Free Gracilis Muscle Transfer Research Articles

Novel Method of Dual-innervated Free Gracilis Muscle Transfer for Facial Reanimation: A Case Series

Background: Dynamic facial reanimation is the gold standard treatment for a paralyzed face. The use of the cross-face nerve graft (CFNG) in combination with the masseteric nerve to innervate the free gracilis muscle has been reported to provide both spontaneity and strong neural input. We report a case series of dual innervation, using a novel method where the branch to masseter is coapted to the side of the CFNG. Methods: Eight patients received free gracilis muscle transfer using the new dual innervation method between September 2014 and December 2017. The CFNG, which was performed nine months prior, was sutured in an end-to-end fashion to the obturator nerve. A nerve graft was coapted to the ipsilateral masseteric nerve and then sutured in an end-to-side fashion to the CFNG proximal to its coaptation to the obturator nerve. Results: All patients recovered smile function with and without teeth clenching around the same time period. Smiles without teeth clenching appeared later in two of eight patients and earlier in one of eight patients, being noted at an average of 8.25 months of follow-up versus 7.6 months. The estimate of true attainment is limited by the spacing of follow-up dates. Average follow-up time was 36.07 months (range: 10–71.5). FACE-Gram software smile analysis with and without biting demonstrated similar excursion on average (7.64 mm versus 8.6 mm respectively, P = 0.93), both of which are significantly improved from preoperation. Conclusion: This novel method of a dual-innervated free gracilis muscle transfer offers a viable technique that achieves a symmetric, strong, and emotional smile.

Comparison of Outcomes of Facial Reanimation Between the Use of Cross-facial Nerve Graft and the Masseteric Nerve as the Donor Nerve for Reinnervation of Gracilis Muscle Flap Transfer.

In patients with facial paralysis, the free functional gracilis muscle transfer is preferred for facial reanimation. The choice of an adequate motor nerve to innervate the transplanted gracilis muscle is one of the procedure's key components. We present a comparative study between cross-facial nerve graft (CFNG) and masseteric nerve as donor nerves for reinnervated gracilis flap transfer in patients with complete facial paralysis. Retrospective analysis was performed on all patients with complete facial paralysis who had a free functional gracilis muscle transfer for facial reanimation between January 2014 and December 2021. Only those who received gracilis transfer reinnervated by either CFNG or masseteric nerve were included in this study. The smile excursion and lip angle were measured for evaluating the outcomes postoperatively. The inclusion criteria were met by a total of 21 free functional gracilis muscle transfers, of which 11 were innervated by CFNG and 10 by the masseteric nerve. Both surgical procedures resulted in a highly considerable smile excursion of the reanimated side and postoperative improvement of static or dynamic lip angle. Masseteric nerve coaptation led to greater smile excursion and more significant improvement of dynamic lip angle than CFNG. For patients who have complete facial paralysis, face reanimation can be successfully accomplished by free gracilis transfer reinnervated by the CFNG or the masseteric nerve. In particular, the masseteric nerve is a reliable choice for dynamic smile reanimation.

Free gracilis muscle transfer with anastomosis of its major to minor pedicle for reconstruction of a popliteal fossa defect: a case report

The authors describe a novel case where the gracilis muscle was used to reconstruct a popliteal defect with the muscle’s own minor pedicle being used for microsurgical anastomosis.

