Lower Extremity Reconstruction with Free Gracilis Flaps

 

 Buy Article Permissions and Reprints

Abstract

Background There have been significant advancements in lower extremity reconstruction over the last several decades, and the plastic surgeon's armamentarium has grown to include free muscle and fasciocutaneous flaps along with local perforator and propeller flaps. While we have found a use for a variety of techniques for lower extremity reconstruction, the free gracilis has been our workhorse flap due to the ease of harvest, reliability, and low donor site morbidity.

Methods This is a retrospective review of a single surgeon's series of free gracilis flaps utilized for lower extremity reconstruction. Demographic information, comorbidities, outcomes, and secondary procedures were analyzed.

Results We identified 24 free gracilis flaps. The duration from injury to free flap coverage was ≤ 7 days in 6 patients, 8–30 days in 11 patients, 31–90 days in 4 patients, and > 90 days in 3 patients. There were 22 (92%) successful flaps and an overall limb salvage rate of 92%. There was one partial flap loss. Two flaps underwent incision and drainage in the operating room for infection. Two patients developed donor site hematomas. Four patients underwent secondary procedures for contouring. Our subset of pediatric patients had 100% flap survival and no secondary procedures at a mean 30-month follow-up.

Conclusion This study demonstrates the utility of the free gracilis flap in reconstruction of small- to medium-sized defects of the lower extremity. This flap has a high success rate and a low donor site morbidity. Atrophy of the denervated muscle over time allows for good shoe fit, often obviating the need for secondary contouring procedures.

• References

• 1 Acland RD. Refinements in lower extremity free flap surgery. Clin Plast Surg 1990; 17 (4) 733-744
  CrossrefPubMedGoogle Scholar
• 2 Cordeiro PG, Neves RI, Hidalgo DA. The role of free tissue transfer following oncologic resection in the lower extremity. Ann Plast Surg 1994; 33 (1) 9-16
  CrossrefPubMedGoogle Scholar
• 3 Serafin D, Voci VE. Reconstruction of the lower extremity. Microsurgical composite tissue transplantation. Clin Plast Surg 1983; 10 (1) 55-72
  PubMedGoogle Scholar
• 4 Bibbo C, Nelson J, Fischer JP , et al. Lower extremity limb salvage after trauma: versatility of the anterolateral thigh free flap. J Orthop Trauma 2015; 29 (12) 563-568
  CrossrefPubMedGoogle Scholar
• 5 Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg 2001; 108 (4) 1029-1041 , quiz 1042
  CrossrefPubMedGoogle Scholar
• 6 Medina ND, Kovach III SJ, Levin LS. An evidence-based approach to lower extremity acute trauma. Plast Reconstr Surg 2011; 127 (2) 926-931
  CrossrefPubMedGoogle Scholar
• 7 Ong YS, Levin LS. Lower limb salvage in trauma. Plast Reconstr Surg 2010; 125 (2) 582-588
  CrossrefPubMedGoogle Scholar
• 8 Zenn MR, Levin LS. Microvascular reconstruction of the lower extremity. Semin Surg Oncol 2000; 19 (3) 272-281
  CrossrefPubMedGoogle Scholar
• 9 Engel H, Lin CH, Wei FC. Role of microsurgery in lower extremity reconstruction. Plast Reconstr Surg 2011; 127 (Suppl. 01) 228S-238S
  CrossrefPubMedGoogle Scholar
• 10 Rodriguez ED, Bluebond-Langner R, Copeland C, Grim TN, Singh NK, Scalea T. Functional outcomes of posttraumatic lower limb salvage: a pilot study of anterolateral thigh perforator flaps versus muscle flaps. J Trauma 2009; 66 (5) 1311-1314
  CrossrefPubMedGoogle Scholar
• 11 Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006; 117 (7) 2468-2475 , discussion 2476–2477
  CrossrefPubMedGoogle Scholar
• 12 Fischer JP, Wink JD, Nelson JA , et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013; 29 (6) 407-416
  Article in Thieme ConnectPubMedGoogle Scholar
• 13 Oh TS, Hallock G, Hong JP. Freestyle propeller flaps to reconstruct defects of the posterior trunk: a simple approach to a difficult problem. Ann Plast Surg 2012; 68 (1) 79-82
  CrossrefPubMedGoogle Scholar
• 14 Xiong L, Gazyakan E, Kremer T , et al. Free flaps for reconstruction of soft tissue defects in lower extremity: a meta-analysis on microsurgical outcome and safety. Microsurgery 2016; 36 (6) 511-524
  CrossrefPubMedGoogle Scholar
• 15 Nelson JA, Fischer JP, Haddock NT , et al. Striving for normalcy after lower extremity reconstruction with free tissue: the role of secondary esthetic refinements. J Reconstr Microsurg 2016; 32 (2) 101-108
  Article in Thieme ConnectPubMedGoogle Scholar
• 16 Carr MM, Manktelow RT, Zuker RM. Gracilis donor site morbidity. Microsurgery 1995; 16 (9) 598-600
  CrossrefPubMedGoogle Scholar
• 17 Deutinger M, Kuzbari R, Paternostro-Sluga T , et al. Donor-site morbidity of the gracilis flap. Plast Reconstr Surg 1995; 95 (7) 1240-1244
  CrossrefPubMedGoogle Scholar
• 18 Osiogo FO, Lai CS, Wang WH, Chye YF, Lin SD. Retrospective review of free gracilis muscle flaps in the management of nonhealing diabetic foot ulceration. J Foot Ankle Surg 2006; 45 (4) 252-260
  CrossrefPubMedGoogle Scholar
• 19 Redett RJ, Robertson BC, Chang B, Girotto J, Vaughan T. Limb salvage of lower-extremity wounds using free gracilis muscle reconstruction. Plast Reconstr Surg 2000; 106 (7) 1507-1513
  CrossrefPubMedGoogle Scholar
• 20 Heckler FR. Gracilis myocutaneous and muscle flaps. Clin Plast Surg 1980; 7 (1) 27-44
  CrossrefPubMedGoogle Scholar
• 21 Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report. Plast Reconstr Surg 1976; 57 (2) 133-143
  Google Scholar
• 22 Manktelow RT, Zuker RM, McKee NH. Functioning free muscle transplantation. J Hand Surg Am 1984; 9A (1) 32-39
  PubMedGoogle Scholar
• 23 Meland NB, Fisher J, Irons GB, Wood MB, Cooney WP. Experience with 80 rectus abdominis free-tissue transfers. Plast Reconstr Surg 1989; 83 (3) 481-487
  CrossrefPubMedGoogle Scholar
• 24 Hill JB, Vogel JE, Sexton KW, Guillamondegui OD, Corral GA, Shack RB. Re-evaluating the paradigm of early free flap coverage in lower extremity trauma. Microsurgery 2013; 33 (1) 9-13
  CrossrefPubMedGoogle Scholar