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Functional Free Muscle Transfer For Upper Extremity Reconstruction Stevanovic2014 +++
Functional Free Muscle Transfer For Upper Extremity Reconstruction Stevanovic2014 +++
Functional Free Muscle Transfer For Upper Extremity Reconstruction Stevanovic2014 +++
F
unctional losses in the upper extremity functional free muscle transfer was first reported
have traditionally been reconstructed with in 1976 at several centers: Harii and colleagues
tendon transfers and functional rotational used a free gracilis muscle for facial reanima-
muscle transfers. More recently, nerve trans- tion3; surgeons at Sixth People’s Hospital in the
fers have expanded the choice of reconstruc- People’s Republic of China used pectoralis major
tive methods available. When presented with muscle to restore finger flexion in a patient with
patients who are not candidates for those pro- Volkmann ischemic contracture4; and Ikuta et al.
cedures, because of late presentation or absence also used the pectoralis major muscle for the same
of local donor muscles or nerves, functional indication. Manktelow5 and Zuker6 popularized
free muscle transfer is the best means of restor-
use of functional free muscle transfer in North
ing function in an otherwise nonreconstructible
America for upper extremity reconstruction.5
limb. Common scenarios where there is a role
for functional free muscle transfer include late Improvements in microsurgical equipment, mag-
reconstruction of brachial plexus injuries, trau- nification, and technique led to the expansion of
matic muscle loss, Volkmann ischemic contrac- indications for functional free muscle transfer.
ture, loss resulting from oncologic resection, and Japanese surgeons have been at the forefront of
congenital absence of motor function as seen in application of these techniques to restore upper
arthrogryposis.
Disclosure: The authors have no financial interest
HISTORICAL PERSPECTIVE to declare in relation to the content of this article.
Functional restoration using a transferred
muscle was first investigated in a canine model
by Tamai et al. in 1970.1,2 Clinical application of Supplemental digital content is available for
this article. Direct URL citations appear in the
From the Department of Orthopedics, University of Southern text; simply type the URL address into any Web
California Keck School of Medicine. browser to access this content. Clickable links
Received for publication August 26, 2013; accepted to the material are provided in the HTML text
November 27, 2013. of this article on the Journal’s Web site (www.
Copyright © 2014 by the American Society of Plastic Surgeons PRSJournal.com).
DOI: 10.1097/PRS.0000000000000405
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Plastic and Reconstructive Surgery • August 2014
extremity function, including the first applica- are contraindications to this procedure. Another
tion of a single functional free muscle transfer to increasingly common problem is patient obesity.
restore two separate functions, and Doi and col- Even a young healthy patient with available donor
leagues’ use of a double functional free muscle muscles will not gain sufficient power in a trans-
transfer to restore multiple functions.7–13 ferred muscle to overcome the weight of a very
heavy limb, especially for shoulder abduction and
PATIENT SELECTION elbow flexion (Table 1).
One of the most important factors leading to
a successful operation is a motivated patient who PRINCIPLES OF FUNCTIONAL FREE
has appropriate expectations from surgery and MUSCLE TRANSFER
has demonstrated compliance with medical care.
The patient must be committed to a prolonged Muscle Physiology
rehabilitation program that may be complex and Skeletal muscle is a unique biological tissue
time consuming. capable of transforming chemical into mechani-
Age is the next critical component of successful cal energy. When considering a functional free
transfers. Successful recovery of motor function is muscle transfer, properties of muscle physiology,
better in children. However, later results in children including force and excursion, must be consid-
are compromised by ongoing growth. The trans- ered to achieve sufficient functional benefit at
ferred muscle may not grow at the same rate as the the recipient site.
bony skeleton, potentially leading to recurrent con- The principal force-generating components
tracture across joints. This may be counteracted with of skeletal muscle are myosin and actin molecules,
ongoing night-time splinting until the child reaches known as thick and thin filaments, respectively.
skeletal maturity. In the authors’ experience, the Myofilaments are arranged in interdigitating
most successful functional free muscle transfers matrices that slide across each other to produce
have been in patients younger than 45 years. Other a muscle contraction. The force generated by a
authors have reported excellent outcomes in those muscle is in direct relationship to the number of
as old as 65 years and recommend 70 years as their filaments and the overlap of the actin and myosin
cutoff for functional free muscle transfer.14,15 proteins.16
Medical conditions such as diabetes, autoim- Muscle resting length is defined as the length
mune diseases, severe chronic viral infections, of the muscle in its most physiologically elon-
heart or peripheral vascular disease, and smok- gated position. In this position, there is maximal
ing can all compromise microcirculation and overlap of the actin and myosin fibers. This rep-
reinnervation of the transplanted muscle and resents the peak of the muscle length-tension
curve. Overstretching of a transferred muscle
decreases the amount of overlap between the
Table 2. Skeletal Muscle Architecture* actin and myosin fibers, resulting in a weakened
Pennate Parallel muscle contraction. Similarly, undertensioning of
Muscle types Unipennate, Strap (gracilis),
the transferred muscle also results in decreased
bipennate, fusiform filament overlap and suboptimal muscle force
or multipennate (gastrocnemius), production. Intraoperative restoration of muscle
(e.g., rectus fan (latissimus)
femoris) resting length is of critical importance in achiev-
Typical Greater cross- Longer fiber length = ing maximal function of the transplanted muscle.
