The Gracilis Myocutaneous Free Flap: A Quantitative Analysis of the Fasciocutaneous Blood Supply and Implications for Autologous Breast Reconstruction

Abstract

BackgroundMastectomies are one of the most common surgical procedures in women of the developed world. The gracilis myocutaneous flap is favoured by many reconstructive surgeons due to the donor site profile and speed of dissection. The distal component of the longitudinal skin paddle of the gracilis myocutaneous flap is unreliable. This study quantifies the fasciocutaneous vascular territories of the gracilis flap and offers the potential to reconstruct breasts of all sizes.MethodsTwenty-seven human cadaver dissections were performed and injected using lead oxide into the gracilis vascular pedicles, followed by radiographic studies to identify the muscular and fasciocutaneous perforator patterns. The vascular territories and choke zones were characterized quantitatively using the ‘Lymphatic Vessel Analysis Protocol’ (LVAP) plug-in for Image J® software.ResultsWe found a step-wise decrease in the average vessel density from the upper to middle and lower thirds of both the gracilis muscle and the overlying skin paddle with a significantly higher average vessel density in the skin compared to the muscle. The average vessel width was greater in the muscle. Distal to the main pedicle, there were either one (7/27 cases), two (14/27 cases) or three (6/27 cases) minor pedicles. The gracilis angiosome was T-shaped and the maximum cutaneous vascular territory for the main and first minor pedicle was 35×19 cm and 34×10 cm, respectively.ConclusionOur findings support the concept that small volume breast reconstructions can be performed on suitable patients, based on septocutaneous perforators from the minor pedicle without the need to harvest any muscle, further reducing donor site morbidity. For large reconstructions, if a ‘T’ or tri-lobed flap with an extended vertical component is needed, it is important to establish if three territories are present. Flap reliability and size may be optimized following computed tomographic angiography and surgical delay.

Biometría del Músculo Grácil: Pedículos Vasculares e Inervación en un Grupo de Individuos Brasileños

“…Dicho tendón tenía entonces, una porción intra y extramuscular, por lo que no estamos de acuerdo con la afirmación de Davis et al (2012) Hay bastante discrepancia o poca claridad tanto en la terminología de los pedículos, como en los criterios para su clasificación como menores o accesorios. En base a la revisión de la literatura, decidimos llamarle Pedículo Principal y Pedículos Menores teniendo como criterio el diámetro de los pedículos (Wei & Mardini;Magden et al;Whitaker et al;Conejero et al;An et al, 2016).…”

“…La inervación motora del MG es proporcionada por el ramo anterior del nervio obturador (Whitaker et al, 2012;Chen et al, 2018).…”

TUGs into VUGs and Friendly BUGs

“…The incorporation of these communicating branches, and the perigracilis fat and fascia, may help to explain the low incidence of ischemic complications observed. 15,22,23 Closure of the vertical donor site distributes tension circumferentially around the thigh, rather than a superoinferior orientation. As a result, any tension of the closure has no possibility of pulling the scar inferiorly or spreading the labia majora.…”

The Gracilis Free Flap in Head and Neck Reconstruction

“…Owing to its reliable anatomy, ability to be neurotized, ease of harvest, and low donor-site morbidity, the gracilis flap has become a prime choice for surgeons in smile restoration, and has become a desirable treatment option for patients. 1,2,[9][10][11][12] In a study of 104 patients requiring gracilis flaps, only 6% of patients had persistent weakness that interfered with walking or running, and a <10% donor site complication rate consisting of infection, bleeding, or pain. 13 Besides facial reanimation, gracilis has also been used to fill soft tissue defects in the head and neck, and has also been well served for aesthetic purposes.…”