Skip to main content

Gracilis Flap

The gracilis is the workhorse pedicled muscle flap of the perineum — the single most useful soft-tissue flap in the reconstructive urologist's toolbox for rectourethral fistula repair, long-segment urethroplasty buttress, penoscrotal reconstruction, neophallus urethral support, vulvoperineal reconstruction, and dead-space obliteration after APR or pelvic exenteration. It is also widely used outside urology — lower-extremity trauma coverage, breast reconstruction (TMG flap), facial reanimation, and functional muscle transfer for elbow flexion, thenar opposition, and quadriceps extension — which means the anatomy is extensively characterized in the literature and the harvest is well-standardized.

See the overview article for comparative context: Flaps in GU Reconstruction, and the anatomy reference: The Leg & Thigh.

External technique atlas: microsurgeon.org — Gracilis Muscle Flap.

Gross Anatomy​

The gracilis is a long, thin, strap-like muscle in the medial compartment of the thigh, superficial to the adductor magnus and posterior to the adductor longus.

FeatureValue
Mean muscle length41 ± 2.1 cm[2]
Musculotendinous unit44 ± 2 cm
Tendinous portion6 ± 2 cm
WidthPatient-dependent; wider in men and fit patients
OriginInferior pubic ramus + pubic symphysis + ischium
InsertionMedial condyle of the tibia (pes anserinus)
Coverage territoryUp to 6 cm wide × 20 cm long

Surface axis: a line from the ischium to the medial tibial condyle. In practice, the gracilis axis lies two to three finger breadths posterior to the palpable adductor longus with the thigh abducted — this is the standard incision guide.

Vascular Anatomy​

A Type II Mathes-Nahai muscle flap (one dominant pedicle, several minor pedicles).[2][3][4]

Dominant Pedicle — Medial Circumflex Femoral Artery​

  • Origin: medial circumflex femoral artery (or its direct continuation as the "artery to the adductors"), a branch of the profunda femoris.
  • Entry into muscle: ~10 ± 1 cm from the ischiopubic attachment (reported separately as ~8–10 cm from the pubic tubercle and ~10 cm below the ischium — these are consistent across studies).
  • Pedicle length: up to ~6 cm.
  • Artery diameter: small, typically 1–2 mm at origin, mean 2.5 ± 0.5 mm. Larger when arising directly from the deep femoral artery (45% of specimens) vs from the artery to the adductors (46%).
  • Course: superficial to the adductor magnus and deep to the adductor longus. Access is via the fascial cleft between the adductor longus and the gracilis.

Venae Comitantes​

  • Paired venae comitantes accompany the artery; they frequently merge proximally to produce a single larger-caliber vein for microvascular anastomosis.[5] Typically one vena is slightly larger than the artery.

Accessory (Minor) Pedicles​

  • Mean 1.8 minor pedicles (range 1–4), entering distal to the dominant pedicle.[2]
  • First accessory pedicle ~2.0 mm caliber, ~266 mm from the pubic tubercle.
  • Routinely ligated during harvest for pedicled perineal transfer.
  • Short leashes preclude their use as a free-flap pedicle, but the distally-pedicled gracilis (based on accessory pedicles) has been described for complex knee reconstruction.[14]

Intramuscular Branching — Relevance for Functional Transfer​

Both the artery and the obturator nerve typically split into two to three longitudinal branches that run parallel to each other through the muscle, supplying the anterior, middle, and posterior portions separately.[3] This is the anatomic basis for:

  • Segmental thinning / debulking before functional muscle transfer
  • Segmental functional transfer (using only a portion of the muscle)
  • Bilobed flap design for larger perineal defects

Neural Supply​

Obturator nerve (anterior division) provides motor innervation, entering with the major vascular pedicle and dividing into 2–3 major branches running longitudinally within the muscle parallel to the arterial branches.[3]

Denervation vs preservation:

  • Preserve nerve when functional muscle transfer is planned (graciloplasty neosphincter, facial reanimation, elbow flexion) — long nerve harvest is required for coaptation to the recipient motor nerve.
  • Divide nerve for static pedicled coverage to prevent postoperative muscle twitching at the recipient site, accepting the trade-off of progressive muscle atrophy.
  • Controversy persists on the optimal approach for perineal dead-space obliteration; many surgeons divide the nerve to avoid muscle contraction pulling on the repair, accepting atrophy as a feature not a bug.

