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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3600_Библиотеки_им_академика_М_И_Перельмана
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The Groin Flap: TheWorkhorse Flap
forUpper Limb Reconstruction
HariVenkatramani, DavidZargaran, DariushNikkhah,
JuliaRuston, andS.RajaSabapathy
33
33.1 Introduction
The groin ap was rst described by Ian A McGregor and
Ian T Jackson in 1972. They assessed the role of the supercial circumex iliac vessels in supplying a self-contained
vascular territory and raised the groin ap based on these
vessels [1]. They described the design of the ap and its
excellent usage as a pedicled ap in 35 patients. Taylor etal.
in 1973 described the clinical application of detaching the
vascular pedicle from the groin to use it as a free ap to cover
a post traumatic wound in the lower limb claiming it to be the
rst described free ap [2].
The ease of harvest and reliable vascular anatomy made
the pedicled groin ap a workhorse ap for coverage of soft
tissue defects distal to the elbow. The robust lymphatics at
the base of the ap are responsible for lack of oedema both
in the ap as well as the part of the hand distal to the ap.
Furthermore, venous drainage through a supercial set into
the saphenous system and the cosmetically advantageous
location of the scar make the pedicled groin ap a strong
potential candidate for upper extremity reconstruction. Its
use as a pedicled ap has been well established by the group
at Ganga Hospital who perform the case over 200 times a
year despite being a centre of microsurgical excellence [3].
H. Venkatramani (*) ∙ S. R. Sabapathy
Department of Plastic, Hand and Reconstructive Microsurgery,
Ganga Hospital, Coimbatore, Tamil Nadu, India
D. Zargaran
Royal Free Hospital, London, UK
D. Nikkhah
Department of Plastic, Reconstructive and Aesthetic Surgery,
Royal Free Hospital, London, UK
J. Ruston
Department of Plastic Surgery, The Royal Free Hospital,
London, UK
Modications have been made for its use as a tubed ap
[4] for reconstructing degloved digits, islanded ap [5],
osteocutaneous ap [6] and a vascularised groin lymph node
ap [6, 7] alongside its already established role as a free ap.
The free ap has been successfully described as an effective
solution for soft tissue coverage in the paediatric population
with good outcomes in congenital, trauma and neoplastic
reconstructions [8].
The free groin ap has been criticised for its variable vessel origin, limited length of vascular pedicle, inconsistent
calibre [9] and, when inclusive of tissue medially, the presence of donor pubic hair. However, its many proponents have
demonstrated that it can be an effective solution with appropriate planning and vessel selection.
33.2 Anatomy
The groin flap is an axial pattern, type A, fasciocutaneous
flap based on the Cormack and Lamberty classification
[10]. The arterial supply of the flap is based on superficial circumflex iliac artery (SCIA) a branch of the femoral artery. The venous drainage is through a network of
superficial veins superficial circumflex iliac veins (SCIV)
which are 1.5mm in diameter and ultimately drain into
saphenous venous network (Fig.33.1).
The supercial circumex iliac artery is 1.92±0.6mm in
diameter [11] and arises deep to deep fascia, approximately
2.8±1cm below the inguinal ligament [12]. It gives a supercial branch which travels towards the anterior superior iliac
spine (ASIS), and the artery then traverses deep to the fascia
over the sartorius and sometimes piercing the muscle and
emerging supercially along the lateral border of the muscle.
It gives many skin branches at this stage. The following variations in arterial anatomy (Fig.33.2) should be kept in mind
when raising as a free ap:
• Direct origin from the femoral artery—42–45%.
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_33
313
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H. Venkatramani et al.
• Common origin along with supercial inferior epigastric
artery (SIEA)—48%.
• Large SCIA with absent SIEA—10–15%.
There are two key venous drainage systems in the area
with the dominant system being the supercial cutaneous
veins which involve the SCIV and SIEV which join into a
common trunk before draining into the saphenous vein. The
venae comitantes along the SCIA are small at approximately
1 mm in diameter and form the deep system of venous
drainage. The sensation to the lateral aspect of the groin ap
is provided and supplied by the lateral cutaneous branches of
the 12th thoracic subcostal nerve with further supply from
the lateral femoral cutaneous nerve (Fig.33.3).
