TECHNIQUE
Tips to Orient Pedicled Groin Flap for Hand Defects
Babu Bajantri, MS, MCh, Latheesh Latheef, MS, DNB,
and Shanmuganathan Raja Sabapathy, MS, MCh, DNB, FRCS, MAMS
Abstract: A groin flap is an axial-patterned cutaneous flap based on
the superficial circumflex iliac arteriovenous system, which can pro-
vide soft-tissue coverage to defects on any aspect of the hand and the
distal two thirds of the forearm. One of the presumed disadvantages of
the pedicled groin flap is the discomfort experienced by the patient
during the time required before flap division. These disadvantages can
be greatly reduced by proper planning to orient the flap toward the
defect, avoid any kinking at the base, and increasing the inset. We
present our technique of orienting the flap to fit to the defect to be
covered with ease. This technique avoids a lengthy flap and tubing,
increases the patients comfort, and also makes the division and inset of
the flap easier. As described, we have found this method simple and
easy to duplicate.
Key Words: pedicled, groin flap, key stitch, upper limb defect
(Tech Hand Surg 2013;17: 68–71)
HISTORICAL REVIEW
Introduction
The development of the groin flap was an important advance
made through our attempts at reconstruction of traumatic soft-
tissue defects.1 This flap based on the superficial circumflex
iliac artery was described in 1972 by McGregor and Jackson.
Later, McGregor and Jackson did extensive studies on groin
flap and described the origin of the vessel, its orientation
within the flap, and its variations.1,2 Chuang put forth a
simplified guideline based on the transverse diameter of the
patient’s index and middle finger at the distal interphalangeal
joint level, which he termed as the rule of “2-finger widths.”3
The rule guides in locating the origin of superficial circumflex
iliac artery vascular pedicle from the femoral vessels 2-finger
width below the inguinal ligament and a safe zone of flap
borders as 2-finger width above the inguinal ligament as the
upper border, as well as 2-finger width below the vascular
origin as the lower border. It helped in predicting the vascular
pedicle position in children and adults with primary closure of
the defect if the dimensions were within the prescribed
boundaries. Many authors advise tubing of the flap up to the
anterior superior iliac spine in order to avoid kinking of the
vessels, reducing the raw area on the pedicle, and facilitating
rehabilitation.4–7 However, tubing makes contouring of the
flap difficult, and, in addition, robust vascular territory can be
lost in tubing. To avoid these shortcomings, Mathes et al8
From the Department of Plastic Surgery, Hand, Reconstructive Micro-
surgery and Burns, Ganga Hospital, Coimbatore, Tamilnadu, India.
Conflicts of Interest and Source of Funding: The authors report no conflicts
of interest and no source of funding.
Address correspondence and reprint requests to Shanmuganathan Raja
Sabapathy, MS, MCh, DNB, FRCS, MAMS, Department of Plastic
Surgery, Hand, Reconstructive Microsurgery and Burns, Ganga
Hospital, 313, Mettuplayam Road, Coimbatore 641043, Tamilnadu,
India. E-mail: rajahand@vsnl.com.
Copyright r 2013 by Lippincott Williams & Wilkins
68 | www.techhandsurg.com Techniques in Hand & Upper Extremity Surgery
described a standard flap that could be transposed to the defect
with or without tubing and noted that a long back cut along the
inferior transverse incision over the inferior aspect of the
femoral triangle increased the flap’s arc of rotation.
Although free flaps have now become the standard of care
in many institutions, the pedicled groin flap continues to be
used extensively in many parts of the world. The pedicled
groin flap is also used as primary soft-tissue coverage before a
microsurgical procedure or as the salvage procedure if the free
flaps should fail. We present our experience whereby suitably
modifying the groin flap’s surgical technique, the flap ori-
entation can be changed so that the dorsal-sided, palmar-sided,
radial-sided, or ulnar-sided defects of the hand and forearm can
be comfortably covered and the morbidity can be greatly
reduced. We have also found that it helps in improving the
esthetic outcome.
TECHNIQUE
The defect dimensions are traced first using a lint piece. The
flap is planned on the groin with the base at the medial border
of the sartorious. An additional 2 to 3 cm is added to the total
length of the defect in order to allow mobility during the
postoperative period. We extend the incision of one of the
margins of the flap beyond the base on the basis of the location
of defect(s) of the hand to be covered, and the key stitch is
taken to orient the flap toward the defects.
For example, to cover the dorsal defect of the hand the
defect is traced (Fig. 1A) and the flap is marked (Fig. 1B). To
orient the flap superiorly, the superior incision is extended for a
distance of B to C, which is equal to the width at the base of
the flap A to B. Therefore, BC = AB and a key stitch (Fig. 1C)
is then taken from the edge of the inferior incision point A and
is stitched to the point B, thereby changing the orientation of
the flap superiorly (Fig. 1D). In this manner, the dorsal defect
can be easily covered (Fig. 1E).
If the flap is to cover the volar-sided defect of the hand
(Fig. 2A), the flap is marked (Fig. 2B) and the inferior incision
is extended for a distance of B to C, which is equal to the width
at the base of the flap from A to B. Therefore, BC = AB and a
key stitch (Fig. 2C) is then taken from the edge of the superior
incision point A and is stitched to a point B, thereby changing
the orientation of the flap inferiorly (Fig. 2D) to cover the volar
defects (Fig. 2E).
For the flap to cover the radial-sided defect(s) (Fig. 3A),
the inferior incision is extended for a distance of B to C, which
equals half the width at the base of the flap from point A to B
(Fig. 3B). So BC = 1/2 AB and a key stitch (Fig. 3C) is then
taken from the edge of the point A and is stitched to a point B,
thereby changing the orientation of the flap obliquely down-
ward (Fig. 3D).
For the ulnar defect(s), the superior incision is extended
for a distance of B to C, which equals half the width at the base
of the flap from point A to B. Therefore, BC = 1/2 AB
(Fig. 4A), and a key stitch (Fig. 4B) is then taken from the edge
 Volume 17, Number 2, June 2013
Techniques in Hand & Upper Extremity Surgery  Volume 17, Number 2, June 2013 Orienting Pedicled Groin Flap to Hand Defects

