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Introduction Recovering from neuromuscular injuries or conditions can be a challenging journey that involves complex surgeries and extensive physical rehabilitation. During this process, individuals often rely on orthotic devices to support and enable movement of the affected limb. However, users have criticized current commercially available powered orthotic devices for their bulky and heavy design. To address these limitations, we developed a novel powered myoelectric elbow orthosis. Materials and Methods The orthosis incorporates 3 mechanisms: a solenoid brake, a Bowden cable-powered constant torque elbow mechanism, and an extension limiter. The device controller and battery are in a backpack to reduce the weight on the affected arm. We performed extensive calculations and testing to ensure that the orthosis could withstand at least 15 Nm of elbow torque. We developed a custom software effectively control the orthosis, enhancing its usability and functionality. A certified orthotist fitted a subject who had undergone a gracilis free functioning muscle transfer surgery with the device. We studied the subject under Mayo clinic IRB no. 20-006849 and obtained objective measurements to assess the orthosis's impact on upper extremity functionality during daily activities. Results The results are promising since the orthosis significantly improved elbow flexion range of motion by 40° and reduced compensatory movements at the shoulder (humerothoracic joint) by 50°. Additionally, the subject was able to perform tasks which were not possible before, such as carrying a basket with weights, highlighting the enhanced functionality provided by the orthosis. Conclusion In brief, by addressing the limitations of existing devices, this novel powered myoelectric elbow orthosis offers individuals with neuromuscular injuries/conditions improved quality of life. Further research will expand the patient population and control mechanisms. [ABSTRACT FROM AUTHOR]

In this commentary, we review Dr. Byrne and colleagues' article "Tri-vector Gracilis Microneurovascular Free Tissue Transfer with Periocular Component to Achieve a Duchenne Smile in Patients with Facial Paralysis." The authors successfully demonstrate the feasibility of separating the gracilis muscle into three bellies while maintaining neuromuscular input to achieve restoration of lower lid movement during smile, resulting in a more natural appearing or "Duchenne smile." Although the concept of spontaneity remains controversial, beautiful smile outcomes are illustrated in the featured photograph and videos.

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

Background The transverse myocutaneous gracilis (TMG) flap is a viable and safe option for breast reconstruction in patients with limited abdominal tissue or other contraindications for abdominal-based flaps. Although it is one of the most common flaps employed for breast reconstruction, data on patient-reported outcomes is limited. Objectives The authors seek to evaluate patient satisfaction and aesthetic outcome after breast reconstruction with the TMG flap. Methods All patients who underwent breast reconstruction with a TMG flap between March 2010 and October 2020 were identified. Invitation to a digital version of the BREAST-Q reconstructive module and the Lower Extremity Function Scale (LEFS) was sent to 105 patients. Patient demographics, complications, and surgical details were collected and retrospectively analyzed. BREAST-Q and LEFS scores were calculated and compared to the literature. Results Eighty-two patients participated in the study. Median follow-up was 5.9 years, with a mean patient age of 45.7 years. Most patients (90.2%) received treatment due to previous cancer of the breast, and 17.1% underwent immediate reconstruction. The mean score for "Satisfaction with Breast" was 66/100. Postoperative lower extremity function was high, with a median LEFS score of 78/80. A LEFS score below the median value was found to be significantly associated with active smoking (P =.049). Patients also reported high satisfaction with donor sites (8/11). Conclusions Patient satisfaction and aesthetic outcome after breast reconstruction with TMG flaps is high and comparable to other common techniques. Lower extremity function is not impaired after flap harvest. Level of Evidence: 3 [ABSTRACT FROM AUTHOR]

Fournier's gangrene is a life-threatening infection which requires prompt recognition, early surgical debridement of unhealthy tissue, and initiation of broad-spectrum antibiotics. Relook debridement are usually performed until all the devitalized tissue has been removed. Involvement of the anal sphincter may result in significant morbidity such as permanent incontinence. Dynamic reconstruction of the anal sphincter has always been one of the holy grails in the field of pelvic reconstruction.

