Lakshmi's gracillis

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wound on lateral side

anterior wound showing exposed bone and surrounding slough

Healed leg 

Healed leg lateral view

Post op photo of flap in ICU with monitoring bleed

Healed flap




flap being insetted


Laxmi is a 25 year old female married who lives in a small town Palwal Haryana India. On ocassion of bhaiduj a Indian festival she got injured while travelling in the bus.Her brother know orthopedic surgeon Dr I K Bansal who works in Apex hospital palwal. Initial mangement was done by Dr I K bansal , extensive loss of skin and soft tissue loss led to need of a plastic surgeon. Apex hospital is a modern hospital setup by Dr Abhisek Jain a ENT surgeon and his wife Dr Twinkle Jain.  Extensive degloving injury are difficult to manage .
In view of extensive tissue loss a decision to do free flap was taken and conveyed to Dr I K Bansal.
On 31/10/2017  we did the gracillis free flap . After anesthesia we did through debridement of leg which resulted in total baring of tibia from top to ankle joint . There was large raw areas on the both area of bone. Dr I K Bansal fixed her tibial fracture with two thick K wire .

We harvested gracillis and connected posterior tibial vessels near ankle artery end to side and single venous anastomosis. Hospital had a excellent carl zeis microscope  It was first micro vascular procedure in palwal city and monitoring was a issue . For next one hour we spend insetting flap and securing homeostasis. Bleeding is the biggest enemy   of free flap surgery and control is very important. We shifted patient to ICU and I spent some time talking to ICU people how to monitor flaps . Then I left hospital, every day morning they will send me flap monitoring video .Patient was discharged after seven days .After one month of surgery we readmitted patient and skin grafted all her raw area including muscle. On January 27,2018 the video was sent by Dr I K Bansal showing her walking .All her wounds healed and her  bones united .
 Doing microvascular surgery in distant unknown hospital has its own challenges things we take for granted in big corporate setup are to be arranged. But microvascular surgery sometime solves problem which other wise very difficult to solve. Large bony defect was long in nature and gracillis being slender muscle is a good choice. Another advantages is that the gracillis is a hidden scar and negligible effect on donor thigh, pedicle vessle are fine. Whenever I have done microvascular surgery in any hospital it I have received good support of nursing staff for monitoring Apex hospital was no exception. I must say though they were doing it first time, they rose to occa

sion.  Timing of surgery has a great bearing on successful rehabilitation  of patient in society and life and ultimate outcome. Early surgery carries good prognosis , it prevents osteomyelitis  , soft tissue contracture ,stiffness. Role of microvascular surgery in these injuries is well established .


Dr Adhishwar Sharma
MB,BS,MS Gen Surgery PGIMER Chd
Mch Plastic Surgery
Fellowship in Hand and microvascular Surgery
brahmanandclinic.com

 8860650846
adhishwar7@gmail.com

Location: Palwal, Haryana 121102, India

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