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Gracilis Flap

The gracilis provides vascularized medial-thigh tissue for perineal fistula interposition, support of a compromised urethral graft bed, and selected pelvic or genital defects. A proximally pedicled muscle flap usually reaches the perineum without microvascular anastomosis. Whether it supplies enough bulk, skin and reach depends on the defect and the patient's anatomy.[1][2]

See Flaps in GU Reconstruction for flap selection and The Leg & Thigh for regional anatomy.

Anatomy That Determines the Operation​

StructureOperative relevance
MuscleSuperficial medial-thigh adductor, with proximal attachment to the pubic body/inferior pubic ramus and distal insertion on the proximal medial tibia as part of the pes anserinus. Distinguish its distal tendon from sartorius and semitendinosus.
Dominant vascular pedicleA proximal pedicle from the deep femoral/adductor arterial system; descriptions include medial circumflex femoral contributions. A named artery or fixed surface distance does not replace identification of the actual pedicle.
Accessory pediclesDistal branches, commonly from the superficial femoral system. These may need division to mobilize a proximally based flap, after its dominant supply is identified and protected.
Venous drainagePaired venae comitantes; proximal convergence may provide a larger vein when free transfer is planned.
Motor nerveBranch of the obturator nerve, usually from its anterior division, entering near the dominant pedicle and branching longitudinally within the muscle.

Anatomical studies use different landmarks and methods. Macchi's CT angiography study of 40 patients reported a mean dominant-pedicle entry approximately 10 cm from the ischiopubic attachment, with direct deep-femoral and adductor-branch origins common. Morris's cadaver study reported a 44 cm musculotendinous unit, including approximately 6 cm of tendon. These are study averages, not a guaranteed usable flap length or interchangeable measurements from the pubic tubercle, groin crease and ischium. Magden's dissections further illustrate variation in which pedicle is dominant.[3][4][5][6]

Match Nerve Handling to the Reconstruction​

  • Static interposition or coverage: decide whether to preserve or divide the motor branch as part of the selected technique. Denervation can cause atrophy; subsequent volume loss matters when filling a cavity.
  • Innervated pedicled transfer: preserve the required motor connection in continuity when contraction is part of the intended function.
  • Distant free functional transfer: plan vascular anastomoses and motor-nerve coaptation. This differs from simply rotating a pedicled muscle into the perineum.[4][7][8]

Pedicled Harvest and Transfer Principles​

The exact dissection depends on muscle-only versus myocutaneous design, required reach and the recipient repair. The following is an operative planning framework; the dedicated procedure and flap design determine the details.[1][2]

  1. Assess both donor and recipient sites. Review medial-thigh operations, vascular disease, prior irradiation, tissue loss and available alternatives. Position and prepare the thigh so the tendon and perineum are accessible without excessive abduction or pressure injury. Selective vascular imaging can help when anatomy or previous surgery raises concern; routine CT angiography has not been established for every uncomplicated pedicled transfer.[3][2]
  2. Identify the muscle and dominant pedicle directly. Use the adductor longus and the medial-thigh anatomy to guide exposure. Preserve the fascia needed for any planned skin paddle rather than stripping it indiscriminately.[6][9]
  3. Mobilize only the tissue needed. Distal tendon release and selective division of accessory vessels permit rotation while the dominant proximal supply remains intact. Tailor further proximal release or extended pedicle dissection to the required reach, with nerve handling matched to the functional plan.[1][2]
  4. Create a generous transfer tunnel. Avoid twisting, traction, compression or an acute turn of the pedicle. Check reach and perfusion with the leg in its expected postoperative position.[1][2]
  5. Inset for the recipient problem. For fistulas, independently repair the involved organs and place viable muscle between the closures. For urethral support, provide a vascular bed without constricting the lumen. For pelvic defects, fill the appropriate dead space and obtain skin closure without undue tension.[10][11][2]
  6. Plan wound and drainage care around the repair. Check donor and recipient wounds for hematoma, infection, ischemia and leakage. Drain removal, catheter duration and activity restrictions depend on output, healing, recipient anatomy and the reconstruction.[12][13][2]

The microsurgeon.org atlas is an additional anatomical resource; its free-flap harvest and recipient-specific postoperative instructions need adaptation to a pedicled GU reconstruction.