Abstract Background A lymphocele or lymphocyst is formed when lymphatic fluid accumulates in a space, following disruption of lymphatic channels. Here, we report a case of a giant lymphocele in a middle-aged female, who underwent Trendelenburg operation (saphenofemoral junction ligation) for varicose veins of her right lower limb. Case presentation A 48-year-old Pakistani Punjabi female presented to the plastic surgery outpatient department with a history of painful, progressive swelling of the right groin and medial aspect of the right thigh for 4 months. After investigation, it was diagnosed as a giant lymphocele. A pedicled gracilis muscle flap was used to reconstruct and obliterate the cavity. There was no recurrence of the swelling. Conclusion Lymphocele is a common complication after extensive vascular surgeries. In the unfortunate case of its development, prompt intervention must be done to prevent its growth and ensuing complications.

Fournier's gangrene is a life-threatening infection which requires prompt recognition, early surgical debridement of unhealthy tissue, and initiation of broad-spectrum antibiotics. Relook debridement are usually performed until all the devitalized tissue has been removed. Involvement of the anal sphincter may result in significant morbidity such as permanent incontinence. Dynamic reconstruction of the anal sphincter has always been one of the holy grails in the field of pelvic reconstruction. We demonstrate a new method of camera shutter style double-opposing gracilis muscle flaps that allows dynamic sphincteric function without the need for electrostimulation. The bilateral gracilis muscles are inset in a fashion that allows orthograde contraction of the muscle to narrow and collapse the neoanal opening. With biofeedback training, the patient is able to regain dynamic continence and return to function without a stoma. There was also no need for neurotization or microsurgery techniques to restore sphincteric function to the anus. The patient was able to reverse his stoma 14 months after the initial insult and reconstruction with biofeedback training without the use of electrostimulation. [ABSTRACT FROM AUTHOR]

Surgical treatment of long-term facial palsy has been reported using various techniques, including functioning muscle-free flaps. The free gracilis muscle flap is the most common because of its many advantages. Our study presents a modified way of shaping the gracilis muscle for transfer to the face to improve the restoration of natural smiles. This retrospective study assessed 5 patients who received the classical technique and 43 patients who received modified, U-shaped, free gracilis muscle flap for smile reanimation from 2013 to 2018. The surgery is single-staged. Preoperative and postoperative photos were taken. Functional outcomes were evaluated using the Terzis and Noah score and the Chuang smile excursion score. The mean patient age at the time of operation was 31 years. The length of gracilis muscle harvested was 12–13 cm. Of the 43 patients who received U-shaped design-free gracilis muscle, results were excellent for 15 (34.9%), good for 20 (46.5%), and fair for 8 (18.6%) followed the Terzis and Noah score. The Chuang smile excursion score was 2 for 16.3%, 3 for 46.5%, and 4 for 37.2% of 43 patients. Of the 5 patients who underwent classical technique, there are no excellent results based on the Terzis and Noah score. The Chuang smile excursion score was only 1 and 2. The U-shaped modification to the gracilis muscle-free flap is a simple and effective technique to help restore a symmetrical and natural smile in patients with facial palsy. [ABSTRACT FROM AUTHOR]

Background Phalloplasty is a challenging procedure in the field of repair and reconstruction. Traditional skin flap methods with prostheses or autologous tissue implantation are still common; however, with this method the reconstructed phallus is static and has a high risk of complications. Aim We aimed to use novel methods for phalloplasty to mimic the normal structure of the phallus while maintaining the patient's ability to obtain sufficient hardness and subjective controllability. Methods The neophallus comprised the bilateral pedicled neurovascular gracilis muscle, which provided neophallus volitional control; the pedicled fascia lata, which mimicked the tunica albuginea; the pedicled anterolateral thigh flap, which was used to reconstruct the neourethra and neoglans; and the thin split-thickness skin grafted on the surface of the fascia lata. The urethral anastomosis was performed simultaneously. The appearance and function of the neophallus, as well as patient satisfaction, were evaluated postoperatively. Outcomes The biomimetic dynamic phalloplasty using the bilateral pedicled gracilis muscle combined with the fascia lata was successfully performed in 4 patients. Results During follow-up at 10-21 months after the procedure, all 4 patients could complete sexual intercourse and were satisfied with the appearance and self-controllability of the neophallus. The size of the neophallus stabilized within 6 months. The tactile, deep touch sensation, and pain sensations of the neophallus partially recovered. All of the patients could stand to urinate. Clinical Implications We used the gracilis muscle combined with the fascia lata to mimic the basic structure of the corpus cavernosum and tunica albuginea and successfully reconstructed the biomimetic dynamic neophallus. Strengths and Limitations This is to our knowledge the first report of biomimetic dynamic phalloplasty using the bilateral pedicled gracilis muscle combined with the fascia lata to mimic the complex structure of the phallus and enable the achievement of erection. However, due to the small number of patients included in this study, the data have no statistical significance. More cases are needed to obtain conclusive data and examine the long-term clinical effects of this procedure. Conclusion Using novel methods for phalloplasty, we successfully maintained the patient's ability to obtain sufficient hardness and subjective controllability without the use of implants, and the preliminary clinical results are encouraging. [ABSTRACT FROM AUTHOR]

