Flow-through anastomosis using a T-shaped vascular pedicle for gracilis functioning free muscle transplantation in brachial plexus injury

Abstract

Objective: In gracilis functioning free muscle transplantation, the limited caliber of the dominant vascular pedicle increases the complexity of the anastomosis and the risk of vascular compromise. The purpose of this study was to characterize the results of using a T-shaped vascular pedicle for flow-through anastomosis in gracilis functioning free muscle transplantation for brachial plexus injury.

Methods: The outcomes of patients with brachial plexus injury who received gracilis functioning free muscle transplantation with either conventional end-to-end anastomosis or flow-through anastomosis from 2005 to 2013 were retrospectively compared. In the flow-through group, the pedicle comprised a segment of the profunda femoris and the nutrient artery of the gracilis. The recipient artery was interposed by the T-shaped pedicle.

Results: A total of 46 patients received flow-through anastomosis, and 25 patients received conventional end-to-end anastomosis. The surgical time was similar between the groups. The diameter of the arterial anastomosis in the flow-through group was significantly larger than that in the end-to-end group (3.87 mm vs. 2.06 mm, respectively, p<0.001), and there were significantly fewer cases of vascular compromise in the flow-through group (2 [4.35%] vs. 6 [24%], respectively, p=0.019). All flaps in the flow-through group survived, whereas 2 in the end-to-end group failed. Minimal donor-site morbidity was noted in both groups.

Conclusions: Flow-through anastomosis in gracilis functioning free muscle transplantation for brachial plexus injury can decrease the complexity of anastomosis, reduce the risk of flap loss, and allow for more variation in muscle placement.

Figure 1

Design of the gracilis musculocutaneous flap.

Figure 2

Intraoperative images. A) Exposure of the dominant vascular pedicle. To avoid injury during the operation, the pedicle was not dissected at first. B) The neurovascular pedicle of the gracilis. Note that the sensory nerve branch (☆) must be resected to ensure enough motor nerve fiber regeneration (a, b). C) Exposure of the profunda femoris. A segment of the profunda femoris was prepared. It is unnecessary to perform a long dissection. D) The T-shaped arterial pedicle of the gracilis musculocutaneous flap (flap placed with the skin paddle downward).

Figure 3

Flow-through anastomosis of the T-shaped pedicle. A) The diameter of the profunda femoris segment is obviously larger than that of the nutrient artery of the gracilis. B) The brachial artery was resected, and the diameters of the segment profunda femoris and brachial artery were well matched. C) Interposed anastomosis to bridge the brachial artery. Two veins were anastomosed in direct end-to-end fashion.