FREE FUNCTIONAL MUSCLE

TRANSFER
MODERATOR DR G AVINASH RAO
DR H R ZARGAR.
FELLOW HAND AND MICROSURGERY.
 Introduction
 Loss of upper extremity function secondary to brachial plexus injuries /
severe trauma / established VIC / Congenital absence of muscle / Muscle
loss after tumor surgery / Peripheral nerve injuries are a challenging
problems in reconstructive hand Surgery.
 These cases have profound functional loss with limited reconstructive
options.
 Advances in microsurgery offered a new approach in the management of
these injuries.
 Vascularized free muscle flaps are indicated for complex reconstruction of:
 Defects requiring filling of dead space
 Coverage of exposed vital structures
 Treatment of osteomyelitis
 Functional reconstruction of muscle loss or absence in congenital conditions
 Coverage of exposed orthopedic hardware

……………………………………………………………………………………..
 fFMT provide useful function apart from the above advantages
mentioned for VfMT
 Tamai et al. Free muscle transplants in dogs, with microsurgical neurovascular
anastomoses. Plast Reconstr Surg. 1970.
 Stevanovic, Seaber, Urbaniak Canine experimental free muscle transplantation.
Microsurgery. 1986.

………………………………………………………………………

 Terzis, Suggested that muscle bulk decreases with muscle transplantation to

25-50%. J Hand Surg, 1978.
 Transplanted muscles regained full strength, sometimes stronger
than pre-transplanted power. Doi K , Clin Plast Surg, 2002 •
 Functional Free Muscle

 Indications

 Deficiency of critical motor function with no suitable

tendon transfer options.

 No suitable rotational muscle transfer - available

 Soft tissue defect requiring coverage in combination with

functional loss.
Functional Free Muscle - Indications

 Functional reconstruction after:

▪▪ Volkmann ischemic contracture

▪▪ Severe brachial plexus preganglionic injury

▪▪ Long-standing neurologic injury

▪▪ Loss of muscle from trauma

▪▪ Loss of muscle from tumor resection

▪▪ Electrical injuries to the upper extremity

▪▪ Congenital muscle absence

FFMT - Upper Extremity Indications

▪▪ Deltoid reconstruction

▪▪ Triceps reconstruction

▪▪ Elbow flexion

▪▪ Finger flexion

▪▪ Finger extension

▪▪ Thumb opposition
 Contraindications - Absolute

▪▪ Medical comorbidities that would not allow a patient to undergo a long

surgical procedure safely

▪▪ No acceptable donor nerve to innervate the transferred Muscle / Inadequate

recipient vessels for microvascular anastamosis

▪▪ Patient unable to participate in and complete the time-consuming

rehabilitation program for the FFMT
 Contraindications - Relative

▪▪ Poor passive range of motion of the involved joints across which the muscle is
to act: The patient may require staged procedures to prepare the upper extremity
for the FFMT, such as tenolysis, capsulotomies, and/or contracture release. This
requires attentive postoperative physiotherapy before the staged FFMT.

▪▪ Lack of antagonistic muscle function: This can be reconstructed with a double

transfer or a second FFMT, or function can be augmented with additional
procedures, such as total wrist arthrodesis.

▪▪ Poor soft-tissue coverage: The FFMT can include a skin paddle to address both a
soft-tissue loss as well as a functional loss.

▪▪ Poor sensation in the hand of the extremity requiring reconstruction: This can
be addressed with sensory nerve reconstruction either before or at the same time as
the FFMT.
 Functional Free Muscle Goals (Manktelow)

 • Supply a useful range of motion.

 • Provide adequate strength for functional activities.

 • FMT must be under volitional (ones will) control.

 Manktelow, Zuker, McKee. Functioning free muscle transplantation. J Hand

Surg [Am]. 1984
 Ideal Candidates for FFMT

▪▪ Excellent results in children

▪▪ Adult patients ideally under the age of 45

▪▪ Compliant and motivated patient

▪▪ Healthy, with no comorbidities that would put the patient at risk during the
FFMT or that would compromise the ability to complete the extensive
rehabilitation Post-op.

▪▪ Access to skilled therapists, knowledgeable in upperextremity and FFMT

rehabilitation
Functional Free Muscle - Pre-requisites

▪▪ Stable soft-tissue coverage at the reconstruction site.

▪▪ Full passive range of motion of the joints across which the transfer will act

▪▪ Tendons with adequate gliding

▪▪ Antagonistic muscle function required.

