radiation
therapy.
CONCLUSIONS:
The extended-dissection technique for gracilis harvest has significant benefits for use in pedicled flaps including greater arc of rotation
and no restriction on post-op ambulation or thigh abduction. These factors are particularly important in the challenging patient population
represented in this study and add to the reliability and versatility of the gracilis flap. Anatomic illustrations for technical guidance
in this procedure are also provided.
Vascularization of the Flexor Hallucis Longus Muscle and Its Implication in Free Fibula Flap
Transfer
Institution where the work was prepared: KleinertKutz Institute, Louisville, KY, USA
Paolo Sassu, MD1; Samir Mardini, MD2; Tuna Ozyurekoglu, MD1; J. Christopher Salgado, MD3; Steven Moran4;
Robert D. Acland, MD5; (1)KleinertKutz Institute, (2)Mayo clinic Rochester, (3)Cooper University Hospital / U.M.D.N.J,
(4)Mayo Clinic, (5)University of Louisville
INTRODUCTION:
Contracture as well as weakness of the flexor hallucis longus (FHL) are possible complications following harvest of the fibula flap.
Clinically significant contracture when it occurs represents a major problem. Possible causes have been related to fibrotic change of the
muscle either due to devascularization or compartment-like syndrome after a tight wound closure. Blood supply to the FHL is partially
disturbed during harvest of the fibula flap. To what degree this occurs is not clear. The purpose of this study is to study the anatomy,
vascularization, and nerve supply of the FHL muscle after fibula flap harvest in a fresh cadaver model.
MATERIALS/METHODS:
A vascularized fibula bone flap was harvested through a lateral approach in twenty fresh limbs. The popliteal artery was isolated and
injected with 40cc of silicone injection compound. . Twenty-four hours later the FHL muscle was isolated and marked into four sections
(one quarter of the entire length) using a marking pen. The vessels supplying the FHL and the nerve to the muscle were studied under
microscopic visualization.
RESULTS:
The distal third and fourth part of the FHL muscle was always found to be located in a tight deep compartment.. The distal part of the
peroneal artery was refilled by the silicone compound in 19 legs. In all specimens at least one branch was found to supply the distal
fourth of the FHL. In all legs the posterior tibialis artery was refilled and an average of two branches were found to supply the muscle.
In all dissections the nerve supplying the FHL originated from the tibialis nerve and its course was strictly close to the tibialis nerve with
an average of three branches perforating the muscle.. No branches of the nerves were injured during the dissection.
CONCLUSIONS:
After harvest of a fibula flap, the FHL muscle maintains adequate vascular supply through the distal portion of the peroneal artery and
the posterior tibialis artery. Since there was no injury to the nerves supplying the FHL, this is unlikely to be a cause of any problems in
clinical cases. The FHL is enclosed in a tight compartment and this may explain the occasional contracture seen in clinical cases. The
results of this study require clinical correlation and lead us to believe that if contracture does occur it is most likely to be related to an
increase in compartment pressure causing some ischemia of the muscle.
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