Clin Plastic Surg 29 (2002) 483 – 495
Basic science behind functioning free muscle transplantation
Kazuteru Doi, MD*, Yasunori Hattori, MD, Soo-Heong Tan, MD,
Vikas Dhawan, MD
Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862 – 3 Shimogo, Ogori, Yamaguchi-ken, 754-0002, Japan
Free muscle transfer can provide a reliable and
powerful motor recovery following brachial plexus
injuries [1,2], Volkman’s contracture [3,4], resection
of malignant soft tissue tumor [5], and facial nerve
palsy. To obtain satisfactory outcome of functional
reconstruction with free muscle transfer, it is imper-
ative to understand the basic science of muscle trans-
fer, ie, vascular anatomy of skeletal muscle, structural
anatomy of skeletal muscle, biomechanical concept
of joint movement, and neurophysiological phenome-
non of free muscle transfer.
In this chapter, basic science for clinical free
muscle transfer is briefly explained step by step.
Donor muscle selection
When planning free muscle transfer, selection of
donor muscle depends on the type of blood supply to
the muscle, the length, volume, shape of muscle, type
of muscle fiber architecture and contractile capacity
of muscle fiber.
Type of blood supply to muscle
Vascular pedicle
The circulation of muscle is based on the vascular
pedicle(s) that enters the muscle belly between its
origin and insertion. The pedicle(s) consist(s) of an
artery, generally a branch of the major artery to the
specific anatomic region of the muscle and paired
venae comitantes that drain into a corresponding
* Corresponding author.
E-mail address: doimac@ca.mbn.or.jp (K. Doi).
0094-1298/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 9 4 - 1 2 9 8 ( 0 2 ) 0 0 0 2 0 - 2
major regional vein. When a muscle has more than
one vascular pedicle, the relative importance of each
vascular pedicle in regard to muscle circulation is
necessary. When division of a pedicle generally re-
sults in muscle avascular necrosis, this pedicle is
defined as a major vascular pedicle. Minor pedicles
represent smaller vascular attachments to muscle.
Use of muscle as free muscle transfer is generally
based on a single vascular pedicle or its dominant
vascular pedicle.
Mathes and Nahai [6] reviewed the vascular anat-
omy of human muscle obtained by cadaver studies
and classified the type of circulation to assist in the
selection of the muscle for use as a flap (Fig. 1).
According to their classification, muscles belong-
ing to Type 1, II and V are primarily chosen for free
muscle transplantation.
Type 1 muscles have one vascular pedicle and
include rectus femoris muscle and tensor fascia lata.
Type II muscles have dominant vascular pedicle and
minor vascular pedicles and include gracilis, biceps
femoris, and soleus. Type IV muscles have one
dominant vascular pedicle and secondary segmental
vascular pedicles and includes latissimus dorsi and
pectoralis major.
Fiber architecture
The arrangement of fibers within a muscle influ-
ence muscle function. These structures affect the
strength of muscular contraction and the range of
motion through which a muscle group can move a
body segment. The two umbrella categories of
muscle fiber arrangement are termed parallel (strap)
and pennate. In a parallel fiber arrangement, the
fibers are oriented largely in parallel with the longi-
484 K. Doi et al. / Clin Plastic Surg 29 (2002) 483–495

Fig. 1. Patterns of vascular anatomy of muscle. Type I, One vascular pedicle; type II, dominant pedicles and minor pedicles;
type III, two dominant pedicles; type IV, segmental vascular pedicles; type V, one dominant pedicle, and secondary seg-
mental pedicles.

