Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 15  |  Issue : 2  |  Page : 44-47

A free gracilis muscle flap for foot resurfacing, the first microsurgical case in a Sub-Saharan African country, Togo


University of Lomé, Department of Surgery, Sylvanus Olympio Teaching Hospital, Lomé, Togo

Date of Submission06-Jun-2019
Date of Acceptance03-Nov-2019
Date of Web Publication17-Jul-2020

Correspondence Address:
Komla Séna Amouzou
1, Rue de l’Hopital, PO Box 20752, Lomé
Togo
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_5_19

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  Abstract 

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 Aug 5];15:44-7. Available from: http://www.njps.org/text.asp?2019/15/2/44/290020


  Introduction Top


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. [1] 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 [1],[2]. 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%,[2] thus overlooked the relatively long operative time and the intra-operative difficulties compared to other reconstructive options. [2]

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. [3]

In the past, our reconstructive activity has been based on skin grafts, local and regional flaps, [3] or cross legs flaps. [4] 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.[3] 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 Top


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 Top


Lacerations over foot and ankle regions occur mostly during road traffic accidents and in young adults.[1] 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.[5] In other African countries, especially those in the sub-Saharan parts, some cases of microsurgery have been reported, performed by teams from Europe.[6],[7] One rare local team in Uganda has published good results with reconstructive microsurgery.[8] In Nigeria, though microsurgery has been reported to exist for decades, the visibility is still limited.[9] However, the new training center in Lagos might be a promising sign for enhancing microsurgery in the country.[10],[11]

The gracilis muscle free flap is a versatile flap used in many indications including face reanimation.[12] 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.[1],[2],[13],[14] Penaud et al.[1] 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.[1],[2],[15]

The free gracilis muscle flap is reported as the workhorse for foot and ankle reconstruction in many centers around the world,[1],[2],[14] and is expected to become of mainstream use in our center after this first experience.


  Conclusion Top


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.

Aknowledgement

We want to thank Rossella Ferrari and Sana El Hasnaoui for their contribution in the editing of this article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Penaud A, Besset M, Quignon R, Bahe L, Danin A, Fouquet B et al. Le lambeau libre de muscle gracilis en chirurgie reconstructrice du pied, de la cheville et du tiers distal de la jambe. Annales de chirurgie plastique esthétique 2014;59:42-52.  Back to cited text no. 1
    
2.
Zukowski M, Lord J, Ash K, Shouse B, Getz S, Robb G. The gracilis free flap revisited: a review of 25 cases of transfer to traumatic extremity wounds. Ann Plast Surg 1998;40:141-4.  Back to cited text no. 2
    
3.
Amouzou KS, Bakriga B, Kouevi-Koko TE, Amegble KJ, Abalo A, Dossim A. Reconstruction of lower limb traumatic soft tissue defects in Togo. Niger J Plast Surg 2017;13:8-11.  Back to cited text no. 3
    
4.
Amouzou KS, Malonga-Loukoula EJC, Berny N, Kouevi-Koko TE, Ezzoubi M. Neurosural fasciocutaneous cross-leg flaps for leg salvage surgery. J Afr Chir Orthop Traumatol 2017;2:86-9.  Back to cited text no. 4
    
5.
Arnot RS, Lee S, Engelbrecht GC, Terblanche J. Microvascular surgery in South Africa. I. The teaching workshop. S Afr Med J 1973;47:1596-1600.  Back to cited text no. 5
    
6.
Rodgers W, Lloyd T, Mizen K, Fourie L, Nishikawa H, Rakhorst H et al. Microvascular reconstruction of facial defects in settings where resources are limited. Br J Oral Maxillofac Surg 2016;54:51-6.  Back to cited text no. 6
    
7.
Giessler GA, Schmidt AB. Noma: experiences with a microvascular approach under West African conditions. Plast Reconstr Surg 2003;112:947.  Back to cited text no. 7
    
8.
Citron I, Galiwango G, Hodges A. Challenges in global microsurgery: A six year review of outcomes at an East African hospital. J Plast Reconstr Aesthet Surg 2016;69:189-95.  Back to cited text no. 8
    
9.
Chukwuanuku TOG. Plastic surgery in Nigeria—scope and challenges. Niger J Surg 2011;17:68-72.  Back to cited text no. 9
    
10.
Mofikoya BO, Ugburo OA, Bankole OB. Challenges in the organisation of a microsurgery laboratory in a low resource country. Niger Postgrad Med J 2010;17:60-3.  Back to cited text no. 10
  [Full text]  
11.
Mofikoya BO, Ugburo AO, Bankole OB. Microvascular anastomosis of vessels less than 0.5 mm in diameter: a supermicrosurgery training model in Lagos, Nigeria. J Hand Microsurg 2011;3:15-7.  Back to cited text no. 11
    
12.
Boahene KO, Owusu J, Ishii L, Ishii M, Desai S, Kim I et al. The multivector gracilis free functional muscle flap for facial reanimation. JAMA Facial Plast Surg 2018;20:300-6.  Back to cited text no. 12
    
13.
Oranges CM, Tremp M, Wang W, Madduri S, Summa PGD, Wettstein R et al. Patient height, weight, BMI and age as predictors of gracilis muscle free-flap mass in lower extremity reconstruction. In Vivo 2018;32:591-5.  Back to cited text no. 13
    
14.
Calotta NA, Pedreira R, Deune EG. The gracilis free flap is a viable option for large extremity wounds. Ann Plast Surg 2018;81:322.  Back to cited text no. 14
    
15.
Smith RO, Clancy RM, Wiper JD. Healing and maturation of the free Gracilis flap in extremity reconstruction: a patient perspective. J Plast Reconstr Aesthet Surg 2019;72:513-27.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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