DOI: 10.1097/PRS.0b013e3181b03a79

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PMID: 19730342

Issn Print: 0032-1052

Publication Date: 2009/09/01


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The Free Gracilis Perforator Flap: Is a Perforator Flap Really Indicated in the Case of the Gracilis Flap?

Arash Momeni; Holger Bannasch; Gordon K. Lee

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Peek et al.1 must be commended on their sophisticated study in which they present their extensive clinical experience with the free gracilis perforator flap and share the results of their anatomical studies with us. As they note correctly, the concept of perforator flap–based reconstruction is becoming increasingly popular, with an increasing number of flaps reported. Despite the very detailed analysis presented, we would like to raise the question of whether perforator flap techniques need to be applied in the case of the gracilis muscle flap and discuss potential limitations of their study.
The concept of perforator flap reconstruction emerged with the aim of reducing donor-site morbidity and has been applied successfully to multiple anatomical sites. The most common donor sites are the lower abdomen (deep inferior epigastric perforator flap), the back (thoracodorsal artery perforator flap), the buttocks (superficial gluteal artery perforators flap), and the thigh (anterolateral thigh flap). The common characteristic of all these flaps is a perforator that typically traverses a large muscle. Thus, functional preservation of these powerful muscles justifies the additional time spent in the operating room for intramuscular dissection of the vessel. This justification may not apply to the gracilis muscle, in particular, as its functional loss has been shown to be imperceptible.2
Peek et al.1 propose the extended gracilis perforator flap with incorporation of the main pedicle and its anastomosis with the minor pedicle for coverage of large defects. The functional and reconstructive benefit of this particular flap is, however, questionable for multiple reasons:
As the authors point out correctly, the main concern with the gracilis myocutaneous flap is not the resulting functional impairment in hip adduction or knee flexion; instead, the aesthetic appearance of the scar is frequently a source of patient dissatisfaction.3 Thus, it is surprising that they use the traditional skin island design with longitudinal closure of the donor site.1 Orienting the skin paddle transversely has been demonstrated to likewise provide a large skin paddle but avoids the large longitudinal incision and places the incision in the inconspicuous groin area, which has been shown to result in a high level of patient satisfaction.4 We have incorporated the transverse incision even when raising a gracilis muscle flap (Figs. 1 and 2).
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