Age-related outcomes of facial reanimation surgery using gracilis free functional muscle transfer innervated by the masseteric nerve: A retrospective cohort study

The free functional muscle gracilis transfer is an established approach in facial reanimation surgery; however, the significance of its neurotization and the patient's age is still inconclusive. Several donor nerves are available for facial reanimation using the free functional gracilis muscle transfer. This retrospective cohort study investigates whether the masseteric nerve is an equally reliable donor nerve in both older and younger patients. We included 46 patients (13-71 years, male and female) who underwent nerve-to-masseter (NTM)-driven free functional muscle transfer (FFMT) between January 2008 and December 2019. Patients were distributed into three cohorts according to their age at surgery. We assessed the facial symmetry before and after surgery using the pupillo-modiolar angle. Commissure height and excursion deviation were measured with the Emotrics software. Patient-reported outcome measurements were taken using the Facial Clinimetric Examination (FaCE) scale. All patients had successful flap innervation, except for one patient in the middle-aged cohort (31-51 years). The postoperative facial symmetry at rest, smiling, and laughing was analyzed with the pupillo-modiolar angle and the Emotrics software and showed similar results between all cohorts. The FaCE scale showed similar scores for the middle-aged (31-51 years) cohort and the senior cohort (52-71 years). The social function score in the senior cohort was higher than in the middle-aged cohort, without statistical significance. One patient in the middle-aged (31-51 years) cohort and the senior cohort (52-71 years), respectively, underwent emergency revision due to impaired flap perfusion and could be salvaged. NTM-driven FFMT for facial reanimation is a safe and reliable procedure across all age groups of patients.

Functional reconstruction of the masseter muscle by microvascular free gracilis muscle transfer: technique and outcome

Microvascular reconstruction of the cheek is most often performed using fasciocutaneous flaps and without functional reconstruction of the masseter muscle. This article reports a technique of masseter muscle resection, dissection of the masseteric nerve, and masseter muscle reconstruction with a functional gracilis muscle flap. The technique was applied in a 38-year-old man with recurrent intramuscular lipoma of the right masseter muscle. The flap was highly stable in form and showed good function. Bite force, electromyography results, and the radiological appearance of the gracilis muscle were similar to those of the contralateral masseter muscle at 12 months after surgery. In conclusion, full rehabilitation of masseter muscle function and good facial aesthetics were achieved by functional gracilis muscle reconstruction of the masseter muscle in a case of total resection.

181. Novel Method Of Double Innervated Free Gracilis Muscle Functional Transfer For Facial Reanimation

PURPOSE: Dynamic facial reanimation is the gold standard treatment for a paralyzed face. The use of the cross-face nerve graft (CFNG) in combination with the masseteric nerve to innervate the free gracilis muscle has been reported, with the goal of providing both spontaneity from the CFNG and strong neural input from the masseteric nerve. We report a series of patients who underwent a novel modification to the existing nerve coaptation configurations. METHODS: Eight patients (Image 1 below) received free gracilis muscle transfer using the new double innervation method between September 2014 and December 2017. The CFNG, which was performed nine months prior, was sutured in an end-to-end fashion to the obturator nerve. A nerve graft was coapted to the ipsilateral masseteric nerve and then sutured in an end-to-side fashion to the CFNG proximal to the end-to-end obturator coaptation (Image 2 below). RESULT: All patients recovered smile function with teeth clenching (average 7.5 months, range 3-12). Seven of eight patients recovered a strong spontaneous smile by an average of 8.9 months (range 7-12), with one patient having weak spontaneous function after 12 months of follow-up. Average follow-up time was 31.52 months. All patients achieved improvements in their smile excursion based on the FACE-Gram software. Smile with or without biting achieved similar excursion on average (7.91mm vs.8.04mm, p=0.93). CONCLUSION: Our novel method of a double-innervated free gracilis muscle transfer represents a viable technique that does not risk denervation of the gracilis muscle and provides a symmetric, spontaneous, emotional smile.

Gracilis Muscle-Free Flap Objective Improvement of Oral Commissure Excursion in Facial Palsy Reanimation Surgery: Systematic Review and Meta-Analysis.

