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One approach to reanimating both upper and lower lips following facial palsy is through staged surgery: cross-face nerve grafting at stage I, free gracilis muscle transfer to levators at stage II and pedicled anterior belly of digastric muscle transfer (ABDMT) to depressors at stage III. The results of this approach were hitherto unquantified.This study retrospectively assessed peer-reviewed, patient-rated and objective outcomes following staged reanimation in adults between 2010 and 2020. Demographics, palsy characteristics and surgery details were recorded. Pre- and postoperative videos were rated by independent assessors using Terzis' aesthetic and symmetry scale. Photographs were analysed using Emotrics and patients completed the Glasgow Benefit Inventory (GBI) patient-rated outcome measure.Ten patients [mean age = 34 (SD = 12.48)] were eligible. All regained lip elevation and depression. All markers of symmetry improved after gracilis transfer. All markers were also improved after ABDMT except for lower lip height when smiling with teeth showing (p 0.05). Five patients (50%) responded to the GBI (mean score = +39.44). No patients reported detriment from the reanimations. Mean Terzis' scores preoperatively and after stages II and III were 1.5, 2.26 and 2.39, respectively (p 0.05). Nine patients underwent aesthetic refinements [lipofilling to lower lip notches (n = 5), debulking of gracilis bulk (n = 6), repositioning of muscle insertion (n = 5) and facelifts (n = 2)].The outcomes were positive objectively and as judged by peers and patients themselves. Aesthetic refinements may also be required to enhance these results.

Summary Introduction When the DIEP flap is unavailable, autologous reconstruction of a moderate-to-large breast presents a surgical challenge. We retrospectively review our experience of unilateral breast reconstruction using double TUG flaps and highlight specific technical considerations. Methods Thirty-four patients underwent double TUG flaps for unilateral breast reconstruction between 2012 and 2020. The average patient age was 50 years and the average BMI was 23.1kg/m2. In all cases, the indication for surgery was breast cancer: 31 patients had immediate reconstruction, 11 had simultaneous axillary surgery and eight had primary contralateral symmetrising surgery. Results Of the 68 TUG flaps, 67 (98.5%) were successful. The mean operative time was 5 hours 50 minutes (195- 460mins) and the mean combined flap weight was 551g (279- 916g). Eight patients returned to the operating theatre in the early post-operative period and five patients underwent secondary lipofilling to address contour deformities. Most commonly (n=22), the flaps were orientated horizontally/obliquely, with one flap anastomosed medially to the internal mammary axis and the other anastomosed lateral to the subscapular system. The internal mammary artery perforators and serratus anterior artery provided the best vessel calibre match with the TUG vessels. Conclusions Double TUG reconstruction is a safe and reliable option for unilateral breast reconstruction and is an important option when the DIEP flap is unavailable.

Background: Functional restoration of upper limb paralysis represents a major reconstructive challenge. Free functional muscle transfer (FFMT) enables reanimation in patients with a lack of local donor tissues or delayed presentation. This systematic review summarises the evidence for FFMT in the reconstruction of upper limb paralysis. Methods: A comprehensive search of MEDLINE and EMBASE was performed with a systematic review using methodology adapted from the Cochrane Handbook and the PRISMA statement. Data from included studies were compiled and narratively synthesised. Studies were assessed for risk of bias. Results: A total of 1155 records were screened, with 39 observational studies of 904 patients included. The most common aetiology was brachial plexus injury (736, 81.4%). Mean time from injury to intervention was 26 months. Restoration of elbow flexion was the commonest reconstructive goal. The most common donor muscle was gracilis (91.5%). Reported outcomes were heterogeneous with patient-reported outcome measures (PROMs) available in only 7 of 39 studies. Nearly half of FFMTs had a post-operative MRC grade of Conclusions: FFMT may be an effective surgical intervention for upper limb paralysis; however, the current evidence has significant shortcomings. There is no consensus regarding outcome measures nor is it possible to identify prognostic factors for its effectiveness. This review highlights a need for improved study design with pre-operative assessment, standardisation in outcome reporting, and the use of PROMs to determine the effectiveness of FFMT in upper limb paralysis.

Dual innervation in free muscle flap facial reanimation has been used to create a functional synergy between the powerful commissure excursion that can be achieved with the masseter nerve and the spontaneity that can be derived from a cross-face nerve graft. The gracilis has been the most frequently used muscle flap, and multiple combinations of neurorrhaphies have been described, including the masseter to the obturator (end-to-end) combined with a cross-face nerve graft to the obturator (end-to-side) and vice versa. Single and staged approaches have been reported. Minimally, dual innervation is as effective as using the motor nerve to masseter alone.

Outcomes following free gracilis muscle transfer have steadily improved during the past decade. Areas for continued improvement include re-creating natural smile vectors, improving midface symmetry, minimizing scarring, improving spontaneity, and increasing reliability using various neural sources. Outcome standardization, pooled data collection, and remote data acquisition methods will facilitate comparative effectiveness research and continued surgical advancements.

Mutations in the TNNT1 gene cause an infantile, lethal form of myopathy named "Amish" Nemaline Myopathy. Adult patients are very rarely described. We report a 49-year-old patient who presented a slowly progressive phenotype characterized by myalgia, exercise intolerance and dyspnea since infancy. In adult life she lapsed into a coma as a result of acute respiratory failure, with the need of tracheostomy, subsequently removed once her respiratory condition improved. Afterwards, non-invasive ventilation was started. Short stature, contractures, a small size posterior cranial fossa and osteonecrosis were additional clinical findings. Muscle MRI showed minor hypotrophy and degenerative changes of the muscles of the posterior thigh compartment and involvement of the paraspinal, medial gastrocnemius and soleus muscles with sparing of the gracilis muscle. Muscle biopsy revealed multiminicores and nemaline rods. Genetic analysis identified a new pathogenetic biallelic deletion c.786delG p.(Lys263Serfs*36) in exon 13 of TNNT1 gene. This case confirms that recessive mutations in TNNT1 gene can manifest mainly with respiratory failure in adult life.

The main objectives of facial reanimation procedures include restoring facial symmetry at resting state and regaining facial mobility. Static procedures usually provide unsatisfactory results, especially in younger patients. For this reason, over the years, several different surgical alternatives based on autologous, locoregional, or muscle free flaps have been proposed. The gracilis muscle is the gold standard technique for dynamic reanimation of long-standing facial paralysis. The excessive muscle bulk and the differences regarding the type of predominant muscle fiber were compared with the zygomaticus major force reconstructive surgeons to search for alternatives to the gracilis as a potential free flap for reanimation. One of them is the sternohyoid muscle flap. We report a patient with long-standing facial paralysis who underwent a dynamic facial reanimation by using a sternohyoid muscle free flap, thus proposing the procedure as an alternative to the conventional gracilis muscle flap.

To compare isometric hamstring strength deficits, knee laxity, functional outcomes, and patient-reported outcomes between patients who underwent anterior cruciate ligament (ACL) reconstruction with doubled semitendinosus and gracilis tendon autograft (ST/G) versus quadrupled semitendinosus autograft (ST), at a minimum follow-up of 1-year postoperatively.Patients who underwent ACL reconstruction with ST/G or ST hamstring autografts were retrospectively identified. Isometric hamstring strength was tested with a hand-held dynamometer at 30, 60, and 90° of knee flexion. Anterior knee laxity was assessed using a KT-1000 arthrometer. Functional outcomes were collected using the single-leg hop test and single-leg squat test. Side-to-side differences were determined and compared between the ST/G and ST groups. Patient-reported outcomes were collected on all patients.Eighty-four patients who underwent ST/G (n = 34) or ST (n = 50) autograft ACL reconstruction were recruited to participate in this study. There was no difference in knee laxity between the groups. Side-to-side hamstring strength deficits increased with increased flexion angles. At 90° of flexion, the ST/G group had a significantly greater flexion strength deficit compared with the ST group (37.8 ± 15.1% vs 24.7 ± 12.5%, P.001). Aside from a significant difference in the KOOS pain Score (P .045), no other significant differences in functional or patient reported outcomes between the groups were identified.Patients who underwent ACL reconstruction with ST/G compared with ST autograft have a significantly greater isometric flexion strength deficit at 90° of flexion. Future investigations are required to determine the clinical relevance of this difference and whether specialized therapy protocols can mitigate this deficit.Level III, retrospective comparative study.

