Preoperative volume estimation in transverse upper gracilis flap surgery: A pilot study.

BACKGROUND: The transverse upper gracilis (TUG) flap provides a good alternative to the gold standard DIEP in breast reconstruction. However, flap volume estimates are subjective, making preoperative planning potentially challenging. STUDY AIM: To derive a reliable, accurate, and reproducible mathematical algorithm for the preoperative calculation of TUG flap volumes. MATERIALS AND METHODS: Nineteen consecutive patients with 30 TUG flaps were prospectively included. On the assumption that the TUG flap resembles two isosceles prisms, the formula of the volume of a prism was used to calculate their preoperative flap weights. These were then intraoperatively compared to the actual flap weights. A regression equation was calculated from the correlation analysis of 10 random flaps. This was then applied to the remaining 20 flaps to assess for improved reliability and weight prediction accuracy. RESULTS: The prism volume equation used to clinically calculate flap volumes was: Geometric flap weight = (h1bT)/2+ (h2bT)/2, (h = height, b = base, T = flap thickness); all in centimetres. Geometric and actual flap weights were found to be significantly correlated (r2 = 0.977) generating the following regression formula: predicted TUG weight = 0.924 × geometric weight + 26.601. When this was applied to the remaining 20 flaps, no significant difference was found (p = 0.625) between predicted and actual flap weights, demonstrating an increased accuracy of predicting flap volume. CONCLUSION: The proposed formula provides the clinician with a more accurate and reliable estimation of available TUG flap volume and may potentially aid with preoperative planning and patient consultations.

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.

A Newly Described, Highly Prevalent Arterial Pedicle Perfuses Both Gracilis and Profunda Artery Perforator Flap Tissues: An Angiographic Study of the Medial Thigh.

BACKGROUND: Novel secondary flap options are paramount for patients who are not candidates for common reconstructive methods. The purpose of this study is to identify the prevalence of single arterial pedicle supplying both the gracilis muscle and medial thigh tissue carried in a profunda artery perforator (PAP) flap. Such a pedicle could allow the creation of a chimeric gracilis and PAP flap with a single-arterial anastomosis. METHODS: We conducted a retrospective review of 157 lower extremity computed tomography (CT) angiograms to assess the vasculature of the thigh soft tissues. Imaging evaluation was supervised by a board-certified musculoskeletal radiologist. RESULTS: Prevalence of a single-arterial pedicle to a gracilis and PAP flap in each patient was 59% (31% within the right leg and 28% in the left leg). Furthermore, 16% of patients had a common arterial pedicle in both lower extremities. CONCLUSION: Existence of a single-arterial pedicle to both the gracilis muscle and PAP flap tissues is frequently present in most patients in at least one lower extremity. This chimeric flap configuration could serve as a reconstructive avenue for patients, particularly those who have exhausted other more common flap options. Screening angiography is warranted in patients looking for this anatomic variation to establish its presence.

FUNCTIONAL RECONSTRUCTION OF SOFT TISSUE OROFACIAL DEFECTS WITH MICROVASCULAR GRACILIS MUSCLE FLAP.

INTRODUCTION: Free flap reconstructive surgery of middle size and large oral and facial defects enables aesthetic and functional rehabilitation. Microvascular flap reconstructive surgery, with flap survival success rate more than 90-98%, is a gold standard in head and neck extensive reconstructions. Currently, head and neck reconstructive surgery is focused not only on defect occlusion and adequate aesthetical result, but the same emphasize is aimed at functional result. Functional result post tongue and lip resection means defect occlusion with the possibility of movement restoration. Free gracilis muscle flap appears to be a choice for functional tongue and lip reconstruction. MATERIAL AND METHODS: We present 1-year experience with 5 microvascular flap functional reconstructions of middle size and large defects of tongue and lip with free gracilis muscle flap. Four patients post tongue resection and one post subtotal lower lip and cheek resection underwent immediate functional microvascular gracilis muscle flap reconstruction. RESULTS: All five patients were successfully reconstructed with functional free gracilis muscle flap, with no flap loss. We found gracilis muscle flap harvest is not technically demanding, provides adequate tissue volume for middle size orofacial defects reconstruction, with possibility for skin island harvest, and simple primary closure of donor site with very low morbidity. Patients after tongue reconstruction with free gracilis flap were swallowing spoon ood 1 week post operation. Patient after total lip resection and immediate reconstruction with free gracilis flap presented with oral competence before the discharge. The functional result in the group of patients with free gracilis flap reconstruction for orofacial defect will have to be further evaluated again after 2 years post operation considering the ability to swallow and articulate during the speech for the tongue reconstructions and the oral competence and facial mimic for the lip reconstruction. CONCLUSION: Microvascular gracilis muscle flap reconstruction compared to radial forearm flap reconstruction enables functional reconstruction of soft tissue defect. Functional reconstruction of soft tissue defects of tongue or lip with microvascular gracilis muscle flap appears to have advantage of adequate volume, very low donor side morbidity and expectancy of movement renewal compared to other microvascular flap reconstructive options such as anterolateral thigh flap, superficial circumflex iliac artery perforator flap, lateral arm free flap or deep inferior epigastric perforator free flap.