Background: Facial palsy patients face significant challenges. Gracilis free flap transfer is a key procedure in facial reanimation. Objective: This study aims to analyze oral commissure excursion improvement after gracilis free flap transfer and the differences regarding donor nerve: cross-facial nerve graft (CFNG), hypoglossal or spinal accessory nerves, motor nerve to masseteric (MNTM), and most recently, double anastomosis using both the MNTM and CFNG. Methods: A systematic review and meta-analysis were conducted of studies reporting oral commissure excursion improvement after free gracilis muscle transfer. Pooled proportions were calculated using a random-effects model. Results: Eighteen studies, 453 patients, and 488 free gracilis flaps were included. The mean change in perioperative oral commissure excursion was 7.0 mm, for CFNG 7.2 mm, for MNTM 7.7, and for double anastomoses 5.5 mm. Conclusions: There is a significant improvement in oral commissure excursion after gracilis muscle-free flap. Unfortunately, we could not make definitive conclusions regarding the optimal choice of donor nerve.

Donor Nerve Selection in Free Gracilis Muscle Transfer; Systematic Review and Meta-Analysis

Introduction: One of the crucial factors in facial reanimation surgery is the donor nerve selection. There have been several neurotizers to reinnervate the free gracilis muscle flap (FGMT). Currently the cross-face nerve graft (CFNG) and motor nerve to masseter are the most favored options. The “dual innervation” is described as potential way to combine the advantages of individual donor nerves and has shown successful results. Materials and Methods: Two databases were searched for the CFNG, masseteric nerve and dual innervation of FGMT. Defined primary measures were applied to the results to compare the extent of commissure excursion, facial symmetry at rest and smile, spontaneity, time to flap contraction for each neurotizer. Meta-analysis was conducted for studies including quantitative data for commissure excursion and facial symmetry. We included all study types except the animal studies. Only articles written in English language from 2001 were taken into consideration. We followed PRISMA guidelines. ROBINS-I and Newcastle-Ottawa tools were used to assess the risk of bias and quality for each study included in the meta-analysis. Results: 147 articles on FGMT were systematically reviewed and 13 studies were evaluated in the meta-analysis. All studies were high in quality. Heterogeneity was high among the studies, limiting the efficiency of our meta-analysis. Conclusion: CFNG is the most frequently utilized reinnervation technique. Masseteric nerve is very reliable and has the potential to provide more commissural excursion and higher success rate. Dual innervation is an effective alternative leading to effective clinical outcomes. A globalized and quantitative measurement method will contribute to the future of facial reanimation surgery.

Dual-Innervated Free Gracilis Muscle Transfer for Facial Reanimation in Children.

Facial palsy may have deleterious effects for pediatric patients. The most common reconstruction is 2-stage free gracilis muscle transfer (FGMT) after cross-face nerve graft (CFNG). This requires a prolonged period from time of surgery to smile. New techniques using both a CFNG and motor nerve to masseter (MNM) as dual power sources in a single-stage surgery have been described in adults. Here, we examine our experience with this technique in children. A retrospective study was performed examining patients who underwent dual-innervated single-stage FGMT at 2 pediatric hospitals from 2016 to 2019. Demographics, etiology, perioperative characteristics, time to mandibular and emotional smile, and Sunnybrook scores were recorded. Five patients met inclusion criteria with a mean age of 11.8 (range, 8-20). Two patients had congenital facial palsy while 3 had acquired facial palsy. Four patients (80%) received dual end-to-end neural coaptations of the CFNG and MNM to the obturator nerve. One (20%) had end-to-side coaptation of the CFNG to the obturator nerve and end-to-end of the MNM to the obturator nerve. The average time to mandibular smile was 103 ± 15.4 days. The average time to emotional smile was 245 ± 48.1 days. The preoperative Sunnybrook scale was 32 ± 7.5 and improved to 55.3 ± 20.6 at 8 months postoperatively. Dual-innervated FGMT is effective for facial reanimation in children with unilateral facial palsy. Patients can harness a stronger motor source (MNM) and the component of an emotional stimulus (CFNG). This approach may be the new criterion standard pediatric facial reanimation.

