Reconstrucción escrotal con colgajo pediculado del músculo gracilis bilateral e injerto de piel parcial / Scrotal reconstruction with bilateral gracilis muscle pedicled flap and split-thickness skin graft

Los defectos en la región escrotal son producidos en la mayoría de los casos por la gangrena de Fournier, y en ocasiones por traumatismo o patologías oncológicas. Estas heridas generan mucha dificultad para el desarrollo de una vida normal a los pacientes que lo padecen; por lo general producen dolor, los testículos quedan desprotegidos y la espermatogénesis puede verse alterada. Actualmente no existe un método estándar de reconstrucción escrotal, y las técnicas tradicionalmente utilizadas no ofrecen una cobertura funcional ni estética. Generalmente producen mucho abultamiento en la región genital, que puede dificultar el movimiento de las piernas y el uso de pantalones. En este trabajo se expone una opción quirúrgica para reconstruir el escroto, por medio del colgajo pediculado de músculo gracilis bilateral e injerto de piel parcial. Para tal efecto, se presenta un caso clínico de un paciente de 64 años con secuelas en la región perineal, posterior a una gangrena de Fournier. El paciente presentaba una pérdida total del escroto y exposición de ambos testículos. El método arriba mencionado es una opción válida para reconstruir el escroto y en este trabajo se describe la técnica empleada de forma detallada, donde se puede apreciar que presenta escasas complicaciones y es fácil de reproducir por un cirujano plástico entrenado.

Defects in the scrotal region are caused in most cases by Fournier's gangrene, and sometimes by trauma or oncological pathologies. These wounds generate difficulties for the development of a normal life; They usually produce pain; the testicles are unprotected and spermatogenesis can be altered. Currently there is no standard method of scrotal reconstruction, and the techniques traditionally used do not offer functional or aesthetic coverage. They generally produce a big bulge in the genital region, which can make it hard to move the legs and wear pants. A surgical option is exposed to reconstruct the scrotum, by means of the bilateral gracilis muscle pedicled flap and split-thickness skin graft. For this purpose, a clinical case of a 64-year-old patient with sequelae in the perineal region, after Fournier's gangrene, is presented. The patient presented a total loss of the scrotum and exposure of both testicles. The method mentioned above is a valid option to reconstruct the scrotum and the technique used is described in detail, where it can be seen that it is easy to reproduce by a trained plastic surgeon.

A biomechanical comparison of matched four-strand and five-strand semitendinosus-gracilis grafts / Estudo biomecânico comparativo entre enxertos quádruplos e quíntuplos pareados de tendões dos músculos semitendíneo e grácil / Estudio biomecânico comparativo entre injertos de tendones semitendinoso e gracilis cuádruple e quíntuple

ABSTRACT Introduction: Recent studies have shown that the likelihood of semitendinosus-gracilis graft rupture is inversely correlated to its diameter. A graft can be prepared in a five-strand or four-strand fashion to increase its diameter. However, the biomechanical superiority of five-strand semitendinosus-gracilis grafts is still under debate. Objective: This study aimed to evaluate the biomechanical characteristics of matched four-strand and five-strand human semitendinosus-gracilis grafts. Methods: We evaluated semitendinosus-gracilis tendons harvested from ten fresh human male and female cadavers, aged 18-60 years. Four-strand or five-strand grafts were prepared with the tendons and fixed to wooden tunnels with interference screws. Each graft was submitted to axial traction at 20 mm/min until rupture; the tests were donor matched. Data were recorded in real time and included the analysis of the area, diameter, force, maximum deformation and stiffness of the grafts. Results: The diameter, area and tunnel size were significantly greater in the five-strand grafts than in the four-strand grafts. There were no significant differences in biomechanical properties. The area and diameter of the graft were positively correlated to stiffness, and inversely correlated to elasticity. There was no significant correlation between graft size and maximum force at failure, maximum deformation or maximum tension. Conclusion: Five-strand hamstring grafts have greater area, diameter and tunnel size than four-strand grafts. There were no significant differences in biomechanical properties. In this model using interference screw fixation, the increases in area and diameter were correlated with an increase in stiffness and a decrease in elasticity. Level of evidence V; biomechanical study.

