Gracilis Anatomy

Gracilis is the most superficial and most medial of the adductor group: a long, flat, strap-like muscle running the whole length of the medial thigh from the pubis to the tibia. It is the only adductor that crosses two joints, and that biarticular course is what gives it a knee action, flexion with internal rotation of the tibia, and its place as the middle tendon of the pes anserinus.

Why it matters. Its clinical importance has almost nothing to do with what it does in the leg. It is functionally expendable, because adductor longus, brevis and magnus dwarf it and its loss produces no measurable adduction deficit, and it has a single dominant proximal neurovascular pedicle with a long, accessible motor nerve. Those three facts have made it the most-transferred muscle in reconstructive surgery: a free tendon graft in the knee, hand and ankle; a pedicled flap for perineal, vaginal and ischial pressure-sore reconstruction; and a functioning free muscle transfer that restores elbow flexion after brachial plexus avulsion and a smile in facial paralysis.

The donor criteria. Examiners want the criteria, not just the name. A muscle is a good functioning free transfer donor when it satisfies all of the following, and gracilis satisfies every one:

• Expendable: its function is fully covered by synergists, the other adductors, so donor morbidity is negligible
• A single dominant pedicle, Mathes-Nahai type II: the muscle survives on one artery and vein, so one anastomosis restores the whole muscle
• A long, single, accessible motor nerve: the anterior division of the obturator nerve enters as a single trunk and can be dissected proximally for length, allowing a tension-free coaptation away from the zone of injury
• Long parallel fibre architecture with adequate excursion: enough to flex an elbow through a functional arc or to pull a commissure
• Adequate but not excessive bulk: thin enough to be split for facial reanimation without creating a bulky cheek, strong enough when whole to lift a forearm against gravity
• Reliable, constant anatomy: the pedicle position varies little, which matters enormously when the same operation must be reproducible

Origin. A thin, flat aponeurosis from the body and inferior ramus of the pubis and the adjacent ischiopubic ramus, immediately lateral to the symphysis. The origin is broad and membranous, only about 2-3 cm wide, and it lies superficial to adductor brevis and adductor magnus. The pubic tubercle is the reference point for every gracilis measurement; the muscle's leading edge is roughly a fingerbreadth lateral to it.

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Course. The muscle descends vertically along the medial thigh and narrows as it goes, broad proximally and a narrow strap by the mid-thigh. The belly ends at approximately the junction of the middle and distal thirds of the thigh and gives way to a long, thin, round-to-flat tendon, which passes behind the medial femoral condyle and then turns anteriorly around it to reach the tibia.

Insertion. The superomedial surface of the tibia, as the middle tendon of the pes anserinus, roughly 2-3 cm distal to the medial joint line and 1-2 cm medial to the tibial tuberosity. At the insertion gracilis lies proximal and anterior to semitendinosus, which is why it is the first tendon encountered when the sartorial fascia is opened. The layers at the pes, superficial to deep:

1. Sartorius fascia
2. Gracilis
3. Semitendinosus
4. Pes anserine bursa
5. Superficial MCL
6. Bone

Harvestable dimensions. Approximately 20-26 cm of usable tendon, shorter than semitendinosus. Total muscle length in an adult is typically 35-45 cm; for free transfer a segment of 12-18 cm is usually taken, tailored to the excursion required. A doubled gracilis is only roughly 5-6 mm in diameter, insufficient alone for an ACL, which is why it is combined with semitendinosus.

Nerve. The anterior division of the obturator nerve, root values L2, L3, L4, predominantly L2 and L3. The parent nerve arises from the lumbar plexus, descends along the medial border of psoas, crosses the pelvic brim behind the common iliac vessels, runs on the lateral pelvic wall and exits through the obturator canal at the superolateral corner of the obturator foramen, dividing into anterior and posterior divisions around adductor brevis.

The two divisions. The anterior division runs anterior to adductor brevis and posterior to pectineus and adductor longus, supplying gracilis, adductor longus and adductor brevis and giving cutaneous branches to the medial thigh. The posterior division runs posterior to adductor brevis, supplying obturator externus and the adductor part of adductor magnus. Adductor brevis is usually supplied by the anterior division and occasionally by the posterior; adductor magnus has dual innervation, obturator for the adductor part and the tibial division of the sciatic for the hamstring part; and pectineus is occasionally supplied by an accessory obturator nerve when one is present.