Harvest Technique​

Positioning and Markings​

  • Supine with the leg fully prepped to the groin.
  • Thigh abducted and externally rotated, knee slightly flexed — "frog-leg" position.
  • Palpate the adductor longus medially with the thigh abducted — the gracilis lies 2–3 finger breadths posterior.
  • Mark the incision along this axis; note the dominant pedicle enters ~10 cm below the ischiopubic attachment, so incision markings should extend distal to this point.
  • Optional distal incision near the medial tibial condyle to transect the distal tendon when full muscle length is needed (avoids one long incision; requires care to identify the correct tendon at insertion).

Standard Open Harvest​

  1. Proximal incision through skin, subcutaneous fat, and the muscular fascia to expose the gracilis belly.
  2. Elevate the fascia off the muscle anteriorly; identify the septal junction between the gracilis and adductor longus.
  3. Enter the fascial cleft by retracting the two muscles apart; identify the pedicle in the areolar plane between them.
  4. Trace the pedicle proximally between the planes of adductor longus and adductor magnus back to its origin on the medial circumflex femoral system.
  5. Free the muscle of all soft-tissue attachments except for the pedicle.
  6. Cauterize the proximal tendon to detach it from the ischiopubic ramus.
  7. Transect the distal muscle at the insertion (or at a distal counter-incision) with cautery.
  8. Transect the obturator nerve — long for functional transfer, short for static coverage.
  9. Tunnel the flap subcutaneously to the perineum through a skin bridge.
  10. Close the thigh wound in layers over a closed-suction drain.

Extended Dissection (Ducic Technique)[11]​

  • Continue proximal dissection of the pedicle by dividing the small perforators to the adductor muscles.
  • Pass the gracilis beneath the adductor longus to allow a longer arc of rotation to the perineum and groin without compromising pedicle integrity or restricting ambulation.
  • Particularly useful for high-perineal / rectourethral fistula and for coverage of complex groin wounds.

Bilobed Gracilis Flap[10]​

  • Includes a second soft-tissue arm from the adjacent medial thigh for moderate-to-large pelvic and perineal defects requiring greater bulk.
  • Preserves the gracilis vascular pedicle and expands the coverage territory.

Bilateral Gracilis "Weave"[8]​

  • Bilateral pedicled gracilis flaps interwoven across the pelvic floor.
  • Creates a muscular sling supporting pelvic contents after extralevator APR or pelvic exenteration.
  • Long-term imaging confirms maintained flap integrity.

Myofasciocutaneous Design (Whetzel-Lechtman)[32]​

The traditional myocutaneous gracilis has been criticized for an unreliable skin paddle because the skin is supplied indirectly via musculocutaneous perforators. Whetzel and Lechtman (1997) showed that including all regional fascia in the flap dramatically improves skin viability — no partial or complete flap necrosis in 18 large flaps (up to 8 × 30 cm) in previously irradiated patients. The myofasciocutaneous variant is now the default when a reliable cutaneous paddle is required, particularly in irradiated fields.

Robotic Harvest[31]​

  • Recently described using the da Vinci Xi through three ports.
  • Enhanced visualization, precise pedicle dissection, potentially reduced donor-site morbidity.
  • Currently a limited single-center experience; further data needed.

Endoscopic Harvest​

Feasibility demonstrated in cadaveric studies (Mohammed et al.). Drawbacks include technical difficulty, bleeding risk, and increased cost vs the open approach. Not yet standard in live patients.

Postoperative Care​

  • Closed-suction drain for 24–72 h or until output drops to <30 mL/day.
  • Ambulation encouraged once the recipient site allows — the gracilis donor site itself does not mandate restricted weight-bearing.

GU Reconstructive Applications​

Perineal / Pelvic Reconstruction After APR or Exenteration​

The principal pedicled reconstructive option for the complex perineum, alongside VRAM. Gracilis is often preferred when:

  • The abdominal wall must be preserved (two-ostomy patients, prior TRAM/DIEP, robot-assisted APR).
  • Bilateral coverage is needed (gracilis allows bilateral harvest with minimal donor asymmetry; VRAM cannot realistically be harvested bilaterally).
  • Donor-site morbidity minimization is a priority.

Pooled donor-site complication rate: 16% for gracilis vs 57.6% for VRAM in meta-analysis (p<0.01).[7]

Rectourethral Fistula Repair​

The signature urologic gracilis indication. Transperineal exposure + gracilis interposition is standard for post-radiation and post-prostatectomy RUFs. The robotic-assisted hybrid approach exposes the fistula transabdominally while the gracilis is rotated in via a perineal incision.

