Introduction and aims: The gracilis muscle is a frequently applied and in several variations described flap either free or pedicled in reconstructive surgery. Increasing experience with that particular tissue portion allowed us to develop several modifications and thus allowed the muscle to be used for more and more indications (breast reconstruction, poland's syndrome, filler material in the face, genital reconstruction, functional transfer, defect coverage). Material and Methods: We are analysing retrospectively our consecutive series of 160 gracilis flaps (153 free versus 7 pedicled) from 01/2001 – 12/2004, describe new technical details, such as the in two halves split free gracilis, the distally based gracilis, and the different possibilities for arterial (via the branch to the adductor magnus muscle) or venous extra anastomosis and flow through designs. The possibilities of endoscopically assisted flap harvest are shown as well as the harvest through the aesthetically pleasing groin crease incision line, and its value for emergency free tissue transfer will be highlighted. Further application for forehead and face reconstructions by radical trimming and thinning of the muscle are introduced. The skin island orientated in the transverse fashion seems in selected cases also ideal for immediate skin sparing mastectomy reconstructions even for larger breasts in which a bilateral gracilis is chosen. Results: The functional outcome as well as the aesthetical results were in more then 88% highly pleasing. The total failure rate in the free flap series (n=153) was less then 3% and the microsurgical revision rate less than 16%. Conclusion: Its distinctive advantages let the gracilis flap become the first choice candidate for free tissue transfer in our hands for defect coverage and some new indications. It is unclear why the gracilis has such a low acceptances among the plastic surgical colleagues and this paper should help to promote the gracilis popularity.

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