RECONSTRUCTIVE

Proximal Vascular Pedicle Preservation forSartorius Muscle Flap Transposition

Liza C. Wu, M.D.Risal S. Djohan, M.D.

Tom S. Liu, M.D.Albert H. Chao, M.D.

Robert F. Lohman, M.D.David H. Song, M.D.

Chicago, Ill.

Background: A variety of muscle flaps have been described to treat complexgroin wounds associated with infected and/or exposed femoral vessels or vas-cular grafts and persistent lymphatic leaks, and for prophylaxis against woundbreakdown following inguinal lymphadenectomy. The sartorius muscle flap hasseveral advantages over other muscle flaps: it is immediately adjacent to thegroin, it is easy to prepare, and the harvest causes no functional morbidity.Despite these advantages, the flap’s reliability has been questioned because ofthe segmental blood supply to the muscle and the flap’s limited arc of rotation.To improve the reliability of the flap, the authors defined the proximal vascularanatomy of the sartorius muscle in 20 human cadavers and assessed the cor-relation with 20 clinical cases. They describe a technique for the harvest of thesartorius muscle transposition flap that preserves the most proximal pedicle.Methods: From July of 2000 to January of 2004, 40 sartorius muscles weredissected in 20 human preserved cadavers. During the same time period, 21sartorius muscle transposition flap procedures were performed in 19 patients fora variety of complex groin wound complications, including infection (n � 10),lymphadenectomy (n � 4), lymphatic leak (n � 3), exposed femoral vessels (n� 3), and high-risk wound (n � 1). The location of the most proximal vascularpedicle with respect to the anterior superior iliac spine was measured in eachcadaveric dissection as well as in each clinical case. Outcomes were assessed in theclinical cases with respect to wound healing.Results: The distance between the anterior superior iliac spine and the proximalvessels in the cadaver specimens was 6.6 � 1.3 cm (range, 5.0 to 9.5 cm). Thedistance between the anterior superior iliac spine and the proximal vessels in theclinical patients was 6.2 � 0.6 cm (range, 5.5 to 7.5 cm). Patients were followed foran average period of 30 months (range, 5 to 45 months). There were no incidencesof partial or total flap necrosis. All wounds healed to completion.Conclusions: The proximal pedicle of the sartorius muscle is consistently locatedat 6.5 cm from the anterior superior iliac spine. Preservation of the proximal pedicleduring dissection ensures the viability of the sartorius muscle transposition flap forthe treatment of complex groin wounds. (Plast. Reconstr. Surg. 117: 253, 2006.)

Transposition of the sartorius 1muscle wasoriginally described to cover the femoralvessels after inguinal lymph node dissec-

tion in 1948.1 Since then, the sartorius muscletransposition flap has been used for a variety ofcomplex groin wounds to prevent against woundbreakdown after lymphadenectomy, to stop per-sistent lymphatic leaks, and to treat exposedand/or infected femoral vessels and grafts after

vascular intervention.2–18 The sartorius muscleflap has several advantages over other muscleflaps: it is immediately adjacent to the groin, it iseasy to dissect, and the harvest causes no func-tional deficit.19–22 Despite these advantages, thereliability of the sartorius muscle flap has beenquestioned because of its segmental blood sup-ply and limited arc of rotation.

The sartorius muscle is attached to the anteriorsuperior iliac spine and inserts on the medial tibia.The blood supply to the sartorius muscle is derivedfrom eight to 11 vascular pedicles that arise fromthe superficial femoral artery. The vascularpedicles course from the superficial femoral arterytoward the medial edge of the sartorius and enterthe muscle belly on the posterior surface.