Some muscles present neuromuscular compartments, one of which is the gracilis muscle. The aim of the present study is to determine the number of compartments present within the gracilis muscle based on its intramuscular innervation patterns; such knowledge could be of value in free functional muscle transfer. The study comprised 72 gracilis muscles (38 women, 34 men), fixed in 10% formalin solution. The muscles were removed and then stained using Sihler's method. When sufficient transparency was achieved, some measurements were made. Three different types of intramuscular innervation were distinguished. Type I (70.8%) was featured by at least one direct proximal nerve branch. Type II (23.6%) presented at least one indirect proximal nerve branch. Type III (5.6%) did not possess any proximal nerve branch. The median of descended nerve branches was five. Considerable anatomical variation is possible within the intramuscular innervation of the gracilis muscle. The muscle presents neuromuscular compartments, but the exact number depends on the type of its intramuscular innervation and the number of the main descendent nerve branches. All three types seem to be appropriate for free functional muscle transfer. Our findings may be of great value for surgeons carrying out complex reconstructions with the use of the gracilis muscle. [ABSTRACT FROM AUTHOR]

Purpose: Complex fistulas often require several attempts at repair and continue to be a challenging task for the surgeon, but above all, a major burden for the affected patient. This study is aimed at evaluating the potential of gracilis muscle transposition (GMT) as a therapeutic option for complex fistulas of diverse etiologies. Methods: A retrospective study was conducted over a period of 16 years with a total of 60 patients (mean age 50 years). All were treated for complex fistula with GMT at St. Josef’s Hospital in Regensburg, Germany. Follow-up data were collected and analyzed using a prospective database and telephone interview. Success was defined as the absence of fistula. Results: A total of 60 patients (44 women, 16 men; mean age 50 years, range 24–82 years) were reviewed from January 2005 to June 2021. Primary fistula closure after GMT was achieved in 20 patients (33%) and 19 required further interventions for final healing. Overall healing rate was 65%. Fistula type was heterogeneous, with a dominant subgroup of 35 rectovaginal fistulas. Etiologies of the fistulas were irradiation, abscesses, obstetric injury, and iatrogenic/unknown, and 98% of patients had had previous unsuccessful repair attempts (mean 3.6, range 1–15). In 60% of patients with a stoma (all patients had a stoma, 60/60), stoma closure could be performed after successful fistula closure. Mean follow-up after surgery was 35.9 months (range 1–187 months). No severe intraoperative complications occurred. Postoperative complications were observed in 25%: wound healing disorders (n = 6), gracilis necroses (n = 3), incisional hernia (n = 2), scar tissue pain (n = 2), suture granuloma (n = 1), and osteomyelitis (n = 1). In 3 patients, a second gracilis transposition was performed due to fistula recurrence (n = 2) or fecal incontinence (n = 1). Conclusion: Based on the authors’ experience, GMT is an effective therapeutic option for the treatment of complex fistulas when other therapeutic attempts have failed and should therefore be considered earlier in the treatment process. It should be seen as the main but not the only step, as additional procedures may be required for complete closure in some cases. [ABSTRACT FROM AUTHOR]

