Extended Pedicle Groin Flap Reconstruction For Large Forearm

Defect. A Case Report

* Dharmendra Widetya Made, **Agus Roy R H Hamid.

* Resident of General Surgery Department of Surgery Faculty, of Medicine,

Udayana University-Sanglah General Hospital, Denpasar Bali

** Plastic, Reconstructive And Aesthetic Surgery Division, Department of Surgery,

Faculty of Medicine, Udayana University-Sanglah General Hospital, Denpasar

Bali.

ABSTRACT

Background

The groin flap is a vascularized axial flap based on the superficial circumflex iliac

artery. It is used regularly by many reconstructive surgeons for covering soft tissue

defects of the hand.

Method

We reported a male 64th years old patient with chief complaint wound on his right

forearm after hit by a chain saw. The patient already done open reduction internal

fixation using plate and screw, repair vascular, extended groin flap to cover the

defect. The result is acceptable.

Discussion

Groin flaps have been the most widely used pedicled flaps in hand reconstruction.

They can cover extensive defects of over 10x15cm without sacrificing a major
artery or the need for end-to-end microvascular anastomosis. The groin flap is an

axial-patterned cutaneous flap based on the superficial circumflex iliac

arteriovenous system. This flap can provide soft-tissue coverage for defects on any

part of the hand and the distal two thirds of the forearm.

Conclusion

Groin flaps have been the most widely used pedicled flaps in hand reconstruction.

This flap can provide soft-tissue coverage for defects on any part of the hand and

the distal two thirds of the forearm. Necrosis of the flap is the worst complication

one can have, but fortunately loss of the whole pedicle flap is very rare.

Keyword: Extended Groin Flap, Forearm Defect, Hand Reconstruction,

Loss of skin and subcutaneous tissue frequently results from serious trauma. The

simplest treatment of these injuries is split-thickness skin grafting. However, in

many areas, such as the hand, forearm and face, this form of treatment on occasion

is inadequate, and application of full-thickness skin and subcutaneous tissue in the

form of a flap is preferred in order to obtain optimal function and appearance1.

The groin flap is a vascularized axial flap based on the superficial circumflex iliac

artery arising from the femoral artery just below the inguinal ligament. It is used

regularly by many reconstructive surgeons for covering soft tissue defects of the

hand 2.

Flaps from the chest, abdomen and groin could be fashioned to close upper

extremity defects in stages based on the musculocutaneous perforators2.

CASE REPORT

We reported a male 64th years old patient reffered from Public Hospital in

Banyuwangi. The patient came with chief complaint wound on his right forearm

after hit by a chain saw when the patient cut down a tree. When arrived at Sanglah

hospital, the patient at stable condition with blood pressure 120/80 mmHg, pulse

rate 90x/minutes, respiratory rate 24 x/minutes, temperature 36,50 C. the patient

already done operation open reduction internal fixation with plate and screw and

also repair vascular on November 23rd 2017.

From the physical examination we found, an open wound at right forearm 25cm X

15cm in size, with bone and plate exposed, we also found necrotic tissue, total

rupture of brachioradialis muscle, partial rupture of superficial flexor digitorum

and finger.

Fig 1. Clinical appearance of the defect on the right forearm.

On November 25th 2017, the patient undergo reconstructive surgery to cover the

defect on the right forearm using extended groin flap and skin graft. The flap is

based on the paraumbilical perforators.

Fig 2. Flap Design, Extended Groin Flap On The Right Forearm, Skin Graft

The patient treated for 14 days, and discharge after evaluation of graft donor. On

January 26th 2018 we evaluate the flap, the flap is viable, although there is a little

necrotic tissue on the flap. On January 30th 2018 the patient undergo operation for

cutting the flap, and debridement necrotomy for the necrotic tissue.
Fig3. Necrotic Tissue On The Flap, Post Necrotomy and Cutting The Flap.

For the defect after necrotomy, we treated conservatively. After follow up for 1

month the defect is narrowing

Fig 4. Defect After Follow Up For 1 Month

Groin flaps have been the most widely used pedicled flaps in hand reconstruction.

They can cover extensive defects of over 10x15cm without sacrificing a major

artery or the need for end-to-end microvascular anastomosis3.

Groin are supplied by a number of perforator vessels. The deep epigastric arcade

forms the abdominal portion of a ventral vascular network linking the subclavian

and external iliac arteries. This network forms the basis of various axial flaps used

in reconstructive surgery. The groin flap is an axial pattern flap based on the

superficial circumflex iliac artery and the superficial venous network of the groin

area2.

The groin flap is an axial-patterned cutaneous flap based on the superficial

circumflex iliac arteriovenous system. This flap can provide soft-tissue coverage

for defects on any part of the hand and the distal two thirds of the forearm 4. The

flap can be designed as a bilobed double-leaf (Y) pattern or other shapes to fit

specific defects. An extended groin flap has also been described that includes the

lateral femoral cutaneous nerve (LFCN) that must be sacrificed. Circulation to the

extended portion is maintained by the communicating branches between the lateral

femoral cutaneous artery (LFCA) and the SCIA9.

Tubercle Pubicum

Lig Inguinale
A. cicumflexa ilium superfical.Femoralis
Symphise

A. Femoralis
Being an axial pattern flap, the groin flap can reliably be raised with good length-

to-breadth ratio. The donor site scar lies in a cosmetically advantageous position.

