Soo Bong Hahn and Hyun Kon Kim
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OF THE EXTREMITY ABSTRACT The authors performed free groin flap transplantation in 36 patients with extensive soft-tissue injury of the extremities. In each case, the vascular anatomy of the groin flap was analyzed during the operation. The anatomic classification of the superficial circumflex iliac artery according to its origin was as follows: a common origin with the superficial inferior epigastric artery in 15 cases (39.5 percent); an isolated origin and absent superficial inferior epigastric artery in 14 cases (36.8 percent), a separate origin in three cases (7.9 percent), and an origin from the profunda femoral artery in six cases (15.8 percent). These results are similar to those reported previously. The overall success rate was 72.2 percent. The success rate was better in the upper extremity (100.0 percent) than in the lower extremity (65.5 percent). Free vascularized groin flap transplantation is a suitable procedure for the one-stage reconstruction of severe soft-tissue injury, especially in the upper extremity.
Free flap transplantation was first carried out experimentally by Krizek and colleagues in 1965.' In 1972, McGregor and Jackson2 first performed a groin pedicle flap transplantation as reconstructive surgery for soft tissue injury in the upper extremity. But such distant flaps have many disadvantages, such as requiring several surgical procedures, too long a treatment period, and a difficult immobilization of the flaps. In comparison free flap transplantation using microsurgical techniques can be done in a one-stage operation, and also can be carried out even when the distance between the donor and recipient sites is very great. In addition, there is the advantage of being able to transplant flaps with bone, joint, epiphyseal plate, sensory nerves, and muscles. Since Daniel and Taylor3 first used the free vascularized groin flap successfully in 1973, many authors 4 - 9 have reported several successful free groin flap transplantations. But reports showing the analysis of a larger number of cases are rare. We used free groin flap transplantation in 36 patients with extensive softtissue injury of the extremities, and analyzed the vas-
cular anatomy of the groin flap, the overall result, and contributing factors for the results.
MATERIALS AND METHODS From January 1985 to August 1988, 36 free groin flap transplantations were performed by the authors at Severance Hospital, Yonsei University College of Medicine, Seoul, Korea. Twenty-two of the patients were male and 14 were female. Ages at the time of operation ranged from three to 61 years. Referring to causes of injuries, traffic accidents (26 cases) were most numerous, followed by machinery injury (six cases). The foot and ankle were the most common sites of lesions. Other lesion sites included the leg, elbow, wrist, forearm, and hand. Lesions were divided in four groups: Group 1 included 12 patients with defects of the skin and soft tissue with exposure of bone or tendons; Group 2 included six patients with defects of the skin
Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea Reprint requests-. Dr. Hahn, Dept. of Orthopedic Surgery, Severance Hospital, 134 Shin Chon-Dong, Seo Dae Moon-Ku, Seoul, Korea, C.P.O. Box 8044 Accepted for publication January 15, 1991 Copyright © 1991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
187
and soft tissue and infection of the bone; Group 3 included nine patients with unstable, poor skin; and Group 4 included nine patients with joint contracture due to scar (Table 1).
Operative Technique Before the operation, angiography of the recipient site was carried out in all cases to confirm vascular variation. All patients were in a supine position during surgery. There are two approaches to the vessels— from either the medial or the lateral end of the flap. Daniel and Taylor10 and Harii and Ohmori 511 favored the lateral approach to avoid damage to the artery and failure to identify the vessels. But O'Brien et a\in and McGregor and Jackson2 favored the dissection beginning at the medial end of the flap so that the suitability of the arterial trunk could be determined. We used the medial approach in all cases, because it was easier then to expose and access the vessels. A longitudinal incision was made over the femoral artery, centered about 5 cm inferior to the inguinal ligament. Using gentle sharp and blunt dissection, we watched carefully for the superficial circumflex iliac artery arising from the medial or anterior aspect of the femoral artery. The veins were identified and dissected gently as well. Dissection was continued, following the superficial circumflex iliac artery as it passed laterally, including the fascia overlying the sartorius, until the artery could be seen passing the fascia into the subcutaneous fat near the lateral border of the sartorius. Before reaching that point, the outline of the flap was incised on the skin, as needed, to permit identification of the vessels and muscular landmarks. Once the vascular pedicle had been dissected and suitable arteries and veins had been identified, the entire skin flap was incised and elevated. The vessels were not transected until preparation of the recipient area was completed and suitable recipient vessels had been identified. After the groin flap had been isolated on its vessels and the recipient site had been prepared, we transected the artery first to allow additional venous drainage, and then transected the veins. The free flap was then placed into the recipient defect and oriented so that the flap vessels matched the recipient vessels.
Table I.
Recipient Site Lesions
Status of the Recipient Site
188
Defect of the skin and soft tissue with exposure of the bone or tendons Defect of the skin and soft tissue with infection of the bone Unstable and poor skin condition Joint contracture due to scar Total
Number 12 6 9 9
36
JULY 1991
Several anchoring sutures were placed in the margins of the flap to avoid dislodgement while the anastomoses were being performed. The artery was sutured by microsurgically using #10 nylon suture. We performed end-to-end or end-to-side anastomosis according to the condition of the donor and recipient vessels. Then, one or two veins were sutured in an end-to-end technique as promptly as possible, to avoid venous congestion in the flap. The donor defect was directly closed by side-to-side suture. Tension on the donor defect was minimized by undermining the skin margins and by flexing the hip. After flap transplantation, the recipient site was immobilized by splinting and was elevated about 10 to 15 degrees to avoid edema. To prevent formation of hematoma at the vessel anastomosis site, multiple drains were placed for two or three postoperative days. The temperature of the room was maintained at 22° C. The hip was maintained in a flexed position for five to seven days, at which time gradual extension was begun and continued for another seven to 10 days. As for the arterial anastomosis, we used end-toend anastomoses in 19 cases and end-to-side anastomoses in 17 cases. In 16 cases, the superficial circumflex iliac artery was sutured to the anterior tibial artery and in 13 cases, to the posterior tibial artery. In all cases, the superficial circumflex iliac veins were sutured to the recipient veins, except one case in which the venae comitantes of the superficial circumflex iliac artery were used. The vein was sutured end-to-end in all cases, and two veins were sutured in six cases. The size of the flap ranged from 8 x 5 cm to 22 x 5 cm. Ischemic time for the flap ranged from 70 min to 150 min (average: 100 min, Table 2).
