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Medial Circumflex Femoral Artery Perforator (MCFAP) Flap

The MCFAP flap is a perforator-based muscle-sparing flap of the superior medial thigh, vascularized by musculocutaneous perforators arising from the gracilis pedicle of the medial circumflex femoral artery (MCFA). First described by Hallock (2003) as a local pedicled and free flap, it preserves the gracilis muscle in situ — perforators are dissected free as island branches.[1][2][3] Its signature niche is scrotal reconstruction after Fournier's gangrene, where Coskunfirat's series argued for its superiority based on thinness, mobility, muscle preservation, and primary donor closure in a single procedure.[17]

For the broader thigh-flap family see Gracilis (musculocutaneous variant TMG/TUG), Medial Thigh, and PMTP Propeller; for the genital-context summary see Scrotal Reconstruction Techniques.

Nomenclature​

NameEmphasis
MCFAP (Hallock 2003 / 2006)Formal perforator-flap nomenclature[1][2][3]
Gracilis perforator flapAnatomical relationship to the gracilis muscle[2][4]
Upper medial thigh perforator flapFreestyle suprafascial approach (Eom & Hong 2011)[5]
TMG / TUG flapMusculocutaneous variant — includes the gracilis muscle[6][7]

The MCFAP is a true perforator flap — only the musculocutaneous perforators from the gracilis pedicle are retained; the gracilis muscle is completely preserved, distinguishing it from the TMG / TUG.[1][2]

Vascular Anatomy​

Source — Medial Circumflex Femoral Artery (MCFA)​

  • Origin: from the deep femoral artery in 64.6% and the common femoral artery in 32.2% (meta-analysis of 4,351 limbs).[8]
  • MCFA + LFCA both originate from the DFA in 50%; the MCFA arises directly from the CFA in 31%.[9]
  • Mean distance from inguinal ligament to MCFA origin: 41.7 mm.[10]
  • Courses posteromedially deep to adductor longus and pectineus, supplying adductors, gracilis, and femoral head.[8][11]

Gracilis pedicle — the perforator source​

  • Principal pedicle enters gracilis ~8–10 cm below the pubic tubercle (mean 10 ± 1 cm from the ischiopubic attachment).[12][13]
  • Principal pedicle artery caliber: 2.5 ± 0.5 mm (CTA); 1.6 mm (cadaveric dominant).[12][13]
  • Dominant pedicle from DFA in 87% / MCFA in 13% (Magden); DFA 45% / "artery to the adductors" 46% (Macchi).[12][13]
  • Mean pedicle length: 5.7 cm (clinical MCFAP breast series, range 3–9); 6 cm (Eom/Hong freestyle); 6.7 ± 1.0 cm (TMG angiosome study).[5][14][15]
  • 1–4 distal accessory pedicles from the SFA (mean caliber 2.0 mm) also supply gracilis.[13]

Perforator characteristics (Peek 2009 cadaveric — 43 specimens)[4]​

  • Musculocutaneous perforators present in 100%; ≥ 0.5 mm in 93%.
  • Septocutaneous perforators present in 84%; ≥ 0.5 mm in 63%.
  • Most musculocutaneous perforators are concentrated in the anterior quarter of the muscle at the pedicle entry.
  • A constant intramuscular anastomosis between the main and second gracilis pedicles allows an extended perforator flap up to 27 cm.

Eom 2011 (40 clinical cases) — 90% of perforators originated from the MCFA; two-thirds septocutaneous, one-third musculocutaneous; mean artery diameter 0.8 mm; mean pedicle 6 cm.[5]

Cutaneous territory​

MCFAP / TMG angiosome 74.1 ± 32.1 cm² (Zaussinger head-to-head) — smaller than the PAP angiosome (98.5 cm²) but comparable to the infragluteal flap (77.2 cm²).[14] The gracilis perforator flap can be harvested up to 18 × 15 cm, extended to 27 cm with the intramuscular anastomosis.[4]

Flap Design and Surgical Technique​

A. Hallock true MCFAP flap​

Preoperative. Handheld Doppler maps perforator(s) ~8–10 cm below the pubic tubercle at the anterior border of gracilis; skin paddle designed transversely over the upper medial thigh centered on the perforator.

Elevation.

  1. Incise the posterior border; dissect posterior → anterior in the suprafascial or subfascial plane.
  2. Identify musculocutaneous perforator(s) emerging through gracilis.
  3. Intramuscular dissection — split muscle fibers in line, preserve the gracilis intact.
  4. Independently dissect the perforator from the gracilis muscular branches — the key muscle-preservation innovation.[1]
  5. Trace the pedicle to the MCFA for maximum length.