Pericyte constriction underlies capillary derecruitment during hyperemia in the setting of arterial stenosis.

Capillary derecruitment distal to a coronary stenosis is implicated as the mechanism of reversible perfusion defect and potential myocardial ischemia during coronary hyperemia; however, the underlying mechanisms are not defined. We tested whether pericyte constriction underlies capillary derecruitment during hyperemia under conditions of stenosis. In vivo two-photon microscopy (2PM) and optical microangiography (OMAG) were used to measure hyperemia-induced changes in capillary diameter and perfusion in wild-type and pericyte-depleted mice with femoral artery stenosis. OMAG demonstrated that hyperemic challenge under stenosis produced capillary derecruitment associated with decreased RBC flux. 2PM demonstrated that hyperemia under control conditions induces 26 ± 5% of capillaries to dilate and 19 ± 3% to constrict. After stenosis, the proportion of capillaries dilating to hyperemia decreased to 14 ± 4% (P = 0.05), whereas proportion of constricting capillaries increased to 32 ± 4% (P = 0.05). Hyperemia-induced changes in capillary diameter occurred preferentially in capillary segments invested with pericytes. In a transgenic mouse model featuring partial pericyte depletion, only 14 ± 3% of capillaries constricted to hyperemic challenge after stenosis, a significant reduction from 33 ± 4% in wild-type littermate controls (P = 0.04). These results provide for the first time direct visualization of hyperemia-induced capillary derecruitment distal to arterial stenosis and demonstrate that pericyte constriction underlies this phenomenon in vivo. These results could have important therapeutic implications in the treatment of exercise-induced ischemia. NEW & NOTEWORTHY In the setting of coronary arterial stenosis, hyperemia produces a reversible perfusion defect resulting from capillary derecruitment that is believed to underlie cardiac ischemia under hyperemic conditions. We use optical microangiography and in vivo two-photon microscopy to visualize capillary derecruitment distal to a femoral arterial stenosis with cellular resolution. We demonstrate that capillary constriction in response to hyperemia in the setting of stenosis is dependent on pericytes, contractile mural cells investing the microcirculation.

Segmental Gracilis Muscle Transplantation for Midfacial Animation in Möbius Syndrome: A 29-Year Experience.

BACKGROUND: Möbius syndrome is a complex congenital disorder of unclear cause involving multiple cranial nerves and typically presenting with bilateral facial and abducens nerves palsies. At The Hospital for Sick Children, Toronto, Ontario, Canada, microneurovascular transfer of free-muscle transplant is the procedure of choice for midfacial animation. The primary aim of this study was to investigate surgical outcomes of the procedure in terms of complications, secondary revisions, and smile excursion gains. METHODS: A retrospective 29-year review was performed using patient records from a single tertiary care center. The authors included children with Möbius syndrome who had undergone facial animation surgery with a free segmental gracilis muscle transfer and microneurovascular repair between January 1, 1985, and August 31, 2014. Smile excursion measures were obtained using the Facial Assessment by Computer Evaluation-Gram on a subset of the included patients. RESULTS: A total of 107 patients undergoing 197 reconstructive procedures met inclusion criteria. Most reconstructions relied on the motor nerve branch to the masseter for innervation [n = 174 (88 percent)]. Thirteen complications were reported, of which six required surgical interventions. Three revision procedures were performed: scar revision, muscle repositioning, and removal of infected permanent suture material. The use of the motor nerve branch to the masseter resulted in good commissure excursion gains (average, 4.61 mm for bilateral cases and 9.34 mm for unilateral reconstructions). CONCLUSION: Midfacial animation with segmental gracilis muscle transfer for patients with Möbius syndrome provides gains in the amplitude and symmetry of oral commissure excursion and carries a reasonably low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Head-to-Head Comparison of the Vascular Basis of the Transverse Myocutaneous Gracilis, Profunda Artery Perforator, and Fasciocutaneous Infragluteal Flaps: An Anatomical Study.