RESULTS Among the 36 cases, 26 had successful results making the success rate 72.2 percent. In the upper extremity, all seven cases resulted in success, compared to the 19 successes among the 29 lower extremity cases (Table 3). As for the method of arterial anastomosis, among the 19 cases with end-to-end anastomosis, 13 resulted in success. Compared to this, the end-toside anastomosis of the artery resulted in 13 successes among the 17 cases. However, there was no statistical significance between these results (Table 4). The anastomosis of two veins showed better results than the one-vein anastomosis, but again there was no statistical significance (Table 5). The average ischemic time was 96 min in the 26 successful cases and 112 min in the 10 failed cases. In the 10 failed cases, free vascularized scapular flaps were used in four cases with good results. In another case, a cross-leg flap was used. In five cases
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FREE GROIN FLAPS, EXTREMITY RECONSTRUCTION/HAHN, KIM
No.
Sex
(yrs)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
F F F F M F F M M F M M F M M M F M M M F M M M M M M M F F F M M M F M
34 6 14 5 4
36
8 10 28 41 11
3 20 5 10 61 53 16 27 6 49 37 5 8 26 12 7 24 42 9 12 5 42 5 6 45 6
Lesion Left leg Right foot Right wrist Left ankle Right foot Left foot Left ankle Right forearm Right leg Right leg Left foot Right ankle Left leg Left foot Left elbow Right ankle Right elbow Right elbow Right ankle Right wrist Left leg Left leg Right foot Right foot Right foot Right foot Left hand Left foot Left ankle Right ankle Right ankle Left ankle Right foot Right foot Right leg Left foot
Flap Size (cm) 6x7 13x6 10 x 9
Diameter of SCIA* (mm)
Pedicle Length (mm)
Method of Anastomosis
Result
0.9 1.1 1.2 0.7 1.0 0.4 0.8 1.0 1.2 0.7 1.0 1.0 0.8 0.9 1.4 1.0 0.8 0.8 1.0 0.9 0.8 1.2 0.8 1.0 0.5 1.0 2.0 1.2 0.8 0.8 1.1 0.9 0.3 1.2 2.5 1.0
1.5 0.8 0.8 1.2 0.8 1.0 0.8 1.2 0.7 1.0 0.8 0.8 0.9 1.0 1.2 1.0 1.6
End-to-side End-to-side End-to-side End-to-end End-to-side End-to-side End-to-side End-to-end End-to-side End-to-side End-to-side End-to-side End-to-end End-to-side End-to-side End-to-side End-to-end End-to-end End-to-end End-to-side End-to-end End-to-side End-to-end End-to-end End-to-end End-to-side End-to-side End-to-end End-to-end End-to-end End-to-end End-to-end End-to-end End-to-end End-to-end End-to-end
Success Success Success Success Success Failure Success Success Failure Success Failure Success Success Success Success Success Success Success Success Success Failure Success Success Failure Failure Success Success Success Failure Success Success Success Failure Success Success Success
13X8
12 x 5 12 x 6 9 X 6
13 x 5 14 x 7 7X6
12 x 8 9x6 13X4 14 x 6 23 x 9 16 x 10 24 x 8 15X8
18 x 8 17x8 7X6 8X5
12 x 7 13X9
23 x 11 17x8 7X6
7.5 x 6 11x5 11x7 9x7 22 x 15 12X8 13X6 7X6
12x6
1.4
0.8 0.8 1.5 1.0 1.0 0.5 1.0 0.8 0.7 0.6 2.0 1.5 0.8 0.5 1.0 1.0 1.0 1.0
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Table 2. Clinical Data Age
'SCIA = superficial circumflex iliac artery.
Table 3. Site of Lesion
Success Rates
Success/Failure
Rate of Success
Upper extremity Lower extremity
7/0 19/10
100.0% 65.5%
Total
26/10
72.2%
Table 5. Results According to Method of Venous Anastomosis Method Number Rate of Success One vein (end-to-end) Two veins (end-to-end)
30 6
21/30 (70.0%) 5/6 (83.3%)
Total
36
26/36 (72.2%)
*p > 0.5.