Conjoint flap option. The gracilis muscle can be separately included on its own branch — wraps and protects exposed vascular structures (e.g., infected femoral graft) while the cutaneous component closes the wound. Muscle and skin are independently mobilized on respective branches from the same source pedicle.[1]

Donor closure. Primary in all cases; scar concealed within the medial groin crease.[1][2]

B. Upper-medial-thigh freestyle (Eom & Hong)[5]​

  • Transverse skin paddle over the upper medial thigh.
  • Elevated entirely suprafascial — no deep fascial incision.
  • Any reliable pulsating perforator encountered is preserved as the pedicle.
  • Flap can be thinned to the recipient bed.
  • Superficial nerves and veins can be included for sensate / supercharged reconstruction.
  • Mean flap size 71.6 cm² (6.4 × 10.9 cm); 39/40 flaps survived (97.5%).

C. Free gracilis perforator flap (Peek)[4]​

  • Flap dimensions up to 18 × 15 cm; 27 cm with the intramuscular anastomosis.
  • "Pliable and thin" — ideal for resurfacing.
  • Gracilis fully preserved; 14/14 clinical flaps survived.

Clinical Applications​

1. Scrotal reconstruction after Fournier's gangrene — signature application​

Hallock 2006 — first case report of MCFAP for neoscrotum creation; muscle-sparing, functional / aesthetic scrotal coverage.[3]

Coskunfirat 2011 — the largest dedicated series, n = 7 post-Fournier's:[17]

ParameterValue
Perforators per flap1 (6 flaps); 2 (1 flap)
TransferTransposition or V-Y advancement
Donor closurePrimary in all
Major complications0
Minor complications2 wound dehiscences (healed conservatively)
Scrotal contourAcceptable in all

Authors argued for MCFAP superiority in scrotal reconstruction on the basis of mobility, thinness, muscle preservation, and primary donor closure — all in a single procedure. Across Alammar 2026 (619 patients, 625 flaps for Fournier's), medial-thigh-based flaps were among the most commonly utilized, with overall flap loss only 1.6%.[19]

2. Groin wound reconstruction (local pedicled flap)​

Hallock 2003 — 4 consecutive groin wounds (vascular intervention bed) with uncomplicated healing; arc of rotation extends throughout the groin and potentially to the lateral thigh; conjoint variant wraps muscle around exposed vessels.[1] Arvanitakis 2019 — 54 perforator-flap groin reconstructions (ALT, PMT, vDIEP), 100% flap survival; pedicled PMT perforator flap (sharing MCFA territory) recommended as first choice when PFA perforators are available.[20]

3. Partial breast reconstruction (free flap)​

Izumi 2013 — 15 patients with immediate free MCFAP for partial breast after BCS:[15]

ParameterValue
True perforator flaps3 (20%)
Muscle-sparing perforator flaps12 (80%)
Mean flap weight138.5 g (77–230 g)
Mean pedicle length5.7 cm (3.0–9.0)
Recipient vesselsSerratus (10), IMA (3), thoracodorsal (2)
Major complications0
Partial necrosis2 (small firm lesions)
Donor seroma / lymphedema0

Suited for partial breast given modest volume (138.5 g); insufficient for total breast reconstruction in most patients without stacking or augmentation.[15][21]

4. Lower-extremity reconstruction (free flap)​

Eom 2011 — upper-medial-thigh perforator flap (90% MCFA-based) for lower-extremity soft-tissue defects, n = 40, 39/40 survived (97.5%); thinned to bed; concealed donor scars closed primarily.[5]

5. Perineal and vulvoperineal reconstruction​

The MCFA territory underwrites the gracilis myocutaneous flap — the workhorse thigh-based flap for perineal reconstruction. The MCFAP perforator-only version preserves muscle for functional or staged future use.

  • Singh 2016 — gracilis perineal n = 40; recipient complications 40%, donor 12.5%; obesity OR 7.5, smoking OR 9.3.[22]
  • Jenkins 2023 — bilateral pedicled gracilis muscle ELAPE n = 50; 86% complete wound healing, 14% donor complications, 22% recipient.[23]
  • Kiiski 2019 — TMG flap pelvic exenteration n = 25; complications 65.4% with flap vs 84.6% without (p = 0.191); TMG favored because it does not interfere with stoma or weaken the abdominal wall.[24]

6. Head and neck — chimeric PAP-gracilis (SIMPLE)​

Yao — SIMPLE (Simultaneous Innervated Muscle and PAP from one Lower Extremity) chimeric harvest from the medial thigh donor for radical-parotidectomy defects needing both soft-tissue coverage and facial reanimation.[25]

TMG / TUG — Musculocutaneous Counterpart​

The musculocutaneous TMG variant includes the gracilis muscle and is the most widely studied member of this vascular family.