From the University of Chicago Hospitals, Section of Plasticand Reconstructive Surgery, and the University of Chicago,Pritzker School of Medicine.Received for publication September 1, 2004; revised November 2,2004.Copyright ©2005 by the American Society of Plastic SurgeonsDOI: 10.1097/01.prs.0000185670.15531.50

www.plasreconsurg.org 253

According to the Mathes and Nahai classifica-tion of muscle flaps, the sartorius is a type IVmuscle; members in this group demonstratemultiple pedicles entering the muscle along itslength between the origin and insertion.23 Ac-cording to anatomic studies, each pedicle sup-plies distinct and separate vascular territories inthe same muscle. The success of muscle flaps isbased on a reliable blood supply. Furthermore,its applicability is dependent on its ability tocover the defect. For the sartorius muscle flap,the integrity of the vascular pedicles must bepreserved to ensure viability, but each vascularpedicle acts as a leash, limiting its potential arcof rotation.

Various techniques of sartorius muscle harvesthave been described, from proximally to distallybased flaps and rotational to twist flaps, with orwithout the division of the tendinous insertionsand with or without the division of up to half ofthe vascular pedicles.2–23 All of these techniqueswere developed to increase the muscle’s arc ofrotation to cover and fill various groin defects.Although initial studies report success with thesartorius transposition flap, it became clear thatmanipulation of the sartorius muscle resulted incompromise of its vascular supply and necrosisof part or all of the muscle.8,10,12,13

To improve the reliability of the sartorius mus-cle flap, we defined the proximal vascular anat-omy of the sartorius muscle in 20 human cadav-ers and assessed the correlation with 19 clinicalcases. We describe a technique for harvesting thesartorius muscle transposition flap that preservesthe most proximal pedicle.

METHODS

Cadaver StudiesThe proximal vascular supply of 40 sartorius

muscles was investigated in 20 preserved cadavers.The average age of the cadavers was 81 years(range, 35 to 99 years). There were six male and14 female cadavers. Each muscle was exposedfrom its tendinous insertion at the anterior supe-rior iliac spine, throughout its length and width,to its attachment in the medial aspect of the tibia.The deep surface of the muscle was exposed andthe most proximal vascular pedicle was identified.The distance between the anterior superior iliacspine and the point where the most proximal vas-cular pedicle entered the muscle was measured foreach sartorius muscle (Figs. 1 and 2).

Clinical StudiesNineteen patients underwent reconstruction

of their groin wounds with sartorius muscle flaps.The average patient age was 61 years (range, 22 to82 years). There were eight male and 11 femalepatients with 21 groin wounds. Ten wounds haddocumented perigraft/graft infections after vas-cular reconstruction, four wounds were the resultof lymphadenectomy, three wounds had exposedgraft/vessels after vascular reconstruction, threegroins were treated for persistent lymphatic leaks,and one groin wound was prophylactic againstbreakdown in an obese patient after vascular by-pass.

In the clinical cases, the dissection began withidentification of the sartorius muscle that lies im-mediately adjacent and lateral to the femoral ves-sels. The original groin incision can be extendedsuperiorly and laterally toward the anterior supe-rior iliac spine to aid in exposure. Dissection con-tinued toward and around the entire lateral bor-der of the muscle. The muscle was detached fromthe anterior superior iliac spine, and care wastaken to include as much of the tendinous portionas possible. The proximal muscle was elevated ju-diciously until the first vascular pedicle was en-countered and preserved. The superior portion ofthe muscle was turned over and transposed tocover or fill the defect as needed. The tendinousportion of the muscle was anchored to the pubis,and several sutures were placed to tack the musclebelly down to the wound bed (Figs. 3 and 4).

The distance between the anterior superioriliac spine and the first vascular pedicle was mea-sured to correlate the clinical findings with thecadaver data. The outcomes of the reconstructionswere assessed.

Fig. 1. Cadaver dissection of the proximal vascular pedicle ofthe sartorius muscle.

Plastic and Reconstructive Surgery • January 2006

254

RESULTSIn the cadavers, the mean distance from the

anterior superior iliac spine to the most proximalvascular pedicle was 6.6 cm (SD, 1.3 cm; range, 5to 9.5cm). In the 19 patients with 21 groin wounds,the mean distance from the anterior superior iliacspine to the most proximal pedicle was 6.2 cm (SD,0.6 cm; range, 5.5 to 7.5 cm). The difference wasnot statistically significant (p � 0.3). The distancevalues for each cadaver and each patient are plot-ted in Figure 5.

