|Year : 2019 | Volume
| Issue : 2 | Page : 44-47
A free gracilis muscle flap for foot resurfacing, the first microsurgical case in a Sub-Saharan African country, Togo
Komla Séna Amouzou, Tete Edem Kouevi-Koko, Gamal Ayouba, Batarabadja Bakriga, Anani Abalo
University of Lomé, Department of Surgery, Sylvanus Olympio Teaching Hospital, Lomé, Togo
|Date of Submission||06-Jun-2019|
|Date of Acceptance||03-Nov-2019|
|Date of Web Publication||17-Jul-2020|
Komla Séna Amouzou
1, Rue de l’Hopital, PO Box 20752, Lomé
Source of Support: None, Conflict of Interest: None
In Togo, reconstructive management has been based on local and regional flaps. In some severe cases and in cases of failure, only a cross leg flap (if possible) or an amputation would save the patient. It has become vital to move forward in the reconstructive ladder in our setting. We report our first case of free gracilis muscle flap for the reconstruction of a foot defect in a 21-year-old male patient who was presented with a foot laceration due to a road traffic accident. The plastic surgeon had training in microsurgery. For other members of the operative team, this was the first microsurgery procedure. The gracilis muscle was harvested from the contralateral thigh and inset in the defect by microsurgical vascular anastomosis. The flap’s monitoring was done clinically. The post-operative course was uneventful. The muscle flap was resurfaced on day 5 using a split thickness skin graft. The patient was discharged on day 12. Total healing was seen on day 21. The patient was very satisfied with the procedure. The success of this first case represents an optimal motivation to build up a microsurgery team and the debut of microsurgery procedures for patients with difficult defects in Togo.
Keywords: Africa, free flap, gracilis, microsurgery, reconstructive surgery
|How to cite this article:|
Amouzou K, Kouevi-Koko TE, Ayouba G, Bakriga B, Abalo A. A free gracilis muscle flap for foot resurfacing, the first microsurgical case in a Sub-Saharan African country, Togo. Nigerian J Plast Surg 2019;15:44-7
|How to cite this URL:|
Amouzou K, Kouevi-Koko TE, Ayouba G, Bakriga B, Abalo A. A free gracilis muscle flap for foot resurfacing, the first microsurgical case in a Sub-Saharan African country, Togo. Nigerian J Plast Surg [serial online] 2019 [cited 2020 Sep 20];15:44-7. Available from: http://www.njps.org/text.asp?2019/15/2/44/290020
| Introduction|| |
In the past decades, the increased knowledge of anatomy and the development of technical skills have prompted many reconstructive surgery procedures. The choice of a reconstructive technique depends upon clinical conditions, technical resources in the setting, and skills of the operative team.
In the foot and ankle anatomic regions, a poor muscle coverage and low laxity of the skin make it hard for coverage when tendons and bones are exposed and require urgent resurfacing. A distant free flap is the optimal option in most of the cases.  In expert reconstructive centers, the gracilis muscular free flap has become the preferred option for small- to medium-sized defects of foot and ankle regions ,. The pedicle is reliable with a length and diameter quite constant that ease the microvascular anastomosis. Some authors reported a success rate of up to 100%, thus overlooked the relatively long operative time and the intra-operative difficulties compared to other reconstructive options. 
In setting where microsurgery is not yet available, procedures such as negative pressure wound therapy followed by skin graft, hemi-soleus flaps, and sural reverse flap are the last options. 
In the past, our reconstructive activity has been based on skin grafts, local and regional flaps,  or cross legs flaps.  In difficult cases, the sacrifice of structures such as tendons aimed to promote spontaneous granulation making it to a skin graft. This procedure has led to a high rate of wound and bone infections, some extreme cases requiring amputation. Therefore, the addition of another ladder to our armamentarium has become vital.
We describe our first case of free gracilis muscle flap for the resurfacing of a foot traumatic defect in Togo.
| Case history|| |
In April 2018, a 21-year-old male was referred to the Department of Surgical Emergency (SED) at the tertiary hospital (SOH) of Lomé (Togo) for a left foot defect following a road traffic accident. He was presented with an open fracture Gustillo–Anderson type IIIB over the left foot. The tarso-metatarsal joint, the first metatarsal bone, and extensor tendons of the first ray were exposed [Figure 1]. Besides the foot trauma, the patient was presented with an opened Gustillo–Anderson type II leg fracture that was treated with an intramedullary locked nail and wound suture.
|Figure 1 Open fracture Gustillo-Anderson type IIIB on the left foot. (A) Before surgical debridement; (B) After debridement|
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In the preoperative evaluation, we assessed the patient for past medical conditions, body weight, height, and the peripheral pulses by palpation. No angiography or Doppler echography was performed in the exploration of the vascular status of the leg. After a first debridement, the defect was classified type III-B according to Gustillo–Anderson score. Three days after the first debridement, a free gracilis muscle flap was indicated. The patient signed consent for the procedure and for using the case in a scientific publication.