SeriesnClosure rateNotes
Wexner 2008[33]36 male RUF (53 patients overall)78% initial; 97% after second gracilis in failures36% had prior failed repairs (mean 1.5 attempts); the landmark RUF series
Sbizzera 2022 (Eur Urol)[34]21 RUF after prostate cancer treatment (RT, surgery, HIFU)95% (20/21)Stoma closed in 83%; only 2 Clavien ≥ IIIb complications (9%); patient satisfaction 9/10; urinary incontinence persisted in 61% (pre-existing)
Higashino 2021[35]19 colorectal/urinary tract fistulas82% overall (31/38 across techniques)No significant difference between RVF and urorectal fistula cure rates
Zmora 2006[36]978% (7/9) after stoma closureUnderlying Crohn's and prior radiation associated with worse prognosis

Rectovaginal and Vesicovaginal Fistula​

For complex / recurrent fistulae that have failed simpler repairs:

  • Rectovaginal fistula — Wexner 2008 reported 75% healing in non-Crohn's RVFs (33% with Crohn's).[33] Chen 2013 combined gracilis transposition with postoperative salvage irrigation-suction for early leaks and reported overall healing of 94.7% in 19 patients.[37]
  • Vesicovaginal fistula — gracilis is among the interposition options when the Martius flap is unavailable or insufficient (recent Cochrane review notes complications including seroma, hematoma, numbness, and pain).[38]
  • Complex multi-failure urogenital fistulae — Paprottka 2016 reported all 12 fistulae successfully eradicated with VRAM (5) or gracilis (8) flaps at mean 6.3-year follow-up, with continence restored in all gracilis patients vs. slight incontinence in VRAM patients.[39]

Long-Segment Urethroplasty Buttress / Coverage​

Wraps the anastomosis or buttresses a buccal mucosal graft when local tissue is poorly vascularized — particularly in post-radiation and salvage cases.

Palmer 2015 (Lahey)[40] is the canonical urologic series — 20 patients with mean stricture length 8.2 cm (range 3.5–15 cm); etiologies radiation 45%, idiopathic 20%, trauma 15%, prostatectomy 10%; 45% had prior failed urethroplasty. Ventral BMG placed on a gracilis muscle flap bed achieved 80% success at mean 40-month follow-up. The technique is specifically designed for strictures with a compromised graft bed and poor vascular supply — the gracilis muscle provides the vascularized bed that the destroyed spongiosum can no longer offer.

Prelaminated BMG Approach​

A staged approach where the buccal mucosal graft is laid on the gracilis as a first-stage procedure and allowed to inosculate. The prelaminated gracilis + BMG composite is then harvested and transposed into the perineum at a second stage for complex reconstruction.[17]

Neophallus Urethroplasty Buttress​

Buttresses urethroplasty during primary neophallus creation or during revision urethroplasty of the neophallus — providing vascularized soft-tissue coverage that is often absent in the reconstructed genitalia.

Graciloplasty Neosphincter​

The gracilis is the only flap that can serve as both a urinary and a fecal neosphincter. Three variants:

  • Adynamic graciloplasty — pedicled gracilis wrapped around the bulbar urethra or bladder neck without electrical stimulation. Guo 2016 — 24 patients (post-RP, post-TURP, post-urethroplasty): 75% cure at mean 31.5 months with significant rise in maximum urethral pressure.[41] Chancellor 1997 reported the same concept in a 3-patient pilot for post-RP + RT incontinence.[42]
  • Dynamic (electrically stimulated) urinary graciloplasty — Janknegt and colleagues wrapped the gracilis around the bladder neck and stimulated it via implanted electrodes, converting fast-twitch to fatigue-resistant slow-twitch fibers. Pilot results: 3/7 continent, 1 partially continent, 3 failures, with urethral pressures ~50 cm H₂O under stimulation. Concept promising but never achieved widespread adoption because of complexity and morbidity.[43][44]
  • Free-flap graciloplasty (experimental) — Van Aalst 1998 and Perez-Abadia 2001 demonstrated anatomical / functional feasibility of using the gracilis as a microsurgical free flap wrapped around the bladder neck in cadaveric and canine models. Long-term canine outlet pressures were consistent with continence; remains investigational.[45][46]

Fecal incontinence — dynamic graciloplasty. Baeten 1995 (NEJM) reported 73% continent at median 2.1 years in 52 patients.[47] Madoff 1999 multicenter overall success 66%, with one-third experiencing major wound complications and therapy failing in 41% of those with complications.[48] The 2021 ACG Clinical Guidelines state that dynamic graciloplasty is "not currently recommended" because of significant morbidity and only modest benefits — sacral nerve stimulation has largely supplanted it as the preferred surgical option for refractory fecal incontinence.[49]