RESUMEN Introducción: Estudios recientes demostraron que la probabilidad de ruptura de los injertos semitendinoso y gracilis (STG) durante el pos operatorio de reconstrucción de ligamento cruzado anterior (LCA) está inversamente correlacionada a su diámetro. Un injerto puede ser preparado para obtener cuatro o cinco hebras para aumentar su diámetro, pero la superioridad biomecanica de los injertos STG de cinco hebras aún se mantiene en discusión. Objetivo: Evaluar las características biomecánicas de los injertos STG de humanos de cuatro o cinco hebras por pares. Métodos: Fueron evaluados tendones STG de diez cadaveres masculinos y diez cadaveres femeninos frescos, entre los 18 y 60 años. Los injertos de cuatro y cinco hebras fueron fijados en túneles de madera con tornillos de interferencia. Cada injerto fue sometido a una tracción axial de 200mm/min hasta su ruptura; estos tendones fueron separados por pares de acuerdo con sus donadores. Los datos fueron registrados en tiempo real y incluyeron el análisis del área del injerto, diámetro, fuerza, deformación máxima y rigidez. Resultados: Los resultados sobre el diámetro, el área y el tamaño del túnel fueron significativamente mayores en los injertos de cinco hebras que en los de cuatro. No existieron diferencias significativas en las propiedades biomecánicas. El área y el diámetro del injerto fueron correlacionados positivamente con la rigidez e inversamente con la elasticidad. No existió correlación significativa entre el tamaño del injerto y la fuerza máxima al momento de la falla, Máxima deformación o máxima tensión. Conclusión: Los injertos de isquiotibiales de cinco hebras tienen una área, diámetro y tamaño de túnel más grande que los injertos de cuatro hebras. No hubieron diferencias biomecánicas significativas. Los aumentos de área y diámetro en este modelo con la fijación de tornillo de interferencia fueron correlacionados con aumento de en la rigidez y una disminución en la elasticidad. Nivel de evidencia V; estudio biomecánico.

RESUMO Introdução: Estudos recentes demonstraram que a probabilidade de ruptura do enxerto dos tendões do semitendíneo e do grácil (STG) é correlacionada inversamente com seu diâmetro. Um enxerto pode ser preparado de forma quádrupla ou quíntupla para se aumentar o diâmetro. No entanto, a superioridade biomecânica dos enxertos STG quíntuplos ainda está em debate. Objetivo: Este estudo teve como objetivo avaliar as características biomecânicas dos enxertos STG humanos quádruplos ou quíntuplos pareados. Métodos: Foram avaliados tendões STG retirados de dez cadáveres masculinos e femininos frescos, com idades entre 18 e 60 anos. Os enxertos quádruplos ou quíntuplos foram preparados com os tendões e fixados em túneis de madeira com parafusos de interferência. Cada enxerto foi submetido à tração axial a 20 mm/min. até a ruptura; os testes foram pareados de acordo com os doadores. Os dados foram registrados em tempo real e incluíram a análise de área, diâmetro, força, deformação máxima e rigidez dos enxertos. Resultados: O diâmetro, a área e o tamanho do túnel foram significativamente maiores nos enxertos quíntuplos do que nos enxertos quádruplos. Não houve diferenças significativas nas propriedades biomecânicas. A área e o diâmetro do enxerto foram correlacionados positivamente com a rigidez e inversamente com a elasticidade. Não houve correlação significativa entre o tamanho do enxerto e a força máxima na falha, deformação máxima ou tensão máxima. Conclusão: Os enxertos quíntuplos dos músculos isquiotibiais têm maior área, diâmetro e tamanho do túnel do que os enxertos quádruplos. Não houve diferenças significativas nas propriedades biomecânicas. Neste modelo de fixação com parafuso de interferência, aumentos da área e do diâmetro foram correlacionados com o aumento da rigidez e a diminuição na elasticidade. Nível de evidência V; Estudo Biomecânico.

Biometría del músculo grácil: pedículos vasculares e inervación en un grupo de individuos brasileños / Biometric characteristics of the gracilis muscle: vascular pedicles and innervation in a group of Brazilian individuals

El músculo grácil (MG) está ubicado en la cara medial del muslo, medial y posterior al aductor largo en su parte proximal. Se origina a nivel del pubis y se inserta en la cara medial de la tibia, en su parte superior. Como colgajo libre funcional ha sido uno de los injertos más utilizados en reconstrucciones diversas, tales como pene, perineo, vagina, pierna, plexo braquial, parálisis facial, lesiones rectales, entre otras. Basado en lo anterior, el objetivo de este estudio fue complementar la anatomía del MG tanto en sus dimensiones como en sus pedículos vasculares e inervación, estableciendo las relaciones biométricas existentes, contribuyendo a la anatomía quirúrgica, en su uso como injerto. Para ello, se utilizaron 30 miembros inferiores de 20 cadáveres de individuos adultos, brasileños, de sexo masculino, 14 derechos y 16 izquierdos; 17 fijados en formol y 13 en glicerina. Se dividió al muslo en 4 cuartiles enumerados de proximal a distal como C1,C2,C3 y C4. Se contabilizó el número de pedículos y se nombraron como pedículo principal (PP), pedículo menor 1 (Pm1), pedículo menor 2 (Pm2) y pedículo menor 3 (Pm3). La longitud media del GM fue de 42,25 cm ± 2,35 cm y su ancho promedio de 32,90 ± 4,86 mm. Con respecto a los pedículos vasculares se encontró un pedículo en 10/30 casos (33,3 %); un pedículo principal y uno menor en 10/30 (33,3 %); un pedículo principal y dos menores en 8/30 (26,7 %) y un pedículo principal y tres menores en 2/30 (6,7 %). Su inervación siempre procedió del ramo anterior del nervio obturador (RaNO). El punto motor se encontró a una distancia promedio de 7,94 mm proximal al ingreso del pedículo principal en el MG. Los registros biométricos están expresados en tablas. Los resultados obtenidos aportarán al conocimiento anatómico, pudiendo ser utilizados como soporte morfológico a los procedimientos quirúrgicos que involucren al músculo grácil.

