The gracilis muscle free flap has been extensively described regarding dynamic return of finger function as a free tissue transfer. Its use as an innervated functional transfer to restore finger flexion after loss of extrinsic flexor muscles is well established. However, its use as coverage for small to medium sized defects in the hand is not well described in the literature. This muscle’s small width, constant pedicle, ease of harvest and inconspicuous donor site all combine to make it ideal for reconstruction of certain types of hand defects. These include predominantly palmar based defects such as those resulting from crush injuries in combination with single or multiple digit amputations, gunshot wounds, palmar full thickness burns, and tumor ablations. The length and width of the muscle make it ideal for longitudinally oriented defects of the palm, where it can extend from the distal forearm across the palm and even to the dorsum of the hand. Vascular connections can be made in the distal forearm away from any potential zone of injury. In addition, its use instead of a radial forearm flap, either free or reversed, preserves the radial blood supply to the hand. The gracilis is less bulky than other muscle flaps and even some fasciocutaneous flaps, such as the scapula or lateral arm in larger patients, although it cannot be used as a sensate flap.

4 cases are presented describing the use of this flap for coverage of hand and forearm defects after tumor ablation. They include reconstruction of soft tissue defects in the hand and forearm after resection of various types of sarcomas. The indications and rationale behind flap choice for the specific defects are analyzed. The technical aspects of flap harvest and microvascular transfer are reviewed.