The document discusses several muscle flaps that can be used for coverage of infected vascular grafts, including the sartorius, gracilis, rectus femoris, tensor fascia lata, and rectus abdominis muscles. It also discusses using the greater omentum. Each option has advantages and disadvantages in terms of blood supply, size, and functional implications. The sartorius is frequently used due to its reliable segmental blood supply and proximity to the groin. The gracilis is suitable for smaller defects while the rectus femoris and tensor fascia lata are good for more extensive coverage.

1. Muscular Flaps for Vascular Coverage
Dr. Asad Moosa

2. • Several muscle flaps were found useful in the coverage of infected vascular grafts.
• The sartorius muscle flap is used extensively as a first-line treatment for groin graft
infections because of its closeness to the groin and proximal thigh and its relative ease
of harvest.
• Disadvantages include the closeness to infection and the segmental blood supply, as no
more than three vascular pedicles can be divided to ensure safe survival of the flap.
• Other flap options include the rectus femoris muscle, rectus abdominis muscle,
gracilis muscle, tensor fascia lata and the omentum
• Different types of muscle flaps provide different benefits, and they can be tailor made
to meet the situation.
• A pedicled muscle flap provides satisfactory single stage wound coverage with
obliteration of dead space, improving local wound healing environment by
increasing local blood flow and thereby increasing the oxygen tension, antibiotic
penetration and macrophage activity.

3. • It also provides a secondary barrier to exposure in case of a suture dehiscence.
• Gracilis is a slim muscle that covers only a small area and is suitable for coverage of
vascular prosthesis when there is no skin deficit.
• Tensor fascia lata flap is a good option for coverage of wound in upper third of the
groin
• Rectus abdominis serves as a good flap for coverage of defects or wounds extending
more than upper third of the groin region and thigh as this muscle flap has an
enormous size

4. A) Sartorius
•The Sartorius is a frequently used muscle flap to cover exposed arterial grafts in the groin.
•The Sartorius arises by tendinous fibers from the anterior superior iliac spine, crosses the
thigh obliquely to the medial side and terminates in an aponeurosis at the medial tibia.
•The simplest technique is Sartorius myoplasty.
– The enveloping fascia is divided longitudinally and herniation of the muscle fibers
occurs.
– Mobilization of the muscle to the medial aspect of the femoral triangle can be
performed and secured with interrupted sutures.
– This myoplasty may not be suitable for wounds requiring major debridement or
coverage up to the inguinal ligament and a full Sartorius transposition is required.
•The Sartorius muscle is detached from its origin at the superior iliac spine and transposed
medially thereby covering the artery and graft.
•The key to the durability of a Sartorius flap is the arterial supply

5. • The sartorius has a segmental arterial supply by the superficial femoral, lateral
circumflex arteries and geniculate branches from the popliteal artery.
• These multiple branches enter the muscle at its postero-medial aspect and transposition
may render the origin of the muscle ischemic affecting tissue viability.
• The sartorius muscle receives a segmental blood supply with 8 to 11 vascular pedicles
from the superficial femoral artery, which enter the muscle from its medial border.
• Division of more than three pedicles may result in necrosis of the mobilized muscle flap
• Since the Sartorius muscle is readily available, and its mobilization does not result in any
functional impairment, it should be the primary choice for the purpose of muscle rotation
in the groin

6. • A documented but infrequently used technique is mobilization of the lateral margin
of the sartorius and twisting the muscle on its medial axis from the lateral side.
• This ``twisting'' technique maintains the arterial supply to the muscle by leaving the
segmental vessels un-dissected and provides excellent wound coverage.

7. • The sartorius muscle fascia is incised longitudinally up to the tendon portion of the
muscle
• With sharp dissection, the lateral and posterior surfaces are mobilized up to, but not
including, the medial border.
• The segmental blood supply entering the muscle from its medial border is left
undissected.

8. • The muscle is twisted on itself such that the anterior surface now comes in close con-tact
with the femoral vessels.
• The tendon is secured to the inguinal ligament with interrupted sutures of monofilament
suture material, and the medial border is firmly secured to the perivascular tissue
similarly.
• It is important to secure the medial border of the rotated muscle very close to the femoral
vessels to prevent the formation of dead space and subsequent collection of lymph or
other body fluids

9. B) Gracilis Flap
Innervation:
•Branch from the obturator nerve to gracilis.
Blood supply:
•Gracilis vessels from the medial femoral circumflex system.
•It can be used to cover wounds roughly up to 6 cm wide and 20 cm long
•A medial thigh muscle, the gracilis takes origin off the pubic symphysis, inferior pubic ramus
and ischium then inserts distally into the medial condyle of the knee
•The afferent artery and efferent veins run superficial to the adductor magnus muscle, underneath
the adductor longus.
•By retracting the adductor longus, the artery can be traced to it's origin on the medial femoral
circumflex vessels, branches of the profunda femoral system.

10. • The patient is placed supine, with the leg prepped entirely free to the groin.
• The thigh is abducted and the knee slightly flexed.
• The axis of the muscle is marked posterior to the adductor longus by two the three finger
breadths.
• Because the pedicle enters the muscle approximately 10 centimeters below the ischium, the
incision markings need to take this into consideration.
• An optional distal incision is made near the muscle insertion at the knee to transect the
distal tendon if the entire length of the flap is needed.