Useful Variants​

VariantRole and limitation
Extended pedicle dissectionDucic's series applied extended dissection to 19 pedicled perineal/groin reconstructions. Passing the muscle beneath adductor longus can improve reach; this requires deliberate protection of the vascular supply.[1]
Bilateral gracilisAdds tissue when one muscle is insufficient and preserves the abdominal donor site. A 50-patient pelvic-oncology series described an interwoven configuration; complete wound healing was reported in 42/49 surviving patients at follow-up.[14]
Myofasciocutaneous flapIncludes the associated fascia and skin. Whetzel–Lechtman's anatomical work and 12-patient/18-flap experience support preserving the fascial vascular network. Muscle survival does not guarantee survival of an extended skin paddle.[9]
Bilobed designAdds an adjacent soft-tissue arm. The original six-reconstruction report establishes a technical option, not comparative superiority or an unrestricted skin territory.[15]
Robotic harvestDescribed for free gracilis transfer. Published early technical experience does not establish lower donor morbidity, lower cost or a preferred approach for routine pedicled perineal transfer.[16]

Fistula Interposition​

Gracilis is an established option for complex or recurrent rectourethral and selected rectovaginal fistulas, especially when the local tissues are scarred or irradiated. The exposure, diversion strategy and choice of interposition depend on fistula level, associated stenosis, tissue quality, prior repairs and bowel/bladder function.[17][10][18]

What the Outcome Numbers Mean​

The 2023 Garoufalia systematic review included 25 studies and 658 patients with mixed complex perineal fistulas. Its pooled 79.4% healing rate included additional procedures, with substantial heterogeneity. In the five studies reporting initial repair separately, pooled success after the index gracilis operation was 62.8%, increasing to 84.5% after further treatment; those additional procedures were often advancement flaps rather than another gracilis transfer. The review rated healing evidence very low certainty. These figures are not a rectourethral-only success rate or an individualized prediction.[19]

SeriesFindings and counseling limits
Wexner 2008Among 36 men with rectourethral fistulas in a 53-patient mixed cohort, initial success was 78% and final clinical healing 97% after additional procedures. The final rate includes further treatment.[17]
Vanni 201074 repairs, 68 using gracilis, with selective buccal onlay. At mean 20-month follow-up, single-stage closure was 100% in 35 nonirradiated cases and 84% in 39 radiation/ablation cases. In the latter group, 31% required permanent fecal diversion. Closure and reversal of diversion are separate outcomes.[18]
Sbizzera 2022Closure in 20/21 patients after prostate-cancer treatment. Of 18 postoperative questionnaire respondents, 11 reported significant urinary incontinence. A closed fistula does not establish continence, and this postoperative rate alone cannot determine how much dysfunction the repair caused.[10]
Park 2022Retrospective comparison: recurrence 8% in 24 gracilis repairs versus 50% in 12 controls. Supports an association with less recurrence, but nonrandom treatment selection limits causal inference.[20]

A 2026 systematic review of post-prostatectomy rectourinary fistulas identified 455 cases across 34 studies, with heterogeneous surgical outcomes. Its proposed management flowchart is an author-developed framework; it does not establish one approach or flap as best for all patients.[21]

Early leakage requires reassessment of the repair and drainage. Chen's small prospective series reported initial healing in 14/19 mixed fistulas and eventual healing in 18/19 after selected irrigation-suction salvage. There was no control group for salvage, and one patient required diversion with persistent fistula. This does not justify routine irrigation of every leak or delaying needed source control.[13]

Urethral Reconstruction​

Same-Stage Buccal Graft Support​

The muscle can provide a vascularized bed beneath a ventral buccal mucosa graft in selected long strictures with compromised local tissue. Rozanski–Vanni's updated retrospective cohort included 30 patients, with patency in 23/30 at mean 32-month follow-up and seven patients requiring an artificial urinary sphincter postoperatively. The earlier 20-patient report and updated 30-patient experience should not be added as independent cohorts; “20-year experience” describes the treatment period, not 20-year follow-up for every patient.[22][11]

See Ventral BMG with Gracilis Support for the urethral operation.