The gracilis muscle is one of the most frequently used muscles in reconstructive surgeries. It can be utilized as both less complex flaps and a free functional muscle flap to restore function to other muscles. As little is known of the precise extramuscular innervation of the gracilis muscle, the present study performs an accurate assessment to provide as much important anatomical information for clinicians as possible.A classical anatomical dissection was performed on eighty-five lower limbs (45 right, 40 left) fixed in 10% formalin solution. The variability in the extramuscular innervation of the gracilis muscle was assessed. Some morphometric measurements were collected.A four-fold classification of extramuscular innervation was created for the gracilis muscle. Type I (64.7%), the most frequent type, presented at least one proximal nerve branch. Type II (25.9%) lacked this branch. Type III (8.2%) possessed an additional neural supply from the muscular nerve branch innervating the adductor longus muscle. Type IV (1.2%) was similar to Type III, but the additional neural supply originated from the muscular nerve branch innervating the adductor magnus muscle.Clear anatomical variability was noted for extramuscular innervation of the gracilis muscle. All the presented Types seem to be suitable for splitting a muscle belly and use its part in free functional muscle transfer. However, it appears that Type III and IV may ease this procedure, because of the additional nerve branches. This classification system can deliver important information for clinicians performing complex reconstructive surgeries with the use of the gracilis muscle.

Replantation still remains the best form of reconstruction following major upper limb amputations. Regaining a functional limb is a challenge in avulsion amputations when there is entire loss of a compartment as it happens in proximal third of forearm amputations or when the avulsion occurs through the musculotendinous junction. In these circumstances, primary repair of the long flexors or extensors is not possible and options of secondary tendon transfers do not exist due to lack of donor tendons. These factors could weigh in negatively in making the decision for replantation at the time of presentation. We are presenting a series of 5 cases of avulsion amputation of the forearm wherein the functional outcome was enhanced by secondary Free Functional Muscle transfers (FFMT) using gracilis for finger flexion. Outcome scores improved from Chen IV to II in three patients and to III in two patients. The feasibility of gaining useful outcome through secondary procedures like FFMT should serve as an encouragement to extend the indications for replantation in avulsion amputations of the forearm.

Background Goals of lower extremity microvascular reconstruction (LEMR) include the restoration of function, prevention of infection, and optimal cosmesis. Indications for LEMR include large defects that are not amenable to pedicled options, a large zone of injury, and large complex defects. The novice microsurgeon should first master a handful of free flaps to develop an armamentarium of options for addressing such defects. The scope of this review is to provide free flap options for LEMR in any of the thirds of the lower leg. After reading this article, the reader will understand variations, advantages, disadvantages, indications, and tips for raising each of these flaps. Methods Six most commonly used free flaps for LEMR are described in this paper, including the anterolateral thigh flap (ALT) and its variations, the radial forearm flap (RFFF), the lateral arm flap (LAF), the gracilis muscle flap, the rectus abdominis flap (RAF) and the latissimus dorsi flap and its variations. Indications, advantages, disadvantages and technique tips are discussed for each flap. Moreover, selection of the recipient vessels, preoperative management along with an algorithm are also provided. Conclusions The ALT flap is a workhorse in covering defects of the leg, foot, and ankle. It's the flap of choice at our institution, especially given the number of traumatic wounds seen as a result of motor vehicles, all-terrain vehicles (ATV), lawnmowers, and gunshot wounds (GSW). At times, the lower extremity zone of injury requires a distant donor site. The RAF can also provide coverage for large soft tissue defects but donor-site morbidity remains its main drawback. The LAF and RFFF provide two pliable options, one that provides pliable soft tissue with minimal donor site morbidity and another that provides a long pedicle. The free gracilis flap is an excellent choice for crossing the ankle joint. Lastly, the free latissimus dorsi is indicated for large defects of the lower extremity independently of the location.

Background In cerebral palsy, spastic muscle's passive forces are considered to be high but have not been assessed directly. Although activated spastic muscle's force-joint angle relations were studied, this was independent of gait relevant joint positions. The aim was to test the following hypotheses intraoperatively: (i) spastic gracilis passive forces are high even in flexed knee positions, (ii) its active state forces attain high amplitudes within the gait relevant knee angle range, and (iii) increase with added activations of other muscles. Methods Isometric forces (seven children with cerebral palsy, gross motor function classification score = II) were measured during surgery from knee flexion to full extension, at hip angles of 45° and 20° and in four conditions: (I) passive state, after gracilis was stimulated (II) alone, (III) simultaneously with its synergists, and (IV) also with an antagonist. Findings Directly measured peak passive force of spastic gracilis was only a certain fraction of the peak active state forces (maximally 26%) measured in condition II. Conditions III and IV caused gracilis forces to increase (for hip angle = 45°, by 32.8% and 71.9%, and for hip angle = 20°, by 24.5% and 45.1%, respectively). Gait analyses indicated that intraoperative data for knee angles 61–17° and 33–0° (for hip angles 45° and 20°, respectively) are particularly relevant, where active state force approximates its peak values. Interpretation Active state muscular mechanics, rather than passive, of spastic gracilis present a capacity to limit joint movement. The findings can be highly relevant for diagnosis and orthopaedic surgery in individuals with cerebral palsy.

Summary PURPOSE Pelvic reconstruction following abdominoperineal resection or pelvic exenteration is associated with signification surgical site morbidity. Immediate pelvic reconstruction with a muscle flap is now the gold standard, associated with reduced perineal morbidity compared to primary closure alone. 2 , 3 The purpose of the present study was to directly compare outcomes of VRAM and gracilis flap pelvic reconstruction following oncologic resection. METHODS A multicenter retrospective review was performed of 88 patients who underwent abdominoperineal resection or pelvic exenteration and immediate pelvic reconstruction, either with a VRAM (N = 61) or Gracilis flap (N = 27). Electronic medical records were analyzed for patient demographics, intraoperative data, and postoperative outcomes. Mortality, minor complication rate, major complication rate and time to complete wound healing was compared between groups. RESULTS Overall, there was no significant difference in the minor complication rate (44% gracilis vs 48% VRAM, p = 0.8), major complication rate (19% gracilis vs 13% of VRAM, p = 0.53), 30-day mortality (0% VRAM vs 0% gracilis, p = 1.0) and median time to complete wound healing (68 days vs 67 days, p = 0.19) between the gracilis and VRAM groups. Muscle-only gracilis flaps had a significantly reduced healing time compared to musculocutaneous gracilis flaps (48 days vs 85 days, p = 0.007). CONCLUSIONS The workhorse flap in pelvic reconstruction remains the VRAM. While previous studies have alluded to the inferiority of thigh based flaps compared to the VRAM, we demonstrate here that pelvic reconstruction with the gracilis flap can be performed with comparable donor and recipient complication rates and similar time to complete wound healing as the VRAM.