The gracilis muscle (GM) is located in the medial aspect of the thigh, medial and posterior to the long adductor in its proximal part. It originates at the pubic level and is inserted in the medial face of the tibia, in its upper part. As a functional free flap, it has been one of the most co mmonly used grafts in various reconstructions, such as penis, perineum, vagina, leg, brachial plexus, facial paralysis, rectal lesions, among others. Based on the above, the objective of this study was to complement the anatomy of the GM both in its dimensions and in its vascular pedicles and innervation, establishing the existing biometric relationships, contributing to the surgical anatomy, in its use as a graft. For this, 30 lower limbs of 20 bodies of adult, Brazilian, male, 14 right and 16 left individuals were used; 17 fixed in formaldehyde and 13 in glycerin. The thigh was divided into 4 quartiles listed from proximal to distal such as C1, C2, C3 and C4. The number of pedicles was counted and they were named as principal pedicle (PP), minor pedicle 1 (mP1), minor pedicle 2 (mP2) and minor pedicle 3 (mP3). The average length of the GM was 42.25 cm ± 2.35 cm and its average width was 32.90 ± 4.86 mm. With respect to vascular pedicles, a pedicle was found in 10/30 cases (33.3 %); one PP and one mP in 10/30 (33.3 %); one PP and two mP in 8/30 (26.7 %) and one PP and three mP in 2/30 (6.7 %). Its innervation always came from the anterior branch of the obturator nerve (aBON). The motor point was found at an average distance of 7.94 mm proximal to the entry of the PP in the GM. Biometric records are expressed in tables. The results obtained will contribute to anatomical knowledge, and can be used as morphological support for surgical procedures that involve the GM.

Application of free gracilis transplantation in reconstruction of traumatic limb / 中华创伤骨科杂志

Functional reconstruction of a major injured nerve or muscle group in a destructive limb caused by high energy has always been a big problem for trauma orthopedists.When no local tendon,muscle or nerve is available for transference,functional free muscle transplantation (FFMT) is an ideal functional reconstruction method for severe limb injury characterized by definite curative effect and quick recovery.Gracilis is considered to be an ideal donor site for FFMT because of its anatomic features of long tendon,good excursion,stable blood supply,long neurovascular pedicle,shaded donor site,little donor site loss and sufficient nourishment of the whole musculocutaneous flap by anastomosis of one single major pedicle.It has been widely applied in clinics.Transplantation of single free gracilis flap,double free gracilis flaps,and adductor longus-gracilis flap with single pedicle anastomosis can meet different clinical applications.The best donor motor nerve,which is critical to functional restoration of the affected limb using FFMT,is always a major concern to many scholars.This paper focuses on the advances in functioning free gracilis transplantation in reconstruction of limb motor function,applied anatomy of the gracilis and application of functional reconstruction for major nerve injury and major muscle group defects in a destructive limb,hoping to provide useful information for wider clinical application of FFMT.

An Anatomical Study Of Gracilis Muscle & Its Role In Clinical Reconstruction Surgeries

Introduction: It is the most superficial of the adductor group of muscles. Gracilis muscle is used oftenly inreconstructive plastic surgery,because ofits reliable vascular and neurological pedicles and the minimal donorsite morbidity.Materials and Methods: The present study was conducted on 40 cadaveric lower limbs (22 males and 18 females)in the Deptartment of Anatomy of VIMS&RC.Metrical and non-metrical characteristics of gracilis muscle andvascular pedicles were analyzed.Results: All the parameter were more in males compared to females. distal tendon length was more than proximaltendon length. P value was significant in all the measurements. The ratios between various components ofmuscle remain fairly constant. Main vascular primary pedicle was arising from profund femoral artery in 60 %& 40% from Medial circumflex femoral artery .Presence of proximal secondary pedicle was only in 30% of thespecimens arising from profunda femoral artery or Medial circumflex femoral artery. Distal secondary pediclesarising from 5% of femoral artery.Conclusion: These parameters will help the reconstructive surgeon in assessing the length of muscle belly ortendon available for reparative procedures before undertaking surgery like Anterior Cruciate Ligament graft,Restoration of sphincteric function in anogenital area, Repair of ano-vaginal or recto-vaginal fistulas, Facialrehabilitation, Upper limb and lower limb defects, Groin wounds and autologous breast reconstruction.