Staged Prelaminated Gracilis–Buccal Composite​

This is a distinct salvage technique for a devastated bulbar urethra. In the original case, stage 1 created a dorsal buccal plate on the corporal bed and a temporary perineal outlet, while a second buccal graft was quilted onto distal gracilis. Eight weeks later, the vascularized muscle–mucosa composite was transferred to form the ventral plate.[2]

The subsequent two-center series contained five patients, with no reported recurrence at mean 61-month follow-up and a mean 6.2-week interval between stages. This supports feasibility in selected salvage cases; it does not define a mandatory interval or establish comparative superiority. Discuss permanent perineal outlet and urinary diversion alongside reconstruction.[23]

See Laminated Gracilis Flap Urethroplasty for the staged concept and follow-up.

Pelvic, Perineal and Genital Coverage​

After APR or Pelvic Exenteration​

Gracilis may be useful when preserving the abdominal wall matters, abdominal donor sites are unavailable, or the defect can be filled with one or both thigh muscles. VRAM and other regional flaps remain options when greater bulk, skin or reach is required.[24][14][1]

The 2022 VRAM–gracilis proportional meta-analysis mainly pooled separate cohorts rather than direct comparisons. Its overall donor-complication analysis included only 56 gracilis and 240 VRAM patients, with inconsistent outcome definitions and important heterogeneity. It suggested fewer overall donor complications with gracilis, but some wound-dehiscence estimates favored VRAM. These data do not establish a universal risk ranking or equivalence. Select the flap for the defect, donor anatomy, planned stomas and surgical experience.[24]

For persistent perineal wounds after proctectomy in IBD, the 2026 Pelly systematic review found 25 publications, no randomized trials and very low certainty for muscle-flap outcomes. It could not pool healing rates meaningfully. Define the sinus, adjacent bowel involvement and deep infection before selecting local repair, gracilis, a larger flap or combined abdominal/perineal treatment. An attractive percentage from a small series is not a validated treatment algorithm.[25]

Vulvovaginal and Penoscrotal Defects​

Myocutaneous gracilis can replace selected vulvar or vaginal tissue, including neovaginal reconstruction after exenteration. Historical experience includes substantial skin necrosis, wound breakdown and prolapse. Goals, required lining, available tissue, hair-bearing skin and alternative flaps guide selection.[26][27][28]

After Fournier's gangrene, muscle may fill a residual deep cavity, while skin grafts or local/perforator flaps provide surface coverage as needed. Hsu and Lee reported small series using myofasciocutaneous gracilis or gracilis combined with an internal pudendal artery perforator flap. These are reconstructive options after adequate debridement and infection control, not substitutes for those steps.[29][30]

Graciloplasty for Continence: Historical and Specialized Uses​

Urinary or fecal graciloplasty seeks a functional outlet, a different objective from static fistula interposition. Its outcomes should not be used to predict success of ordinary gracilis coverage.

ApplicationEvidence boundary
Adynamic urinary wrapGuo's 24-patient series reported 18 cures, but five of six patients with severe incontinence did not achieve a good result. The uncontrolled cohort does not establish equivalence to standard continence surgery.[31]
Electrically stimulated urinary wrapJanknegt's 1995 pilot included seven patients: three continent, one partially continent and three treatment failures. This remains a small historical feasibility experience.[32]
Free-flap urinary neosphincterAnatomical and canine experiments demonstrated feasibility. Animal outlet-pressure measurements are not human continence outcomes.[33][34]
Dynamic fecal graciloplastyBaeten reported continence in 38/52 patients. In the later multicenter study, 85/128 graciloplasty patients met a study-specific success endpoint, which was not uniformly complete continence; major wound complications were common. These historical results require specialist interpretation and do not make graciloplasty routine first-line treatment.[35][36]

Morbidity and Follow-Up​

Track flap viability, wound healing, fistula closure, urethral patency, continence and quality of life separately. Also record whether repeat procedures or ongoing diversion were needed.[10][11][19]

The donor site can develop dehiscence, seroma, hematoma, infection, sensory symptoms or functional complaints. Preserving other thigh adductors often limits disability, but absence of persistent gait impairment or edema in a small series is not a guarantee. In a later 101-patient perineal-reconstruction cohort, eight patients had early major complications, 13 had late major complications and 33 had minor complications; the study extended earlier institutional experience rather than supplying an independent population to add to it.[37][12]

