Conventional versus endoscopic free gracilis muscle harvest

Compared with conventional techniques, the endoscopically assisted harvest of free tissue has advantages such as minimal interference with cosmesis and reduced donor-site morbidity. However, the procedure also requires training and has an extensive learning period. In this series of 22 patients, the initial gracilis muscle flaps were harvested using a conventional method; the subsequent flaps were harvested with the aid of endoscopic instrumentation. Endoscopically assisted gracilis muscle harvest in 16 patients was compared with open method harvest in six patients. The endoscopically assisted group had an average incision length of 6.5 cm; that of the conventional group was 15.5 cm. There was one reexploration in the endoscopically assisted group, but all flaps were transferred successfully. Using this minimally invasive technique of vascular and muscular dissection, assisted by endoscopic instruments designed for distal muscle dissection and transection, the gracilis muscles can be harvested within 40 minutes. We consider endoscopically assisted harvest of free gracilis muscle to be safe, relatively simple, and cost-effective.     

The adductor flap: a new method for transferring posterior and medial thigh skin

Skin flaps from the medial aspect of the thigh have traditionally been based on the gracilis musculocutaneous unit. This article presents anatomic studies and clinical experience with a new flap from the medial and posterior aspects of the thigh based on the proximal musculocutaneous perforator of the adductor magnus muscle and its venae comitantes. This cutaneous artery represents the termination of the first medial branch of the profunda femoris artery and is consistently large enough in caliber to support much larger skin flaps than the gracilis musculocutaneous flap. In all 20 cadaver dissections, the proximal cutaneous perforator of the adductor magnus muscle was present and measured between 0.8 and 1.1 mm in diameter, making it one of the largest skin perforators in the entire body. Based on this anatomic observation, skin flaps as large as 30 x 23 cm from the medial and posterior aspects of the thigh were successfully transferred. Adductor flaps were used in 25 patients. On one patient the flap was lost, in one the flap demonstrated partial survival, and in 23 patients the flaps survived completely. The flap was designed as a pedicle island flap in 14 patients and as a free flap in 11.When isolating the vascular pedicle for free tissue transfer, the cutaneous artery is dissected from the surrounding adductor magnus muscle and no muscle is included in the flap. Using this maneuver, a pedicle length of approximately 8 cm is isolated. In addition to ample length, the artery has a diameter of approximately 2 mm at its origin from the profunda femoris artery. The adductor flap provides an alternative method for flap design in the posteromedial thigh. Because of the large pedicle and the vast cutaneous territory that it reliably supplies, the authors believe that the adductor flap is the most versatile and dependable method for transferring flaps from the posteromedial thigh region.     

Distally based anterolateral thigh flap: an anatomic and clinical study

The distally based anterolateral thigh flap has been used for coverage of soft-tissue defects of the knee and upper third of the leg. This flap is based on the septocutaneous or musculocutaneous perforators derived from the lateral circumflex femoral system. The purpose of this study was to examine the results of anatomical variations of the descending branch of the lateral circumflex femoral artery and the retrograde blood pressure of the descending branch of the lateral circumflex femoral artery so that the surgical technique for raising and transferring a distally based anterolateral thigh flap to the knee region could be improved. The authors have actually used this flap in three cases. In 11 thighs of six cadavers, the descending branch of the lateral circumflex femoral artery had a rather consistent connection with the lateral superior genicular artery or profunda femoral artery in the knee region. The pivot point, located at the distal portion of the vastus lateralis muscle, ranges from 3 to 10 cm above the knee. In their three cases, the maximal flap size was 7.0 x 16.0 cm and was harvested safely, without marginal necrosis. The mean pedicle length was 15.2 +/- 0.7 cm (range, 14.5 to 16 cm). The average proximal and distal retrograde blood pressure of the descending branch of the lateral circumflex femoral artery was also studied in another 11 patients, and the anterolateral thigh flap being used for reconstruction of head and neck defects showed 58.3 and 77.7 percent of proximal antegrade blood pressure, respectively. The advantages of this flap include a long pedicle length, a sufficient tissue supply, possible combination with fascia lata for tendon reconstruction, and favorable donor-site selection, without sacrifice of major vessels or muscles.     

