Gracilis musculotendinous free flap for lower extremity reconstruction after surgical removal of malignant tumors: A report of five cases

Background: Lower extremity reconstruction is challenging because of the need to restore form and function. Despite the many options for soft-tissue coverage, little research has addressed combined tendon and soft-tissue reconstitution. We present a series of patients undergoing lower extremity tendon reconstruction and wound coverage with a single free gracilis flap and its tendon. Methods: We studied five patients (age range, 51–81 years) undergoing lower limb reconstruction for defects involving soft tissue and tendon between 1998 and 2016 in the senior author's practice. Wounds (all in the foot and ankle region) were caused by sarcoma (n = 4) and Merkel cell carcinoma (n = 1) and ranged from 6.5–10 × 8–12 cm. Donor tendons, 2–18 cm long, were used to reconstruct the tibialis anterior, extensor hallucis longus, extensor digitorum longus, and extensor retinaculum. Patient characteristics and outcomes were reviewed retrospectively. Results: Reconstructions used a gracilis muscle free flap and its tendon. Flap sizes ranged 5–6.5 × 11–14 cm. Complications were one case of cellulitis and one case of reoperation for flap thinning and tenolysis. All patients had at least 7 months of follow-up (mean: 37 months; range: 7–104 months). At latest follow-up, all patients were ambulatory. On average, patients resumed assisted ambulation 27 days postoperatively and unassisted ambulation 62 days postoperatively. Conclusions: For complex wounds with soft-tissue and tendinous defects, the gracilis muscle free flap may be a reconstructive option. We recommend it be considered as a single-donor incision option for lower extremity reconstruction.