7.3.1.1 Step 1

The entrance of the pedicle on the deep surface of the gracilis muscle is then marked 10 cm below the pubic tubercle. The skin is incised at this level, following the premarked line between the pubic tubercle and the medial condyle. The dissection is then continued through subcutaneous tissue until the muscular fascia is reached. The neurovascular pedicle is located at the anterior part of the upper third of the muscle 10 cm below the ischium (Fig. 7.2).

7.3.1.2 Step 2

At this point, the septal junction between the gracilis and adductor longus must be identified. This space is then entered by retracting the two muscles from each other, and the pedicle to the gracilis is identified in this areolar plane (Fig. 7.3).

7.3.1.3 Step 3

Once the vascular supply has been safely located as protected, the muscle dissection can be completed. In most of cases, a second small incision approximately 10 cm proximal the medial condyle is made, in order to reach the distal part of the muscle (Fig. 7.4).

7.3.1.4 Step 4

The gracilis muscle-tendon unit is then divided, and the gracilis muscle is finally separated from the adductor longus and adductor magnus muscles working from a distal to proximal direction. Minor pedicles are ligated. Closure of the wound is done in layers over suction drains. The patient can be allowed to walk after 5 days (Fig. 7.5).

7.3.2 TUG Flap

As the gracilis muscle free flap has gained wide popularity due to its predictable vascular anatomy and minimal donor-site morbidity, by contrast, the myocutaneous one is less used because of previously documented unreliability of the overlying skin island [3–5]. More recently, two variations of the myocutaneous flap have been described: the transverse island [6] and the vertically oriented one [3]. Usually, when a myocutaneous flap is required, the transverse upper gracilis (TUG) flap represents the most common variation of the simple gracilis flap. It was described first by Yousif et al. [6] in 1992, with the first clinical reports in 1993 [7]. The skin paddle and underlying fat are horizontally oriented as a wide ellipse over the proximal upper one-third of the gracilis muscle. This kind of skin orientation has the main advantage of a low donor-site morbidity but has also some limitations such as the potential damage to the lymphatic drainage of the leg, the limited amount of tissues, and the widening and lowering of the donor-site closure scar with time [8–11]. The technique consists in planning the skin paddle transversely, with the widest point centered over the gracilis muscle. The operating surgeon must be careful not to resect too much skin, since closure can be difficult. The dissection starts anteriorly in the subcutaneous tissue. The saphenous vein can be included in the flap if necessary. Once the edge of the adductor longus is reached, the muscular fascia is incised, and the pedicle to the gracilis is identified under the adductor longus. Now, the dissection is started posteriorly until the margin of the gracilis is reached. Finally, the proximal and distal muscles are divided. And the pedicle is traced to its origin to gain length as necessary.