Purpose To report the clinical outcomes of elbow flexion reconstruction using a reverse free gracilis muscle flap plus Steindler flexorplasty in patients with previously failed reconstruction of extended upper-type brachial plexus paralysis. Methods Twenty-four male patients were reoperated upon an average of 45 months (SD, ± 45 months) after brachial plexus repair. The gracilis tendon was secured to the acromion, and the muscle belly was sutured to the biceps distal tendon. Vascular repair was performed preferentially end to end to the radial artery and cephalic vein. Nerve repair was achieved by coapting the nerve to the gracilis to motor fascicles of the median or ulnar nerve. The medial epicondyle was osteotomized, proximally advanced by 4 to 5 cm and secured to the anterior side of the humerus. Results Active elbow flexion was restored in 23 of 24 patients. Sixteen patients ultimately achieved M4 strength, among whom 6 had full range of motion (ROM), and the remaining 10 recovered an average of 110° (95% confidence interval [95% CI], 100°–120°) of elbow flexion. Seven patients exhibited M3 elbow flexion strength recovery, which was associated with weaker hands and incomplete ROM, averaging 94° (95% CI, 86°–102°). There was, on average, a 10° (95% CI, 4.4°–15.6°). elbow flexion contracture. Among the 16 patients with M4 level recovery of elbow flexion, supination was partially restored in 12. Conclusions In patients previously operated upon, using a reversed free gracilis muscle flap in association with a Steindler procedure is effective as salvage surgery to restore elbow flexion and partial supination. Type of study/level of evidence Therapeutic IV.

The anatomy of gracilis muscle flap pedicle and its dissection technique are well described in the literature, although dissecting its most proximal portion is technically challenging, because of the deep location and the tension in the adductor muscles posed by the harvesting position. Some modifications have been described to facilitate proximal pedicle dissection, mainly combining approaches below and above the adductor longus muscle. Throughout his experience in several hundreds of gracilis free functioning muscle transfers, the senior author has found one maneuver particularly useful in deep pedicle dissection with minimal or no need for assistance.

Background Conflicting anatomical reports and the little attention given to the pubic ligaments impede the interpretation of radiological and clinical examinations on groin pain. Morphometric data on the pubic ligaments are lacking. Methods The muscular relations of the symphysis pubis were examined in layered dissection (n = 10), hemipelves (n = 60) and (un)stained plastinated body slices of body donors (n = 3). The sagittal and coronal areas, width, mean and maximum thickness of pubic ligaments were determined. Results The adductor longus, brevis, rectus abdominis and pyramidalis muscles are attached to the anterior pubic ligament (APL). The adductor brevis and gracilis muscle are connected to the inferior pubic ligament (IPL). The IPL and superior pubic ligament (SPL) are thicker than the APL and posterior pubic ligament (PPL). The PPL is the thinnest pubic ligament. The APL has a larger sagittal area in women than in men compared to the IPL. The SPL and IPL are thicker in men compared to women. Conclusion The APL is the ligamentous anchor for the originating and inserting muscles. Investigations of the pubic ligaments might help to determine symphysis instability or severity of injury and should be included as a further criterion for surgical management.

The aim of this study was to provide information about the mechanical properties of grafts used for knee ligament reconstructions and to compare those results with the mechanical properties of native knee ligaments.Eleven cadaveric knees were dissected for the semitendinosus, gracilis, iliotibial band (ITB), quadriceps and patellar tendon. Uniaxial testing to failure was performed using a standardized method and mechanical properties (elastic modulus, ultimate stress, ultimate strain, strain energy density) were determined.The elastic modulus of the gracilis tendon (1458±476MPa) (P0.001) and the semitendinosus tendon (1036±312MPa) (P0.05) was significantly higher than the ITB (610±171MPa), quadriceps tendon (568±194MPa), and patellar tendon (417±107MPa). In addition, the ultimate stress of the hamstring tendons (gracilis 155.0±30.7MPa and semitendinosus 120.1±30.0MPa) was significantly higher (P0.001, respectively P0.05), relative to the ITB (75.0±11.8MPa), quadriceps tendon (81.0±27.6MPa), and patellar tendon (76.2±25.1MPa). A significant difference (P0.05) could be noticed between the ultimate strain of the patellar tendon (24.6±5.9%) and the hamstrings (gracilis 14.5±3.1% and semitendinosus 17.0±4.0%). No significant difference in strain energy density between the grafts was observed.Material properties of common grafts used for knee ligament reconstructions often differ significantly from the original knee ligament which the graft is supposed to emulate.

Summary Background Free functional muscle transfers represent the ‘criterion standard' for smile reconstruction in facial paralysis. The gracilis muscle is a common donor muscle; however, no data exist regarding the volume of the muscle tissue that is necessary for symmetric commissure excursion. Methods All patients with facial paralysis receiving a free functional muscle transfer for facial reanimation surgery between January 2009 and November 2015 were retrospectively analysed. Only patients with unilateral facial paralysis and documented weight of the muscle portion were included. The extent of oral commissure amplitude was determined from standardised photographs. Results In total, 42 free functional gracilis transfers were performed during the study period, of which 22 met the inclusion criteria. Eight muscles were innervated by a cross-facial nerve graft (CFNG) and 14 by the masseteric nerve. Segments between 19 and 50 g of weight (mean: CFNG, 33.9 g and masseteric nerve, 31.7 g; p = 0.59) were transferred. Coaptation to the masseteric nerve led to increased commissure excursion compared to coaptation to the CFNG. We observed a significant increase in commissure excursion with increasing muscle weight in the masseteric nerve group. In this group, four patients underwent secondary flap debulking in flaps weighing ≥27 g. In the CFNG group, only one patient, who had an initial flap weight of 50 g, underwent secondary flap reduction. Thinning reduced the oral commissure movement but improved the symmetry of commissure excursion and the aesthetic result. Conclusion The ideal muscle weight depends on the donor nerve and should be smaller for masseteric nerve than for CFNG coaptation in adults.

Objective To analyze and report 30-day, 90-day, and long-term complications and surgical outcomes over a 17-year period for anterior transperineal repair of rectourethral fistulas (RUFs) resulting from pelvic radiation and surgery. Materials and Methods We performed a retrospective review of patients undergoing RUF repair between January 1, 1998 and February 28, 2015, at a single institution. All RUF were repaired using an anterior transperineal approach with an interposition muscle flap and selective use of a buccal mucosa graft onlay. Results Ninety-eight patients underwent repair with an anterior transperineal approach and muscle interposition flap (49 non–radiation induced and 49 radiation or ablation induced). Thirty- and 90-day complication rates were 29% and 2%, respectively, for non-radiated RUF, and 29% and 24%, respectively, for radiated RUF. Urethral diverticula, urinary incontinence, urethral stricture, and bowel problems were delayed complications requiring surgery. At a median follow-up of 14.5 months (range 3-144), 98% (48 of 49) of non-radiated RUF were closed with 1 procedure, whereas 86% (42 of 49) of radiated RUF were closed with 1 procedure. Gastrointestinal tract continuity was restored in 94% (45 of 48) of non-radiated RUF and in 65% (30 of 46) of radiated RUF. Conclusion Successful RUF closure is possible in 98% of non-radiated and in 86% of radiated or ablated patients with 1 procedure. Most radiation-induced RUF, regardless of size, can be successfully repaired with minimal short-term complications. Delayed complications may arise and require surgery, and thus continued surveillance is recommended.