局限性小切口开胸术在胸外科中的应用

目的：通过对标准的胸外科手术切口与局限性小切口的对比,了解局限性小切口的优点。方法：146例患者,随机分为2组,分别行标准的胸外科手术切口与局限性小切口,观察2组术中失血量,术后3天胸腔引流量,住院时间,住院花费及术后疼痛程度。进行对比及统计学分析。结果：局限性小切口组的术中失血量,术后3天胸腔引流量,住院时间,住院花费及术后疼痛程度明显好于标准的胸外科手术切口组。结论：局限性小切口能够减少术中失血量及术后引流量。缓解术后疼痛,缩短住院时间,减少住院花费,是一值得推广的方法。     

The long head of the triceps brachii as a free functioning muscle transfer

This anatomic study investigates the possibility of using the long head of the triceps brachii muscle as a free functioning muscle transfer for the upper limb. It has been reported that the long head is not difficult to harvest and that its loss does not create significant donor-site morbidity. The muscle was studied in 23 fresh frozen upper limbs. The long head in all 23 specimens had a constant and proximal vascular pedicle from the profunda brachii artery and vein. The mean pedicle was long (4 cm) and had large-caliber vessels (diameter, 3-mm artery and 4-mm vein). Angiograms were carried out in five specimens and dye perfusion studies in six specimens. A single branch from the radial nerve of at least 7 cm in length innervated the muscle. Muscle architecture was studied in 12 specimens and revealed that the long head of the triceps is better suited for forearm reconstruction than either the gracilis or the latissimus dorsi muscles. The mean physiologic cross-sectional area (8.36 cm(2)) and fiber length (10.8 cm on the superficial surface and 8.2 cm on the deep surface) of the long head match more closely those of the flexor digitorum profundus and the extensor digitorum communis, the muscles most commonly replaced.     

Segmental gracilis free flap based on secondary pedicles: anatomical study and clinical series

The gracilis muscle has been used extensively in reconstructive surgery, based on the proximal dominant pedicle. In the literature, little attention has been paid to the secondary distal pedicles. The distribution of the secondary pedicles of the gracilis muscle was investigated in 20 cadaver thighs. The mean number of secondary pedicles was 2.2 (range, two to three). When two pedicles were present-the most common situation-they were located at a mean distance of 12.4 and 17.5 cm from the knee joint line. The most proximal secondary pedicle was injected with barium sulfate in five specimens, and constant and abundant connections with the main pedicle were noted. A series of seven clinical cases of segmental gracilis free muscle flaps based on a secondary pedicle is reported. The flaps were successfully transferred to reconstruct traumatic defects of limited size, with one case of partial necrosis caused by a technical error. The morbidity of this flap is minimal, the scar is well hidden, the muscle need not be sacrificed, elevation is fast and straightforward under tourniquet control, and the pedicle is sizable. This flap should be considered a viable option when a small, straightforward free flap is needed.     

A fasciocutaneous flap for vaginal and perineal reconstruction

A skin and fascia flap from the medial thigh is proposed for vaginal and perineal reconstruction. Dissection, vascular injection, and radiographs of 20 fresh cadaver limbs uniformly demonstrated the presence of a communicating suprafascial vascular plexus in the medial thigh. Three to four nonaxial vessels were consistently found to enter the proximal plexus from within 5 cm of the perineum. Preservation of these vessels permitted reliable elevation of a 9 X 20 cm fasciocutaneous flap without using the gracilis muscle as a vascular carrier. Fifteen flaps in 13 patients were used for vaginal replacement and coverage of vulvectomy, groin, and ischial defects. Depending on the magnitude of the defect, simultaneous and independent elevation of the gracilis muscle provided additional vascularized coverage as needed. Our experience indicates that the medial thigh fasciocutaneous flap is a durable, less bulky, and potentially sensate alternative to the gracilis musculocutaneous flap for vaginal and perineal reconstruction.     