tudinal axis of the muscle (Fig. 2). The gracilis,
rectus abdominalis, latissimus dorsi, and biceps bra-
chii have parallel fiber orientations and are termed as
strap muscles or parallel fibered muscles. A pennate
fiber arrangement is one in which the fibers lie at an
angle to the muscle’s longitudinal axis and is termed
as unipennate muscle or bipennate muscle. Each
fiber in a pennate muscle attaches to one or more
tendons, some of which extend the entire length of
the muscle. The fibers of a muscle may exhibit more
than one angle of pennation (angle of attachment) to
a tendon. The rectus femoris, and deltoid muscles
have pennate fiber arrangement. When tension is
developed in a parallel-fibered muscle, any short-
ening of the muscle is primarily the result of the
shortening of its fibers. When the fibers of a pennate
muscle shorten, they rotate about their tendon at-
tachment or attachments, progressively increasing
the angle of pennation [7]. The greater the angle of
pennation, the smaller the amount of effective force
actually transmitted to the tendon or tendons to move
the attached bones (Fig. 3). Pennate muscles contain
more fibers per unit of muscle volume and they can
generate more force than parallel-fibered muscles of
the same size. However, parallel fiber arrangement
enables greater shortening of the entire muscle than
is possible with a pennate arrangement. Parallel-
fibered muscle can move body segment through
larger ranges of motion than comparably sized pen-
nate-fibered muscle.
When selecting a donor muscle for free muscle
transfer, parallel fibered muscle such as gracilis is
indicated for finger function, it needs great range of
motion but not so much power. Whereas, pennate
fibered muscle such as rectus femoris is indicated for
elbow flexion needs much power but not so great a
range of motion.
Length of muscle fiber
The amount of maximum isometric tension of a
muscle partly depends on the muscle’s length and
also the range of motion of a joint, muscle moves
depend on the muscle’s length and type of fiber
arrangement. From the experimental studies, the
muscle fibers contract maximum to around 40% of
the resting length and elongate to around 160% of
the resting length. In a human body, however, the
 K. Doi et al. / Clin Plastic Surg 29 (2002) 483–495 485

Fig. 2. Muscle fiber arrangement. Left, parallel fiber arrangement (strap muscle); Right, pennate fiber arrangement (pennate
muscle); and bipennate muscle

elastic components of muscle such as tendon add to
tension present in the muscle when the muscle is
stretched. It is also estimated that with maximum
contraction, a muscle can shorten between 40% and
57% of its fully stretched length [8,9]. Practically,
excursion amplitude of muscle can be calculated
around 40% of resting muscle fiber length. Among
available muscles for free muscle transfer, sartorius
has the longest muscle fibers, but its segemental
blood supply excludes sartorius from being a donor
muscle. Subsequently, gracilis is the most suitable
donor muscle with the greatest range of motion
(Table 1) [10]. The degree of shortening of a strap
muscle such as the gracilis with about 30 cm long,
resting length would be at least 12 cm in its normal
state (30 cm  40%). Similarly, the pectoralis major
with a resting length of 23 cm would have a
contractile capacity of 9.2 cm (23 cm  40%). In a
pennate muscle, fasciculi are arranged at an angle to
the line of the pull of the muscle [11]. These fasciculi

Fig. 3. Differences of contraction length between strap muscle (A) and pennate muscle (B)
486 K. Doi et al. / Clin Plastic Surg 29 (2002) 483–495

Table 1
Charcteristics of muscle
Total Length of muscle Type of Type of
Muscle length(cm) belly(cm)* Weight(g) vascular pedicle muscle fiber
Sartorius 50.8 47 138.3 IV parallel
Rectus femoris 40.5 33.6 200.8 I pennate
Gracilis 42 31.9 83.8 II parallel
Latissimus dorsi 42.2 30.7 247.4 V parallel
Biceps femoris 39.6 30.5 235.5 II parallel
Semitendinosus 41.1 27.9 152.1 II parallel
Gastrocnemius 41.1 23 330.2 I pennate
Pectralis major 27.6 22.7 280 V parallel
Brachioradialis 31.3 20.2 46.9 II parallel
Tensor fascia lata 47.7 16.7 86.1 I pennate
Extensor carpi radialis longus 29.9 12.4 44.8 II parallel
Extensor digitorum brevis 13.7 6.4 12.4 I parallel
* The length is muscle belly, not muscle fibers.

usually are much shorter than those of the strap
muscle. A bipennate muscle such as the rectus
femoris should be expected to contract about 40%
of the average muscle fascicule length of 6 to 7 cm.
