Groin Flap

Flap type: osteomyocutaneous flap (composite or compound) of the axial pattern type. Flap components: skin, subcutaneous, muscle (internal oblique), bone (ilium). The groin flap can be transferred as a bone graft only (iliac crest bone graft), as a bone graft with muscle, or as a bone graft with muscle and skin (osteomyocutaneous flap). Use: microvascular transfer. Vascular pedicle: The osteomyocutaneous flap is supplied by the superficial and deep circumflex iliac arteries. The deep circumflex iliac artery is the more important of the two, arising from the external iliac artery posterior to the inguinal ligament (Fig. 14.2, 1). Its vascular pedicle has a length of 80-120 mm and a caliber of 3 mm and chiefly supplies the ilium. In 75% of cases there is an ascending branch with perforators, which supplies the internal oblique muscle along with a 2.5 x 8-cm skin area over the iliac crest (Fig. 14.2, 4). The superficial circumflex iliac artery (Fig. 14.2, 3) arises from the femoral artery 30 mm below the inguinal ligament. Its vascular pedicle has a length of 5-20 mm and a caliber of 1.5 mm. The vessel mainly supplies a 12 x 23-cm skin area over the iliac crest (Fig. 14.2, 5). If only a small skin paddle is required, the deep circumflex iliac artery (Fig. 14.2, 2) is the only vessel that needs to be anastomosed at the recipient site. If a larger skin paddle is needed, the superficial circumflex iliac artery (Fig. 14.2, 3) should also be anastomosed (Remmert et al. 1998). Position: supine.

Flap elevation: First the inguinal ligament, femoral artery, and iliac crest are marked out on the skin (Fig. 14.2,6 and 7). The skin paddle is outlined and its perimeter incised, dividing the skin and subcutaneous tissue down to the abdominal wall musculature. When the skin paddle is raised from the external oblique muscle, an area of muscle about 3 x 8 cm is left on the upper iliac crest. The muscle and skin in this area should not be divided to preserve the perforator vessels to the skin paddle. After the external oblique muscle has been divided, leaving a flap about 2-4 cm wide on the iliac crest, an adjacent internal oblique muscle flap based on the iliac crest is cut to match the size of the defect. The underlying trans-versus abdominis muscle is divided like the external oblique, leaving a strip of muscle about 2-4 cm wide on the iliac crest. This muscular cuff transmits the deep circumflex iliac artery (Fig. 14.2, 2) with its per-

Groin Flap

External oblique muscle Internal oblique muscle

-J— Skin paddle Transversus abdominis muscle Deep circumflex iliac artery

M M, it-Iliac crest

External oblique muscle Internal oblique muscle

-J— Skin paddle Transversus abdominis muscle Deep circumflex iliac artery

-Vena comitans lliacus muscle

a The groin flap can be designed as a myocutaneous or osteomyocutaneous transfer (compound flap, see text).

1 External iliac artery

2 Deep circumflex iliac artery

3 Superficial circumflex iliac artery

4 Size of the skin area supplied by the deep circumflex iliac artery

5 Size of the skin area supplied by the superficial circumflex iliac artery

6 Iliac crest

7 Inguinal ligament

8 Femoral artery b The skin paddle and muscle are elevated on the deep circumflex iliac artery and its venae comitantes (after Bootz 1992).

c The iliacus muscle is detached medially, the tensor fasciae latae and gluteus medius laterally, and the sartorius anteriorly. The bone fragment (outlined from a pattern) is removed with a saw. d The composite (compound) iliac crest flap has been harvested with its skin paddle (viewed from the medial side).

forators. After the tensor fasciae latae and gluteus medius are separated from the lateral aspect of the ilium, the vascular pedicle is exposed by detaching all abdominal wall layers at the level of the anterior superior iliac spine. The deep circumflex iliac artery arises from the external iliac artery posterior to the inguinal ligament. The vascular pedicle is dissected free, proceeding in a medial to lateral direction as far as the anterior superior iliac spine. Finally the iliacus muscle is released from the medial surface of the ilium, fully exposing both the medial and lateral aspects of the bone. A bone fragment of the necessary size and shape (determined from a pattern) is cut from the ilium with an oscillating saw, the vascular pedicle is divided, and the osteomyocutaneous flap is transferred to the recipient site. The donor site is carefully closed in layers to prevent hernia formation (Remmert et al. 1998).

Indications and advantages:

- This flap is used for reconstructions of the mandible, maxilla, cheek, and occasionally the forehead.

- Consistent vascular anatomy.

- Skin, muscle, and bone can all be reconstructed with one flap.

- Bone from the iliac crest provides a good bed for dental implants.

- Tumor resection and reconstruction can be performed in one operation.

- There is no need to reposition the patient in-traoperatively.

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