Influence of the relative difference in chair seat height according to different lower thigh length on floor reaction force and lower-limb strength during sit-to-stand movement

Chair-seat height affects the burden on the lower-limbs during sit-to-stand (STS) movement. Previous studies used the same height chair, attaching importance to practicability, but the difference in each subject's lower thigh length may relate to the burden on the lower-limbs. This study aimed to examine the influence of different lower thigh lengths on floor reaction force and lower-limb strength during an STS movement. Thirty young-adult male subjects participated in this study (age: 22.7+/-2.6 yr, height: 172.8+/-4.8 cm, body-mass: 66.3+/-5.2 kg). The subjects were divided into three groups (G1>42 cm, 42 cm > or =G2 > or =38 cm, 38 cm >G3) based on lower thigh length (G1: 44.1+/-2.5 cm, G2: 39.8+/-1.3 cm, G3: 34.3+/-2.1 cm). Namely, G1 was characterized by lower thigh length longer than 105% of 40 cm, G2 by 95-105% of lower thigh length and G3 by lower thigh length less than 95% of 40 cm, respectively. Subjects performed an STS movement twice from chairs at 40 cm-height and height adjusted by the lower thigh length of each subject. Vertical floor reaction force and electromyogram (EMG) on the rectus femoris and tibialis anterior muscles during an STS movement were measured to evaluate the force of knocking over and the burden on the lower-limbs. Fifteen parameters regarding floor reaction force (10) and EMG (5) were selected for analyses. Significant differences were found in floor reaction force at hip-syneresis (F1) and the impulse between hip-syneresis and appearance of the peak floor reaction force (F2). G1 was greater than G2 for the former, and G3 for the latter. Significant differences were found in active muscle mass of the tibialis anterior from the beginning of an STS movement to hip-syneresis (TE1) and peak active muscle level of the tibialis anterior (TE6). G1 was greater than G2 for the former, and G2 and G3 for the latter. It was suggested that when an STS movement is performed using a chair with the same height for each subject, the load imposed on the subject's leg at the time of an STS movement and the STS movement achievement strategy differed since chair seat height changes relatively by the difference in lower thigh length. Moreover, it is thought that the difference in these load conditions and movement strategies occurs when the chair seat height of a subject's lower thigh length is longer than 110%. When conducting the ability to achieve STS movement rating test, chair seat height considering each subject's lower thigh length may be needed.     

Topographic mapping of the superior transverse scapular ligament: a cadaver study to facilitate suprascapular nerve decompression

Division of the superior transverse scapular ligament for decompression of suprascapular nerve entrapment can be curative. However, the superior transverse scapular ligament can be difficult to locate, and large incisions are often required. This study was designed to determine the topographic coordinates of the superior transverse scapular ligament to permit reproducible surgical localization and reduce incision size. In 20 cadavers, the superior transverse scapular ligament was identified through a superior approach. Measurements were obtained from the superior transverse scapular ligament to external landmarks. The superior transverse scapular ligament was located 1.3 +/- 0.3 cm (+/- SD) posterior to the posterior border of the clavicle and 2.9 +/- 0.8 cm from the acromioclavicular joint in a two-dimensional surface plane. The depth of the superior transverse scapular ligament from the skin surface was 3.9 +/- 0.7 cm. An incision (mean length, 6.3 +/- 0.7 cm) derived from a novel system of planning marks facilitated access to the superior transverse scapular ligament. The authors conclude that the superior transverse scapular ligament can be located consistently through an incision located on the superior aspect of the shoulder on the basis of palpable topographic landmarks. The superior approach permits small incision size and the maintenance of local muscle anatomic integrity.     

Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation

Thirty-seven consecutive free anterolateral thigh flaps in 36 patients were transferred for reconstruction of head and neck defects following cancer ablation between January of 1997 and June of 1998. The success rate was 97 percent (36 of 37), with one flap lost due to a twisted perforator. The anatomic variations and length of the vascular pedicle were investigated to obtain better knowledge of anatomy and to avoid several surgical pitfalls when it is used for head and neck reconstruction. The cutaneous perforators were always found and presented as musculocutaneous or septocutaneous perforators in this series of 37 anterolateral thigh flaps. They were classified into four types according to the perforator derivation and the direction in which it traversed the vastus lateralis muscle. In type I, vertical musculocutaneous perforators from the descending branch of the lateral circumflex femoral artery were found in 56.8 percent of cases (21 of 37), and they were 4.83 +/- 2.04 cm in length. In type II, horizontal musculocutaneous perforators from the transverse branch of the lateral circumflex femoral artery were found in 27.0 percent of cases (10 of 37), and they were 6.77 +/- 3.48 cm in length. In type III, vertical septocutaneous perforators from the descending branch of the lateral circumflex femoral artery were found in 10.8 percent of cases (4 of 37), and they were 3.60 +/- 1.47 cm in length. In type IV, horizontal septocutaneous perforators from the transverse branch of the lateral circumflex femoral artery were found in 5.4 percent of cases (2 of 37). They were 7.75 +/- 1.06 cm in length. The average length of vascular pedicle was 12.01 +/- 1.50 cm, and the arterial diameter was around 2.0 to 2.5 mm; two accompanying veins varied from 1.8 to 3.0 mm and were suitable for anastomosis with the neck vessels. Reconstruction of one-layer defect, external skin or intraoral lining, was carried out in 18 cases, through-and-through defect in 17 cases, and composite mandibular defect in two cases. With increasing knowledge of anatomy and refinements of surgical technique, the anterolateral thigh flap can be harvested safely to reconstruct complicated defects of head and neck following cancer ablation with only minimal donor-site morbidity.     

Designing a surgical device for harvesting autologous fascia lata grafts as a minimal invasive procedure]

AIMS: Fascia lata is used in different shapes and sizes as a graft material in surgical procedures. The conventional method of harvesting a fascia lata graft is through a long skin incision on the lateral aspect of the thigh. Minimal invasive procedures have been established to reduce the disadvantages of an extensive surgical approach for obtaining the autotransplant. However, they do not facilitate to suture the remaining fascia after harvesting the transplant and therefore bear the risk of a symptomatic herniation of the muscle belly. The aim of this study was to design a surgical device to harvest a fascia lata graft and close the resulting fascia defect as a minimal invasive procedure. MATERIALS AND METHODS: The prototype was tested in 11 human cadaver specimens. It was introduced subcutanously via two small skin incisions. The device contained a special fixation- and working mechanism which enabled the fascial closure using a continuous suture. After the harvest procedure, both the transplant and the sutured fascia lata were examined. RESULTS: The experiments demonstrated the suitability of this method for minimal invasive harvesting of fascia lata. The removed transplants complied in all experiments with the expected dimensions. The continuous suture of the femoral fascia ran with accurate gaps between the sutures and constant tension without dehiscence. Neither the transplant nor the tissue in the region of harvest have shown unduly macroscopic damage due to the use of the device. CONCLUSION: The designed prototype can be used for harvesting a fascia lata graft and repairing the resulting defect minimal invasively. Clinical implementation seems possible. However, improvements could be made mainly concerning the handling of the device.     

