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An easy and safe approach to the vascular pedicle of the gracilis muscle flap is described. With
this technique the vascular pedicle can be harvested with maximum length and the largest
possible caliber for functioning free muscle transfer. (J Hand Surg 2002;27A:534 –536. Copy-
right © 2002 by the American Society for Surgery of the Hand.)
Key words: Gracilis muscle, functioning free muscle transfer.
The gracilis muscle is widely used as a donor monitoring of the circulation is designed proximal to
muscle for functioning free muscle transfer (FFMT) distal in an oblique direction over the gracilis muscle
because of its single motor nerve supply, anatomic (Fig. 1). After the skin is incised along the skin flap
consistency of the vascular pedicle, and large amount anteriorly, the deep fascia is incised over the adduc-
of excursion. We have used more than 100 gracilis tor longus muscle and posteriorly over the adductor
muscles for FFMT mainly in brachial plexus recon- magnus muscle. The main vascular pedicle and mo-
struction.1 Compared with the use of the gracilis tor nerve of the gracilis are identified underneath the
muscle as a pedicled island transfer, it is necessary to adductor longus muscle at the junction of the upper
harvest a longer vascular pedicle in FFMT. We have quarter and lower three quarters of the gracilis mus-
reported our endoscopic harvesting technique of the cle (Fig. 2), but at this time the neurovascular pedicle
gracilis muscle for FFMT.2 In this article we describe is not dissected. The gracilis muscle distal to the skin
in detail our vascular dissection technique for an easy flap is harvested endoscopically.2 After the distal
and safe approach to the vascular pedicle. part is harvested (Fig. 3), the neurovascular pedicle is
dissected. For exposure of the neurovascular pedicle
Technique the adductor longus muscle is retracted anteriorly
The patient is placed in supine position with the
thigh abducted and the knee flexed. A 10 ⫻ 5– cm
skin flap to facilitate easy closure and postoperative
Figure 2. The adductor longus muscle is retracted for Figure 4. Dissection of the vascular pedicle is developed
exposure of the neurovascular pedicle. Small arrow shows underneath the retracted adductor longus muscle. Small
the vascular pedicle, middle arrow shows the motor nerve arrow shows the vascular pedicle and large arrow shows
of the gracilis muscle, and large arrow shows the retracted the retracted adductor longus muscle.
adductor longus muscle.
Discussion
The gracilis muscle flap is one of the most useful
flaps for wound coverage and the first choice for
donor muscle in FFMT. Approach to the vascular
pedicle, however, is sometimes difficult through an-
terior retraction of the adductor longus muscle,3,4
especially in obese or muscular patients. Unless the
pedicle is traced to its origin from the profunda Figure 7. Completion of the harvesting. Small arrow
femoris vessels, the vascular length and diameter are shows the artery, middle arrow shows the vein, and large
not adequate for safe and easy microvascular proce- arrow shows the motor nerve of the gracilis muscle.
dure. Our technique in which the adductor longus
muscle is retracted anteriorly and next posteriorly
facilitates exposure of the pedicle origin. The useful-
FFMT for brachial plexus reconstruction, the vascu-
ness of this technique was originally suggested by
lar pedicle of the gracilis muscle should be of the
O’Brien and Morrison.5 Based on our experience of
largest possible length and diameter. We usually use
the thoracoacromial vessels and thoracodorsal ves-
sels as recipient vessels in that procedure.1 With our
technique the diameters of the harvested vessels of
the gracilis flap pedicle are almost the same as those
of recipient vessels.
References
1. Doi K, Muramatsu K, Hattori Y, et al. Restoration of pre-
hension with the double free muscle technique following
complete avulsion of the brachial plexus. J Bone Joint Surg
2000;82A:652– 666.
2. Doi K, Hattori Y, Tan SH, Hiura Y, Kawakami F. Endo-
scopic harvesting of the gracilis muscle for reinnervated
free-muscle transfer. Plast Reconstr Surg 1997;100:1817–
1823.
3. Strauch B, Yu HL. Atlas of microvascular surgery. New
York: Thieme Medical, 1993:166 –173.
Figure 6. Close view of the origin of the vascular pedicle. 4. Masquelet AC, Gilbert A. An atlas of flaps in limb recon-
Small arrow shows the artery, middle arrow shows the struction. London: Martin Dunitz, 1995:104 –106.
vein that becomes one large vein, and large arrow shows 5. O’Brien BM, Morrison WA. Reconstructive microsurgery.
the profunda femoris artery. New York: Churchill Livingstone, 1987:272–274.