11. • The proximal incision is carried down through the fat and the muscular fascia to the muscle.
• The fascia is elevated off the muscle anteriorly and the septal junction of the gracilis and
adductor longus is identified.
• This space is then entered by retracting the two muscles from each other and the pedicle to
the gracilis is identified in this areolar plane.
• The muscle is then freed of all soft tissue attachments except for the pedicle.
• The proximal tendon is cauterized to detach it from the ischiopubic ramus and the distal
muscle is transected with cautery near the insertion or at the distal wound, depending on the
length needed

12. • The gracilis muscle is then passed beneath the adductor muscle through the interspace
between the adductor and the sartorius muscles, and into the femoral triangle
• Monofilament sutures may be used to secure the flap in the desired position

13. B) Rectus femoris
•The rectus femoris is bulky, long and with a wide arc of rotation it is a very mobile flap
for use as graft coverage.
•Unlike the segmental arterial supply of the sartorius, the rectus femoris derives its blood
supply from the profunda femoris artery (PFA).
•Mobilisation of the muscle is from distal to proximal ensuring the proximal arterial
inflow is preserved and provides good coverage over a large graft area.
Innervation:
•motor nerve to rectus femoris from femoral nerve, it often enters as two segmental
branches.
Blood supply:
•Descending branch of lateral femoral circumflex artery.

14. • The rectus femoris muscle provides a large donor
muscle with a consistent blood and nerve supply,
providing a potential strong functional muscle
• The disadvantage of harvest is loss of muscle
strength of the thigh.
• The muscle arises from the anterior inferior iliac
spine and the ilium just superior to the acetabulum.
• The insertion is at the patella.
• A line drawn from the anterior superior iliac spine
to the mid aspect of the patella denotes the
longitudinal axis of the muscle.
• The incision is made in a lazy-'s' fashion to expose
the required length of muscle.

15. • The pedicle arises just proximal to the junction of the
proximal and middle thirds of the muscle.
• The rectus femoris and sartorius muscles are identified
deep to the muscular fascia.
• The sartorius is retracted medially and away from the
leg to expose the areolar plane underneath and to
identify the lateral femoral circumflex vessels.
• The femoral nerve and branches are also identified at
this level.
• The muscle is freed of fascial connections on its medial,
lateral, deep and superficial surface.
• It can then be divided proximal and distal to the pedicle
and is isolated on the descending branch.
• The nerve to the muscle is ligated and divided.

17. D) Tensor Fascia Lata
Innervation:
•the lateral cutaneous sensory nerve of the thigh
•The motor branch by a distal branch of the superior
gluteal nerve.
Blood supply:
•Ascending branch of lateral femoral circumflex artery.
•The TFL muscle takes origin from the anterior iliac
crest in an arc and inserts into the iliotibial tract.
•The vascular pedicle enters the TFL muscle at the
level of the junction of the proximal and middle thirds
of an axis drawn from the anterior superior iliac spine
to the lateral patella.
•Laterally, the fascia lata thickens to form the iliotibial
tract which attaches distally to the lateral condyle of the
tibia.

18. • The patient is prepped and draped supine
• The anterior part of the flap runs along the axis of the
septum between the vastus lateralis and the rectus
femoris.
• A line drawn from from the anterior superior iliac spine
to the lateral patella locates this anterior landmark.
• The entry point of the pedicle is at the level of the
junction of the proximal and middle third of the
aforementioned line.
• The flap is marked as an ellipse over the axis of the
TFL muscle and to incorporate the pedicle proximally.
• The flap is elevated from distal to proximal.
• The skin and deep fascia are incised together and the
plane deep to the iliotibial tract fascia is elevated
sharply while coagulating small perforators.

20. E) Rectus Abdominis
•The transposed rectus abdominis muscle relies on a single pedicle and thus theoretically
provides the same advantages as the rectus femoris.
•The inferior pedicle of the rectus abdominis arises from the external iliac artery, an
artery frequently involved in cases of atherosclerotic disease.
•A further disadvantage of using the rectus abdominis is the more extensive dissection
required for its elevation.
Innervation:
•Intercostal nerves.
Blood supply:
•The deep inferior epigastric artery and venae originating on the external iliac vessels just
above the inguinal ligament.
•The origin of the muscles is the pubic symphysis and pubic crest, while the insertion is
the fifth to seventh costal cartilages.

21. • The muscle can be exposed through a vertical or lower transverse incision.
• The total length of the incision depends on the amount of muscle to be harvested.
• The subcutaneous fat is divided down to the level of the rectus sheath. Perforators are ligated
and divided.
• The rectus sheath is divided longitudinally.
• The fascia is elevated medially and laterally while gentle retraction is performed with Aliss
clamps.
• At the lateral inferior muscle, the muscle is gently retracted medially.
• The deep inferior epigastric artery and it's accompanying veins are identified.
• The origin of the muscle near the pubis is isolated by encircling the muscle with the index
finger.
• The muscle is then divided with cautery while protecting the pedicle.
• The superior muscle is likewise encircled and divided to isolate the rectus on the pedicle.
• The superior epigastric vessels must be securely ligated or cauterized to stop bleeding from the
superior retracting muscle edge.

24. F) Greater Omentum
•The omentum possesses a rich arterial arcade with three
dominant vessels descending from the gastroepiploic artery,
along the greater curvature of the stomach.
•A right, middle and left omental branch arise from
gastroepiplic system, with smaller intervening branches and
adjacent draining veins.
•The flap is isolated on the right omental artery and the right
gastroepiploic artery.
•The greater curvature of the stomach and the right and left
gastroepiploic vessels are identified as are the major
descending branches to the omentum.
•The omentum is flipped superiorly, exposing the posterior
attachements to the large colon.
•These attachments are freed, with perforating vessels ligated
and divided.

25. • The omentum is then isolated on its attachment to the greater curvature of the stomach.
• The flap is then dissected free of stomach, beginning on the left side by ligating
branches entering the omentum.
• The left and middle descending branches are divided, as are smaller branches arising
from the gastroepiploic system.
• The entire flap is isolated on the right omental artery pedicle.

27. Thank you !