characteristics sectional area; greater excursion Muscle force can be calculated based on the
higher mass =
greater force physiologic cross-sectional area of the muscle, with
*From Lieber RL, Friden J. Clinical significance of skeletal muscle a larger cross-sectional area representing a greater
architecture. Clin Orthop Relat Res. 2001;383:140–151. number of myofilaments. Muscle mass can be used
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Volume 134, Number 2 • Upper Extremity Reconstruction
Table 3. Technique Summary for Anterior Deltoid, Biceps, and Triceps Reconstruction
Shoulder Flexion Elbow Flexion Elbow Extension
(Anterior Deltoid) (Fig. 1) (Fig. 2; Video 1) (Fig. 3)
Donor muscle options • Gracilis* • Gracilis* • Gracilis*
• Tensor fasciae latae • Latissimus dorsi • Latissimus dorsi
• Latissimus dorsi • Tensor fasciae latae • Tensor fasciae latae
• Medial gastrocnemius • Medial gastrocnemius
New origin • Lateral half of the clavicle • Distal half of clavicle • Lateral third of the
to the acromion (gracilis) scapular spine
• Coracoid (latissimus) • Posterior acromion
New insertion • Anatomical insertion • Distal biceps tendon • Remnant of triceps
of the deltoid on the hu- • Bone at radial tuberosity tendon
merus • Bone at ulna—level of • Directly to
tuberosity olecranon
Recipient vessels (options) Artery: Artery: Artery:
• Thoracoacromial • Thoracoacromial • Profunda brachii
Vein: • Thoracodorsal • Thoracodorsal
• Venae comitantes Vein: Vein:
• Tributary of cephalic • Venae comitantes • Venae comitantes
• Cephalic vein branch • Vein graft to cephalic
• Transposed cephalic vein
Recipient nerve (options) • Spinal accessory nerve • Musculocutaneous • Branches of radial
(terminal branch) nerve nerve
• Spinal accessory nerve • Nerve graft to intercostals
(terminal branch) • Terminal branch of
• Intercostal nerves spinal accessory nerve
• Medial pectoral nerve (not with or without graft
preferred because of size)
Position for restoration • Arm in hyperextension at • Full elbow extension • Full elbow flexion
of resting length† the shoulder
Postoperatively • Arm immobilized in flexion • Immobilization at 90 • Immobilization in
and abduction for 8 wk degrees of elbow full extension
• Gunslinger or customized flexion for 8 wk for 8 wk
brace
• Alternatively, a thoracic cast
with arm spica and struts can
be used to control arm position
Special considerations • The latissimus muscle
origin does not have
a tendinous portion;
securing the muscle to
the biceps tendon can
be difficult; the muscle
can be wrapped around
the tendon if present;
alternatively, the muscle
can be anchored to the
medial ulna
*Preferred muscles.
†Resting length is established in this position; however, the repair is performed with the muscle not on tension.
