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Fig. 37.4 The gracilis should now be palpated. The forceps in the left image point to the gracilis enclosed in fascia. In the right image the fascia
between adductor longus and gracilis is marked for incision
R. Miller et al.
Fig. 37.5 Dissection to expose the gracilis muscle (blue arrow) with
the GSV retracted superiorly (black arrow)
Fig. 37.6 Retraction of the AL superiorly (white arrow) aids identication of the neurovascular pedicle (blue arrow) entering the gracilis
(black arrow)
37 Medial Circumex Femoral Artery: Gracilis Muscle Flap
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Fig. 37.7 The pedicle (blue arrow) is dissected proximally between
the AL and adductor magnus (white arrows). The gracilis is indicated
by the black arrow
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Fig. 37.8 Black arrow = gracilis. Blue arrow = pedicle. White
arrow=motor nerve
Fig. 37.9 A swab is placed around the proximal gracilis and monopolar cautery used to divide it
• Step 11. Free the ap distally. During this you may
encounter further pedicles, which can either be preserved
or ligated.
• Step 12. Place the gracilis at resting tension and mark the
muscle at set intervals (every 1cm, for example. See clinical case 1). This step is necessary for reanimation procedures to facilitate tensioning at inset. It may be omitted
when muscle tensioning is not necessary (for example, in
lower limb trauma).
• Step 13. Divide the ap distally. Options:
(a) Split the muscle distally at the required length. Place
a swab around the muscle and slow division with
(b) Split the gracilis tendon approximately 5cm distal to
the musculotendinous junction.
(c) Make a separate distal incision over the insertion,
trace the tendon down to the tibia (between the sartorius and semitendinosus) and harvest at its insertion
(Fig.37.10).
• Step 14. Divide the ap proximally, either through the
muscle or through the proximal tendinous origin, depending on the length required.
(a) Remember for the musculocutaneous ap you will
also need to incise the posterior border of the skin
paddle.
monopolar cautery can be used to reduce bleeding
(Fig.37.9).
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Fig. 37.10 This demonstrates a distal incision at the tendinous insertion which will be divided for harvest
37.6 Core Surgical Techniques inFlap
Dissection
There are several modications and techniques to the gracilis
ap raise. This is predominantly regarding the ap dimensions and components raised as outlined in step 13 above.
For muscle-only aps (step 13a), the muscle and proximal
tendinous portion can be trimmed to the appropriate size and
shape. Unless inclusion of one or both musculotendinous
junctions is essential, trimming of the muscle to length is
dependent on adequate positioning of the pedicle.
If the distal gracilis tendon is needed (step 13 b and c), the
ap may be raised with or without a skin paddle. Most commonly this is used in limb reconstruction and may only
require a small skin paddle for ap monitoring, if so desired.
However, these should be used with caution as the skin
paddles can be unreliable, appearing unhealthy when the
underlying muscle is healthy. If a long length of tendon is
required it should be remembered that there are two slips of
the distal tendon (see Fig. 37.11 lower image). The rst,
inserting to the medial tibial condyle, can be divided. The
main terminal slip can be raised with tibial periosteum to
achieve approximately 1cm more length [6]. Whether using
R. Miller et al.
muscle alone or a musculocutaneous ap for functional free
ap reconstruction, the muscle should be marked prior to
division. This can be under functional or resting tension.
Whichever is used, the same should be used at inset
(Figs.37.12 and37.13b).
For musculocutaneous aps, the surgeon should ensure
the paddle is appropriately designed over the gracilis muscle
and it may be necessary to redesign the skin paddle once the
gracilis muscle is identied. If a large skin paddle is needed,
from step 6 above you should aim to include septa between
the gracilis – adductor magnus and gracilis – sartorius to
increase the septocutaneous supply and improve skin paddle
survival. If independent movement between muscle and skin
is desired this can be achieved by separating the skin ap and
muscle. This can be done with ligation/ cautery of musculocutaneous perforators until the proximal AL-Gracilis septum
is reached, at which point septal perforators to the skin can
be identied and preserved. The skin paddle can then be
rotated and placed at inset [6].