The Split Hypoglossal Nerve and Cross-Face Nerve Graft for Dual Innervation of the Functional Muscle Transfer in Facial Reanimation.

Facial paralysis is a disabling deformity. The affected individual is seriously affected both esthetically and functionally. Free functional muscle transfer is currently the corner stone in the management of long-standing facial nerve paralysis. Several nerve options are available to supply the free muscle transfer. These nerves can be used alone or in combination. The aim of this work is to study the possibility and results of dually innervating the free functioning muscle transfer. The dual innervation is done using the split hypoglossal nerve and cross-face nerve graft (CFNG) both sutured in an end-to-end manner to the nerve to gracilis. Twenty-nine patients with unilateral long-standing facial nerve paralysis (more than 1y) were treated using free gracilis muscle transfer dually supplied by the split hypoglossal nerve and CFNG, both sutured in an end-to-end manner. The gained excursion after the free gracilis transfer was 9 to 29mm (mean: 17.24mm). A statistically significant increase ( P -value=0.0001) in the distance from where the midline crosses the lower vermilion border to commissure occurred from preoperative (mean: 16.55mm) to postoperative setting (mean: 33.79mm). Spontaneity was achieved in 26 patients (89.6%). In conclusion, dual innervation of the free muscle transfer using both the split hypoglossal nerve and CFNG (both sutured in an end-to-end manner to the nerve to gracilis) is a good possible option to treat long-standing cases of facial nerve paralysis. It yields adequate muscle excursion with acceptable spontaneity.

105. Long Term Surgical and Patient Reported Outcomes After Cross Face Nerve Graft Reconstruction in Pediatric Facial Paralysis

Purpose: Free functioning muscle transfer is the gold standard for pediatric facial paralysis reconstruction and using the contralateral facial nerve for neurotization via a cross face nerve graft enables spontaneous smile restoration. Outcomes of pediatric facial reanimation beyond 10 years are not known, including how smiles change with aging and how adult patients report their facial function and quality of life. This study evaluated long term surgical and patient-reported outcomes for adults who underwent facial reanimation as children. Methods: This cross-sectional study enrolled patients who underwent facial reanimation with a staged cross face nerve graft and free gracilis muscle transfer as children at least 10 years ago. FACE-Gram software was used to quantify commissure excursion on frontal photographs in repose and maximal smile at three time points: preoperative, early postoperative within 2 years, and current (long term follow up). Patient-reported outcomes were evaluated quantitatively using the FaCE Scale and FACE-Q instruments for patient satisfaction, and qualitatively with semi-structured interviews. Results are reported as mean ± SD and parametric statistical analysis was performed with alpha of 0.05. Results: Eighteen patients who underwent facial reanimation as children more than 10 years ago were included (14 females, 5 males; 10 congenital, 8 acquired; age at stage 1 surgery 7.4 ± 3.6 years). Commissure excursion was measured as -1.3 ± 3.5 mm preoperatively, 5.9 ± 2.3 mm postoperatively within 2 years, and 7.6 ± 3.5 mm at long term follow up (mean 20.5 ± 6.9 years). Commissure excursion increased 7.2 ± 4.9 mm from preoperative to early postoperative time points (p<0.0001) and did not significantly increase or decrease at long term follow up (p>0.05). For patient reported outcomes, mean FaCE scale score for facial movement was 44/100 when including eyebrow function and 79/100 when excluding eyebrow function. Mean FaCE scale scores were 63/100 for eye comfort and 81/100 for social function. On the FACE-Q Satisfaction with Outcome scale, 17/18 respondents somewhat agreed or definitely agreed with the statement, “I am pleased with the result.” On the FACE-Q Social Function scale, 16/18 respondents somewhat agreed or definitely agreed with the statement, “I feel confident when I meet a new person.” Conclusions: Pediatric facial reanimation with cross face nerve grafting improves commissure excursion and this is maintained with aging. Adult patients report overall high satisfaction and social functioning. Ongoing ocular issues remains a problem for many patients, underscoring the importance of refining techniques for reanimation of the eye.