Fig. 33.1 Markings for standard pedicled groin ap
Fig. 33.2 Variations in vessel anatomy of the groin ap
33 The Groin Flap: TheWorkhorse Flap forUpper Limb Reconstruction
Fig. 33.3 Incorporation of
the lateral cutaneous branches
providing a sensory groin ap
33.3 Preoperative Investigation
The high incidence of anatomical variation makes preoperative marking of vessels and preparation essential.
Handheld Doppler is used to identify the femoral artery
rst. The origin of SCIA can be marked by a handheld
Doppler, but we nd the use of ultrasound colour Doppler
scan more useful in identifying and marking the artery and
accompanying veins [13]. The size and direction of the vessels also can be identied with ultrasound colour Doppler
scan. The more supercial and thin groin ap harvested
needs a higher frequency ultrasound probe. The standard
probes of 13–20 Mhz are enough for the main vessels. CT
angiograms are not used for this purpose. We prefer to trim
the pubic hair in all cases of groin aps, and it is very
important to keep in mind the outline of hair and not to
raise any part of it while transferring the ap.
315
33.4 Flap Design andMarkings
First mark the midline, and then trace your hand to identify
the most prominent point along the hip which is the ASIS.
Now draw a line from midline to ASIS which is the inguinal
ligament. Along the ASIS draw the outline of the sartorius
muscle.
The next step is to palpate the femoral artery and mark it.
Two nger breadths below and parallel (3cm) to the inguinal
ligament the SCIA is given off, and it goes towards the
ASIS. At the lateral border of the sartorius, the pedicle
becomes supercial (Fig.33.4).
The ap is marked 5cm below and above the inguinal
ligament and the length on an average between 10 and
20cm is marked. Primary closure is possible if the width of
the ap is up to 10cm.
Fig. 33.4 Illustration of anatomical landmarks determining the location of the SCIA
33.5 Flap Raise/Elevation: AStep-by-Step
Guide
Setup
• Position of patient: Supine with a folded sheet under the
hip to raise the side of harvest. Good access to the lateral
aspect of groin is important.
• Anaesthesia: The surgery can either be done under
regional anaesthesia or general. If regional is preferred,
an upper limb block and spinal or combined spinal with
epidural anaesthesia is advised.
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Fig. 33.5 Illustration
demonstrating the plane of
dissection incorporating the
fascia over the sartorius so
that the SCIA is included in a
pedicled or free groin ap
H. Venkatramani et al.
Pedicled Groin Flap
• Incision made on superior margin followed by lateral
margin using a number 10 or number 15 blade.
• Flap raise: The ap is raised suprafascially till we reach
the lateral margin of the sartorius. Once the lateral border
of the sartorius is reached, the dissection proceeds subfascially (Fig.33.5).
• Pedicle identication: Once the fascia over the sartorius
is raised, along the medial margin, the SCIA can be seen
and raised along with the ap. There may be small muscular branches entering the sartorius which need to be
carefully cauterised with bipolar cautery.
• Pedicle dissection: The lateral femoral cutaneous nerve
is seen 1cm inferior and medial to ASIS and should be
safeguarded. It could be sacriced if coming between the
pedicles. The ap is raised up to its origin from the femoral artery. As mentioned before in more than half of the
patients, we will encounter common trunk of SCIA and
SIEA.The dissection proceeds up to the femoral artery in
case of free groin ap, whereas in pedicle ap we can stop
the dissection up to medial border of the sartorius.
• Closure of donor site: Up to 10cm width of ap can be
closed primarily in most cases; wider aps would need
skin grafting of donor site. Flexing the hip and knee facilitates donor site closure.
• Flap division: The ap is divided at 3weeks and inset is
completed. In case of tubed groin ap as done for thumb
loss or degloving, a delay at the base of ap is done at
3 weeks, and then nal division and inset are given at
4weeks. The delay is carried out under local anaesthesia,
a handheld Doppler is used to mark the axial vessel and
then the incision is kept, and the vessels are divided and
cauterised. The skin closed and at the time of division, the
incision passes through the delay site.
there is a combined SCIA and SIEA take- off from the femoral artery, it is better we visualise their origin from the femoral artery rst.
