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Tensor Fascia Lata, Rectus Femoris, Gracilis Flaps

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Presentation on theme: "Tensor Fascia Lata, Rectus Femoris, Gracilis Flaps"— Presentation transcript:

1 Tensor Fascia Lata, Rectus Femoris, Gracilis Flaps
Ian Maxwell

2 Tensor Fascia Lata

3 Overview Classification: Mathes and Nahai type I muscle flap
Pedicle length: up to 10cm Pedicle calibre: mm (artery) Uses Groin Ischium Perineum Lower abdomen Sacrum Trochanter

4 Anatomy Origin: Insertion: Blood supply: Innervation:
anterior iliac crest Insertion: illiotibial tract Blood supply: ascending branch of the lateral circumflex femoral artery Innervation: Sensory: lateral cutaneous sensory nerve of the thigh Motor: distal branch of the superior gluteal nerve The TFL muscle takes origin from the anterior iliac crest in an arc and inserts into the iliotibial tract.  The vascular pedicle enters the TFL muscle at the level of the junction of the proximal and middle thirds of an axis drawn from the anterior superior iliac spine to the lateral patella. The TFL muscle flap is supplied by the ascending branch of the lateral circumflex femoral artery.  The descending branch supplies the anterolateral thigh and rectus femoris flaps.  The descending branch can be harvested with the anterolateral thigh skin to enlarge the perfused vascular territory of the TFL flap.  Taking a large width of flap can create a significant aesthetic donor deformity, especially if skin grafting is required to close the defect.  The lateral femoral cutaneous nerve of the thigh travels through the flap skin and fat proximally to supply distal flap sensation.

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6 Variations Bone (ASIS) +/- TFL muscle Neurosensory
Include lateral sensory branch of T12 or lateral femoral cutaneous nerve Expanded or transverse skin paddle Perforator flap V-Y advancement

7 Surgical Markings Mark a line from ASIS to the lateral patella (anterior axis) Pedicle is located anywhere from 8-12 cm below ASIS Axis of femur marks posterior aspect of flap The patient is prepped and draped supine with a bump under the ipsilateral hip. The anterior part of the flap runs along the axis of the septum between the vastus lateralis and the rectus femoris. A line drawn from from the anterior superior iliac spine to the lateral patella locates this anterior landmark. The entry point of the pedicle is at the level of the junction of the proximal and middle third of the aforementioned line. The posterior aspect of the TFL is denoted by the axis of the femur. The flap is marked as an ellipse over the axis of the TFL muscle and to incorporate the pedicle proximally.

8 Dissection Elevate flap from distal to proximal
More proximally, retractor placed between rectus femoris and vastus lateralis First identify descending branch of LFCA, then identify ascending branch more superiorly Isolate pedicle course to TFL Pedicle can be traced to lateral femoral circumflex vessels/profundus to gain calibre and length The flap is elevated from distal to proximal. The skin and deep fascia are incised together and the plane deep to the iliotibial tract fascia is elevated sharply while coagulating small perforators. As one ascends proximally, the space between the rectus femoris and vastus lateralis is retracted with a self retaining retractor to identify the descending branch of the lateral femoral circumflex artery. The ascending branch is then identified as one proceeds in a superior direction. With the ascending branch identified, its course to the TFL can be isolated. The proximal flap is then divided by electrocautery while protecting the pedicle. The pedicle can be traced to the origin of the lateral femoral circumflex vessels to gain length and caliber.

9 Cases:

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12 Rectus Femoris

13 Overview Reliable blood supply and motor innervation
Classification: Mathes and Nahai type 2 (dominant and minor arterial supply) Major disadvantages are: Not a particularly expendable muscle Pedicle can be affected by atherosclerosis Coverage of lower abdomen, groin, ischium, trochanteric region, functional muscle transplantation

14 Anatomy Origin: iliac portion of acetabulum and ASIS
Insertion: patella Arterial supply: Dominant = descending branch of lateral femoral circumflex artery Minor = ascending branch of lateral femoral circumflex artery and muscular branch of SFA Vein = venae commitantes Pedicle length/calibre = 5cm/2mm Nerve = motor branch from femoral nerve

15 Variations With or without skin paddle Innervated functional muscle
Most perforators within middle third of thigh Innervated functional muscle

16 Surgical Markings Draw line from ASIS to mid patella for longitudinal axis Lazy S incision over muscle Pedicle just proximal to junction of proximal and middle thirds of thigh (8-10 cm below AIIS) Length limited to middle 1/3rd of thigh A line drawn from the anterior superior iliac spine to the mid aspect of the patella denotes the longitudinal axis of the muscle.  The incision is made in a lazy-'s' fashion to expose the required length of muscle.  The pedicle arises just proximal to the junction of the proximal and middle thirds of the muscle.  A skin paddle can be harvested with the width determined by ability to close the thigh with a pinch test, while the length is limited to middle third of the thigh. Cutaneous perforators can be determined with the pencil Doppler.

17 Flap dissection Incise through skin paddle (if required)
Through muscular fascia Sartorius and rectus femoris identified Sartorius retracted medially Lateral femoral circ vessels lie here on proximal portion of muscle Pedicle is 8-10cm below AIIS Muscle freed from medial, lateral, distal fascial attachments Raised on pedicle

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19 Gracilis

20 Overview Workhorse flap
Used for pedicled coverage of groin, vaginal/groin reconstruction Used as free innervated functional muscle for facial reanimation Segmental motor nerve supply allows muscle to be sectioned (3 branches: anterior, mid, posterior) Mathes and nahai type 2 muscle flap Pedicle length/calibre = 6cm/1-2mm

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22 Anatomy Origin = pubic ramus Insertion = pes anserinus Arterial supply
Dominant = terminal branch of MFCA Minor = branches of SFA and PFA Venous drainage = venae commitantes Nerve motor = anterior branch of obturator nerve Enters 1-2 cm superior to vascular pedicle Sensory = medial cutaneous nerve of thigh

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24 Flap variations: Can harvest with skin paddle (i.e. TUG flap)
Common second choice for breast FTT +/- innervated

25 Skin markings Axis of flap is line from ischium to medial condyle of knee Or palpate adductor longus: gracillis is 2-3 finger breadths posterior pedicle marked 10cm below ischium

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27 Flap dissection Incise over axis of muscle proximally
Optional distal incision to disinsert distal insertion Dissect down to fascia over gracillis and adductor longus until septum reached Retract these muscles apart from each other Pedicle lies here Proximal origin divided, pedicle dissected

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