Use of Rectus Femoris Muscle Flap in Patients With Absent Profunda Femoris Vascular Flow

Complex groin wounds are a serious complication among patients who have undergone infrainguinal vascular bypass surgeries and can result in loss of limb and even life if not managed properly. The etiology of such wounds, particularly those associated with graft exposure following peripheral vascular surgery, have been attributed to poor local blood supply, seroma formation, skin maceration, and/or inadequate wound care leading to infection and compromised healing.¹ The gold standard for management of such wounds is secondary reconstruction by way of a muscle flap, which functions to provide blood flow, prevent infection, and obliterate dead space within the recipient wound.

The rectus femoris (RF) muscle is an excellent choice for pedicled rotational flap coverage of groin wounds because of its minimal distal attachments, easily identifiable vascular pedicle, pedicle proximity to groin, and low rate of donor site complications. Furthermore, the RF flap has been proven to be reliable in the presence of peripheral vascular disease (PVD).² This finding is significant because of the nature of the RF muscle’s vascular supply, which is considered to be a Mathes-Nahai type II muscle. This type of vascular anatomy is characterized by 1 dominant pedicle and secondary minor pedicles that cannot sustain the muscle in the absence of the dominant pedicle. With regards to the RF muscle, the descending branch of the lateral circumflex femoral artery (dLCFA)—which originates from the profunda femoris artery (PFA) in the proximal thigh—is the dominant pedicle. Therefore, compromise of the PFA would, in theory, suggest an elevated risk of flap failure when elevating the RF flap. We present a series of 3 cases in which pedicled RF muscle flaps were successfully used for coverage of complex groin wounds in patients with known PFA occlusion.

Patient A

Patient A was a 62-year-old male with history of chronic heart failure, kidney disease, hypertension, and PVD who underwent right iliofemoral bypass with Dacron graft, right common femoral artery endarterectomy with patch angioplasty, and right femoral to below-knee popliteal bypass with polytetrafluoroethylene graft after presenting with a nonhealing ulcer of the right foot because of lower limb arterial insufficiency. Prior to surgery, physical examination revealed no palpable femoral pulse on the right lower extremity, and computed tomography angiography (CTA) imaging of the right lower extremity demonstrated severe atherosclerotic disease with occlusion of the majority of the external iliac artery extending throughout most of the right superficial femoral artery. The PFA was occluded proximally on the CTA but appeared to reconstitute distally.

At vascular surgery clinic follow-up 6 weeks postoperatively, the patient presented with right groin and abdominal surgical site dehiscence with purulent drainage concerning for a deep wound infection (Figure 1). The patient was admitted and started on broad spectrum IV antibiotics. He underwent irrigation and debridement, and deep wound cultures were positive for Proteus mirabilis. Due to exposure of grafts following debridement, plastic surgery was consulted for wound coverage.

After appropriate debridement and antibiotic therapy, the patient underwent coverage of the exposed bypass graft, utilizing a pedicled RF muscle flap to the right groin and abdominal wall (Figure 2). During the procedure, the RF muscle was isolated and detached from its distal tendinous insertion. Blunt dissection and electrocautery were carried out in a distal-to-proximal direction towards the vascular pedicle, which was noted to be a branch of the lateral femoral circumflex artery. Handheld doppler confirmed flow through the pedicle. The flap was passed through a subcutaneous tunnel superiorly into the abdominal wound, achieving sufficient coverage of both exposed grafts.

At final operative treatment, the abdominal wound was able to be closed primarily over the underlying muscle flap, and a skin graft was placed over the muscle flap within the groin wound, which healed without complication (Figure 3).

Patient B

Patient B was a 62-year-old male who presented with moderate right aortoiliac and femoral popliteal occlusive disease, treated by vascular surgery with an endarterectomy of the right external iliac, common femoral and deep femoral arteries, along with a right femoral-above knee popliteal bypass with a polytetrafluoroethylene graft. Of note, operative findings described the first several centimeters of the PFA being severely calcified with high-grade stenosis and near occlusion, as well as occlusion of the superficial femoral artery at its origin. This surgery was complicated by development of pseudoaneurysm of the right PFA and thrombus formation within the femoral-popliteal bypass graft requiring pseudoaneurysm repair, thrombectomy, and placement of stents to the right common femoral and external iliac arteries. A postoperative wound infection further complicated this patient’s recovery, and after irrigation and debridement, the patient had exposure of his bypass graft within the wound bed. He subsequently underwent RF muscle flap closure with immediate skin grafting of the muscle belly. Again, handheld doppler confirmed flow through the muscle’s pedicle prior to transposition.