The motor entry point, the number that matters. The gracilis branch enters the muscle on its deep (lateral) surface, in the proximal third, typically 8-12 cm distal to the pubic tubercle, and characteristically slightly proximal to and deep to the vascular pedicle. It enters as a single trunk in most specimens and can be traced proximally within the adductor compartment to yield 6-10 cm of dissectible nerve. That length is the point: for a functioning free muscle transfer the coaptation must be tension-free and outside the zone of injury, and taking the nerve long, by dissecting proximally toward the obturator canal, is what makes that possible.

Intramuscular topography. Within the muscle the nerve divides into branches running proximally and distally, which permits the muscle to be split longitudinally into independently innervated segments. That is the anatomical basis for splitting a gracilis for facial reanimation and for double free muscle transfer.

Testing. Isolated testing is unreliable, because adductor longus, brevis and magnus dominate hip adduction. Gracilis is best inferred from the combination of adduction weakness with knee flexion weakness in a patient with intact hamstrings. Obturator neuropathy is covered under native pathology below.

The dominant pedicle. The adductor branch of the medial circumflex femoral artery, itself a branch of the profunda femoris artery, occasionally arising directly from the profunda or the femoral artery. It enters the deep (lateral) surface of the muscle approximately 8-10 cm distal to the pubic tubercle, that is, in the proximal third, and is approximately 6-8 cm long when dissected back to the profunda. The artery is 1.5-2.5 mm in calibre, with two venae comitantes typically 2-3 mm: comfortable calibres for microvascular anastomosis, and one reason the flap is so reliable.

Minor pedicles and the Mathes-Nahai type. One or two minor pedicles from the superficial femoral artery enter the middle and distal thirds of the muscle. Ligating them is part of the standard free harvest and does not compromise the muscle, because the dominant proximal pedicle perfuses the whole length. One dominant pedicle plus minor pedicles is Mathes-Nahai type II, the classification the examiner will ask for.

Skin territory. A skin paddle can be raised over the proximal third of the muscle, based on musculocutaneous perforators from the dominant pedicle, usually within 8-12 cm of the pubic tubercle. The distal skin over the muscle is not reliably perfused, a common cause of partial flap loss when an over-long skin paddle is designed, which is why a myocutaneous gracilis flap has a proximally sited, relatively small paddle and why a monitoring skin island is placed proximally.

After a tendon harvest. Tendon-only harvest divides the distal tendon and its small distal vessels; the muscle belly retains its dominant proximal pedicle and remains fully viable. Harvesting the tendon does not preclude later use of the muscle as a flap, although scarring makes the dissection harder, a point worth remembering when both procedures might be needed in the same patient.

In the medial thigh. Gracilis is the most superficial adductor, so it is the first muscle encountered on a medial thigh approach. Its relations, surface by surface:

• Superficial (medial): skin, subcutaneous fat, the great saphenous vein running just anterior to the muscle in the distal thigh, and the deep fascia
• Deep (lateral): adductor brevis and adductor magnus proximally; the sartorius crosses superficial to it anteriorly in the distal thigh
• Anterior: adductor longus proximally, then sartorius distally
• Posterior: adductor magnus and, further posteriorly, semimembranosus

At the knee. Behind the medial femoral condyle the tendon lies superficial to the superficial MCL before it turns anteriorly to the pes. Immediately superficial to it are the sartorial fascia and, within or deep to it, the infrapatellar branch of the saphenous nerve running transversely; immediately deep and posterior are the semitendinosus tendon and, beyond it, the medial head of gastrocnemius. Like semitendinosus, gracilis gives fascial expansions to the crural fascia and, less constantly, to the medial gastrocnemius fascia, and they must be released before stripping.

Actions. At the hip, adduction with a small contribution to flexion; its contribution to total adduction torque is small, roughly a tenth of the adductor group's capacity. At the knee, flexion and internal rotation of the flexed tibia. As a pes tendon it contributes with sartorius and semitendinosus to the medial dynamic sling, a secondary restraint to valgus and to tibial external rotation.

Architecture. Long, parallel fibres run almost the whole length of the muscle, giving a small physiological cross-sectional area but a large excursion of roughly 10-12 cm. The trade-off is excursion, not power: a muscle with long parallel fibres moves a long way but generates modest force, which is exactly the profile required for a functioning free transfer that must pull a tendon or a commissure through a distance. A pennate muscle such as adductor magnus is the opposite, high force and short excursion, and useless as a functioning transfer for elbow flexion.