Vulvoperineal and Vaginal Reconstruction​

  • Short gracilis myocutaneous flap — excellent for vulvoperineal reconstruction after radical vulvectomy.[29][30] Muscular survival ~100%, partial distal cutaneous necrosis 35–40% (distal third, usually managed conservatively).
  • Bilateral pedicled gracilis myocutaneous flaps for neovagina construction. Bilateral gracilis neovagina is one of the NCCN-recommended options for neovaginal reconstruction after pelvic exenteration for cervical cancer.[50]

Largest historical series — Copeland 1989 (107 patients with gracilis neovagina after total pelvic exenteration):[51]

  • No increase in operative time, blood loss, or hospitalization vs. exenteration without reconstruction
  • Early series: 65% neovaginal prolapse (25% severe). After technique modifications (smaller flaps, fascial anchoring, pedicle ligation when needed): prolapse decreased to 16% (6% severe)
  • 66% free of wound breakdown or necrosis after modifications; severe necrosis decreased from 24% to 13%
  • The procedure of choice for most women undergoing exenterative procedures in the pre-perforator-flap era

Penoscrotal Reconstruction​

Pedicled muscle or myocutaneous variants cover complex penoscrotal defects after Fournier's gangrene, oncologic resection, or trauma where STSG alone is inadequate.

  • Ismayilzade 2023 — gracilis muscle interposition to fill perianal dead space after Fournier's gangrene decreased hospital LOS (23.5 vs. 31 days, p = 0.039) and time from surgery to discharge (5.1 vs. 12.7 days, p = 0.022) vs. reconstruction without dead-space obliteration.[52]
  • Hsu 2007 — unilateral gracilis myofasciocutaneous advancement flap for single-stage scrotal / perineal reconstruction in 8 patients (defects 12 × 7 cm to 30 × 15 cm). All defects covered successfully; one hematoma; no dehiscence.[53]
  • Lee 2012 — combined gracilis muscle flap + IPAP flap for penoscrotal defects in 7 patients (6 Fournier's, 1 extramammary Paget's): all flaps survived with good functional and aesthetic outcomes.[54]
  • Kayikçioğlu 2003 — short gracilis variant (based on obturator-artery branches at the pubic origin) offers greater mobility, no "dog ears," easier donor closure, and significant atrophy over time — advantageous for scrotal reconstruction.[55]

Outcomes in Perineal / Pelvic Reconstruction​

From the pooled urologic and colorectal perineal literature:[1][6][8][9]

OutcomeRange
Flap success95–100%
Complete perineal wound healing86–91%
Recipient-site complications22–40% (mostly hematoma, seroma, dehiscence managed conservatively)
Donor-site complications12.5–14%
Major complications7.9–17.5%
Perineal herniaRare to none

Independent Risk Factors for Complications[6]​

  • Obesity — OR 7.5 for minor complications
  • Active smoking — OR 9.3 for minor complications
  • Neoadjuvant chemoradiation — OR 21.4 for any complication

These are the levers for patient optimization where possible.

Non-GU Applications (for context)​

The gracilis is a workhorse outside urology. Key indications and outcomes:

Lower Extremity Trauma[12][13][14]​

  • Free gracilis: 93–95% flap success, 95% limb salvage after acute trauma, 96% infection resolution in posttraumatic osteomyelitis.
  • "Spreaded gracilis" for large defects (≥150 cm²) without increased complications.
  • Distally-pedicled gracilis for complex knee wounds.

Breast Reconstruction — Transverse Myocutaneous Gracilis (TMG)[15][16][17][18][19]​

  • Alternative to DIEP for small-to-moderate breasts or when abdomen is unavailable.
  • Concealed donor scar (medial-thigh-lift appearance).
  • 97–100% flap success; high BREAST-Q satisfaction; Lower Extremity Function Scale ~78/80.
  • Volume limitation the main drawback; often supplemented with fat grafting or flap stacking.

Facial Reanimation — the Gold Standard for Longstanding Facial Paralysis[20][21][22][23][24]​

  • Mean smile-excursion improvement 7.5 mm.
  • Masseteric-nerve innervation — larger excursion, faster rehab, single-stage, no spontaneous smile.
  • Cross-facial nerve graft — natural, spontaneous smile; two-stage; longer rehab.

