Annals ofBurns and Fire Disasters - vol. VIII - n. 4 - December 1995

THE USE OF FASCIOCUTANEOUS THIGH FLAPS IN THE RECONSTRUCTION OF GROIN AND TROCHANTERIC DEFECTS

Higazi M, Ayad H, Shalaby H.

Plastic and Reconstuctive Surgery Unit, Tanta University, Tanta, Egypt

SUMMARY. Anterolateral and anteromedial fasciocutaneous thigh flaps were used in the treatment of fifteen patients suffering from postburn groin contracture. The anterolateral fasciocutaneous flap was used to cover trochanteric bedsores in five patients. The flaps were found to be large enough to cover extensive defects. The vascular pedicle is long with a wide are of rotation and minimal anatomical variation. The morbidity of the donor site is acceptable.

Post-burn contracture of the groin, although uncommon, causes patients distressing symptoms that are difficult to treat. A variety of different techniques are available: skin grafting, local cutaneous flaps, and fascio- or myocutancous flaps. Roberts and Dickson' stated that skin grafting has multiple disadvantages as it is of uncertain take and needs prolonged splinting and immobilization, with recontracture not being uncommon. The use of local flaps is suitable only for narrow contractures and needs sufficient normal skin around the contracted area, while it is always insufficient. Nahai et al.' described the use of tensor fascia lata myocutaneous flap for groin defects. Bostwick et al.' used the omentum and myoeutaneous flaps for the repair of groin defects after ablative surgery. Wang et al.' used the medial fasciocutaneous flap for the repair of perineum, vagina and groin defects. Hayashi and Maruyawa,' Turley et al.' used the same flap for post-burn groin contracture. Maruyama et al.' used the lateral thigh flap for the repair of ischial trochanteric defects.

Fig. 1 - The design of the anterornedial fasciocutaneous thigh flap in a case of contracted groin and axilla. Fig. 2 - The vascular pedicle of the anterornedial fasciocutaneous thigh flap.

In the present study we used medial and lateral fasciocutaneous thigh flaps to cover groin and trochanteric defects.

This study was performed in fifteen patients suffering from post-bum contracted groin and five patients suffering from trochanteric bedsores. The age range was from six to fifteen years. Fourteen patients were female and six were male.
According to the severity of the contracture and the area of healthy skin on the thigh, the patients with postburn contracture were treated with one of the two techniques, while the patients with trochanteric bedsores were treated with the anterolateral fasciocutaneous thigh flap.

Under general anaesthesia, and after sterilization of the area with 10% povidone iodine, the recipient site was prepared by release of the contracture in burned patients and by excision of all dead tissue in trochanteric defects.

1. Anteromedial fasciocutaneous flap

First the design of the flap was drawn, as shown in Fig. 1. For elevation of the flap, skin incision was started at the lower border and continued at the medial and lateral borders. The wound was then deepened and the deep fascia was sutured to the skin to prevent shearing movements The flap was elevated from below, upwards and sub fascially as far as the rotation point 6-8 cm below the inguinal ligament in the midline of the thigh, where the vascular pedicle was searched for around the border of the sartorius muscle at the apex of the femoral triangle (Fig. 2). The flap was rotated to cover the defect either under a tunnel or directly in severe cases. The deep fascia was fixed by Vicryl 3/0 interrupted sutures and the skin was closed by silk sutures. The donor site was closed either pri marily or with skin grafting (Fig. 3).
The flap was designed and drawn on the thigh with the patient supine, the thigh slightly flexed and the hip internally rotated.
2. Anterolateral fasciocutaneou s thigh flap The posterior edge of the iliotibiallract was traced up from the lateral condyle of the femur to the greater trochanter. The vascular supply of the skin could be detected at the middle of this line at the mid-inguinal point (Fig. 4),
Dissection started distally and proceeded on both sides deep to the fascia. The edges of the fascia were sutured to the skin to prevent any shearing effect. The vascular pediele was searched for and followed proximally to lengthen the arc of rotation. It is present at a fixed point on a line drawn from the anterior superior iliae spine to the lateral edge of the patella. The cutaneous branch either penetrates the vastus lateralis, in which case a cuff of the muscle has to be excised with the vessel, or it passes into the intermuscular space.' The flap was then rotated to cover the defect and the donor site was closed primarily or by grafting (Fig. 5).

The patients were classified in four groups on the basis of ' the severity of the contracture and the area of healthy skin availableon the abdomen and thigh.

Fig. 3 - The flap in position and the donor site closed primarily. The contracted axilla repaired by multiple Z-plasty. Fig. 4 - The design of the anterolateral fasciocutaneous thigh flap. Fig. 5 - The flap transposed under skin tunnel to the recipient site. Fig. 6 - Giant defect closed with anterolateral flap and split thickness skin graft. The donor site closed primarily.