Biarticular consequences. Gracilis cannot shorten maximally at both hip and knee simultaneously. Hip abduction with knee extension places it on maximal stretch, the position that provokes pain in adductor-related groin pain and the position in which its tendon is most easily palpated. Its knee flexion moment arm is small compared with the hamstrings, so isolated gracilis loss is functionally silent at the knee.

What removing it costs. Unilateral harvest leaves no measurable adduction deficit in the great majority of patients, because the other adductors compensate completely, and no measurable hip flexion or knee flexion deficit attributable to the gracilis alone. The reproducible deficit after a combined semitendinosus and gracilis harvest is knee flexion weakness in deep flexion, and that is largely attributable to the semitendinosus.

Excursion, tension and the transferred muscle. The commonest technical failure in a functioning free muscle transfer is setting the wrong resting length, not thrombosis. A muscle produces maximal active force at its optimal sarcomere length: set it too short and it has no force reserve, set it too long and it cannot shorten enough to complete the arc. The standard technique is to place marking sutures at fixed intervals, commonly 5 cm, along the muscle in situ at its natural resting length before dividing the pedicle, and after inset to re-tension the transferred muscle until those marks are the same distance apart, which restores the in-vivo sarcomere length reliably.

• For elbow flexion the muscle is inset with the elbow in a defined position, commonly around 90-100 degrees of flexion, and tensioned so the marks are restored; too little tension gives a weak flexion, too much gives a flexion contracture
• For facial reanimation the vector and tension are set against the contralateral resting commissure position, with deliberate slight over-correction because the transferred muscle will relax

Palpation at the groin. With the hip abducted and the knee extended, the gracilis stands out as the most posterior and most superficial cord at the medial thigh root, immediately posterior to adductor longus. Adductor longus is the more prominent, more anterior cord at the groin, and the two are easily distinguished by resisted adduction; mistaking one for the other is the pitfall.

Palpation at the knee. With the patient supine in the figure-of-four position (hip flexed, abducted and externally rotated, knee flexed) and the knee flexed against resistance, two cords appear beneath the sartorial fascia at the posteromedial knee. The anterior, thinner, flatter cord is the gracilis; the posterior, thicker, rounder cord is the semitendinosus. A palpable gap at the pes after harvest is expected and does not indicate a complication.

Named tests. The table gives the tests that bear on gracilis, and what a positive result does and does not localise.

Grading. Adduction strength is graded 0-5 but is insensitive to isolated gracilis loss. After a functioning free transfer, grading uses the British Medical Research Council motor scale (M0-M5) applied to the new function: for elbow flexion, M3, movement against gravity, is the minimum useful result and M4, against resistance, the goal. For facial reanimation the outcome is graded by symmetry of the smile at rest and on animation, commissure excursion in millimetres, and validated patient-reported measures.

Donor site. Seroma and haematoma in the medial thigh dead space are the commonest donor-site problem after a muscle harvest, reduced by careful haemostasis of the minor pedicles, quilting sutures and a closed suction drain. The groin is a moist, mobile, contaminated area, so infection and dehiscence rates are higher than at most donor sites. Adduction weakness is minimal and rarely measurable after unilateral harvest, because the remaining adductors are far larger; medial thigh numbness, when it occurs, is from injury to the cutaneous branches of the obturator nerve, not the saphenous nerve; a lymphocele if the dissection strays into the femoral triangle; and a scar along the medial thigh, which the two-incision technique with tunnelling improves cosmetically.

Neurological. Obturator nerve injury during proximal dissection puts all four adductors at risk if the main trunk rather than the gracilis branch is damaged. Injury to the infrapatellar branch of the saphenous nerve at the pes during a tendon harvest is the same problem as with semitendinosus: a vertical incision at the pes is the mechanism, and an oblique incision parallel to the nerve the prevention.