Introduction Free tissue transfers are a highly reliable procedure routinely performed for reconstruction of a wide range of defects. Main complication in free flap surgery is usually venous thrombosis. Many technical controversies exist regarding the technical details of the microvascular anastomosis in order to prevent occurrence of thrombosis and optimize outcomes. We therefore evaluated our results regarding the execution of one versus two venous anastomoses in a variety of free flaps (fasciocutaneous- or muscle free flap) utilized for lower limb reconstruction. Patients and methods Between 2009 and 2015, 354 patients underwent 386 free ALT- or gracilis flaps for lower limb defect reconstruction after trauma, infection, or malignancies at our institution. The data was retrospectively screened for patients’ demographics, perioperative details, flap survival, and surgical complications. The cases were divided into two groups regarding the number of microsurgically performed venous anastomosis: one versus two veins. Results Regarding the preoperative evaluation, there were no significant differences regarding comorbidities between the two groups. Overall, there was no significant difference regarding the rate of major (1 vein: 20.38% versus 2 veins: 18.78%, p > 0.05) and minor (1 vein: 1.27% versus 2 veins: 2.18%, p > 0.05) surgical complications during our 3-months follow-up period. Major complications included total flap losses of 5.73% (1 vein) versus 8.78% (2 veins). Conclusion This study analyzed a large series of microsurgical reconstructions, with a focus on the impact of the number of venous anastomosis. The findings suggest that successful free tissue transfer for lower limb reconstruction can be achieved independent of the number of venous anastomoses, however two should be performed when technically feasible.

Introduction The traumatic lesions of the brachial plexus in adults are devastating injuries causing continuous severe functional impairment for both work and daily living activities. The restoration of elbow flexion is one of the most important movements for patient recovery to previous activities. Free gracilis muscle transfer has good outcomes for cases with late presentation or as a rescue surgery to regain elbow flexion, however, bad results are present in all cohorts with insufficient recovery of muscle strength for elbow flexion. A number of hypotheses can be postulate to explain the fair results observed in some cases of free gracilis muscle transfer for elbow flexion. Most studies in the current literature compare the choice of the donor nerve used in neurotisation and nerve grafts. The aim of this study is to evaluate if technical components of microvascular anastomosis could influence the functional outcome of free functional muscle transfer for elbow flexion in adult patients with traumatic brachial plexus injury. Material and methods Included all adult patients with traumatic brachial plexus injury submitted to free functional gracilis muscle transfer for elbow flexion. The complications and functional results according to British Medical Research Council (BMRC) score were recorded. Results We assessed 26 patients with mean age of 32,8 years. The most common donor nerve for gracilis muscle was the accessory nerve in 18 patients. Eighteen patients presented with good result (M3/M4). The mean ischemia time was higher for patients with bad results (132 minutes) comparing with patients with good results (122 minutes). Patients with only one venous anastomosis had 41% of poor functional outcome compared with 22% of cases with two venous anastomoses. No statistically significant difference in the ischemia time of the cases with good or poor functional outcome was observed (p = 0.657), as for the number of venous anastomoses (p = 0.418). Conclusion Our study observes that patients with only one venous anastomoses for drainage of free gracilis and those with longer intraoperative ischemia time had higher incidence of poor functional outcome of free gracilis muscle transfer for elbow flexion, but not statistically significant. Level of proof II; prospective cross-sectional study.

Introduction The traumatic lesions of the brachial plexus in adults are devastating injuries causing continuous severe functional impairment for both work and daily living activities. The restoration of elbow flexion is one of the most important movements for patient recovery to previous activities. Free gracilis muscle transfer has good outcomes for cases with late presentation or as a rescue surgery to regain elbow flexion, however, bad results are present in all cohorts with insufficient recovery of muscle strength for elbow flexion. A number of hypotheses can be postulate to explain the fair results observed in some cases of free gracilis muscle transfer for elbow flexion. Most studies in the current literature compare the choice of the donor nerve used in neurotization and nerve grafts. The aim of this study is to evaluate if technical components of microvascular anastomosis could influence the functional outcome of free functional muscle transfer for elbow flexion in adult patients with traumatic brachial plexus injury. Material and methods Included all adult patients with traumatic brachial plexus injury submitted to free functional gracilis muscle transfer for elbow flexion. The complications and functional results according to British Medical Research Council (BMRC) score were recorded. Results We assessed 26 patients with mean age of 32.8 years. The most common donor nerve for gracilis muscle was the accessory nerve in 18 patients. Eighteen patients presented with good result (M3/M4). The mean ischemia time was higher for patients with bad results (132 minutes) comparing with patients with good results (122 minutes). Patients with only one venous anastomosis had 41% of poor functional outcome compared with 22% of cases with two venous anastomoses. No statistically significant difference in the ischemia time of the cases with good or poor functional outcome was observed (p = 0.657), as for the number of venous anastomoses (p = 0.418). Conclusion Our study observes that patients with only one venous anastomoses for drainage of free gracilis and those with longer intraoperative ischemia time had higher incidence of poor functional outcome of free gracilis muscle transfer for elbow flexion, but not statistically significant. Level of proof II; prospective cross-sectional study.

A 42-year-old man, who is the first author of this article, presented with pain and left ankle swelling during a 100-km running race. He experienced a sharp pain and popping sensation while running upstairs 15 days after the race. He had previously received a steroid injection around the medial malleolus. Foot inversion was impossible; left toe gait was difficult. Magnetic resonance imaging revealed posterior tibial tendon discontinuity. Although the tendon was found to be discontinued 2-cm proximally to the medial malleolus on surgery for reconstruction, the history of steroid injection could also be responsible for the degeneration of the cut ends. Because of the degeneration, the debrided cut ends showed a gap that could not be directly sutured. Some researchers have reported good tendon transfer results using the flexor digitorum longus, which is situated along the posterior tibial tendon below the medial malleolus. However, loss of function of the flexor digitorum longus can cause a loss of the toe grip power, resulting in an inability to run. Therefore, we adopted the gracilis muscle tendon for tendon transfer. The degenerated cut ends were debrided and reconstructed using a gracilis muscle tendon of the same side. Active range-of-motion exercises were initiated after 3 weeks of below-knee casting. Jogging was permitted at 12 weeks after surgery. He completed a 100-km run at 11 months after surgery. Following one-and-half year, the function was restored. The case warrants publication because this novel tendon transfer technique has not been reported and was effective for a runner.

Free functional muscle transfers remain a powerful reconstructive tool to restore upper extremity function when other options such as tendon or nerve transfers are not available. This reconstructive technique is commonly used for patients following trauma, ischemic contractures, and brachial plexopathies. Variable outcomes have been reported following free functional muscle transfers that are related to motor nerve availability and reinnervation. This article highlights considerations around donor motor nerve selection, dissection, and use of the gracilis muscle, and the surgical approach to performing a free functional muscle transfer to restore elbow flexion and/or digit flexion.

Purpose Gracilis muscle reinnervated by the contralateral facial nerve via cross-graft technique is nowadays considered to be a first-line procedure for facial animation in unilateral palsies. Despite the wide number of papers published analyzing technical aspects, refinements, functional results, and cosmetic outcomes, only a few authors have focused their publications on the patient's perspective and impact on QOL of these procedures. Material and methods Changes in quality of life in 42 patients treated with gracilis muscle transplant reinnervated via cross-face graft were analyzed through a comparison of preoperative and postoperative items on the Facial Disability Index questionnaire. Statistical evaluation with a paired t -test was performed concerning overall results and specific items modifications. Results Overall improvement of QOL was found to be highly significant (p = 0.001). Mouth and eye functions were the most improved (p = 0.001), whereas isolation (p = 0.004) and feeling calm and peaceful (p = 0.001) were the most improved among the social functions. Conclusions Facial animation with gracilis neuromuscular transplantation reinnervated with contralateral healthy facial nerve via a cross-graft procedure has been demonstrated to be a safe and reliable procedure in the treatment of congenital or established facial palsies. Our results on quality of life impact support that these operations are not only reliable and safe but also of primary relevance to patients' everyday lives.

