Microsurgical breast reconstruction and primary hypercoagulable disorders.

BACKGROUND: Primary hypercoagulable disorders pose a significant challenge to microsurgeons and have traditionally been regarded as a relative contraindication to free tissue transfer. Since free flaps offer numerous advantages in breast reconstruction, there is an effort to expand the population to whom these operations can be safely offered. The purpose of this study is to describe our chemoprophylaxis regimen in cases of primary hypercoagulability, as well as to compare flap outcomes and complications between women with and without hypercoagulability. PATIENTS AND METHODS: A single institution retrospective review identified 15 patients (25 flaps) with known primary hypercoagulability who underwent microsurgical breast reconstruction from 2010 through 2020. There were 785 patients (1268 flaps) without primary hypercoagulability who underwent microsurgical breast reconstruction, including 40 patients (73 flaps) with a history of venous thromboembolism (VTE), evaluated for comparison. Patient characteristics, thromboprophylaxis regimen, and surgical outcomes were collected. In carrying out this cohort study, we have adhered to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. RESULTS: Fifteen patients with primary hypercoagulability were identified, including heterozygous factor V Leiden mutation (n = 12), protein S deficiency (n = 1), prothrombin mutation (n = 1), and primary antiphospholipid syndrome (n = 1). Thirteen of these (87%) were discharged with an extended LMWH course. There was no postoperative VTE or mortality in this cohort, and no significant difference in hematoma or transfusion compared with the control group (p = .31, p = .87, respectively). The flap loss rate was 4% in the hypercoagulable group compared with 0.92% in the control group (p = .15). The salvage for arterial or venous compromise in the hypercoagulable group was poor (0% vs. 52%, p = .3). CONCLUSION: Microsurgical breast reconstruction in women with primary hypercoagulability disorders is feasible with acceptable risk of flap loss but poor salvage potential. Postoperative thromboprophylaxis with extended prophylactic LMWH in this population appears to be a safe regimen.

Clinical course of venous thromboembolism following abdominally based microsurgical breast reconstruction: A case series.

BACKGROUND: Venous thromboembolism (VTE) is a potentially devastating complication following abdominally based microsurgical breast reconstruction, with a reported incidence of 0.08-4%. The authors aim to describe disease presentation and clinical course following VTE diagnosis in patients within their practice. METHODS: A retrospective chart review identified patients who underwent microsurgical breast reconstruction from January 2007 through December 2018. Patients with VTE diagnosed within 90 days of surgery were included. Demographics, co-morbidities, signs and symptoms, and characteristics of oncologic, surgical, and post-operative care were analyzed. RESULTS: Seven hundred one patients underwent microsurgical breast reconstruction. Eleven patients with pulmonary embolism (PE) and four with deep vein thrombosis (DVT) were identified, resulting in VTE incidence of 2.1% (0.57% DVT, 1.6% PE). Patients were on average 51 years old and had an average body mass index (BMI) of 31.7 kg/m2. Two had a history of VTE, and none had a known hypercoagulable disorder. Using the 2005 Caprini model, all were high risk and seven were highest risk. Among those with PE, the most common symptom was shortness of breath, and the most common signs were desaturation or supplemental oxygen requirements. VTE was diagnosed on average 14.2 days post-operatively (range 2-52 days). CONCLUSION: VTE is an infrequent complication following abdominally based microsurgical breast reconstruction. We recommend a high index of suspicion in women reporting shortness of breath or having desaturation, especially in those with high BMI, high Caprini scores, post-operative complications, or early return to the operating room.

Microsurgical Breast Reconstruction in the Obese: A Better Option Than Tissue Expander/Implant Reconstruction?