Free-transfer specific. Each has a mechanism, and most have a prevention already described:

• Flap failure from arterial or venous thrombosis, the standard microvascular risk, mitigated by careful anastomosis, appropriate recipient vessel choice and vigilant monitoring
• Pedicle injury from blind dissection of the deep surface in the proximal third, prevented by exposing the pedicle under direct vision before mobilising the muscle
• Failure of reinnervation, from a tense coaptation, a coaptation inside the zone of injury, an inadequate axon source, or too long a delay before transfer
• Incorrect tension, a flexion contracture if over-tensioned and a weak or absent excursion if under-tensioned, prevented by the in-situ marking sutures
• Bulkiness at the recipient site, particularly in facial reanimation, where a full-width gracilis produces an obviously fat cheek; take a narrow slip and consider secondary debulking
• Distal skin paddle necrosis from an over-long skin island
• Synkinesis or unnatural movement: the intercostal-neurotised muscle contracts with respiration and the masseteric-neurotised smile requires biting, and both need dedicated motor retraining

Related pages. The tendon it is harvested with: Semitendinosus Anatomy is the other half of the hamstring graft, and Hamstring Injuries with Proximal Hamstring Injuries and Proximal Hamstring Avulsion cover the donor group's own pathology.

As a Free Tendon Graft

Where it goes. The tendon is a standard free graft across the limb:

• ACL reconstruction: combined with semitendinosus as the classic four-strand hamstring graft; doubled gracilis alone is never adequate on its own
• MPFL reconstruction: the standard graft in most units. The native MPFL fails at around 200 N and a doubled gracilis is several times stronger, so graft strength is never the limiting factor; tunnel position and tension are
• MCL and posteromedial corner, posterolateral corner, PCL augmentation and multiligament reconstruction
• Hand and wrist ligament reconstruction where a longer graft than the palmaris longus is required
• Ankle and foot: lateral ligament, spring ligament and deltoid reconstruction; peroneal and tibialis posterior tendon reconstruction
• Acromioclavicular joint and coracoclavicular ligament reconstruction

Harvest. The same discipline as a semitendinosus harvest, with an easier strip:

1. Position supine, hip flexed, abducted and externally rotated, knee flexed 90 degrees, the figure-of-four
2. A 2-3 cm oblique incision over the pes, roughly 2-3 fingerbreadths distal to the medial joint line, oriented parallel to the infrapatellar branch of the saphenous nerve
3. Identify the sartorial fascia; the gracilis is the more proximal and thinner cord palpable through it, semitendinosus the more distal and thicker
4. Incise the fascia along the superior border of the gracilis, deliver the tendon with a right-angled clamp and whip-stitch it
5. Release the fascial expansions and the dense investing fascia on the deep surface with firm distal traction, sharply and under direct vision. Gracilis strips more easily than semitendinosus because it has fewer and less substantial accessory attachments, against the semitendinosus accessory insertion found in 77 per cent of cadaveric knees, but they still misdirect a stripper
6. Detach the tibial insertion subperiosteally, then advance the closed-loop stripper coaxially with steady traction; never force it
7. Prepare and measure the graft, and close the sartorial fascia

Sparing the gracilis. Increasingly favoured in young patients, using a quadrupled or quintupled semitendinosus alone, to preserve a future graft source and to reduce donor deficit. Regeneration cannot be assumed: in a two-year MRI study both the semitendinosus and gracilis had regenerated in only 35 per cent of patients, and donor muscle loss was greater where the tendon had not regenerated, another argument for sparing the gracilis where the semitendinosus alone will suffice.

Functioning Free Muscle Transfer

Brachial plexus reconstruction. The indication is restoration of elbow flexion, and in the Doi double free muscle technique also finger flexion and extension, after a complete (C5-T1) brachial plexus avulsion or in a late presentation where the native biceps has undergone irreversible motor endplate loss, generally beyond 12 months from injury, since a denervated muscle cannot be usefully reinnervated after that window. A nerve transfer requires a viable target muscle, and beyond about a year the biceps has fibrosed and no nerve transfer will work; a functioning free muscle transfer brings its own muscle, so the time limit no longer applies.

Donor nerves for neurotisation. The table sets the donors against each other by strength, spontaneity and the number of stages required.

Technique for elbow flexion. The recipient vessels are the thoracoacromial or thoracodorsal vessels, or the brachial artery with an end-to-side anastomosis and a venous anastomosis to a comitans or the cephalic vein. The muscle origin is secured to the clavicle, second rib or coracoid, because a fixed proximal anchor is essential or the muscle has nothing to pull against, and the tendon is woven into the biceps tendon or, in the Doi double transfer, routed further to the finger flexors. Tension is set by restoring the in-situ marking-suture intervals with the elbow flexed. First contraction appears at 3-6 months and plateau function at 18-24 months.