FIGURE 1. A, Clinical picture showing a dorsal defect on the left hand. B, The defect is traced and marked over the left groin and the
width of the base marked as AB, the superior extension is marked as BC, which equals AB. C, The key stitch is taken from point A to point
B. D, The flap orientation changed superiorly with no kink at the base. E, Flap inset performed on to the left-hand dorsal defect and the
hand is in comfortable position.

FIGURE 2. A, Clinical picture showing defect in the volar aspect of right index, middle, and ring finger with iliac crest bone grafts
replacing the lost phalanges and surgically syndactylized fingers. B, The defects traced and flap marked over the right groin. The width
of the base marked as AB, the inferior extension is marked as BC, which equals AB. C, The key stitch is taken from point A to point B.
D, The flap orientation is changed inferiorly. No kink at the base of the flap, no tubing. E, Flap inset performed covering the volar defects
of the right index, middle, and ring fingers.

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Bajantri et al Techniques in Hand & Upper Extremity Surgery  Volume 17, Number 2, June 2013

FIGURE 3. A, Clinical picture showing a radial soft-tissue defect over the right forearm. B, The flap is marked and elevated and the base
of the flap is marked as distance between point A and point B. An extension of the inferior incision was made up to point C. The distance
BC, which is equal to half of AB. C, The key stitch is taken from point A to point B, thereby turning the flap obliquely downward. D, The
final flap inset over the defect with no kinking at the base with comfortable hand position.

FIGURE 4. A, A flap marked for the ulnar defect of the right hand. The base of the flap is the distance between the point A and the point
B. An extension of superior incision is done from point B to point C, which is equal to half AB. B, The key stitch taken from point A to
point B turning the flap obliquely upward. C, The final position of the flap and the inset with no kink at the base and hand is in
comfortable position.