BACKGROUND: Obesity has reached epidemic proportions, with 72 million people in the United States classified as obese in 2010. This significant increase in obese patients is reflected in the breast cancer population seeking breast reconstruction. Previous studies demonstrated increased complication rates and decreased satisfaction in obese patients undergoing breast reconstruction. This study aims to directly compare prosthetic and autologous reconstruction in the obese population by evaluating surgical outcomes and patient satisfaction. METHODS: In an institutional review board-approved study, a retrospective chart review was conducted on patients with a body mass index of 30.0 kg/m or greater who underwent breast cancer reconstruction after mastectomy with either free tissue transfer from the abdomen or prosthetic reconstruction over a 3-year period. The authors identified 96 patients with 141 reconstructions. Demographic, intraoperative, and postoperative variables were collected. All patients were sent the BREAST-Q questionnaire by means of mail to study the impact and effectiveness of breast surgery from the patient's perspective. Statistical analysis was completed with Fisher's exact test, Mantel-Haenszel chi-square test, Pearson chi square test, or Mann-Whitney-Wilcoxon test. RESULTS: Prosthetic-based breast reconstruction was associated with increased major breast complications (p < 0.001), mastectomy skin flap necrosis (p = 0.009), infection (0.006), and overall reconstructive failure (p < 0.0001) compared with autologous reconstruction. When evaluating the results of the BREAST-Q studies, the autologous reconstruction group had improved satisfaction with breasts (p < 0.0001), satisfaction with outcome (p = 0.01), psychosocial well-being (p = 0.007), and sexual well-being (p = 0.006). CONCLUSION: In the obese population, reconstruction with free tissue transfer from the abdomen resulted in decreased complications of the breast reconstruction site and improved patient satisfaction with outcomes compared with prosthetic reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Discussion of preoperative mammography in women undergoing reduction mammaplasty.

PURPOSE: Reduction mammaplasty is one of the most common procedures performed by plastic surgeons. Previous studies demonstrated that most plastic surgeons do not require preoperative mammography prior to reduction mammaplasty. The incidental discovery of malignant or high-risk lesions in breast reduction specimens may preclude the possibility of breast-conserving surgery. The purpose of this study was to examine the factors associated with discussion of preoperative mammography with reduction mammaplasty patients. METHODS: About 638 consecutive patients were identified between January 2000 and December 2010 who underwent reduction mammaplasty. Clinicopathologic and treatment information was collected. Factors associated with discussion of preoperative mammography prior to surgery were compared. RESULTS: Of 638 patients, the median age was 36 (range 18-77) with 44% ≥40. Approximately half (56.0%) were White and 37.5% were African-American. The use of mammography was discussed in 43.3% of patients and completed in 41.5%. On final pathology, eight patients (1.3%) had high-risk lesions and two (0.3%) demonstrated malignancy (1 DCIS, 1 invasive). Of these 10 patients, two were under the age of 40 and four had preoperative mammograms. Factors associated with mammography discussion were age ≥40, White race, the presence of comorbidities, family history of breast cancer, prior breast surgery, prior breast biopsy, history of breast cancer (all P < 0.0001) and tobacco use (P = 0.04). CONCLUSIONS: Due to the potential risk of invasive cancer and high-risk lesions in the final surgical specimen, preoperative mammography should be discussed with selected patients by plastic surgeons, particularly those who fall within national screening guidelines.

Current Practices in the Management of Postoperative Arterial Vasospasm in Microsurgery.

BACKGROUND: Postoperative microvascular arterial vasospasm is a rare clinical entity. There are no published management algorithms and also the pathophysiology of this phenomenon has not been elucidated. METHODS: An email survey of American Society for Reconstructive Microsurgery (ASRM) and World Society for Reconstructive Microsurgery (WSRM) members regarding their experiences with postoperative arterial vasospasm was conducted, returning 116 responses. A comprehensive literature search was conducted regarding the current body of knowledge on this entity. RESULTS: Sixty-five percent of respondents encountered cases where postoperative arterial vasospasm was clearly the cause of flap ischemia. The majority (62%) of surgeons believed a damaged segment of the artery was responsible for the spasm, with technical issues cited as the most likely cause. Sixty-two percent and 50% of surgeons used segmental resection of the recipient and donor vessels, respectively.Rated for proclivity to vasospasm, superficial inferior epigastric artery (SIEA) was the flap, superior thyroid artery (STA) the recipient vessel, and the lower limb the anatomic region most frequently mentioned.Most widely used management strategies were: topical vasodilators (91%), adventitial stripping (82%), and dilation of recipient and donor vessels (76%). Over 50% of surgeons used some type of vessel resection technique. CONCLUSIONS: When flap ischemia is encountered without mechanical issues or thrombus, vasospasm can be the root cause. Certain vessels (SIEA, STA) and anatomic regions (lower limb) pose a higher risk for this phenomenon. When a vessel is affected, it is common practice to excise the questionable segment and use a graft as needed. Vessel resection as part of a multimodal approach can result in a reasonable salvage rate.