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

Introduction: In the last decade, fascia research increased significantly in various aspects such as anatomical and biomechanical features related to epimuscular force transmission. Methods: The present anatomic study focuses on macroscopic observations of the potential gracilis and semitendinosus paratenons, as well as fascial surroundings connections in the posteromedial knee region on 17 lower-limbs dissections. Results: The gracilis and semitendinosus expansions and paratenons were observed in all specimen and further connections with the fascia lata and crural fascia were demonstrated. Contrary to the previously described expansions connected to the tendons, we observed that the expansions were the edges of the paratenon tunnel and that the paratenon structure surrounded the overall muscle. Both paratenons of gracilis and semitendinosus were connected to the crural fascia and, respectively, to the sartorius fascia (part of the fascia lata), to the semimembranosus and the fascia lata. Furthermore, numerous connections between the fascia lata and the neighboring structures in the posteromedial knee region are described. Discussion–conclusion: The present study describes for the first time gracilis and semitendinosus paratenons and other surrounding fascial connections. Such macroscopic observations may represent a new basis for further characterization of the myofascial pathway of epimuscular force transmission in the knee region. [ABSTRACT FROM AUTHOR]

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Facial palsy has a broad clinical presentation and the effects on psychosocial interaction and facial functions can be devastating. Pediatric facial palsy, in particular, introduces unique familial and technical considerations as anatomy, future growth potential, and patient participation influence treatment planning. Though some etiologies of pediatric facial palsy are self-limiting, congenital and long-standing facial palsies pose difficult challenges that require a combination of surgical, adjunctive, and rehabilitative techniques to achieve facial reanimation. Given the spectrum of ages and symptom severity, as well as the various surgical options available for facial palsy, a tailored approach needs to be developed for each child to restore facial balance and function. Here, we review the etiologies, workup, and treatment of pediatric facial palsy and present our novel algorithmic approach to treatment.

Anorectal malformation or imperforate anus is a congenital anomaly of rectum and anus. Mullerian duct anomalies are abnormal development of uterus, cervix, and vagina. Imperforate anus with double uterus is extremely rare and cannot explain by normal embryologic development. Moreover, guideline in treatment is inconclusive. We report an extremely rare case of a young adult female who presented with recurrent pelvic inflammatory disease caused by rectovaginal fistula in congenital imperforate anus and didelphys uterus, and successfully neoanal reconstruction with gracilis muscle flap. Aims for treatment are closed rectovaginal fistula, and anal sphincter reconstruction. To our best knowledge, the imperforate anus with double uterus is extremely rare anomaly. Furthermore, successfully anal sphincter reconstruction with functional gracilis muscle in the imperforate anus with double uterus has never been reported in English literature.

Introduction The masseter nerve has been used as a donor nerve for facial reanimation procedures due to the multiple advantages it offers; it has been generally considered that sacrifice of the masseter nerve does not alter the masticatory apparatus; however, there are no objective studies to support this claim. Objective To evaluate the impact that the use of the masseter nerve in dynamic facial reconstruction has on the electrical activity of the masseter muscle and on bite force. Materials and Methods An observational and prospective longitudinal study was performed measuring bite force and electrical activity of the masseter muscles before and 3 months after dynamic facial reconstructive surgery using the masseter nerve. An occlusal analyzer and surface electromyography were employed for measurements. Results The study included 15 patients with unilateral facial paralysis, with a mean age of 24.06 ± 23.43. Seven patients were subjected to a masseter–buccal branch nerve transfer, whereas in eight patients, the masseter nerve was used as a donor nerve for gracilis free functional muscle transfer. Electrical activity of the masseter muscle was significantly reduced after surgery in both occlusal positions: from 140.86 ± 65.94 to 109.68 ± 68.04 (p = 0.01) in maximum intercuspation and from 123.68 ± 75.64 to 82.64 ± 66.56 (p = 0.01) in the rest position. However, bite force did not show any reduction, changing from 22.07 ± 15.66 to 15.56 ± 7.91 (p = 0.1) after the procedure. Conclusion Masseter nerve transfer causes a reduction in electromyographic signals of the masseter muscle; however, bite force is preserved and comparable to preoperative status.