Distal half leg complex wounds are usually a formidable problem that necessitates either local or free flap coverage. The aim of this study was to compare cost billing charges in free Gracilis flap (fGF) and local fasciocutaneous perforator flap (lFPF) in reconstructing complex soft tissue leg and foot defects.Thirty consecutive adult (15-year-old) patients with soft tissue defects in the leg and/or foot requiring tissue coverage with a flap in the period between 2012 and 2015 were randomly assigned (block randomization) to either an fGF or lFPF procedure. The outcome measures addressed were total billed charges costs, perioperative billed charges cost, partial or complete flap loss, length of hospital stay, inpatient postsurgical care duration, complications, operating time and number of operative scrub staff.One patient suffered from complete flap loss in each group. Reconstruction with lFPF showed total lower billed charges costs by 62% (2509 USD) (p 0.001) and perioperative billed charges cost by 54% (779 USD) (p 0.001), and shorter total hospital stay (36.5 days; p 0.001), inpatient postsurgical care duration (6.4 days; p 0.001), operating time (4.3 h; p 0.001) and fewer scrub staff (2.2 persons; p 0.001).These results suggest that neither flap is totally superior to the other; the choice should instead be based on the outcome sought and logistics. lFPF requires lower billed charges cost and resource use and saves operative time and personnel and reduces length of hospital stay. Our approach changed towards using perforator flaps in medium-sized defects, keeping the free flap option for larger defects.

Reconstruction of the perineum is required following oncological resections. Plastic surgical techniques can be used to restore the aesthetics and function of the perineum. The gracilis myocutaneous flap provides a substantial skin paddle, with minimal donor site morbidity. The flap is pedicled on a perforator from the medial circumflex femoral artery, giving it limited reach across the perineum. Tunnelling the flap under the adductor longus muscle may free up more of the arterial pedicle, increasing its reach. On three female cadavers, bilateral gracilis flaps were raised in the standard surgical manner, giving six flaps in total. With the flaps pedicled across the perineum, the distance from the tip of each flap was measured to the anterior superior iliac spine (ASIS). The flaps were then tunnelled under the adductor longus muscle. The distances to the ASIS were measured again. The average pedicle length was greater than 7 cm. Tunnelling the flap under the adductor longus muscle increased the reach by more than 4 cm on average. Cadaveric dissection has shown that tunnelling of the flap in a novel way increase its reach across the perineum. This additional flexibility improves its use clinically and is of benefit to plastic surgeons operating in perineal reconstruction.

Objective To evaluate the efficacy of adynamic gracilis urethral myoplasty with a pedicled gracilis muscle flap wrapped around bulbar urethra for treatment of male acquired urinary incontinence. Patients and Methods Twenty-four patients with acquired urinary incontinence (8 after radical prostatectomy, 7 after transurethral resection of the prostate, and 9 after posterior urethroplasty) were included in our study. Eighteen of these patients (75.0%) had mild to moderate urinary incontinence, and 6 (25.0%) had severe urinary incontinence. All patients received adynamic gracilis urethral myoplasty with a pedicled gracilis muscle flap wrapped around bulbar urethra and had a close follow-up. Results The mean postoperative maximum urethral pressure after the gracilis muscle wrapped around bulbar urethra was significantly higher than that of the preoperative measurements ( P Conclusion A pedicled gracilis muscle flap wrapped around bulbar urethra can raise the urethral pressure. Adynamic graciloplasty with a pedicled gracilis muscle flap wrapped around bulbar urethra is a safe and effective surgical option in the treatment of male patients with mild to moderate incontinence, but is not suitable for severe incontinence.

OBJECTIVE: To investigate the feasibility of using free gracilis muscle transfer along with the brachialis muscle branch of the musculocutaneous nerve to restore finger and thumb flexion in lower trunk brachial plexus injury according to an anatomical study and a case report. METHODS: Thirty formalin-fixed upper extremities from 15 adult cadavers were used in this study. The distance from the point at which the brachialis muscle branch of the musculocutaneous nerve originates to the midpoint of the humeral condylar was measured, as well as the length, diameter, course and branch type of the brachialis muscle branch of the musculocutaneous nerve. An 18-year-old male who sustained an injury to the left brachial plexus underwent free gracilis transfer using the brachialis muscle branch of the musculocutaneous nerve as the donor nerve to restore finger and thumb flexion. Elbow flexion power and hand grip strength were recorded according to British Medical Research Council standards. Postoperative measures of the total active motion of the fingers were obtained monthly. RESULTS: The mean length and diameter of the brachialis muscle branch of the musculocutaneous nerve were 52.66±6.45 and 1.39±0.09 mm, respectively, and three branching types were observed. For the patient, the first gracilis contraction occurred during the 4th month. A noticeable improvement was observed in digit flexion one year later; the muscle power was M4, and the total active motion of the fingers was 209°. CONCLUSIONS: Repairing injury to the lower trunk of the brachial plexus by transferring the brachialis muscle branch of the musculocutaneous nerve to the anterior branch of the obturator nerve using a tension-free direct suture is technically feasible, and the clinical outcome was satisfactory in a single surgical patient.

Summary Background Limitations of the transverse upper gracilis (TUG) flap for autologous breast reconstruction include: short pedicle, modest volume, muscle sacrifice and a problematic donor site. The Profunda Artery Perforator (PAP) flap utilises large perforators posterior to the gracilis muscle. We describe our preliminary experience of its use and compare it to our large series of TUG flaps. Method Our technique has evolved from frog-leg to lithotomy position, and from an anterio-posterior to cranio-caudal raise. This allows either the descending branch of the inferior gluteal artery perforators (IGAP) or the TUG flap as alternatives should PAP perforators be unsuitable intra-operatively. A prospective database was utilised to compare TUG and PAP flaps undertaken 2010–2013. Results 54 TUG and 22 PAP flaps were performed. 4 PAP flaps were converted to IGAP flaps and 1 to TUG intra-operatively. 97% of all flaps were successful. Mean flap weight was 295 g (TUG) and 242 g (PAP). Donor site complications for both series included seroma (4 TUG, 1 PAP) sensory disturbance (2 TUG, 1 PAP) and scar revision (3 TUG, 1 PAP). Conclusion Our preliminary experience of the PAP flap has not been universally favourable compared to the TUG flap. It is a more challenging flap to raise, which carries with it a learning curve, especially if raised in the supine position; we present our learning points for safer flap harvest, allowing the TUG as a bail out option. The benefits of the PAP include a longer pedicle, without the need to sacrifice muscle; the perforators should have a more defined and larger perfusion zone. The scar is better hidden, but we have not yet proven significant improvements to the donor site compared to the TUG flap. Level of Evidence: III

Summary Background and purposes The use of skin flap as a monitoring tool cannot sensitively reflect the vascularity of a functioning free muscle transfer (FFMT), and it may result in delayed detection of vascular compromise. We report the use of compound muscle action potentials (CMAPs) as a supplemental method in the monitoring of free gracilis transfers. Subjects and methods In 46 successful free gracilis transfers in 23 patients following total brachial plexus injury (BPI), CMAPs were measured every hour for 75 h postoperatively. We analyzed the amplitude, latency, and duration to understand the Wallerian degeneration effect and thresholds to warn vascular compromise clinically. After the primary study, we applied CMAP monitoring for 23 clinical cases. Main findings Three basic wave patterns of the CMAPs with or without dispersion were recognized. Forty-two CMAPs were successfully traced and 27 CMAPs with one constant wave pattern showed two types of amplitude and latency changes; positive and negative Wallerian degeneration. The mean 1-h maximal decreases of amplitudes and elongation of latency were 36% and 77%, respectively; however, they returned to the original pattern within 1 h. There were no significant differences of reinnervation time and final strength of elbow flexion between these 46 muscle transfers. In the clinical series, we experienced two cases of vascular compromise that showed CMAP critical alterations without skin flap changes. Conclusions Our preliminary results show that the measurement of CMAPs has great potential for the sensitive and reliable monitoring of muscle circulation after FFMT. The clinical critical values of CMAP amplitude changes for vascular compromise are >40% sudden decrease, and they continued to decrease further. This technique is most useful for postoperative vascular monitoring of a buried muscle flap, and it is proven to be of clinical significance in current vascular compromised cases. Level of evidence Level Ⅳ, Case Series.