Table 4. Results According to Method of Artificial Anastomosis Method
Number
Rate of Success
End-to-end anastomosis End-to-side anastomosis
19 17
13/19(68.4%) 13/17(76.5%)
Total
36
26/36 (72.2%)
*p > 0.5.
with poor blood flow in the recipient vessel or severe thrombus formation, split- or full-thickness skin grafts were done. We also analyzed the anatomic variations of the superficial circumflex iliac artery and the diameter and length of the vascular pedicles in our 36 cases. There were four anatomic variations according to the origin of the superficial circumflex iliac artery. The superficial circumflex iliac artery had a common origin with the superficial inferior iliac artery in 15 patients (39.5 per-
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Table 7. Diameter and Pedicle Length of the Vessels Vessel Superficial circumflex iliac artery Superficial circumflex iiac vein
Diameter {mm)/ Length of pedicle (mm) 1.0 (0.3 to 2.0)/9.7 (5 to 20) 1.7 (0.2 to 3.0)/14.4 (3 to 25)
transplanted from the right groin area (Fig. 2B). The superficial circumflex iliac artery had an isolated origin from the femoral artery, without the superficial inferior epigastric artery (Fig. 2C). The superficial circumflex iliac artery (diameter 0.9 mm) was anastomosed CASE REPORTS to the anterior tibial artery (diameter 2.5 mm) by an end-to-end technique. Then the superficial circumflex CASE 1. A 24-year-old male patient had a crushiliac vein (diameter 1.4 mm) was anastomosed to the ing injury on the left hand produced by a pressor. After vena comitans of the anterior tibial artery (diameter primary treatment in another hospital, he was admit- 1.5 mm) end-to-end. One year after the operation, a ted to our clinic with a skin defect and exposure of the good result was obtained without complication (Fig. third and fourth extensor tendons in the dorsum of the 2D, E). The donor site healed without functional disturleft hand (Fig. 1A). Eleven days later, a free groin flap (7 bance by secondary closure (Fig. 2F). x 6 cm) was transplanted from the right groin, and CASE 3. A 27-year-old man was admitted with a tenolysis of the extensor tendons was done at the same poor skin condition on the right proximal forearm and time (Fig. IB). The superficial circumflex iliac artery flexion contracture of the fourth and fifth fingers (diameter 2.0 mm) and the radial artery (diameter 4.0 caused by scar adhesion of the flexor muscle (Fig. 3A). mm) were connected by end-to-side anastomosis. He had an injury of the right proximal forearm caused Then, the superficial circumflex iliac vein (diameter 3.0 by an electric saw, and a skin graft had been performed mm) was anastomosed to the cephalic vein (diameter at another hospital. Five months after trauma, the poor 3.4 mm) end-to-end. One year after the operation, the skin and scars were excised and an adhesion of the patient showed a satisfactory result, with no limitation flexor muscle was released. Then, a free groin flap (15 x of finger motion (Fig. 1C, D). The donor site with pri8 cm) was transplanted from the left groin (Fig. 3B). The mary closure had no functional deficit (Fig. IE). superficial circumflex iliac artery had a common origin CASE 2. A 42-year-old man was admitted to our with the superficial inferior epigastric artery from the hospital with wide soft-tissue injury on the left ankle femoral artery (Fig. 3C). The superficial circumflex iliac and foot, combined with multiple fracture and necrosis artery (diameter 0.8 mm) was anastomosed to the of the big toe caused in a traffic accident. After man- posterior ulnar recurrent artery (diameter 1.5 mm) (Fig. agement of the wound and amputation of the big toe 3D) with an end-to-end technique. Then, the superfi(Fig. 2A), a wide free groin flap (22 x 15 cm) was cial circumflex iliac vein (diameter 2.0 mm) was anastomosed to the branch of the basilic vein (diameter 2.5 mm) end-to-end. Fifteen months after the operation, the result was good with a full range of flexion of the Table 6. Anatomic Classification finger, although mild limitation of extension of the of the Superficial Circumflex Iliac Artery Daniel & fourth and fifth fingers remained (Fig. 3E, F). Number (%)
Taylor (1975) 1 0
1. Common origin with superficial inferior epigastric artery 2. Isolated origin & absent superficial inferior epigastric artery 3. Separate origin from femoral artery 4. Origin from profunda femoral artery
15(39.5%)
40%
Total
Classification
190
DISCUSSION 14 (36.8%)
29%
3 (7.9%)
14%
6(15.8%)
17%
36(100%)
100%
In 1973, Daniel and Taylor3 first performed a successful transplantation of the free groin flap. Thereafter, many successful cases of free groin-flap transplantation were reported by O'Brien et a!.,712 Harii and Ohmori,511 Rigg,8 Baudet et al.,4 Karkowski and Buncke,6 and Serafin et al.9 The free vascularized groin flap has several advantages, such as its potentially
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cent) and a separate origin from the femoral artery in three patients (7.9 percent). In 14 cases (36.8 percent), the superficial inferior epigastric artery was absent, and the superficial circumflex iliac artery had a direct origin from the femoral artery. In six cases (15.8 percent), the superficial circumflex iliac artery and the superficial inferior epigastric artery showed a separate origin from the profunda femoral artery (Table 6). The average diameter of the superficial circumflex iliac artery was 1.0 mm and that of the vein was 1.7 mm. The average length of the vascular pedicle was 9.7 mm in the artery and 14.4 mm in the vein (Table 7).
JULY 1991
FREE GROIN FLAPS, EXTREMITY RECONSTRUCTION/HAHN, KIM
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B
Figure 1. Case 1. Preoperative findings A, Skin defect and exposure of third and fourth extensor digitorum communis tendons on the dorsum of the left hand. B, Flap design of the right groin (7 x 6 cm). C, Postoperative appearance at 12 months with fullflexionof all fingers. D, Postoperative appearance at 12 months with full extension of all fingers. E, Donor site appearance at 12 months.
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B
Figure 2. Case 2. Preoperative findings A, Skin and soft tissue defect on the left foot and ankle with amputation of the big toe. Br Flap design on the right groin area (22 x 15 cm). C, Elevation of the flap and identification of the superficial circumflex iliac artery. D, Anterior view 12 months after the operation. (Figure continued on next page)
192
Figure 2, cont.
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FREE GROIN FLAPS, EXTREMITY RECONSTRUCTION/HAHN, KIM
E, Medial view 12 months after the operation. F, Donor-site appearance four months after the operation.