* Group one: localized narrow band or web of contracture with healthy surrounding skin
* Group two: diffuse or broad band of contracture with intact abdominal and thigh~skin
* Group three: diffuse or broad band of contracture with scarred abdominal and normal thigh skin
* Group four: diffuse contracture with scarred abdominal and thigh skin

The post-burn patients described in this work belonged to the first three groups. It was difficult preoperatively to predict the Size of the defect, but after contracture release the extent ranged from 7 x 12 to 20 x 23 em. In wide defects the flap was not sufficient and split-thickness skin graft was used either above or below the flap (Fig. 6). The vascular pedicle of the anteromedial fasciocutaneous flap. was found at the superomedial border of the sartorius, muscle at the apex of the femoral triangle 6-8 em from the mid-inguinal point.
The vascular pediele of the anterolateral fasciocutaneous flap was found-to be constant. Dissection of the descending branch as far as its origin gave a long pedicle facilitating the flap's arc of rotation. The donor site of both flaps was closed primarily in twelve cases. In the other cases split-thickness skin graft was used to cover the donor site (Fig. 7).
The commonest complication was seroma, which was overcome by use of a Portovae suction drainage system at the recipient site under the flap. Necrosis of the distal end of the flap occurred in one case of anteromedial fasciocutaneous flap. This healed after conservative treatment without surgical intervention (Fig. 8). The end results of both kinds of flap were functionally and aesthetically good, with minimal complications and morbidity in donor sites (Figs. 9, 10, 11).

Turley et al.1 reports on a variety of techniques used by different authors for the reconstruction of groin defects, none of which is ideal, including multiple Z-plasty, local cutaneous flaps and myocutaneous flaps.
Skin grafting has several disadvantages, e.g. uncertain graft take with recontracture requiring prolonged immobilization. Larson et al.1 and Roberts and Dickson' have found that skin grafting commonly leads to hyperpigmentation and poor cosmetic results.
To prevent these complications, Mathes and Nahai" and Budo et al.11 preferred to use flaps for the coverage of flexor areas. The use of muscle and myocutaneous flaps, although suitable for covering deep defects of the groin and bedsores, as used by Bostwick et al.,I Hill et al." and Gopinath et al.," leads to marked defects at the donor site and a bulk at the recipient site. Ponten" and Maruyama et al.' preferred the use of fasciocutaneous flaps to cover the defects and to prevent the drawbacks of myocutaneous flaps.
In this work the use of the fasciocutaneous flap showed the following advantages:

1. the flap is large enough, having a long vascular pedicle with a wide arc of rotation and minimal anatomical variations.
2. the dissection and raising of the flap is easy and leaves minimal morbidity at the donor site, which is commonly a linear scar.

Fasciocutaneous thigh flaps are therefore recommended in the treatment of groin and trochanteric defects.

Fig. 7 - Groin defect covered with anterolateral flap. The donor site closed with skin graft. Fig. 8 - Healed superficial necrosis of distal end of anterornedial flap. Fig. 9 - Late result of the anteromedial flap. Fig. 10 - Late result of the bilateral anterolateral flap. Fig. 11 - Late result of the anterolateral flap in trochanteric bedsore.

RESUME. Les auteurs ont utilisé le lambeau antérolatéral et antéromédial fasciocutané de la cuisse dans le traitement de quinze patients atteints de contractures inguinales dues aux brûlures, et le lambeau fasciocutané antérolatéral pour couvrir les escarres de décubitus chez cinq patients. Les lambeaux étaient assez grands pour couvrir des défects étendus. Le pédicule vasculaire est long, avec un large arc de rotation et une variation anatomique minimale. La morbidité du site donneur est acceptable.

BIBLIOGRAPHY

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2. Nahai F., Hill H.L., Hister T.R.: Experiences with the tensor fascia lata flap. Plast. Reconstr. Surg., 63: 788, 1979.
3. Bostwick J., Hill H.L., Nahai F.: Repair of large soft tissue defects of inguinal region and perineurn with myocutaneous or omental flaps. Plast. Reconstr. Surg., 63: 186, 1979.
4. Wang T., Whetzel T., Mathes S.J., Vasconez L.O.: Fasciocutaneous flap for vaginal and perineal reconstruction. Plast. Reconstr. Surg., 80: 95-102, 1987.
5. Hayashi A., Maruyama Y.: The use of the anteromedial thigh fasciocutaneous flap in the reconstruction of the lower abdomen and inguinal region; a report of two cases. Brit. J. Plast. Surg., 41: 6338, 1988.
6. Turley C.B., Cutting P., Clarke J.A.: Medial fasciocutaneous flap of thigh for release of post-bum groin contractures. Brit. J. Plast. Surg., 44: 36-40, 1991.
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13. Gopinath K.S., Chandra Shekhar M., Kumar M.V., Sirkant K.S.: Tensor fascia lata myocutaneous flaps to reconstruct skin defects after radial inguinal lymphadenectomy. Brit. J. Plast. Surg., 41: 366, 1988.
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