The Gracilis Musculocutaneous Flap As a Method of Closure of Ischial Pressure Sores: Preliminary Report

THE GRACILIS MUSCULOCUTANEOUS FLAP AS A METHOD OF CLOSURE OF ISCHIAL PRESSURE SORES: PRELIMINARY REPORT

By JOHN C. MCGREGOR, F.R.C.S. Edenhall Hospital, Musselburgh and Bangour General Hospital, West Lothian, Scotland

Abstract. Ischial pressure sores were treated by excision and repair with a gracilis musculocutaneous flap. The operative technique and results are discussed.

Key words: Ischial pressure sore; Gracilis musculocutaneous flap.

Introduction

WHILE the majority of ischial pressure sores can be excised and closed directly, this is not invariably so as when they are large or when previous operations have failed. Conservative and non-operative measures can be employed but take time, and scarred tissue is less durable to further trauma (Conway & Griffith, I956). These authors recommended ischiectomy, biceps femoris muscle flap turned into the defect and a medially based thigh rotation flap. With the realisation of the potential value of incorporating muscle and overlying skin as a musculo- or myo-cutaneous flap in the last few years (McCraw et al., I977) it was not long before musculo cutaneous flap repair of ischial defects was described. Various muscles have been used in these flaps including gluteus maximus (Minami et al., 1977), biceps femoris (James & Moir, I980), hamstring muscles (Hagerty et al., 1980), and the gracilis muscle (McCraw et al., 1977; Bostwick et al., 1979; Labandter, 1980). The gracilis muscle is a flat, thin, accessory adductor of the thigh which is expendable, even in the non-paraplegic. It is situated superficially on the medial

FIG. I A diagrammatic representation of the relationship of the various muscles on the medial aspee t of the thigh. 217 218 PARAPLEGIA aspect of the thigh between the adductor longus and sartorius anteriorly, semi membranosus posteriorly and adductor magnus posteriorly (Fig. I). The muscle has its origin from the inferior portion of the pubic symphysis. Its insertion is tendinous on to the upper medial aspect of the tibia. The major superior vascular pedicle (a branch of the profunda femoris) enters the muscle about 8 to 10 cm from the pubic tubercle. There are several minor vessels in the distal third of the muscle. In spite of its relatively superficial position on the medial compartment of the thigh, this muscle and associated vascularised skin may not be easy to identify. Not only is it a narrow muscle (about 3 to 4 cm wide), but it has been found that the amount of overlying skin that can safely be taken with the muscle is also rather limited (Bostwick et al., 1979). For these reasons it is advised that considerable care must be taken otherwise the wrong amount of skin and even the wrong muscle may be elevated.

Elevation of Gracilis Musculocutaneous Flap The identification and dissection is made considerably easier if the patient can be operated on in the lithotomy position and if it is remembered that the anterior border of the flaplies on a line drawn between the pubic tubercle and the adductor tubercle on the medial aspect of the tibia at the knee. The cutaneous portion of the flap extends 6 to 9 cm posterior to this line and is centred over the gracilis muscle. About 20 to 25 cm in length are available as the distal limit lies at the junction of the middle and distal thirds of the muscle. Figs 2 to 7 illustrate the dissection and use of a gracilis musculocutaneous flap in the repair of a recurrent

FIG. 2 With the patient in the lithotomy position the scarred area enclosing a recurrent ischial pressure sore has been outlined. The proposed skin flap has also been marked on the medial aspect of the thigh. The anterior limit is on an axis joining the pubic tubercle to the adductor tubercle. The posterior limit is about 8 cm from the anterior line. THE GRACILIS MUSCULOCUTANEOUS FLAP 219 ischial sore. The key to the operation is the identificationof the correct muscle and the preservation of the superior vascular pedicle. By using a small transverse incision at the distal end of the proposed flap, identifying the correct muscle becomes easy, especially if traction is performed (Fig. 4). In females, the gracilis muscle may be identified at the proximal end per vaginam (Freshwater, 1980).