▪▪Reconstructive site with reliable recipient vessels for microvascular

anastomosis

▪▪ Reconstructive site with a pure, undamaged motor nerve to innervate the

FFMT

▪▪ Less complicated options for reconstruction either not available or

unsuccessful
 There is no fixed time limits for the procedure from
the time of injury or loss of function – Provided all
the prerequisites are fulfilled.
Mathes Nahai – Myocutaneous
Flap
 Free muscle transfer

• Type of blood supply

I. One vascular pedicle - Rectus femoris,Tensor fascia lata, AbdDM.

II. Dominant pedicles and minor pedicles - Gracilis, Biceps femoris, Soleus,

Trapezius.

III.Two Dominant Vessels – Rectus Abdominis, G.Maximus, Serratus,

Temporalis.

IV. Segmental Supply – Sartorius, T.Anterior, FHL.

V. One dominant pedicle and secondary segmental pedicles - Latissimus dorsi,

Pectoralis major.
 Donor Muscle Options

 Gracilis
 Latissimus
 Rectus femoris
 Pectoralis Major
 Medial gastrocnemius
 Tensor fascia lata
 Serratus
Donor Muscle - General Considerations

• Expendible donor muscle

– sacrificed with acceptable donor site Morbidity

• Adequate length and excursion for new function

• Vascular pedicle permits transfer

 Muscle Type – pennate (stronger) Rectus femoris – strap (better
excursion) Gracilis, Latissimus dorsi

• Cross sectional area – pennate - greater cross sectional area results in

greater strength.

Muscle Excursion – Ideally 6-7 cm of muscle excursion to produce

functional range of flexion of fingers and elbow.
 Examination/Imaging

 Physical Exam

▪▪ A detailed preoperative physical exam is important to evaluate which nerves are

functioning in the upper extremity, and to identify the options for innervating the FFMT.

▪▪ A focused vascular exam of the upper extremity is also important. This involves
identifying palpable arteries and those that can be identified by Doppler. It is also
important to perform a preoperative Allen test for planning reconstructive procedures
in the forearm.

▪▪ The soft-tissue coverage for the site of the transfer should be assessed to ensure it is
adequate.

▪▪ Passive range of motion of the joints across which the muscle is to act should be
evaluated, and the excursion of the recipient tendons should be tested.
 Investigation

▪▪ Nerve conduction studies are usually not helpful for preoperative planning.

▪▪ Electromyography can be useful to evaluate pronator quadratus, which can

give useful information about the functional status of the anterior
interosseous nerve.
 Surgical Technique

▪▪ Free functional muscle transfers are complex reconstructive procedures that

often require prolonged operative time, and skilled anesthesiologists
experienced in the care of patients undergoing these procedures.

▪▪ It is important that the patient maintain excellent peripheral perfusion and a

normal body temperature during the procedures so as not to compromise
the FFMT. It is also important the patients do not receive long-acting
paralytic medication, to enable intraoperative stimulation of donor nerves.

.
▪▪Well-maintained microsurgical instruments are important for the microsurgical
component of the procedure.

▪▪ The operating microscope is used.

▪▪ 9.0 or 10.0 nylon suture is used with 70–100 micron needle for the vascular
anastomosis and nerve coaptation.

▪▪ A nerve stimulator is needed.

▪▪ Fibrin glue is used to augment the nerve coaptation.

 Patient Positioning

▪▪ For free functional gracilis muscle transfers, patients are most commonly
placed supine. This allows access to the upper extremity for reconstruction
as well as to the leg for gracilis muscle harvest.

▪▪ The gracilis muscle is harvested with the patient in a frog-leg position.

▪▪ The preference is to use the contralateral gracilis for elbow flexion and
finger extension reconstruction and the ipsilateral gracilis for finger
flexion reconstruction. This orientation is chosen based on the position of
the recipient vessels.

▪▪Free functional latissimus dorsi muscle transfer requires planning for patient
positioning.
▪▪ The latissimus dorsi muscle can be harvested with the patient either prone or
in the lateral decubitus position.

▪▪ Muscle transfer and origin and insertion creation require repositioning the
patient into the supine position.

▪▪ Occasionally, for finger flexion or extension reconstruction, the entire

procedure can be performed in the lateral decubitus position.

▪▪ A tourniquet is used on the upper extremity during the preparation of the

forearm for functional finger flexion or extension reconstruction.