Weitgasser 2021 (largest series, 300 TMG free flaps, breast reconstruction, 30 yr):[7]

OutcomeRate
Mean flap weight320 g
Mean pedicle length70 mm
Flap loss19/300 (6.3%)
Cellulitis10/300 (3.3%)
Donor wound-healing disturbance28/300 (9.3%)

Schoeller 2008 — 111 patients, 154 TMG flaps; 3 complete losses (1.9%); transient posterior-thigh sensory deficit in 49/111 (44%).[6] Siegwart 2021 — 38 patients (59 TMG flaps); normal-to-slightly-diminished superficial sensation in 98.4% of thigh skin; strength / mobility unimpaired in > 80%; high PROMs.[26]

MCFAP vs TMG vs PAP​

ParameterMCFAP (true perforator)TMG / TUG (musculocutaneous)PAP (profunda perforator)
SourceMCFA → gracilis perforatorsMCFA → gracilis pedicleProfunda femoris → adductor magnus perforators
GracilisPreservedSacrificedPreserved
Mean pedicle length5.7–6.0 cm6.7–7.0 cm8.8–10.3 cm
Mean pedicle diameter (artery)0.8 mm2.9 mm external3.6 mm external
Angiosome area~74 cm²74.1 ± 32.1 cm²98.5 ± 26.7 cm²
Mean flap weight (breast)138.5 g295–320 g242 g
Flap survival97.5–100%93.7–98.1%97–100%
Vascular complicationsLow5.0%0.6% (p < 0.01 vs TUG)
Donor scarMedial groin creaseMedial groin creasePosterior medial thigh / gluteal crease
Sensory deficitMinimal44% transient posterior-thighMinimal
Primary indicationScrotal / groin reconstruction; partial breastBreast reconstruction; perinealBreast reconstruction; perineal
[1][2][5][6][7][14][15][17][26][38][39]

Key comparative findings. PAP has significantly fewer vascular complications than TUG (0.6% vs 5.0%, p < 0.01), a longer pedicle, and a larger angiosome — making it more versatile for free breast reconstruction.[14][38][39] The true MCFAP has the shortest pedicle (5.7–6.0 cm) and smallest vessel (0.8 mm), limiting its free-flap utility but making it ideal as a local pedicled flap for groin and scrotal reconstruction.[1][15] When PAP perforators are insufficient intraoperatively, the gracilis perforator is a reliable "escape" alternative with a perfusion area of 182 ± 42 cm² vs PAP 204 ± 90 cm².[40]

Combined and Chimeric Configurations​

  • TUGPAP (Ciudad 2019). TUG + PAP from the same medial-thigh donor on their respective pedicles — muscle for dead-space obliteration / functional reconstruction + fasciocutaneous PAP for external resurfacing; skin paddles up to 30 × 8 cm.[41]
  • Pedicled PAP + bilateral gracilis (Sharp 2021). Vaginal and pelvic-floor reconstruction after ELAPE; 6 patients (18 flaps), all flaps survived except 1 cm PAP loss; median time to heal 4 mo.[42]
  • Bilobed gracilis (Weinstein 2020). Second soft-tissue arm bilobed design for moderate-large perineal defects; n = 6 (5 oncologic, 1 Fournier's).[43]

Advantages​

  1. Complete gracilis preservation — leaves the muscle available for future functional transfer / perineal reconstruction.[1][2]
  2. Consistent pedicle location — gracilis pedicle is familiar to plastic surgeons.[1][21]
  3. Thin, pliable — matches scrotal contour and resurfacing needs.[4][17]
  4. Concealed donor scar in the medial groin crease.[1][2][15]
  5. Primary donor closure virtually always.[1][15][17]
  6. Minimal donor morbidity — no seroma / lymphedema in the MCFAP series.[15]
  7. Conjoint flap capability — muscle independently included for vascular protection.[1]
  8. Versatile — local pedicled (groin / scrotum / perineum) or free flap (breast / extremity).[1][2][5][15]