Facial reanimation. The indications are long-standing facial paralysis, generally beyond 18-24 months, congenital facial palsy including Möbius syndrome, and ablative surgery in which the facial nerve has been sacrificed. Two routes to the nerve supply are in use:

• Two-stage classical technique: stage one is a cross-face sural nerve graft from selected buccal branches of the contralateral, normal facial nerve, tunnelled across the upper lip and banked in the paralysed cheek; stage two, 9-12 months later once an advancing Tinel confirms axonal arrival, transfers a free gracilis segment and coapts it to the banked graft
• Single-stage alternative: free gracilis neurotised by the ipsilateral masseteric nerve, giving a stronger and faster but initially non-spontaneous smile. Some units perform a dual innervation technique combining both

The inset. Only a slip of gracilis, 3-4 cm wide, is taken, based on the dominant pedicle. It is anchored proximally to the zygomatic arch and preauricular fascia and distally to the modiolus and the orbicularis oris at the oral commissure, along the vector of the contralateral smile, typically 30-45 degrees above the horizontal. The recipient vessels are the facial artery and vein, or the superficial temporal vessels. First movement appears at 4-6 months, with maturation over 1-2 years and commissure excursion measured in millimetres as the outcome metric.

The pedicled gracilis flap. Based on the same dominant proximal pedicle, the muscle can be rotated locally for perineal, vaginal, anal sphincter (dynamic graciloplasty), ischial pressure sore and groin reconstruction. Its arc of rotation reaches the perineum, ischium and the contralateral groin, but not the knee; for knee and proximal tibial cover the gastrocnemius is the flap of choice.

Native Pathology

Adductor-related groin pain. Gracilis is part of the adductor group implicated in the Doha agreement category of adductor-related groin pain, pain at the adductor origin reproduced by resisted adduction. The gracilis-specific presentation is pain at the pubic origin that is worse with the knee extended, the biarticular stretch, and relieved by knee flexion. Gracilis syndrome, a described entity of chronic pain with a fibrous, stenosed musculotendinous origin that occasionally requires release, is uncommon and should be a diagnosis of exclusion. Management is load management, progressive adductor strengthening with the Copenhagen adduction exercise programme, and correction of the kicking or skating mechanics that provoke it.

Strain and avulsion. Musculotendinous strain of the gracilis occurs in kicking sports and gymnastics, typically at the proximal musculotendinous junction. Distal avulsion at the pes is very rare and is managed non-operatively. Apophyseal avulsion of the ischiopubic ramus in adolescents involves the gracilis and adductor origins; radiographs make the diagnosis and management is almost always non-operative.

Obturator neuropathy. It presents with medial thigh pain and paraesthesia, exercise-induced adductor pain and weakness of adduction. The settings:

• Sportsman's obturator neuropathy: entrapment of the anterior division by the fascia over adductor brevis, producing exercise-induced medial thigh pain and adductor weakness in Australian-rules footballers and other kicking athletes; treated by fascial release where conservative measures fail
• Obturator hernia: compression of the nerve in the obturator canal producing the Howship-Romberg sign, medial thigh and knee pain provoked by hip extension, abduction and internal rotation and relieved by flexion; classically an elderly, thin woman with bowel obstruction, and a surgical emergency
• Iatrogenic injury: pelvic and gynaecological surgery, acetabular fracture fixation through an anterior intrapelvic (modified Stoppa) approach, hip arthroscopy with excessive medial traction, and cement extrusion medially in acetabular arthroplasty

Pes anserine bursitis. The bursa lies deep to all three pes tendons and superficial to the superficial MCL, roughly 4-5 cm distal to the medial joint line, and gracilis is one of the tendons overlying it. Presentation, discriminators and management are as for semitendinosus; the point to hold is that the tenderness is distal and anterior to the joint line, not on it.

Structures at risk. Each is placed relative to a landmark, with the manoeuvre that protects it.

The adductor canal contents, the femoral artery and vein, the saphenous nerve and the nerve to vastus medialis, lie deep and anterior, protected by adductor longus and sartorius but reachable if the dissection strays anteriorly.