Patient C

Patient C was a 71-year-old female with a history of PVD and bilateral infrainguinal vascular surgeries performed at an outside facility, including femoral-popliteal bypass with subsequent revision and transmetatarsal amputation following dry gangrene of a left toe. She presented with a large pseudoaneurysm at the level of the proximal anastomosis of her left femoral-popliteal bypass, as confirmed via doppler arterial and CTA imaging. CTA of the left lower extremity revealed extensive arterial calcification that limited runoff distally.

She underwent pseudoaneurysm repair and RF flap elevation for groin coverage. During the operation, 3 branches of the PFA were observed. Transection of the largest and most proximal of these branches was required for adequate repair of the pseudoaneurysm and its associated defect. The defect was repaired with a bovine pericardial patch, and the transected branch of the PFA was transposed and anastomosed into the femoral artery patch repair. Upon completion of pseudoaneurysm repair, she had exposure of the common femoral-profunda complex with bovine patch visible in the wound bed. After confirming flow through the pedicle with handheld doppler, the groin wound was closed using a pedicled left RF muscle flap to obliterate the dead space, followed by primary closure of the overlying skin, which healed uneventfully.

All 3 patients presented with history of PVD and severe atherosclerotic disease affecting the PFA, confirmed by CTA and/or intraoperative observation. Each patient presented with a groin wound complication following femoral-popliteal bypass surgeries, with deep wound infection present in 2 of 3 patients and pseudoaneurysm formation in 2 of 3 patients. Mean patient age was 65 years (range: 62-71), and all patients presented with a comorbidity associated with delayed wound healing, including hypertension, current tobacco use, and chronic kidney disease (Table 1).

All 3 patients underwent uncomplicated pedicled RF muscle flap procedures for groin wound coverage. The mean length of hospital stay following flap coverage was 9.67 days (range: 5-17) (Table 2). Initial clinic follow-up averaged 26.67 days postop (range: 19-39) with final follow-up averaging 108.67 days postop (range: 89-119). There were no flap failures, donor- or recipient-site infections, nor sites that required reoperation.

The success of the RF muscle flap for coverage of groin wounds is well-documented. Using limb and graft salvage rates as outcome indicators for RF flaps in patients with groin wound complications following infrainguinal vascular surgery, Alkon et al (90% and 78.3%),² Mirzabeigi et al (94.2% and 78.4%),³ and Wübbeke et al (89% and 80%)⁴ all reported favorable results. Of more relevance to the scope of this case series, there were no flap failures in the Mirzabeigi³ and Alkron² studies, and only a 6% flap failure rate in the Wübbeke study⁴ despite the presence of PVD in 69%, 78.8%, and 78.7% in each cohort population, respectively. These prior studies, however, did not investigate the extent of PVD, specifically whether or not the vasculature supplying the RF muscle was directly compromised. It is important to consider this variable because the RF muscle’s Mathes-Nahai type II classification theoretically would infer flap failure if the dLCFA was compromised. Therefore, the presence of lower extremity PVD seemingly increases the risk of RF flap failure. With that being said, the PFA has shown significant resistance to atherosclerotic changes compared with other lower extremity arteries. In a retrospective study reviewing angiograms of patients with suspected lower extremity vascular disease, Halvorson et al⁵ demonstrated mean stenoses of 12.5% in the PFA and 10% in the dLCFA. All other arteries in the study—including the superficial femoral, popliteal, tibioperoneal trunk, posterior tibial, anterior tibial, and peroneal—displayed mean stenoses greater than 50%,⁵ suggesting that the vascular supply to the RF muscle would be potentially compromised in a small percentage of patients with lower extremity PVD. The question that remains and that this case series attempts to assess is the viability of the RF flap in known occlusion of the PFA.