B
Figure 3. Case 3. Preoperative findings. A, Poor skin condition of the proximal forearm and flexion contracture of fourth and fifth fingers due to scar adhesion. B, Flap design on the left groin area (15 x 8 cm). C, Elevation of the flap and identification of the superficial circumflex iliac artery. (Figure continued on next page)
193
JULY 1991
Figure 3, cont. D, Angiogram of the recipient site (arrow indicates the posterior ulnar recurrent artery). E, Postoperative appearance at 15 months with improvement of extension lag of fourth and fifth fingers. F, Postoperative appearance at 15 months with nearly full flexion of all fingers.
194
large size, comfortable position of the patient during surgery, minimal donor-site morbidity, possible coverage of the donor-site scar with a bikini, a multiple arterial and venous system, and the potential for incorporating bone with the overlying skin. However, there are some disadvantages such as difficult vessel dissection, many vessel variations, short length of the vascular pedicle, narrow vessel diameter, and a too bulky flap in the obese patient. The groin flap receives its blood supply through the superficial circumflex iliac artery, with or without the combined superficial inferior epigastric artery, the branches of the femoral artery. Daniel and Taylor10 reported an anatomic relationship between the superficial circumflex iliac artery and the superficial inferior epigastric artery, as reflected in their origin and distribution in 100 dissections. Their series showed four distinct patterns: 1) separate origins of the two vessels (14 percent); 2) common origin (40 percent); 3) absent superficial inferior epigastric artery with a compensatory larger superficial circumflex iliac artery and extended distribution (29 percent); and 4) both vessels arising from a "parent" artery instead of the femoral
artery (17 percent). They also reported that the diameter of the superficial circumflex iliac artery was 1.1 mm to 1.4 mm. In our series of 36 cases, the anatomic classification of the superficial circumflex iliac artery according to its origin was as follows: common origin with the superficial inferior epigastric artery in 15 cases (39.5 percent); isolated origin and absent superficial inferior epigastric artery in 14 cases (36.8 percent); separate origin in three cases (7.9 percent); and origin from the profunda femoral artery in six cases (15.8 percent). These results are similar to those of Daniel and Taylor. In our series, the average diameter of the superficial circumflex iliac artery was smaller than that of Daniel and Taylor. According to the above classifications, a prediction of the anatomic vessel variations, a major factor influencing results, may be possible. Reports on the success rates of free groin flaps are rare. Baudet and colleagues 4 reported nine successes in their 10 cases. Serafin et al.9 reported 10 successes in 14 cases. In our series, the success rate was 72.2 percent in 36 cases, and the result was better in the upper extremity than in the lower.
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 7, NUMBER 3
FREE GROIN FLAPS, EXTREMITY RECONSTRUCTION/HAHN, KIM
REFERENCES 1. Krizek TJ, Tari T, Desprez ID: Experimental transplantation of composite grafts by microsurgical vascular anastomosis. Plast Reconstr Surg 36:538, 1966 2. McGregor 1A, Jackson IT: The groin flap. Br I Plast Surg 25:3, 1972 3. Daniel RK, Taylor GI: Distant transfer of an island flap by microvascular anastomosis: A clinical technique. Plast Reconstr Surg 52:111, 1973 4. Baudet I, LeMaire ), Guimberteau I: Ten free groin flaps. Plast Reconstr Surg 57:577, 1976 5. Harii K, Ohmori K: Free groin flaps in children. Plast Reconstr Surg 55:588, 1975 6. Karkawski I, Buncke HI: A simplified technique for free transfer of groin flaps by use of a Doppler probe. Plast Reconstr Surg 55:682, 1975 7. O'Brien BM, MacLeod MA, Hayhurst IW, Morrison WA: Successful transfer of a large island flap from the groin to the foot by microvascular anastomoses. Plast Reconstr Surg 52:271, 1973 8. Riggs BM: Transfer of a free groin flap to the heel by microvascular anastomoses. Plast Reconstr Surg 55:36, 1975 9. Serafin D, Villareal-Rios A, Georgiade N: Fourteen free groin flap transfers. Plast Reconstr Surg 57:707, 1976 10. Daniel RK, Taylor GI: The anatomy of several free flap donor sites. Plast Reconstr Surg 56:243, 1975 11. Harii K, Ohmori K, Ohmori S: Successful clinical transfer of ten free flaps by microvascular anastomoses. Plast Reconstr Surg 53:259, 1974 12. O'Brien BM, Morrison WA, Ishida H, et al..-. Free flap transfers with microvascular anastomoses. Br I Plast Surg 27:220, 1974 13. Godina M: Preferential use of end-to-side arterial anastomosis in free flap transfers. Plast Reconstr Surg 64:673, 1979
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The major complications causing flap necrosis are known to be arterial and venous thromboses. These complications may be due to discrepancies in the diameter of the anastomosed vessels, excessive tension of the anastomosis site, excessive vessel length, kinking of the vessel, or poor vessel condition. In our series, we agree that the causes of flap necrosis were discrepancies in the vessel diameters or poor vessel condition, especially in the lower extremity. For early detection and treatment of these major complications, it is necessary to monitor skin temperature and capillary pulse continuously. Godina13 reported that results were better with end-to-side anastomosis than the end-to-end anastomosis. He suggested that the end-to-side technique had several advantages such as preservation of the vessels to the distal part of the limb, the possibility of easier surgical planning, the avoidance of retraction and spasm in the supplying recipient artery, and the prevention of gross disturbances in the resulting flow. In our cases, results were better with the end-to-side anastomosis, but there was no statistical significance between the different techniques. We consider that free groin-flap transplantation is a suitable procedure for one-stage reconstruction of severe soft-tissue injury, especially in the upper extremity.