• Incision: A medial incision is rst made and overlying the
femoral vessels and the origin if SCIA is seen. The origin
also gives us an idea on the size of the pedicle. Once visualised the incision is kept lower and parallel to inguinal
ligament. If on medial access incision we nd that the
vessel size is too small, a pedicled ap can still be raised
for extremity reconstruction.
• Alternative incision: An alternative approach which some
authors advocate is making the incision in the same fashion as the pedicled approach; however, a medial approach
enables tailoring of the length of the pedicle and the skin
paddle. This was the initial description as per Taylor etal.
• Flap dissection is carried out subfascially till the sarto-
rius, and upon reaching the sartorius, the pedicle previously identied is kept in full view on the medial aspect of
the ap. Further, dissection should continue right to the
origin of the femoral artery to ensure maximal pedicle
length. The incision of fascia is then performed with both
the pedicle in view medially and the medial aspect of the
sartorius identied laterally. Note: Inclusion of the deep
branch of SCIA is paramount, which runs beneath the fascia of the sartorius.
• Venous selection for anastomosis: In addition to the
venae comitantes, we advocate incorporation of another
supercial vein.
33.6 Core Surgical Techniques inFlap
Dissection
Free Groin Flap Identication of the SCIA pedicle
should ideally be performed preoperatively with a colour/
pencil Doppler. If the location of SCIA is not clear and if
• Pedicle appraisal. Upon identication of the pedicle for
the free groin ap, if the pedicle is too small or insufcient, the supercial inferior epigastric artery could offer
33 The Groin Flap: TheWorkhorse Flap forUpper Limb Reconstruction
an alternative or consideration given to the contralateral
side.
• Skin ap raising. When determining how thin the ap is to
be upon initial inset, holding the distal edges of the ap
under tension with skin hooks and the use of toothed forceps
with McIndoe scissors has been found to be effective.
• Donor site closure. Flexion of the hip can help facilitate
donor site closure.
• Skin island placement. Lateral placement of the skin
island provides both an increase in pedicle length and
reduction of the thickness of the medial portion of the ap
and helps avoid the presence of hair-bearing tissue.
• Dissection over the sartorius muscle (critical step).
• Adjustment of ap markings. Once the pedicle has been
identied through dissection, the markings can be
adjusted to centralise the pedicle on the ap.
33.7 Clinical Scenario
33.7.1 Clinical Scenario A: Dr. Sabapathy andDr.
Venkatrami: Loss ofThumb Following
Trauma (Figs.33.6, 33.7, 33.8, 33.9, 33.10,
33.11, 33.12, and33.13)
317
Fig. 33.7 Status after debridement
The rst stage is surgical debridement and pedicled groin
ap cover. The key steps are marking the ap and keeping
the ap base along the medial border of the sartorius. The
opposite thumb girth is measured and the ap designed keeping the width of the ap equal on both sides of the line marking the course of SCIA.The ap is inset into the dorsal side
rst, and then tubing starts, and the seam of the ap is kept
along the medial inner aspect of the new thumb. This way we
have both options once the ap has settled, namely, osteoplastic reconstruction using an iliac crest bone graft and a
Littler’s island ap for sensation. The other option is second
toe transfer with part of metatarsal. This patient had the
former.
Fig. 33.8 A groin ap has been raised to cover the defect and provide
soft tissue for further reconstruction
Fig. 33.6 Crush injury right hand which has resulted in gangrene of
the thumb referred for further reconstruction
Fig. 33.9 Groin ap raised up to anti-superior iliac spine
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Fig. 33.10 The ap is attached in the direction of the thumb. (Note:
Suture line comes from inner side which could be opened up for further
reconstruction. The donor area primarily closed)
