Anatomical Study On The Long Gracilis Myocutaneous Flap Supplied By Obturator Artery And Its Clinical Significance

Objectives The purposes of the present study are as follows: (1)Anatomicalstudy including observation and measurement of the shapes,main bloodvessels and nerves,the lengths of pedicle and the position where thevessels and nerves entered the gracilis muscle. (2)Clarifying theorigin,,course,extemal caliber and distribution of the obturatorartery in gracilis. (3)Clarifying the origin,,course,extemal caliberand distribution of the medial circumflex femoral artery in gracilis.(4)Illustrating the anastomosis between the obturator artery and themedial circumflex femoral artery and clarifying its regulation ingracilis. (5) Applying the producation of anatomical studies to theclinical treament and observing the results.Materrical and Methods On 38 sides of the adult cadaveric lower limbs specimens perfusedwith red relax,the shapes,main blood vessels and nerves of gracilis,thelength of pedicle and the position where the vessles and nerves enteredthe muscle were dissected and measured.The origin,course,branches, the occurrence rate and distributionof the obturator artery in gracilis muscle were observed on 38 adultcadaveric lower limbs perfused with latex.The origin,course,branches, the occurrence rate and distributionof the medial circumflex femoral artery in gracilis muscle wereobserved on 38 adult cadaveric lower limbs perfused with latex.The anastomosis between the obturator artery and the medialcircumflex femoral artery were observed on 38 adult cadaveric lowerlimbs perfused with latex. Two fresh specimens,injecting red gelatin into femoralartery,cutting flap after dealing with formalin and get x-ray photos. To reconstruction vulvoviginal immediately,four long gracilismyocutaneous flaps supplied by obturator artery transfersperformed .Three patients had unilateral flaps and one had bilateralprocedures. Design the island flap according to the size and site ofthe coloboma following radical vulvoviginalvectomy.In the gracilisglap modification,the deep femoral artery is deliberatery sacrificed.The clinical data included the surgery date,defect description and site,complications were taken record.Results 1. The lengths of gracilis ,muscle belly and tendon were (40.5±1.8)cm,( 29±0.5)cm ,( 11.3±1.2)cm respectively.The widthest of themuscle belly positoned in the 1/3 common boundary between the upsideand the middle part,the width was (3.1±0.7) cm,the thicknees was(0.8±0.2) cm. The blood supply of gracilis originated mainly from thegracilis branch of deep femoral artery,the outer diameter of thisbranch origin was (3.0±0.3)mm, the outer diameter of this branchentered into the muscle was(1.31±0.37)mm,the length of vessel pediclewas (9.8±2.4)cm.Gracilis was innervated by the anterior branch ofobturator nerve,the transverse diameter of the nerve in the positionwhere it entered muscle was (2.03±0.15)mm,the distance from theobturator canal to the site where it enter the gracilis was (10.2±1.6)cm. 2. Forty obturator artery branches occurred in 37 of 38 sides ofadult cadavers and the occurrence rate was 97.37% which invovlved twofrom the anastomosis between obturator artery and medial circumflexfemoral artery.After giving off the internal iliac artery (theoriginal point were2.3±0.37mm ),the obturator artery went down orforward through the outboard of pelvis, divided into the former branchand the back branch in the front of obturator membrane.The former branchrunned before the obturator foramen,went into the muscle ahead theadductor brevis.It is (2.84±8.27)cm from the point where this branchentered into the muscle to the origin of the muscle. The outer diameterof obturator artery in the point was (0.62±0.45)mm.Small branches(1-2) arised from the obturator artery,distributed in the proximal onethird of the gracilis muscle.The length of this artery in the musclewas (6.63±4.32)cm. 3.The occurrence rate of the medial circumflex femoral artery ingracilis muscle was 95%(36 sides in 38).After giving off the deepfemoral artery,the medial circumflex femoral artery decended in themedial aspect of pelvis,divided into the deep branch and the superiorbranch in the front of iliopsoas.The deep branch entered into thegracilis muscle between the adductor longus and the adductor breviswhere the outboard of gracilis. The outer diameter of this branchentered the muscle was (0.88±0.29) mm.Two or three branches arisedfrom the medial circumflex femoral artery after it entered into themuscle,widely distributed in the proximal one third of the gracilismuscle,and anastomosed with obturator.This artery alonged with twovein which external diameter were (1.12±0.25) mm and (0.8±0.17) mmrespectively. 4.Widely vessel anastomosis exist between the obturator artery andthe medial circumflex femoral artery.The main anastomosis types areterminal caplillary netlike anastomosis,the diameter of thisanastomosis was (1.18±0.25)mm。 5.The angiography of gracilis revealed that its blood supply wasvery profuse,the obturator artery widely anastomosed with medialcircumflex femoral artery,deep femoral artery and genicular artery orpoplital artery which lied in the terminal 1/3 of gracilis muscle. 6. All skin flaps survived and first intention was 3 of 4cases.Minor infection occurred in the edges of one flap,healed afterdressing change. The period of follow-up in all cases is 24-42months.The neovulvaginal has a relatively normal appearance.Thetechnique is improving the cosmetic and functional outcome of theneovulvagina formed with the graft improve the post-operative course.Conclusion 1.The obturator artery is the important blood which lied in theproximal one third of the gracilis muscle with the advantage of havinga permanent positon.Furthermore,it widely anastomosed with medialcircumflex femoral artery.The blood supplying of gracilis muscle camefrom the anastomosis existed between obturator artery-medialcircumflex femoral artery-deep femory artery when deliberaterysacrificed the deep femory artery. 2.The long gracilis myocutaneous flap supplied by obturator arterycan be designed for immedialy repairing the defect following vulvaginalcancer accoding to the course, distribution of the obturator arteryand the anastomosis between obturator artery and medial circumflexfemoral artery in gracilis muscle. 3.The above mentioned operation could be a simple,ideal method forvulvovaginal reconstruction with the advantages of reliable bloodsupply,abundant tissue and the pedicle neared by vulvovaginal. Theresults were satisfactory with improving postoperative function.