A rare approach? Microsurgical breast reconstruction after severe burns

Breast deformity, in post-burn patients, is a common problem leading to lower self-esteem and reclusive behavior that impairs quality of life. The authors present the course of treatment of an 18-year-old immigrant girl who suffered second- to third-degree burns over approximately 20% of her total body surface area in her early childhood. The second- to third-degree burns were located on her right trunk and abdomen, as well as her right shoulder, neck, and right groin area. Since it was not offered in her home country, reconstructive surgery, including microsurgical breast reconstruction, was sought abroad. Due to the lack of available skin and soft tissue, a bilateral breast reconstruction with free transverse myocutaneous gracilis flaps was offered. This case illustrates one method of using microsurgery to address post-burn breast deformities in order to alleviate psychological suffering and improve quality of life.

Demonstration of intramuscular artery and nerve distribution in the same whole mount gracilis muscle by different colors / Demostración de la distribución intramuscular de la arteria y nervio del músculo grácil mediante diferentes colores

The goal of this study was to describe the intramuscular artery and nerve distribution in detail by different colors in the same whole mount gracilis muscle. Red latex injection into the external iliac artery was performed on 14 fresh human cadavers. Two weeks later, 28 gracilis muscles were harvested from the cadavers and during this course the number of the arterial pedicle of each specimen was counted. Then, the muscle specimens were fixed in 10 % formalin 4 weeks for fixation and Sihler's staining procedures was performed on each muscle specimens. After all of the procedures, the gracilis muscle appeared almost transparent, and the extra- and intramuscular artery and nerve branches, even the terminals, were clearly demonstrated in red and dark blue separately. Two of the 28 specimens were supplied by a single main arterial pedicle alone, 14 specimens by a main arterial pedicle and an accessory pedicle, 8 specimens by a main pedicle and 2 accessory pedicles, while 4 specimens by a main arterial pedicle and 3 accessory pedicles. Although the number of the arterial pedicles was inconsistent, the intramuscular artery branches anastomosed with each other and formed a whole arterial system in all specimens. The nerve innervating the gracilis muscle divided into two or three major branches, which directed distally and innervated the distal two thirds of the muscle, while running longitudinally and parallel to the muscle fibers. We found the innervation pattern was remarkably consistent from specimen to specimen. This study provided very detailed and useful information for anatomists, physiologists and reconstructive surgeons. Furthermore, we here also provided a new method to demonstrate the intramuscular artery and nerve distribution in the same whole mount muscle by different colors for other researchers to refer to.

El objetivo de este estudio fue describir en detalle la distribución intramuscular de la arteria y el nervio del músculo grácil por diferentes colores en un solo montaje. Se realizó inyección de látex rojo en la arteria ilíaca externa en 14 cadáveres humanos frescos. Dos semanas más tarde se retiraron 28 músculos grácil de los cadáveres y se realizó un conteo del número de pedículos arteriales de cada muestra. Las muestras de músculo se fijaron en formalina al 10 % durante 4 semanas para los procedimientos de tinción de Sihler. Al término de todos los procedimientos, el músculo grácil parecía casi transparente, y las ramas extra e intramusculares de las arterias y los nervios, incluso los terminales, se observaron en azul y rojo oscuro por separado. Dos de los 28 especímenes presentaron por pedículo arterial principal único, 14 muestras un pedículo arterial principal y un pedículo accesorio, 8 de las muestras un pedículo principal y dos pedículos accesorios, mientras que 4 muestras un pedículo arterial principal y tres pedículos accesorios. Aunque el número de los pedículos arteriales era inconsistente, las ramas de la arteria intramuscular se anastomosaban entre sí y formaban un sistema arterial conjunto en todos los especímenes. El nervio que inerva el músculo grácil se encontró dividido en dos o tres ramos principales, dirigidos distalmente e inervaron los dos tercios distales del músculo, mientras que otro discurre longitudinalmente y en paralelo a las fibras musculares. Encontramos que el patrón de inervación fue notablemente consistente de un espécimen a otro. Este estudio proporciona información muy detallada y útil para los anatomistas, fisiólogos y cirujanos. Además, también se proporcionó un método innovador para demostrar la distribución intramuscular de la arteria y el nervio en un mismo músculo, entero, y con diferentes colores.

