Tensor Fascia Lata, Rectus Femoris, Gracilis Flaps

Ian Maxwell

Tensor Fascia Lata

Overview

• Classification: Mathes and Nahai type I muscle flap• Pedicle length: up to 10cm• Pedicle calibre: 1.5-2.5mm (artery)• Uses

– Groin– Ischium– Perineum– Lower abdomen– Sacrum– Trochanter

Anatomy• Origin:

– 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

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

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

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

Cases:

Rectus Femoris

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

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

Variations

• With or without skin paddle – Most perforators within middle third of thigh

• Innervated functional muscle

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

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

Gracilis

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

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

Flap variations:

• Can harvest with skin paddle (i.e. TUG flap)– Common second choice for breast FTT

• +/- innervated

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

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