Gracilis Muscle: Its Continuing Role in Extremity Microvascular Reconstruction

The gracilis is a thin, longitudinal adductor muscle of the medial thigh. As a pedicle flap, it can be used for soft tissue and functional perineal reconstructions. As a free flap, it is used for functional limb reconstruction, facial reanimation, and soft-tissue coverage. It is a tremendously malleable flap, able to be contoured to fit the defect, and is an excellent choice for upper and lower extremity reconstruction. In lower extremity reconstruction, the gracilis can be harvested from the ipsilateral thigh, thus limiting the morbidity of both the original injury and the surgery to one extremity. The author reviewed experience with the gracilis muscle in upper and lower extremity reconstruction and reaffirmed its vital role in reconstructive surgery.

Over a 5-year period, 63 extremities required free flap reconstruction with 65 flaps. Of these, 28 were with the gracilis muscle (43%). There were 20 lower extremities (leg = 7, ankle = 2, foot = 11) and eight upper extremities (humerus = 5, elbow = 2, forearm = 1). Limb salvage after sarcoma resection was the most common reason for reconstruction (n = 13), followed by trauma (n = 10), brachial plexus injury (n = 3), and osteomyelitis (n = 2). Five gracilis flaps were for functional innervated elbow flexion. Seven gracilis flaps were harvested with fasciocutaneous islands, the largest being 8 × 15 cm, which survived completely. The remainder had skin grafts applied over the muscle.

One flap failed due to a hypercoagulable state. Overall flap survival rate was 96.4%. Three patients required concurrent soft tissue, tendon, and nerve reconstruction on the dorsal foot. In these three, the gracilis flap provided all four components required: nerve, tendon, muscle, and skin, thus achieving soft-tissue reconstruction while reducing donor morbidity, as all tissue components were obtained from one flap and through one incision. Of the six gracilis flaps used for functional elbow restoration, five patients had successful reinnervation and can flex their elbows against gravity and light resistance. None have reported any major deficits in the leg from the harvest of the gracilis.

The gracilis continues to be an important muscle in the reconstructive surgeon's choice of flaps. It has many advantages, including its versatility for use, from an innervated muscle for functional restoration to thin pliable tissue for soft-tissue coverage. The resultant low morbidity and malleability should not be forgotten in light of wider choices of flaps available to surgeons currently, particularly the perforator fasciocutaneous flaps.