The medial approach to the thigh. The incision is longitudinal along the medial thigh, one fingerbreadth posterior to the palpable adductor longus, or, for a cosmetically superior free harvest, two short transverse incisions, proximal for the pedicle and nerve and distal for the tendon, with subcutaneous tunnelling between them. Incising the deep fascia exposes gracilis, the most superficial and posterior muscle in the field. The key interval is the plane between adductor longus anteriorly and gracilis posteriorly: retracting adductor longus anteriorly exposes adductor brevis and, on its anterior surface, the anterior division of the obturator nerve with the branch to gracilis, and this is the same interval used for obturator neurectomy. The pedicle is found on the deep surface of gracilis in the proximal third, entering from the direction of the profunda. The approach serves free and pedicled gracilis harvest, adductor tenotomy, obturator neurectomy, and access to the medial femur and the lesser trochanter.

Sequence of a free functioning gracilis harvest.

1. Mark the pubic tubercle, the medial femoral condyle and the line between them before draping; the muscle lies along this line
2. Proximal incision; expose gracilis and confirm its identity by tracing it distally, since adductor longus is anterior and does not cross the knee
3. Identify the pedicle on the deep surface in the proximal third, under direct vision, before mobilising the muscle
4. Identify the obturator branch just proximal and deep to the pedicle and dissect it proximally to maximum length
5. Distal incision at the pes; detach the tendon subperiosteally and deliver the muscle proximally
6. Place the marking sutures along the muscle in situ, at resting length, before dividing anything
7. Ligate the minor pedicles deliberately rather than avulsing them, because the resulting haematoma obscures the dissection; divide the muscle to the required length
8. Divide the pedicle last, immediately before transfer, to minimise ischaemia time
9. Inset at the recipient site with the marking sutures restored to their original intervals
10. Anastomose artery and vein, then perform the nerve coaptation without tension

Contraindications and cautions.

• Prior groin surgery or radiotherapy compromising the pedicle
• Significant peripheral vascular disease: a gracilis harvest is not dangerous to the limb, but the microvascular anastomosis may fail
• Bilateral harvest is possible and is done in the Doi double free muscle technique, but should not be undertaken casually
• Lymphoedema risk if the groin dissection strays into the femoral triangle lymphatics

Anatomical Variation Across Populations

• The gracilis pedicle position is remarkably constant across cadaveric series from European, North American, South Asian and East Asian populations, entering the proximal third of the muscle. Reported distances from the pubic tubercle vary with limb length rather than with population, which is why measuring from a bony landmark rather than in absolute centimetres is the safer habit.
• Muscle length and width scale with stature, and reported gracilis dimensions are consistently smaller in South and East Asian series. For facial reanimation this is an advantage — less debulking is required.
• Accessory obturator nerve, present in roughly one in ten to one in five people, supplies pectineus and occasionally contributes to the hip joint; it does not alter gracilis innervation but matters in obturator neurectomy.
• Pedicle origin variation: the adductor branch arises from the medial circumflex femoral artery in most limbs, but directly from the profunda femoris or the superficial femoral artery in a minority. Expect the variant rather than being surprised by it.

Differences in Described Technique

Practice Signals

• National ligament registries report hamstring autograft (semitendinosus with or without gracilis) as the most-used ACL graft worldwide, and demonstrate that graft diameter influences revision risk — the practical reason the gracilis is added to the semitendinosus.
• There is no international registry for functioning free muscle transfer; the evidence base is single-centre series and systematic reviews of them. The consistent signals are that younger patients, shorter denervation intervals and stronger motor donors give better results.
• For facial reanimation, comparative series consistently show that masseteric neurotisation gives greater commissure excursion while cross-face grafting gives more spontaneous, emotionally driven movement, which is why dual innervation has gained ground.

High- and Limited-Resource Practice

• Well-resourced settings: microvascular free transfer with intraoperative nerve stimulation, dual innervation techniques, and formal motor retraining programmes.
• Limited-resource settings: the pedicled gracilis flap requires no microsurgery and remains a highly effective option for perineal and ischial reconstruction. For the knee, the gracilis tendon graft needs only a stripper and sutures. Where microsurgical facilities are unavailable, regional muscle transfers (such as a Steindler flexorplasty or a pedicled latissimus transfer) remain the alternative for elbow flexion, and static slings remain an option for facial symmetry at rest.
• The universal point: gracilis is the donor of choice precisely because its anatomy is constant and its loss costs the patient nothing.