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Abstract

Sir: Momemi et al. question the value of the gracilis perforator flap. In their opinion, a complex dissection is not justified to save the gracilis muscle, which is functionally not relevant. We would like to answer first their technical comments and second the general need for the gracilis perforator flap. First, Momemi et al. mention concern about muscle viability after harvest of the extended gracilis perforator flap. The gracilis muscle has more than two pedicles: Macchi et al. report two to five pedicles,1 and Cavadas et al. report three to four pedicles.2 Shatari et al. always found some arteries at the origin of the muscle having a mean maximum diameter of 0.34 mm and suggested that they might be able to support the whole gracilis without supply from the main pedicle.3 Our clinical experience confirms more than two pedicles. Theoretically, it might therefore be possible that a nonvascularized muscle is left behind if two pedicles are incorporated. However, we did not encounter this in clinical practice, and most likely other pedicles supply the gracilis muscle. The argument of a functional impairment with the extended gracilis flap caused by an intramuscular dissection and scarring is rather surprising. Even with complete muscle harvest, a functional impairment is not likely; therefore, we do not believe that intramuscular dissection results in impairment. We performed an intraoperative neural stimulation of a proximal aspect of the intact obturator nerve. This resulted in gracilis muscle contraction and does—in our opinion—very well reflect a functional neuromuscular unit that we left behind after harvest of the perforator flap. Obviously, if only the muscle itself is stimulated, this does not show anything about an intact neuromuscular unit. The transverse incision for raising the gracilis muscle flap is definitely a technical improvement.4,5 Regarding a skin island, we have taken the gracilis muscle with a transverse, vertical, or combined skin island. The quality of the scar can vary significantly, and we have seen excellent and unacceptable scars with either skin flap. With a larger transverse flap, the scar commonly descends distally. With a smaller transverse flap, tissue bulk is limited. Schoeller et al.5 had to use bilateral gracilis flaps to reconstruct one breast in 15.3 percent of their reconstructions. Some indications therefore require the longitudinal flap design, which allows for a larger tissue bulk and which still leaves an acceptable scar on the inner thigh. Second, we agree that indications for the gracilis perforator flap are rare, and—according to the literature—harvest of the gracilis muscle does not cause any clinically relevant impairment. Saving the muscle is therefore not our primary indication, but the need for a thin fasciocutaneous flap is. The same applies to the anterolateral thigh flap. Harvesting a muscle cuff of the vastus lateralis has—to our knowledge—not shown any functional impairment. For many indications, perforator flaps have become state of the art, with better aesthetic results, decreased donor-site morbidity, and increased quality of life. Whereas the first perforator flaps—such as the deep inferior epigastric perforator flap—have revolutionized microsurgical reconstruction, more recent achievements such as the thoracodorsal artery perforator flap or superficial gluteal artery perforator flap have had less impact. Still, these flaps have enriched the family of perforator flaps, as does the gracilis perforator flap. Even if indications are rare, the gracilis perforator flap is a useful addition to the techniques available for reconstruction. Steffen P. Baumeister, M.D. Department of Plastic and Reconstructive Surgery Markus Krankenhaus Frankfurt, Germany Alberto Peek, M.D. Clinic of Plastic Surgery Holle & Peek Frankfurt, Germany