Surgical Highlights

The gracilis muscle is easily harvested with the patient in a supine position and the lower limb in a flexed and abducted position exposing the inner thigh. A linear incision is made over the muscle along a line tangent to the pubis and medial condyle of the tibia. The intermuscular septum between the gracilis muscle and adductor longus muscle is identified, and the skin and subcutaneous tissues are dissected off the gra-cilis. The vascular pedicle (medial femoral circumflex artery and vein) is noted entering the anterior aspect of the gracilis muscle posterior to the adductor longus muscle. The anterior branch of the obturator nerve is also noted along the posterior border of the adductor longus muscle splitting to innervate several longitudinal muscular fascicles separately upon entering the gracilis muscle. If only a single functional unit is needed, only the anterior longitudinal half of the muscle is harvested since the vascular pedicle enters this portion. The neurovascular pedicles are dissected proximally and divided. Prior to release of the muscle distally and proximally, several shallow

Figure 35 The neurovascular anatomy of the gracilis free flap. Note the anterior branch of the obturator nerve entering the deep aspect of the gracilis muscle. The medial femoral circumflex vessels supply the flap.

sutures are placed through the muscular fascia exactly 1 cm apart to mark the resting tension of the muscle. The muscle is re-expanded in the face during insetting to approximate the resting tension marked by the sutures. Cross-face nerve grafting is usually required several months prior to flap transfer. The hypoglossal nerve can also be used.

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