Relative Donor Site Morbidity and Complication Rates of Gracilis Myocutaneous and Muscle Flaps in Reconstructive Surgery.

The gracilis flap is a versatile muscle flap that can be utilized as a muscle only or myocutaneous flap for soft tissue coverage, as well as for reconstruction of facial animation or extremity function. Few studies have compared donor site complications of free and pedicled gracilis flaps, including the effect of skin paddle harvest on donor site morbidity. We performed a retrospective review of patients who underwent a free or pedicled gracilis flap at our institution from 2013-2023. Gracilis flaps were categorized as: pedicled gracilis muscle flaps used for vaginectomy in gender reaffirming surgery, free gracilis muscle flaps, and free gracilis myocutaneous flaps. Outcome variables were duration of drain placement and complications including seroma, hematoma, infection, dehiscence, and persistent numbness. We identified 128 gracilis flaps including 19 free myocutaneous flaps, 35 free muscle flaps, and 74 pedicled muscle flaps. Free myocutaneous flaps required longer drain placement as compared to free muscle flaps or pedicled flaps (13.6 vs 8.4 vs 7.4 days, respectively, p=0.002). Free myocutaneous flaps displayed a higher complication rate (36.8%) as compared to pedicled muscle flaps (10.8%), or free muscle flaps (11.4%, p=0.020). After adjusting for age, BMI, and ASA status, free myocutaneous flaps demonstrated higher odds of major donor site complication as compared to pedicled muscle flaps (OR 1.23, p<0.001), while free muscle flaps were not associated with increased odds of major complication (OR 1.08, p=0.117). Of the documented complications, the most common were surgical site infection (36.8%), hematoma (21.1%) and seroma (21.1%). The inclusion of a skin paddle during gracilis flap harvest is associated with increased duration of drain placement and donor site complications including surgical site infection, hematoma, and seroma. These factors should be carefully considered in the context of patients' reconstructive needs and other risk factors.