195
FREE GROIN FLAPS MICROSURGICAL RECONSTRUCTION Downloaded by: University of British Columbia. Copyrighted material.
OF THE EXTREMITY ABSTRACT The authors performed free groin flap transplantation in 36 patients with extensive soft-tissue injury of the extremities. In each case, the vascular anatomy of the groin flap was analyzed during the operation. The anatomic classification of the superficial circumflex iliac artery according to its origin was as follows: a common origin with the superficial inferior epigastric artery in 15 cases (39.5 percent); an isolated origin and absent superficial inferior epigastric artery in 14 cases (36.8 percent), a separate origin in three cases (7.9 percent), and an origin from the profunda femoral artery in six cases (15.8 percent). These results are similar to those reported previously. The overall success rate was 72.2 percent. The success rate was better in the upper extremity (100.0 percent) than in the lower extremity (65.5 percent). Free vascularized groin flap transplantation is a suitable procedure for the one-stage reconstruction of severe soft-tissue injury, especially in the upper extremity.
Free flap transplantation was first carried out experimentally by Krizek and colleagues in 1965.' In 1972, McGregor and Jackson2 first performed a groin pedicle flap transplantation as reconstructive surgery for soft tissue injury in the upper extremity. But such distant flaps have many disadvantages, such as requiring several surgical procedures, too long a treatment period, and a difficult immobilization of the flaps. In comparison free flap transplantation using microsurgical techniques can be done in a one-stage operation, and also can be carried out even when the distance between the donor and recipient sites is very great. In addition, there is the advantage of being able to transplant flaps with bone, joint, epiphyseal plate, sensory nerves, and muscles. Since Daniel and Taylor3 first used the free vascularized groin flap successfully in 1973, many authors 4 - 9 have reported several successful free groin flap transplantations. But reports showing the analysis of a larger number of cases are rare. We used free groin flap transplantation in 36 patients with extensive softtissue injury of the extremities, and analyzed the vas-
cular anatomy of the groin flap, the overall result, and contributing factors for the results.
MATERIALS AND METHODS From January 1985 to August 1988, 36 free groin flap transplantations were performed by the authors at Severance Hospital, Yonsei University College of Medicine, Seoul, Korea. Twenty-two of the patients were male and 14 were female. Ages at the time of operation ranged from three to 61 years. Referring to causes of injuries, traffic accidents (26 cases) were most numerous, followed by machinery injury (six cases). The foot and ankle were the most common sites of lesions. Other lesion sites included the leg, elbow, wrist, forearm, and hand. Lesions were divided in four groups: Group 1 included 12 patients with defects of the skin and soft tissue with exposure of bone or tendons; Group 2 included six patients with defects of the skin
Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea Reprint requests-. Dr. Hahn, Dept. of Orthopedic Surgery, Severance Hospital, 134 Shin Chon-Dong, Seo Dae Moon-Ku, Seoul, Korea, C.P.O. Box 8044 Accepted for publication January 15, 1991 Copyright © 1991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
187
and soft tissue and infection of the bone; Group 3 included nine patients with unstable, poor skin; and Group 4 included nine patients with joint contracture due to scar (Table 1).
Operative Technique Before the operation, angiography of the recipient site was carried out in all cases to confirm vascular variation. All patients were in a supine position during surgery. There are two approaches to the vessels— from either the medial or the lateral end of the flap. Daniel and Taylor10 and Harii and Ohmori 511 favored the lateral approach to avoid damage to the artery and failure to identify the vessels. But O'Brien et a\in and McGregor and Jackson2 favored the dissection beginning at the medial end of the flap so that the suitability of the arterial trunk could be determined. We used the medial approach in all cases, because it was easier then to expose and access the vessels. A longitudinal incision was made over the femoral artery, centered about 5 cm inferior to the inguinal ligament. Using gentle sharp and blunt dissection, we watched carefully for the superficial circumflex iliac artery arising from the medial or anterior aspect of the femoral artery. The veins were identified and dissected gently as well. Dissection was continued, following the superficial circumflex iliac artery as it passed laterally, including the fascia overlying the sartorius, until the artery could be seen passing the fascia into the subcutaneous fat near the lateral border of the sartorius. Before reaching that point, the outline of the flap was incised on the skin, as needed, to permit identification of the vessels and muscular landmarks. Once the vascular pedicle had been dissected and suitable arteries and veins had been identified, the entire skin flap was incised and elevated. The vessels were not transected until preparation of the recipient area was completed and suitable recipient vessels had been identified. After the groin flap had been isolated on its vessels and the recipient site had been prepared, we transected the artery first to allow additional venous drainage, and then transected the veins. The free flap was then placed into the recipient defect and oriented so that the flap vessels matched the recipient vessels.
Table I.
Recipient Site Lesions
Status of the Recipient Site
188
Defect of the skin and soft tissue with exposure of the bone or tendons Defect of the skin and soft tissue with infection of the bone Unstable and poor skin condition Joint contracture due to scar Total
Number 12 6 9 9
36
JULY 1991
Several anchoring sutures were placed in the margins of the flap to avoid dislodgement while the anastomoses were being performed. The artery was sutured by microsurgically using #10 nylon suture. We performed end-to-end or end-to-side anastomosis according to the condition of the donor and recipient vessels. Then, one or two veins were sutured in an end-to-end technique as promptly as possible, to avoid venous congestion in the flap. The donor defect was directly closed by side-to-side suture. Tension on the donor defect was minimized by undermining the skin margins and by flexing the hip. After flap transplantation, the recipient site was immobilized by splinting and was elevated about 10 to 15 degrees to avoid edema. To prevent formation of hematoma at the vessel anastomosis site, multiple drains were placed for two or three postoperative days. The temperature of the room was maintained at 22° C. The hip was maintained in a flexed position for five to seven days, at which time gradual extension was begun and continued for another seven to 10 days. As for the arterial anastomosis, we used end-toend anastomoses in 19 cases and end-to-side anastomoses in 17 cases. In 16 cases, the superficial circumflex iliac artery was sutured to the anterior tibial artery and in 13 cases, to the posterior tibial artery. In all cases, the superficial circumflex iliac veins were sutured to the recipient veins, except one case in which the venae comitantes of the superficial circumflex iliac artery were used. The vein was sutured end-to-end in all cases, and two veins were sutured in six cases. The size of the flap ranged from 8 x 5 cm to 22 x 5 cm. Ischemic time for the flap ranged from 70 min to 150 min (average: 100 min, Table 2).