The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?

Introduction: During a two-stage free gracilis muscle transfer (FGMT) to restore smile to patients with facial paralysis, some surgeons assess nerve regeneration through the cross-face nerve graft (CFNG) with the Tinel sign and a nerve biopsy. Objective: To test whether ultimate smile reanimation outcomes are correlated with (1) the Tinel sign or (2) myelinated axons of the biopsied CFNG at the time of FGMT. Methods: Retrospective case series was performed at a tertiary care facial nerve center. Dynamic smile outcomes were quantified with Emotrics analysis of pre- and postoperative photographs. Results: Of the 113 FGMT surgeries by CFNG performed since 2002, 92 patients had pre- and postoperative photo-documentation. Most patients (89%, N = 82) had a positive Tinel sign at the time of FGMT; however, 14 patients with positive Tinel signs were deemed failures. Interestingly, 4 patients with a negative Tinel sign went on to have successful dynamic outcomes and 16 patients lacking myelinated axons in their CFNG biopsy ultimately achieved successful smile outcomes. Conclusion: Although the majority of patients had a positive Tinel sign and myelinated axons in the CFNG at the time of FGMT, the presence or absence of either factor did not predict ultimate smile outcome in this series.

Commentary on: "The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?" by Greene et al.

Facial Plastic Surgery & Aesthetic MedicineVol. 24, No. 4 Invited CommentaryCommentary on: “The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?” by Greene et alBabak Azizzadeh and Adrian E. HouseBabak Azizzadeh*Address correspondence to: Babak Azizzadeh, MD, Center for Advanced Facial Plastic Surgery, 9401 Wilshire Boulevard, Suite #650, Beverly Hills, CA 90212, USA. E-mail Address: drazizzadeh@gmail.comhttps://orcid.org/0000-0002-5607-1022Center for Advanced Facial Plastic Surgery, Beverly Hills, California, USA.Search for more papers by this author and Adrian E. HouseCenter for Advanced Facial Plastic Surgery, Beverly Hills, California, USA.Search for more papers by this authorPublished Online:29 Jul 2022https://doi.org/10.1089/fpsam.2022.0027AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Commentary on: “The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?” by Greene et al." Facial Plastic Surgery & Aesthetic Medicine, 24(4), pp. 260–261FiguresReferencesRelatedDetails Volume 24Issue 4Aug 2022 Information© 2022, American Academy of Facial Plastic and Reconstructive Surgery, Inc.To cite this article:Babak Azizzadeh and Adrian E. House.Commentary on: “The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?” by Greene et al.Facial Plastic Surgery & Aesthetic Medicine.Aug 2022.260-261.http://doi.org/10.1089/fpsam.2022.0027Published in Volume: 24 Issue 4: July 29, 2022Online Ahead of Print:June 3, 2022PDF download

Post-surgery Rehabilitative Intervention Based on Imitation Therapy and Mouth-Hand Motor Synergies Provides Better Outcomes in Smile Production in Children and Adults With Long Term Facial Paralysis.

Rehabilitation after free gracilis muscle transfer (smile surgery, SS) is crucial for a functional recovery of the smiling skill, mitigating social and psychological problems resulting from facial paralysis. We compared two post-SS rehabilitation treatments: the traditional based on teeth clenching exercises and the FIT-SAT (facial imitation and synergistic activity treatment). FIT-SAT, based on observation/imitation therapy and on hand-mouth motor synergies would facilitate neuronal activity in the facial motor cortex avoiding unwanted contractions of the jaw, implementing muscle control. We measured the smile symmetry on 30 patients, half of whom after SS underwent traditional treatment (control group, CG meanage = 20 ± 9) while the other half FIT-SAT (experimental group, EG meanage= 21 ± 14). We compared pictures of participants while holding two postures: maximum and gentle smile. The former corresponds to the maximal muscle contraction, whereas the latter is strongly linked to the control of muscle strength during voluntary movements. No differences were observed between the two groups in the maximum smile, whereas in the gentle smile the EG obtained a better symmetry than the CG. These results support the efficacy of FIT-SAT in modulating the smile allowing patients to adapt their smile to the various social contexts, aspect which is crucial during reciprocal interactions.

