Sir: Peek et al.1 must be commended on their sophisticated study in which they present their extensive clinical experience with the free gracilis perforator flap and share the results of their anatomical studies with us. As they note correctly, the concept of perforator flap–based reconstruction is becoming increasingly popular, with an increasing number of flaps reported. Despite the very detailed analysis presented, we would like to raise the question of whether perforator flap techniques need to be applied in the case of the gracilis muscle flap and discuss potential limitations of their study. The concept of perforator flap reconstruction emerged with the aim of reducing donor-site morbidity and has been applied successfully to multiple anatomical sites. The most common donor sites are the lower abdomen (deep inferior epigastric perforator flap), the back (thoracodorsal artery perforator flap), the buttocks (superficial gluteal artery perforators flap), and the thigh (anterolateral thigh flap). The common characteristic of all these flaps is a perforator that typically traverses a large muscle. Thus, functional preservation of these powerful muscles justifies the additional time spent in the operating room for intramuscular dissection of the vessel. This justification may not apply to the gracilis muscle, in particular, as its functional loss has been shown to be imperceptible.2 Peek et al.1 propose the extended gracilis perforator flap with incorporation of the main pedicle and its anastomosis with the minor pedicle for coverage of large defects. The functional and reconstructive benefit of this particular flap is, however, questionable for multiple reasons: The gracilis muscle is a type II muscle; thus, incorporating the main and minor pedicles in the skin flap leaves behind an innervated but potentially devascularized muscle. Incorporating both vascular pedicles in the extended gracilis perforator flap may further result in functional compromise, as the amount of scar that forms within the muscle correlates with the length of intramuscular dissection. To demonstrate functional preservation, intraoperative neural stimulation was used. This, however, does not reliably reflect the functional status of a muscle, as even denervated and devascularized muscles display contraction when stimulated intraoperatively. In our experience, incorporating a small muscle segment of the gracilis muscle when raising a musculocutaneous flap only moderately increases flap bulk which, however, resolves as the muscular component atrophies significantly over a short period of time. Thus, adding complexity to the dissection seems unnecessary to decrease bulk. As the authors point out correctly, the main concern with the gracilis myocutaneous flap is not the resulting functional impairment in hip adduction or knee flexion; instead, the aesthetic appearance of the scar is frequently a source of patient dissatisfaction.3 Thus, it is surprising that they use the traditional skin island design with longitudinal closure of the donor site.1 Orienting the skin paddle transversely has been demonstrated to likewise provide a large skin paddle but avoids the large longitudinal incision and places the incision in the inconspicuous groin area, which has been shown to result in a high level of patient satisfaction.4 We have incorporated the transverse incision even when raising a gracilis muscle flap (Figs. 1 and 2).5Fig. 1.: Postoperative appearance after raising a gracilis flap through a transverse incision. Note the inconspicuous scar located on the proximal thigh.Fig. 2.: Postoperative appearance after raising a gracilis flap through a transverse incision. Note the inconspicuous scar located on the proximal thigh.Arash Momeni, M.D. Gordon K. Lee, M.D. Department of Surgery Stanford University Medical Center Stanford, Calif. Holger Bannasch, M.D. Department of Plastic and Hand Surgery University of Freiburg Medical Center Freiburg, Germany