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Plastic and Reconstructive Surgery • August 2014
Table 4. Technique Summary for Finger Extension, Finger Flexion, and Thenar Reconstruction
Finger Extension Finger Flexion Thenar Reconstruction
(Fig. 4) (Figs. 5–9; Video 2) (Fig. 10)
Donor muscle options • Gracilis* • Gracilis* • Distal two slips of serratus
• Latissimus dorsi • Latissimus dorsi anterior*
• Tensor fasciae latae • Tensor fasciae latae • Gracilis (portion using a
single neuromuscular terri-
tory only)*
• Abductor hallucis muscle
New origin • Lateral epicondyle and • Medial epicondyle of hu- • Ulnar side of fifth metacarpal
common extensor fascia merus and flexor-pronator (superficial to hypothenar
fascia muscles)
New insertion • Tendons of EDC; EPL can • Tendons of flexor • Distal third of first metacar-
also be included digitorum profundus at pal and proximal third of
the distal forearm the proximal phalanx (radial
side)
Recipient vessels (options) Artery: Artery: Artery:
• Radial artery • Anterior interosseous • Radial artery (end-to-side)
• Branch of radial artery • Radial artery (end-to-end) Vein:
Vein: • Ulnar artery (end-to-side) • Venae comitantes
• Venae comitantes • Brachial artery (end-to-side)
Vein:
• Venae comitantes
• Local superficial veins to aug-
ment drainage of skin flap
Recipient nerve (options) • Posterior interosseous nerve • Anterior interosseous • Median recurrent nerve
• Motor branch to pronator • Median nerve motor
teres fascicles†
Position for restoration • Full elbow extension • Elbow, wrist, and fingers in • Full thumb planar abduction
of resting length‡ • Wrist flexion at 20–30 full extension and MCP joint extension
degrees
• Finger metacarpophalangeal
joint flexion at 90 degrees
Postoperatively • Immobilization for 6 wk • Immobilization for 4–5 wk • Immobilization in palmar
with elbow at 90 degrees of • Elbow at 90 degrees of abduction and MCP joint
flexion, wrist at 30 degrees flexion, wrist at 30 degrees flexion
of extension, and full of flexion, MCP joints at 90 for 5–6 wk
MCP extension degrees of flexion
• IP joints can be left free • Thumb in palmar abduction
and IP joint flexion
Special considerations • EDC tendons are sewn • The gracilis muscle can • Some authors have used the
together using a side-to-side be separated into separate transverse carpal ligament
technique neuromuscular territories to as the neomuscle origin; we
• Pulvertaft weave is used to provide independent thumb find this too short a distance
secure transferred muscle flexion; this requires two to adequately reestablish
to EDC separate donor fascicles muscle resting length and
• EPL reconstruction • If thumb flexion is restored provide sufficient abduction
• Included in functional as a single unit, the FPL power
transfer tendon must not be as tight • Median motor branch must
• Rerouted to radial side of as the finger flexors, to that be functional for this transfer
first metacarpal finger flexion occurs before
• Pulley reconstruction to the thumb flexes
provide abduction moment
and prevent bowstringing
• Separately secured to
transferred muscle along the
radial side
EDC, extensor digitorum communis; EPL, extensor pollicis longus; FPL, flexor pollicis longus; MCP, metacarpophalangeal; IP, interphalangeal.
*Preferred muscles.
†Separate fascicles should be used for independent FPL reconstruction when necessary.
‡Resting length is established in this position; however, the repair is performed with the muscle not on tension.
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Volume 134, Number 2 • Upper Extremity Reconstruction
Fig. 1. Diagrammatic representation of the gracilis muscle used Fig. 3. Diagrammatic representation of the gracilis muscle used
for anterior deltoid reconstruction. (Copyright © Timothy C. for triceps reconstruction for elbow extension. (Copyright ©
Hengst, printed with permission.) Timothy C. Hengst, printed with permission.)
Fig. 2. (Left) Diagrammatic representation of the gracilis muscle used for biceps reconstruction. This 19-year-
old college student sustained an upper trunk injury to the brachial plexus. He presented 2 years after injury
with minimal shoulder girdle function and absent elbow flexion. Hand function was normal. He under-
went a functional free muscle transfer using the ipsilateral gracilis muscle. (Copyright © Timothy C. Hengst,
printed with permission. Previously published by Slutsky D. The Art of Microsurgical Hand Reconstruction.
New York: Thieme; 2013.) (Right) Elbow flexion 18 months after functional free muscle transfer, rated as
Medical Research Council grade 4 flexion strength. (Authors retain copyright.)
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The muscle is secured to its new origin site a compartment-like syndrome can occur when the
using nonabsorbable suture. The origin may be reperfused muscle swells postoperatively.
secured to periosteum and surrounding fascia, Details of site-specific reconstruction are
bone tunnels, or suture anchors as needed. The listed in Tables 3 and 4 ( Figs. 1 through 10).
new muscle origin should be spread out as much as (See Video, Supplemental Digital Content 1,
possible to match the width of the old origin. The which demonstrates the results of free func-
muscle is stretched to restore its resting length, tional gracilis transfer 14 months after the pro-
and the distal tenorrhaphy is performed. When cedure. This 14-year-old boy had a traumatic
possible, a Pulvertaft weave provides a strong global brachial plexus palsy at age 6. He had
tenorrhaphy site. The neurorrhaphy is completed undergone previous wrist fusion. At age 14, he
last, placing the neurorrhaphy site as close as pos- underwent free functional gracilis transfer to
sible to the transplanted muscle. restore elbow flexion, http://links.lww.com/PRS/
Wound closure should be performed with B49. See Video, Supplemental Digital Content
attention to avoiding compression of the vascular 2, which demonstrates the results shown at 2
pedicles. Tight skin closure should be avoided, as years from functional free muscle transfer. The
patient is a 22-year-old man who had prolonged
compression to his right forearm resulting in
partial necrosis of volar forearm skin and all
of the flexor compartment muscles. He under-
went functional free muscle transfer to restore
finger flexion and extensor carpi radialis longus
tendon transfer to restore independent thumb
function, http://links.lww.com/PRS/B50.)
