Background: The best secondary option for autologous breast reconstruction remains controversial. Limitations of the gracilis myocutaneous flap, including volume, skin paddle reliability, and donor morbidity, have been addressed by several modifications, hereby expanding its role in the decision tree for autologous breast reconstruction. This report documents the authors' experience with gracilis flap breast reconstruction. Methods: This is a retrospective case series of a prospectively maintained database of patients undergoing breast reconstruction with the free gracilis myocutaneous flap, including the transverse upper gracilis, vertical upper gracilis, and bilateral stacked vertical upper gracilis. Results: Twenty-two patients received gracilis myocutaneous flaps. Fourteen (63.6 percent) had previous attempted breast reconstructions. Indications for gracilis donor site were previous abdominoplasty/abdominal flap (n = 15, 68 percent), insufficient abdominal tissue (n = 6, 27 percent), and patient preference (n = 1, 5 percent). Six patients underwent bilateral reconstruction, and five underwent unilateral reconstruction with bilateral stacked gracilis flaps. The skin paddle was transverse in four flaps (12 percent) and vertical in 29 (88 percent). There was one flap loss (3 percent); there were two occurrences of fat necrosis (6 percent). There were two minor donor site dehiscences (6 percent), one infection (3 percent), and one seroma (3 percent). Conclusions: The free gracilis flap is a versatile option for patients undergoing breast reconstruction, particularly when the abdominal donor site is unavailable. The vertical pattern is the authors' preferred technique, as it avoids some of the problems associated with transverse patterns. Stacked flaps further expand the utility of this technique, which the authors regard as the best secondary option for autologous breast reconstruction.
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