Vascular Actions of Angiotensin 1-7 in the Human Microcirculation: Novel Role for Telomerase.

OBJECTIVE: This study examined vascular actions of angiotensin 1-7 (ANG 1-7) in human atrial and adipose arterioles. APPROACH AND RESULTS: The endothelium-derived hyperpolarizing factor of flow-mediated dilation (FMD) switches from antiproliferative nitric oxide (NO) to proatherosclerotic hydrogen peroxide in arterioles from humans with coronary artery disease (CAD). Given the known vasoprotective properties of ANG 1-7, we tested the hypothesis that overnight ANG 1-7 treatment restores the NO component of FMD in arterioles from patients with CAD. Endothelial telomerase activity is essential for preserving the NO component of vasodilation in the human microcirculation; thus, we also tested whether telomerase activity was necessary for ANG 1-7-mediated vasoprotection by treating separate arterioles with ANG 1-7±the telomerase inhibitor 2-[[(2E)-3-(2-naphthalenyl)-1-oxo-2-butenyl1-yl]amino]benzoic acid. ANG 1-7 dilated arterioles from patients without CAD, whereas dilation was significantly reduced in arterioles from patients with CAD. In atrial arterioles from patients with CAD incubated with ANG 1-7 overnight, the NO synthase inhibitor NG-nitro-l-arginine methyl ester abolished FMD, whereas the hydrogen peroxide scavenger polyethylene glycol catalase had no effect. Conversely, in vessels incubated with ANG 1-7+2-[[(2E)-3-(2-naphthalenyl)-1-oxo-2-butenyl1-yl]amino]benzoic acid, NG-nitro-l-arginine methyl ester had no effect on FMD, but polyethylene glycol catalase abolished dilation. In cultured human coronary artery endothelial cells, ANG 1-7 significantly increased telomerase activity. These results indicate that ANG 1-7 dilates human microvessels, and dilation is abrogated in the presence of CAD. Furthermore, ANG 1-7 treatment is sufficient to restore the NO component of FMD in arterioles from patients with CAD in a telomerase-dependent manner. CONCLUSIONS: ANG 1-7 exerts vasoprotection in the human microvasculature via modulation of telomerase activity.

Oblique pedicled paraumbilical perforator-based flap for reconstruction of complex proximal and mid-forearm defects: a report of two cases.

Reconstruction of complex proximal and mid-forearm wounds can be challenging. Free tissue transfer might not be feasible in certain patients or at institutions lacking microsurgical expertise and equipment. Traditional pedicled flaps are either insufficient in length to reach more proximal forearm defects or are used sparingly due to donor site complications and extremity stiffness. We present a novel technique to reconstruct forearm defects using the oblique pedicled paraumbilical perforator (PUP) based flap. This flap is simple to harvest, has low donor site morbidity, and allows elbow and shoulder range of motion during the interval between flap transfer and pedicle division.

Advancing deep inferior epigastric artery perforator flap breast reconstruction through multidetector row computed tomography: an evolution in preoperative imaging.

Perforator flaps have become increasingly popular tools in microvascular breast reconstruction. Previous criticism of these techniques, particularly deep inferior epigastric artery perforator (DIEAP) flap, have included the variability in the path of the perforators through the rectus muscle, the tedious and time-consuming need to look for and to clamp various perforators to determine the "dominant" perforator, and uncertainty whether adequate perforators exist following previous abdominal surgery. Preoperative imaging has contributed significantly to the reliability, speed, and minimal donor site morbidity of these procedures. A major evolution in preoperative imaging has been the introduction of multidetector row computed tomography (MDCT) as a replacement for color duplex imaging. There are multiple advantages to MDCT with few disadvantages, and so it has become the gold standard for the preoperative planning of DIEAP flap breast reconstruction in the practices of both authors, completely eliminating the use of color duplex. Improvements in the preoperative understanding of the anatomy of each perforator from its branching pattern in the subcutaneous fat, to its perforation through the anterior rectus sheath and rectus muscle toward the groin facilitate this type of surgery in a manner only possible with MDCT and not duplex imaging.

Endoscopic-assisted Fascial Decompression for Forearm Exertional Compartment Syndrome: A Case Report and Review of the Literature.