Similarly, the gracilis ap can be raised with an independent skin ap from a medial circumex perforator artery as a
conjoint ap [6, 16]. This requires identication of musculocutaneous perforators pre-op using a hand-held Doppler and
the skin paddle should be designed centred longitudinally on
the selected perforator and elevated as a perforator ap with
intra-muscular dissection of the perforators to the main vessel. Elevation of the gracilis muscle ap is then carried out as
described above. Similarly, a transversely orientated skin
paddle [15] can be designed for a musculocutaneous ap in
breast reconstruction. In this case it is not necessary to isolate the transverse skin paddle as a perforator ap. The ap
raise should follow the steps for musculocutaneous ap raise
above with an adapted skin paddle design.
When using the gracilis muscle or musculocutaneous ap
as a pedicled ap in reconstruction of the lower abdomen,
groin, vagina or perineum the steps outlined above for ap
raise can be followed without division of the pedicle. Patient
positioning depends on access to the recipient site, with
supine, lithotomy and even prone positioning described as
necessary [17].
37 Medial Circumex Femoral Artery: Gracilis Muscle Flap
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Fig. 37.11 Different ap harvest designs. The top image demonstrating muscle alone for a lower limb reconstruction and the lower image demonstrating the full muscle length with distal tendon (blue arrow) for free functional muscle transfer. Black arrow=pedicle
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dynamic facial movement. The ap was harvested with the
vascular pedicle and motor nerve clearly demonstrated in
Fig.37.13a. The gracilis muscle was marked (Fig.37.13b) to
ensure correct tensioning on transfer and inset as discussed
above. Figure37.13c demonstrates the ap inset and tension-
ing. The vascular pedicle and motor branch can be clearly
seen at inset. The ap was thinned to approximately 10g in
situ. The facelift type access was closed and the buried ap
was monitored by hourly Doppler signals for the rst 24h
followed by 2 hourly to 36h. A Penrose drain secured in the
post-auricular region was removed at 24h as was a suction
drain to the thigh. Post-op recovery was uneventful and facial
therapy commenced at 2weeks. Dynamic facial movement
was reestablished at week 7.
Fig. 37.12 The muscle can be placed under functional tension and
marked at 1cm intervals prior to division
37.7 Clinical Scenario
37.7.1 Case 1: Facial Reanimation: Surgeon
Graeme Glass
This case demonstrates an innervated free gracilis ap for
left-sided facial reanimation in a child. Pre-operative examination revealed signicant facial asymmetry at rest and on
37.7.2 Case 2: Upper Limb Reanimation:
Surgeons Dariush Nikkhah and Jeremy
Rawlins
The gentleman in this case suffered a pan plexus injury to his
brachial plexus after a high-speed motorbike road trafc
accident. Previous nerve transfers had been unsuccessful. In
this case a free functional gracilis muscle transfer was performed to reanimate elbow exion. The gracilis ap was harvested with gracilis tendon using a two-team approach. The
arterial ap pedicle was anastomosed onto the thoracoacromial artery and the ap obturator nerve was anastomosed to
the spinal accessory nerve. The proximal end of the gracilis
was anchored onto the clavicle and the distal end inserted
with a Krakow repair onto the biceps tendon. A small window was kept to monitor the muscle and a Doppler signal
was recorded (Fig. 37.14). The patient had an uneventful
post-operative recovery and achieved an MRC 4 as demonstrated in the video (Video 37.1).
360
R. Miller et al.
a
b
c
Fig. 37.13 (a) This demonstrated the gracilis muscle ap prior to divi-
sion of the pedicle and muscle. The motor nerve is seen on the left
(black arrow) and the pedicle superiorly (white arrow). (b) This demonstrated the marking of the muscle to facilitate tensioning on inset.
(c) This demonstrates the ap after inset and after thinning with the
motor nerve (black arrow) and vascular pedicle(white arrow) again
highlighted
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361
Fig. 37.14 These images demonstrate the patient journey from pre-op, intra-op ap raise and inset and post-operative outcome. Note the window
left post-operatively to allow ap monitoring. The post-operative images demonstrating 4/5 elbow exion power at 6months
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37.8 Pearls andPitfalls
Pearls
• Suturing the skin paddle to the muscle fascia is
advised during the harvest of musculocutaneous
aps to prevent shearing of the musculocutaneous
perforators.
• When using a skin paddle, starting ap elevation
with the anterior incision allows the adductor longus to be easily identied by its prominent proximal
tendon (which is also easily palpated). This gracilis
is readily identied posteriorly to this in the upper
thigh and allows the step of a distal incision to identify the gracilis tendon and check skin paddle placement to be omitted.
• When using a free gracilis muscle ap, a small window can be left to allow ap monitoring instead of
using a skin paddle which may not correlate to the
underlying muscle (Fig.37.14).