▪▪ It is important to ensure the tourniquet is deflated, before performing the

microvascular anastomosis
 Surgical Sequence

▪▪ Before harvesting of a free functional muscle, the recipient site should be

dissected and prepared. This is done to ensure there is adequate arterial
inflow and venous outflow for the transferred muscle, as well as a suitable
donor nerve.

▪▪ The dissection can often be difficult, depending on the amount of scar tissue
in the site for reconstruction. This can be made easier by working in a
proximal to distal direction along the damaged structures and going from
normal to abnormal tissue.

▪▪ The new origin and insertion for the free functional muscle should be
prepared before transfer. This may include placement of strong,
nonabsorbable (PDS) suture to secure the muscle once it is harvested.
▪▪ Plan incisions for exposure and for tendon coverage.

▪▪ Prepare tendon for muscle insertion – to maintaining normal cascade.

▪▪ Select healthy vessels close to the muscle pedicle.

▪▪ Select healthy motor nerve.

▪▪ Perform a nerve repair as close to the muscle as possible to minimize time of denervation.

▪▪ Secure fixation at origin and insertion to minimize stretching.

▪▪ Ensure correct resting length of the muscle.

▪▪ In obese patients, deltoid reconstruction and elbow flexion can have less than optimal
results due to the weight that the transferred muscle has to control.

▪▪ If there is any question on the health of the donor nerve to power the FFMT, an
intraoperative biopsy should be performed before starting the functional muscle dissection.
 Pitfalls

 Acute surgical complications

▪▪ Infection.

▪▪Wound breakdown.

▪▪ Arterial inflow or venous outflow failure (even if the patient can be brought back to
the operating room and the problem is corrected, the functional outcome is
significantly compromised, especially if the ischemic period is greater than 1 hour).
 Delayed

▪▪ Tendon adhesions.

▪▪Wrist flexion deformities caused by weak antagonistic extensor muscles or from

ongoing growth in the pediatric population (these can be prevented with diligent
night splinting until bony maturity, or corrected with wrist arthrodesis).
 Gracilis

 Relevant Anatomy

▪▪ The gracilis is a strap muscle, with an average muscle fiber length of 24 cm. The
muscle fibers insert sequentially into its tendon.

▪▪ An adult gracilis muscle shortens 12 to 16 cm when stimulated to maximal

contraction; hence, the useful range of powerful muscle excursion is ~ 8 to 10
cm.

▪▪ The gracilis is anatomically located in the medial thigh, posterior to the adductor
longus muscle and superior to the adductor magnus muscle.

▪▪ The sartorius muscle is lateral.

▪▪ The semimembranosus and semitendinosus muscles are posterior.

▪▪ The origin is the pubic tubercle.

▪▪ The insertion is over the medial aspect of the tibial tubercle (pes anserinus).

▪▪The gracilis muscle is classified as a type II muscle, with a dominant pedicle

and minor pedicles.

▪▪ Its dominant blood supply is the ascending branch of the medial femoral
circumflex artery, originating from the profunda femoral artery, and entering
the superior third of the muscle. The pedicle enters 8–12 cm distal to the
origin of the muscle at the pubic tubercle. It is 1–2 mm in diameter and can
be dissected to 4–6 cm in length.

▪▪ Minor blood supply: 1–2 perforators from the superficial femoral artery
entering the distal half of the muscle.
▪▪ The dominant pedicle has two venae comitantes, each measuring 1 to 4 mm
in diameter. They commonly converge to one main vena comitans at the
level of the profunda femoral vein.

▪▪ Innervation is from the obturator nerve (anterior division).

▪▪ There is a single motor nerve, the anterior branch of the obturator nerve,
composed of two or three fascicles. The nerve enters the muscle
immediately proximal to the vascular pedicle and lies under the adductor
longus. With nerve stimulation, the adult gracilis muscle shortens more than
50% of its extended length, for a functional contraction of 12 to 15 cm.
▪▪ By using a nerve stimulator with frequency and voltage control, it is usually
possible to separate the muscle into longitudinal, separately functioning
neuromuscular territories.

**Ninety percent of the time, a single fascicle controls the anterior 20% to
50% of the muscle, with the remaining portion controlled by the remaining
fascicles.

▪▪ This functional separation is useful when the muscle is used to provide

independent thumb and finger flexion.
 Gracilis
▪▪ The axis for a myocutaneous flap is marked 2–3 cm posterior to a line between the pubic

tubercle and the medial femoral condyle.