An Anatomical Study of Gracilis Muscle and its Vascular Pedicles.

Background: Gracilis muscle being easily accessible and functionally a weak muscle is suitable for muscle graft to replace the damaged muscle in any part of the body. The length of the muscle, vascular pedicles and limited donor site morbidity helps the surgeon to plan accordingly. The muscle receives a number of vascular pedicles ranging from one to five. The source of these pedicles varies. Material and Methods: The study was conducted on 36 formalin fixed lower limbs of both sexes of unknown age from the department of Anatomy, BMCRI, Bangalore. Results and Discussion: In 75% of limbs two vascular pedicles were seen penetrating the muscle at different levels and in 25% accessory pedicles were seen in the lower 2/3rd of the muscle. Conclusion: The findings suggest that the first vascular pedicle to the muscle is always constant in position accompanied by its venae comitans and branch from obturator nerve and is placed at a distance of 10.5cms±2cms from the pubic tubercle.

Flow-through anastomosis using a T-shaped vascular pedicle for gracilis functioning free muscle transplantation in brachial plexus injury

OBJECTIVE: In gracilis functioning free muscle transplantation, the limited caliber of the dominant vascular pedicle increases the complexity of the anastomosis and the risk of vascular compromise. The purpose of this study was to characterize the results of using a T-shaped vascular pedicle for flow-through anastomosis in gracilis functioning free muscle transplantation for brachial plexus injury. METHODS: The outcomes of patients with brachial plexus injury who received gracilis functioning free muscle transplantation with either conventional end-to-end anastomosis or flow-through anastomosis from 2005 to 2013 were retrospectively compared. In the flow-through group, the pedicle comprised a segment of the profunda femoris and the nutrient artery of the gracilis. The recipient artery was interposed by the T-shaped pedicle. RESULTS: A total of 46 patients received flow-through anastomosis, and 25 patients received conventional end-to-end anastomosis. The surgical time was similar between the groups. The diameter of the arterial anastomosis in the flow-through group was significantly larger than that in the end-to-end group (3.87 mm vs. 2.06 mm, respectively, p<0.001), and there were significantly fewer cases of vascular compromise in the flow-through group (2 [4.35%] vs. 6 [24%], respectively, p=0.019). All flaps in the flow-through group survived, whereas 2 in the end-to-end group failed. Minimal donor-site morbidity was noted in both groups. CONCLUSIONS: Flow-through anastomosis in gracilis functioning free muscle transplantation for brachial plexus injury can decrease the complexity of anastomosis, reduce the risk of flap loss, and allow for more variation in muscle placement. .

Gracilis Muscle Free Flap Transplantation Followed Up Over 10 Years

PURPOSE: Gracilis muscle free flap transplantation is chosen in the medium sized soft tissue defect and bone exposure from trauma and chronic osteomyelitis in the lower extremity. We set a study to search for gracilis free flaps to know whether symptoms were cured or recurred in patients that have passed over 10 years from flap transplantation. MATERIALS AND METHODS: From August 1995 through September 2010, we have performed 28 cases of gracilis muscle free flap in the lower extremities. Ever since no case visited to demand any discomfort, breakdown or recurrence in the flap site on outpatient basis. We made a telephone call to patients or relatives documented in the medical record and only 2 cases visited outpatient department and 9 cases postponed the visit who satisfied with the final result but 17 cases had wrong telephone numbers. Causes, area of lower extremity, recipient vessels in the lower extremity, condition of the donor thigh and overall satisfaction of the flap transplantation in activities of daily living were investigated and written down in the medical record. RESULTS: 11 cases were reviewed after average postoperative 13.7 years. Gracilis muscle flaps were not break down at the recipient site in all cases. The wound of donor thigh wound healed good and overall activities of daily living was satisfied in all cases. CONCLUSION: Gracilis muscle flaps which had performed and followed up average 13.7 years revealed confident in the medium sized soft tissue defect and bone exposure from trauma and chronic osteomyelitis in the lower extremity.