Theoretically, 3 cm would be the maximum contrac-
tion in its normal location.
Muscle volume
Muscle strength is derived both from the amount
of tension the muscles can generate and from the
moment arms of the contributing muscles with
respect to the joint center. The tension-generating
capacity of a muscle is related to its cross-sectional
area. The force generating capacity per cross-sectional
area of muscle is approximately 90 N/cm2 [12]. The
weight of muscle is relatively proportion to the cross-
sectional area (CSA). For massive function such as
knee extension or elbow flexion, the heavy weight
muscle such as latissimus dorsi should be selected. It
has been suggested that, following muscle trans-
plantation, one should expect to obtain a muscle bulk
of 25% to 50% of the pretransplanted size [13,14]. In
the authors’ experience with clinical cases, however,
most of the transplanted muscles regained full
strength and sometimes, stronger than pretransplanted
power [1,5]. This may be explained as a result of
postoperative muscle strengthening exercises.
Requirement of recipient function/ required function
of the recipient site
An ideal donor muscle is close in size, shape,
length of muscle fiber, and physiological CSA to the
lost muscle. These factors effect on excursion of
muscle and muscle strength. In its natural location,
although the full range of contraction of a muscle is
rarely employed, and if it should be, the last portion
of the range of contraction usually is not carried out
against significant resistance. Therefore, in the trans-
plantation situation, the last few centimeters of
contraction should not be expected to be of use in
finger flexion, where requirement is for good
strength at full finger flexion. Because of these
factors, a muscle should be selected that normally
has amplitude of motion greater than the desired
range of motion in its transplanted site. When
replacing long finger musculature, amplitude of
motion of 7cm is required for a full finger move-
ment throughout the range of wrist position. The
gracilis, pectralis major, and latissimus dorsi with
contractile capacities of at least 12 cm, 10 cm, and
12 cm respectively, satisfy the requirements for a
full range of movement. These muscles have a
potential of between 25% and 50% more movement
in their normal sites than that required in the trans-
planted locations. The rectus femoris, with a con-
tractile capacity of 3 cm, does not satisfy the range
of movement requirement for finger flexors. Among
these muscles, gracilis is the choice of donor muscle
for finger reconstruction because of shape of muscle
and long tendinous portion for good excursion in the
distal forearm.
For elbow flexion, the long head of biceps brachii
acts as the main elbow flexor. It operates over a
broader range of the force – length curve (length
change 56% of optimal length 12.8 cm) [15], and
the muscles that satisfy both contractile and powerful
capacities of biceps brachii are latissimus dorsi, and
pectoralis major. Rectus femoris has enough power
 K. Doi et al. / Clin Plastic Surg 29 (2002) 483–495
strength, however, its excursion is short and this
transfer tends to result in flexion contracture of
elbow. The cross-sectional area of gracilis seems to
be insufficient to flex elbow, however, clinical experi-
ence shows that after the gracilis transfer was carried
out, complete elbow flexion was achieved. This may
be due to muscle strengthening exercises during
postoperative rehabilitation, and moment arm effect
of the muscle on elbow flexion rather than the
interplay of architecture [15].
Donor nerve selection
Component of motor nerve fiber
General selection
The pure motor nerves such as spinal accessory
nerve and motor branch to the individual muscle are
the first choice as donor motor nerve. However the
mixed nerves such as intercostals or ulnar, are also
usually used as a donor motor nerve.
Biochemical assay
The greater the number of motor nerve fibers in
the donor nerve, the better the functional recovery.