The choice of the motor donor nerve is a crucial point in free flap transfer algorithms. In the case of unilateral facial paralysis, the contralateral healthy facial nerve can provide coordinated smile animation and spontaneous emotional expression, but with unpredictable axonal ingrowth into the recipient muscle. Otherwise, the masseteric nerve ipsilateral to the paralysis can provide a powerful neural input, without a spontaneous trigger of the smile. Harvesting a bulky muscular free flap may enhance the quantity of contraction but esthetic results are unpleasant. Therefore, the logical solution for obtaining high amplitude of smiling combined with spontaneity of movement is to couple the neural input: the contralateral facial nerve plus the ipsilateral masseteric nerve. Thirteen patients with unilateral dense facial paralysis underwent a one-stage facial reanimation with a gracilis flap powered by a double donor neural input, provided by both the ipsilateral masseteric nerve (coaptation by an end-to-end neurorrhaphy with the obturator nerve) and the contralateral facial nerve (coaptation through a cross-face nerve graft: end-to-end neurorrhaphy on the healthy side and end-to-side neurorrhaphy on the obturator nerve, distal to the masseteric/obturator neurorrhaphy). Their facial movements were evaluated with an optoelectronic motion analyzer. Before surgery, on average, the paretic side exhibited a smaller total three-dimensional mobility than the healthy side, with a 52% activation ratio and30% of asymmetry. After surgery, the differences significantly decreased (analysis of variance (ANOVA), p 0.05), with an activation ratio between 75% (maximum smile) and 91% (maximum smile with teeth clenching), and20% of asymmetry. Similar modifications were seen for the performance of spontaneous smiles. The significant presurgical asymmetry of labial movements reduced after surgery. The use of a double donor neural input permitted both movements that were similar in force to that of the healthy side, and spontaneous movements elicited by emotional triggering.

In this retrospective cross-sectional study clinical and muscle imaging data of patients with Miyoshi distal myopathy phenotype (MMD1 and MMD3) and limb girdle muscular dystrophy 2L (LGMD2L) were described. MMD1 and MMD3 are genetically heterogenous diseases based on DYSF and ANO5 gene defects. MMD3 and LGMD2L are clinically different diseases caused by an ANO5 gene defect. All groups showed predominant fatty degeneration of the gluteus minimus muscle and of the posterior segments of the thigh and calf muscles with sparing of the gracilis muscle. Muscle atrophy, hypertrophy and asymmetric muscle involvement on muscle imaging did not differ between groups. The pattern of fatty degeneration of muscles and of muscle weakness shows only minor differences between MMD1 (n=6) and MMD3 (n=8) patients with more frequently fatty degeneration of the rectus femoris, anterior tibial, and extensor digitorum muscles and more frequently muscle weakness in the anterior tibial, peroneal and calf muscle in MMD1. In the ANO5 related phenotypes the lateral head of the gastrocnemius muscle was less frequently involved in LGMD2L (n=13) and no differences in the incidence of muscle weakness was found. Therefore, MMD3 and LGMD2L should be considered as part of one spectrum of ANO5 related muscle disease.

Purpose To report our technique and experience with use of free functioning muscle transfer (FFMT) in reconstruction of traumatic brachial plexus injuries (BPIs) in children as well as its complications and outcomes. Methods Twelve patients with complete BPI underwent FFMT for reconstruction between 2000 and 2012. Eight had single-stage gracilis transfer for restoration of elbow flexion, and 4 children had double free gracilis muscle transfer for restoration of elbow flexion and prehension. Mean duration of follow-up was 27 months (range, 14–55 mo). Results Eleven out of 12 patients achieved at least M3 elbow flexion, with 8 patients achieving M4 or greater elbow flexion. Eight of 12 patients had nerve transfers to the musculocutaneous nerve. Mean active elbow arc of motion was 79° (range, 30°–130°). Two patients aged 8 and 11 years with open growth plates developed elbow joint contractures, which limited range of motion, but they recovered M4 and M5 elbow flexion strength. Conclusions FFMTs can result in good outcomes following reconstruction for traumatic BPI. The use of FFMT should be carefully considered in children prior to skeletal maturity because of the risk of the development of an elbow flexion contracture. Type of study/level of evidence Therapeutic IV.

OBJECTIVES: It has been a long time since seaweeds have been used for food ingredients in Asian countries. Recently, a body of research has revealed the health benefits of bioactive compounds in seaweeds, especially their antioxidant capacities. Although numerous seaweeds inhabit in the ocean, only a small percentage has been explored for functional food. Therefore, the purpose of this study was to analyze the antioxidant capacities of various seaweeds grown off the Korean coast to screen for the potential functional food sources. METHODS: Ten ethanol extracts of Korean seaweeds were provided by the National Marine Biodiversity Institute of Korea, which included Scytosiphon gracilis, Scytosiphon lomentaria, Sargassum muticum, Sargassum confusum, Petrospongium rugosum, Sargassum fusiforme, Petalonia fascia, Sargassum nigrifolium, Ishige foliacea, and Myelophycus simplex. Hundred mg/L of samples in 80% methanol was used to measure their ABTS, DPPH, and superoxide radical scavenging activities. Mg vitamin C equivalent antioxidant capacity (VCEAC)/100 mg was used to express the ABTS and DPPH radical scavenging capacities. For the superoxide radical scavenging capacity, inhibition rate of superoxide radical generation (%) was calculated. RESULTS: Among the ten seaweeds, S. nigrifolium and I. foliacea exhibited the most significant radical scavenging capacities. DPPH radical scavenging capacities of I. foliacea and S. nigrifolium were 122.4 mg VCEAC/100 mg and 95.8 mg VCEAC/100 mg, respectively. For ABTS radical scavenging capacity, I. foliacea exhibited 178.5 mg VCEAC/100 mg, followed by S. nigrifolium as 80.9 mg VCEAC/100 mg. I. foliacea inhibited about 68% of superoxide radical generation followed by S. nigrifolium (40.6%) while vitamin C as positive control inhibited about 28.9% of superoxide radical generation. The antioxidant capacities measured by the three assays were positively correlated with each other. CONCLUSIONS: The current study explored total antioxidant capacities of various Korean seaweeds and found I. foliacea and S. nigrifolium as the most potential antioxidant-rich food resources. Further research would be warranted to investigate bioactive compounds from S. nigrifolium and I. foliacea. FUNDING SOURCES: This work was supported by the Pukyong National University Research Fund in 2018.

