Surgical Approach to the Vascular

Pedicle of the Gracilis Muscle Flap

Yasunori Hattori, MD, PhD, Kazuteru Doi, MD, PhD,
Yukio Abe, MD, PhD, Keisuke Ikeda, MD, Vikas Dhawan, MD, PhD,
Yamaguchi, Japan

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
muscle for functioning free muscle transfer (FFMT)
because of its single motor nerve supply, anatomic
consistency of the vascular pedicle, and large amount
of excursion. We have used more than 100 gracilis
muscles for FFMT mainly in brachial plexus recon-
struction.1 Compared with the use of the gracilis
muscle as a pedicled island transfer, it is necessary to
harvest a longer vascular pedicle in FFMT. We have
reported our endoscopic harvesting technique of the
gracilis muscle for FFMT.2 In this article we describe
in detail our vascular dissection technique for an easy
and safe approach to the vascular pedicle.
Technique
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
monitoring of the circulation is designed proximal to
distal in an oblique direction over the gracilis muscle
(Fig. 1). After the skin is incised along the skin flap
anteriorly, the deep fascia is incised over the adduc-
tor longus muscle and posteriorly over the adductor
magnus muscle. The main vascular pedicle and mo-
tor nerve of the gracilis are identified underneath the
adductor longus muscle at the junction of the upper
quarter and lower three quarters of the gracilis mus-
cle (Fig. 2), but at this time the neurovascular pedicle
is not dissected. The gracilis muscle distal to the skin
flap is harvested endoscopically.2 After the distal
part is harvested (Fig. 3), the neurovascular pedicle is
dissected. For exposure of the neurovascular pedicle
the adductor longus muscle is retracted anteriorly

From the Department of Orthopedic Surgery, Ogori Daiichi General

Hospital, Yamaguchi, Japan.
Received for publication October 10, 2001; accepted in revised form
February 1, 2002.
No benefits in any form have been received or will be received from
a commercial party related directly or indirectly to the subject of this
article.
Reprint requests: Yasunori Hattori, MD, PhD, Department of Ortho-
pedic Surgery, Ogori Daiichi General Hospital, Shimogo, 862-3, Ogori,
Yoshikigun, Yamaguchi, Japan 754-0002.
Copyright © 2002 by the American Society for Surgery of the Hand
0363-5023/02/27A03-0021$35.00/0 Figure 1. The design of the skin flap for harvesting the
doi:10.1053/jhsu.2002.32962 gracilis muscle flap for FFMT.

534 The Journal of Hand Surgery

 The Journal of Hand Surgery / Vol. 27A No. 3 May 2002 535
Figure 2. The adductor longus muscle is retracted for
exposure of the neurovascular pedicle. Small arrow shows
the vascular pedicle, middle arrow shows the motor nerve
of the gracilis muscle, and large arrow shows the retracted
adductor longus muscle.
(Fig. 4). The nerve to the gracilis is traced as prox-
imal as possible to the obturator foramen where the
branch to the gracilis is divided. Some branches from
the vascular pedicle to the adductor longus muscle
are ligated to isolate the vascular pedicle. The vas-
cular pedicle should be traced to its origin from the
profunda femoris artery and vein. Because the view
of the vascular pedicle underneath the adductor lon-
gus muscle is not adequate, dissection of the plane
between the adductor longus muscle and superficial
femoral artery and vein is developed. One or 2 minor
vascular pedicles to the adductor longus muscle from
the superficial femoral vessels are ligated. After dis-
Figure 3. The distal part of the gracilis muscle is har-
vested endoscopically.
Figure 4. Dissection of the vascular pedicle is developed
underneath the retracted adductor longus muscle. Small
arrow shows the vascular pedicle and large arrow shows
the retracted adductor longus muscle.
section around the adductor longus muscle is com-
pleted, it is retracted posteriorly to expose the origin
of the pedicle (Fig. 5). The large ascending branch is
usually ligated before it joins the profunda femoris
artery. The venae comitantes often become one large
vein just before joining the profunda femoris vein.
The length of the pedicle is approximately 6 to 8 cm
and the diameter of the vessel is about 1.2 to 1.8 mm
(Fig. 6). After the vascular pedicle is ligated at the
Figure 5. Posterior retraction of the adductor longus mus-
cle exposes the origin of the pedicle. Small arrow shows
the vascular pedicle, middle arrow shows the profunda
femoris vessels, and large arrow shows the posterior re-
tracted adductor longus muscle.
536 Hattori et al / Approach to the Vascular Pedicle of the Gracilis Flap
junction of the profunda femoris vessels, the origin
of the gracilis is detached and harvesting of the
gracilis muscle flap is completed (Fig. 7).
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
femoris vessels, the vascular length and diameter are
not adequate for safe and easy microvascular proce-
dure. Our technique in which the adductor longus
muscle is retracted anteriorly and next posteriorly
facilitates exposure of the pedicle origin. The useful-
ness of this technique was originally suggested by
O’Brien and Morrison.5 Based on our experience of
Figure 6. Close view of the origin of the vascular pedicle.
Small arrow shows the artery, middle arrow shows the
vein that becomes one large vein, and large arrow shows
the profunda femoris artery.
Figure 7. Completion of the harvesting. Small arrow
shows the artery, middle arrow shows the vein, and large
arrow shows the motor nerve of the gracilis muscle.
FFMT for brachial plexus reconstruction, the vascu-
lar pedicle of the gracilis muscle should be of the
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
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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.
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