Introduction. A clear knowledge on the variations of blood supply and innervation of muscles in different areas of the body allows the surgeon to select the neurovascular pedicle, when performing muscle transposition operations using microsurgical techniques, to correctly choose the muscle flap, the method of replacing the defect and the localization of the donor area. The objective of the study: to clarify the information about the sources of innervation and blood supply to the gracilis muscle, adductor muscles and pectineus muscles, as well as to investigate the intramuscular distribution of nerves and arteries in the muscles of the medial group of the thigh in human fetuses aged 4-10 months. Materials and methods. The peculiarities of the fetal topography of the arteries and nerves of the medial femoral group muscles were studied in 42 human fetuses aged 4-10 months using the methods of macro microscopic preparation, vascular injection, surface staining of the prepared vessels and nerves, and morphometry. Results. It has been established that the distribution of nerves and arteries is uneven in the thickness of the muscles of the medial group of the thigh, at the same time the middle third of all adductor muscles is supplied with blood and innervated more intensively. The places where nerves penetrate into the thickness of the muscles of the medial femoral group, do not coincide with the places where the arteries enter, pectineus muscle is an exception. The nature of the intramuscular distribution of nerves and arteries depends on the structure and function of the muscle. The intramuscular nerve trunks are interconnected in the gracilis and adductor magnus muscles, forming loops and arcades. Nerve connections between the obturator and sciatic nerves are found in the thickness of the adductor magnus muscle. Conclusions. In the picture of the intramuscular distribution of nerves and arteries in the muscles of the medial group of the thigh in human fetuses, three forms can be distinguished: loose, trunk, and mixed. In the thickness of the muscles of the medial femoral group, the distribution of nerves and arteries is uneven. Segmentation is preserved in the intramuscular distribution of arteries in the muscle gracilis, adductor longus and magnus muscles, while in the distribution of nerves in these muscles segmentation is absent.

Cerebral palsy (CP) describes some upper motoneuron disorders due to non-progressive disturbances occurring in the developing brain that cause progressive changes to muscle. While longer sarcomeres increase muscle stiffness in patients with CP compared to typically developing (TD) patients, changes in extracellular matrix (ECM) architecture can increase stiffness. Our goal was to investigate how changes in muscle and ECM architecture impact muscle stiffness, gait and joint function in CP. Gracilis and adductor longus biopsies were collected from children with CP undergoing tendon lengthening surgery for hamstring and hip adduction contractures, respectively. Gracilis biopsies were collected from TD patients undergoing anterior cruciate ligament reconstruction surgery with hamstring autograft. Muscle mechanical testing, two-photon imaging and hydroxyproline assay were performed on biopsies. Corresponding data were compared to radiographic hip displacement in CP adductors (CPA), gait kinematics in CP hamstrings (CPH), and joint range of motion in CPA and CPH. We found at matched sarcomere lengths muscle stiffness and collagen architecture were similar between TD and CP hamstrings. However, CPH stiffness (R 2  = 0.1973), collagen content (R 2  = 0.5099) and cross-linking (R 2  = 0.3233) were correlated to decreased knee range of motion. Additionally, we observed collagen fibres within the muscle ECM increase alignment during muscular stretching. These data demonstrate that while ECM architecture is similar between TD and CP hamstrings, collagen fibres biomechanics are sensitive to muscle strain and may be altered at longer in vivo sarcomere lengths in CP muscle. Future studies could evaluate the impact of ECM architecture on TD and CP muscle stiffness across in vivo operating ranges. KEY POINTS: At matched sarcomere lengths, gracilis muscle mechanics and collagen architecture are similar in TD patients and patients with CP. In both TD and CP muscles, collagen fibres dynamically increase their alignment during muscle stretching. Aspects of muscle mechanics and collagen architecture are predictive of in vivo knee joint motion and radiographic hip displacement in patients with CP. Longer sarcomere lengths in CP muscle in vivo may alter collagen architecture and biomechanics to drive deficits in joint mobility and gait function., (© 2024 The Author(s). The Journal of Physiology published by John Wiley & Sons Ltd on behalf of The Physiological Society.)

