|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| 3. The greater saphenous vein crosses the subcutaneous tissue along the medial inner thigh anterior to the anterior border of the gracilis muscle. This landmark is useful in dissection. The vein and its branches are a valuable source of vein grafts and should be protected during dissection.
4. The adductor magnus muscle lies directly below and behind the gracilis muscle in the proximal and middle thigh.
5. The sartorious muscle is a fleshy muscular mass that is directly adjacent and anterior to the gracilis muscle in the most distal portion of the thigh at the knee.
6. The semimembranosus muscle is seen as a broad fascial expanse adjacent and posterior to the gracilis muscle in the distal thigh.
7. The position of the dominant vascular pedicle to the gracilis muscle from the medial femoral circumflex vessels is approximately 10 to 12 cm inferior to the pubic tubercle. The vessels emerge from deep in the thigh medially beneath the adductor longus muscle and on top of the adductor magnus muscle.
8. The motor nerve to the gracilis muscle, a branch from the obturator nerve, is easily located approximately 2 cm proximal to the dominant vascular pedicle as it enters the muscle medially. It usually bifurcates as it reaches the vascular pedicle.
9. There are almost always two secondary pedicles, one at the midpoint and another in the distal portion of the muscle. A variable secondary pedicle located proximal to the dominant pedicle and motor nerve high in the medial thigh near the origin of the muscle is present in approximately 40% of cases.
The dissection is performed through a longitudinal incision in the medial thigh. The saphenous vein should always be anterior to the incision. Transverse branches from this vein are encountered in the fat crossing the incision.
The muscle is easily freed from the underlying adductor magnus. The dominant vascular pedicle is identified in its predicted location beneath the fascia separating the gracilis from the adductor longus. The pedicle dissection proceeds proximally on the vessels beneath the adductor longus into the depth of the thigh. Multiple short, perforating branches to the adductor muscles from the gracilis pedicle must be carefully ligated. This is the most difficult part of the gracilis dissection. Two to three groups of such branches are encountered before reaching the origin of the proximal pedicle.
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