The 3 patients included in this case series all had evidence of atherosclerotic disease affecting the PFA, yet all underwent successful groin reconstruction without RF flap failure. Prior studies on the viability of the RF muscle following harvest of the anterolateral thigh flap—which utilizes the dLCFA as its pedicle—may offer insight as to why the flaps survived in these 3 patients. Following a prospective intraoperative study utilizing temporary selective occlusion of vessels supplying the RF muscle, Wong et al⁶ concluded that the muscle would remain viable as long as it had a vessel of greater than 1-mm diameter providing vascular supply. This finding opens the door for 2 possible explanations for viability of the RF flap in our patients: either the dLCFA remained sufficiently patent (>1 mm) despite stenosis of the PFA, or an alternative supply developed that cumulatively provided adequate blood flow to the muscle, possibly through dilatory and/or angiogenic changes of traditionally regarded minor vessels because of longstanding PVD. Among the patients presented in this series, 1 demonstrated near occlusion of the PFA, 1 demonstrated complete occlusion, and the last underwent a PFA reconstruction at the time of flap coverage.

The former theory is supported by prior findings that show an overall incidence rate of any degree of stenosis in the dLCFA to be approximately half of that found in the PFA.⁵ Furthermore, of the 13% of patients in the study showing atherosclerotic changes to the dLCFA, only approximately 65% had a degree of stenosis greater than 50%.⁵ Therefore, this data would suggest that the majority of patients with PFA stenosis would maintain a dLCFA of sufficient diameter to supply the RF muscle. This explains the likely success of the RF flap in patient B.

The latter of the 2 explanations is based on recent studies exploring the complexity and diversity of the RF muscle vascular supply and possible physiologic compensation in response to ischemic/arterial occlusive conditions. Using CTA images of the bilateral lower extremities of 25 patients without underlying vascular disease, Zhan et al⁷ found that despite 70% of all arterial branches entering the RF muscle being of dLCFA origin, the majority of RF muscles exhibited a first proximal branch entry from other arteries, including the ascending branch of the LCFA (n = 23), oblique branch of the LCFA (n = 5), femoral artery (n = 5), PFA (n = 1), and the trunk of the LCFA (n = 1). Their study also recognized the possibility of small vessels within the fascia and muscle sarcolemma with potential to sustain the muscle.⁷ Whereas together the aforementioned branches and small vessel networks are considered supplemental nutrient supplies to the RF muscle, long- and short-term physiologic adaptations may augment these vessels to a sufficient degree to maintain the flap after elevation. In PVD models in mice, mature collateral vessels to the hindlimb showed an increase in diameter of 2.1- to 2.4-fold, along with a capillary density increase of 1.7-fold.⁸ These findings suggest that, in the presence of profunda femoris occlusion, the augmentation of vascular competency in the aforementioned vessels may form a robust enough network to support the RF muscle without its primary pedicle. This explanation is potentially why the flap remained viable in patient A.

Regardless of the mechanism by which the RF flap survives in the presence of PFA occlusion, the findings of this case series provide further support for the RF flap as a workhorse flap in complex groin reconstruction. Other flaps traditionally used in groin reconstruction include the sartorius muscle transposition flap and the gracilis myofasciocutaneous flap. With regards to the large muscle bulk often required to adequately fill dead space and provide graft coverage in the groin, these 2 options are less desirable to the RF. With added relevance to this series, occlusion of the PFA is recognized as a contraindication in the use of the gracilis myofasciocutaneous flap.²

The RF muscle flap has displayed efficacy and reliability in its utilization for groin reconstruction. However, because of its classification as a Mathes-Nahai type II muscle, PFA compromise leads to logical concern regarding the viability of the flap. This case series of patients with known compromise of the PFA who underwent successful groin coverage with RF muscle flaps provides evidence to support the use of this flap in patients with PVD. Despite these findings, thorough preoperative assessment via precise CTA imaging and intraoperative evaluation using handheld doppler should be used to ensure sufficient arterial supply to the RF muscle in these patients prior to complete flap elevation.

Affiliations: University of Mississippi Medical Center Division of Plastic and Reconstructive Surgery, Jackson, MS

Correspondence: Katherine C Benedict, MD; kbenedict@umc.edu

Disclosures: None of the authors have any relevant financial disclosures to make.