• Alternatively, a buried free gracilis ap may be
monitored using Doppler ultrasound only. In the
absence of peer-reviewed evidence a reasonable
protocol is hourly monitoring for the rst 24h and 2
hourly overnight for the next 12h. At this point, the
senior author discontinues protocolled monitoring.
• If using the gracilis as a functional muscle, the resting tension of the inset must equal the resting tension of the muscle in situ. To help get this right,
measure and mark (with absorbable sutures) 1cm
intervals along the muscle in situ. Measure again
during ap inset to ensure the tension is right.
• When using a free gracilis ap for facial reanimation, it is advisable to use the gracilis muscle from
the same side as the side of the face to be reanimated, as, during inset, the orientation of the nerve
and vessels better corresponds to the position of the
facial vessels and the likely nerve donors. (If performing the procedure in two teams, the ap harvest
surgeon may sit on the opposite side while the facial
preparation is done on the ipsilateral side).
• Measure the distance between the junction of the
tragus and zygomatic arch and the oral commissure
and add 2–3cm for the muscle split. This provides
the length of the muscle ap harvest. Next measure
the distance between the palpable facial artery as
it curves around the body of the mandible and the
oral commissure. This provides an estimate for the
length of the pedicle needed.
• Inset the distal ap prior to the arterial and venous
anastomosis. Then do the nerve coaptation followed
be the proximal ap insertion. This provides ap
stability while maintaining exibility of inset and
minimizes ischaemic time.
R. Miller et al.
Pitfalls
• Do not confuse the adductors for the gracilis. This
may happen if the incision is not marked approximately 2 cm posterior to the main portion of the
muscle body. When the patient is supine with the
knee exed (as positioned on the operating table)
the gracilis is not under tension and will fall posteriorly. If the incision markings have not been placed
as described, the gracilis may be posterior to the
incision, causing confusion.
• Insufcient pedicle length. Dissect the pedicle right
to its insertion from profunda femoris. This can be
facilitated by a window above the adductor longus
to help take as much pedicle as needed [18].
• Muscle aps are more sensitive to ischaemia and
therefore one should limit the ischaemic time of the
muscle. Ensure the microsurgical setup is well prepared to facilitate this. Aim for an ischaemic time of
less than 2h.
• Pedicle mismatch. Be prepared to do end to side
anastomosis or perforator to perforator in lower
limb.
• It can be more challenging to elevate muscle aps
versus fasciocutaneous aps down the line if the
ap needs to be elevated to facilitate removal of
metal work in the lower limb, for example. Muscle
aps can die if the pedicle is divided down the line
and therefore careful case selection is advised when
used in lower limb trauma.
37.9 A Note onMonitoring Muscle Flaps
forVascular Compromise
Studies indicate that irreversible ischaemic changes occur
within 2h of compromised skeletal muscle [19]. We must
therefore assume that we have a window of no more than 2h
from the onset of ap compromise to the re-establishment of
tissue perfusion. In practical terms, the likelihood of successful surgical salvage of a congested muscle ap is therefore
low. Logically, the decision about whether to commence a
protocol of post-operative ap monitoring must therefore
consider whether the resources and logistical infrastructure
at the surgeons’ disposal can facilitate a rapid return to the
operating room if necessary. This must be balanced against
the fact that ap monitoring is demanding on clinical time
and exhausting for the patient. Thus, given that most ap
problems occur within the rst 36h, a rigorous protocol of
ap monitoring during this critical period seems reasonable.
By contrast, there is little logical merit in prolonged, tapered
protocols. Ultimately, the time to make these decisions is not
in the lull of mental exhaustion that follows a successful free
ap surgery. Protocols should be agreed in advance based on
37 Medial Circumex Femoral Artery: Gracilis Muscle Flap
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363
the resources available and deviations from agreed protocols
must have a basis in logic.
37.10 Selected Readings
• Giordano PA, Abbes M, Pequignot JP.Gracilis blood supply: anatomical and clinical re-evaluation. Br J Plast Surg.
1990;43 (3):266–272.
This classic paper provides the groundwork for anatomical investigations and studies of the gracilis ap
vasculature, following on from the work by Mathes and
Nahai [9].
• Hattori Y1, Doi K, Abe Y, Ikeda K, Dhawan V.Surgical
approach to the vascular pedicle of the gracilis muscle
ap. J Hand Surg Am. 2002 May;27 (3):534–6.