Interposición de músculo gracilis para reparar fístulas ano y rectovaginales recurrentes / Transposition of gracilis muscle for treatment of recurrent anal and rectovaginal fistula

Introducción: La fistula rectovaginal por definición es la que comunica la región anorrectal hacia la pared posterior de la vagina, como resultado de enfermedad inflamatoria intestinal, lesión iatrogénica, malignidad y trauma. El tratamiento depende de la clasificación de la fístula (simple o compleja). Existen a la fecha pocas publicaciones acerca del uso de la interposición del músculo gracilis como tratamiento factible y seguro para las fístulas rectales, vaginales y uretrales. Casos clínicos: En este artículo presentamos la experiencia inicial en tres pacientes a quienes se les realizó interposición del músculo gracilis, en el Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, centro médico de tercer nivel en la ciudad de México. Conclusiones: El uso de músculo gracilis para reparar fístulas rectovaginales y anorrectales complejas es aplicable en nuestro medio si bien debe limitarse a fístulas recurrentes, después de haber fracasado con otros procedimientos.

BACKGROUND: Rectovaginal fistula is defined as a result of an abnormal connection between the rectum and vagina. It is often a result of inflammatory bowel disease, iatrogenic illness, malignancy or trauma. Rectovaginal fistula treatment is dependent on the classification of the fistula (simple or complex). There are few reports on transposition of gracilis muscle as a feasible option for treatment of rectal, vaginal and urethral fistula. CLINICAL CASES: We present the first three case experiences from the Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran," a tertiary-care medical center in Mexico City. CONCLUSIONS: Gracilis muscle transposition is a feasible procedure in our population for treatment of recurrent rectovaginal and anorectal fistulas.

Operación de Pickrell o graciloplastía no estimulada: ¿Tiene un rol en el manejo quirúrgico actual de la incontinencia anal severa? / Non stimulated gracilis muscle transposition for fecal incontinence: non stimulated graciloplasty (Pickrell's operation): does it play a role to day in the management of the severe anal incontinence?

Pickrell procedure or non stimulated gracilis muscle transposition is used for the management of severe fecal incontinence. We report four males and one female, aged 6 to 68 years, with severe incontinence, that were operated. Surgical complications were wound dehiscence in two patients, a deep venous thrombosis in one patient and chronic pain in the zone of muscle insertion in one patient. There was an improvement in the voluntary contraction pressure of the sphincter in four of five patients and a significant reduction in the incontinence score.

Se presenta la casuística de Operación de Pickrell o graciloplastía no estimulada realizada por uno de los autores (CJB). Se analizan sus indicaciones, técnica, complicaciones, manejo postoperatorio y resultados. Se presentan 5 pacientes (4 hombres y una mujer) operados por incontinencia anal severa, realizándose una graciloplastía no estimulada u operación de Pickrell. Las principales complicaciones fueron dehiscencia cutánea en 2 pacientes, trombosis venosa profunda y dolor crónico de la zona de desinserción en un caso. No hubo mortalidad. En el postoperatorio se envió a estimulación eléctrica del gracilis. Se evaluó la presión del esfínter con manometría anorrectal pre y postoperatoria. La incontinencia fue medida con la escala de Jorge y Wexner. En esta serie, hubo mejoría significativa de la Presión de Contracción Voluntaria y disminución significativa del puntaje de incontinencia. La graciloplastía es alternativa a una ostomía definitiva o al implante de un esfínter artificial en aquellos pacientes en que la incontinencia anal severa no es posible de manejar con técnicas habituales (esfinteroplastía), que fracasaron a la esfinteroplastía, o que presentan inexistencia de esfínter o de una lesión anatómica que reparar.

Comparative Study of the Latissimus Dorsi and Gracilis Muscle Reconstruction for Reanimation of a Paralyzed Face

PURPOSE: The most accepted method for the reanimation of a paralyzed face is the two-stage method that combines cross-face nerve grafting with free-muscle transfer. Although the results of reconstruction with this method are satisfactory, there is an excessive delay between the stages, which prolongs the period of rehabilitation. In order to overcome this drawback, a one- stage, neurovascular free-flap reconstruction method using free neurovascular muscle flaps is introduced. METHODS: From 1994 to 2004, 35 patients with longstanding facial palsy were treated. Fifteen patients underwent the single-stage reconstruction with the latissimus dorsi muscle, and 20 patients underwent the two-stage reconstruction method with the gracilis muscle. We compared the long-term results of the two methods of reconstruction. The mean follow-up period was 28.7 months for one-stage reconstruction, and 35.2 months for the two-stage, respectively. RESULTS: In the patient group of the single stage reconstruction, both mouth corner excursion and animation grade were markedly improved at the final postoperative visit. Moreover, the first muscle contraction occurred earlier in this group, than in the two-stage reconstruction group. However, four patients in the single stage group never achieved a first muscle contraction or mouth corner excursion. CONCLUSION: Facial palsy is a very challenging condition for cosmetic surgeons to deal with. Traditional methods for treatment of chronic facial palsy use a two- stage muscle flap which is time-consuming and burdensome to patients, many of whom are averse to waiting 8 to 12 months to complete the two stages. The one- stage reconstruction method described herein uses a atissimus dorsi free-flap and has demonstrated consistent positive outcomes in clinical assessments.