Summary Purpose Rectovaginal fistulas constitute a serious burden for the affected patient and a major challenge for the attending surgeon. Definitive surgical treatment of the fistula depends on the size and location of the fistula, the underlying disease, and any previous therapies. In regards to complicated recurrent rectovaginal fistulas, transposition of the gracilis muscle is one of the well-established therapeutic options with a success rate of up to 70%. Material and methods Between 01/2004 and 06/2010, ten patients diagnosed with a recurrent rectovaginal fistula were treated in the surgical department of Klinikum Oldenburg by gracilis muscle transposition; their data were collected and analyzed. Post-operative evaluation was performed using a standardized telephone interview. All patients had a protective stoma. The primary endpoint of assessment was the long-term healing of the fistula following stoma reversal, and the comparison between those who were treated successfully versus those who were not. Results Over a time span of 6 years, ten women with a complicated rectovaginal fistula underwent fistula repair with the gracilis muscle transposition. Patient age ranged from 29 and 64 years. There were five rectovaginal fistulas, four pouch-vaginal fistulas, and one anovaginal fistula. The underlying disease was rectal cancer in seven patients, Crohn's disease in one patient, previous complicated gynecologic surgery in one patient, and idiopathic anal fistula in one patient. All seven patients with rectal cancer underwent radiochemotherapy with 50.4 Gy (n = 6 neo-adjuvant, n = 1 adjuvant). All ten patients had previously undergone repair by a different surgical approach while five presented with a second or third recurrence. Post-operative complications were noted in two patients (perineal wound defect, thigh hematoma). Follow-up of the patients ranged from 8 to 60 months. Recurrent rectovaginal fistula occurred in four patients. Evaluation of the data failed to identify statistically significant criteria for treatment failure of rectovaginal fistula repair. Conclusion Our results are similar to previous studies in this area. For the majority of the patients, the gracilis muscle transposition was a long-term effective treatment of recurrent rectovaginal fistulas, however recurrences were noted in 40% of cases. Predictive criteria for treatment failure could not be established.

Summary Introduction Muscle transfer is used to restore function typically using a single vector of contraction. Although its use with two independently functional muscular units has been employed, in order to refine this concept we endeavoured to detail the intramuscular anatomy of gracilis, a muscle commonly used for transfer. A novel method to capture intramuscular fibre bundle and neurovascular arrangement was used to create a three-dimensional (3D) digital model that allowed for accurate representation of the relationships between all the intramuscular structures to facilitate flap planning. Methods Twenty gracilis muscles were harvested from 15 cadavers. All components of the muscle were digitised using a Microscribe G2 Digitiser. The data were exported to the 3D animation software Autodesk ® Maya ® 2012 whereupon it was rendered into a 3D model that can be exported as static images or videos. Neurovascular anatomy and muscle architecture were analysed from these models, and fibre bundle length, pennation angle and physiological cross-sectional area were calculated from digitised data. Results The muscle is composed of a variable number of distinct longitudinal segments with muscle fibres spiralling onto the tendon. The main artery to the muscle has three main intramuscular patterns of distribution. The venae comitantes drain discrete zones without intramuscular macroscopic anastomoses. The minor pedicles form an anastomotic chain along the anterior border of the muscle and all vessels were biased to the deep surface. The nerve is related to the vessels in a variable manner and both run between longitudinal muscular compartments. Conclusions The digitisation technique may be used to advance knowledge of intramuscular architecture and it demonstrated that the gracilis muscle is comprised of four to seven muscular compartments, each representing a functional unit that may theoretically be differentially activated and could be harnessed for more sophisticated muscle transfers.

Background To show whether mechanics of activated spastic muscle are representative of the functional deficiencies clearly apparent in the joints, our goal was to test the following hypotheses: (1) The muscle's joint range of force exertion is narrow, and (2) high muscle forces are available at low muscle length. Methods During remedial surgery, we measured the forces of the Gracilis muscle of spastic cerebral palsy patients (n = 7, 10 limbs tested) as a function of knee joint angle from flexion (120°) to full extension (0°). Findings The spastic Gracilis exerted non-zero forces for the entire knee angles studied. For four limbs, the peak force was exerted at the highest length. For the remainder limbs, the closest knee angle of peak force exertion to 120° was 66°. Maximally 79.1%, and for most limbs only a much lower percentage (minimally 22.4%) of peak Gracilis force (mean 41.59 N (SD 41.76 N)) was available at 120° knee flexion. Moreover, a clinical metric was obtained showing that the occurrence of a contracture was not correlated significantly with key determinants of knee angle-Gracilis force characteristics. Interpretation Our hypotheses are rejected: the spastic Gracilis has no narrow operational joint range of force exertion and no supreme active resistance capacity to stretch at low length. We conclude that if activated alone, spastic muscle shows no abnormal mechanics representative of joint movement disorder. Simultaneous stimulation of other muscles as in daily activities may change this situation.

Neurovascular free muscle transfer is one of the main reconstructive options for established or long-standing facial paralysis. The two-stage gracilis muscle transfer combined with the cross-face nerve graft (two-stage method) has been supplanted by one-stage reconstruction using the latissimus dorsi muscle (LD) at our institution. This study retrospectively evaluated the results of one-stage LD transfer.Between September 1993 and December 2008, 344 patients (133 males, 211 females; age range, 5-75 years) with unilateral facial paralysis underwent 351 one-stage LD transfers. Patients were evaluated with a custom grading scale. Differences in grading scale score were compared according to age, past surgical history and the duration from operation to neuromuscular recovery.Contraction of the transferred muscle was recognised in 305 (87.0%) transfers. The duration until neuromuscular recovery ranged from 3 to 16 months (average ± standard deviation: 6.48 ± 1.92 months). The grading scale was significantly lower in middle-age group than in younger and elder groups (P 0.01). Duration until neuromuscular recovery was significantly different when comparing the younger group and the oldest group. There was no difference in grading scale score or in duration until neuromuscular recovery when comparing the patients with a past surgical history and those without. The grading scale negatively correlated with the duration until neuromuscular recovery.The results are consistent and statistical analysis revealed the versatility of the one-stage LD transfer. Although we believe the two-stage method is still a good option for facial reanimation, the one-stage method is advantageous regarding the shorter period of recovery and little donor-site morbidity.

Many procedures exist to provide both static and dynamic reanimation of the paralyzed face. At the present time, microneurovascular free muscle transfer provides the best outcome in restoring dynamic facial symmetry as well as spontaneous mimetic function. Of the techniques used, free gracilis muscle transfer is currently the most common; this article describes the procedure in detail.

Summary Background Reconstruction of total full-thickness lower lip defects combined with extensive composite mandibular defects particularly in the setting of close-range high-energy ballistic injury presents a formidable challenge for the reconstructive plastic surgeon. While the fibular flap has been widely accepted for its usefulness in the reconstruction of composite mandibular defects, to date, there is no definitive widely established method of total lower lip reconstruction. The article presents authors' approach using innervated gracilis muscle flap for total lower lip reconstruction in the setting of high-energy gunshot injuries to the face. Methods Three patients underwent composite mandibular defect reconstruction using fibular osteocutaneous flap and functional lower lip reconstruction using innervated gracilis muscle flap. Lip lining was reconstructed using the skin paddle of the fibular flap. The external surface of the gracilis muscle was skin-grafted. Facial artery myomucosal flap provided vermilion reconstruction in two patients. Results All fibular ( n = 3) and gracilis flap transfers ( n = 3) were viable. An electromyographic study at 1 year postoperatively demonstrated successful re-innervation of the gracilis muscle. Starting at about 10 weeks postoperatively, patients exhibited voluntary lip movements and oral competence. In addition, all patients achieved near-normal speech, evidence of recovered protective sensitivity and satisfactory appearance. The mean follow-up was 16.1 months. Conclusions Our preliminary report in three patients demonstrated that innervated gracilis muscle transfer combined with fibular flap provides a successful reconstruction of extensive composite mandibular and total lower lip defects resulting from gunshot injuries to the face. Oral continence was achieved by combination of regained tonicity and voluntary movement of the gracilis muscle following re-innervation and assistance of the cheek muscles on the gracilis muscle. The described technique was reliable and the results were promising.