H. Venkatramani et al.
Fig. 33.11 The ap after division before further reconstruction. The
ap length is adequate for both osteoplastic reconstruction and toe
transfer
Figs. 33.12 and 33.13 Second toe transfer done using ap skin on the side and ap excised
33 The Groin Flap: TheWorkhorse Flap forUpper Limb Reconstruction
33.7.2 Clinical Scenario B: Dr Dariush Nikkhah
and Dr Jeremy Rawlins Elbow
Resurfacing withFree Groin Flap
A 56-year-old man sustained a motor vehicle accident
(Fig.33.14). He had an elbow defect with exposed olecranon
319
Fig. 33.16 Radial artery perforator chosen as recipient vessels for free
groin ap
Fig. 33.14 Elbow defect pre-debridement
Fig. 33.15 Post-debridement of the elbow showing exposed
olecranon
Fig. 33.17 Markings for a modied free groin ap
after initial debridement (Fig.33.15). A CT angiogram demonstrated good recipient vessels with a perforator emerging
from the radial artery (Fig.33.16). A modied free groin ap
was harvested through a medial approach. The SCIA/V vessels were anastomosed to a perforator originating from the
radial artery, and a secondary supercial vein was anastomosed for additional venous drainage (Figs.33.17, 33.18, and
33.19). The patient had an uneventful outcome (Fig.33.20).
33.7.3 Case Scenario C: Dr Sabapathy andDr
Venkatrami
This case demonstrates a staged pedicled groin ap for volar
skin loss of the right middle ring and little ngers (Figs.33.21,
33.22, 33.23, 33.24, 33.25 and 33.26).
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H. Venkatramani et al.
Fig. 33.20 Early result demonstrating robust wound coverage in a
single stage
Fig. 33.18 Medial approach demonstrating SCIA/V vessels
Fig. 33.19 Free groin ap raised demonstrating short pedicle
Fig. 33.21 Composite tissue loss on volar aspect of the right, middle,
ring and little ngers with exposure of the exor tendons after debridement and loss of FDP in the ring nger
33 The Groin Flap: TheWorkhorse Flap forUpper Limb Reconstruction
321
Fig. 33.24 Picture after division
Fig. 33.22 Pedicled groin ap raised and the donor area closed
Fig. 33.25 Functional outcome after syndactyly separation and thin-
ning of aps
Fig. 33.23 Groin ap inset into the defect
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Fig. 33.26 Final result after ap inset and digits separated
33.8 Pearls andPitfalls
Pearls
Hairless skin lies along the groin crease laterally
and the skin island should be centred over this
region.
• Primary closure possible in majority of cases if
the width of the ap is less than 10cm. One can
also undermine the upper abdominal ap to
facilitate closure.
• The inclusion of lymphatic tissue in the ap
helps mitigate distal oedema.
• Secondary thinning is safe [14].
• Can take really long ap going along the trunk.
H. Venkatramani et al.
Pitfalls
• In patients with a high BMI, there is difculty in harvest and it may not be an appropriate choice of ap.
• Pedicle size and length can be short and small when
used as free ap. The pedicle length can range from
2 cm – 6 cm however placing the skin island more
lateral can help provide a longer pedicle when performing a free ap.
• Joint stiffness in crush injury of the hand (particularly in pedicled ap).
• Edge necrosis if a very long ap is raised.
• Need for delay in tubed aps.
33.9 Selected Readings
• McGregor IA, Jackson IT. The groin ap. Br J Plast
Surg. 1972 Jan;25(1):3–16. https://doi.org/10.1016/
s0007-1226(72)80003-1.
First paper to describe the groin ap [1].
• Smith PJ, Foley B, McGregor IA, Jackson IT.The anatomical basis of the groin ap. Plast Reconstr Surg. 1972
Jan;49(1):41–7. https://doi.org/10.1097/00006534-197,
201,000-00008.
Anatomical paper identifying that the supercial circumex iliac artery was consistently present [15].
• Knutson GH.The groin ap: a new technique to repair
traumatic tissue defects. Can Med Assoc J. 1977 Mar
19;116(6):623–5.
Seminal paper which popularised the groin ap [16].
• Cobb ARM, Koudstaal MJ, Bulstrode NW, Lloyd TW,
Dunaway DJ.Free groin ap in hemifacial volume reconstruction. Br J Oral Maxillofac Surg. 2013 Jun;51(4):
301–6. https://doi.org/10.1016/j.bjoms.2012.09.004.
Consecutive case series of 14 patients who had hemifacial augmentation with a free groin ap [5].
• Hough M, Fenn C, Kay SP.The use of free groin aps in
children. Plast Reconstr Surg. 2004 Apr 1;113(4):1161–6.
https://doi.org/10.1097/01.prs.0000110329.68009.4c.
Consecutive case series of 33 patients who had reconstructions with a free groin ap for a variety of aetiologies including trauma, congenital and tumour based
[8].
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