The Therapeutic Effect of Perineal Urethroplasty using a Gracilis Muscle Flap in a Recurrent Complete Posterior Urethral Stricture / 대한비뇨기과학회지

PURPOSE: To evaluate the usefulness of a gracilis muscle flap for the reconstruction of a complete posterior urethral stricture, where previous treatment had failed. MATERIALS AND METHODS: Between March 1998 and April 2006, 56 patients, in whom previous urethroplasty or visual internal urethrotomy had failed, were treated with a gracilis muscle flap. All patients had been referred from other institutions. Of the 56 treated patients, 32(group I) underwent perineal urethroplasty, using a stepwise approach of urethral mobilization, including bulbar urethra mobilization, separation of the corporal bodies, inferior pubectomy and retrocrural urethral re-routing 24(group II) underwent perineal urethroplasty, with a gracilis muscle flap for replacement of the dead space, using a stepwise approach. RESULTS: The mean stricture lengths were 2.7(0.5-5.5) and 3.5cm(1.0-6.5) in groups I and II, respectively(p=0.135). The success rates were 87.5 and 95.8% in groups I and II, respectively(p=0.279). The success rates of patients with urethral stricture of greater than 3cm were 71.4 and 100% in groups I and II, respectively(p=0.037). The success rates of patients who had undergone previous perineal urethroplasty were 82.6 and 100% in groups I and II, respectively(p=0.045). A gracilis muscle flap made no difference to the incidences of erectile dysfunction and incontinence. The incidences of restricture were 15.6 and 0% in groups I and II, respectively (p=0.042). CONCLUSIONS: Our results showed that a gracilis muscle flap can be useful method with a stricture greater than 3cm in length and in patients having undergone previous perineal urethroplasty.

Transversely Dividing Gracilis Muscle Free Flap for the Simultaneous Reconstruction of Two Anatomically Distant Defects

Free muscle flap for the simultaneous coverage of two anatomically distant sites has previously entailed the harvest of tissue from separate donor areas, Although it may be possible to achieve this goal with a variety of available donor site, the transfer of a single donor muscle to two different sites has been considered. The gracilis muscle is commonly usef by reconstructive surgeon in a variety of application as pedicled muscle or musculocutaneous flap and as a free tissue transfer for soft tissue coverage or a functioning muscle transfer. The gracilis muscle is classified as having a type II blood supply that anatomy is reliable. The main arterial supply to the gracilis muscle is a branch of the profunda femoris, which enters the muscle 10+/-1cm from its attachment to the pubis on its deep(lateral) surface. The distal portion of muscle between the main arterial pedicle and musculotendinous junction is supplied by one to three small arterial branches of the superficial femoral artery. The first minor pedicle located approximately 20 cm from the pubis. In 1990 Tadeusz reported the successful treatment of patient with bilateral calcaneal fractures and posttraumatic osteomyelitis using a longitudinal single split free gracilis muscle transfer. In 2001 We performed a transversely dividing gracilis muscle free flap in the patient with two soft tissue defects and osteomyelitis in anterior tibial region and foot.

Anthropometric Study on Neurovascular Supply of the Gracilis Muscle in Korean / 체질인류학회지

Gracilis muscle, the most superficial to the adductor groups of muscles in the thigh, is widely used to make musculo-cutaneous flap because this muscle has several advantages; 1) Removal of the muscle does not elicit any functional deficit, 2) It is easy to make a flap, 3) It is able to make flaps of various sizes in according to the size of the wound. This study demonstrates the characteristics of the arterial supply of the gracilis muscle for flap. Total 102 thighs from 51 Korean cadavers (32 males/ 19 females), clinically normal and without deformity, were dissected and length and width of gracilis muscles were measured. The pattern of distribution of the arteries supplying the muscle were studied, and entering point of each arteries to the muscle were located in according to following point; A: Pubic tubercle, B: Medial condyle of femur and tibia on gracilis muscle. 1. The average width of gracilis muscle were 31.9 +/-8.1 mm. The length of female subjects was significantly shorter than that of male subjects. 2. Arteries supplying the gracilis muscle were obturator artery (11.0%), medial circumflex femoral artery (100%), first muscular branch of femoral artery (100%), second muscular branch of femoral artery (45.2%), third muscular branch of femoral artery (17.8%), and popliteal artery (9.6%). 3. Medial circumflex femoral artery had 1 -10 pedicles and divided into ascending, transverse and descending branches. The existence of ascending branches were 14.8%, the ascending and descending branches were 22.7%, the ascending, transverse and descending branches were 22.7%, the transverse and descending branches were 22.0%, and the only descending branches were 22.0%. 4. The frist muscular branch of femoral artery pierced the gracilis muscle at a distance which represented 61.9 +/-12.8% of the length from A to B. The external diameter were 1.4 +/-0.4 mm. 5. Obturator nerves reached the gracilis muscle at a distance which represented 29.0 +/-7.4% of the length from A to B. The maximum external width and length were 1.0 +/-0.4 mm and 59.7 +/-25.0 mm, respectively. In conclusion, the length and width of the gracilis muscle in Korean were different depending on gender. These data also provides the anatomical characteristics of the arterial supply of the gracilis muscle in Korean in clinical relevance with musculocutaneous flap

