<iframe data-testid="embed-iframe" style="border-radius:12px" src="https://open.spotify.com/embed/episode/02MnnX4c06yN5TeMsg7zVA?utm_source=generator&t=0" width="100%" height="352" frameBorder="0" allowfullscreen="" allow="autoplay; clipboard-write; encrypted-media; fullscreen; picture-in-picture" loading="lazy"></iframe> ## 1. Understand gracilis muscle anatomy and neurovascular supply ### a) Explain the markings of the pedicle - Key surface landmarks - Mark the pubic tubercle (pubic symphysis region) and the medial tibial condyle first — these define the gracilis axis (pubis → medial tibial condyle). - Palpate and mark the adductor longus tendon/muscle (becomes prominent with thigh abduction/“frog‑leg” or knee extension). The gracilis runs just posterior to the adductor longus. - Draw a straight line just posterior to the adductor longus tendon connecting the pubic tubercle to the medial femoral condyle — this approximates the anterior border of gracilis. - Pedicle / perforator localization (practical marking sequence) - From the pubic tubercle measure inferiorly ~8–12 cm and apply a handheld Doppler sweep here. The dominant pedicle / large musculocutaneous perforators are typically found in this zone (commonly cited 8–10 cm or 8–12 cm). - Mark the strongest Doppler signal(s) with an “X” — plan your skin paddle to include this X. - For TUG/TMG (transverse) design: center the transverse skin paddle over the upper third of the muscle, with the proximal limb ~4 cm inferior to the gluteal–groin crease. Transverse paddle can be up to ~30 × 10 cm in select patients but plan with a pinch test for primary closure. - For longitudinal (vertical) design: set the proximal incision 2–3 cm below the pubic tubercle. The reliable skin paddle should remain within the proximal two‑thirds of the muscle (width typically 5–8 cm; length up to ~15 cm depending on laxity). - Practical “pinch and Doppler” rule - Use pinch test to ensure donor-site can be closed primarily. Usually up to ~9 cm width closes primarily. - Always center the skin island over the Doppler-identified perforator(s). Perforators are most abundant in the proximal third; distal two‑thirds are less reliable. - Muscle-specific markings for harvest or functional transfer - Mark the full length of gracilis if needed (muscle length ≈ 25–30 cm; width ≈ 5 cm). - If planning functional transfer, mark the muscle at set intervals (common teaching: 5‑cm markings along the muscle) while the muscle is at its in‑situ resting or stretched length — this preserves length–tension relationships at inset. - Pitfalls related to markings - Misidentifying adductor longus or sartorius → misplacing skin paddle or incision. Remember: gracilis lies posterior to adductor longus and is the only adductor crossing knee and hip (palpable on knee extension). - Designing skin paddle into distal third of muscle → high risk of distal skin necrosis. Limit skin paddle to proximal two‑thirds unless delay or special technique used. - Failing to Doppler/pincht — skin paddle not over perforator → unreliable cutaneous perfusion. - Pearls and Pitfalls - Mark saphenous vein course and avoid injuring it during anterior approach. - For best results in free transfer, plan to dissect the pedicle proximally to the profunda/proximal source (gives extra 1–2 cm of reach and larger vessel caliber). - For transverse TUG/TMG flap, orient the paddle posteriorly (captures more abundant posterior angiosome) and maintain a small anterior window over femoral triangle to avoid lymphatic injury. - Always perform pinch test to ensure donor skin can be closed primarily (skin paddle width generally ≤9 cm for primary closure). - Center the skin paddle over muscle; include the fascia and septum toward adductor longus to capture posterior perforators. - When planning a TUG, keep the proximal limb ~4 cm below the gluteal–groin crease to avoid dog‑ears. - Designing a skin paddle extending into the distal third of the muscle has a high risk distal tip necrosis. - Skin paddle vertical length should not exceed ~2/3 muscle length; width limited by pinch test (≤9 cm commonly for tension‑free closure). ### b) Discuss the vascular classification, vessel size and the path/location of the describe dominant (medial femoral circumflex) and minor pedicles and typical entry point (8–12 cm inferior to pubic tubercle), - Vascular classification - Mathes–Nahai type II muscle: one dominant pedicle + multiple minor segmental pedicles. - Dominant pedicle = branch of the medial femoral circumflex system (most common regional source: profunda femoris / deep femoral). In ≈10% the main pedicle may arise directly from the profunda femoris. - Dominant pedicle: anatomy & path - Entry point: enters deep (medial) surface of gracilis ~8–12 cm (commonly 8–10 cm) inferior to the pubic tubercle. - The pedicle is very reliable and passes deep to (posterior to) the adductor longus and superficial to adductor magnus; the anterior branch of the obturator nerve usually enters the muscle ~1–2 cm proximal to vessels. - Dominant pedicle: vessel size & length - Arterial diameter: mean ≈ 1–1.6 mm (ranges reported 0.5–2.0 mm depending on series). - Venous diameter (venae comitantes): mean ≈ 1.5–3 mm (often coalesce to a single larger vein near origin — useful for microanastomosis). - Pedicle length: commonly reported 6–8 cm (can gain more length by dissecting to profunda femoris). - Minor pedicles: anatomy & clinical notes - Proximal minor pedicle: present in ~85% as additional supply; origins variable — small branch of obturator, medial circumflex, or femoral system. Ligation usually tolerated. - Distal minor pedicles: multiple segmental vessels supplying mid/distal muscle — typically from superficial femoral artery; most distal can come from popliteal. These are small (diameter ~0.5 mm; length 2–3 cm). - Septocutaneous perforator: often the first minor pedicle distal to the dominant pedicle — can supply skin; basis for harvesting small perforator flaps without muscle. - Perforator distribution & angiosome - Most musculocutaneous perforators concentrated in proximal two‑thirds, highest density in proximal third. - Practical surgical implications - Free tissue transfer: dissect pedicle to its source (profunda/proximal medial circumflex) for maximum vessel diameter and length to facilitate microanastomosis — sometimes necessary because artery can be <1 mm at origin. - Extended dissection (beneath adductor longus) can add ~1–2 cm reach and often yields a larger single venous outflow (vena comitans confluence). - If pedicle length/diameter insufficient, consider taking saphenous vein as secondary venous outflow or revise recipient selection. - Avoid deep skeletonizing dissection around femoral triangle to minimize lymphedema risk — particularly with transverse designs.