Introduction: Transposition of the gracilis has been used in a large number of reconstructive procedures. Its advantage is its proximity to these defects and a good blood supply. Traditionally, the gracilis mobilization is performed by open surgery with one or more incisions. We describe our initial experience with the video-endoscopic mobilization of gracilis. Method: We described a retrospective review of all patients who underwent gracilis muscle mobilization for treatment of rectourethral fistula, performed by video-endoscopy, between March 2013 and September 2017, for treatment of rectourethral fistula. Also, our surgical technique is described in detail. Results: Three patients, with a mean age of 66.6 years, underwent the procedures. The mean time for mobilization of the gracilis was 107 min (range 60–145). There was no case of donor area infection, no change in the sensitivity of the medial aspect of the thigh or chronic pain. Conversion to open surgery was not necessary in any case. The hospital discharge occurred in average after 4 days. The bladder catheter was removed after 4 weeks after cystography was performed without evidence of leakage. One patient had a recurrence of the fistula. Discussion: The gracilis is an excellent choice of tissue to be interposed in reconstructive procedures of the perineal region, especially in the treatment of rectourinary fistulas. However, endoscopic harvest of the gracilis muscle has not yet found its way into everyday practice. The results in the treatment of rectourinary fistulas are excellent, with a success rate of 87.7%. Our rate of 67% is below, probably due to the small number of cases. In open surgery, complications are uncommon; however, approximately half of the patients expressed concern about the painful scar, which can be reduced by minimally invasive access. Conclusion: Video-endoscopic mobilization of gracilis muscle for the treatment of rectourethral fistula is feasible and safe. Studies comparing this technique with the conventional mobilization are required. [ABSTRACT FROM AUTHOR]

The result of an extra-levator abdominoperineal excision of the rectum (ELAPE) is a composite three-dimensional defect. This is performed for locally advanced anorectal cancer, and may involve partial excision of the vagina. The aim of reconstruction is to achieve wound healing, restore the pelvic floor and to allow micturition and sexual function. We aim to evaluate the concurrent use of profunda artery perforator (PAP) and bilateral gracilis flaps for vaginal and pelvic floor reconstruction. We performed a retrospective case note review of patients undergoing pelvo-perineal reconstruction with combined gracilis and PAP flaps between July 2018 and December 2019. Eighteen pedicled flaps were performed on six patients with anal or vulval malignancies. All underwent pre-operative radiotherapy. Four patients had extended abdominoperineal tumour resections, while two patients underwent total pelvic exenteration. The median age was 57 (range 47–74) years, inpatient stay was 22 (11–47) days and the follow-up was 10 (5–21) months. Four patients developed partial perineal wound dehiscence, of which one was re-sutured. One patient had a post-operative bleed requiring radiological embolisation of an internal iliac branch and had subsequent 1cm PAP flap loss. All other flaps survived completely. Median time to heal was 4 (1–6) months. This is the first series reporting combined bilateral gracilis and PAP flaps for pelvic reconstruction. The wound dehiscence rate and healing times were expected in the context of irradiation and radical pelvic tumour resection. This is a reliable technique for perineal and vaginal reconstruction with minimal donor site morbidity. [ABSTRACT FROM AUTHOR]

Snapping pes anserinus is the main extra-articular cause of snapping on the medial side of the knee. There are limited articles that describe the mechanism of the condition, especially only when flexion of the knee. We report a case of snapping pes anserinus in a 23-year-old skier, which was reproduced on only active flexion of both knees in the posteromedial aspect of the tibia, with pain for 6 years, diagnosed using dynamic ultrasonography for elucidating a new mechanism of the gracilis tendon. We performed dynamic ultrasonography of the right knee of the patient; the gracilis tendon was twisting and folding and then, snapping occurred when the gracilis tendon passed by the sartorius muscle. The atypical movement of the gracilis tendon was considered the primary factor for snapping in this patient, which was diagnosed with dynamic ultrasonography.