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Volume 134, Number 2 • Upper Extremity Reconstruction
Fig. 10. Diagrammatic representation of the distal two slips of the serratus anterior muscle used for thenar muscle reconstruc-
tion for thumb opposition. (Copyright © Timothy C. Hengst, printed with permission. Previously published by Slutsky D. The Art of
Microsurgical Hand Reconstruction. New York: Thieme; 2013.)
should have adequate fascia and tendon to free muscle transfer in the upper extremity
support secure attachments to the new origin (Table 5).
and insertion sites. Several muscles meet these The donor muscle should have adequate
criteria and are suitable for use as functional power to support the planned function. It is
difficult to determine the exact force of a mus-
free muscles. These include the gracilis, latissi-
cle. Estimates based on cross-sectional area or
mus dorsi, tensor fasciae latae, rectus femoris, weight give a rough estimate of force potential
medial gastrocnemius, serratus anterior, pecto- of a muscle. Excursion can also be difficult to
ralis major, and combined gracilis with adduc- assess. Six to 7 cm of excursion is required to
tor longus. Of these muscles, the gracilis has restore adequate elbow and finger flexion. The
proved to be the workhorse of most functional donor muscle should be innervated by a single
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Plastic and Reconstructive Surgery • August 2014
Fig. 11. (Above) Necrosis of the median nerve. Although the nerve was
not constricted in this case of Volkmann contracture, the nerve was not
functioning in the preoperative examination. The whitish area of nerve
was sclerotic and dysvascular over a 7-cm section. (Below) Median nerve
reconstruction using sural nerve autograft. The obturator nerve of the
gracilis muscle was coapted to the anterior interosseous nerve after his-
tologic analysis demonstrated normal fascicles in the area of nerve repair.
(Authors retain copyright.)
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Volume 134, Number 2 • Upper Extremity Reconstruction
Fig. 12. The gracilis muscle is harvested with fascia of the thigh. The subcutaneous
tissue is elevated widely above the level of the fascia both anteriorly and posteriorly.
Anteriorly, the fascia is incised along the posterior border of the sartorius, taking a wide
harvest of fascia anterior to the gracilis muscle. Posteriorly, the fascia is less robust and
can be incised along the posterior border of the gracilis. (Above) Diagrammatic repre-
sentation of harvesting of the gracilis muscle. The vascular pedicle arises from the femo-
ral artery. The obturator nerve enters the muscle just proximal to the vascular pedicle.
(Below) Harvested gracilis muscle ensheathed in fascia. (Copyright © Timothy C. Hengst,
printed with permission. Previously published in Seal A, Stevanovic M. Free functional
muscle transfer for the upper extremity. Clin Plast Surg. 2011;38:561–575.)
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Plastic and Reconstructive Surgery • August 2014
nerve, and only muscles with Mathes and Nahai and insertion sites, and, very importantly, to limit
types I, II, and V vascular supply can be consid- the need for skin grafts directly over the trans-
ered for transplantation.20,21 The location of the ferred muscle belly or tendon.
donor muscle neurovascular pedicle should be Sensory deficits can limit the usefulness of
considered to optimize location relative to the functional reconstruction. Every effort should be
anticipated recipient vessels. made to restore protective sensation to critical
areas of the hand. Patients with brachial plexus
PREOPERATIVE PLANNING palsy without sensation may benefit from sensory
reconstruction of the median nerve using sen-
Preoperative planning is a critical compo-
sory fascicles of the intercostal nerves. Patients
nent of successful functional free muscle trans-
fer. A detailed physical examination should with Volkmann contracture without sensation
assess passive range of motion across the joint should undergo primary grafting of the median
for the planned transfer, functioning motor nerve at the time of functional reconstruction
and sensory nerves proximal and distal to the (Fig. 11).
area of deficit, vascular assessment of the limb
including in-office Doppler examination when DONOR MUSCLE DISSECTION
indicated, and evaluation of the soft-tissue The two most commonly used muscles for
envelope at the reconstructive site. Also impor- upper extremity reconstruction are the gracilis
tant is an evaluation of the entire previous zone muscle and the latissimus dorsi muscle.
