**Region:** Upper Extremity # Quaba Flap ## Anatomy - Pedicle: medial circumflex femoral artery (or occasionally directly from the profunda femoris); accompanied by two venae comitantes of similar size. Pedicle enters the gracilis approximately 10 ± 2 cm below the pubic tubercle, measures 1–2 mm in diameter, and a pedicle length of approximately 6–8 cm can typically be obtained. A double main pedicle is a described variation. - Course: the dominant pedicle is typically found deep to the adductor longus. Prior to entering the muscle the main pedicle divides into 3–6 branches that continue to the skin either as musculocutaneous branches (through the muscle) or septocutaneous branches (via the intermuscular septum between adductor longus and gracilis). The vascular territory extends more posteriorly than anteriorly and also vertically in the region overlying the gracilis. - Perforator pattern: musculocutaneous perforators are more numerous, located more proximally, and are smaller caliber than the septocutaneous perforators. Perforators tend to orient transversely (which underlies the transverse paddle design). Linking vessels connect adjacent perforasomes; choke vessels exist between the main pedicle and surrounding cutaneous vasculature, particularly the superficial femoral artery. - Nerves: the anterior branch of the obturator nerve supplies gracilis (motor and cutaneous sensory fibers). This nerve lies deep to the vascular pedicle and is typically divided during harvest unless a functional muscle transfer is intended (i.e., for reinnervation). - Included tissues: muscle (gracilis) with overlying skin paddle and subcutaneous tissue; fascia over the adductor complex is encountered and preservation of fascial perforators is emphasized. Skin paddle size up to 12 × 25 cm can be harvested (especially with posterior extension); typical safe flap width for direct closure usually ≤ 9–10 cm. The gracilis is a thin, strap-like adductor (thin profile), so the flap is generally for small-to-medium volume needs. - Arc of rotation / common variants: the flap is commonly used as a free flap (transverse upper gracilis, TUG) but can be used as a pedicled flap for pelvic/genitoperineal reconstruction. Variations include posteriorly extended horizontal TUG, vertical-extension TUG (VUG, trilobed), diagonal upper gracilis (DUG), perforator-only gracilis flap (muscle-sparing), bilateral stacked TUGs, and combined TUG + profunda artery perforator designs. ## Dissection Steps 1. Positioning, markings, landmarks. - Patient positioning: most commonly lithotomy or supine with lower extremities frog‑legged for harvest. - Skin markings: horizontal crescent/ellipse centered over upper medial thigh. Superior border typically lies in the groin crease but should be no closer than 4 cm to the midline (introitus). Anterior margin must not cross the inguinal crease to avoid disrupting lymphatics. Posterior extent may be extended to the gluteal crease. Use a pinch test to determine inferior margin and flap width; usually limit width to 9–10 cm to allow direct closure. - Perforator planning: use handheld/continuous Doppler to identify perforators when planning the skin paddle; perforators of the medial circumflex femoral artery commonly arise most commonly ~10 cm distal to the pubic tubercle. 2. Plane (suprafascial/subfascial), perforator identification (handheld/IO Doppler). - Initial incision: make along the superior border and carry dissection down to muscle to determine vertical height and to identify the intermuscular septum between adductor longus and gracilis. - Anterior dissection: elevate the fascia overlying the adductor longus from anterior to posterior. Preserve fascial perforators to augment flap blood supply. Anteriorly, dissection may remain in the subcutaneous plane until reaching posterior to the femoral triangle. - Posterior/deeper dissection: posterior to the femoral triangle, carry the plane deeper to the adductor fascia and then down to the muscular fascia of semimembranosus if including it with the flap. - Perforator identification: locate musculocutaneous and septocutaneous perforators; musculocutaneous perforators are more numerous and more proximal. Confirm perforator location with Doppler and by direct visualization once fascia is opened. 3. Pedicle dissection: exposure, control, division; transfer/inset; perfusion checks. - Muscle handling: once the gracilis is encountered, decide whether to raise as a perforator flap (suprafascial / perforator dissection) or as a myocutaneous flap (include muscle). If perforators are confirmed within the planned skin territory, muscle can be spared/segmentally harvested. - Elevation direction: raise the flap distal → proximal. Perform segmental muscle harvest if needed and continue elevating to the proximal pedicle. - Pedicle exposure and skeletonization: the dominant pedicle lies under the adductor longus and should be exposed by elevating the surrounding fascia; skeletonize the pedicle proximally to its origin at the medial circumflex femoral artery or profunda femoris to obtain maximal length (typical available length 6–8 cm). - Vessel control and division: ligate and divide minor branches as encountered. The posterior branch of the greater saphenous vein (if encountered) is ligated and divided; the anterior branch of the saphenous vein should be spared when possible. The obturator nerve branch is usually divided unless preserving function. - Transfer/inset: the TUG is most commonly transferred as a free flap for breast reconstruction (small-to-medium volume) but can be pedicled for perineal/pelvic reconstruction. Flap may be coned to improve projection or stacked/combined to increase volume. - Perfusion checks: use Doppler and clinical assessment (capillary refill, color). The pinch test is used intraoperatively to confirm donor-site closure laxity and plan flap dimensions; include assessment of distal paddle perfusion especially when posteriorly extended. 