The quantitative assessment of motor nerve fiber
component can be examined by biochemical mea-
sures. The authors used intraoperative measurement
of choline acetyltransferase (CAT) activity for evalu-
ation of the functional viability of donor nerves
during functioning free muscle transfer (FFMT)
[16]. The authors studied 12 patients in whom FFMT
was performed. Seven patients had brachial plexus
injury, 3 Volkman’s contracture, 1 chronic peroneal
nerve injury, and 1 forearm extensor muscle loss
following wide resection of soft tissue sarcoma. The
purpose of reconstruction using FFMT was to
achieve wrist extension in 4 patients, simultaneous
elbow flexion and finger extension in 3, elbow
flexion in 2, finger extension in 1, finger flexion in
1 and ankle dorsiflexion in 1 patient. The gracilis
muscle was transferred in all cases. The donor nerves
for FFMT, which were evaluated by CAT activity,
included 5 spinal accessory nerves, 4 posterior inter-
osseous nerves, 2 anterior interosseous nerves, and 1
deep peroneal nerve. The fascicles with CAT activity
above 2000 cpm were considered to be reliable and
used as a donor motor nerve. All muscles had
reinnervation by 3.2 months (range 2 to 5 months)
and achieved useful recovery. This study shows that
intraoperative measurement of CAT activity can pro-
vide direct and quantitative information on the func-
tional status of donor nerves during FFMT. This
487
technique can be applied to evaluate the injured
nerve for being available as a donor motor nerve. It
is difficult to distinguish between the stump of
injured nerve involved in scar tissue and the normal
motor nerve by macroscopic findings. Measurement
of CAT activity makes it easy to distinguish between
the two.
Electrophysiological method
In root avulsion of brachial plexus injuries, C5
nerve root is frequently postganglionic injury and
serves as a donor motor nerve for free muscle
transfer. Proximal continuity of the nerve root
stump is distinguished by CAT activity, evoked
spinal cord potentials (ESCPs) or somatosensory-
evoked potential measurements (SEPs). Measure-
ment of CAT activity needs radioimmunoassay,
however, the later two procedures are common
electrodiagnosis. Sasaki et al [17] reported that
ESCPs were recorded intraoperatively in the
19 cases of brachial plexus injury in order to
diagnose the level of the nerve root injury.
Recording electrode was catheter electrode, which
was inserted in the epidural space one day before
the operation. Nerve roots were stimulated directly
after exposure. No response was obtained after
stimulation of damaged nerve roots whose myelo-
gram and macroscopic findings were abnormal.
The cases in which ESCPs showed good response
and amplitude higher than 5 uV, achieved func-
tional recovery of the target muscles following
nerve repair (Fig. 4). When the nerve root is used
as donor motor nerve, measurement of ESCPs/
Fig. 4. Spinal-evoked potential
488 K. Doi et al. / Clin Plastic Surg 29 (2002) 483–495

SEPs and CAT activity intraoperatively is useful in Placement and routing of muscle
the patients with brachial plexus injuries ESCPs
technique is also applicable to the distal nerve Muscle attachment
stump, as same technique of measurement of nerve
action potential. The authors’ understanding of the force – velocity
and length – tension relationships for muscle tissue
Type of muscle fiber are derived from the experimental works that directly
measured the force generated by the muscle. In the
After being stimulated, the fibers of some motor human body, however, the muscle strength is most
units contract to reach maximum tension more commonly measured as the amount of torque a
quickly than others do. Based on these distinguishing muscle group can generate at a joint. Torque is the
characteristics, fibers may be divided into the cat- product of force and the force moment arm, or the
egories of fast twitch (FT) and slow twitch (ST). A perpendicular distance at which the force acts from an
fast twitch fiber reaches peak tension relatively quick, axis of rotation. A muscle moment arm is affected by
and a slow twitch fiber reaches peak tension rel- two equally important factors. The first is the distance
atively slow. It takes FT fibers only about one- between the muscle anatomical attachment to bone
seventh the time required by ST fibers to reach peak and the axis of rotation at the joint center (Fig. 5), and
tension [18]. FT fibers are also divided into two the second is the angle of muscle attachment to bone,
categories, Type II a and Type II b, based on which is typically a function of relative joint angle.
histochemical properties. Most skeletal muscles con- The greatest amount of torque is produced by
tain both FT and ST fibers, with the relative amounts maximum tension in a muscle that is oriented at a
varying from muscle to muscle and individual to 90 degree angle to the bone, and anatomically
individual. A high percentage of fast twitch fibers is attached as far from the joint center as possible
advantageous for generating fast movements and a (Fig. 6). For example, when reconstructing elbow
high percentage of slow twitch fibers is beneficial for flexion by free muscle transfer, the distal attachment
activities requiring endurance. Although training may of the muscle to the radius should be fixed as distal as
cause fibers to convert from ST to FT or the reverse, possible and not to the original insertion of the biceps
this has not been found to be the case. Within the FT
fibers, though, conversions from Type II b to Type II
a fibers have been found to occur with nerve crossing
procedures [19], heavy resistance (strength) training,
endurance training, and concentric and eccentric iso-
kinetic training [18,20,21].