of injury, as this may affect areas of planned
vascular anastomosis and neurorrhaphy. The Gracilis
planned donor site should be examined to con-
firm there are no previous injuries or scarring The gracilis muscle is usually harvested with
at the donor site and to confirm function of the the patient supine in a frogleg position. Based on
donor muscle. Selection of the ipsilateral ver- the position of the recipient vessels, the contra-
sus contralateral donor muscle will depend on lateral gracilis is preferred for anterior deltoid,
the location of the donor and recipient nerves biceps, and finger extensor reconstruction. The
and vessels. ipsilateral gracilis is preferred for triceps recon-
Electromyography is not always helpful or struction and thenar reconstruction. Either con-
indicated. Magnetic resonance angiography or tralateral or ipsilateral gracilis can be used for
angiography can be useful to assess upper extrem- finger flexor reconstruction (Table 6 and Figs. 12
ity vascularity and potential recipient vessels. In through 15).
the forearm, an intact anterior interosseous artery
will frequently correlate with an uninjured ante-
rior interosseous nerve.22 Magnetic resonance
imaging can be useful in showing pathologic sig-
nal alterations in denervated muscles, confirming
clinical examination. Higher strength magnets
with appropriate acquisition and software can
be used to demonstrate nerve abnormality and
may have a future role in helping identify donor
nerves.23
Planning for the operating room includes
adequate microsurgical equipment and magnifi-
cation, and an experienced anesthesiologist who
can keep the patient well-hydrated, perfused, and
normothermic. Short-acting paralytic agents may Fig. 13. Surgical dissection of the gracilis. A distal incision was
be used for the anesthetic induction but should made to identify the tendon of gracilis and help outline the sur-
not be used during surgery. A pathologist experi- gical incision for harvesting the gracilis with its overlying skin
enced in neurohistochemical staining should be paddle. A branch of the saphenous vein is seen in the proximal
available if there is a question regarding the suit- portion of the dissection. This can be used to augment venous
ability of the recipient-site donor nerve. Surgical outflow if necessary. The gracilis muscle is being reflected pos-
incisions should be planned to optimize access to teriorly. The neurovascular pedicle lies in the fat seen just distal
(1) recipient vessels and nerve and (2) new origin to the branch of the saphenous vein. (Authors retain copyright.)
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Volume 134, Number 2 • Upper Extremity Reconstruction
Fig. 14. (Above) The harvested gracilis muscle. The skin edges have been
secured to the underlying fascia to prevent shear injury to the perforating
branches. (Below) The deep surface of the harvested gracilis muscle, which is
encased in fascia. (Authors retain copyright.)
Fig. 15. The gracilis muscle has two distinct neuromuscular territories,
supplied by separate fascicles of the obturator nerve. These can func-
tion independently by using different donor nerves. In the forearm,
this can allow independent function of the thumb. (Authors retain
copyright.)
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Plastic and Reconstructive Surgery • August 2014
Latissimus
The use of the contralateral or ipsilateral latis-
simus is based on the function to be reconstructed
rather than on the position of the recipient vessels.
Typically, if the ipsilateral latissimus is considered
for elbow flexion or extension reconstruction, a
rotational latissimus is used. If this if not an option,
the contralateral free latissimus can be used for
elbow extension or flexion. For reconstruction
of elbow extension, the patient is placed in the
POSTOPERATIVE MANAGEMENT
Most vascular complications occur within the
first 8 hours after free tissue transfer. This is the most
critical period of monitoring, when flap evaluation
should be performed every 30 minutes by an expe-
rienced nursing staff. Close inpatient monitoring is
Fig. 16. Diagrammatic representation of the dissection of the continued for 3 to 5 days, with decreasing frequency
latissimus dorsi muscle. The arm is in a position of abduction for of flap evaluation. The flap is monitored for Dop-
marking of the resting length. (Copyright © Timothy C. Hengst, pler signal, color, temperature, and turgor. We have
printed with permission.) noted that any petechial hemorrhage present in the skin
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Volume 134, Number 2 • Upper Extremity Reconstruction
Fig. 18. Partial skin necrosis of the gracilis skin flap 12 hours after functional free
muscle transfer for restoration of finger flexion. The patient was returned emer-
gently to the operating room. Both the arterial and venous vascular anastomoses
were patent. The necrotic skin was débrided. The underlying muscle was healthy.