Full-length phrenic nerve transfer by means of video-assisted thoracic surgery in treating brachial plexus avulsion injury

Phrenic nerve transfer has been widely used in treating brachial plexus avulsion injury. However, the present method crosses the thoracic part of the phrenic nerve, and nerve graft is needed, resulting in a long period of regeneration and partly irreversible muscle atrophy. We present our early experience of using video-assisted thoracic surgery to harvest a full length of phrenic nerve for transfer. Fifteen patients (mean age, 28 years) were treated. The thoracic part of the phrenic nerve was freed by means of video-assisted thoracic surgery and taken out of the thoracic cavity, and a full-length phrenic nerve was transferred to the musculocutaneous nerve to recover elbow flexion. The patients were followed. Another 29 patients with long-term follow-up who underwent traditional cervical phrenic nerve to musculocutaneous nerve transfer in our institute between 1994 and 1997 were selected. The period of newborn potential appearing in the biceps and the period for biceps to achieve M3 between two groups were compared. The operation was safe and no complications occurred. The additional length of phrenic nerve was 12.3 +/- 4.5 cm. Eleven patients received sufficient follow-up. Eight patients achieved biceps recovery to M3 (elbow flexion against gravity), and mean time was 198.8 +/- 36.0 days, much earlier than that of the traditional method (p < 0.01). Pulmonary function recovered to the preoperative level 9 months after operation. This new method is safe and minimally invasive. The result of full-length phrenic nerve transfer is much better than that of the traditional method. It obviously shortens the time required for nerve reinnervation, and offers a promising method for patients who have had a long interval from injury to operation and for forearm muscle reconstruction by phrenic nerve transferred to the median nerve or combined with free-muscle transfer.     

Growth hormone treatment in growth hormone-deficient adults. I. Effects on muscle mass and strength

The effect of recombinant DNA human growth hormone (rhGH) treatment in adults with growth hormone (GH) deficiency was studied in 24 patients in a double-blind placebo-controlled trial. The dose was 0.07 U/kg body wt daily. After 6 mo of treatment, significant increases were noted in the rhGH group for total cross-sectional area of thigh muscle (+11.2 +/- 3.1 vs. -0.5 +/- 3.0 cm2; P = 0.015 vs. placebo) and quadriceps muscle (+4.1 +/- 0.8 vs. +0.4 +/- 1.2 cm2; P = 0.031) measured by computerized tomography. Strong correlations were noted between lean body mass (measured as total body potassium) and total thigh muscle area in normal and GH-deficient adults both before and after rhGH treatment. Strength of hip flexors (+1.25 +/- 0.27 vs. +0.25 +/- 0.12 z-scores; P = 0.004) and limb girdle muscles increased (P = 0.02) in the rhGH group. We conclude that 1) rhGH increases lean tissue and skeletal muscle mass in adults with human GH deficiency, 2) this suggests a role for GH in the regulation of body composition of adult humans, 3) the increase in strength of limb girdle muscles after rhGH treatment suggests that adults with GH deficiency may have a proximal myopathy, and 4) the failure to demonstrate an increase in strength in other muscle groups may require the study of larger numbers of patients.     

Iliac crest bone graft harvesting techniques: a comparison

This study was undertaken to compare the morbidity of traditional iliac bone graft harvesting techniques for grafting alveolar clefts to minimally invasive techniques. Fifty-five age-matched patients, ages 6.5 to 16 years (mean, 11.2 years), 22 girls and 33 boys, were divided into three groups. The traditional bone window open harvesting technique served as the control group. Two different minimally invasive techniques, one that used a bone grinder and another that used a trephine, for bone harvesting were compared with the control. Both invasive techniques were statistically superior, p < 0.05, in terms of total time pain medication was necessary (mean of 12.0 hours for bone grinder, 17.6 hours for trephine, 26.0 hours for control), operative time for bone harvest (mean of 11 minutes for bone grinder and trephine, 20 minute for control), and mean incision length (2 cm for bone grinder and trephine, 5 cm for control). Patients exposed to the minimally invasive techniques had fewer complications, a trend toward earlier ambulation, and shorter hospital stays when compared with the bone grinder technique. The patients exposed to the bone grinder demonstrated earlier ambulation and fewer requirements for analgesia when compared with the trephine technique, although these results did not reach statistical significance. The trephine technique was useful when maxillary osteotomies were combined with alveolar bone grafting, because it provided structural bone grafts and cancellous bone. On the basis of these findings, the bone grinder is the preferred technique for harvesting alveolar bone grafts when no structural support is required. These authors no longer use the traditional bone window open harvesting technique.     