Following free muscle transfer, muscle fiber type
composition converts from the original muscle in site
to the muscle reinnervated by the new donor nerve.
Hattori et al [19] studied the resulting contractile
properties of the muscle following free transfer and
nerve-crossing procedure of spinal accessory nerve
and intercostal nerves to the motor nerve of the
transplanted muscle. The muscles reinnervated by
spinal accessory nerve (A transfers) acquired the
properties of FT fibers, fatigable muscles, whereas
those reinnervated by intercostal nerves (IC transfers)
acquired the properties of ST fibers, fatigue-resistant
muscles. Furthermore, histochemical studies showed
that type II fibers were predominant in A transfers,
whereas type I fibers were predominant in IC trans-
fers. This study clearly demonstrates the possibility of
changing the muscle fiber components depending on
difference of the donor motor nerve following free
muscle transfer. Subsequently, donor nerve is selected Fig. 5. Torque (Tm) produced by a muscle at the joint center
depending on work requirement, whether it needs of rotation is the product of muscle force (Fm) and muscle
momentary power or continuous tolerance. moment arm (Dr).
 K. Doi et al. / Clin Plastic Surg 29 (2002) 483–495 489

Fig. 6. The component of muscular force that produces torque at the joint crossed (Ft) is directed perpendicular to the attached bone.

brachii. In clinical cases, even when reconstructing
elbow flexion, the authors prefer the distal attachment
of muscle to radius as distal as possible and not to the
biceps tuberosity of radius. Compared with simple
elbow flexion, in which the distal attachment of
muscle is proximal radius (the double free muscle
procedure, in which it is connected to the finger
extensor in the distal forearm) better results of range
of elbow motion were achieved, since the later
moment arm is far longer than the former (Fig. 7).
Neglecting the bowstringing of the muscle, the
distal attachment of the muscle is oriented at a
90-degree angle to bone.
Simultaneous multiple joint movement
Many muscles in the human body cross two or
more joints. Although single joint movement by
transplanted muscle is very easy to perform, free
muscle transfer also should cross over two or three

Fig. 7. Distal attachment of muscle in double free muscle transfer lengthen moment arm to increase power strength of muscle.
490 K. Doi et al. / Clin Plastic Surg 29 (2002) 483–495
joints. In brachial plexus injuries, the limited number
of available motor nerves is utilized to reconstruct
simultaneously multiple joint function such as elbow
flexion and finger extension by one muscle with one
donor motor nerve as described earlier (Fig. 7) [1,2].
However there were disadvantages associated with
achieving function of two-joint and multijoint
muscles, which can fail to produce force when
proximal joints are unstable and bowstringing of
muscle cannot be controlled.
Significance of proximal joint stability
Recent interest in reconstruction of the upper limb
following brachial plexus injuries was focused on the
restoration of prehension following complete avul-
sion of the brachial plexus. Double free muscle
transfer, described earlier [1,2], consisted of the first
free muscle transfer reinnervated by the spinal
accessory nerve for elbow flexion and finger exten-
sion. The second free muscle transfer reinnervated by
the fifth and sixth intercostals nerves for finger
flexion, intercostal nerves to restore elbow extension,
and suturing of the sensory rami of the intercostal
nerves achieved reliable prehensile function follow-
ing irreparable injuries.
