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Inner Thigh Flap

The Transverse Upper Gracilis (TUG) Flap

Anatomic considerations

Tissue:
A skin, fat and muscle flap. The skin paddle can be from 11 cm wide up to 25 centimeters long.
Innervation:
Branch from the obturator nerve to gracilis is not used unless a functional muscle transplant is needed.
Blood supply:
Gracilis vessels from the medial femoral circumflex system.
Artery:
Usually small caliber, from 1 to 2 mm.
Vein(s):
Two venae, one usually slightly larger than the artery.
Pedicle length:
6 to 8 centimeters long.

Anatomy

The cutaneous perforators of the gracilis muscle supply both the anterior and posterior inner thigh skin reliably. The transverse orientation of the flap allows for a large skin paddle, with some independence from the muscle below.

Anatomy of the Tug Flap

The perforator for the transverse upper gracilis flap travels through the gracilis muscle. The muscle is small and expendable, with no resultant hernia formation or bulging after removal.

A medial thigh muscle, the gracilis takes origin off the pubic symphysis, inferior pubic ramus and ischium then inserts distally into the medial condyle of the knee. The axis of the muscle can be defined by drawing a line from the ischium to the medial femoral condyle. The axis can be found alternatively by palpating the adductor longus medially with the thigh abducted. The gracilis axis is defined 2 to 3 finger breadths posterior to palpable edge of the adductor longus.

Anatomy of the Tug Flap

The perforator for the transverse upper gracilis flap travels through the gracilis muscle. The muscle is small and expendable, with no resultant hernia formation or bulging after removal.

The skin paddle of the flap is marked transversely, with the widest point centered over the gracilis muscle. Care must be taken not to resect too much skin, since closure can be difficult.

Tug Flap

The flap is harvested from the inner upper thigh, and has a crescent like shape.

The patient is placed in the supine position with the legs abducted and the knees bent. The anterior flap is elevated first.

The flap is elevated superficial to the muscular fascia, preserving or ligating the saphenous vein as necessary for flap harvest.

Flap Marking

The flap is marked in the crease of the inner thigh, just below the inguinal ligament and extending posteriorly in the inferior buttock crease.

Flap Elevation

The anterior flap is elevated, sparing the anterior branch of the saphenous vein. The posterior branch travels within the substance of the flap and is ligated and divided.

When the edge of the adductor longus medial aspect is reached, the muscular fascia is incised and the pedicle to the gracilis is identified under the adductor longus. When the pedicle is identified, the posterior flap can be elevated.

Isolating the Pedicle

The muscular fascia is incised anterior to the posterior edge of the adductor longus, and the pedicle to the gracilis is identified.

After the posterior flap is elevated, the proximal and distal muscle can be divided. The pedicle is traced to it's origin to gain length as necessary.

The Tug Flap is Isolated

Once the pedicle is identified and dissected free the posterior flap is elevated and the proximal and distal ends of the gracilis muscle are divided.

Closure of the would is done in layers over suction drains.