Split-thickness skin graft was used to cover the exposed muscle. The patient did
require a tenolysis at scar revision 8 months after surgery. He achieved good
functional recovery with nearly full active finger flexion and Medical Research
Council grade 4 motor function. (Authors retain copyright.) (Above) Necrosis seen
around the margins of the skin paddle. (Center) Necrotic tissue débrided. (Below)
Finger flexion at 18 months postoperatively.
paddle is a harbinger of impending flap failure and compartment syndrome and later ischemic con-
warrants immediate return to the operating room tracture of the flexor compartment of the forearm,
for exploration. At times, this may represent only a http://links.lww.com/PRS/B51.) Any vascular com-
compromised skin paddle without problems with promise in the postoperative period may affect final
the underlying muscle25 (Fig. 18). (See Video, Sup- functional recovery of the transferred muscle.
plemental Digital Content 3, which demonstrates During the initial recovery phase, the new
that, despite partial skin flap necrosis described in muscle origin and insertion need to be protected.
Figure 18, the patient had excellent finger flexion This requires 6 to 8 weeks of relative immobiliza-
18 months after functional free muscle transfer tion. Joint mobility and tendon gliding should be
with gracilis for reconstruction of finger flexion. maintained as much as possible with passive range-
This 6-year-old patient sustained a supracondylar of-motion exercises, always with attention to protec-
humerus fracture and subsequently developed a tion of the tenorrhaphy sites. Removable splinting
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Volume 134, Number 2 • Upper Extremity Reconstruction
application of functional free muscle transfer. First excursion and power of the transferred muscle,
performed at the Sixth People’s Hospital in Shang- inadequate recovery of muscle power for the
hai in 1973, the lateral portion of the pectoralis desired level of function, and fracture at the site
major was used to reconstruct the flexor muscles of new muscle origin. Pediatric patients may expe-
of the forearm for a patient with Volkmann isch- rience bone growth that is more rapid than that
emic contracture.4 Zuker et al. published a series of the transferred muscle. This can lead to joint
of functional free muscle transfers using a gracilis contracture with growth. Acute complications at
donor muscle in 1991, reporting on seven patients. the donor site include hematoma or seroma for-
All patients achieved less than 2-cm pulp to palm mation. The latissimus dorsi donor site frequently
grip. Grip strength was approximately 25 percent forms a seroma. Quilting and use of fibrin sealant
that of the contralateral side. All patients achieved at the donor site may reduce this complication.41
an independent functional nondominant hand.6 Several authors have reported transient peroneal
In 2011, they reported on a modification of their or sciatic nerve palsy related to intraoperative posi-
technique to provide independent thumb flexion tioning.42–44 Long-term donor-site complications
by separating the fascicles of the obturator nerve include painful unsightly scar, donor-site pain
and using two donor nerves, providing separate or dysesthesia, and measurable functional losses
innervation to the neurovascular territories of the at the donor site. Despite measured decrease in
gracilis muscle.29 Krimmer et al. used the gracilis muscle strength (5 to 10 percent shoulder girdle
muscle in 15 patients with a primary indication strength45 and 11 percent decreased adductor
of Volkmann contracture. Thirteen of 15 muscles strength),44 the decreased strength is often not
demonstrated reinnervation. Ten patients achieved noted by the patient.
full active motion.30,31 Liu et al. used the medial gas-
trocnemius muscle in 20 patients, reporting electro-
myographic activity at 6 to 20 months. Functional CONCLUSIONS
outcomes were reported as satisfactory, but the clin- Functional free muscle transfer is a power-
ical photographs suggest incomplete finger flexion, ful tool in upper extremity reconstruction when
likely related to the short excursion of the muscle.32 other options are not available. Appropriate
Reconstruction after tumor resection has been patient selection, a skilled surgical reconstructive
most frequently reported for lower extremities. In team, and a dedicated postoperative rehabilita-
the upper extremity, good functional recovery has tion program are essential for restoration of lost
been reported, with time to reinnervation occur- function and patient satisfaction.
ring at approximately 5.5 months.14,15,33–36
Other indications including reconstruction Milan Stevanovic, M.D.
Department of Orthopedics
after trauma and congenital deficits have also
2025 Zonal Avenue
been reported with similar functional outcomes, GNH Room 3900
typically recovering Medical Research Coun- Los Angeles, Calif. 90033
cil grade 4 motor recovery.7,37–40 Lin et al. noted stevanov@usc.edu
a higher rate of failure of functional recovery
when a functional free muscle transfer was used
in the acute setting to achieve wound coverage REFERENCES
and reconstruct function.40 This has not been our 1. Tamai S, Komatsu S, Sakamoto H, Sano S, Sasauchi N. Free
experience in the acute setting. muscle transplants in dogs, with microsurgical neurovascular
anastomoses. Plast Reconstr Surg. 1970;46:219–225.
2. Stevanovic MV, Seaber AV, Urbaniak JR. Canine experimen-
COMPLICATIONS tal free muscle transplantation. Microsurgery 1986;7:105–113.