4. Donor-site closure techniques. - Closure approach: donor-site closure follows principles of a medial thigh lift. Limit undermining to preserve lymphatics. Secure the superficial fascia of the lower wound edge to Colles' fascia superiorly to prevent scar migration and traction on the labia (helps avoid labial spreading). - Scar planning: place scar in the groin crease when possible to conceal it; avoid excessive tension by respecting the pinch-test width limits (typically ≤ 9–10 cm). ## Indications and Contraindications - Indications: - Primary: autologous breast reconstruction for small-to-medium volume breasts (TUG as free flap). - Secondary/other uses: head and neck reconstruction; upper and lower extremity reconstruction; pelvic/genitoperineal reconstruction (pedicled use). - When abdomen is contraindicated as donor site or when patients prefer to avoid abdominal/buttock/back scars. - Situations requiring a thin, strap-like tissue component (gracilis is thin). - When additional volume strategies are planned (stacked bilateral TUGs, combined flaps, posteriorly extended designs). - Size limits / volume considerations: - Limited harvest volume relative to abdominal flaps; a single TUG best for small-to-medium breasts. Skin paddle up to 12 × 25 cm has been reported with posterior extension, but practical flap width for direct closure usually ≤ 9–10 cm. - Sensate reconstruction: - The anterior branch of the obturator nerve carries motor and cutaneous sensory fibers; this nerve is typically divided unless a sensate or functional muscle transfer is planned. - Contraindications: - The source emphasizes limitations rather than explicit contraindications. Relative limitations include insufficient donor volume for larger reconstructions and risk of donor-site morbidities (thigh scar contracture, labial spreading). The distal third of the thigh should not be included in the flap because blood supply becomes progressively tenuous. - Avoid incisions crossing the inguinal crease anteriorly to reduce risk of iatrogenic lower-extremity lymphedema. ## Postoperative Care - The attached source does not provide a detailed, protocolized postoperative monitoring schedule or anesthesia/antithrombotic regimens. - Donor-site care notes from the source: - Close attention to donor-site closure similar to medial thigh lift; limit undermining to preserve lymphatics. - Superficial fascia of lower wound edge should be secured to Colles' fascia superiorly to minimize scar migration and traction on labia. - Any specific monitoring methods (implantable Doppler), warming protocols, venous thromboprophylaxis, drain management, mobilization timelines, or analgesic/diet recommendations are not specified in the provided text. ## Complications (rates & management) - Reported donor-site complications and flap-specific issues from the source: - Donor-site: scar contracture of the medial thigh scar and subsequent labial spreading/traction described as recognized complications. - Lymphedema risk: disruption of lymphatic channels if anterior flap margin crosses the inguinal crease can cause iatrogenic lower-extremity lymphedema. - Vascular territory limits: distal third of thigh has tenuous blood supply; distal tip necrosis risk increases if included. - Frequencies/rates: - The provided material does not report numeric complication rates or percent frequencies. - Management algorithms: - The source outlines preventive technical measures (avoid crossing inguinal crease, limit undermining, secure superficial fascia to Colles' fascia) but does not provide stepwise management algorithms (e.g., leeching, re-exploration thresholds, thrombolysis protocols). No specific re-exploration time windows or success rates are provided in the text. ## Key Clinical Pearls - Use Doppler preoperatively to localize medial circumflex femoral perforators, which most commonly arise ~10 cm distal to the pubic tubercle. - Mark the superior border in the groin crease but maintain ≥ 4 cm from the midline (introitus) to reduce risk of labial traction/lymphatic disruption. - Limit flap width to permit direct closure — usually no wider than 9–10 cm on pinch test. - Preserve fascial perforators by elevating the fascia over the adductor longus from anterior → posterior; this increases blood supply to the skin paddle. - Avoid dissecting/incising over the femoral triangle and avoid crossing the inguinal crease anteriorly to minimize lymphatic injury and risk of lymphedema. - Raise the flap distal → proximal, confirm perforators within the muscle before committing to a perforator-only harvest; musculocutaneous perforators are more numerous and more proximal than septocutaneous perforators. - Skeletonize the pedicle to the medial circumflex femoral/profunda origin to obtain maximal length (typical 6–8 cm) and identify that pedicle lies under the adductor longus. - Secure the superficial fascia of the lower wound edge to Colles' fascia during closure to prevent scar migration and traction on the labia.