Historical developments: The groin flap- I was there

12th March 2010

 

In 1969 I went up to Glasgow University to teach anatomy and whilst there Ian MacGregor was seeking help to establish the anatomical basis of the groin flap. MacGregor and Jackson had sought to explain the success of the Bakamjian delto-pectoral flap on the basis that it was an axial pattern flap centred around a vascular pedicle and they came up with the concept of vascular territories. The delto-pectoral flap broke all the rules, it was based on the midline, which was reputedly avascular, it was an extremely pale flap and could be raised well in excess of what was then regarded as the safe 1 to 1 ratio for raising a flap.

They therefore searched around for another site on which to design an axial pattern flap and settled upon the groin around the superficial circumflex iliac flap. Ten of these flaps were raised clinically and I believe two had problems with the vascularity. At this point they sought my help in clarifying the vascular anatomy. 

We undertook numerous studies, we looked at angiograms of the iliac vessels and studied some 55 of these to try and get an idea of the axis of the superficial circumflex iliac artery. I also undertook excision of the skin in the groin and using a clearing technique we could determine the orientation of the vessels having previously injected the vessels with a latex dye.

Finally, I undertook dissection of the groins in the Anatomy Department to trace out the origin of the superficial circumflex iliac vessel and to plot a safe axis around which it could be raised.  Ian MacGregor was going to a plastic surgery meeting at Williamsberg and was very keen to present these findings.  Hence, the original dissections only amounted to some fourteen cadavers.  However, we found a safe axis running from 2 centimetres below the superficial inguinal ligament along a parallel to it and below the anterior superior iliac spine.  We also found that this axis was slightly higher in more obese individuals and made the important discovery that in elevating the flap from lateral to medial when one came to the medial border of sartorius that the vessels penetrated the overlying fascia and that the fascia had to be elevated along with the vessels, otherwise the flap would kink at that point.  The other advantage of doing this was of course that it gave you about an extra five centimetres of pedicle.  MacGregor and Jackson were very specific about the fact that the pedicle of the clinical groin flap should be at least ten centimetres long. This was to allow the pedicle to be tubed and a full range of motion was to be undertaken at the shoulder, elbow, wrist and hand joints. This fact has been forgotten by many people who used pedicled groin flaps. 

I had three weeks to prepare this paper before MacGregor was due to present it at the International Meeting in Williamsberg.  For some years afterwards I thought that all papers were produced at that speed.  Would that they were. MacGregor and Jackson went on to describe the many clinical uses of the groin flap and it became one of the most important flaps in plastic surgery at that time.

Some years later when I was doing Orthopaedics I was presented with a man who had an ulcerated area over the site of a long existing tibial fracture and suggested to my Orthopaedic Consultant that a free groin flap would be a good way to go providing durable skin cover and improving the blood supply to this chronic non union.  Martin Webster undertook this at Canniesburn and I went up to watch. The flap worked beautifully and the year was 1974. I remember the patient’s name to this day.

Paul Smith

 

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