Overview of Gracilis Tissue Transfer
The earliest recorded use of a “flap” – a piece of tissue that is still attached to your body with its own blood supply – dates back to 600 BC. This was when a surgeon named Sushruta Samita used local flaps for fixing noses. Unlike tissue grafts, which survive by drawing nutrients from a wound, flaps are removed with their own blood supply.
In 1972, a surgeon named Orticochea was the first to describe the use of a muscle known as the gracilis for creating such a flap. His technique has been refined over the years and in the same year, another doctor named Harri used this method to repair various soft tissue injuries. Soft tissues are parts of your body like muscles, fat, and tendons.
Today, the gracilis flap is a key tool for surgeons who perform reconstructive surgeries. Because it has a reliable blood supply, is versatile, and doesn’t cause much harm to the area it is taken from, the gracilis flap can be used to fix a wide variety of soft tissue problems.
Anatomy and Physiology of Gracilis Tissue Transfer
The gracilis muscle is the most outwardly present in a group of muscles known as the adductor muscles. It starts at the joint of the pubic bones and reaches out to the inner surface of the tibia, which is one of the bones in your lower leg. It’s broad and flat where it starts, but it becomes narrower as it reaches the leg. This muscle helps in bringing your limbs closer to your body, bending your knee and hip, and rotating your hip inward.
According to research by Mathes and Nahai, the gracilis relies on a Type 2 blood supply, meaning it has one dominant blood vessel and several smaller ones. The main blood vessel for this muscle is from the descending branch of the medial femoral circumflex artery. However, other branches directly from the deep artery of the thigh have been identified. The main blood vessels usually found approximately 10 cm below the pubic tubercle. Other branches from the femoral artery, go deep into the adductor longus and superficial to the adductor magnus muscles. Usually, two accompanying veins follow the main artery.
Mentioned above, the gracilis can also be harvested with a skin flap at the base of the muscle thanks to small vessels that supply the skin and muscle. The anterior branch of the obturator nerve, coming from the obturator foramen (a hole in the pelvis), gives signals to the muscle and the surrounding skin. This nerve then splits into two under a muscle called the pectineus muscle. Then the anterior branch goes between the adductor longus and brevis to provide signals to the deep portion of the gracilis muscle. Both the blood vessels and nerve branches can be harvested with about 7 cm of length, which is why the gracilis muscle is commonly used for tissue transfer surgeries.
Why do People Need Gracilis Tissue Transfer
The gracilis is a muscle in your leg that can be used in a procedure known as a “free tissue transfer.” This procedure essentially takes one part of your body (in this case, the gracilis muscle from your leg) and moves it to another part of your body to aid in recovery. This can be “functional” or “non-functional.”
A functional tissue transfer means the muscle is moved with its nerve still attached. This allows the muscle to move in its new location, providing a ‘live’ repair. Doctors have used this method with the gracilis muscle in cases such as nerve damage in the arm to regain bending of the elbow, to return wrist movement after certain muscular disorders, to help muscles in the face move again, and to restore finger movement after the removal of a tumor.
On the other hand, a non-functional tissue transfer does not keep the muscle’s ability to move in its new location. The main use for this method is to provide extra soft tissue coverage after an injury to the lower leg. The gracilis muscle has also been used as a secondary option for breast reconstruction surgery.
When a Person Should Avoid Gracilis Tissue Transfer
Essentially, there are no absolute reasons why a procedure called “free tissue transfer” cannot be performed. This procedure involves moving tissue from one part of the body to another. Importantly, being older does not increase the risk or complications of having this procedure.
That being said, there are a few factors that can increase the chances of complications occurring, such as the surgery not being successful or the transferred tissue failing. These factors include being in poor general health (described medically as being ‘ASA class III’), having a longer surgery time, being a smoker, and being overweight. However, it’s important to note that not one of these factors alone would make the surgery completely off-limits.
Equipment used for Gracilis Tissue Transfer
In simple terms, the tools needed for this type of surgery are pretty similar to those used in any standard surgery, but with the added requirement of certain highly specialized tools known as microsurgical instruments. One critical tool is something that magnifies the area being worked on. This could involve the use of magnifying glasses, known as loupes, or a microscope.
A microsurgical tray, which contains the microsurgical instruments, include tools similar to those that a jeweler might use, like jewelers’ forceps, along with micro scissors, tiny needle holders, very small clamps for blood vessels, and vessel dilators which are tools used to open up or widen blood vessels. Another essential part of the tray is the very tiny thread used for stitching, referred to as micro sutures (8-0, 9-0).