Optimize smoking, nutrition, diabetes and other modifiable risks; factor prior chemoradiation and donor/recipient tissue quality into planning. Associations reported in a small cohort do not provide a validated individual risk score. Follow-up should address both wounds, the reconstructed organ and the patient's functional goals.[37][12][10]

Other Reconstructive Uses​

Free gracilis is also used for limb coverage, breast reconstruction and functional reanimation. Transverse upper gracilis provides limited breast volume; functional transfers require a suitable motor source and rehabilitation. Facial-reanimation reviews found heterogeneous reporting and could not establish one optimal donor nerve; spontaneous smiling has been reported after masseteric innervation, but assessment methods and results vary. Results from these different operations should not be pooled into GU flap-survival or donor-risk estimates.[38][39][7][40]

Videos​

Gracilis Harvest Playlist.

References​

1. Ducic I, Dayan JH, Attinger CE, Curry P. "Complex Perineal and Groin Wound Reconstruction Using the Extended Dissection Technique of the Gracilis Flap." Plast Reconstr Surg. 2008;122(2):472–478. doi:10.1097/PRS.0b013e31817d607d

2. Nikolavsky D. "Prelaminated Gracilis Flap with Buccal Mucosal Graft for Salvage of Devastated Urethra." Case Rep Urol. 2015;2015:490518. doi:10.1155/2015/490518. Full text.

3. Macchi V, Vigato E, Porzionato A, et al. "The Gracilis Muscle and Its Use in Clinical Reconstruction: An Anatomical, Embryological, and Radiological Study." Clin Anat. 2008;21(7):696–704. doi:10.1002/ca.20685

4. Morris SF, Yang D. "Gracilis Muscle: Arterial and Neural Basis for Subdivision." Ann Plast Surg. 1999;42(6):630–3. doi:10.1097/00000637-199906000-00008

5. Magden O, Tayfur V, Edizer M, Atabey A. "Anatomy of Gracilis Muscle Flap." J Craniofac Surg. 2010;21(6):1948–50. doi:10.1097/SCS.0b013e3181f4ed81

6. Hasen KV, Gallegos ML, Dumanian GA. "Extended Approach to the Vascular Pedicle of the Gracilis Muscle Flap: Anatomical and Clinical Study." Plast Reconstr Surg. 2003;111(7):2203–8. doi:10.1097/01.PRS.0000060114.95065.C5

7. Vila PM, Kallogjeri D, Yaeger LH, Chi JJ. "Powering the Gracilis for Facial Reanimation — A Systematic Review and Meta-Analysis of Outcomes Based on Donor Nerve." JAMA Otolaryngol Head Neck Surg. 2020;146(5):429–436. doi:10.1001/jamaoto.2020.0065

8. Chancellor MB, Watanabe T, Rivas DA, et al. "Gracilis Urethral Myoplasty: Preliminary Experience Using an Autologous Urinary Sphincter for Post-Prostatectomy Incontinence." J Urol. 1997;158(4):1372–1375. doi:10.1016/s0022-5347(01)64218-6

9. Whetzel TP, Lechtman AN. "The Gracilis Myofasciocutaneous Flap: Vascular Anatomy and Clinical Application." Plast Reconstr Surg. 1997;99(6):1642–1652; discussion 1653–1655. PubMed.

10. Sbizzera M, Morel-Journel N, Ruffion A, et al. "Rectourethral Fistula Induced by Localised Prostate Cancer Treatment: Surgical and Functional Outcomes of Transperineal Repair With Gracilis Muscle Flap Interposition." Eur Urol. 2022;81(3):305–312. doi:10.1016/j.eururo.2021.09.017

11. Rozanski AT, Vanni AJ. "Ventral Buccal Mucosa Graft Urethroplasty With Gracilis Muscle Flap for High Risk, Long Segment Urethral Strictures: A 20-Year Experience." Urology. 2020;140:178–180. doi:10.1016/j.urology.2020.03.008

12. Rinkinen JR, Fruge S, Welten VM, et al. "Long-Term Outcomes Analysis of Flap-Based Perineal Reconstruction." J Gastrointest Surg. 2024;28(1):57–63. doi:10.1016/j.gassur.2023.11.006