Functional Muscle Transfer[25][26][27][28]​

  • Elbow flexion (Tinel-advanced results vs non-free-flap transfers)
  • Anterior deltoid reconstruction
  • Thenar opposition
  • Quadriceps extension (combined with nerve transfer)

Donor-Site Morbidity​

Generally low:[6][7][15][17]

  • Overall rate 12.5–16% (significantly lower than VRAM)
  • Wound dehiscence 7.7–19.3%
  • Hematoma 4–5%, seroma 2–3%, infection 2%
  • Transient posterior thigh sensory deficit — common, usually resolves
  • No long-lasting functional disability in most series
  • No gait impairment or chronic edema
  • Gracilis is an expendable muscle — loss produces minimal functional deficit

Preoperative Imaging​

CT angiography can provide personalized planning, detailed vascular anatomy, and reduce risk of iatrogenic damage, particularly in reoperative fields or patients with atypical anatomy.[2] Not universally required for standard perineal transfer but worth considering for free transfer or after prior medial-thigh surgery.

Videos​

Technique demonstrations of gracilis harvest are available on the author's curated YouTube playlist: Gracilis Harvest Playlist.

To embed individual videos on this page via the <VideoCards /> component, provide individual video URLs.

Key Takeaways​

  1. Gracilis is the workhorse pedicled muscle flap for the perineum — particularly when the abdominal wall must be preserved.
  2. The dominant pedicle (medial circumflex femoral a.) enters ~10 cm from the ischiopubic attachment — this determines the incision and reach.
  3. Arc of rotation reliably reaches the perineum; extended dissection beneath adductor longus extends reach further.
  4. Donor-site morbidity is significantly lower than VRAM (16% vs 58%).
  5. Obesity, active smoking, and neoadjuvant chemoradiation are the principal complication risk factors.
  6. Preserve the nerve for functional muscle transfer; divide for static coverage.
  7. Bilateral, bilobed, and distally-pedicled variants expand the flap's reach and bulk.
  8. Flap success rates are uniformly 95–100% across modern series.

References​

1. Chong TW, Balch GC, Kehoe SM, Margulis V, Saint-Cyr M. "Reconstruction of Large Perineal and Pelvic Wounds Using Gracilis Muscle Flaps." Ann Surg Oncol. 2015;22(11):3738–44. doi:10.1245/s10434-015-4435-1

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Redett RJ, Robertson BC, Chang B, Girotto J, Vaughan T. "Limb Salvage of Lower-Extremity Wounds Using Free Gracilis Muscle Reconstruction." Plast Reconstr Surg. 2000;106(7):1507–13. doi:10.1097/00006534-200012000-00010

14. Mitsala G, Varey AH, O'Neill JK, Chapman TW, Khan U. "The Distally Pedicled Gracilis Flap for Salvage of Complex Knee Wounds." Injury. 2014;45(11):1776–81. doi:10.1016/j.injury.2014.06.019

15. Mahrhofer M, Schwaiger K, Fierdel F, et al. "Patient-Reported Outcomes Following Breast Reconstruction With the Transverse Myocutaneous Gracilis Flap Using the BREAST-Q and Lower Extremity Function Scale." Aesthet Surg J. 2023:sjad311. doi:10.1093/asj/sjad311

16. Schoeller T, Huemer GM, Wechselberger G. "The Transverse Musculocutaneous Gracilis Flap for Breast Reconstruction — Guidelines for Flap and Patient Selection." Plast Reconstr Surg. 2008;122(1):29–38. doi:10.1097/PRS.0b013e318177436c

17. Jessica AS, Zhao J, Mackey S, Blackburn AV. "Transverse Upper Gracilis Flap Breast Reconstruction — A 5-Year Consecutive Case Series of Patient-Reported Outcomes." Plast Reconstr Surg. 2022;150(2):258–268. doi:10.1097/PRS.0000000000009362

18. 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

19. McKane BW, Korn PT. "The Fleur-De-Lis Upper Gracilis Flap for Breast Reconstruction — Flap Design and Outcome." Ann Plast Surg. 2012;69(4):383–6. doi:10.1097/SAP.0b013e31824b25c1

20. Bui MA, Vu TT. "Modified Gracilis Muscle Flap in Facial Reanimation — U-Shaped Design." J Plast Reconstr Aesthet Surg. 2023;80:182–189. doi:10.1016/j.bjps.2023.02.009