Functional Outcome Comparison of Free Gracilis Muscle Anchoring Methods in Patients with Facial Paralysis: Upper Lip Red Line Incision versus Facelift Incision Approach.

The greatest challenge of a free-muscle transfer in facial reanimation surgery is anchoring muscle to perioral soft tissue. An additional incision provides a better way to anchor the transferred muscle but leaves a visible scar. Herein, we compared the functional and aesthetic outcomes in a conventional facelift incision approach with and without the addition of a red line incision. This study included patients experiencing unilateral facial paralysis who underwent free gracilis transfer between December 2016 and December 2018. Anchoring through facelift incision with extended neck incision was performed in the control group, while a red line incision was added in the red line group by avoiding extended neck incision. Oral commissure excursion, upper lip and commissure height differences, and symmetry were measured. A total of 24 patients met the criteria and were included in this study. Of these, 10 patients were assigned to the red line group and 14 to the control group. The red line and control groups demonstrated a similar symmetry index in both resting (0.96 ± 0.18 and 0.92 ± 0.10, respectively; p = 0.435) and smiling (0.94 ± 0.12 and 0.91 ± 0.10, respectively; p = 0.314). However, the upper lip height difference demonstrated greater postoperative improvement (resting: 2.12 ± 1.13 vs. 3.92 ± 1.41 mm, p = 0.002, and smiling: 1.68 ± 0.88 vs. 3.41 ± 1.69 mm, p = 0.004, respectively). A scar could be easily concealed on the mucocutaneous line of the lip. This novel method for muscle anchoring in facial reanimation surgery allows surgeons to approach perioral muscle more directly. This leads to improved surgical results by securely anchoring the transferred muscles using a fixation point that is more medially located than in other approaches. Our method is effective and offers an improved surgical outcome for the free functional gracilis muscle transfer.

Microsurgical Reconstruction for Reanimation of Foot Dorsiflexion in Children.

Summary:Foot drop is a debilitating condition, which causes physical disability and psychological challenges associated with difficulties walking. We report the indications, novel technique, and successful outcomes of two children (three limbs) who underwent free functional gracilis muscle transfers coaptated to the common peroneal nerve to reanimate active foot dorsiflexion and correct foot drop secondary to loss of the anterior compartment.

Advances and future directions in the care of patients with facial paralysis

Advances and future directions in the care of patients with facial paralysis

Dynamic Reconstruction of the Lower Lip With Free Functioning Gracilis Muscle Transfer.

The restoration of large full-thickness lip defects still remains a formidable challenge for the reconstructive surgeons. Traumatic injuries, infections and tumors (primarily squamous cell carcinoma) are the most common source of the lip defects. Lower lips are more important in providing oral competence, unfortunately throughout the life-time they are significantly more exposed to ultraviolet radiation and thus are the most common site for the lip cancers (89%). This type of defect requires a complex reconstruction of an adequate sphincter function, defined vermilion, proper oral lining and sufficient mouth opening. To maintain the oral competence, it is of paramount importance to restore the function of orbicularis oris, which principally composes the body of the lip. Currently, the dynamic reconstructions are gaining considerable interest. They enables not only improvement of appearance but also a restoration of function and preservation of health-related quality of life. The use of the free gracilis muscle transfer to reconstruct the lower lip and its dynamic character in contrast to other, static reconstructions can provide the sufficient movement of the lower lip, which does not depend on function of other mimic muscles as it becomes an independent motor unit with its own neurotization. In our opinion the free functioning gracilis muscle flap, due to its anatomic and functional features as well as low-rate donor-site morbidity is the worth considering option for a lower lip reconstruction.

