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Sartorius muscle “twist” rotation flap: An answer to flap necrosis
TECHNICAl, NOTE
Sartorius muscle "twist" rotation flap: An answer to flap necrosis Ismail M. Khalil, M.D., and Laura Sudarsky, M.D., New York, N.Y. Transposition of the sartorius muscle was originally described in 1948 to cover exposed femoral vessels after inguinal lymph node dissection? This technique has since been used as a definitive or prophylactic treatment in groin infections after surgical reconstruction of the femoral vessels.2'3 This procedure is usually performed by division of the origin of the sartorius muscle, mobilization of the entire muscle medially, and reattachment of the muscle to the inguinal ligament and femoral sheath.4 The sartorius muscle receives a segmental blood supply with 8 to 11 vascular pedicles from the superficial femoral artery, which enter the muscle from its medial border. Division of more than three pedides may result in necrosis of the mobilized muscle flap. s Necrotic muscle usually becomes infected, resuiting in devastating complications in the underlying vascular suture line, especially in the presence of prosthetic material. Since the sartorius muscle is readily available, and its mobilization does not result in any functional impairment, it should be the primary choice for the purpose of muscle rotation in the groin. Other muscles can be used (e.g., the gracilis, rectus femoris, and rectus abdominis muscles), but their mobilization requires far more dissection and tends to prolong the operative procedure unnecessarily. In our experience with the old technique, we encountered three cases with flap necrosis that subsequently had significant morbid complications. During the past 6 years we have advocated this simple technique routinely in more than 20 patients with groin sepsis from drug abuse, infected lymph fistulas, and complex lower limb injuries without any incidence of muscle flap necrosis. We recommend the use of this new simple technique to prevent the rare but significant complication of muscle flap necrosis.
From the Departmentof Surgery,New YorkUniversityMedical Center. Reprint requests: IsmailM. Khalil, M.D., F.A.C.S., New York University Medical Center, 530 First Avenue, Suite 6D, New York, NY 10016.
l Fig. 1. Sartorius muscle exposed, its tendon detached at dotted line. Femoral artery (a) and vein (v) seen in medial aspect of wound.
TECHNIQUE The sartorius muscle fascia is incised longitudinally up to the tendon portion of the muscle (Fig. 1). With sharp dissection, the lateral and posterior surfaces are mobilized up to, but not including, the medial border. The segmental blood supply entering the muscle from its medial border is left undissected. Subsequently the muscle is twisted on itself such that the anterior surface now comes in close con-
93
94
Khalil and Sudarsky
Journalof VASCULAR SURGERY
\
\
Fig. 2. Lateral and posterior surface of muscle mobilized. Vascular pedicles seen entering medial and posterior surface of muscle. These pedicles should be left intact and attached to medial surface.
tact with the femoral vessels (Fig. 2). Finally the tendon is secured to the inguinal ligament with interrupted sutures of monofilament suture material, and the medial border is firmly secured to the perivascular tissue similarly (Fig. 3). It is important to secure the medial border of the rotated muscle very close to the femoral vessels to prevent the formation of dead space and subsequent collection of lymph or other body fluids. In muscular patients in whom the sartorius muscle can be hypertrophied, the muscle can be divided along the dotted line (Fig. 3), thereby permitting complete rotation of the flap. This final step prevents the thick muscle from bulging beyond the skin level, which may interfere with wound healing. SUMMARY Coverage of the femoral vessels with viable muscle flap after vascular reconstruction in the presence of infection is essential to prevent serious complications. Necrosis of the muscle flap as a result of
Fig. 3. Rotated muscle reattached to inguinal ligament and perivascular soft tissues with interrupted monofilament sunares. Vascular pedicles seen uninterrupted. Dotted line indicates level at which muscle could be completely transected to permit complete rotation if muscle belly is unusually hypertrophied.
interruption of its vascular pedicle can lead to complications that jeopardize the patient's life and limb. Our simple technique prevents such complications by preserving the muscle blood supply. We have used this method routinely during the past 6 years in patients with groin sepsis and did not encounter any case of muscle necrosis. REFERENCES 1. Baronofsky I. Technique of inguinal node dissection. Surgery 1948;24:555-6. 2. Fry WJ, Lindenauer SM. Infection complicating the use of plastic arterial implants. Arch Surg 1967;94:600-7. 3. Fernandez MM, Quast DC, Geis RC, et al. Distally based sartorius muscle flap in the treatment of infected femoral artery prostheses. J Cardiovasc Surg 1980;21:628-31. 4. Hines GL. The sartorius transposition in extra-anatomical bypass grafts. Vase Surg 1981;15:99-101. 5. Mathes SJ, Nahai F. Clinical applicatons for muscle and musculocutaneous flaps. St. Louis: CV Mosby Co, 1982:58-62.