▪▪ The gracilis is usually more posterior in the medial thigh than initially thought, and

palpation of the adductor longus can help to ensure the designed incision is in the

correct position.

▪▪ A skin paddle is can be designed over the center of this axis. This can cover the entire

length of the muscle and remain viable by including an extended amount of the fascia

from the surrounding muscles.

▪▪ The skin is first incised distally to isolate the gracilis tendon. Once it is identified, it is

freed circumferentially and a Penrose drain is placed around it. With traction on the

muscle, the central axis of the flap can be confirmed.

▪▪ The skin is incised around the skin paddle, and the subcutaneous tissue is
beveled outward down to the fascia.

▪▪ Once the fascia is encountered, the subcutaneous tissue is elevated widely

both anteriorly and posteriorly to maximize the blood supply to the skin
paddle. This is particularly important with large skin paddles.

▪▪ A superficial branch of the saphenous vein is included with the cutaneous

paddle proximally to augment venous outflow from the flap once it is
transferred if needed. The saphenous vein can also be used as a landmark
during dissection through the subcutaneous tissue, and if it is encountered,
this suggests dissection is too anterior and should proceed posteriorly and
inferiorly down to the gracilis muscle fascia.
▪▪ Once the surrounding fascia is divided widely, it is sutured to the overlying skin
paddle to prevent shearing injury during the remainder of the dissection.

▪▪ The muscle is isolated on its neurovascular pedicle in a distal to proximal

direction.

▪▪ The minor pedicles are encountered during this dissection and need to be divided.

▪▪ Once the dominant pedicle is identified, it can be dissected back to branches

traveling upward to the adductor longus muscle. and the vessels are traced to
their origin from the profunda femoral artery. At this level, the two venae
comitantes usually converge to form a single vein originating from the profunda
femoral vein. A pedicle length of 4–6 cm should be expected.
▪▪ The obturator nerve is found just proximal to the vascular pedicle and should be
dissected to an adequate length. This is done to ensure no nerve grafts are needed
for coaptation in the upper extremity.

▪▪ Before division of the origin and insertion of the gracilis, the resting length of the
muscle should be marked. The hip is maximally abducted and the knee extended. Silk
sutures are placed at 5 cm intervals.

▪▪ The insertion of the muscle is divided first, followed by the origin. The gracilis muscle
should be completely surrounded by fascia after completion of the dissection.

▪▪ The neurovascular pedicle is divided only once the microscope has been brought into
the operative field for the upper extremity and the donor vessels and nerve have been
properly prepared. In addition, the new origin and insertion for the muscle in the upper
extremity should be ready to receive the gracilis muscle before the pedicle is divided.
Achieve optimal muscle resting length
 Revascularization
▪▪ Once the gracilis neurovascular pedicle is divided, it is brought to the upper
extremity and prepared under the microscope.

▪▪ The muscle should be placed in the position of full stretch before

anastomosis to ensure the pedicle does not kink or become stretched with
motion.

▪▪ Coaptation of the nerve should be performed as close to the muscle as

possible to minimize the time for reinnervation.

▪▪ The nerve repair is performed using the surgical microscope with minimal
suturing using 9.0 or 10.0 nylon and augmented with fibrin glue.

▪▪ The vascular anastomosis is completed using 9.0 or 10.0 nylon suture.

▪▪ Approximately 5 minutes following the arterial and venous anastomosis is
allowed to observe revascularization of the muscle. Following this, the venous
flow though the comitant vein should be assessed and can indicate the
adequacy of perfusion. The vein should not appear engorged or have a dark
color.

▪▪ The edge of the skin paddle, or muscle, can also be used to assess the success
of the anastomosis, where bright blood should be seen from its divided edge.

▪▪ The goal is to limit the ischemia time to 30 minutes.

▪▪ Outcomes are less successful if there are problems with reperfusion or if

establishment of good arterial inflow and venous outflow to the muscle takes
longer than 2 hours.
 Latissimus Dorsi

▪▪ The latissiumus dorsi is anatomically located in the posterior-inferior trunk.

▪▪ The majority of the muscle is superior to the posterior trunk musculature

(erector spinae, serratus posterior inferior, and serratus anterior).

▪▪ The lateral border can have adhesions with the serratus anterior muscle, and it
is important to recognize and divide these during flap harvest.

▪▪ The origin is the T6–T12 vertebrae, lower four ribs, posterior iliac crest, and
minor attachments to the scapula.