Scrotal Reconstruction by the Gracilis Muscle Flap Following Fournier's Gangrene

Fournier's gangrene is life-threatening disease characterized by abrupt onset of a rapidly progressive necrotizing soft tissue infection involving the perineum and scrotum. In Fournier's original descriptions, the disease arose in healthy subjects without an obvious cause. Despite controversy still surrounds its etiology, current studies identify definite urologic and colorectal causes with its combined disease in a majority of cases. We experienced cases of large scrotal and perineal defect caused by Fournier's gangrene. Aggressive and extensive debridement with a parenteral broad spectrum antimicrobial agents was executed at the important points to the treatment. The patient also received adjuvant hyperbaric oxygen therapy. The clinical efficacy of hyperbaric oxygen was discussed. After control of infection and unavoidable loss of soft tissue, the major concern following Fournier's gangrene lies on the protection of the testicles and adequate volumetric scrotal appearance. The defect was successfully reconstructed with unilateral or bilateral gracilis muscle flap transposition and split- thickness skin graft. We present this article utilizing bilateral gracilis muscle flaps as an acceptable alternative in the approach to scrotal reconstruction in Fournier's gangrene.

Repair of Complicated Posterior Urethral Stricture Using Inferior Pubectomy and Gracilis Muscle Flap / 대한비뇨기과학회지

PURPOSE: To evaluate the usefulness of an inferior pubectomy and a gracilis muscle flap for the reconstruction of a complicated posterior urethral stricture, where urethroplasty had failed, or due to a long urethral defect. MATERIALS AND METHODS: A total of sixty eight patients with complicated posterior urethral strictures, following a pelvic bone fracture, were managed by a one-stage perineal repair at Pundang CHA hospital between March 1998 and April 2002. End-to-end anastomosis was performed in all cases, with corporeal body separation, or an inferior pubectomy and transposition of the gracilis muscle flap performed in a progressive manner if required. RESULTS: The success rate of all the cases was 95.6%. Additional procedures made no differences to the incidence of impotence, and the incidences of restricture and incontinence were low. CONCLUSIONS: Our results shows that an inferior pubectomy and a gracilis muscle flap can be useful methods in the treatment and prevention of incontinence and restricture in most cases of complicated posterior urethral strictures.

Long-term follow-up of gracilis muscle transposition in children

Sixteen children of uncontrollable fecal incontinence have been treated with Pickrell's gracilis muscle transposition since 1983: 12 had an imperforate anuses with multiple corrective operative procedures and 4 had traumatic destructions of anal sphincters. We report a series of 11 cases whom we followed-up over a period of 0.8 to 10.5 years (mean; 5.6 years). Seven patients were evaluated by anorectal manometry. All patients except one who had left hemipelvectomy and permanent colostomy showed nearly normal continence during the follow-up period. There was no evidence of fibrosis in the transposed muscles and the tensions of the transposed muscles were well maintained. The voluntary contractions of the transposed muscles were well maintained and efficient in all cases. The general manometric parameters did not correlate well with the functional results; however, there was a strong correlation in the S/R ratio (maximum squeeze pressure/resting pressure) with the functional results. We believe that the good functional outcome of this procedure need not only the meticulous surgical technique but also the personal motivation and the compliance with physiotherapy. In conclusion, although the gracilis muscle transposition never results in normal continence, acceptable continence can be achieved in the selected patients.

2 Cases of Female Lower Urinary Tract Fistula Treated with Gracilis Muscle Flap / 대한비뇨기과학회지

The successful closure of a fistula clearly involves application of spectrum of techniques depending variable factors. There was variety of opinions regarding the timing and optimum surgical technique for repair of fistula. Several muscles and myocutaneous flaps are applicable to a variety of tissue defects. The gracilis muscle is especially useful as adjuncts for wound coverage, vaginal or penile reconstruction and as interpositional tissue for the closure of various fistulas. We experienced two cases of female urinary tract fistula treated with gracilis muscle flap successfully.