Endoscopically assisted reconstruction of male and female poland syndrome

Poland syndrome produces deformities of the breast and chest wall that can be highly disfiguring in both men and women. Incisions from traditional surgical approaches can be unsightly, especially if a muscle harvest is used as part of the reconstruction. Herein is described a case series in which minimally invasive techniques were used to reconstruct defects in male and female patients with Poland syndrome. When evaluating patients with Poland syndrome, one should consider using minimally invasive techniques as an alternative reconstructive option.     

Facial animation in children with Möbius syndrome after segmental gracilis muscle transplant

M?bius syndrome is a complex congenital anomaly involving multiple cranial nerves, including the abducens (VI) and facial (II) nerves, and often associated with limb anomalies. Muscle transplantation has been used to address the lack of facial animation, lack of lower lip support, and speech difficulties these patients experience. The purpose of this study was to investigate the results of bilateral, segmental gracilis muscle transplantation to the face using the facial vessels for revascularization and the motor nerve to the masseter for reinnervation. The outcome of the two-stage procedure was assessed in 10 consecutive children with M?bius syndrome by direct interview, speech assessment, and oral commissure movement. Preoperative data were collected from direct questioning, viewing of preoperative videotapes, notes from prior medical evaluations, and rehabilitation medicine and speech pathology assessments. All of the patients developed reinnervation and muscle movement. The children who described self-esteem to be an issue preoperatively reported a significant posttransplant improvement. The muscle transplants produced a smile with an average commissure excursion of 1.37 cm. The frequency and severity of drooling and drinking difficulties decreased postoperatively in the seven symptomatic children. Speech difficulties improved in all children. Specifically, of the six children with bilabial incompetence, three received complete correction and three had significant improvement. Despite the length and complexity of these procedures, complications were minimal. Muscle transplantation had positive effects in all problematic areas, with a high degree of patient satisfaction and improvement in drooling, drinking, speech, and facial animation. The surgical technique is described in detail and the advantages over regional muscle transfers are outlined. Segmental gracilis muscle transplantation innervated by the motor nerve to the masseter is an effective method of treating patients with M?bius syndrome.     

Modified temporal incision for facial rhytidectomy: an 18-year experience

An 18-year experience with the senior author's temporal incision is expounded. First, the existing sideburn is outlined with a marking pen. A sideburn is designed approximately 2 cm wide and 2 cm long, regardless of the extent of the existing sideburn providing the minimum sideburn. The posterocaudal portions of the newly designed sideburn will correspond to that of the existing dense portion of the sideburn. After dissection and removal of excess skin, the entire vertical portion of the scar will remain within the hair-bearing skin, eliminating the potential for visibility unless preoperatively the sideburn is less that 2 cm wide. There are several advantages to this approach. First, the configuration of the sideburn remains essentially unaltered. Second, the length of distribution for the redundant redraped facial skin is increased in comparison with most other incisions, thus avoiding a dog-ear regardless of the extent of the excess facial skin. Rhytidectomy is more effective because the distance from the incision to the nasolabial crease and the oral commissure is reduced, thereby effectively transmitting the traction forces to these sites compared with the conventional temporal incision that is placed above the ear. In addition, exposure of the surgical field is significantly enhanced by the added ability to rotate the skin flap medially. The potential disadvantage is that the operative time is increased to accommodate meticulous repair of the temporal incision. A slight modification of this incision has been implemented over the past 18 years, placing the anterior vertical incision farther posterior compared with the original report. The horizontal and posterior vertical portions of the incision are positioned at the hairline, resulting in an inconspicuous scar. None of the 125 patients in this latter group required a scar revision compared with 37 (4.28 percent) of 865 patients before this modification. This technique effectively achieves the goal of facial rhytidectomy and maintains a natural appearance without discernible scars for most patients. Patient and surgeon satisfaction with this method has been very high, and consequently, it has been used for almost all patients in the senior author's (Guyuron's) practice.     

