Note: last updated before 2015

GENERAL CONSIDERATIONS

1. Indications
2. Contraindications

PRE-OPERATIVE CONSIDERATIONS

1. Consent
2. Antibiotics
   1. Should have Unasyn or equivalent OCTOR
3. Patient should have had pictures taken, and these should be printed and hung up in the OR

NURSING CONSIDERATIONS

1. Room set-up
   1. Need special OR bed that allows splitting the legs apart (surgeon needs to be seated next to medial thigh for flap harvest)
   2. Need a gel pad on the OR bed, particularly where patient's sacrum will lay (just before the bed splits into legs), as there is increased pressure with external rotation of legs during gracilis harvest
   3. Patient should have a sacral mepilex placed
   4. Pre-warm room to 74 degrees Fahrenheit
   5. Hang up patient pictures on OR wall
2. Instrumentation and equipment
   1. Need sterile circuit for ETT (tube will be prepped and dirty circuit switched out)
   2. Lighted retractors
   3. Bipolar scissors
3. Patient positioning
   1. Following intubation, patient generally will need to be shifted downward on the bed, such that their bottom is at the level of the leg split in the bed
      1. Depending on patient height, may need to remove head board so that head is near the edge of the bed
   2. Bed will be turned 90 degrees with head towards the door
   3. No SCD for operative leg (preferentially will use right leg)
4. Medications
   1. Plain 1:100,000 epinephrine for face (off the field)
   2. No injection for leg
5. Prep and drape
   1. Sterilizer tape wrapped around head to secure hair back and allow stapling of head drape to the tape (rather than the patient)
   2. Betadine prep for the leg (270 degrees around leg), alcohol prep for the face
   3. Blue towels around face (include entire face) and squared off around thigh, followed by regular split drape, with another half sheet to cover inferior towels in middle.
      1. Will cut split drape down the middle when time to move to the leg
6. Drains and dressings
   1. Penrose drain for the face, with loose burn netting/fluffs to collect drainage around neck, bacitracin to face incision
   2. 19 gauge large suction for leg, with Kerlix roll and 4 in ACE wrap around leg

ANESTHESIA CONSIDERATIONS

1. Intubation - plan for nasotracheal intubation with regular endotracheal tube, typically on non-operative side
   1. Tube should be sutured in with 2-0 silk, with peach tape (from anesthesia) placed right at the nostril, and the sutured tied down onto this (holds better)
   2. Will switch to sterile circuit following prep and draping

OPERATIVE PROCEDURE

1. Face
   1. Will start here initially, move to leg, then go back to face once flap harvested
2. Free flap harvest
   1. Marking the leg (use right leg preferentially)
      1. Locate the "bump" from the adductor tendons near the pubis
      2. Run fingers back and forth and then mark it - straight line from there down to the medial tibial tubercle
   2. Procedure
      1. Incision though skin and subcutaneous fat, with bipolar to cauterize any vessels as they are encountered
         1. Often a large vein will be present that can be harvested and set aside for possible vein grafting if needed
            1. Not used in diabetics or others who may suffer from the loss of the venous drainage
      2. Identify muscle belly (usually readily visible)
         1. Work on superior and inferior surfaces of the muscle belly to free the muscle from surroundings
      3. Keep in mind the pedicle
         1. Generally will enter muscle about 8 cm from the pubic tubercle
         2. Generally passes underneath adductor longus and above adductor magnus, and enters fairly close to a right angle to the gracilis muscle
         3. Obturator nerve runs superiorly and obliquely to gracilis muscle in the same plane as the pedicle
      4. Free up circumferentially around gracilis both inferiorly (below pedicle) and superiorly (above nerve)
      5. Make tunnel into the area of junction of longus and magnus both superior and inferior to open up the space where you'll look for the pedicle (Stevens scissors good here for dissection and cutting); taking it far inferior gives better access and opening superiorly allow for greater pedicle harvest
      6. There is usually a rather large fascia/fat bad between longus and magnus/gracilis - carefully dissect through and release to visualize the pedicle deep and along top of magnus (on the "carpet")
      7. Dissect as much length as possible on the obturator nerve, then cut and release, and reflect back on the muscle
      8. Measuring the muscle
         1. Mark the muscle with marking pen at the hilum
         2. Previously, should have measured on face from oral commissure to tragus, and add ~3 cm to this length for muscle harvest
         3. Adjust the length superiorly/inferiorly from the hilum to be harvested, adjusting how much on each side based on where we want the vascular pedicle to be in relation to the donor facial vessels
            1. Mark inferior and superior extents with a silk suture
      9. Use bipolar scissors to cut muscle, removing approximately 50-60% of bulk (ideally want between 25-40 g of muscle) - PROTECT PEDICLE AT ALL TIMES (i.e. with penrose or vessel loop to keep out of the way)
         1. In peds patients, may need to harvest the entire muscle width to get enough size
      10. Carefully dissect out the pedicle
          1. Use lighted retractor to pull up the longus and follow pedicle superiorly
          2. Apply hemoclips to perforators that go up into longus and add length to the pedicle
          3. Take down the pedicle with snaps individually and tie off
   3. Measurements - will take several measurements throughout the case (typically Dr. Henstrom will bring a sheet of paper with blanks to fill out)
      1. Length, width, and thickness of flap in situ, following harvest, and during nerve stimulation
      2. Weight of flap following harvest
   4. Closure
      1. One JP drain
      2. Close deeply with 2-0 Vicryl, deep dermal with 3-0 Vicryl, and running subcuticular with 4-0 Monocryl in segments, Steri-strips (placed perpendicular to incision)
      3. Wrap leg with Kerlix gauze roll and Ace wrap