3. Harii K, Ohmori K, Torii S. Free gracilis muscle transplan-
Complications can be divided into acute and tation, with microneurovascular anastomoses for the treat-
long-term complications, and also donor- and ment of facial paralysis: A preliminary report. Plast Reconstr
recipient-site complications. Acute complications Surg. 1976;57:133–143.
at the recipient site include flap loss, partial flap 4. Free muscle transplantation by microsurgical neurovascular
loss (either skin paddle or partial muscle loss), anastomoses: Report of a case. Chin Med J (Engl.). 1976;2:47–50.
hematoma, and infection. Long-term complica- 5. Manktelow RT, McKee NH. Free muscle transplantation to
provide active finger flexion. J Hand Surg Am. 1978;3:416–426.
tions at the recipient site include scarring and 6. Zuker RM, Egerszegi EP, Manktelow RT, McLeod A, Candlish
tendon adhesions requiring revision surgery, S. Volkmann’s ischemic contracture in children: The results
attenuation at the tendon repair site resulting in of free vascularized muscle transplantation. Microsurgery
a shortened muscle resting length and decreased 1991;12:341–345.
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Plastic and Reconstructive Surgery • August 2014
7. Doi K, Arakawa Y, Hattori Y, Baliarsing AS. Restoration of muscle transfers with a second ischemic event: A report of
elbow flexion with functioning free muscle transfer in three cases. J Reconstr Microsurg. 2012;28:267–271.
arthrogryposis: A report of two cases. J Bone Joint Surg Am. 26. Chung DC, Carver N, Wei FC. Results of functioning free
2011;93:e105. muscle transplantation for elbow flexion. J Hand Surg Am.
8. Doi K, Kuwata N, Muramatsu K, Hottori Y, Kawai S. Double 1996;21:1071–1077.
muscle transfer for upper extremity reconstruction follow- 27. Barrie KA, Steinmann SP, Shin AY, Spinner RJ, Bishop AT.
ing complete avulsion of the brachial plexus. Hand Clin. Gracilis free muscle transfer for restoration of function after
1999;15:757–767. complete brachial plexus avulsion. Neurosurg Focus 2004;16:E8.
9. Doi K, Muramatsu K, Hattori Y, et al. Restoration of prehension 28. Gousheh J, Arasteh E. Upper limb functional restoration in
with the double free muscle technique following complete avul- old and complete brachial plexus paralysis. J Hand Surg Eur
sion of the brachial plexus: Indications and long-term results. J Vol. 2010;35:16–22.
Bone Joint Surg Am. 2000;82:652–666. 29. Zuker RM, Bezuhly M, Manktelow RT. Selective fascicular
10. Doi K, Sakai K, Ihara K, Abe Y, Kawai S, Kurafuji Y. coaptation of free functioning gracilis transfer for restoration
Reinnervated free muscle transplantation for extremity of independent thumb and finger flexion following Volkmann
reconstruction. Plast Reconstr Surg. 1993;91:872–883. ischemic contracture. J Reconstr Microsurg. 2011;27:439–444.
11. Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Reconstruction 30. Krimmer H, Hahn P, Lanz U. Free gracilis muscle trans-
of finger and elbow function after complete avulsion of the plantation for hand reconstruction. Clin Orthop Relat Res.
brachial plexus. J Hand Surg Am. 1991;16:796–803. 1995;314:13–18.
12. Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Double free- 31. Krimmer H, van Schoonhoven J, Lanz U. Transplantation of
muscle transfer to restore prehension following complete the M. gracilis in the reconstruction of hand function (in
brachial plexus avulsion. J Hand Surg Am. 1995;20:408–414. German). Orthopade 1998;27:445–450.
13. Hattori Y, Doi K, Ikeda K, Pagsaligan JM, Watanabe M. 32. Liu XY, Ge BF, Win YM, Jing H. Free medial gastrocnemius
Restoration of prehension using double free muscle tech- myocutaneous flap transfer with neurovascular anastomosis
nique after complete avulsion of brachial plexus in children: to treat Volkmann’s contracture of the forearm. Br J Plast
A report of three cases. J Hand Surg Am. 2005;30:812–819. Surg. 1992;45:6–8.