However, some patients who achieved voluntary
finger movement by the double free transfer pro-
cedure could not use the reconstructed hand in daily
activities because of loss of voluntary movement
and stability of the proximal joints such as elbow
and shoulder. Wrist joint can be stabilized by splint
or arthrodesis. However, shoulder stabilization by
the glenohumeral arthrodesis decreased use of the
reconstructed fingers since the patient could not
move the hand in space voluntarily. Most authors
dismissed the significance of elbow stabilization
and, because of technical difficulty, failed to provide
some form of stabilization. Subsequently, even if
their patients regained powerful wrist extension or
finger flexion, they were not able to use their fingers
optimally in daily activities because of unstable
elbow. All transferred muscles act to simultaneously
cause elbow flexion and wrist extension or finger
flexion, similar to the transferred brachioradialis
muscle in cases of spinal cord injury. In such
situations, patients stabilize the unstable elbow with
the contralateral hand because of absent elbow
extensors, a useless maneuver in daily activities.
Reconstruction of elbow extension is imperative
whenever prehension is being reconstructed by the
transfer of one muscle that moves multiple joints
simultaneously [22].
The authors described the third and fourth inter-
costals nerves transfer to the motor nerves of the
triceps muscle to stabilize the elbow joint for the
fresh cases. For delayed cases with muscle atrophy
of the triceps, the alternative procedures such as the
recovered infraspinatus or biceps muscle transfer was
recommended for improvement of prehensile func-
tion. The authors also found the functional signifi-
cance of shoulder movement and in recent cases of
double free muscle transfer the repairable ipsilateral
C5 nerve root, or the contralateral C7 nerve root
were used to neurotize the suprascapular nerve using
nerve graft to reconstruct the optimal shoulder
abduction and external rotation. Selected cases with
satisfactory recovery of prehensile function under-
went wrist arthrodesis.
Bowstringing of muscle
Bowstringing of the muscle is the other most
important problem, when free muscle transfer is
performed crossing two or more joints,, It disperses
power to move the target joint. To prevent bowstring-
ing of the muscle or tendon, the pulley system is
imperative to negate this power dispersion.
Route of muscle
The muscle should be simply placed in a straight
line not to lose power, and not in a spiral line or
through the bony hole or interosseous membrane.
Antagonist
Without an antagonist muscle, the functional
outcome is unsatisfactory. The supplemental dy-
namic splint is not useful in daily use of the
reconstructed hand. The functioning antagonist
muscle is an important requirement for free muscle
transfer in the extremity, and double free muscle
transfer can solve this problem, because dynamic
tenodesis is not enough to extend the range of
motion of transferred muscle.
Muscle tension at suturing
Length-tension relationship
The amount of maximum isometric tension a
muscle is capable of producing is partly dependent
on the muscle’s length. In single muscle fibers and
isolated muscle preparations, force generation is at its
peak when the muscle is at normal resting length
 K. Doi et al. / Clin Plastic Surg 29 (2002) 483–495
(neither stretched nor contracted). When the length of
the muscle increases or decreases beyond resting
length, the maximum force the muscle can produce
decreases, following the form of a bell-shaped curve
(Fig. 8) [7]. However In the human body, force
generation capability of muscle increases when the
muscle is slightly stretched. Parallel-fibered muscles
produce maximum tensions at just over resting
length, and pennate muscles generate maximum ten-
sions at between 120% and 130% of resting length
[23]. This phenomenon is due to the contribution of
the elastic components of muscle (primarily the series
elastic components tendon) that add to the tension
present in the muscle when the muscle is stretched.
The total tension present in a stretched muscle is the
sum of the active tension provided by the muscle
fibers and the passive tension provided by the tendon
and muscle membranes.
This relationship is applicable to muscle tension
while suturing. When harvesting the muscle, before
its detachment, the resting length of muscle was
reproduced, and black-silk ligatures were placed on
the surface of the muscle at 5-cm intervals, as
described by Manktelow and colleagues [3,24]. It is
essential that the correct muscle tension be repro-
duced in the recipient site before final suturing of the
muscle to the target muscle or attaching to the bone.