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Techniques in Hand & Upper Extremity Surgery  Volume 17, Number 2, June 2013
FIGURE 5. A, The straight line drawn along the base of the flap before division. B, The stage of flap division. There is no loss of skin. C,
The flap donor site leaves behind a good scar. D, The inset of the flap on the hand.
of the point A and is stitched to a point B, thereby changing the
orientation of the flap obliquely upward (Fig. 4C).
To summarize, for dorsal and volar defects, the extra-
length incision is made (B to C), which equals the width of the
flap at the base, and the key stitch is taken between the base
incision points (A to B). This will turn the flap by 90 degrees
and the pedicle of the flap will have no kink. For the ulnar and
radial defects, we need the flaps to orient obliquely by 45
degrees. Therefore, an extralength incision measuring half the
width (B to C) at the base is made beyond the base points of
the flap, and the key stitch is taken connecting the base points
(A to B).
The division and inset of the flap are performed by
making an incision at the base of the flap in line with the distal
wound (Figs. 5A–D).
RESULTS
In our unit, we perform around 200 groin flaps a year. The
above techniques are used in all cases where the donor defect
could be primarily closed. Even in patients where the size of
the flap will not allow primary closure of the donor area, the
principle of this technique is still used to orient the direction of
the flap.
ADVANTAGES OF THIS TECHNIQUE
When the flap is planned with tubing of the pedicle, the flap
needs to be long. The part of the flap that has good blood
supply is used as a bridge segment for tubing, and the part that
is inset to the defect is usually the random pattern of the flap.
The inherent nature of the tubing reduces the extent of inset. At
the time of division, the inset of the flap margin in the hand is
difficult because of the bulkiness at the end.
By following the technique that we have described, we
have been able to avoid tubing and a shorter bridge segment is
used. In this manner, the well-perfused part of the flap is used
to cover the defect. Inset of the flap both in the recipient and
r 2013 Lippincott Williams & Wilkins
Orienting Pedicled Groin Flap to Hand Defects
the donor sites is easy and esthetically better. The small
amount of raw area in the inner aspect of the pedicle does not
require a skin graft and can easily be closed.
CONCLUSIONS
The groin flap has been the workhorse for the coverage of hand
defects for a long period. Although the advent of free flaps has
altered the indications for the groin flap, it continues to be used
even in busy microsurgical centers. This refinement in the
standard technique helps to reduce the patient morbidity and
extend the usefulness of the flap.
REFERENCES
1. Masqulet AC, Gilbert A.. Historical review. In: Masqulet AC, Gilbert A,
eds. Atlas of Flaps in Limb Reconstruction. 1st ed. London: Martin
Duntiz Ltd; 1997:3–4.
2. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg. 1972;25:
3–16.
3. Chaung DCC, Colony LH, Chen HC, et al. Groin flap design and
versatility. Plast Reconstr Surg. 1989;84:100–106.
4. Masqulet AC, Gilbert A. Groin flap In: Masqulet AC, Gilbert A, eds?
Atlas of Flaps in Limb Reconstruction. 1st ed. London: Martin Duntiz
Ltd.; 1997:223–225.
5. Pederson WC. Nonmicrosurgical coverage of the upper extremity. In:
Wolfe SW, Hotchkiss RN, Pederson WC, et al, eds. Green’s Operative
Hand Surgery. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone;
2011:1699–1705.
6. Knuston HK. The groin flap: a new technique to repair traumatic tissue
defects. Can Med Assoc. 1977;116:623–625.
7. Smith PJ, Foley B, McGregor IA, et al. The anatomical basis of the
groin flap. Plast Reconstr Surg. 1972;49:41–45.
8. Mathes S, Nahai F. Groin flap. In: Mathes S, Nahai F, eds.
Reconstructive Surgery Principles Anatomy and Technique. 2nd ed.
Churchill: Livingstone Inc; 1997:10015–10018.
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