Plastic Surgery Research Council
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UTILITY OF PRE-OPERATIVE MRA IN ASSESSING GRACILIS FLAP VASCULAR ANATOMY
Presenter: Jamie A Schwartz, MD
Co-Authors: Smith M; Dayan JH; Sultan MR; Kagen A; Iyer AR; Samson W
St Lukes Roosevelt Hospital Center

The versatility of gracilis flaps has been attributed to the relative expendability of the muscle, a well-concealed donor site, and a perceived consistency of the vascular pedicle anatomy. More recently, the transverse upper gracilis myocutaneous free flap (TUG flap), alternative skin paddle variations of the gracilis flap, and gracilis perforator free flaps have gained popularity for use in breast reconstruction. As experience with these flaps has increased, reports of gracilis vascular pedicle variations have emerged. A double main pedicle is a vascular anomaly that may have significant clinical impact. This variant has been reported to occur in as many as 4.7 to 9% of limbs. Intra-operative algorithms have been developed to address this clinical scenario. In general, the smaller (less dominant) of the two pedicles may be ligated; however, this may result in flap failure, particularly when a large cutaneous territory is required. Magnetic resonance angiography (MRA) has been useful in pre-operative planning of abdominal flap-based, autologous breast reconstruction. This modality can be applied to pre-operative imaging of lower extremities prior to gracilis free flap surgery. When the appropriate limb is selected flaps with double main pedicles can be avoided. Twenty-nine consecutive patients underwent lower extremity MRA for pre-operative planning. These imaging studies were reviewed by all of the senior authors to characterize the anatomy of the gracilis vascular pedicle(s). One patient had previously undergone unilateral resection of a gracilis muscle for management of sarcoma; therefore, a total of 57 limbs were evaluated. Two limbs (3.5%) in two different patients were found to have a double main pedicle. The remaining limbs demonstrated a single dominant vascular pedicle.The incidence of gracilis muscles with a double main pedicle in this series is slightly lower than recent reports. Nevertheless, pre-operative MRA is an effective modality to identify anomalies of the gracilis muscle vascular anatomy. Pre-operative imaging may assist with appropriate selection of optimal donor sites.


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