This paper describes an easy and safe approach to
the vascular pedicle of the gracilis muscle ap. With this
technique the vascular pedicle can be harvested with
maximum length and the largest possible calibre for functioning free muscle transfer [20].
• Tremp M, Oranges CM, Wang WJ, Wettstein R, Zhang
YX, Schaefer DJ, Kalbermatten DF.The “nugget design”:
A modied segmental gracilis free ap for small-sized
defect reconstruction on the lower extremity. J Plast
Reconstr Aesthet Surg. 2017.
The paper introduces a technical renement for smallsized three-dimensional defect reconstruction on the foot
using a segmental free gracilis muscle ap supplied but
secondary proximal pedicles. Although in the majority of
cases the gracilis is based on it is dominant pedicle, it
should be remembered that this is a versatile ap that can
be adapted to a wide range of reconstructions [21].
• Franco MJ, Nicolson MC, Parikh RP, Tung TH.Lower
Extremity Reconstruction with Free Gracilis Flaps. J
Reconstr Microsurg. 2017 Mar;33 (3):218–224.
This paper discusses the use of the gracilis ap in
lower limb reconstruction. It supports its use for smalland medium-sized defects and highlights the benet of a
denervated muscle ap for this reconstruction with good
long-term outcomes [7].
• Coelho JAJ, McDermott FD, Cameron O, Smart NJ,
Watts AM, Daniels IR.Single centre experience of bilateral gracilis ap perineal reconstruction following extralevator abdominoperineal excision. Colorectal Dis.
2019;21 (8):910–91.
This recent paper reports the authors use of the gracilis ap for perineal reconstruction. They have found success in positioning the patient prone, as discussed above,
and is worth reviewing if this is to be attempted [17].
• Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Double
free-muscle transfer to restore prehension following com-
plete brachial plexus avulsion. The Journal of Hand
Surgery. 1995 May 1;20 (3):408–14.
A fantastic paper from Doi etal. on the use of double
functional free muscle transfers in brachial plexus injury.
Although in this series the gracilis is not used in isolation,
it is the favoured ap and highlights its importance in the
function of reconstructing the upper limb [22].
References
1. Pickrell KL, Broadbent TR, Masters FW, Metzger JT.Construction
of a rectal sphincter and restoration of anal continence by transplanting the gracilis muscle; a report of four cases in children. Ann
Surg. 1952;135(6):853–62.
2. Orticochea M. The musculo-cutaneous ap method: an immediate and heroic substitute for the method of delay. Br J Plast Surg.
1972;25(2):106–10.
3. McCraw JB, Massey FM, Shanklin KD, Horton CE.Vaginal reconstruction with gracilis myocutaneous aps. Plast Reconstr Surg.
1976;58(2):176–83.
4. Harii K, Ohmori K, Sekiguchi J.The free musculocutaneous ap.
Plast Reconstr Surg. 1976;57(3):294–303.
5. Mathes SJ, Nahai F.Classication of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg.
1981;67(2):177–87.
6. Wei F-C, Mardini S. Flaps and reconstructive surgery. Elsevier;
2009.
7. Franco MJ, Nicoson MC, Parikh RP, Tung TH. Lower extremity reconstruction with free Gracilis aps. J Reconstr Microsurg.
2017;33(3):218–24.
8. Peek A, Müller M, Ackermann G, Exner K, Baumeister S. The
free gracilis perforator ap: anatomical study and clinical renements of a new perforator ap. Plast Reconstr Surg. 2009;123(2):
578–88.
9. Giordano PA, Abbes M, Pequignot JP. Gracilis blood supply: anatomical and clinical re-evaluation. Br J Plast Surg.
1990;43(3):266–72.
10. Lykoudis EG, Spyropoulou GA, Vlastou CC. The anatomic
basis of the gracilis perforator ap. Br J Plast Surg. 2005;58(8):
1090–4.
11. Kappler UA, Constantinescu MA, Büchler U, Vögelin E.Anatomy
of the proximal cutaneous perforator vessels of the gracilis muscle.
Br J Plast Surg. 2005;58(4):445–8.
12. Magden O, Tayfur V, Edizer M, Atabey A. Anatomy of gracilis
muscle ap. J Craniofac Surg. 2010;21(6):1948–50.
13. Whitaker IS, Karavias M, Shayan R, etal. The gracilis myocutaneous free ap: a quantitative analysis of the fasciocutaneous blood
supply and implications for autologous breast reconstruction. PLoS
One. 2012;7(5):e36367.