Follow-up for patients who underwent theproximal pedicle preservation technique for sar-torius muscle transposition ranged from 6 to 30months. There were no cases of total or partialmuscle flap loss. There were four complications:one hematoma resolved without intervention; onelymphatic leak after a sartorius muscle flap for aninfected vascular graft was treated with re-explo-ration and a vacuum-assisted closure device overthe sartorius muscle; and two graft hemorrhageswere treated by emergency patch angioplasty. Allwounds healed to completion without any addi-tional muscle flaps. There were no cases of am-putation or death.

DISCUSSIONIn the groin, wound complications are prev-

alent and include infection, skin necrosis, se-roma or hematoma formation, and lymphaticleaks. The incidence of wound complicationsafter inguinal lymphadenectomy has been re-ported to be as high as 40 to 60 percent.2– 4,24 –27

After vascular bypass surgery, the rate of groinwound complications has been reported to beas high as 15 to 25 percent and associated witha limb loss rate of 11 to 75 percent, with amortality rate as high as 20 to 75 percent.5–19,28

The increased rate of complications with groinwounds has been attributed to many factors. Skinflaps can be significantly devascularized, with con-comitant interruption of collateral lymphatic andvascular channels. The groin is in close proximity toskin folds and the perineum, sources of bacterial

Fig. 2. The proximal vascular pedicle of the sartorius muscle.

Fig. 3. Proximal pedicle preservation for sartorius muscle flaptransposition in a patient. (Above) Preoperative markings of theanterior superior iliac spine, sartorius muscle, and approximatelocation of the proximal vascular pedicle, 6.5 cm from the anteriorsuperior iliac spine. (Below) The proximal sartorius muscle is ele-vated from the anterior superior iliac spine to the proximal vas-cular pedicle.

Volume 117, Number 1 • Proximal Vascular Pedicle Preservation

255

contamination.29,30 Regardless of the cause, thegroin wound has become a significant cause of op-erative morbidity and mortality.

Several methods have been developed to pro-phylax against groin wound complications, includ-ing reoriented skin incisions to prevent skin necro-sis, placement of closed suction drainage systems toprevent seroma or hematoma formation, antibiotictreatment to prevent infection, and the applicationof fibrin glue or the like to hasten healing.31–33 De-spite these interventions, complications remainprevalent.

The use of muscle flaps to reconstruct variouscomplex defects is well recognized.34,35 Well-vas-cularized muscle can deliver increased levels ofoxygen, nutrients, and antibiotics, as well as con-form and fill defects. Originally described for thereconstruction of lower extremity wounds, the useof muscle flaps has expanded to reconstruct anydefect on the body, with demonstrable physio-logic, clinical, and financial advantages.34–38

Muscle flaps for groin wounds have been shownto be beneficial by reducing morbidity and mortal-ity. Various muscle flaps have been described forthe coverage of groin wounds, such as the rectusabdominis, rectus femoris, tensor fasciae latae, gra-

cilis, and sartorius muscle flaps.2–19,21,24,25 The sarto-rius muscle flap has several advantages over othermuscle flaps: it is immediately adjacent to the groinand the harvest causes no functional deficit.

Transposition of the sartorius muscle was orig-inally described in 1948 to cover the femoral ves-sels after inguinal lymph node dissection.1 Sincethen, the sartorius muscle transposition flap hasbeen used for a variety of complex groin wounds,to prevent against wound breakdown after lymph-adenectomy, to stop persistent lymphatic leaks,and to treat exposed and/or infected femoral ves-sels and grafts after vascular intervention.