Limitations​

  1. Short pedicle (5.7–6.0 cm) — shortest among medial-thigh flaps; may need vein grafts as a free flap.[5][14][15]
  2. Small artery diameter (0.8 mm) — technically demanding anastomosis.[5]
  3. Limited volume (138.5 g MCFAP / 320 g TMG) — insufficient for total breast reconstruction without stacking.[7][15][21]
  4. Variable perforator anatomy — septocutaneous ≥ 0.5 mm in only 63%.[4]
  5. Intramuscular dissection required when only musculocutaneous perforators are available — added operative time / technical demand.[4]
  6. Limited MCFAP-specific evidence — most large series report the musculocutaneous TMG / TUG; the true perforator flap remains a small-series / case-report literature.[1][3][15][17]

See Also​

References​

1. Hallock GG. The medial circumflex femoral (gracilis) local perforator flap — a local medial groin perforator flap. Ann Plast Surg. 2003;51(5):460–464. doi:10.1097/01.SAP.0000096149.92205.44

2. Hallock GG. The gracilis (medial circumflex femoral) perforator flap: a medial groin free flap? Ann Plast Surg. 2003;51(6):623–626. doi:10.1097/01.SAP.0000067961.05231.11

3. Hallock GG. Scrotal reconstruction following Fournier gangrene using the medial circumflex femoral artery perforator flap. Ann Plast Surg. 2006;57(3):333–335. doi:10.1097/01.sap.0000218505.13232.1b

4. Peek A, Müller M, Ackermann G, Exner K, Baumeister S. The free gracilis perforator flap: anatomical study and clinical refinements of a new perforator flap. Plast Reconstr Surg. 2009;123(2):578–588. doi:10.1097/PRS.0b013e3181956519

5. Eom JS, Sun SH, Hong JP. Use of the upper medial thigh perforator flap (gracilis perforator flap) for lower extremity reconstruction. Plast Reconstr Surg. 2011;127(2):731–737. doi:10.1097/PRS.0b013e3181fed789

6. Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg. 2008;122(1):29–38. doi:10.1097/PRS.0b013e318177436c

7. Weitgasser L, Mahrhofer M, Schwaiger K, et al. Lessons learned from 30 years of transverse myocutaneous gracilis flap breast reconstruction: historical appraisal and review of the present literature and 300 cases. J Clin Med. 2021;10(16):3629. doi:10.3390/jcm10163629

8. Tomaszewski KA, Henry BM, Vikse J, et al. The origin of the medial circumflex femoral artery: a meta-analysis and proposal of a new classification system. PeerJ. 2016;4:e1726. doi:10.7717/peerj.1726

9. Zlotorowicz M, Czubak-Wrzosek M, Wrzosek P, Czubak J. The origin of the medial femoral circumflex artery, lateral femoral circumflex artery and obturator artery. Surg Radiol Anat. 2018;40(5):515–520. doi:10.1007/s00276-018-2012-6

10. Patel S, Lalani A, Bray J, et al. A novel clinically based classification system for the profunda femoris artery and the circumflex femoral arteries. Ann Vasc Surg. 2022;85:204–210. doi:10.1016/j.avsg.2022.03.001

11. Lazaro LE, Klinger CE, Sculco PK, Helfet DL, Lorich DG. The terminal branches of the medial femoral circumflex artery: the arterial supply of the femoral head. Bone Joint J. 2015;97-B(9):1204–1213. doi:10.1302/0301-620X.97B9.34704

12. Magden O, Tayfur V, Edizer M, Atabey A. Anatomy of gracilis muscle flap. J Craniofac Surg. 2010;21(6):1948–1950. doi:10.1097/SCS.0b013e3181f4ed81

13. Macchi V, Vigato E, Porzionato A, et al. The gracilis muscle and its use in clinical reconstruction: an anatomical, embryological, and radiological study. Clin Anat. 2008;21(7):696–704. doi:10.1002/ca.20685

14. Zaussinger M, Tinhofer IE, Hamscha U, et al. A head-to-head comparison of the vascular basis of the transverse myocutaneous gracilis, profunda artery perforator, and fasciocutaneous infragluteal flaps: an anatomical study. Plast Reconstr Surg. 2019;143(2):381–390. doi:10.1097/PRS.0000000000005276

15. Izumi K, Fujikawa M, Tashima H, et al. Immediate reconstruction using free medial circumflex femoral artery perforator flaps after breast-conserving surgery. J Plast Reconstr Aesthet Surg. 2013;66(11):1528–1533. doi:10.1016/j.bjps.2013.07.003