FIG. 3 The sore and surrounding scarred area have been excised and projecting ischium has been removed.

FIG. 4 Identification of the gracilis muscle at the distal edge of the proposed musculocutaneous flap. By applying traction on the muscle it is possible to confirm that it lies under the marked area of overlying skin. 220 PARAPLEGIA

FIG. 5 The skin has been incised along the anterior and posterior markings. Care is taken to include the underlying gracilis muscle (which has been divided at the distal end of the wound). The main vascular pedicle lies near the end of the artery forcep and must be preserved.

FIG. 6 The skin island and underlying muscle pedicle are now mobile enough to be moved into the ischial defect. THE GRACILIS MUSCULOCUTANEOUS FLAP 221

FIG. 7 Flap sutured in position. Donor area in thigh has been closed directly.

Clinical Observations Six gracilis musculocutaneous flapshave been used to close six ischial pressure sore effects in five patients (Table I). In four of these, the sore in question had previously been treated by excision and direct closure. The decision to perform a gracilis flap was made because of the previous failure to achieve permanent healing. In the remaining two patients, the gracilis flap was selected because of the large size of the ischial defects. Two of the flaps healed quickly as did their respective donor areas; in one flap some necrosis occurred in the upper portion which required desloughing followed by direct closure. In the remaining three flaps, small areas of flap necrosis occurred which healed with conservative care. All donor areas in the thigh were closed directly and in three patients there were some problems with wound breakdown and delay in healing. Total in-patient time from operation to discharge varied from 4 weeks to 5 months with increased time in hospital directly associated with problems of flap and donor area healing. Follow up after discharge from hospital varied from 3 months to 3 years. Recurrence of the ischial pressure sore has occurred in two cases, only one of which required surgery (Fig. 8). This recurrence developed from direct trauma on the flap as a result of a road traffic accident. It was easily treated by direct closure as there was plenty of flaptissue and healthy muscle still present. Well-healed gracilis flaps are shown in Figures 9 and 10.

Discussion The management of ischial pressure sores is by no means easy and remains controversial. Undoubtedly, many of the smaller sores can be treated conserva tively. The problem is that many of them tend to recur since the predisposing N N N TABLE I Summary of cases and problems where gracilis musculocutaneous £lap was used to close ischial sores.

Case Site Previous history Flap closure-problems In-patient time Recurrence after flap ------.--_.------I.R.(F) Left 1970 Direct closure Slough in part required 5 weeks None-Follow-uP-3 years 51 years 1977 Recurrence excision and direct closure 1977 Gracilis flap

C.G.(F) Left 1976 New sore- Slight breakdown superior 4 weeks Accident-Direct trauma 33 years Gracilis flap aspect donor area thigh after 15 months (Fig. 8) treated by direct closure. 6 >-;j No recurrence months. :;.. ::<:l :;.. M.G.(F) Right 1973 Direct closure None 5 weeks None-Follow-up-21 years >-;j t-' 27 years 1976 Direct closure tTl Cl 1977 Direct closure ..... 1978 Gracilis flap :;..

Left 1974 Direct closure Distal part T.F.L. flap necrosed 2 months None-Follow-up-6 months 1979 Direct closure gracilis flap to repair-some 1979 T.F.L. flap necrosis part gracilis flap. 1979 Gracilis flap Healed conservatively

A.M.(M) Left 1977 Direct closure Necrosis distal part flap 5 months Superficial breakdowns x 2 71 years 1977 Recurrence and part donor wound thigh. Treated conservatively 1977 Gracilis flap Healed conservatively Died 1979

G.M.(M) Left 1979 Direct closure Flap-no problems 4 months None-Follow-uP-3 months 36 years 1980 Recurrence Dehiscence upper part donor 1980 Gracilis flap wound. Healed conservatively THE GRACILIS MUSCULOCUTANEOUS FLAP 223