The success of the sartorius muscle flap, as inany muscle flap, is based on the preservation of theblood supply. Furthermore, its usefulness is de-pendent on its ability to cover the acquired defect.For the sartorius, the integrity of the pedicles mustbe preserved to ensure viability. This requirementcan decrease the arc of rotation, with each vascularpedicle acting as a leash. To overcome this poten-tial limitation, various techniques have been de-scribed to increase the arc of rotation at the ex-pense of its vascular supply. In the past, someinvestigators have divided either proximal or distalpedicles; this resulted in the partial or total ne-crosis of the muscle.15–17 It was concluded that thesartorius was unreliable or that the muscle’s lim-ited arc of rotation makes it inadequate as a mus-cle flap reconstruction. Studies demonstrating therelative importance of preserving all of the vascu-lar supply are scant, and there is uncertainty as tothe relative contribution and importance of eachvascular pedicle. Kaiser et al.20 reported that thesartorius muscle is adequately perfused as long aseither the proximal or distal supply remains intact.Habermeyer et al.21 concluded that the proximalarterial branch alone is sufficient to supply thewhole muscle. To determine the relative contri-bution of the proximal vascular pedicle, we useda vascular duplex scan to assess proximal muscleperfusion while compressing the first segmentalvessel using microsurgical clamps. This maneuverresulted in hypoperfusion of the proximal portionof the muscle, pallor of the muscle, and loss of theDoppler signal (Fig. 6). This finding suggests thatthe first vascular pedicle may be vital to the survivalof the proximal part of the muscle.

The sartorius muscle flap can be harvested so thatnone of its vascular pedicles need to be divided and itsblood supply is preserved in its entirety. Originallydescribed in an article by Khalil and Sudarsky,19 thesartorius muscle can be turned over to cover the ma-jority of groin defects without sacrificing vascularity orarc of rotation.

Fig. 4. The arc of rotation.

Plastic and Reconstructive Surgery • January 2006

256

CONCLUSIONSWe investigated the proximal vascular anatomy of

the sartorius muscle and defined the distance fromthe anterior superior iliac spine to the proximal vas-cular pedicle at approximately 6.5 cm. This findingwill aid us in using the proximal vascular pedicle pres-ervation technique for sartorius muscle flap transposi-tion, which has proven to be a reliable and effective

technique that leaves no functional deficit for themanagement of complex groin wounds.

David H. Song, M.D.University of Chicago Hospitals

Section of Plastic and Reconstructive Surgery5841 S. Maryland Avenue, MC 6035

Chicago, Ill. 60637dsong@surgery.bsd.uchicago.edu

Fig. 6. Flow Doppler ultrasonography of the proximal sartorius muscle. (Above, left and right)Before clamping the proximal vascular pedicle. (Below, left and right) After clamping the pedicle.

Fig. 5. The distance between the anterior superior iliac spine (ASIS) and the proxi-mal vascular pedicle (PVP) for all anatomic dissections in cadavers (black boxes) andpatients (gray boxes).

Volume 117, Number 1 • Proximal Vascular Pedicle Preservation

257

REFERENCES1. Baronofsky, I. Technique of inguinal node dissection. Surgery 24:

555, 1948.2. Soots, G., Mikati, A., Warembourg, H., Jr., Watel, A., and Noblet,

D. Treatment of lymphorrhea with exposed or infected vascularprosthetic graft in the groin using sartorius myoplasty. J. Cardio-vasc. Surg. 29: 42, 1988.

3. Wong, J. J., Daly, B., Krebs, T. L., Elias, E. G., and Jacobs, S. C.Surgical transfer of the sartorius muscle to the groin after lymph-adenectomy debridement: CT findings. Am. J. Roentgenol. 166:109, 1996.

4. Paley, P. J., Johnson, P. R., Adcock, L. L., et al. The effect ofsartorius transpositions on wound morbidity following inguinal-femoral lymphadenectomy. Gynecol. Oncol. 64: 237, 1997.