14. Krishnan K. An illustrated handbook of ap-raising techniques.
NewYork: Thieme; 2008. p.24–8.
15. Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger
JR.The transverse gracilis musculocutaneous ap. Ann Plast Surg.
1992;29(6):482–90.
16. Hallock GG. The medial circumex femoral (gracilis) local perforator ap--a local medial groin perforator ap. Ann Plast Surg.
2003;51(5):460–4.
17. Coelho JAJ, McDermott FD, Cameron O, Smart NJ, Watts AM,
Daniels IR.Single Centre experience of bilateral gracilis ap perineal reconstruction following extra-levator abdominoperineal excision. Color Dis. 2019;21(8):910–6.
364
R. Miller et al.
18. King IC, Obeid N, Woollard AC, Jones ME.Maximizing length and
safety in gracilis free ap dissection. J Plast Reconstr Aesthet Surg.
2016;69(10):1452–3.
19. Labbe R, Lindsay T, Walker PM.The extent and distribution of
skeletal muscle necrosis after graded periods of complete ischemia.
J Vasc Surg. 1987;6(2):152–7.
20. Hattori Y, Doi K, Abe Y, Ikeda K, Dhawan V.Surgical approach to
the vascular pedicle of the gracilis muscle ap. J Hand Surg Am.
2002;27(3):534–6.
21. Tremp M, Oranges CM, Wang WJ, et al. The "nugget design": a
modied segmental gracilis free ap for small-sized defect reconstruction on the lower extremity. J Plast Reconstr Aesthet Surg.
2017;70(9):1261–6.
22. Doi K, Sakai K, Kuwata N, Ihara K, Kawai S.Double free-muscle
transfer to restore prehension following complete brachial plexus
avulsion. J Hand Surg Am. 1995;20(3):408–14.
Profunda Artery Perforator Flap
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TomoyukiYano
38
38.1 Introduction
The profunda artery perforator (PAP) ap was rst introduced as a free ap for soft tissue defects by Angrigiani etal.
(2001). Allen etal. (2012) applied this technique in the eld
of breast reconstruction in 2012. Since then, various studies
on PAP ap breast reconstruction have been conducted, and
the PAP ap has become one of the alternative ap options
for autologous breast reconstruction. Nowadays, the PAP
ap is a thin and pliable ap option for head and neck reconstruction and soft tissue defect in the extremity as well.
An advantage of the PAP ap is it has less anatomical
variation and it has a straightforward pedicle dissection. A
skin paddle can harvest adequate adipose tissue volume
without any damage to surrounding muscles, which leads to
less donor site morbidity after surgery. Moreover, the donor
site wound will be nicely hidden in the posterior medial side
of the thigh or inguinal crease. A disadvantage of the PAP
ap is that only a limited width of the skin paddle can be
harvested to achieve primary safe donor site closure. A
small- to moderate-sized defect, which needs a certain
amount of adipose tissue, will be a good indication for the
PAP ap.
38.2 Anatomy
Finally, this perforator gives off two or three cutaneous
branches to the posterior medial thigh region. The location of
perforators are consistent, and there is little anatomical variation. Actually, in our experience with 38 cases of the PAP
ap, there was no case that did not have any single perforator
in the posterior medial region. You can always nd at least
one adequate perforator of the PAP ap in the posterior
medial region, and this might be a distinct difference between
the PAP ap and ALT ap. On the other hand, the second and
third perforators of the profunda femoris artery supply the
semi-membranosus, biceps femoris and vastus lateralis
muscles.
**
*
***
The profunda femoris artery gives off three perforators in the
posterior compartment of the thigh. The rst perforator of
the profunda femoris artery supplies the adductor magnus
and gracilis muscles. This perforator penetrates these muscles, takes an intra-muscular course, or a septal course, and
branches to the posterior medial thigh skin (Fig. 38.1).
Usually, the rst perforator is approximately 8–10cm from
the groin crease and 2–3 cm below the gracilis muscle.
T. Yano (*)
Cancer Institute hospital for JFCR, Tokyo, Japan
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_38
Fig. 38.1 A schema of the anatomy of the PAP ap. The red and blue
boxes indicate the profunda artery and vein, the femoral artery and vein.
The red circle shows the great saphenous vein. The single, double and
triple asterisks indicate the gracilis muscle, adductor longus muscle and
adductor magnus muscle, respectively. The red line with accompanying
double blue line represents the perforator of the PAP ap
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