FIG. 8 A recurrent ischial pressure sore in a previously applied gracilis musculocutaneous flap. Note the presence of healthy muscle fibres. This defect was closed directly and healed rapidly without complication. factors may remain and scar is less desirable than healthy tissue. Even with surgical closure, recurrence is still a problem. Conway and Griffith (1956), in their analysis of pressure sores, quoted a 77 per cent recurrence within 2 years for those treated conservatively. In their opinion the best results were obtained by ischiectomy, a biceps femoris muscle flap turned into the excision cavity, a large regional rotation skin flap and a split skin graft to the donor site of the flap (recur rence 3 per cent). Whichever surgical technique was used there appeared to be a significant problem in delayed wound healing related to the frequent occurrence of haematomas. It was claimed, however, that the use of a muscle to fillin the ischial cavity reduced the risk of these. Musculocutaneous flaps are of relatively recent use in reconstructive surgery (Pers & Medgyesi, 1973; Ger & Levine, 1976; McCraw et al., 1977; McGregor et al., 1980). Although the tensor fasciae latae (T.F.L.) musculocutaneous flap is an ideal flap for the repair of trochanteric sores, its use and reliability for ischial sores is by no means certain (McGregor & Buchan, 198ob). The gracilis musculocutaneous flap appears to have certain qualities that make it attractive for the repair of ischial defects. In particular it is well situated and lies relatively superficially on the medial aspect of the thigh. The donor area can be closed directly and the eventual scar is not normally subject to pressure. If care is taken, the identification of the muscle and subsequent elevation is not difficult. The lithotomy position provides a most comfortable way of enabling the operation to be performed and allows bilateral ischial sores to be repaired simultaneously (Wingate & Friedland, 1978). 224 PARAPLEGIA

FIG. 9 A well-healed musculocutaneous flap 5 weeks after surgical repair of a recurrent ischial sore. Note the scarring and grafted area from previous surgical procedures. This flap has remained completely healed for 3 years.

While most flaps healed relatively rapidly and appeared to provide a well padded cushion of tissue, post-operative progress was not entirely uneventful. The problems in primary healing of the gracilis flap and thigh donor area reflect both the unreliability of the vascularity of the flap and the liability of the perineal area to bacterial contamination. There was no evidence that haematoma formation was responsible in any of our cases and this would support the view that the insertion of muscle into the excision cavity does indeed reduce this troublesome complication. The fact that there were problems with wound healing was unex pected but these were a significant factor in delaying discharge from in-patient care. The reliability and advantages of the gracilis flapover other possible methods of repair must be questioned and contrasts with the rapid trouble-free healing of the tensor fasciae latae musculocutaneous flap (T.F.L.) in the repair of trochan teric defects (McGregor & Buchan, 1980a, b). The T.F.L. flap has been used on three occasions to provide closure of ischial pressure sores, including one where ischial and trochanteric defects were repaired with one flap. In all three cases there were minor areas of breakdown at the terminal portions of the flap; one of these required a gracilis musculocutaneous flap to complete healing (Case THE GRACILIS MUSCULOCUTANEOUS FLAP 225

FIG. 10 This shows a well-healed gracilis musculocutaneous flapon the right I year after surgery for an ischial ulcer. On the left a T.F.L. flap had been used to try to close a left ischial sore. This area of breakdown was subsequently successfully closed by a gracilis flap. Both gracilis flaps remain intact to date.

M.G., Table J). While the T.F.L. flap is an admirable method of repairing trochanteric defects, it is a rather extravagant flap to use for closure of ischial sores-unless ischial and trochanteric defects co-exist. Bostwick et al. (1979) are in no doubt that the T.F.L. flap is safer, more reliable, provides more tissue and is better vascularised than the gracilis flap and is now their first choice for repair of perineal and ischial defects. The gracilis musculocutaneous flap can be considered as a means of repairing ischial sores but requires further study to discover its place and what advantages, if any, it offers over other methods.