BACKGROUND: Perforator flaps of the upper thigh or buttock provide a valuable secondary choice in autologous breast reconstruction. The purpose of this study was to compare the vascular territories and supplying vessels of the transverse myocutaneous gracilis flap, the profunda artery perforator flap, and the fasciocutaneous infragluteal flap. METHODS: In total, 26 lower limbs from 13 fresh specimens were investigated. All flap pedicles were selectively injected with methylene blue, eosin red, or green ink. The pedicle external diameters, lengths, and locations were measured. The dimensions of angiosomes, their intraindividual and interindividual correlations, and their relations to anatomical landmarks were analyzed. RESULTS: The profunda artery perforator pedicle had the greatest mean external diameter with 3.6 ± 0.7 mm, followed by the transverse myocutaneous gracilis and fasciocutaneous infragluteal pedicles with 2.9 ± 0.6 mm and 2.9 ± 0.7 mm, respectively. The fasciocutaneous infragluteal pedicle was longest with a mean length of 12.5 ± 1.5 cm, whereas the profunda artery perforator and transverse myocutaneous gracilis pedicles had lengths of 8.8 ± 1.0 cm and 6.7 ± 1 cm on average. The profunda artery perforator angiosome provided the largest size, with a mean area of 98.5 ± 26.7 cm(2), followed by the fasciocutaneous infragluteal angiosome (77.2 ± 9.0 cm(2)) and the transverse myocutaneous gracilis angiosome (74.1 ± 32.1 cm(2)). CONCLUSIONS: The authors' anatomical findings about the transverse myocutaneous gracilis, profunda artery perforator, and fasciocutaneous infragluteal territories provide clinically valuable data for flap selection in breast reconstruction if an abdominal flap is not feasible.

[Breast reconstruction with free flap of gracilis]. / La reconstruction du sein avec le lambeau libre de gracilis à palette cutanée transversale (TMG flap).

Breast reconstruction with free flap of gracilis has been described since 2004. The procedure consists in harvesting a flap made of the gracilis muscle and a transverse cutaneous paddle originating from the internal root of the thigh. The pedicle of the flap is the main pedicle of the gracilis muscle. After weaning, the vessels are anastomosed to the internal thoracic artery and vein. The modeling of the breast is done by folding the cut points in front of the muscle to obtain the shape of a cone. This surgical technique allows the realization of autologous breast reconstructions of small to medium size, immediate or delayed, unilateral or bilateral.

Dietary fats modify vascular fat composition, eNOS localization within lipid rafts and vascular function in obesity.

We tested whether dietary fatty acids alter membrane composition shifting localization of signaling pathways within caveolae to determine their role in vascular function. Wild type (WT) and caveolin-1-deficient mice (cav-1 KO), required for vascular caveolae formation, were fed low fat (LF), high saturated fat (HF, 60% kcal from lard), or high-fat diet with 50:50 lard and n-3 polyunsaturated fatty acid-enriched menhaden oil (MO). HF and MO increased body weight and fat in WT but had less effect in cav-1 KO. MO increased unsaturated fatty acids and the unsaturation index of aorta from WT and cav-1 KO. In LF WT aorta, endothelial nitric oxide synthase (eNOS) was localized to cav-1-enriched low-density fractions which shifted to actin-enriched high-density fractions with acetylcholine (ACh). HF and MO shifted eNOS to high-density fractions in WT aorta which was not affected by ACh. In cav-1 KO aorta, eNOS was localized in low-density non-caveolar fractions but not shifted by ACh or diet. Inducible NOS and cyclooxygenase 1/2 were not localized in low-density fractions or affected by diet, ACh or genotype. ACh-induced dilation of gracilis arteries from HF WT was similar to dilation in LF but the NOS component was reduced. In WT and cav-1 KO, dilation to ACh was enhanced by MO through increased role for NOS and cyclooxygenase. We conclude that dietary fats affect vascular fatty acid composition and membrane localization of eNOS but the contribution of eNOS and cyclooxygenase in ACh-mediated vascular responses is independent of lipid rafts.

FGF23 impairs peripheral microvascular function in renal failure.