Summary Objective One-stage free-flap facial reanimation may be accomplished by using a gracilis transfer innervated by the masseteric nerve, but this technique does not restore the patient's ability to smile spontaneously. By contrast, the transfer of the latissimus dorsi innervated by the contralateral facial nerve provides the correct nerve stimulus but is limited by variation in the quantity of contraction. The authors propose a new one-stage facial reanimation technique using dual innervation; a gracilis muscle flap is innervated by the masseteric nerve, and supplementary nerve input is provided by a cross-face sural nerve graft anastomosed to the contralateral facial nerve branch. Methods Between October 2009 and March 2010, four patients affected by long-standing unilateral facial paralysis received gracilis muscle transfers innervated by both the masseteric nerve and the contralateral facial nerve. Results All patients recovered voluntary and spontaneous smiling abilities. The recovery time to voluntary flap contraction was 3.8 months, and spontaneous flap contraction was achieved within 7.2 months after surgery. According to Terzis and Noah's five-stage classification of reanimation outcomes, two patients had excellent outcomes and two had good outcomes. Conclusions In this preliminary study, the devised double-innervation technique allows to achieve a good grade of flap contraction as well as emotional smiling ability. A wider number of operated patients are needed to confirm those initial findings.

An in vitro muscle strip incubation system was developed to measure the rate of catabolism of 1 mmol/L [1-(14)C]octanoate, 1 mmol/L [1-(14)C]nonanoate, 1 mmol/L [9-(14)C]nonanoate, and 10 mmol/L [U-(14)C]glucose by measuring the recovery of (14)CO(2). Muscle strips (13 mm × 1.5 mm, ~50 mg) were isolated from triceps brachii and gracilis muscles of newborn and 2-d-old, small (950 g) and large (1450 g) piglets. The position of the (14)C label in the substrate affected the rate and amount of recovery in (14)CO(2). Therefore, comparisons were made between age groups (0 vs. 2 d old) within substrates but limited across substrates to comparisons of [1-(14)C]-labeled fatty acids. The medium-chain fatty acid (MCFA) oxidation rates [pmol/(h · mg)] in muscle strips isolated from piglets from the 2 weight groups (950 and1450 g) did not differ (P0.99), there was a trend towards a difference between triceps brachii and gracilis muscle (P = 0.09; data not shown), and there were no significant interactions involving pig weight or muscle type; therefore, results were pooled across these factors. During the first 2 d of life, MCFA oxidation [pmol/(h • · mg muscle strip)] increased (P0.05) 50-80%, but the glucose oxidation rate did not change (P0.82). By d 2, the oxidation rate of nonanoate as represented by the one carbon was 25% greater than for octanoate (P0.05). The conversion of [9-(14)C]nonanoate to (14)CO(2) indicated that muscle had the capacity to oxidize the propionyl-CoA produced by β-oxidation of nonanoate and that odd-chain C-9 MCFA provided anabolic carbon to the citric acid cycle.

Purpose Facial paralysis is a congenital or acquired disorder of varying severity leading to an asymmetric or absent facial expression. It represents an important debilitation from both esthetic and functional points of view. In this article we report our experience with patients treated with gracilis muscle transplantation innervated by the motor nerve to the masseter muscle. We discuss the surgical technique and the functional and esthetic results and evaluate the effectiveness of this donor nerve in providing adequate innervation to the muscle transfer for lower facial reanimation. Materials and Methods Fifteen patients with unilateral facial paralysis were seen and surgically treated at the Department of Maxillofacial Surgery, University of Parma, Parma, Italy, between 2003 and 2007. In this study we report on 8 cases treated with gracilis muscle transfer reinnervated by the motor nerve to the masseter muscle. Results In this series all free-muscle transplantations survived transfer, and no flap was lost. Facial symmetry at rest and while smiling was excellent or good in all patients, and we observed a significant improvement in speech and oral competence. With practice, the majority of patients developed the ability to smile spontaneously and without jaw movement. Conclusions We consider the masseter motor nerve a powerful and reliable donor nerve, allowing us to obtain a commissure and upper lip movement similar to those of the normal site for amount and direction. This is why we think that there may be a larger role for the masseter motor nerve for innervation of patients with unilateral facial paralysis who would otherwise have been considered candidates for cross–facial nerve graft innervation of the muscle transfer.

Free re-innervated gracilis muscle transfer is used to restore fingers or wrist flexion or extension after severe forearm injuries and when none muscle transfer is possible. The long-term function after this procedure is evaluated for three patients treated in our unit. This microsurgical transfer is technically demanding but allows good fingers mobility and good autonomy for daily activities and working.

Summary Background The present study was conducted to investigate the anatomy of the motor nerve to the gracilis muscle (MNG) to provide the anatomical basis for harvesting a one-stage gracilis transfer with a long nerve for re-animation of the paralysed face. Methods An anatomical study was performed on 24 lower-limb specimens (from the pelvis down to the knee) from 12 embalmed cadavers. The MNG was dissected from the surface of the muscle to the obturator foramen. Two anatomical regions were defined in the course of the nerve. The first region includes the part of the nerve that can easily be reached through a standard incision in the medial aspect of the thigh, that is, from the surface of the muscle to the posterior border of the adductor brevis muscle and the second region from there to the obturator foramen. Measurements of both anatomical regions and the maximum length of the nerve were taken with a calliper. The anatomical relations of the nerve were also noted and photo-documented. Results The median maximum length of the MNG from the surface of gracilis to the posterior border of adductor brevis (‘first anatomical region') was 7.7cm (Range 6.3–10.5cm); from there to the obturator foramen (‘second anatomical region') the length was 3.7cm (Range 2–6cm), giving a median length of dissection of the nerve as 11.5cm (Range 9.9–13.6cm). Intraneural dissection of the MNG has to be performed proximally in the course of the nerve (the part corresponding to the second anatomical region), just where it runs inside the fascia over the obturator externus muscle. Conclusions Over 10-cm length of the MNG can be obtained when dissected along the course of the nerve up to the obturator foramen. To achieve the maximum length, intraneural dissection must normally be performed after the nerve passes the posterior border of the adductor brevis. An endoscopic approach or extended proximal incision is recommended to easily reach the proximal part of the nerve as far as the obturator foramen.

Background Moebius syndrome, a rare congenital disorder of varying severity, involves multiple cranial nerves and is characterized predominantly by bilateral or unilateral paralysis of the facial and abducens nerves. The paralysis of the VI and VII cranial nerves leads to a lack of function in the muscles they supply. Facial paralysis often causes bilabial incompetence with speech difficulties, oral incompetence, problems with eating and drinking, including pocketing of food in the cheek and dribbling, as well as severe drooling. Methods In this study, we report on pediatric patients with Moebius and Moebius-like syndromes seen and treated surgically from 2003 to September 2007 at the Operative Unit of Maxillofacial Surgery, Head and Neck Department, University of Parma, Italy. Results Twelve patients underwent microsurgical reconstruction for restoration of facial movement. The contralateral facial nerve was used as a motor donor nerve in 4 procedures, the motor nerve to the masseter muscle was used in 8 patients, and the gracilis muscle was used in all operations, with a total of 17 free-muscle transplantations. All free-muscle transplantations survived transfer, and no flap was lost. We observed a significant improvement in drooling, drinking, speech, and facial animation with a high degree of patient satisfaction. Conclusions The gracilis muscle free transfer is a surgical procedure well tolerated by the young patients and well accepted by their families. We consider it a safe and reliable technique for facial reanimation with good aesthetical and functional results in children with Moebius and Moebius-like syndromes.