A case of chronic exertional compartment syndrome of the forearm treated with endoscopic-assisted fascial decompression is presented. The diagnosis of exertional compartment syndrome of the forearm was confirmed by direct measurement of intracompartmental pressures. Following endoscopic-assisted fascial decompression, the patient was able to begin rehabilitation therapy within 2 weeks. There were no wound-related complications. The patient reported no recurrence of symptoms after returning to work requiring heavy lifting, and morbidity associated with open decompression was avoided. Endoscopic release is not an option in traumatic compartment syndrome, but a minimally invasive approach may be considered in cases of exertional compartment syndrome. Reports of endoscopic-assisted fascial decompression in exertional compartment syndrome of the forearm are relatively scarce. Confirmation of the safety and efficacy of these evolving techniques in the hand surgery literature remains important.

Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Part IV--aesthetic breast surgery.

SUMMARY: This is part IV of four articles describing the three-step principle for easy shaping of the breast in reconstructive and aesthetic breast surgery. This article may seem overdue because aesthetic corrections are routinely performed, frequently written about, and easier to execute, as no prior ablative surgery or radiotherapy has damaged the gland. Nevertheless, a number of difficult aesthetic breast surgery cases can present themselves that might be more challenging to correct (e.g., tubular breast deformities or corrections after failed aesthetic breast surgery). By understanding the three main anatomical features of a breast--the footprint, the conus, and the skin envelope--and how they interact, as explained in part I, one is able not only to analyze the deformities of each individual problematic breast but also to teach others and to execute a specific surgical strategy on how to obtain reproducible aesthetically pleasing results. The three-step principle will be applied and explained for breast augmentation, reduction, mastopexy, and tubular breast deformity.

Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Part III--reconstruction following breast conservative treatment.

SUMMARY: Of the relatively few studies that exist regarding the cosmetic satisfaction of patients following breast conservation therapy, several indicate significant dissatisfaction in many patients. Breast conservation often results in some of the most challenging and complex reconstructive problems. Indeed, even defining the problem or analyzing the defect can be difficult for the junior surgeon. For the more seasoned reconstructive surgeon, analyzing the problem and applying solutions may be less difficult, but clearly communicating the defects typically seen after an aggressive lumpectomy and radiotherapy can be difficult, especially with trainees or junior surgeons. The goal of this article, the third in a four-part series, is to provide a template for the analysis and surgical reconstruction of defects resulting from breast conservation therapy utilizing a systematic three-step method. Part I of this series described the three main anatomical features of the breast--the footprint, the conus of the breast, and the skin envelope--and how they interact. By systematically analyzing the breast with this three-step method, a "problem list" based in specific anatomic traits of the breast can be generated, allowing the surgeon to then generate an appropriate surgical plan for reconstruction. Surgical approaches based on the percentage of breast parenchyma resected are suggested, with a focus on glandular rearrangement, breast reduction techniques, and locoregional flaps. The three-step method of breast analysis, evaluating the anatomical deformation of the breast footprint, conus, and skin envelope, remains the fundamental "fall-back" principle of this approach.

Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Part II--Breast reconstruction after total mastectomy.

This is Part II of four parts describing the three-step principle being applied in reconstructive and aesthetic breast surgery. Part I explains how to analyze a problematic breast by understanding the main anatomical features of a breast and how they interact: the footprint, the conus of the breast, and the skin envelope. This part describes how one can optimize results with breast reconstructions after complete mastectomy. For both primary and secondary reconstructions, the authors explain how to analyze the mastectomized breast and the deformed chest wall, before giving step-by-step guidelines for rebuilding the entire breast with either autologous tissue or implants. The differences in shaping unilateral or bilateral breast reconstructions with autologous tissue are clarified. Regardless of timing or method of reconstruction, it is shown that by breaking down the surgical strategy into three easy (anatomical) steps, the reconstructive surgeon will be able to provide more aesthetically pleasing and reproducible results. Throughout these four parts, the three-step principle will be the red line on which to fall back to define the problem and to propose a solution.

Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle.