Outcome of free gracilis muscle transfer for the restoration of elbow flexion in traumatic brachial plexus palsy.

Objectives The aim of this study was to evaluate the functional outcomes of patients with free gracilis muscle transfer (FGMT) for the restoration of elbow flexion. Patients and methods Between January 2012 and January 2019, a total of 16 patients (13 males, 3 females; mean age: 27.3±11.7 years; range: 18 to 53 years) who underwent FGMF to achieve elbow flexion after traumatic brachial plexus palsy (TBPP) were retrospectively analyzed. Data including demographic and clinical characteristics of the patients, etiology, affected side, injury level, accompanying injuries, time between injury and surgery, follow-up time, complications, whether nerve reconstruction and artery repair were performed previously, and details of the procedure were recorded. The outcome measures were elbow range of motion in degrees, muscle strength, and Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores.Results The mean follow-up was 30±11.5 (range, 24 to 42) months. Two patients had C5-C8 injuries, two patients had C6-T1 injuries, and all other patients had injuries to the C5-T1 roots. Muscle strength was M3/M4 in 11 (68.8%) patients, M2 in two (12.5%) patients, and M0 in one (6.2%) patient. The median active range of motion of the elbow joint in patients with successful results (M3 and above) was measured as 75 (range, 30 to 100) degrees. A statistically significant improvement was observed in the pre- and postoperative DASH scores and in some SF-36 subscale scores of patients with successful results.Conclusion Free gracilis muscle flap is a reliable option in the restoration of elbow flexion in patients with TBPP. Although there is an improvement in functional results, disability, and quality of life, there may be no change in patients’ mental status and pain.

An Anatomical Feasibility Study on the Use of the Hypoglossal and Hemihypoglossal Nerve as a Donor Motor Nerve for Free Functioning Muscle Transfer in Upper Extremity Reconstruction

Brachial plexus injuries (BPI) with complete root avulsions remains a clinical challenge due to a paucity of nerves available for nerve transfer and innervation of free functioning muscle transfers (FFMT). The hypoglossal and hemihypoglossal nerve has not been studied as a donor nerve option for FFMTs in brachial plexus reconstruction, despite successful outcomes of hypoglossal nerve transfers in facial reanimation surgery. We hypothesized that the hypoglossal nerve could be an appropriate candidate for surgical repair of BPI using FFMT. A cadaveric study was performed to determine the anatomic feasibility of using the hypoglossal and hemihypoglossal nerves as donor nerves to neurotize the gracilis or latissimus dorsi muscle in an FFMT to restore elbow flexion. Twelve cadavers (6 males and 6 females) were studied. The hypoglossal nerve, thoracodorsal nerve, and obturator nerve branches to the gracilis muscle were dissected, measured, and analyzed. The average length of the hypoglossal nerve was 6.3 ± 0.5 cm in both sexes. The average distance between the lowest point of the hypoglossal nerve and the lateral clavicle was 8.4 ± 1.3 cm in males and 7.7 ± 0.8 cm in females. When the hypoglossal nerve was transected distally, the average distance to the clavicle was 4.5 ± 1.6 cm in males and 3.8±1.5 cm in females. The maximum theoretical length of the donor nerve required to perform an adequate FFMT using the hypoglossal nerve was 8.9 ± 1.2 cm, which was well exceeded by the lengths of the thoracodorsal nerve (14.5 ± 1.3 cm) and nerve to the gracilis muscle (12.7± 1.7 cm). This cadaveric study demonstrated that the hypoglossal or hemihypoglossal nerves may be used as potential motor donor nerves to innervate a free gracilis or latissimus dorsi muscle transfer for the restoration of elbow flexion via a direct nerve transfer without the need for nerve grafting.