21. Roy M, Corkum JP, Shah PS, et al. "Effectiveness and Safety of the Use of Gracilis Muscle for Dynamic Smile Restoration in Facial Paralysis — A Systematic Review and Meta-Analysis." J Plast Reconstr Aesthet Surg. 2019;72(8):1254–1264. doi:10.1016/j.bjps.2019.05.027

22. Kalra GS, Kalra S, Gupta S. "Facial Reanimation Using Free Functional Muscle Transfer — Lessons Learnt From a Long-Term Experience Comparing Innervation With Cross Facial Nerve Graft and Masseter Nerve." J Craniofac Surg. 2022;33(8):e791–e796. doi:10.1097/SCS.0000000000008606

23. Greene JJ, Tavares J, Mohan S, Jowett N, Hadlock T. "Long-Term Outcomes of Free Gracilis Muscle Transfer for Smile Reanimation in Children." J Pediatr. 2018;202:279–284.e2. doi:10.1016/j.jpeds.2018.06.043

24. 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

25. 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

26. Gstoettner C, Laengle G, Boesendorfer A, et al. "Free Functional Gracilis Transfer for Reconstruction of Isolated Anterior Deltoid Atrophy Following Surgical Proximal Humerus Fixation." J Plast Reconstr Aesthet Surg. 2024;99:160–167. doi:10.1016/j.bjps.2024.09.003

27. Baker PA, Watson SB. "Functional Gracilis Flap in Thenar Reconstruction." J Plast Reconstr Aesthet Surg. 2007;60(7):828–34. doi:10.1016/j.bjps.2007.03.001

28. Donaldson EK, Chandler RM, Clark TA, Hayakawa TEJ, Giuffre JL. "Reconstruction of Quadriceps Function Using a Single Functional Gracilis Muscle Transfer With an Adductor Longus Nerve to Femoral Nerve Branch of the Rectus Femoris Nerve Transfer." Ann Plast Surg. 2022;89(4):419–430. doi:10.1097/SAP.0000000000003282

29. 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

30. 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

31. 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

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

33. 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

34. 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

35. Higashino T, Sakuraba M, Fukunaga Y, et al. "Surgical Outcome for Colorectal or Urinary Tract-Related Fistula: Usefulness of Vascularized Tissue Transfer — A Retrospective Study." J Plast Reconstr Aesthet Surg. 2021;74(5):1041–1049. doi:10.1016/j.bjps.2020.10.046

36. Zmora O, Tulchinsky H, Gur E, et al. "Gracilis Muscle Transposition for Fistulas Between the Rectum and Urethra or Vagina." Dis Colon Rectum. 2006;49(9):1316–1321. doi:10.1007/s10350-006-0585-3

37. 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

38. Okada Y, Matsushita T, Hasegawa T, et al. "Surgical Interventions for Treating Vesicovaginal Fistula in Women." Cochrane Database Syst Rev. 2026;1:CD015413. doi:10.1002/14651858.CD015413

39. Paprottka FJ, Krezdorn N, Lohmeyer JA, et al. "Plastic Reconstructive Surgery Techniques Using VRAM or Gracilis Flaps in Order to Successfully Treat Complex Urogenital Fistulas." J Plast Reconstr Aesthet Surg. 2016;69(1):128–137. doi:10.1016/j.bjps.2015.08.026

40. 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

41. 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

42. 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

43. Janknegt RA, Baeten CG, Weil EH, Spaans F. "Electrically Stimulated Gracilis Sphincter for Treatment of Bladder Sphincter Incontinence." Lancet. 1992;340(8828):1129–1130. doi:10.1016/0140-6736(92)93153-e

44. 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.

45. 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

46. 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

47. 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

48. 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

49. Wald A, Bharucha AE, Limketkai B, et al. "ACG Clinical Guidelines: Management of Benign Anorectal Disorders." Am J Gastroenterol. 2021;116(10):1987–2008. doi:10.14309/ajg.0000000000001507

50. National Comprehensive Cancer Network. "Cervical Cancer (NCCN Guidelines)." Updated 2025-11-10.

51. 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

52. Ismayilzade M, Dadaci M, Kendir MS, Ince B. "Gracilis Muscle Interposition to Fill the Perianal Dead Space May Decrease Hospital Length of Stay in Fournier's Gangrene." Ann Plast Surg. 2023;90(4):356–362. doi:10.1097/SAP.0000000000003517

53. 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

54. 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

55. Kayikçioğlu A. "A New Technique in Scrotal Reconstruction: Short Gracilis Flap." Urology. 2003;61(6):1254–1256. doi:10.1016/s0090-4295(03)00158-4