Cardiovascular diseases account for ~50% of mortality in patients with chronic kidney disease (CKD). Fibroblast growth factor 23 (FGF23) is independently associated with endothelial dysfunction and cardiovascular mortality. We hypothesized that CKD impairs microvascular endothelial function and that this can be attributed to FGF23. Mice were subjected to partial nephrectomy (5/6Nx) or sham surgery. To evaluate the functional role of FGF23, non-CKD mice received FGF23 injections and CKD mice received FGF23-blocking antibodies after 5/6Nx surgery. To examine microvascular function, myocardial perfusion in vivo and vascular function of gracilis resistance arteries ex vivo were assessed in mice. 5/6Nx surgery blunted ex vivo vasodilator responses to acetylcholine, whereas responses to sodium nitroprusside or endothelin were normal. In vivo FGF23 injections in non-CKD mice mimicked this endothelial defect, and FGF23 antibodies in 5/6Nx mice prevented endothelial dysfunction. Stimulation of microvascular endothelial cells with FGF23 in vitro did not induce ERK phosphorylation. Increased plasma asymmetric dimethylarginine concentrations were increased by FGF23 and strongly correlated with endothelial dysfunction. Increased FGF23 concentration did not mimic impaired endothelial function in the myocardium of 5/6Nx mice. In conclusion, impaired peripheral endothelium-dependent vasodilatation in 5/6Nx mice is mediated by FGF23 and can be prevented by blocking FGF23. These data corroborate FGF23 as an important target to combat cardiovascular disease in CKD. NEW & NOTEWORTHY In the present study, we provide the first evidence that fibroblast growth factor 23 (FGF23) is a cause of peripheral endothelial dysfunction in a model of early chronic kidney disease (CKD) and that endothelial dysfunction in CKD can be prevented by blockade of FGF23. This pathological effect on endothelial cells was induced by long-term exposure of physiological levels of FGF23. Mechanistically, increased plasma asymmetric dimethylarginine concentrations were strongly associated with this endothelial dysfunction in CKD and were increased by FGF23.

Lisfranc Joint Ligament Complex Reconstruction: A Promising Solution for Missed, Delayed, or Chronic Lisfranc Injury Without Arthritis.

The current classifications of "Lisfranc injury" can be purely ligamentous (low-grade midfoot sprains) or involve the osseous and articular structures (high-grade Lisfranc fracture displacements). The first type is often difficult to detect. If these patients are not properly treated, long-term disability can result. The rate of missed or delayed diagnoses has ranged from 13% to 24%, primarily owing to the subtlety of the radiographic findings. This is relatively more common in cases of subtle ligamentous injury (19%). The aim of the present report was to provide a new technique for missed or delayed Lisfranc injury without degenerative local signs. The Lisfranc ligament complex reconstruction is performed with a gracilis tendon graft and is protected by temporary screw fixation. We performed this technique in 3 patients. All 3 patients obtained good results, have been able to resume their previous activities, and have stated they would undergo this type of procedure again. The minimum follow-up length was 2 years.

Experiences with functional gracilis muscle flap in lower lip reconstruction.

OBJECTIVE: Reconstruction of the lips is pivotal because the lips play an essential role in facial aesthetics and have unique functional properties. We presented our experience in reconstruction of total or subtotal lower lip defects with functional gracillis muscle flap covered split-thickness skin graft (STSG) in patients. METHODS: Between 2009 and 2011, seven patients underwent resection of lower lip squamous cell carcinoma and lip reconstruction. Gracillis muscle flap was performed for reconstruction. Recipient vessels were the facial artery and vein. Motor nerve of the gracillis muscle was coapted to the marginal branch of the facial nerve. Gracillis muscle was covered with STSG. Patients were evaluated about mouth opening, oral competence, word articulation, the color match of the graft, the contraction of the muscle by physical examination. Electromyographic studies and sensation tests were performed. RESULTS: Postoperative course was uneventful for all of the flaps. No microvascular revisions were needed. One patient was reoperated because of wound dehiscence under local anaesthesia. Mean follow up period was 15 months. After three months, movement of the reconstructed lip was observed. Color of the grafted skin was matched with the skin of the face. The patients had no problems with word articulation, oral continence, or mouth opening. The electromyographic study showed recovery of motor innervation. After 1 year, the patients demonstrated recovered sensitivity with the sensation test. CONCLUSION: Considering functional results, superior aesthetic appearance, and minimal donor-site morbidity of the functional gracillis transfer covered skin graft, we think that this method may be an alternative for reconstruction of large full-thickness defects of the lower lip. © 2015 Wiley Periodicals, Inc. Microsurgery 37:487-493, 2017.

Use of the submental vessels for free gracilis muscle transfer for smile reanimation.

BACKGROUND: Free muscle transfer is an important in dynamic facial reanimation; however, suitable donor vessels in this population can be inadequate. In this case series, the submental vessels were used as donors to free gracilis muscle in vessel-depleted patients. METHODS: Five patients underwent free gracilis muscle transfer for smile reanimation, 2 with a prior failed free gracilis transfer, 2 with vascular anomalies, and 1 with previous distal ligation of the facial vessels. The submental artery was used as a donor in all cases, and the submental vein was used in 3 cases. RESULTS: There were no complications or flap failure. Postoperative arterial and venous blood flow was confirmed in all patients using Doppler color flow imaging above and below the anastomoses. CONCLUSION: The submental vessels are suitable for microvascular anastomosis for free flaps having short pedicles, such as the free gracilis muscle flap, in the vessel-depleted hemiface. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-E2503, 2016.