The gracilis myofasciocutaneous flap: vascular anatomy and clinical application

Unreliable skin perfusion has been reported frequently in the gracilis myocutaneous flap, resulting in moderately high partial flap necrosis. We modified the traditional myocutaneous operative technique by including all available regional fascia and created a myofasciocutaneous flap with increased skin viability. In addition, we defined the arterial anatomy of the flap that contributes to enhanced flap survival. In a cadaver study, blue latex was injected into the external iliac arteries of 11 cadaveric legs and the gracilis myofasciocutaneous flap dissected. Selective ink injection of the pedicle and perforating vessels also was performed in 8 legs. Two additional legs were injected with a barium-latex mixture, cut into 2-cm-thick transverse sections, and radiographed. Dissections demonstrated arterial connections between the pedicle vessel (medial femoral circumflex artery) and fasciocutaneous perforating vessels from the superficial femoral artery. Perforating vessels contribute to an axially oriented fascial network that supplies the overlying skin. Selective ink injections demonstrated the individual primary cutaneous vascular territories for each perforator. Radiographs of 2-cm-thick transverse sections confirmed the presence of arterial connections between the pedicle and the superficial femoral artery perforators. Twelve patients, previously pelvically irradiated, then underwent harvest of 18 large, longitudinally oriented (8-cm-wide, up to 30-cm-long) gracilis myofasciocutaneous flaps. All fascia beneath the skin paddle was taken in continuity with the deep fascia surrounding the gracilis muscle to minimize disturbance of any connecting vasculature held within the fascia. Patients were followed for an average of 12.1 months (range 3 to 31 months). Minor complications related to the flaps occurred in 6 of 12 patients (50 percent), i.e., seromas, mild wound infections, and a partial dehiscence; however, vascularity was excellent with no partial or complete flap necrosis. All wounds healed completely.