POST-OPERATIVE CARE

1. Patients will generally go to 3JPW rather than the SICU
2. Flap checks
   1. Every 4 hours by nursing AND by residents (alternating so that patient has a flap check every 2 hours) for the first 24 hours
3. No activity restrictions - should be up and ambulating as soon as possible
4. May start mechanical soft diet post-operatively, and will generally advance the following day on POD 1
5. IV antibiotics while inpatient
6. Generally will not plan on pharmacologic DVT prophylaxis unless history of thrombotic events

REFERENCES

Boahene KO, Owusu J, Ishii L, Ishii M, Desai S, Kim I, Kim L, Byrne P. The Multivector Gracilis Free Functional Muscle Flap for Facial Reanimation. JAMA Facial Plast Surg. 2018 Jul 1;20(4):300-306. doi: 10.1001/jamafacial.2018.0048. Erratum in: JAMA Facial Plast Surg. 2018 Jul 1;20(4):340. PMID: 29566121; PMCID: PMC6145838.

Miller MQ, Hadlock TA. Lessons from Gracilis Free Tissue Transfer for Facial Paralysis: Now versus 10 Years Ago. Facial Plast Surg Clin North Am. 2021 Aug;29(3):415-422. doi: 10.1016/j.fsc.2021.03.001. PMID: 34217444.

FACE:

1-Use sterilizing tape around back of head and over ears to pull back the hair.

2-Prep face with alcohol, hairline with betadine.

3-Staple blue towels to tape line. Mark Nasolabial fold, preferably before patient intubated.

4-Inject plain epinephrine into plane for dissection (subSmas). Tape eyes shut first, then use sponge in off hand to give traction.

5-Facelift type of incision extending up into hairline

6-Typical parotid approach raising flap even further medially, over parotidmasseteric fascia. Open and expose widely and broadly.

7-Identify individual branches of nerve (if needed, but likely non-functioning at this point right!?)

8-Identify facial vessels

9-Identify Masseteric branch of Trigeminal if needed.

10-5 single O Vicryls will be put into lateral aspect of orbicularis (or surrounding tissue if OO not present). Two above commissure, one at commissure, and two below commissure. Matching with preop smile on other side. Take great care, and double check with finger palpation and visually, that no sutures have gone through the oral mucosa. Once in place, hold in place with mosquito through the handles to keep in order for insetting medial aspect of muscle. Bite is from superficial to deep

Order: (1-5 and keep in order)

Superficial to deep in OO, then deep-sup of muscle flap, then back sup to deep at OO at same spot as before and back through flap then tie off. 5 sutures at corner of mouth, only 4 at lateral anchor point. Inset the flap in order of the sutures

11-Consider defatting some of the buccal fat so the bulge isn’t as prominent. 

12-Create neo-tendon in harvested muscle by suturing a 3-0 vicryl around the ends, locking them in place wrapping around the ends.

13-Insetting the flap. Do medially first. Then do vessel anastomosis, then neurorraphy, then distal (lateral) insetting.

14- Inset the flap in order of the sutures

15-Ensure that the Gracilis information sheet is filled in, photo taken of inset flap showing vessels. Superficial skin mark/stitch placed on skin over vessels.