Surgical technique and clinical application of the transverse gracilis myocutaneous free flap

The unreliability of the distal skin component of the gracilis myocutaneous free flap has been frequently reported. To improve the reliability of the skin we orientated the cutaneous paddle in a transverse direction in the proximal third of the gracilis muscle, as first described by Yousif et al in 1993. Their anatomical studies showed that cutaneous branches of the dominant proximal pedicle have a pronounced tendency to travel in a transverse direction, supplying the skin anteriorly over the adductor longus and sartorius muscles and extending beyond the posterior margin of the gracilis muscle. We adopted this transverse design and transferred myocutaneous gracilis flaps measuring up to 17×9 cm. The transverse gracilis myocutaneous flap was dissected in the subfascial plane to include the peri-gracilis fascia, which preserved the fascial vascular network and thus optimised skin-paddle perfusion. Ten transverse gracilis myocutaneous free flaps were performed over 3 years. Skin paddles ranged in size from 10×7 cm (70 cm2) to 17×9 cm (153 cm2) with a mean of 113.4 cm2. Five defects were located in the head and neck region, three in the lower leg, one in the thigh and one in the thorax. Patients were followed for an average of 16.6 months (range: 6–46 months). Minor complications (donor-site wound dehiscence and flap-wound-edge separation) occurred in four patients; however, all 10 flaps survived and healed with complete cutaneous survival.