Authors: Emma Tubæk Nielsen, MD., Caroline Lilja, MD., and Magnus Balslev Avnstorp, MD.
Illustrator: Emma Tubæk Nielsen, MD.

This chapter explains and illustrates two different types of gracilis flap:

1. Gracilis myocutaneous free flap.
2. Gracilis free muscle transfer.

Gracilis myocutaneous free flap

1. Pre-operatively using a doppler, the vascular supply is identified and marked. The pedicle is usually identified 5-10 cm inferiorly to the pubic tubercle.
2. The patient is placed in a supine position. The patient’s leg is placed abducted, slightly externally rotated, and flexed.
3. The surgical field – reaching from the knee to the inguen – is prepped and draped.
4. A line going straight from the pubic tubercle to the medial femoral condyle is drawn, marking the axis of the gracilis muscle – approximately two to three finger widths posterior to the adductor longus.
5. Flap size – equivalent to the defect at the recipient site – is marked as an elliptical skin flap, centered on the gracilis muscle axis. The flap can be placed according to orientation need, being placed transversely, obliquely, or longitudinal to the gracilis muscle.
6. Distally, the tendon of the gracilis tendon is palpated just proximally to the medial femoral condyle, and the incision site is marked.
7. The doppler is used to confirm the location of vascular supply. The arteria is marked on the skin.
   • The nerve innervation of the gracilis muscle is usually located about 1,5 cm superior to the vascular pedicle.
8. Local anesthesia is injected along the edges of the flap.
9. A proximal incision is made through the skin, moving distally along the anterior line of the elliptical draft.
10. Dissection of the superficial saphenous vein is performed, and the vein is preserved.
11. Dissection through subcutaneous tissue and down to the fascia of the gracilis muscle.
12. The fascia is elevated off the muscle anteriorly, and the septal junction between the gracilis and adductor longus muscles is identified.
13. The adductor longus is retracted to identify the vascular pedicle (the medial circumflex femoral artery). Vessel loops are placed to ensure correct identification of the artery and vein.
14. An incision is made corresponding to the marking at the gracilis tendon insertion site. A vessel loop is placed around the tendon.
15. Dissection is continued toward the medial circumflex femoral artery, allowing for additional vessel length. It is important to ensure the vascular pedicle is as long as possible. The pedicle is dissected distally to proximally, ligating branches to the adductor longus and magnus until the pedicle is reached.
    • If preserved motor function is indicated, the nerve is identified superior to the vascular pedicle and harvested with the flap. The nerve should be dissected as far up as possible, usually at the bifurcation of the obturator nerve.
16. Dissection is extended around the gracilis muscle to isolate the muscle.
17. The posterior border of the elliptical draft is incised and dissected is continued through the subcutaneous tissues.
18. The muscle belly is incised inferiorly at the desired flap length.
19. From distal to proximal end, the flap is elevated by freeing the gracilis muscle until it is only attached to the vascular pedicle, the nerve and its superior/proximal insertion point.
20. Perforating vessels extending from the gracilis muscle to the skin island are preserved. Vessel clips are placed to ensure optimal vessel handling.
21. At the desired length, the muscle is incised superiorly/proximally.
22. The vascular pedicle is clamped medially and divided together with the nerve.
23. Hemostasis is secured before direct closing the donor site in 3 layers. Closure is preferably done with sutures in the fascia, dermal inverters sutures and intradermal suture but can also be done with a simple continuous suture.
24. Before completing the closure, a wound drain is placed distally to the incision and secured with a drain knot followed by either a half hitch or double half hitch. The knot should be close to the skin surface.
25. Compression bandages are applied to minimize swelling, bleeding and seroma.^{1, 3, 7}

Gracilis free muscle transfer

1. Pre-operatively using a doppler, the vascular supply is identified and marked. The pedicle is usually identified 5-10 cm inferiorly to the pubic tubercle.
2. The patient is placed in a supine position. The patient’s leg is placed abducted, slightly externally rotated, and flexed.
3. The surgical field – reaching from the knee to the inguen – is prepped and draped.
4. A line going straight from the pubic tubercle to the medial femoral condyle is drawn, marking the axis of the gracilis muscle – approximately two to three finger widths posterior to the adductor longus.
5. Flap size – equivalent to the defect at the recipient site – is marked as an elliptical skin flap, centered on the gracilis muscle axis. The flap can be placed according to orientation need, being placed transversely, obliquely, or longitudinal to the gracilis muscle.
6. Distally, the tendon of the gracilis tendon is palpated just proximally to the medial femoral condyle, and the incision site is marked.
7. The doppler is used to confirm the location of vascular supply. The arteria is marked on the skin.
   • The nerve innervation of the gracilis muscle is usually located about 1,5 cm superior to the vascular pedicle.
8. Local anesthesia is injected along the edges of the flap.
9. A proximal incision is made through the skin, moving distally along the anterior line of the elliptical draft.
10. Dissection of the superficial saphenous vein is performed, and the vein is preserved.
11. Dissection through subcutaneous tissue and down to the fascia of the gracilis muscle.
12. The fascia is elevated off the muscle anteriorly, and the septal junction between the gracilis and adductor longus muscles is identified.
13. The adductor longus is retracted to identify the vascular pedicle (the medial circumflex femoral artery). Dissection is continued toward the medial circumflex femoral artery, allowing for additional vessel length. It is important to ensure the vascular pedicle is as long as possible. The pedicle is dissected distally to proximally, ligating branches to the adductor longus and magnus until the pedicle is reached.
14. If preserved motor function is indicated, the nerve is identified superior to the vascular pedicle and harvested with the flap. The nerve should be dissected as far up as possible, usually at the bifurcation of the obturator nerve.
15. The dissection is extended around the gracilis muscle to isolate the muscle.
16. The posterior border of the elliptical draft is incised and dissected is continued through the subcutaneous tissues.
17. The muscle belly is incised inferiorly at the desired flap length.
18. From distal to proximal end, the flap is elevated by freeing the gracilis muscle until it is only attached to the vascular pedicle, the nerve and its superior/proximal insertion point.
19. Perforating vessels extending from the gracilis muscle to the skin island are preserved. Vessel clips are placed to ensure optimal vessel handling.
20. At the desired length, the muscle is incised superiorly/proximally.
21. The vascular pedicle is clamped medially and divided together with the nerve.
22. Hemostasis is secured before direct closing the donor site in 3 layers. Closure is preferably done with sutures in the fascia, dermal inverters sutures and intradermal suture but can also be done with a simple continuous suture.^{1, 3, 7}
23. Before completing the closure, a wound drain is placed distally to the incision and secured with a drain knot followed by either a half hitch or double half hitch. The knot should be close to the skin surface.