RESULTS Among the 36 cases, 26 had successful results making the success rate 72.2 percent. In the upper extremity, all seven cases resulted in success, compared to the 19 successes among the 29 lower extremity cases (Table 3). As for the method of arterial anastomosis, among the 19 cases with end-to-end anastomosis, 13 resulted in success. Compared to this, the end-toside anastomosis of the artery resulted in 13 successes among the 17 cases. However, there was no statistical significance between these results (Table 4). The anastomosis of two veins showed better results than the one-vein anastomosis, but again there was no statistical significance (Table 5). The average ischemic time was 96 min in the 26 successful cases and 112 min in the 10 failed cases. In the 10 failed cases, free vascularized scapular flaps were used in four cases with good results. In another case, a cross-leg flap was used. In five cases
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No.
Sex
(yrs)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
F F F F M F F M M F M M F M M M F M M M F M M M M M M M F F F M M M F M
34 6 14 5 4
36
8 10 28 41 11
3 20 5 10 61 53 16 27 6 49 37 5 8 26 12 7 24 42 9 12 5 42 5 6 45 6
Lesion Left leg Right foot Right wrist Left ankle Right foot Left foot Left ankle Right forearm Right leg Right leg Left foot Right ankle Left leg Left foot Left elbow Right ankle Right elbow Right elbow Right ankle Right wrist Left leg Left leg Right foot Right foot Right foot Right foot Left hand Left foot Left ankle Right ankle Right ankle Left ankle Right foot Right foot Right leg Left foot
Flap Size (cm) 6x7 13x6 10 x 9
Diameter of SCIA* (mm)
Pedicle Length (mm)
Method of Anastomosis
Result
0.9 1.1 1.2 0.7 1.0 0.4 0.8 1.0 1.2 0.7 1.0 1.0 0.8 0.9 1.4 1.0 0.8 0.8 1.0 0.9 0.8 1.2 0.8 1.0 0.5 1.0 2.0 1.2 0.8 0.8 1.1 0.9 0.3 1.2 2.5 1.0
1.5 0.8 0.8 1.2 0.8 1.0 0.8 1.2 0.7 1.0 0.8 0.8 0.9 1.0 1.2 1.0 1.6
End-to-side End-to-side End-to-side End-to-end End-to-side End-to-side End-to-side End-to-end End-to-side End-to-side End-to-side End-to-side End-to-end End-to-side End-to-side End-to-side End-to-end End-to-end End-to-end End-to-side End-to-end End-to-side End-to-end End-to-end End-to-end End-to-side End-to-side End-to-end End-to-end End-to-end End-to-end End-to-end End-to-end End-to-end End-to-end End-to-end
Success Success Success Success Success Failure Success Success Failure Success Failure Success Success Success Success Success Success Success Success Success Failure Success Success Failure Failure Success Success Success Failure Success Success Success Failure Success Success Success
13X8
12 x 5 12 x 6 9 X 6
13 x 5 14 x 7 7X6
12 x 8 9x6 13X4 14 x 6 23 x 9 16 x 10 24 x 8 15X8
18 x 8 17x8 7X6 8X5
12 x 7 13X9
23 x 11 17x8 7X6
7.5 x 6 11x5 11x7 9x7 22 x 15 12X8 13X6 7X6
12x6
1.4
0.8 0.8 1.5 1.0 1.0 0.5 1.0 0.8 0.7 0.6 2.0 1.5 0.8 0.5 1.0 1.0 1.0 1.0
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Table 2. Clinical Data Age
'SCIA = superficial circumflex iliac artery.
Table 3. Site of Lesion
Success Rates
Success/Failure
Rate of Success
Upper extremity Lower extremity
7/0 19/10
100.0% 65.5%
Total
26/10
72.2%
Table 5. Results According to Method of Venous Anastomosis Method Number Rate of Success One vein (end-to-end) Two veins (end-to-end)
30 6
21/30 (70.0%) 5/6 (83.3%)
Total
36
26/36 (72.2%)
*p > 0.5.
