Gracilis Muscle Flap

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Bartholdson and Hulten described the gracilis muscle flap for perineal reconstruction in 1975 [29]. This fusiform muscle lies along the medial side of the thigh and knee and serves to adduct the thigh, and to flex and medially rotate the leg. It attaches proximal-ly at the body and inferior ramus of the pubic bone and distally to the superior part of the medial surface of the tibia. The dominant vascular pedicle of this flap is the medial femoral circumflex artery and vein that branches off the profunda femoris artery and vein [18]. The muscle is exposed through a longitudinal thigh incision and the distal end is divided near the knee (Fig. 2). It may be rotated as a muscle or as a myocutaneous unit. Usually the muscle alone is used for rotation as the overlying skin has a rather uncertain blood supply. Moreover, the inclusion of the skin tends to limit the degree of muscle transposition into the perineal wound. Furthermore, the donor site may be difficult to close [16].

Skeletal Muscle Blood Supply
Fig. 1. V-Y fasciocutaneous flap. Two large triangular flaps extending to the inner aspects of the thighs are marked (top). The skin, subcutaneous fat and deep fascia are incised (middle). The flaps are mobilised 4-6 cm medially on each side and sutured (bottom)

This flap can be used as a pedicle graft for filling the cavity created after excision of a long perineal sinus. Some authors consider the gracilis muscle flap the technique of choice for many perineal wounds. Ryan [30] reported a successful healing in 12 of 15 patients [80%), including 9 with ulcerative colitis and 6 with Crohn's disease. The same good results have

Gracilis Muscle Strain

Fig. 2. Gracilis muscle flap reconstruction for PPS

thigh is intimately associated with the vascular pedicle and provides the opportunity of transferring a flap that maintains a certain skin sensitivity. The point of rotation of the flap is 5 cm above the ischial tuberosity which overlies the emergence of the inferior gluteal artery from underneath the piriformis muscle. The central axis of the flap is midway between the greater trochanter and the ischial tuberosity, running perpendicularly to the gluteal crease.

The donor site can be usually sutured straightforwardly. To facilitate donor site closure, the flap should be designed to be less than 12 cm in width. It may be extended to within 8 cm from the popliteal fossa. In a series of 19 patients with 21 buttock and perineal wounds closed in a single stage, Hurtwitz et al. demonstrated the reliability, versatility and low morbidity of the gluteal thigh flap [18, 32]. It provides excellent soft tissue bulk and usually little to no functional deficit is noted postoperatively [19]. Many authors consider it to be the gold standard for the chronic, deep midline perineal defect, while others feel that de-epithelialised fasciocutaneous flaps have a limited capability in filling completely dead spaces, especially in complex sinuses [18].

Fig. 2. Gracilis muscle flap reconstruction for PPS

recently been reported by Rius et al. [31].

According to Keighley [16], the gracilis muscle flap is a useful option in postirradiation perineal sinuses, and he warns about the risk of sensory loss related to the long and potentially painful thigh incision. The principle drawback to this flap is that it frequently may not provide sufficient bulk to fill the dead space in large, complex perineal wounds. In addition, the proximal two thirds of the gracilis muscle, which represents the main bulk of the flap, may not reach the deepest point of the perineal wound due to its low axis of rotation [18]. Finally the vascu-larity of the distal third of the flap may be unreliable. For these reasons many reconstructive surgeons are actually cautious in utilising this flap.

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