The original muscle length is restored by stretching
the muscle until the distance between markers is 5 cm
and the muscle is stretched a little depending on the
type of muscle, between 110% and 130% of
Fig. 8. Length – tension relationship curve. The total tension
present in a stretched muscle is the sum of the active ten-
sion provided by the muscle fibers and the passive tension
provided by the tendons and muscle membranes.
491
the resting length. The position of the stumps of the
target tendon is noted and marked. The tenorrhaphies
are completed at the previously marked sites. Using
the tenodesis principle, the appropriateness of tension
in the transfer is evaluated.
Postoperative monitoring of muscle circulation
Post-operative vascular compromise continues to
jeopardize the success of free tissue transfer. Early
detection is essential so that early exploration and
subsequent correction of the cause can save the flap
that would otherwise be lost [25]. A common pro-
cedure to monitor circulation of muscle is to examine
the accompanying skin flap, however, the skin flap
overlying the muscle sometimes does not indicate the
exact condition of the muscle circulation. The accom-
panying skin flaps of gracilis or rectus femoris from
the thigh, are fasciocutaneous flaps and have few
muscular perforators. Whenever the muscle flap does
not include enough fascia of the muscle, the skin flap
does not act exactly as the monitor of muscle. The
skin changes are usually delayed compared with
circulation of muscle.
Muscle flap, on the other hand, because of its
active metabolic rate, is even more acutely sensitive
to ischemia and tolerates a shorter period of ischemia
than does skin. Ischemic studies on rabbit rectus
femoris muscles show that after 3 hours of normo-
thermic total ischemia, although 77% of the muscle
is still viable, this figure decreases to only 10.7% by
4 hours [18]. Similarly, 2 hours of normothermic
ischemia in the pig latissimus dorsi myocutaneous
flap results in 6.8% necrosis in the muscle, which
increases significantly to 50.3% with 4 hours of
ischemia 26. By six to seven hours of ischemia, total
necrosis of the muscle results [24,26 – 28]. This is
especially important clinically if the muscle flap is to
be used as a functioning free muscle for reconstruc-
tion in Volkman’s ischemic contracture or in brachial
plexus injury. Even if successful restoration of blood
flow to the muscle flap were established before 6 to
7 hours of ischemia, the ultimate functional outcome
will be poor as most muscle fibers would have
become necrotic and will be replaced by fibrous
tissue. Hence a post-operative monitor that can pro-
vide very early detection of vascular compromise is
essential in free muscle flaps.
Use of muscle contraction, in response to an
electrical stimulus, to monitor free muscle transfers
has been reported [14]. However, this technique
cannot be used for buried muscle flaps. Localized
contractility may visibly persist long after blood
492 K. Doi et al. / Clin Plastic Surg 29 (2002) 483–495
flow is lost [29]. Tan et al [30] investigated the use
of an intrinsic property of muscle; the compound
muscle action potential (CMAP) and its response to
ischemia as a possible post-operative monitor in
free muscle transfer for early detection of vascular
compromise. CMAP provides objective indication
of vascular compromise as early as 10 minutes of
its occurrence. Both the latency and amplitude
changes are important parameters to distinguish total
ischemia, arterial ischemia or venous ischemia,
although changes in the amplitude are usually more
easily seen.
Postoperative recovery of nerve
Motor recovery
Time to elecromyographic reinnervation of trans-
ferred muscle depends on length between nerve
suture site and neuromotor unit of muscle and the
donor motor nerve that is used [1]. The authors’
clinical cases of brachial plexus injuries showed
muscles that were reinnervated by the spinal acces-
sory nerve recovered significantly earlier (mean,
3.9 months) than did those that were reinnervated by
the intercostals nerves (mean, 4.8 months) ( P < 0.05).
On the average, voluntary contraction occurred
approximately two months later.
Early sign of nerve recovery
When mixed nerves were used as donor motor
nerve, sensory nerve axons regenerate earlier than
motor nerve axons. Before electromyographical rein-
nervation of motor nerve to muscle, patients com-
plain of radiating pain to the donor nerve territory
while grasping the muscle. The authors termed this
phenomenon as grasping pain, which is the earliest
recovery sign of donor nerve. Recently, Hattori and
colleague [31] reported experimental studies of sen-
sory recovery of skin graft applied on the free muscle
graft following nerve repairs of the motor branch of
the muscle and donor sensory nerve.