5. Mendez Fernandez, M. A., Quast, D. C., Geis, R. C., and Henly,W. S. Distally based sartorius muscle flap in the treatment ofinfected femoral arterial prostheses. J. Cardiovasc. Surg. (Torino)21: 628, 1980.

6. Kaufman, J. L., Shah, D. M., Corson, J. D., Skudder, P. A., andLeather, R. P. Sartorius muscle coverage for the treatment ofcomplicated vascular surgical wounds. J. Cardiovasc. Surg. (Torino)30: 479, 1989.

7. Meyer, J. P., Durham, J. R., Schwarcz, T. H., Sawchuk, A. P., andSchuler, J. J. The use of the sartorius muscle rotation-transfer inthe management of wound complications after infrainguinalvein bypass: A report of eight cases and description of the tech-nique. J. Vasc. Surg. 9: 731, 1989.

8. Mixter, R. C., Turnipseed, W. D., Smith, D. J., Acher, C. W., Rao,V. K., and Dibbell, D. G. Rotational muscle flaps: A new techniquefor covering infected vascular grafts. J. Vasc. Surg. 9: 472, 1989.

9. Petrasek, P. F., Kalman, P. G., and Martin, R. D. Sartorius myo-plasty for deep groin wounds following vascular reconstruction.Am. J. Surg. 160: 175, 1990.

10. Perler, B. A., Vander Kolk, C. A., Dufresne, C. R., and Williams,G. M. Can infected prosthetic grafts be salvaged with rotationalmuscle flaps? Surgery 110: 30, 1991.

11. Perler, B. A., Vander Kolk, C. A., Manson, P. M., and Williams,G. M. Rotational muscle flaps to treat localized prosthetic graftinfection: Long-term follow-up. J. Vasc. Surg. 18: 358, 1993.

12. Meland, N. B., Arnold, P. G., Pairolero, P. C., and Lovich, S. F.Muscle-flap coverage for infected peripheral vascular prosthesis.Plast. Reconstr. Surg. 93: 1005, 1994.

13. Calligaro, K. D., Veith, F. J., Schwartz, M. L., et al. Selectivepreservation of infected prosthetic arterial grafts. Ann. Surg. 220:461, 1994.

14. Perez-Burkhardt, J. L., Gonzalez-Fajardo, J. A., Carpintero, L. A.,and Mateo, A. M. Sartorius myoplasty for the treatment of in-fected groins with vascular grafts. J. Cardiovasc. Surg. 36: 581,1995.

15. Maser, B., Vedder, N., Rodriguez, D., and Johansen, K. Sartoriusmyoplasty for infected vascular grafts in the groin: Safe, durable,and effective. Arch. Surg. 32: 522, 1997.

16. Galland, R. B. Sartorius transposition in the management ofsynthetic graft infection. Eur. J. Vasc. Endovasc. Surg. 23: 175, 2002.

17. Graham, R. G., Omotoso, P. O., and Hudson, D. A. The effec-tiveness of muscle flaps for the treatment of prosthetic graftsepsis. Plast. Reconstr. Surg. 109: 108, 2002.

18. Colwell, A. S., Donaldson, M. C., Belkin, M., and Orgill, D. P.Management of early groin bypass graft infections with sartoriusand rectus femoris flaps. Ann. Plast. Surg. 52: 49, 2004.

19. Khalil, I. M., and Sudarsky, L. Sartorius muscle “twist” rotationflap: An answer to flap necrosis. J. Vasc. Surg. 6: 93, 1987.

20. Kaiser, E., Genz, K. S., Habermeyer, P., and Mandelkow, H.Arterial supply of the sartorius muscle. Chirurg 55: 731, 1984.

21. Habermeyer, P., Kaiser, E., Mandelkow, H., Schweiberer, L., andStock, W. Anatomy and clinical aspects of sartoriusplasty. Hand-chir. Mikrochir. Plast. Chir. 19: 21, 1987.