There are also certain medications that are applied directly to the surgical area or inside blood vessels, like papaverine, a drug that helps keep blood vessels open; a solution of saline and heparin, which prevents blood clots; and TPA, a medication used to dissolve blood clots. These should also be readily available during the operation.
The method used to monitor the ‘flap’, which is the tissue being moved around or worked on, can vary depending on where the surgery is being performed. Some methods might include the use of special devices that can detect blood flow inside your body (internal Doppler devices), monitors that measure the level of oxygen in your body through your skin (transcutaneous SpO2 monitors), or a handheld device that uses sound waves (a Doppler probe) to check blood flow.
Who is needed to perform Gracilis Tissue Transfer?
It’s best if the hospital team that assists in microscopic surgeries receives special training at the same hospital. Microscopic surgery tools are delicate and very different from standard surgical tools. When you’re in the ICU (Intensive Care Unit), nurses who have been trained to monitor skin and tissue grafts should be taking care of you. It’s crucial that the hospital staff have the right training to ensure the best results for your health.
Preparing for Gracilis Tissue Transfer
Like all operations, it’s important to have a detailed medical history and examination conducted beforehand. All potential risks and existing health conditions are reviewed and managed if needed. An important part of the process before the surgery is having a deep discussion with the anesthetic and nursing team. They make sure to avoid using certain types of medications that can affect blood pressure. It’s also important to have medicines on hand that prevent blood clotting. To reduce the risk of pressure sores, suitable padding is used on areas of the body that jut out, like hips and shoulders. The patient is then prepared for the operation by being thoroughly cleaned and covered with a sterile sheet to prevent infections.
How is Gracilis Tissue Transfer performed
The operation to lift the gracilis muscle, a thin muscle located on the inside of your thigh, is fairly straightforward. It is done under general anesthesia and the type of cut made into the skin can vary according to whether a skin flap is needed as part of the operation.
When prepping for surgery, the area from your pubic area to below your knee is sterilized. The leg on which surgery is happening is then positioned so it is moved away from your body and rotated outwards. This makes a muscle called the adductor longus tight and easy to feel at the point where it connects to your pubis, or pubic bone. The gracilis muscle is situated just behind this point. A line is then drawn from the start of the gracilis muscle down to the inside of your knee.
The gracious muscle is found under two thigh muscles called the adductor longus and adductor magnus. If there is uncertainty, the surgeon can move your knee because the gracilis is the only one of these three muscles that crosses the knee joint. After identifying the muscle, the surgeon carefully dissects the area around the muscle to identify its blood supply from deep within. This blood supply is usually found 10 cm from the pubic bone located between the adductor longus and magnus. The blood supply is then separated carefully from the surrounding structures.
If the muscle flap is being removed for a special type of tissue transfer that involves blood vessel reconnection, the surgeon locates a nerve branch called the anterior branch of the obturator nerve and follows it as far as necessary. The gracilis muscle is then divided or cut right where it starts and then again close to the pes anserinus, a place where it is attached at the inside of your knee, through a separate cut. This place is located just between the Sartorius muscle which is closer to the skin surface and semitendinosus muscle that’s deeper.
After lifting the flap of your muscle, it’s flushed with a solution containing a blood thinner called heparin and put in place in the affected area. It’s kept safe before it’s attached securely. Various techniques exist to connect the blood vessels. Sometimes stitches are used for the arteries, a type of blood vessel, and a venous coupler, a special device to directly connect veins, blood vessels that carry blood towards the heart, is used. After the blood flow to the flap is resumed, the flap is fitted into the defect or the area needing reconstruction.
If it was just the muscle that is transferred, depending on the surgeon’s preference, they can either apply a skin graft immediately or wait a few days. For muscle and skin flaps, the skin portion is fit into the defect, and an artery is identified for monitoring blood flow.
Possible Complications of Gracilis Tissue Transfer
Just like any other type of surgery, moving tissues from one part of your body to another can have complications. These complications might be minor, such as the skin dying off or only a part of the moved tissue (flap) not functioning properly. In more serious cases, the moved tissue might completely fail to work. According to a study, elderly individuals above 70 years and those with a high ASA (American Society of Anesthesiologists) score tend to experience more general complications from tissue transfer surgery. This ASA score is a measure that doctors use to assess a patient’s fitness before surgery. The higher the ASA score, the greater the risk for this surgery, and it also implies an increased likelihood of major complications with the moved tissue.
What Else Should I Know About Gracilis Tissue Transfer?
The free gracilis procedure is something all microsurgeons should know about and be able to do. It’s one of their go-to methods used for reconstruction. This surgery can be performed on many parts of the body to fix a wide range of soft tissue damages, functional problems, and to prevent the amputation of limbs.