13. Chen XB, Wang YX, Jiang H, et al. "Salvage Irrigation-Suction in Gracilis Muscle Repair of Complex Rectovaginal and Rectourethral Fistulas." World J Gastroenterol. 2013;19(39):6625–6629. doi:10.3748/wjg.v19.i39.6625

14. Jenkins E, Humphrey H, Finan C, et al. "Long-Term Follow-Up of Bilateral Gracilis Reconstruction Following Extra-Levator Abdominoperineal Excision." J Plast Reconstr Aesthet Surg. 2023;76:198–207. doi:10.1016/j.bjps.2022.10.025

15. Weinstein B, King KS, Triggs W, Harrington MA, Pribaz J. "Bilobed Gracilis Flap — A Novel Alternative for Pelvic and Perineal Reconstruction." Plast Reconstr Surg. 2020;145(1):231–234. doi:10.1097/PRS.0000000000006341

16. Sert G, Yıldızdal S, Güdeloğlu A, Selber J. "Robotic Harvest of the Free Gracilis Muscle Flap." J Plast Reconstr Aesthet Surg. 2024;90:323–325. doi:10.1016/j.bjps.2024.02.031

17. Wexner SD, Ruiz DE, Genua J, et al. "Gracilis Muscle Interposition for the Treatment of Rectourethral, Rectovaginal, and Pouch-Vaginal Fistulas: Results in 53 Patients." Ann Surg. 2008;248(1):39–43. doi:10.1097/SLA.0b013e31817d077d

18. Vanni AJ, Buckley JC, Zinman LN. "Management of Surgical and Radiation Induced Rectourethral Fistulas With an Interposition Muscle Flap and Selective Buccal Mucosal Onlay Graft." J Urol. 2010;184(6):2400–2404. doi:10.1016/j.juro.2010.08.004

19. Garoufalia Z, Gefen R, Emile SH, et al. "Gracilis Muscle Interposition for Complex Perineal Fistulas: A Systematic Review and Meta-Analysis of the Literature." Colorectal Dis. 2023;25(4):549–561. doi:10.1111/codi.16427

20. Park KM, Rosli YY, Simms A, et al. "Preventing Rectourethral Fistula Recurrence With Gracilis Flap." Ann Plast Surg. 2022;88(4 Suppl 4):S316–S319. doi:10.1097/SAP.0000000000003085

21. de Angelis M, Scilipoti P, Leni R, et al. "Clinical and surgical management of recto-urinary fistula after radical prostatectomy: a systematic review on current evidence." Prostate Cancer Prostatic Dis. 2026. doi:10.1038/s41391-026-01114-7.

22. Palmer DA, Buckley JC, Zinman LN, Vanni AJ. "Urethroplasty for High Risk, Long Segment Urethral Strictures With Ventral Buccal Mucosa Graft and Gracilis Muscle Flap." J Urol. 2015;193(3):902–905. doi:10.1016/j.juro.2014.09.093

23. Sterling J, Schardein J, Joshi PM, Kulkarni SB, Nikolavsky D. "Long-term outcomes from a multi-institutional experience with prefabricated composite gracilis-buccal mucosal flap for reconstruction of devastated urethras." Int Urol Nephrol. 2022. doi:10.1007/s11255-022-03154-z.

24. Eseme EA, Scampa M, Viscardi JA, et al. "Surgical Outcomes of VRAM vs Gracilis Flaps in Vulvo-Perineal Reconstruction Following Oncologic Resection — A Proportional Meta-Analysis." Cancers. 2022;14(17):4300. doi:10.3390/cancers14174300

25. Pelly T, Anand E, Holubar S, Tozer P, Hart A. "Systematic review: The management of unhealed wounds and persistent perineal sinuses following proctectomy in inflammatory bowel disease." Tech Coloproctol. 2026;30:5 (published online December 2025). doi:10.1007/s10151-025-03242-z. Full text.

