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Surgical Approach to the Vascular

Surgical Approach to the Vascular

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Published by TAMBAKI EDMOND
PLASTIC SURGERY
PLASTIC SURGERY

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Categories:Types, Research
Published by: TAMBAKI EDMOND on Aug 20, 2010
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09/25/2010

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Surgical Approach to the VascularPedicle of the Gracilis Muscle Flap
Yasunori Hattori, MD, PhD, Kazuteru Doi, MD, PhD,Yukio Abe, MD, PhD, Keisuke Ikeda, MD, Vikas Dhawan, MD, PhD,
Yamaguchi, Japan 
Aneasyandsafeapproachtothevascularpedicleofthegracilismuscleflapisdescribed.Withthis technique the vascular pedicle can be harvested with maximum length and the largestpossible caliber for functioning free muscle transfer. (J Hand Surg 2002;27A:534–536. Copy-right © 2002 by the American Society for Surgery of the Hand.)
Key words:
Gracilis muscle, functioning free muscle transfer.
The gracilis muscle is widely used as a donormuscle for functioning free muscle transfer (FFMT)because of its single motor nerve supply, anatomicconsistency of the vascular pedicle, and large amountof excursion. We have used more than 100 gracilismuscles for FFMT mainly in brachial plexus recon-struction.
1
Compared with the use of the gracilismuscle as a pedicled island transfer, it is necessary toharvest a longer vascular pedicle in FFMT. We havereported our endoscopic harvesting technique of thegracilis muscle for FFMT.
2
In this article we describein detail our vascular dissection technique for an easyand safe approach to the vascular pedicle.
Technique
The patient is placed in supine position with thethigh abducted and the knee flexed. A 10
5–cmskin flap to facilitate easy closure and postoperativemonitoring of the circulation is designed proximal todistal in an oblique direction over the gracilis muscle(Fig. 1). After the skin is incised along the skin flapanteriorly, the deep fascia is incised over the adduc-tor longus muscle and posteriorly over the adductormagnus muscle. The main vascular pedicle and mo-tor nerve of the gracilis are identified underneath theadductor longus muscle at the junction of the upperquarter and lower three quarters of the gracilis mus-cle (Fig. 2), but at this time the neurovascular pedicleis not dissected. The gracilis muscle distal to the skinflap is harvested endoscopically.
2
After the distalpart is harvested (Fig. 3), the neurovascular pedicle isdissected. For exposure of the neurovascular pediclethe adductor longus muscle is retracted anteriorly
From the Department of Orthopedic Surgery, Ogori Daiichi GeneralHospital, Yamaguchi, Japan.Received for publication October 10, 2001; accepted in revised formFebruary 1, 2002.No benefits in any form have been received or will be received froma commercial party related directly or indirectly to the subject of thisarticle.Reprint requests: Yasunori Hattori, MD, PhD, Department of Ortho-pedic Surgery, Ogori Daiichi General Hospital, Shimogo, 862-3, Ogori,Yoshikigun, Yamaguchi, Japan 754-0002.Copyright © 2002 by the American Society for Surgery of the Hand0363-5023/02/27A03-0021$35.00/0doi:10.1053/jhsu.2002.32962
Figure 1.
The design of the skin flap for harvesting thegracilis muscle flap for FFMT.
534
The Journal of Hand Surgery
 
(Fig. 4). The nerve to the gracilis is traced as prox-imal as possible to the obturator foramen where thebranch to the gracilis is divided. Some branches fromthe vascular pedicle to the adductor longus muscleare ligated to isolate the vascular pedicle. The vas-cular pedicle should be traced to its origin from theprofunda femoris artery and vein. Because the viewof the vascular pedicle underneath the adductor lon-gus muscle is not adequate, dissection of the planebetween the adductor longus muscle and superficialfemoral artery and vein is developed. One or 2 minorvascular pedicles to the adductor longus muscle fromthe superficial femoral vessels are ligated. After dis-section around the adductor longus muscle is com-pleted, it is retracted posteriorly to expose the originof the pedicle (Fig. 5). The large ascending branch isusually ligated before it joins the profunda femorisartery. The venae comitantes often become one largevein just before joining the profunda femoris vein.The length of the pedicle is approximately 6 to 8 cmand the diameter of the vessel is about 1.2 to 1.8 mm(Fig. 6). After the vascular pedicle is ligated at the
Figure 2.
The adductor longus muscle is retracted forexposure of the neurovascular pedicle. Small arrow showsthe vascular pedicle, middle arrow shows the motor nerveof the gracilis muscle, and large arrow shows the retractedadductor longus muscle.
Figure 3.
The distal part of the gracilis muscle is har-vested endoscopically.
Figure 4.
Dissection of the vascular pedicle is developedunderneath the retracted adductor longus muscle. Smallarrow shows the vascular pedicle and large arrow showsthe retracted adductor longus muscle.
Figure 5.
Posterior retraction of the adductor longus mus-cle exposes the origin of the pedicle. Small arrow showsthe vascular pedicle, middle arrow shows the profundafemoris vessels, and large arrow shows the posterior re-tracted adductor longus muscle.
The Journal of Hand Surgery / Vol. 27A No. 3 May 2002
535

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