Background: The gracilis myocutaneous flap is a versatile reconstructive option. Despite wide applicability, concerns are often raised regarding the unreliable vascular perfusion of the distal third of the flap's skin paddle. This study presents our experience utilizing the pedicled gracilis myocutaneous flap for various oncologic defects to highlight the versatility, safety, and utility of this flap. Methods: A retrospective analysis was performed for patients who underwent reconstruction utilizing a gracilis myocutaneous flap over the course of 20 years (January 1998–June 2018). Postoperative outcomes were reviewed to determine the incidence of infection, dehiscence, seroma, or hematoma for both donor and recipient sites. Incidence of flap skin or muscle loss was also recorded. Results: A total of 37 patients met our inclusion criteria, and data from 41 vertically oriented gracilis myocutaneous flaps was analyzed. A majority of our patients had a previously irradiated wound bed (73%). The overall donor site complication rate was 19.5%. The recipient site complication rate was 41.5% and included partial flap loss (14.6%). Partial flap loss included distal flap skin necrosis incidence (9.7%). Conclusion: When taking into account the size of the primary defect prompting reconstruction and prior recipient bed irradiation history, our cohort shows reasonable complication rates. Distal tip skin necrosis rate was also low, which suggests that the distal third's vascular supply should not be a limiting factor. Level of evidence Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Breast deformity, in post-burn patients, is a common problem leading to lower self-esteem and reclusive behavior that impairs quality of life. The authors present the course of treatment of an 18-year-old immigrant girl who suffered second- to third-degree burns over approximately 20% of her total body surface area in her early childhood. The second- to third-degree burns were located on her right trunk and abdomen, as well as her right shoulder, neck, and right groin area. Since it was not offered in her home country, reconstructive surgery, including microsurgical breast reconstruction, was sought abroad. Due to the lack of available skin and soft tissue, a bilateral breast reconstruction with free transverse myocutaneous gracilis flaps was offered. This case illustrates one method of using microsurgery to address post-burn breast deformities in order to alleviate psychological suffering and improve quality of life.

Facial palsy has a broad clinical presentation and the effects on psychosocial interaction and facial functions can be devastating. Pediatric facial palsy, in particular, introduces unique familial and technical considerations as anatomy, future growth potential, and patient participation influence treatment planning. Though some etiologies of pediatric facial palsy are self-limiting, congenital and long-standing facial palsies pose difficult challenges that require a combination of surgical, adjunctive, and rehabilitative techniques to achieve facial reanimation. Given the spectrum of ages and symptom severity, as well as the various surgical options available for facial palsy, a tailored approach needs to be developed for each child to restore facial balance and function. Here, we review the etiologies, workup, and treatment of pediatric facial palsy and present our novel algorithmic approach to treatment. [ABSTRACT FROM AUTHOR]

The gracilis muscle (GM) is located in the medial aspect of the thigh, medial and posterior to the long adductor in its proximal part. It originates at the pubic level and is inserted in the medial face of the tibia, in its upper part. As a functional free flap, it has been one of the most co mmonly used grafts in various reconstructions, such as penis, perineum, vagina, leg, brachial plexus, facial paralysis, rectal lesions, among others. Based on the above, the objective of this study was to complement the anatomy of the GM both in its dimensions and in its vascular pedicles and innervation, establishing the existing biometric relationships, contributing to the surgical anatomy, in its use as a graft. For this, 30 lower limbs of 20 bodies of adult, Brazilian, male, 14 right and 16 left individuals were used; 17 fixed in formaldehyde and 13 in glycerin. The thigh was divided into 4 quartiles listed from proximal to distal such as C1, C2, C3 and C4. The number of pedicles was counted and they were named as principal pedicle (PP), minor pedicle 1 (mP1), minor pedicle 2 (mP2) and minor pedicle 3 (mP3). The average length of the GM was 42.25 cm ± 2.35 cm and its average width was 32.90 ± 4.86 mm. With respect to vascular pedicles, a pedicle was found in 10/30 cases (33.3 %); one PP and one mP in 10/30 (33.3 %); one PP and two mP in 8/30 (26.7 %) and one PP and three mP in 2/30 (6.7 %). Its innervation always came from the anterior branch of the obturator nerve (aBON). The motor point was found at an average distance of 7.94 mm proximal to the entry of the PP in the GM. Biometric records are expressed in tables. The results obtained will contribute to anatomical knowledge, and can be used as morphological support for surgical procedures that involve the GM. [ABSTRACT FROM AUTHOR]