22. Yang, D., Morris, S. F., and Sigurdson, L. The sartorius muscle:Anatomic considerations for reconstructive surgeons. Surg. Ra-diol. Anat. 20: 307, 1998.

23. Mathes, S. J., and Nahai, F. Classification of the vascular anatomyof muscles: Experimental and clinical correlation. Plast. Reconstr.Surg. 67: 177, 1981.

24. Goldstein, J. A., Janu, P., and Fields, B. Rectus femoris flap repairof recalcitrant inguinal lymphoceles after heart transplantation.J. Heart Lung Transplant. 13: 549, 1994.

25. Bare, R. L., Assimos, D. G., McCullough, D. L., Smith, D. P.,DeFreanzo, A. J., and Marks, M. W. Inguinal lymphadenectomyand primary groin reconstruction using rectus abdominis muscleflaps in patients with penile cancer. Urology 44: 557, 1994.

26. Zhang, S. H., Sood, A. K., Sorosky, J. I., Anderson, B., and Buller,R. E. Preservation of the saphenous vein during inguinal lymph-adenectomy decreases morbidity in patients with carcinoma ofthe vulva. Cancer 89: 1520, 2000.

27. Bevan-Thomas, R., Slaten, J. W., and Pettaway, C. A. Contempo-rary morbidity from lymphadenectomy for penile squamous cellcarcinoma: The M. D. Anderson Cancer Center experience.J. Urol. 167: 1638, 2002.

28. Evans, G. R., Francel, T. J., and Manson, P. N. Vascular prostheticcomplications: Success of salvage with muscle-flap reconstruc-tion. Plast. Reconstr. Surg. 91: 1294, 1993.

29. Goldstone, J., and Moore, W. S. Infection in vascular prosthesesclinical manifestations and surgical management. Am. J. Surg.128: 225, 1974.

30. Szilagyi, D. E., Smith, R. F., Elliott, J. P., and Vrandecic, M. P.Infection in arterial reconstruction with synthetic grafts. Ann.Surg. 176: 321, 1972.

31. Van Lindert, A. C., Symons, E. A., Damen, B. F., and Heintz, A. P.Wound healing after radical vulvectomy and inguino-femorallymphadenectomy: Experience with filgrastim. Eur. J. Obstet. Gy-necol. Reprod. Biol. 62: 217, 1995.

32. Giovannacci, L., Renggli, J. C., Eugster, T., Stierli, P., Hess, P.,and Gurke, L. Reduction of groin lymphatic complications byapplication of fibrin glue: Preliminary results of a randomizedstudy. Ann. Vasc. Surg. 15: 182, 2001.

33. Gould, N., Kamelle, S., Tillmanns, T., et al. Predictors of compli-cations after inguinal lymphadenectomy. Gynecol. Oncol. 82: 329,2001.

34. Mathes, S. J., and Nahai, F. Clinical Applications for Muscle andMusculocutaneous Flaps. St. Louis, Mo.: Mosby-Year Book, 1982.Pp. 58-59.

35. Russell, R. C., Graham, D. R., Feller, A. M., Zook, E. G., andMathur, A. Experimental evaluation of the antibiotic carryingcapacity of a muscle flap into a fibrotic cavity. Plast. Reconstr. Surg.81: 162, 1988.

36. Chang, N., and Mathes, S. J. Comparison of the effect of bacterialinoculation in musculocutaneous and random-pattern flaps.Plast. Reconstr. Surg. 70: 1, 1982.

37. Calderon, W., Chang, N., and Mathes, S. J. Comparison of theeffect of bacterial inoculation in musculocutaneous and fascio-cutaneous flaps. Plast. Reconstr. Surg. 77: 785, 1986.

38. Gosain, A., Chang, N., Mathes, S., Hunt, T. K., and Vasconez, L.A study of the relationship between blood flow and bacterialinoculation in musculocutaneous and fasciocutaneous flaps.Plast. Reconstr. Surg. 86: 1152, 1990.

Plastic and Reconstructive Surgery • January 2006

258