▪▪ The insertion is the medial border of the intertubercular groove of the humerus.

▪▪ The latissimus dorsi muscle is classified as a type V muscle, as it has one

dominant artery and multiple segmental perforators.
▪▪ Its dominant blood supply is the thoracodorsal artery, originating from the
subscapular artery. It is 1.5–3.0 mm in diameter and enters the muscle ~
10–15 cm inferior to the muscle insertion on the humerus.

▪▪ Its minor blood supply consists of posterior lumbar perforating vessels,

medially, and posterior intercostal perforating vessels, laterally.

▪▪ The dominant artery is accompanied by two venae comitantes, which usually

join to form a single vein as they approach the subscapular vein. The single
vena comitans usually varies in size from 3 to 5 mm.

▪▪ Innervation is from the thoracodorsal nerve.

▪▪ The nerve travels with the vascular pedicle.

▪▪ Like the obturator nerve supplying the gracilis, the thoracodorsal nerve divides into
two motor territories that can be isolated for independent functional reconstruction.
One division supplies the lateral portion of the muscle, and the other supplies the
medial portion, allowing two functionally separate neuromuscular territories in 80%
of muscles.

▪▪ An oblique incision is designed from the posterior axillary line superiorly, to the
posterior inferior iliac crest inferiorly. This parallels the lateral border of the
latissimus dorsi muscle.

▪▪ The skin paddle is centered on the muscle and should start 6–8 cm inferior to the
axilla.

▪▪ The skin paddle can extend as far distally as needed to cover the transferred muscle
completely.
▪▪ The ideal skin paddle width should be 8–10 cm or less to ensure the donor site can
be closed primarily. This is influenced by the laxity of the patient’s skin and the
patient’s body habitus.

▪▪ The incision is made around the skin paddle and the subcutaneous tissue is
beveled outward to preserve as much blood supply as possible.

▪▪ The fascia overlying the muscle should be preserved, as this facilitates muscle
contracture and glide once transferred to the upper extremity.

▪▪ Once the subcutaneous tissue has been completely elevated from the muscle and
its fascia, the resting length of the latissimus dorsi is marked with the arm in
180 degrees of abduction and forward flexion. Silk sutures are placed at 5 cm
intervals starting from the musculotendinous junction
▪▪ The origin of the muscle is divided, and the muscle is then elevated toward the
insertion.

▪▪ Minor pedicle perforators from the lumbar and intercostal vessels should be ligated
during the dissection.

▪▪ During elevation, the vascular pedicle to the underlying serratus anterior is identified
lying on the superficial surface of the muscle, and this is used as a key landmark to
identify common thoracodorsal pedicle.

▪▪ The serratus pedicle is ligated close to its division with the thoracodorsal artery to allow
the dissection to continue superiorly.

▪▪ The thoracodorsal pedicle can then be traced to its origin from the subscapular artery.
This requires division of several other branches, such as those to the teres major, as
well as the circumflex scapular artery and venae comitantes.
▪▪ The thoracodorsal nerve travels with the vascular Pedicle, and careful attention
should be paid to ensure no injury occurs to the nerve during the dissection.

▪▪ Once the neurovascular pedicle is identified and protected, the dissection

superior to this can proceed rapidly. This allows the isolation of the latissimus
dorsi tendinous insertion on the humerus. The tendinous portion of the muscle
should be divided as close to the insertion as possible.

▪▪ The same principles outlined for the gracilis muscle harvest apply for the
latissimus dorsi, where the neurovascular pedicle should be divided only when
the recipient site has been prepared completely to receive the muscle.

▪▪ The revascularization principles outlined for the gracilis muscle are identical for
the latissimus dorsi in upper extremity reconstruction.
 Site-Specific Reconstruction Principles

 Deltoid –

▪▪ The acromion and distal half of the clavicle are used for the origin of the
FFMT

▪▪ The insertion is usually into the humerus directly or into remnants of the
deltoid anatomic insertion on the anterolateral portion of the humerus.

▪▪ If possible, the thoracodorsal artery is used as the recipient artery. The venae
comitantes are used for venous outflow.

▪▪ The muscle is sutured into position, with the origin firmly fixed to the
acromion and clavicle by sutures or anchors. After anastomosis of the artery
and the vein, the motor nerve (branch of Accesory nerve) is coapted.
Gracilis muscle inset as FFMT for deltoid reconstruction. Origin is created from the lateral half
of the clavicle, with the insertion into the humerus at the deltoid
▪▪ The resting length of the muscle is recreated with the shoulder in
hyperextension posteriorly, and the muscle is then stretched until the marks
are 5 cm apart.

