Vein/Arterial Grafts Harvested within the Incision for a Free Groin Flap.

The free groin flap results in less donor-site morbidity than other skin flaps and is suitable for use in children and adolescents. However, the vascular pedicle is relatively short and vessel diameter is small, which makes vascular anastomosis technically difficult. To overcome this limitation, we harvested vein and arterial grafts from the flap elevation area without placing additional skin incisions. Use of short (2-3 cm) vein/arterial grafts greatly simplified flap insetting and vascular anastomosis. This procedure may expand the indications for free groin flap transfer.

The groin flap was developed as a pedicled distant flap and was later used as the first free skin flap based on the superficial circumflex iliac artery.[1-3] Donor morbidity is minimal, and the flap allows primary closure and results in an inconspicuous scar. Because of these favorable characteristics, this flap is a good option for young, growing patients.[4,5] However, the vascular pedicle is short and small, which makes vascular anastomosis technically demanding. In addition, use of this technique gradually diminished after its introduction as a free flap.[6,7] We harvested vein and arterial grafts within the flap dissection area to address the limitations of this technique. No additional skin incisions were required.

SURGICAL PROCEDURE

After groin flap elevation and harvest, the vessels suitable for grafting are dissected out from within the flap dissection area. Usually, the branches of the great saphenous vein (GSV) or superficial inferior epigastric artery (SIEA) are harvested for this purpose (Fig. 1). Because the SIEA often lacks the appropriate diameter and length, the branches of the GSV are dissected first. Usually, the diameter of these vessels is similar to that of the vascular pedicle of the free groin flap. After elongating the vascular pedicle of the flap with the graft, vascular anastomosis with recipient vessels is performed.

Figure 1.

Schematic diagram of vein/arterial graft harvest. Soft tissue in the shaded area is harvested as a free groin flap. Branches of the GSV and/or SIEA are utilized. Flap insetting and vascular anastomosis are much easier with this procedure.

RESULTS

The procedure was performed in 5 patients. Patient age at surgery was 8–21 years (mean, 15.4 years). Both the artery and vein of the vascular pedicle were elongated in 1 case, whereas only the artery was elongated in 4 cases. A branch of the GSV was used in all cases, and the SIEA was used in 1 case. The grafts used were 2.0–3.0 cm (mean, 2.3 cm) in length and 2.0–3.0 mm (mean, 2.4 mm) in diameter. The size of the flap ranged from 17 × 6.5 cm to 23 × 8 cm (Table 1). Postoperative course was uneventful in all patients, and all flaps survived without complications associated with the vein/arterial graft harvest.

Table 1.

Summary of the Cases

CASE REPORT

Case 1

An 8-year-old boy with open metatarsal fractures and degloving injury to the dorsum of the left foot was primarily treated by placement of artificial dermis. Ten days after artificial dermis application, open reduction and artificial bone grafting were performed, followed by free groin flap coverage. First, the dorsalis pedis artery was dissected as a recipient artery; however, blood flow was not sufficient to perfuse the free flap. The recipient artery was then switched to the posterior tibial artery, which required extension of the flap vascular pedicle. To avoid placing an extra skin incision for vein graft harvest, branches of the GSV were harvested as a 2-cm-long graft and anastomosed to the flap, to elongate the vascular pedicle. However, the length of the vascular pedicle was not sufficient to reach the posterior tibial artery. Therefore, a 2-cm-long SIEA was harvested from the flap dissection area, and these two grafts were chained, which allowed the vascular pedicle to be extended by 4 cm. This was followed by end-to-side anastomosis to the posterior tibial artery. The vein of the flap was anastomosed to the cutaneous vein in the dorsum of the foot in end-to-end fashion (Fig. 2). The flap survived completely and the donor-site wound healed well (Fig. 3).

Figure 2.

A, Intraoperative photograph showing flap insetting and arterial anastomosis in case 1. B, Schematic diagram of the vein (GSV) and arterial (SIEA) graft anastomoses. These grafts were chain connected, thereby extending the arterial pedicle (superficial circumflex iliac artery, SCIA) by 4 cm. This was followed by end-to-side anastomosis to the posterior tibial artery (PTA). The vein of the flap was anastomosed to the cutaneous vein in the dorsum of the foot in end-to-end fashion. SCIV indicates superficial circumflex iliac vein.

Figure 3.

A photograph of case 1 at 3 months postoperatively shows complete wound healing.

Case 2

A 21-year-old woman was referred to our clinic for treatment of substantial atrophy of the right cheek due to lupus erythematosus profundus. After consulting with the dermatology department, soft-tissue augmentation of the cheek was planned. Since the patient preferred a single-stage free-flap transfer to a multistage fat injection procedure, use of a free groin flap was indicated. An 18 × 7 cm free groin flap was harvested from the right inguinal region and the flap was denuded. Then, the artery and vein were extended by 2 cm by anastomosing two vein grafts harvested from the flap dissection area to the ipsilateral facial artery and vein, which enabled optimal subcutaneous placement of the flap in the limited dissection area and a minimum number of skin incisions. The donor site was closed primarily. Postoperative course was uneventful, and the flap survived completely (see Supplemental Digital Content 1, which displays a preoperative photograph of case 2, http://links.lww.com/PRSGO/A97).

DISCUSSION

Free groin flap transfer is technically demanding because of the short and small vascular pedicle. Short vascular pedicles limit flap insetting, and the discrepancy in vessel size between the flap pedicle and recipient vessels increases both the technical difficulty of vascular anastomosis and the risk of thrombosis.[8] The superficial circumflex iliac artery perforator (SCIP) flap[6,9] can address most of the disadvantages of free groin flap, especially the short vascular pedicle of the flap. However, it requires more delicate, precise microsurgical dissection, which is more technically demanding. Designing the SCIP flap for use in a more distal (lateral) area and/or de-epithelialization of the proximal part of the SCIP flap enable use of a longer vascular pedicle; however, the donor-site scar in more lateral areas may be difficult to completely cover with undergarments. Another simple and common solution is vein grafting, which provides length and addresses the size disparity between donor and recipient.[7] With vein grafting, a longer vascular pedicle is obtained, and the donor-site scar is limited to the medial area, which can be covered by undergarments. The greatest advantage of the free groin flap is the minimal functional and aesthetic morbidity at the donor site. Thus, additional skin incisions should be avoided, even for vein graft harvesting. Vein/arterial graft harvesting within the flap harvesting area does not require additional skin incisions.

Extension of the vascular pedicle using 2–3 cm of vein/arterial grafts dramatically simplifies flap insetting and vascular anastomosis to the recipient vessels and does not require an additional skin incision for graft harvest. In case 1, the flap was able to be placed in the ideal position using this technique. The maximum available length of the graft was 3 cm in our series, which is one of the limitations of this technique. In case 2, we chained two grafts, which doubled the extension of the vascular pedicle for proper flap placement. The indications and adverse effects of using a vein graft for a free groin flap have also not been described in detail. Cooper et al[7] used vein grafts for free groin flaps in 28 cases and concluded that vein grafting did not decrease the success rate. We agree that the merits of vein/arterial grafting outweigh the disadvantages. Although 1 or 2 additional microvascular anastomoses are required, this straightforward method is advantageous for patients and surgeons and has the potential to expand the indications of the free groin flap.