The venous drainage is through a superficial set, which drains into the saphenous

system. The deep venae comitantes are a less important route of drainage and may

also join the saphenofemoral junction or may pass deeply beneath the femoral artery

to enter the femoral vein8-9.

The best form of reconstruction for total degloving injury of the hand is replantation

of the avulsed skin and this has been done successfully on some rare occasions. But

when the avulsed part is not available, they need to be covered by flaps.

Microsurgical options exist, but when a single free flap isused, it shares the same

disadvantage of being bulky with pedicled flaps. Even then a single flap may not

suffice and multiple free flaps may be needed6.

The following advantages explain their wide use:

1. vascular reliability even when anatomic variations exist

2. good vascular supply that enhances the viability of surrounding tissue near

the flap

3. simple procedure that can be carried out by less experienced surgeons, and

short operative time

4. secondary division and insetting procedures can be performed in a short

outpatient procedure

5. it can be used in emergency cases because of the quickness of the procedure

and the large surface of the flap

using other distant flaps such as the abdominal wall flap graft that may have

similar indications

7. good quality, hairless skin, with a good cosmetic appearance

8. acceptable donor site scar, easily hidden by underwear

9. the groin flap donor site also provides full access to the iliac crest for bone

graft harvest when required without creating another scar.

Disadvantages of pedicled groin flaps have been discussed in various recent reports.

The flaps are usually bulky, require multiple stages, necessitate longer hospital stay,

cause patient discomfort, stiffness, and do not allow elevation of the hand after

acute trauma6-8.

dorsal hand and forearm defects are easily covered by inferiorly based flaps based

on the superficial circumflex and SIEAs. Volar forearm defects are better managed

by superiorly based flaps raised on the paraumbilical perforators5.

Necrosis of the flap is the worst complication one can have, but fortunately loss of

the whole pedicle flap is very rare. Marginal necrosis can occur. The patient is

conservatively treated if excision of the compromised flap would not expose a vital

structure or another flap is considered7-10.

CONCLUSION

Groin flaps have been the most widely used pedicled flaps in hand reconstruction.

The groin flap is an axial-patterned cutaneous flap based on the superficial

circumflex iliac arteriovenous system. This flap can provide soft-tissue coverage

for defects on any part of the hand and the distal two thirds of the forearm.
dorsal hand and forearm defects are easily covered by inferiorly based flaps based

on the superficial circumflex and SIEAs. Volar forearm defects are better managed

by superiorly based flaps raised on the paraumbilical perforators.

Necrosis of the flap is the worst complication one can have, but fortunately loss of

the whole pedicle flap is very rare.

1. Amouzou, K. S. et al. (2017) ‘The pedicled groin flap in resurfacing hand burn scar

release and other injuries: a five-case series report and review of the literature.’,

Annals of burns and fire disasters, 30(1), pp. 57–61. Available at:

http://www.ncbi.nlm.nih.gov/pubmed/28592937%0Ahttp://www.pubmedcentr

al.nih.gov/articlerender.fcgi?artid=PMC5446912.

2. Chuang, D. C. C. et al. (1989) ‘Groin flap design and versatility’, Plastic and

Reconstructive Surgery, 84(1), pp. 100–107. doi: 10.1097/00006534-198907000-

00019.

3. Goertz, O. et al. (2012) ‘The effectiveness of pedicled groin flaps in the treatment

of hand defects: Results of 49 patients’, Journal of Hand Surgery. Elsevier Inc.,

37(10), pp. 2088–2094. doi: 10.1016/j.jhsa.2012.07.014.

4. Gupta, P. (2017) ‘Groin Flap in Paediatric Age Group to Salvage Hand after Electric

Contact Burn: Challenges and Experience’, Journal of Clinical and Diagnostic

Research, 11(8), pp. 10–12. doi: 10.7860/JCDR/2017/29124.10332.

5. Jokuszies, A. et al. (2010) ‘Der gestielte Leistenlappen zur Defektdeckung an der

Hand’, Operative Orthopadie und Traumatologie, 22(4), pp. 440–451. doi:

10.1007/s00064-010-9017-6.

6. Knutson, G. H. (1977) ‘The groin flap: a new technique to repair traumatic tissue

defects.’, Canadian Medical Association journal, 116(6), pp. 623–5. Available at:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1879168&tool=pm

centrez&rendertype=abstract.

7. McGREGOR, I. A. N. A. (1972) ‘<THE GROIN FLAP.pdf>’, Plast Reconstr Surg, 25,

pp. 3–16. doi: 10.1097/00006534-197308000-00086.

8. Report, C. (2004) ‘Use of groin flap in the closure of through and through defect
 of a forearm : A case report’, 12(1), pp. 47–48.

9. Sabapathy, S. R. and Bajantri, B. (2014) ‘Indications, selection, and use of distant

pedicled flap for upper limb reconstruction’, Hand Clinics, 30(2), pp. 185–199. doi:

10.1016/j.hcl.2014.01.002.

10. Sabapathy, S. R., Venkatramani, H. and Martin Playa, P. (2015) ‘The use of

pedicled abdominal flaps for coverage of acute bilateral circumferential degloving

injuries of the hand’, Trauma Case Reports. Elsevier B.V., 1(3–4), pp. 25–31. doi:

10.1016/j.tcr.2015.08.001.