Creating or recreating an aesthetically pleasing breast shape in reconstructive and aesthetic breast surgery is an act that most experienced "breast" surgeons will find self-evident. We propose a simple three-step philosophical and hands-on approach that will make it easier for young and unexperienced plastic surgeons to not only analyze the problematic breast but also come up with an easy surgical strategy to create reproducible results.This is Part I of four parts describing the three-step principle being applied in reconstructive and aesthetic breast surgery. Part I explains how to analyze a problematic breast by understanding the three main anatomical features of a breast and how they interact: the footprint, the conus of the breast, and the skin envelope. Part II deals with reconstructions after complete mastectomy and Part III covers reconstruction after breast conservation surgery. Finally, Part IV applies the same principles in the field of aesthetic breast surgery. Throughout these four parts, the three-step principle will be the red line to fall back on to define the problem and to propose a solution.

Autologous breast augmentation with the lateral intercostal artery perforator flap in massive weight loss patients.

The body contour deformities that develop in morbidly obese patients following bariatric surgery often involve the breasts. Mastopexy is virtually always required in the female massive weight loss patient, and breast augmentation is often an important adjunct to breast-lifting procedures. The lateral intercostal artery perforator (LICAP) pedicled flap provides ample material for autogenous breast augmentation in such patients. Between June 2001 and June 2005, bilateral LICAP flaps were used as a method of autologous breast augmentation in six patients after massive weight loss. Of the 12 pedicled LICAP flaps raised, the average flap dimension was 23.6x10.6 cm. Mean flap harvesting time was 60 min (range 45-75 min) for a single flap. All but two flaps were based on one perforator. All donor sites were closed primarily. Complete flap survival was achieved in all cases. A minor wound dehiscence occurred in two cases both of which healed secondarily. Patient satisfaction with both the appearance of their breasts and lateral axillary-thoracic region was high. The improved contour of the lateral axillary region was frequently noted as a significant benefit. In massive weight loss patients, harvesting the lateral skin-fat excess based on the LICAP provides supple tissue for breast augmentation, while simultaneously improving the contour of this area frequently affected by skin excess. Additionally, harvesting these flaps without sacrifice of the underlying muscle eases postoperative recovery and reduces donor site morbidity.

Surgical technique in pedicled thoracodorsal artery perforator flaps: a clinical experience with 99 patients.

BACKGROUND: The thoracodorsal artery perforator flap is considered a technically difficult flap because of significant anatomical variations in perforator location. The authors' strategy to facilitate the harvest of these flaps includes careful preoperative mapping of perforators and a standardized planning and harvesting technique. The authors evaluated 99 pedicled thoracodorsal artery perforator flaps, with an emphasis on preoperative planning, surgical technique, and analysis of complications. METHODS: Between May of 2000 and October of 2006, 99 patients underwent pedicled thoracodorsal artery perforator flaps in the authors' department. Their charts and postoperative results were reviewed retrospectively. RESULTS: A thoracodorsal artery perforator flap was harvested in 90 cases. The perforators were unsuitable in the other 10 flaps; therefore, a muscle-sparing technique was used (type I or type II). Unidirectional Doppler imaging was used exclusively in 92 percent of cases to map the perforator preoperatively. The average flap size was 20 x 8 cm. Average operative time for flap harvest was 80 minutes. Perforators were located at 8 to 13 cm from the axillary crease (average, 10.8 cm). Major flap necrosis occurred in one case (1 percent). Limited partial or palpable fat necrosis occurred in three cases (3 percent). Seroma formation was not encountered in any of the thoracodorsal artery perforator flaps or muscle-sparing thoracodorsal artery perforator type I flaps. CONCLUSION: Careful preoperative perforator mapping and a standardized approach to flap planning and harvest can significantly reduce the difficulty of executing pedicled thoracodorsal artery perforator flaps.

Acute felon as a complication of systemic paclitaxel therapy: case report and review of the literature.

Breast cancer now affects 1 in 8 American women and the taxane agent paclitaxel (Taxol Bristol-Myers Squibb) is a major tool in the treatment of many such patients. Hand surgeons are therefore likely to encounter upper extremity complications related to the use of taxane therapy. We present an unusual case of a felon developing in a breast cancer patient on paclitaxel therapy with no antecedent history of trauma. Whereas onycholysis and subungual hemorrhage are reported complications of taxane therapy (Fig. 1), an acute felon with or without associated paronychia is an unusual and more aggressive manifestation of this drug-related nail dystrophy.

Improved myoelectric prosthesis control accomplished using multiple nerve transfers.