The operative team was composed of a plastic surgeon, a resident general surgeon, a resident orthopedic surgeon, an anesthesiologist, and four assistant nurses. Except for the plastic surgeon that was trained in microsurgery, this was the first microsurgery procedure for all other members of the team.
Epidural anesthesia was administered. The gracilis muscle flap was harvested from the contralateral thigh [Figure 2] under loupe magnification. The donor site was closed primarily over a corrugated drain.
|Figure 2 Intraoperative and post operative view. (A) Site of harvest of gracilis muscle on the right thigh; (B) Gracils flap completely severed from the right thigh; (C) Flap inset on left foot defect; (D) Dressing with a hole that allow clinical monitoring of the flap|
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The donor vessels on the recipient site were the anterior tibial artery and vein. End-to-end anastomoses under microscope magnification (Leica Wild M680) were performed using 10/0 Nylon for veins and 9/0 Nylon for the artery. The flap was inserted in the defect with absorbable 3/0 polyglactin 910 sutures [Figure 2].
The operation field was regularly flushed with a warm solution of Ringer Lactate containing additional 1% xylocaine and heparin. The overall operative time was 8 hours.
The patient was admitted in a warmed room, and IV 24-hour continuous heparin (5000 UI) was administered for three days. The flap was monitored clinically (a window in the dressing enabled a direct surveillance of the color of the flap, and a scratching over the surface of the muscle with a needle was regularly applied to provoke superficial bleeding) [Figure 2].
The post-operative course was uneventful (no bleeding, no infection, no flap ischemia, no wound dehiscence on the donor site). On day 5, we resurfaced the muscle flap with a meshed autologous split thickness skin graft [Figure 3]. The patient was discharged on day 12. The wound healed completely in 21 days. The donor site also healed completely and sutures were removed on day 12. The reconstructed foot was bulky [Figure 3]. The patient was informed that the bulkiness will disappear over time. The patient was satisfied with the procedure.
|Figure 3 Follow-up views. (A) Flap at day 5 ready for a skin graft; (B) Split thickness skin graft over the muscle flap; (C) Anterior view of the reconstructed left foot; (D) lateral view of the reconstructed left foot|
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| Discussion|| |
Lacerations over foot and ankle regions occur mostly during road traffic accidents and in young adults. These anatomic regions are challenging for plastic surgeons, who thus are prompt to research sophisticated reconstructive techniques.
To date, free tissue transfer has become an avoidable tool for the reconstruction of complex defects. In Africa, the feasibility of microsurgery is still uncommon due to poor technical conditions and few trained surgeons. South Africa has been one of the earliest countries to initiate microsurgery as late as 1970. In other African countries, especially those in the sub-Saharan parts, some cases of microsurgery have been reported, performed by teams from Europe., One rare local team in Uganda has published good results with reconstructive microsurgery. In Nigeria, though microsurgery has been reported to exist for decades, the visibility is still limited. However, the new training center in Lagos might be a promising sign for enhancing microsurgery in the country.,
The gracilis muscle free flap is a versatile flap used in many indications including face reanimation. In our case, the gracilis free flap has proven its simplicity of harvesting, minimal donor site morbidity, reliable pedicle, and dimensions appropriate to cover small and large defects as referred in the literature.,,, Penaud et al. reported an average 6 hours for the free gracilis procedure. In our case, the longer operative time (8 hours) may have been linked with the limited experience of the young operative team.
The bulky aspect of the flap is expected to decrease from six months to two years to a more flatten and aesthetically appreciated aspect.,,
The free gracilis muscle flap is reported as the workhorse for foot and ankle reconstruction in many centers around the world,,, and is expected to become of mainstream use in our center after this first experience.
| Conclusion|| |
This first case of gracilis muscle free flap for a traumatic foot reconstruction showed a good result and the feasibility of microsurgery in settings with limited resources.
The success of this first experience represents an essential incentive to develop a microsurgery team for the reconstruction of difficult defects enhancing the prospects of surgical care in Togo.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We want to thank Rossella Ferrari and Sana El Hasnaoui for their contribution in the editing of this article.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]