Anorectal malformation or imperforate anus is a congenital anomaly of rectum and anus. Mullerian duct anomalies are abnormal development of uterus, cervix, and vagina. Imperforate anus with double uterus is extremely rare and cannot explain by normal embryologic development. Moreover, guideline in treatment is inconclusive. We report an extremely rare case of a young adult female who presented with recurrent pelvic inflammatory disease caused by rectovaginal fistula in congenital imperforate anus and didelphys uterus, and successfully neoanal reconstruction with gracilis muscle flap. Aims for treatment are closed rectovaginal fistula, and anal sphincter reconstruction. To our best knowledge, the imperforate anus with double uterus is extremely rare anomaly. Furthermore, successfully anal sphincter reconstruction with functional gracilis muscle in the imperforate anus with double uterus has never been reported in English literature. [ABSTRACT FROM AUTHOR]

Introduction  The masseter nerve has been used as a donor nerve for facial reanimation procedures due to the multiple advantages it offers; it has been generally considered that sacrifice of the masseter nerve does not alter the masticatory apparatus; however, there are no objective studies to support this claim. Objective  To evaluate the impact that the use of the masseter nerve in dynamic facial reconstruction has on the electrical activity of the masseter muscle and on bite force. Materials and Methods  An observational and prospective longitudinal study was performed measuring bite force and electrical activity of the masseter muscles before and 3 months after dynamic facial reconstructive surgery using the masseter nerve. An occlusal analyzer and surface electromyography were employed for measurements. Results  The study included 15 patients with unilateral facial paralysis, with a mean age of 24.06 ± 23.43. Seven patients were subjected to a masseter–buccal branch nerve transfer, whereas in eight patients, the masseter nerve was used as a donor nerve for gracilis free functional muscle transfer. Electrical activity of the masseter muscle was significantly reduced after surgery in both occlusal positions: from 140.86 ± 65.94 to 109.68 ± 68.04 (p = 0.01) in maximum intercuspation and from 123.68 ± 75.64 to 82.64 ± 66.56 (p = 0.01) in the rest position. However, bite force did not show any reduction, changing from 22.07 ± 15.66 to 15.56 ± 7.91 (p = 0.1) after the procedure. Conclusion  Masseter nerve transfer causes a reduction in electromyographic signals of the masseter muscle; however, bite force is preserved and comparable to preoperative status. [ABSTRACT FROM AUTHOR]

Objective: To identify criteria to guide surgeons regarding indications for use of the Singapore and gracilis muscle flaps in obstetric fistula repair.Methods: This is a retrospective case series. Obstetric fistula surgeons in Lilongwe, Malawi, have been incorporating plastic surgery techniques with the Singapore and gracilis muscle flaps since collaborating with plastic surgeons in 2016. We describe the surgical outcomes of procedures utilizing each flap individually and those using both.Results: Between February 2016 and June 2019, 69 patients received a flap at the time of obstetric fistula repair at the Fistula Care Center in Lilongwe, Malawi. A total of 32 (46.4%) received a Singapore flap, 20 (29.0%) received a gracilis flap, and 17 (24.6%) received both types of flap.Conclusion: Based on our outcomes, we note the possible advantage of incorporating the gracilis flap even when it is thought that the Singapore flap is sufficient. However, more data are needed. [ABSTRACT FROM AUTHOR]

Functional free tissue transfer in the form of muscle free flap is a challenging surgical procedure and needs a steep learning curve. A porcine model for free muscle transfer and insetting in a distant area is of great interest in reconstructive microsurgery due to the experience and learning curve necessary to perform these surgeries. The aim of this study was to assess the feasibility of a swine model for gracilis muscle free transfer and to describe the donor site anatomy. Ten gracilis free flap transfer surgery models were performed under general anesthesia in a porcine model, based on a vascular pedicle depending of the external iliac vessels and a branch of the obturator nerve with microsuture mediated connection to head and neck nerves and vessels. The gracilis myocutaneous or muscle-only free flap was successfully transferred in all cases using as receptors the vagus nerve, the common carotid artery, and the external or internal jugular veins. In two cases, nervous connection had to be redone. All vascular anastomoses were correctly functioning. Despite the anatomical and design variations, porcine gracilis free flap transferred to the head and neck area with microvascular anastomosis and nerve connection provides a suitable training model for functional reconstructive microsurgery. [ABSTRACT FROM AUTHOR]