SUMMARY The gracilis muscle-skin flap can be used to close pressure sores of the ischium. It requires careful dissection. Further assessment is required before advising the use of this flap in all cases.

RESUME

On peut utiliser Ie lambeau de peau qui se trouve au-dessus du muscle 'gracilis' dans la fermeture des escarres (de compression) de l'ischium. On doit Ie dissequer avec soin. On a besoin de plus recherche avant de l'utilisation de ce lambeau dans tous les cas.

ZUSAMMENFASSUNG

Der Hautlappen, der sich tiber dem Gracilis-Muskel befindet, kann zur Schliefiung druckempfindlicher Wundstellen des Sitzbeins (Ischium) verwendet werden. Man mufi dabei sorgfaltig sezieren. Eine weitere Begutachtung ist erforderlich, bevor in allen Fallen eine Verwendung dieses Hautlappens anzuraten ist. 226 PARAPLEGIA

Acknowledgements. I am grateful to the Department of Medical Illustration in Bangour General Hospital for providing the illustrations and to Mrs J. K. Meredith for typing the manuscript. The Editor of the British Journal of Plastic Surgery kindly gave permission for Fig. 10 to be published.

REFERENCES

BOSTWICK, J., HILL, H. L. & NAHAl, F. (1979). Repairs in the lower abdomen, groin or perineum with myocutaneous or omental flaps. Plastic and Reconstructive Surgery, 63, 186-194. CONWAY, H. & GRIFFITH, B. H. (1956). Plastic surgery for closure of decubitus ulcers in patients with paraplegia based on experience with 1000 cases. Am. J. Surgery, 91, 946-975· FRESHWATER, M. F. (1980). Intra-operative identification of the gracilis muscle for vaginal reconstruction. Plastic and Reconstructive Surgery, 65, 356-357. GER, R. & DEVINE, S. A. (1976). The management of decubitus ulcers by muscle trans portation. An 8-year review. Plastic and Reconstructive Surgery, 58, 419-428. HAGERTY, R. F., HAGERTY, R. O. & HAGERTY, H. F. (1980). The hamstring myocutaneous flap in the repair of ischial decubiti. Annals of Plastic Surgery, 5, 227-231. JAMES, J. H. & MOIR, I. H. (1980). The biceps femoris musculocutaneous flap in the repair of pressure sores around the hip. Plastic and Reconstructive Surgery, 66, 736-739. LABANDTER, H. P. (1980). The gracilis muscle flap and musculocutaneous flap in the repair of perineal and ischial defects. British Journal of Plastic Surgery, 33, 95-98. MCCRAW, J. B., DIEBEL, D. G. & CARRAWAY, J. H. (1977). Clinical definition of inde pendent myocutaneous vascular territories. Plastic and Reconstructive Surgery, 60, 341-352. MCGREGOR, J. C., BUCHAN, A. C. & WATSON, A. C. H. (1980). Musculocutaneous flaps in reconstructive surgery. Journal of the Royal College of Surgeons of Edinburgh, 25, 400-414. MCGREGOR, J. C. & BUCHAN, A. C. (1980a). Our clinical experience with the tensor fasciae latae myocutaneous flap. British Journal of Plastic Surgery, 33, 270-276. MCGREGOR, J. C. & BUCHAN, A. C. (1980b). Tensor fasciae latae flap and its use in the closure of trochanteric and ischial pressure sores. Paraplegia, 18, 301-305. MINAMI, R. T., MILLS, R. & PARDOE, R. (1977). Gluteus maximus myocutaneous flaps for repair of pressure sores. Plastic and Reconstructive Surgery, 60, 242-249. PERS, M. & MEDGYESI, S. (1973). Pedicle muscle flaps and their applications in the surgery of repair. British Journal of Plastic Surgery, 26, 313-321. WINGATE, G. B. & FRIEDLAND, J. A. (1978). Repair of ischial pressure sores with gracilis myocutaneous island flaps. Plastic and Reconstructive Surgery, 62, 245-248.