Table 4. Results According to Method of Artificial Anastomosis Method
Number
Rate of Success
End-to-end anastomosis End-to-side anastomosis
19 17
13/19(68.4%) 13/17(76.5%)
Total
36
26/36 (72.2%)
*p > 0.5.
with poor blood flow in the recipient vessel or severe thrombus formation, split- or full-thickness skin grafts were done. We also analyzed the anatomic variations of the superficial circumflex iliac artery and the diameter and length of the vascular pedicles in our 36 cases. There were four anatomic variations according to the origin of the superficial circumflex iliac artery. The superficial circumflex iliac artery had a common origin with the superficial inferior iliac artery in 15 patients (39.5 per-
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Table 7. Diameter and Pedicle Length of the Vessels Vessel Superficial circumflex iliac artery Superficial circumflex iiac vein
Diameter {mm)/ Length of pedicle (mm) 1.0 (0.3 to 2.0)/9.7 (5 to 20) 1.7 (0.2 to 3.0)/14.4 (3 to 25)
transplanted from the right groin area (Fig. 2B). The superficial circumflex iliac artery had an isolated origin from the femoral artery, without the superficial inferior epigastric artery (Fig. 2C). The superficial circumflex iliac artery (diameter 0.9 mm) was anastomosed CASE REPORTS to the anterior tibial artery (diameter 2.5 mm) by an end-to-end technique. Then the superficial circumflex CASE 1. A 24-year-old male patient had a crushiliac vein (diameter 1.4 mm) was anastomosed to the ing injury on the left hand produced by a pressor. After vena comitans of the anterior tibial artery (diameter primary treatment in another hospital, he was admit- 1.5 mm) end-to-end. One year after the operation, a ted to our clinic with a skin defect and exposure of the good result was obtained without complication (Fig. third and fourth extensor tendons in the dorsum of the 2D, E). The donor site healed without functional disturleft hand (Fig. 1A). Eleven days later, a free groin flap (7 bance by secondary closure (Fig. 2F). x 6 cm) was transplanted from the right groin, and CASE 3. A 27-year-old man was admitted with a tenolysis of the extensor tendons was done at the same poor skin condition on the right proximal forearm and time (Fig. IB). The superficial circumflex iliac artery flexion contracture of the fourth and fifth fingers (diameter 2.0 mm) and the radial artery (diameter 4.0 caused by scar adhesion of the flexor muscle (Fig. 3A). mm) were connected by end-to-side anastomosis. He had an injury of the right proximal forearm caused Then, the superficial circumflex iliac vein (diameter 3.0 by an electric saw, and a skin graft had been performed mm) was anastomosed to the cephalic vein (diameter at another hospital. Five months after trauma, the poor 3.4 mm) end-to-end. One year after the operation, the skin and scars were excised and an adhesion of the patient showed a satisfactory result, with no limitation flexor muscle was released. Then, a free groin flap (15 x of finger motion (Fig. 1C, D). The donor site with pri8 cm) was transplanted from the left groin (Fig. 3B). The mary closure had no functional deficit (Fig. IE). superficial circumflex iliac artery had a common origin CASE 2. A 42-year-old man was admitted to our with the superficial inferior epigastric artery from the hospital with wide soft-tissue injury on the left ankle femoral artery (Fig. 3C). The superficial circumflex iliac and foot, combined with multiple fracture and necrosis artery (diameter 0.8 mm) was anastomosed to the of the big toe caused in a traffic accident. After man- posterior ulnar recurrent artery (diameter 1.5 mm) (Fig. agement of the wound and amputation of the big toe 3D) with an end-to-end technique. Then, the superfi(Fig. 2A), a wide free groin flap (22 x 15 cm) was cial circumflex iliac vein (diameter 2.0 mm) was anastomosed to the branch of the basilic vein (diameter 2.5 mm) end-to-end. Fifteen months after the operation, the result was good with a full range of flexion of the Table 6. Anatomic Classification finger, although mild limitation of extension of the of the Superficial Circumflex Iliac Artery Daniel & fourth and fifth fingers remained (Fig. 3E, F). Number (%)
Taylor (1975) 1 0
1. Common origin with superficial inferior epigastric artery 2. Isolated origin & absent superficial inferior epigastric artery 3. Separate origin from femoral artery 4. Origin from profunda femoral artery
15(39.5%)
40%
Total
Classification
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DISCUSSION 14 (36.8%)
29%
3 (7.9%)
14%
6(15.8%)
17%
36(100%)
100%
In 1973, Daniel and Taylor3 first performed a successful transplantation of the free groin flap. Thereafter, many successful cases of free groin-flap transplantation were reported by O'Brien et a!.,712 Harii and Ohmori,511 Rigg,8 Baudet et al.,4 Karkowski and Buncke,6 and Serafin et al.9 The free vascularized groin flap has several advantages, such as its potentially
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cent) and a separate origin from the femoral artery in three patients (7.9 percent). In 14 cases (36.8 percent), the superficial inferior epigastric artery was absent, and the superficial circumflex iliac artery had a direct origin from the femoral artery. In six cases (15.8 percent), the superficial circumflex iliac artery and the superficial inferior epigastric artery showed a separate origin from the profunda femoral artery (Table 6). The average diameter of the superficial circumflex iliac artery was 1.0 mm and that of the vein was 1.7 mm. The average length of the vascular pedicle was 9.7 mm in the artery and 14.4 mm in the vein (Table 7).
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FREE GROIN FLAPS, EXTREMITY RECONSTRUCTION/HAHN, KIM
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B
Figure 1. Case 1. Preoperative findings A, Skin defect and exposure of third and fourth extensor digitorum communis tendons on the dorsum of the left hand. B, Flap design of the right groin (7 x 6 cm). C, Postoperative appearance at 12 months with fullflexionof all fingers. D, Postoperative appearance at 12 months with full extension of all fingers. E, Donor site appearance at 12 months.
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B
Figure 2. Case 2. Preoperative findings A, Skin and soft tissue defect on the left foot and ankle with amputation of the big toe. Br Flap design on the right groin area (22 x 15 cm). C, Elevation of the flap and identification of the superficial circumflex iliac artery. D, Anterior view 12 months after the operation. (Figure continued on next page)
192
Figure 2, cont.
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FREE GROIN FLAPS, EXTREMITY RECONSTRUCTION/HAHN, KIM
E, Medial view 12 months after the operation. F, Donor-site appearance four months after the operation.