Androgen therapy improves muscle mass and strength but not muscle quality: results from two studies

The relationship of strength to muscle area was used to assess change in muscle quality after anabolic interventions. Study 1: asymptomatic human immunodeficiency virus-positive men (39 +/- 9 yr) were randomized to nandrolone (600 mg/wk) +/- resistance training (RT). Study 2: older healthy men (72 +/- 5 yr) were randomized to oxandrolone (20 mg/day) or placebo. Maximum voluntary strength was determined by the 1-repetition maximum (1-RM) method for leg press, flexion and extension, and cross-sectional area of leg muscles by MRI. From study week 0 to study week 12, muscle quality was unchanged with nandrolone, oxandrolone, or oxandrolone placebo, respectively, for total thigh muscles (1.23 +/- 0.012 vs. 1.27 +/- 0.29 kg/cm2; 9.0 +/- 1.1 vs. 8.9 +/- 1.2 N/cm2; 8.9 +/- 1.2 vs. 8.9 +/- 1.9 N/cm2) and hamstrings (0.41 +/- 0.08 vs. 0.43 +/- 0.07 kg/cm2; 0.90 +/- 0.14 vs. 0.95 +/- 0.016 N/cm2; 0.94 +/- 0.23 vs. 0.93 +/- 0.21 N/cm2). Lower-extremity 1-RM strength increased several times greater with RT+nandrolone (51-63% increases) than with nandrolone alone (4.7-16%), despite similar increases in muscle area; therefore, muscle quality increased from 1.13 +/- 0.17 to 1.51 +/- 0.18 kg/cm2 (+36 +/- 19%; P < 0.001) for total thigh muscle, 0.37 +/- 0.10 to 0.53 +/- 0.08 kg/cm2 (+49 +/- 39%; P < 0.001) for hamstrings, and 0.73 +/- 0.19 to 1.07 +/- 0.16 kg/cm2 (+55 +/- 36%; P < 0.001) for quadriceps. Thus androgen therapy alone did not improve muscle quality, but the addition of RT to nandrolone produced substantive improvements.     

Extended approach to the vascular pedicle of the gracilis muscle flap: anatomical and clinical study

Dissection of the proximal gracilis vascular pedicle proceeds in a dark tunnel-like space deep to the adductor longus. With the application of a previously described technique for an extended approach to the lateral arm free flap, the authors describe a novel technique that improves observation and thus facilitates dissection of the proximal gracilis vascular pedicle. A retrospective review of data for 18 consecutive patients who underwent gracilis muscle free flap harvesting with this modified technique between March of 1999 and October of 2001 was conducted, to assess flap viability and patient outcomes. A cadaveric dissection was also performed, to study the anatomical features of the region in depth and to test the proposed flap modification. After the standard incision has been made, the dominant pedicle is exposed on the medial aspect of the gracilis muscle, running in a fascial cleft between the adductor longus and the adductor magnus. Intramuscular branches to the adductor longus are divided. A space is bluntly created anterior and lateral to the adductor longus by separating the fibrous connections to the surrounding adductor and sartorius muscles on both sides of the vascular pedicle. The gracilis muscle is then divided and passed deep to the adductor longus, into this space. With this new position, the final dissection of the pedicle can easily be performed. The confluence of the venae comitantes is frequently encountered, providing a larger-caliber single vein for microvascular anastomosis. The ages of the patients ranged from 9 to 70 years. The majority (14 of 18 patients) had traumatic wounds. The free flap survival rate was 100 percent. One minor complication of a seroma at the donor site was observed. One major complication of venous thrombosis was detected on postoperative day 3, with complete flap salvage. No other complications were noted. This technique is safe and permits direct approach to and excellent observation of the proximal aspect of the gracilis pedicle, without the need for headlights or deep retractors. An additional benefit is the frequent finding of a single larger vein from the merging of the venae comitantes close to the deep femoral vessels.