26. Chen SH, Hentz VR, Wei FC, Chen YR. "Short Gracilis Myocutaneous Flaps for Vulvoperineal and Inguinal Reconstruction." Plast Reconstr Surg. 1995;95(2):372–7. doi:10.1097/00006534-199502000-00018

27. Burke TW, Morris M, Roh MS, Levenback C, Gershenson DM. "Perineal Reconstruction Using Single Gracilis Myocutaneous Flaps." Gynecol Oncol. 1995;57(2):221–5. doi:10.1006/gyno.1995.1129

28. Copeland LJ, Hancock KC, Gershenson DM, et al. "Gracilis Myocutaneous Vaginal Reconstruction Concurrent With Total Pelvic Exenteration." Am J Obstet Gynecol. 1989;160(5 Pt 1):1095–1101. doi:10.1016/0002-9378(89)90168-3

29. Hsu H, Lin CM, Sun TB, Cheng LF, Chien SH. "Unilateral Gracilis Myofasciocutaneous Advancement Flap for Single Stage Reconstruction of Scrotal and Perineal Defects." J Plast Reconstr Aesthet Surg. 2007;60(9):1055–1059. doi:10.1016/j.bjps.2006.09.005

30. Lee SH, Rah DK, Lee WJ. "Penoscrotal Reconstruction With Gracilis Muscle Flap and Internal Pudendal Artery Perforator Flap Transposition." Urology. 2012;79(6):1390–1394. doi:10.1016/j.urology.2012.01.073

31. Guo H, Sa Y, Xu Y, Wang L, Fei X. "Adynamic Graciloplasty With a Pedicled Gracilis Muscle Flap Wrapped Around Bulbar Urethra for Treatment of Male Acquired Urinary Incontinence." Urology. 2016;91:208–214. doi:10.1016/j.urology.2015.12.073

32. Janknegt RA, Heesakkers JP, Weil EH, Baeten CG. "Electrically Stimulated Gracilis Sphincter (Dynamic Graciloplasty) for Treatment of Intrinsic Sphincter Deficiency: A Pilot Study on Feasibility and Side Effects." J Urol. 1995;154(5):1830–1833. PubMed.

33. van Aalst VC, Werker PM, Stremel RW, et al. "Electrically Stimulated Free-Flap Graciloplasty for Urinary Sphincter Reconstruction: A New Surgical Procedure." Plast Reconstr Surg. 1998;102(1):84–91. doi:10.1097/00006534-199807000-00013

34. Perez-Abadia G, Van Aalst VC, Palacio MM, et al. "Gracilis Muscle Neosphincter for Treating Urinary Incontinence." Microsurgery. 2001;21(6):271–280. doi:10.1002/micr.1051

35. Baeten CG, Geerdes BP, Adang EM, et al. "Anal Dynamic Graciloplasty in the Treatment of Intractable Fecal Incontinence." N Engl J Med. 1995;332(24):1600–1605. doi:10.1056/NEJM199506153322403

36. Madoff RD, Rosen HR, Baeten CG, et al. "Safety and Efficacy of Dynamic Muscle Plasty for Anal Incontinence: Lessons From a Prospective, Multicenter Trial." Gastroenterology. 1999;116(3):549–556. doi:10.1016/s0016-5085(99)70176-9

37. Singh M, Kinsley S, Huang A, et al. "Gracilis Flap Reconstruction of the Perineum: An Outcomes Analysis." J Am Coll Surg. 2016;223(4):602–10. doi:10.1016/j.jamcollsurg.2016.06.383

38. Heidekrueger PI, Ehrl D, Ninkovic M, et al. "The Spreaded Gracilis Flap Revisited — Comparing Outcomes in Lower Limb Reconstruction." Microsurgery. 2017;37(8):873–880. doi:10.1002/micr.30245

39. Blough JT, Saint-Cyr MH. "Modern Approaches to Alternative Flap-Based Breast Reconstruction — Transverse Upper Gracilis Flap." Clin Plast Surg. 2023;50(2):313–323. doi:10.1016/j.cps.2022.11.001

40. Griepp DW, Shah NV, Scollan JP, et al. "Outcomes of Gracilis Free-Flap Muscle Transfers and Non-Free-Flap Procedures for Restoration of Elbow Flexion — A Systematic Review." J Plast Reconstr Aesthet Surg. 2022;75(8):2625–2636. doi:10.1016/j.bjps.2022.04.025