B
Figure 3. Case 3. Preoperative findings. A, Poor skin condition of the proximal forearm and flexion contracture of fourth and fifth fingers due to scar adhesion. B, Flap design on the left groin area (15 x 8 cm). C, Elevation of the flap and identification of the superficial circumflex iliac artery. (Figure continued on next page)
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JULY 1991
Figure 3, cont. D, Angiogram of the recipient site (arrow indicates the posterior ulnar recurrent artery). E, Postoperative appearance at 15 months with improvement of extension lag of fourth and fifth fingers. F, Postoperative appearance at 15 months with nearly full flexion of all fingers.
194
large size, comfortable position of the patient during surgery, minimal donor-site morbidity, possible coverage of the donor-site scar with a bikini, a multiple arterial and venous system, and the potential for incorporating bone with the overlying skin. However, there are some disadvantages such as difficult vessel dissection, many vessel variations, short length of the vascular pedicle, narrow vessel diameter, and a too bulky flap in the obese patient. The groin flap receives its blood supply through the superficial circumflex iliac artery, with or without the combined superficial inferior epigastric artery, the branches of the femoral artery. Daniel and Taylor10 reported an anatomic relationship between the superficial circumflex iliac artery and the superficial inferior epigastric artery, as reflected in their origin and distribution in 100 dissections. Their series showed four distinct patterns: 1) separate origins of the two vessels (14 percent); 2) common origin (40 percent); 3) absent superficial inferior epigastric artery with a compensatory larger superficial circumflex iliac artery and extended distribution (29 percent); and 4) both vessels arising from a "parent" artery instead of the femoral
artery (17 percent). They also reported that the diameter of the superficial circumflex iliac artery was 1.1 mm to 1.4 mm. In our series of 36 cases, the anatomic classification of the superficial circumflex iliac artery according to its origin was as follows: common origin with the superficial inferior epigastric artery in 15 cases (39.5 percent); isolated origin and absent superficial inferior epigastric artery in 14 cases (36.8 percent); separate origin in three cases (7.9 percent); and origin from the profunda femoral artery in six cases (15.8 percent). These results are similar to those of Daniel and Taylor. In our series, the average diameter of the superficial circumflex iliac artery was smaller than that of Daniel and Taylor. According to the above classifications, a prediction of the anatomic vessel variations, a major factor influencing results, may be possible. Reports on the success rates of free groin flaps are rare. Baudet and colleagues 4 reported nine successes in their 10 cases. Serafin et al.9 reported 10 successes in 14 cases. In our series, the success rate was 72.2 percent in 36 cases, and the result was better in the upper extremity than in the lower.
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 7, NUMBER 3
FREE GROIN FLAPS, EXTREMITY RECONSTRUCTION/HAHN, KIM
REFERENCES 1. Krizek TJ, Tari T, Desprez ID: Experimental transplantation of composite grafts by microsurgical vascular anastomosis. Plast Reconstr Surg 36:538, 1966 2. McGregor 1A, Jackson IT: The groin flap. Br I Plast Surg 25:3, 1972 3. Daniel RK, Taylor GI: Distant transfer of an island flap by microvascular anastomosis: A clinical technique. Plast Reconstr Surg 52:111, 1973 4. Baudet I, LeMaire ), Guimberteau I: Ten free groin flaps. Plast Reconstr Surg 57:577, 1976 5. Harii K, Ohmori K: Free groin flaps in children. Plast Reconstr Surg 55:588, 1975 6. Karkawski I, Buncke HI: A simplified technique for free transfer of groin flaps by use of a Doppler probe. Plast Reconstr Surg 55:682, 1975 7. O'Brien BM, MacLeod MA, Hayhurst IW, Morrison WA: Successful transfer of a large island flap from the groin to the foot by microvascular anastomoses. Plast Reconstr Surg 52:271, 1973 8. Riggs BM: Transfer of a free groin flap to the heel by microvascular anastomoses. Plast Reconstr Surg 55:36, 1975 9. Serafin D, Villareal-Rios A, Georgiade N: Fourteen free groin flap transfers. Plast Reconstr Surg 57:707, 1976 10. Daniel RK, Taylor GI: The anatomy of several free flap donor sites. Plast Reconstr Surg 56:243, 1975 11. Harii K, Ohmori K, Ohmori S: Successful clinical transfer of ten free flaps by microvascular anastomoses. Plast Reconstr Surg 53:259, 1974 12. O'Brien BM, Morrison WA, Ishida H, et al..-. Free flap transfers with microvascular anastomoses. Br I Plast Surg 27:220, 1974 13. Godina M: Preferential use of end-to-side arterial anastomosis in free flap transfers. Plast Reconstr Surg 64:673, 1979
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The major complications causing flap necrosis are known to be arterial and venous thromboses. These complications may be due to discrepancies in the diameter of the anastomosed vessels, excessive tension of the anastomosis site, excessive vessel length, kinking of the vessel, or poor vessel condition. In our series, we agree that the causes of flap necrosis were discrepancies in the vessel diameters or poor vessel condition, especially in the lower extremity. For early detection and treatment of these major complications, it is necessary to monitor skin temperature and capillary pulse continuously. Godina13 reported that results were better with end-to-side anastomosis than the end-to-end anastomosis. He suggested that the end-to-side technique had several advantages such as preservation of the vessels to the distal part of the limb, the possibility of easier surgical planning, the avoidance of retraction and spasm in the supplying recipient artery, and the prevention of gross disturbances in the resulting flow. In our cases, results were better with the end-to-side anastomosis, but there was no statistical significance between the different techniques. We consider that free groin-flap transplantation is a suitable procedure for one-stage reconstruction of severe soft-tissue injury, especially in the upper extremity.
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