** This length is noted, and then insertion repair is performed with the arm
forward flexed and abducted to remove tension.

▪▪ The arm is immobilized in this position for 8 weeks.

 Elbow Flexion

▪▪ The musculocutaneous nerve is usually used in cases of biceps and brachialis

muscle loss. Approximately 50% of the cross-sectional area of the
musculocutaneous nerve is sensory, and the cross-sectional diameter is much
larger than the gracilis motor nerve. It is therefore necessary to identify the motor
component of the musculocutaneous nerve to obtain good innervation. This can be
done by identifying branches that lead to remnants of the biceps and brachialis.

▪▪ The most suitable donors in cases of multiple root avulsions are the suprascapular
nerve, or the second to fourth intercostal nerves, which can be directly coapted to
the gracilis recipient nerve in the upper arm without a nerve graft. Phrenic nerve
palsy is a relative contraindication.
▪▪ The intercostal nerves travel in the intercostal space inferior to the intercostal artery
and vein. The intercostal nerves contain between 1,200 and 1,300 myelinated
fibers. Each nerve divides into a motor branch, a lateral sensory branch to the
chest wall, and a collateral branch. Each intercostal nerve ends in anterior
cutaneous branch.

▪▪ The motor branch is usually deep to the sensory branch and can be followed
beyond the mid-clavicular line.

▪▪ An anterior thoracic exposure facilitates direct suture of the intercostal nerves to the
gracilis recipient nerve. A semicircular incision is extended from the usual upper
arm incision at the anterior border of the axilla onto the chest wall. The nerve is
located between the intercostales intimi and the internal intercostal muscles, taking
care not to perforate the pleura.
▪▪ Insetting of the origin for the FFMT is performed into the lateral third of the clavicle to
the acromion using either sutures directly or suture anchors.

▪▪ The brachial artery, profunda brachii, humeral circumflex arteries, and ulnar recurrent
artery are suitable donor vessels for the FFMT. Venae comitantes are usually
available for venous anastomosis.

▪▪ The distal insertion is ideally into the biceps tendon. Alternatively, suture anchors can
be used in the radial tuberosity, or a drill hole at the same level in the ulna, if the
biceps tendon is unavailable.

▪▪ The resting length of the muscle is recreated with the arm in full extension at the
elbow. Once this is marked, the insetting is performed with the elbow flexed to 90
degrees to remove tension from the repair site.

▪▪ The arm is immobilized with the elbow flexed at 90 degrees for 7–8 weeks.
Elbow flexion reconstruction with free functional gracilis muscle. Origin is created at the
lateral third of the clavicle and the acromion. The distal insertion is ideally into the biceps
tendon.
 Triceps Reconstruction

▪▪ Ideally, branches of the radial nerve are used for for reinnervation. Any suitable
local vessels can be used for revascularization, including the brachial artery and
axillary vein.

▪▪ If this is not possible, intercostal nerves or the spinal accessory nerve can be used.

▪▪ The origin for the transferred free function muscle is inset into the superior-lateral
aspect of the scapula or the posterior aspect of the acromion.

▪▪ The insertion is created either into the triceps tendon distally at its insertion to the
olecranon, or into the olecranon directly using drill holes and suture anchors.

▪▪ The resting length for the muscle is recreated with the elbow in full flexion.

▪▪ The distal insertion is sutured with the elbow reduced to ~ 20 degrees of flexion to
remove tension from the repair site.
Triceps reconstruction with gracilis FFMT.
 Finger Flexion

▪▪ The prerequisites for this transfer have been mentioned and include supple
finger joints, undamaged tendons in the hand, intrinsic muscle function,
motors for finger extension and wrist stabilization, good skin coverage in the
distal forearm, and an undamaged motor nerve.

▪▪ The origin for a free functional muscle used to restore finger flexion should
be the medial epicondyle.

▪▪ Insertion is placed into the flexor digitorum profundus (FDP) tendons for the
index, long, ring and small fingers. These need to be prepared before repair
with side-to-side suturing to allow them to function as a single unit. The
flexor digitorum superficialis (FDS) tendons are excised at the wrist to help
minimize adhesion formation.
▪▪ The FFMT is secured to the FDP tendons using a Pulvertaft weave for
maximal strength. Tensioning of this weave should be performed so there is
a slight progressive increased flexion of the digits from radial to ulnar.