Sartorius muscle "twist" rotation flap: An answer to flap necrosis Ismail M. Khalil, M.D., and Laura Sudarsky, M.D., New York, N.Y. Transposition of the sartorius muscle was originally described in 1948 to cover exposed femoral vessels after inguinal lymph node dissection? This technique has since been used as a definitive or prophylactic treatment in groin infections after surgical reconstruction of the femoral vessels.2'3 This procedure is usually performed by division of the origin of the sartorius muscle, mobilization of the entire muscle medially, and reattachment of the muscle to the inguinal ligament and femoral sheath.4 The sartorius muscle receives a segmental blood supply with 8 to 11 vascular pedicles from the superficial femoral artery, which enter the muscle from its medial border. Division of more than three pedides may result in necrosis of the mobilized muscle flap. s Necrotic muscle usually becomes infected, resuiting in devastating complications in the underlying vascular suture line, especially in the presence of prosthetic material. Since the sartorius muscle is readily available, and its mobilization does not result in any functional impairment, it should be the primary choice for the purpose of muscle rotation in the groin. Other muscles can be used (e.g., the gracilis, rectus femoris, and rectus abdominis muscles), but their mobilization requires far more dissection and tends to prolong the operative procedure unnecessarily. In our experience with the old technique, we encountered three cases with flap necrosis that subsequently had significant morbid complications. During the past 6 years we have advocated this simple technique routinely in more than 20 patients with groin sepsis from drug abuse, infected lymph fistulas, and complex lower limb injuries without any incidence of muscle flap necrosis. We recommend the use of this new simple technique to prevent the rare but significant complication of muscle flap necrosis.
From the Departmentof Surgery,New YorkUniversityMedical Center. Reprint requests: IsmailM. Khalil, M.D., F.A.C.S., New York University Medical Center, 530 First Avenue, Suite 6D, New York, NY 10016.
l Fig. 1. Sartorius muscle exposed, its tendon detached at dotted line. Femoral artery (a) and vein (v) seen in medial aspect of wound.
TECHNIQUE The sartorius muscle fascia is incised longitudinally up to the tendon portion of the muscle (Fig. 1). With sharp dissection, the lateral and posterior surfaces are mobilized up to, but not including, the medial border. The segmental blood supply entering the muscle from its medial border is left undissected. Subsequently the muscle is twisted on itself such that the anterior surface now comes in close con-
93
94
Khalil and Sudarsky
Journalof VASCULAR SURGERY
\
\
Fig. 2. Lateral and posterior surface of muscle mobilized. Vascular pedicles seen entering medial and posterior surface of muscle. These pedicles should be left intact and attached to medial surface.
tact with the femoral vessels (Fig. 2). Finally the tendon is secured to the inguinal ligament with interrupted sutures of monofilament suture material, and the medial border is firmly secured to the perivascular tissue similarly (Fig. 3). It is important to secure the medial border of the rotated muscle very close to the femoral vessels to prevent the formation of dead space and subsequent collection of lymph or other body fluids. In muscular patients in whom the sartorius muscle can be hypertrophied, the muscle can be divided along the dotted line (Fig. 3), thereby permitting complete rotation of the flap. This final step prevents the thick muscle from bulging beyond the skin level, which may interfere with wound healing. SUMMARY Coverage of the femoral vessels with viable muscle flap after vascular reconstruction in the presence of infection is essential to prevent serious complications. Necrosis of the muscle flap as a result of
Fig. 3. Rotated muscle reattached to inguinal ligament and perivascular soft tissues with interrupted monofilament sunares. Vascular pedicles seen uninterrupted. Dotted line indicates level at which muscle could be completely transected to permit complete rotation if muscle belly is unusually hypertrophied.
interruption of its vascular pedicle can lead to complications that jeopardize the patient's life and limb. Our simple technique prevents such complications by preserving the muscle blood supply. We have used this method routinely during the past 6 years in patients with groin sepsis and did not encounter any case of muscle necrosis. REFERENCES 1. Baronofsky I. Technique of inguinal node dissection. Surgery 1948;24:555-6. 2. Fry WJ, Lindenauer SM. Infection complicating the use of plastic arterial implants. Arch Surg 1967;94:600-7. 3. Fernandez MM, Quast DC, Geis RC, et al. Distally based sartorius muscle flap in the treatment of infected femoral artery prostheses. J Cardiovasc Surg 1980;21:628-31. 4. Hines GL. The sartorius transposition in extra-anatomical bypass grafts. Vase Surg 1981;15:99-101. 5. Mathes SJ, Nahai F. Clinical applicatons for muscle and musculocutaneous flaps. St. Louis: CV Mosby Co, 1982:58-62.