14. Doi K, Kuwata N, Kawakami F, Hattori Y, Otsuka K, Ihara 33. Stevanovic M, Sharpe F. Functional free gracilis transfer for upper
K. Limb-sparing surgery with reinnervated free-muscle trans- extremity reconstruction. Atlas Hand Clinics 2002;7(1);163–180.
fer following radical excision of soft-tissue sarcoma in the 34. Ihara K, Shigetomi M, Muramatsu K, et al. Pedicle or free
extremity. Plast Reconstr Surg. 1999;104:1679–1687. musculocutaneous flaps for shoulder defects after oncologi-
15. Ihara K, Shigetomi M, Kawai S, Doi K, Yamamoto M. cal resection. Ann Plast Surg. 2003;50:361–366.
Functioning muscle transplantation after wide excision of sar- 35. Muramatsu K, Ihara K, Taguchi T. Selection of myocutane-
comas in the extremity. Clin Orthop Relat Res. 1999;358:140–148. ous flaps for reconstruction following oncologic resection of
16. Oatis CA. Biomechanics of skeletal muscle. In: Oatis CA, sarcoma. Ann Plast Surg. 2010;64:307–310.
ed. Kinesiology: The Mechanics and Pathomechanics of Human 36. Seal A, Stevanovic M. Free functional muscle transfer for the
Movement. 2nd ed. Philadelphia: Lippincott Williams upper extremity. Clin Plast Surg. 2011;38:561–575.
&Wilkins; 2008:45–68. 37. Fan C, Jiang P, Fu L, Cai P, Sun L, Zeng B. Functional recon-
17. Lieber RL, Friden J. Clinical significance of skeletal muscle struction of traumatic loss of flexors in forearm with gastrocne-
architecture. Clin Orthop Relat Res. 2001;383:140–151. mius myocutaneous flap transfer. Microsurgery 2008;28:71–75.
18. Becker MH, Wermter TB, Brenner B, Walter GF, Berger 38. Kay S, Pinder R, Wiper J, Hart A, Jones F, Yates A.
A. Comparison of clinical performance, histology and sin- Microvascular free functioning gracilis transfer with nerve
gle-fiber contractility in free neurovascular muscle flaps. J transfer to establish elbow flexion. J Plast Reconstr Aesthet Surg.
Reconstr Microsurg. 2000;16:525–534. 2010;63:1142–1149.
19. Kuzon WM Jr, McKee NH, Fish JS, Pynn BR, Rosenblatt JD. 39. Kobayashi MR, Brenner KA, Gupta R, Evans GR. Functional
The effect of intraoperative ischemia on the recovery of con- biceps brachii reconstruction using the free tensor fasciae
tractile function after free muscle transfer. J Hand Surg Am. latae. Plast Reconstr Surg. 2004;114:1208–1214.
1988;13:263–273. 40. Lin SH, Chuang DC, Hattori Y, Chen HC. Traumatic major
20. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscle loss in the upper extremity: Reconstruction using
muscles: Experimental and clinical correlation. Plast Reconstr functioning free muscle transplantation. J Reconstr Microsurg.
Surg. 1981;67:177–187. 2004;20:227–235.
21. Taylor GI, Gianoutsos MP, Morris SF. The neurovascular ter- 41. Bailey SH, Oni G, Guevara R, Wong C, Saint-Cyr M. Latissimus
ritories of the skin and muscles: Anatomic study and clinical dorsi donor-site morbidity: The combination of quilting and
implications. Plast Reconstr Surg. 1994;94:1–36. fibrin sealant reduce length of drain placement and seroma
22. Zuker RM, Manktelow RT. Functioning free muscle trans- rate. Ann Plast Surg. 2012;68:555–558.
fers. Hand Clin. 2007;23:57–72. 42. Addosooki AI, Doi K, Hattori Y. Technique of harvesting the
23. Stoll G, Bendszus M, Perez J, Pham M. Magnetic reso- gracilis for free functioning muscle transplantation. Tech
nance imaging of the peripheral nervous system. J Neurol. Hand Up Extrem Surg. 2006;10:245–251.
2009;256:1043–1051. 43. Carr MM, Manktelow RT, Zuker RM. Gracilis donor site mor-
24. Theeuwes HP, Gosselink MP, Bruynzeel H, Kleinrensink GJ, bidity. Microsurgery 1995;16:598–600.
Walbeehm ET. An anatomical study of the length of the neu- 44. Deutinger M, Kuzbari R, Paternostro-Sluga T, et al. Donor-
ral pedicle after the bifurcation of the thoracodorsal nerve: site morbidity of the gracilis flap. Plast Reconstr Surg. 1995;95:
Implications for innervated free partial latissimus dorsi flaps. 1240–1244.
Plast Reconstr Surg. 2011;127:210–214. 45. Russell RC, Pribaz J, Zook EG, Leighton WD, Eriksson E,
25. Dodakundi C, Doi K, Hattori Y, et al. Viability of the skin Smith CJ. Functional evaluation of latissimus dorsi donor
paddle does not predict the functional outcome in free site. Plast Reconstr Surg. 1986;78:336–344.
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