16. Heredero S, Falguera-Uceda MI, Sanjuan-Sanjuan A, Dean A, Solivera J. Chimeric profunda artery perforator–gracilis flap: a computed tomographic angiography study and case report. Microsurgery. 2021;41(3):250–257. doi:10.1002/micr.30694

17. Coskunfirat OK, Uslu A, Cinpolat A, Bektas G. Superiority of medial circumflex femoral artery perforator flap in scrotal reconstruction. Ann Plast Surg. 2011;67(5):526–530. doi:10.1097/SAP.0b013e318208ff00

19. Alammar A, Laing K, Somasundaram J, Wallace DL, Rogers AD. Flap reconstruction following Fournier's gangrene: a systematic review of techniques and outcomes. Burns. 2026;52(3):107888. doi:10.1016/j.burns.2026.107888

20. Arvanitakis M, Schlagnitweit P, Franchi A, et al. Groin defect reconstruction with perforator flaps: considerations after a retrospective single-center analysis of 54 consecutive cases. J Plast Reconstr Aesthet Surg. 2019;72(11):1795–1804. doi:10.1016/j.bjps.2019.05.052

21. Blough JT, Saint-Cyr MH. Modern approaches to alternative flap-based breast reconstruction: transverse upper gracilis flap. Clin Plast Surg. 2023;50(2):313–323. doi:10.1016/j.cps.2022.11.001

22. Singh M, Kinsley S, Huang A, et al. Gracilis flap reconstruction of the perineum: an outcomes analysis. J Am Coll Surg. 2016;223(4):602–610. doi:10.1016/j.jamcollsurg.2016.06.383

23. Jenkins E, Humphrey H, Finan C, et al. Long-term follow-up of bilateral gracilis reconstruction following extra-levator abdominoperineal excision. J Plast Reconstr Aesthet Surg. 2023;76:198–207. doi:10.1016/j.bjps.2022.10.025

24. Kiiski J, Räikkönen K, Vuento MH, et al. Transverse myocutaneous gracilis flap reconstruction is feasible after pelvic exenteration: 12-year surgical and oncological results. Eur J Surg Oncol. 2019;45(9):1632–1637. doi:10.1016/j.ejso.2019.04.021

25. Yao CMK, Jozaghi Y, Danker S, et al. The combined profunda artery perforator–gracilis flap for immediate facial reanimation and resurfacing of the radical parotidectomy defect. Microsurgery. 2023;43(4):309–315. doi:10.1002/micr.30997

26. Siegwart LC, Bolbos A, Haug VF, et al. Donor-site morbidity in unilateral and bilateral transverse musculocutaneous gracilis (TMG) flap breast reconstruction: sensation, function, aesthesis and patient-reported outcomes. J Clin Med. 2021;10(21):5066. doi:10.3390/jcm10215066

38. Hunter JE, Lardi AM, Dower DR, Farhadi J. Evolution from the TUG to PAP flap for breast reconstruction: comparison and refinements of technique. J Plast Reconstr Aesthet Surg. 2015;68(7):960–965. doi:10.1016/j.bjps.2015.03.011

39. Borrelli MR, Spake CSL, Rao V, et al. A systematic review and meta-analysis comparing the clinical outcomes of profunda artery perforator versus gracilis thigh flap as a second choice for autologous breast reconstruction. Ann Plast Surg. 2023;90(5S Suppl 3):S256–S267. doi:10.1097/SAP.0000000000003226

40. Winters H, Tielemans HJP, van Wegen M, et al. Alternative perforator options for insufficient profunda artery perforators: a case and anatomical study. Ann Plast Surg. 2020;84(6):679–683. doi:10.1097/SAP.0000000000002258

41. Ciudad P, Huang TC, Manrique OJ, et al. Expanding the applications of the combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for extensive defects. Microsurgery. 2019;39(4):316–325. doi:10.1002/micr.30413

42. Sharp O, Kapur S, Shaikh I, Rosich-Medina A, Haywood R. The combined use of pedicled profunda artery perforator and bilateral gracilis flaps for pelvic reconstruction: a cohort study. J Plast Reconstr Aesthet Surg. 2021;74(10):2654–2663. doi:10.1016/j.bjps.2021.03.038

43. Weinstein B, King KS, Triggs W, Harrington MA, Pribaz J. Bilobed gracilis flap: a novel alternative for pelvic and perineal reconstruction. Plast Reconstr Surg. 2020;145(1):231–234. doi:10.1097/PRS.0000000000006341