▪▪ The resting length for the muscle is recreated with the wrist and fingers in full
extension. Once the location for the tendon suturing is marked, this is then
performed with the wrist and fingers in flexion to minimize tension on the
repair.

▪▪ Thumb flexion restoration requires special mention.

▪▪ If there are no tendon transfer options, the flexor pollicis longus (FPL) tendon
can be woven with the FDP tendons to the gracilis tendon to allow for
combined finger and thumb flexion.
▪▪ It is important that the FPL not be tensioned as tight as the finger flexors in
order for the fingers to flex before the thumb, and to allow for the thumb to
pinch against the index for key pinch.

▪▪ If a gracilis muscle is used, this can be divided into separate neuromuscular

territories to allow for independent finger and thumb flexion. The obturator
nerve fascicles are individually stimulated before the muscle is
harvested to mark the territories. Two donor nerves are required for 2
separate nerve coaptations.

▪▪ Postoperatively, the hand is splinted with the wrist at 20–30° of flexion, the
MCP joints at 70–90° flexion, and the IP joints straight.
▪▪ The thumb is splinted in abduction with the MCP and IP joints in slight flexion.

▪▪ For the first 4 weeks postoperatively, the elbow is also splinted in flexion of ~
90 degrees. Passive range of motion flexor tendon protocols are employed
during this time period.
 Finger Extension

▪▪ The posterior interosseous nerve is the nerve of choice for finger extension
after it exits from the supinator.

▪▪ The arteries on the extensor aspect of the forearm are usually inadequate for
anastomoses; hence, the radial artery can be used as an end-to-side repair
or the radial recurrent branch of the radial artery. Routing of the gracilis
artery to the radial artery can be either under or over the extensor carpi
radialis brevis and longus and the brachioradialis. The deep location is
preferred because it is better protected than when lying on the surface. A
superficial or deep vein in the forearm is usually used for venous outflow.

▪▪ The origin of the muscle is reattached to the lateral epicondyle and

surrounding fascia.
▪▪ The extensor digitorum communis tendons are woven together to allow for
coordinated finger extension. The extensor pollicis longus (EPL) tendon can
also be rerouted and incorporated into the tendon coaptation with the FFMT.
This is performed if there are no good tendon transfer option for thumb
extension/abduction.

▪▪ The correct resting length of the muscle is restored with the fingers and wrist
placed in full flexion. The position of tendon overlap is noted, and the wrist is
then brought into extension to remove tension from the repair site.

▪▪ Tendon-to-tendon repairs are performed with a Pulvertaft weave.

▪▪ Postoperative care involves maintaining the wrist in 30–45 degrees of
extension, with the MCP joints flexed at 70 degrees, and the proximal
interphalangeal (PIP) and distal interphalangeal (DIP) joints in full extension.

▪▪ In addition, the elbow is maintained flexed at 90 degrees for 4 weeks.

 Dressings and Postoperative Monitoring and Care

▪▪ The initial postoperative care is similar to that for other free tissue transfers
and involves close monitoring for 3–5 days.

▪▪ The first 24 hours is the most critical time, and flap checks should be
performed every 30 minutes to 1 hour.

▪▪ Therapists involved in the care of these patients post operativelyare

important to the success of the procedure. The first few weeks to months
involve passive stretching of the upper extremity to ensure that contractures
do not develop, and for the tendons to maintain their gliding.

▪▪ Electrical stimulation of the muscle is performed with a transcutaneous

muscle simulation device twice a day, either by the therapist or by the patient
and family at home.
▪▪ When spontaneous muscle contraction is observed, the patient is
encouraged to contract the muscle actively throughout the day.

▪▪ Resistance exercises are started 3–4 months after surgery to ensure that
rupture of the muscle origin or insertion does not occur. A graduated strength
program is then initiated.

▪▪ Swim therapy programs are excellent for range of motion and strength.
 Outcomes

▪▪ Muscle contraction in the transferred muscle can be expected to be observed 3–6

months after surgery.

▪▪ Functional outcomes can continue to improve up to 2 years following transfer.

▪▪ Patients requiring free FFMT have a great variability in their initial presentation and
functional deficits, and this can make objective comparisons of outcomes difficult.

▪▪ For shoulder reconstruction, an excellent outcome would include shoulder

abduction of 80 degrees or greater.

