Mid-term Clinical Outcome of Microvascular Gracilis Muscle Flaps for Defects of the Hand

Abstract

Purpose: Gracilis muscle flaps are useful to cover defects of the hand. However, there are currently no studies describing outcome measurements after covering soft tissue defects using free flaps in the hand.

Aim: To analyze mid-term results of gracilis muscle flap coverage for defects on the hand, with regard to functional and esthetic integrity.

Methods: 16 patients aged 44.3 (range 20-70) years were re-examined after a mean follow-up of 23.6 (range 2-77) months. Mean defect size was 124 (range 52-300) cm² located palmar (n = 9), dorsal (n = 6), or radial (n = 1). All flaps were performed as microvascular muscle flaps, covered by split thickness skin graft.

Results: Flaps survived in 15 patients. 6 patients required reoperations. Reasons for revisions were venous anastomosis failure with total flap loss (n = 1) requiring a second gracilis muscle flap; necrosis at the tip of the flap (n = 1) with renewed split thickness skin cover. A surplus of the flap (n = 2) required flap thinning and scar corrections were performed in 2 patients. Mean grip strength was 25% (range 33.3-96.4%) compared to the contralateral side and mean patient-reported satisfaction 1.4 (range 1-3) (1 = excellent; 4 = poor).

Conclusions: Gracilis muscle flaps showed a survival rate of 94%. Patients showed good clinical outcomes with acceptable wrist movements and grip strength as well as high reported satisfaction rates. Compared to fasciocutaneous free flaps, pliability and thinness especially on the palmar aspect of the hand are advantageous. Hence, covering large defects of the hand with a gracilis muscle flap can be a very satisfactory procedure.

Level of evidence: IV observational.

Keywords: Covering hand defects; Gracilis muscle flap; Hand surgery; Microsurgery; Soft tissue defects hand.

Fig. 1

20-year-old female with severe devascularising milling injury with deep osteotendocutaneous defect zone, which had led to an index ray amputation and pronounced soft tissue defect (A–B). The size of the defect was 56 cm², mainly palmar and crossing the wrist joint. Initial treatment included osteosynthesis of the forearm, soft tissue reconstruction of tendons and nerves as well as vessels and ligaments. After 4 days, a microvascular gracilis muscle flap including a meshed split thickness skin graft was performed (C – D). Pictures E – F demonstrate the clinical and radiological follow-up of 9 months after surgery. She rated her subjective cosmetically and functional outcome with 85% and her overall satisfaction rate was 1 (excellent)

Fig. 2

Outcome after a microvascular gracilis muscle flap including a meshed split thickness skin graft in a 34-year-old male after an infection

Fig. 3

Outcome of a 56-year-old male after a motorcycle accident and ray amputation of 2nd and 5th digit