BACKGROUND: The control of shoulder-level disarticulation prostheses is significantly more difficult than that of prostheses for more distal amputations. Amputees have significant difficulties coordinating the separate functions of prosthetic shoulder, elbow, wrist, and hand/hook components. The user must lock one joint at a particular position in space before subsequently moving a different joint. METHODS: A patient with bilateral humeral disarticulations after an electrical injury underwent a novel nerve transfer procedure designed to improve the control of a myoelectric prosthesis. The median, radial, ulnar, and musculocutaneous nerves were transferred to the nerves of segments of the pectoralis major and minor muscles. Those muscles then act as bioamplifiers of peripheral nerve signals when the normal upper extremity nerves are activated by the patient's brain. Therefore, when the patient thinks "flex elbow," the transferred musculocutaneous nerve fires, and a segment of the pectoralis major contracts. An electromyographic signal is then detected transcutaneously and causes the prosthetic elbow to flex. RESULTS: Three of the four nerve transfers were successful. One of the nerve transfers unexpectedly yielded two separate controllable muscle segments. Standardized testing using a "box-and-blocks" apparatus was performed with the patient's previous myoelectric device and the current device after nerve transfers. The patient's performance improved by 246 percent. CONCLUSIONS: Nerve transfers to small muscle segments are capable of creating a novel neural interface for improved control of a myoelectric prosthesis. This is done using standard techniques of nerve and flap surgery, and without any implantable devices.

Transdermal sustained-delivery oxygen improves epithelial healing in a rabbit ear wound model.

HYPOTHESIS: Transdermal sustained-delivery oxygen therapy improves wound healing. DESIGN: Experimental study using a well-established rabbit ear model for acute wound healing. SETTING: Wound-healing research laboratory in a university center. METHODS: Four full-thickness 7-mm punch wounds were created on each ear of young, female New Zealand white rabbits. Treated ears received transdermal sustained delivery of oxygen via silicone tubing tunneled subcutaneously to a pocket under a semiocclusive dressing. Oxygen production (100% oxygen at 3 mL/h continuously) relied on a small, self-contained device connected to the silicone tubing and secured to the rabbit's back for the duration of the experiment using a body harness. Ears were harvested at each of 2 time points: day 5 and day 8. RESULTS: Histologic analysis of the wounds showed significantly greater healing at both day 5 and day 8 in response to oxygen therapy. Most significantly, epithelial wound coverage was almost doubled in treated ear wounds when compared with controls. CONCLUSION: Our results suggest that epithelial wound healing is improved by transdermal sustained-delivery treatment with 100% oxygen.

Early results with use of gracilis muscle flap coverage of infected groin wounds after vascular surgery.

INTRODUCTION: Management of a nonhealing femoral wound after vascular surgery can pose a challenging problem, particularly when there is prosthetic material involved. We prefer to use pedicled gracilis muscle flaps (PGMFs) to cover problematic groin wounds when more conventional management is not possible. METHODS: We describe the technique for using PGMFs to provide groin coverage, report a summary of our short-term and long-term results, and describe why we prefer this reconstructive technique. RESULTS: Twenty PGMFs were placed in 18 patients to treat nonhealing and infected groin wounds. Exposed prosthetic vascular reconstructions were covered with the PGMF in 14 wounds, and in situ autogenous vascular reconstructions were covered in four. Seven wound infections were polymicrobial, 10 had a single gram-positive organism, and one had a single gram-negative organism. Pseudomonas cultured out in four wounds, and Candida in one wound. Two patients had a virulent combination of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus. Complete healing was initially achieved in all wounds, and no patient died within 30 days of surgery. Two PGMFs failed, at 2 weeks and 2 months, respectively, one from tension on the flap pedicle and one from acute inflow occlusion. Underlying prosthetic reconstruction was salvaged in 12 of 14 wounds; the remaining wounds with autogenous reconstructions or exposed femoral vessels all closed successfully. At a mean follow-up of 40 +/- 10 months there were no recurrent groin infections. Seven patients died, at 2.5, 3, 8, 12, 14, 22, and 28 months, respectively. CONCLUSION: PGMF transposition is an effective option to cover infected or exposed femoral vessels or salvage prosthetic graft material in the groin. In appropriately selected patients, when complete graft removal and extra-anatomic bypass is not an acceptable option, gracilis muscle flap coverage is a viable alternative. The technique is relatively simple, and morbidity from PGMF harvest is minimal.