▪▪ Patients undergoing FFMT to restore deltoid anterior flexion and active shoulder
flexion to ~ 60 degrees, and it may correct chronic glenohumeral subluxation.

▪▪ FFMT for elbow flexion should result in the ability to flex at least 90–120
degrees.
▪▪ Goals for the transfer are British Medical Research Council (BMRC)
strength 4 or greater, and the ability to lift a 5-pound (2.25 kg) weight.

▪▪ Kay et al found 70% of their patients to achieve a > 1 BMRC gain in strength
to BMRC 3 or greater.5

▪▪ Chuang et al achieved BMRC strength of 4 or more in 100% of their patients

using the musculocutaneous nerve as a donor to power the FFMT. With
intercostal nerves used for donor nerves, BMRC > 4 was achieved in 78% of
their patients (18/23).

▪▪ For finger flexion reconstruction, results are considered excellent when the
fingers can flex to touch the proximal palmar crease and coordinated pinch
can be achieved.
Serratus Anterior
Rectus Femoris
Illustrative case:
Free gracilis transfer to reconstruct finger flexion after
rhabdomyosarcoma resection
Free gracilis for finger flexion

tumor
Free gracilis for finger flexion
Free gracilis for finger flexion
Free gracilis for finger flexion
Free gracilis for finger flexion
 Illustrative case:

Free serratus anterior to reconstruct opposition 3 yrs

after crush left hand and thenar muscle debridement.
 .
Imaging
Loss of opposition function and significant
loss of thenar bulk preoperatively.
Operative
Preparation of recurrent motor branch of median nerve to innervate FFMT
 Operative

Preparation of origin and insertion in

hypothenar and thenar pockets in the
hand.
Operative
 Operative

Serratus anterior
Operative
Operative
Operative
Opposition retraining postoperatively, 3
months posttransfer.
Reconstruction of thumb
opposition with free functional
serratus anterior muscle transfer
Immediate Reconstruction
of
finger flexion after severe
Compartment Syndrome
with liquifactive muscle
necrosis
Immediate Functional
Reconstruction
Flexor Tendons

Median Nerve
Functioning Free Gracilis Muscle Transfer for Restoration
of Elbow Flexion in Adult Brachial Plexus Palsy – (Ganga
Hospital)

Right sided global palsy,with failed spinal

accessory to musculocutaneous nerve transfer.
Vascular anastomosis between the thoracoacromial
trunk and the gracilis pedicle
Pilot holes being drilled in the clavicle with a 1.5
mm k wire.
Nerve co-aptation between the obturator and Spinal
accessory nerves.
PDS sutures being passed through the clavicle
PRE Op 18 month post
operative showing MRC
Grade 4 outcome
 Summary

 Free functional muscle transfers are innovative procedures that are at the
cutting edge of upper extremity reconstruction.
 When they are performed successfully, the functional outcome for severely
debilitating injuries can be greatly improved, resulting in a rewarding result
for the patients and the surgical teams involved in their care.
References
 Zuker RM, Manktelow RT. Functioning free muscle transfers. Hand Clin 2007;23(1):57–72 PubMed

 Seal AN, Stevanovic M. Free functional muscle transfer for the upper extremity. Clin Plast Surg 2011;38(4):561–575

 Doi K, Muramatsu K, Hattori Y, et al. Restoration of prehension with the double free muscle technique following
complete avulsion of the brachial plexus. Indications and long-term results.J Bone Joint Surg Am 2000;82(5):652–666
PubMed

 Manktelow RT, Zuker RM, McKee NH. Functioning free muscle transplantation. J Hand Surg Am 1984;9A(1):32–39
PubMed

 Kay S, Pinder R, Wiper J, Hart A, Jones F, Yates A. Microvascular free functioning gracilis transfer with nerve transfer
to establish elbow flexion. J Plast Reconstr Aesthet Surg 2010;63(7): 1142–1149 PubMed

 Chuang DC, Epstein MD, Yeh MC, Wei FC. Functional restoration of elbow flexion in brachial plexus injuries: results
in 167 patients (excluding obstetric brachial plexus injury). J Hand Surg Am 1993;18(2):285–291 PubMed

 Functioning Free Gracilis Muscle Transfer for Restoration of Elbow Flexion in Adult Brachial Plexus Palsy - The Ganga
Hospital Approach - Hari Venkatramani, Praveen Bhardwaj, S Raja Sabapathy.