Postoperative rehabilitation
Rehabilitation schedule
Rehabilitation following free muscle transfer is
divided into two stages, ie, initial stage and late
stage. The initial stage, which implies before elec-
tromyographic evidence of reinnervation of trans-
ferred muscles, is usually 4 to 6 months after
operation. In this stage, the use of electrical stimu-
lation to the transferred muscles and nerve-repaired
muscles remains controversial because there are
opposite opinions on prevention or delay of muscle
atrophy by electrical stimulation. However, the
authors prefer to use electrical stimulation on the
paralyzed target muscle.
In the late stage after electromyographic docu-
mentation of reinnervation of the transferred muscle,
electromyographic biofeedback techniques are started
in order to train the transferred muscles to move the
target joint. Motor reeducation is indicated when
patients display minimal active contraction with an
identified muscle or muscle group. The initial goal of
reeducation for patients is to reactivate voluntary
control of the muscle. When the patient is working
with a weak muscle, the intensity of motor unit
activity and the frequency of the muscle contraction
are emphasized. Treatment sessions should be short
and end when fatigue is noted due to decreasing
ability of the patient to achieve the set goal level.
For efficient rehabilitation, understanding of bio-
mechanics of free muscle transfer is imperative.
For example, the maximum power is produced at
90 degrees flexion of elbow. Less than 90 degrees
flexion of elbow, the rotary component of torque
decreases proportional to the angle. In the initial
phase of rehabilitation for power strengthening of
the muscle, the optimal position of elbow is 90 degree
of flexion, otherwise, in the position of the angle less
than 90 degrees of flexion, the power of the muscle
reinnervated partly would not move the initial move-
ment of joint and sometimes passive elongation of
muscle may injure muscle fibers. Although the flex-
ion contracture of elbow may happen, the elbow
should be immobilized in 90 degrees of flexion,
and muscle strengthening rehabilitation should be
started at this position, and not in less angle than
90 degrees.
Force-velocity relationship
The force-velocity relationship for muscle tissue
concerns muscle strength training and is described
in Fig. 9. When the resistance force is negligible,
muscle contracts with maximal velocity. As the load
progressively increases, concentric contraction velo-
city slows to zero at isometric maximum. As the
load increases further, the muscle lengthens eccen-
trically. However, the force-velocity relationship also
does not imply that it is impossible to move a
light load at a slow speed. Most activities of daily
living require slow, controlled movements of sub-
 K. Doi et al. / Clin Plastic Surg 29 (2002) 483–495
Fig. 9. Force – velocity relationship curve. When the re-
sistance is negligible, muscle contracts with maximal
velocity. As the load progressively increases, concentric
contraction velocity slows to zero at isometric maximum. As
the load increases further, the muscle lengthens eccentrically.
maximal loads. The stronger a muscle, the greater
the magnitude of its isometric maximum on the
force-velocity curve. Following free muscle transfer,
eccentric strength training is more effective than
concentric training in increasing muscle size and
strength [21]. However, eccentric training is also
associated with increased muscle soreness and struc-
tural damage [32].
Muscle power
Muscle power is the product of muscular force
and velocity of muscle shortening. Maximum power
occurs at approximately one-third of maximum velo-
city and at approximately one-third of maximum
concentric force [33,34]. Training designed to
increase muscular power over range of resistance
occurs most effectively with loads of one-third of
one maximum repetition [35].
Individuals with a predominance of FT fibers
generate more power at a given load than individuals
with a high percentage of ST compositions. Primary
FT compositions also develop their maximum power
at faster velocities of muscle shortening [36]. The
ratio for mean peak power production by Type II b,
Type II a and Type I fibers in human skeletal muscle
is 10:5:1 [32].
Muscular endurance
Muscular endurance is the ability of the muscle to
exert tension over a period of time. Training for
muscular endurance typically involves large numbers
493
of repetitions against relatively light resistance. This
type of training does not increase muscle fiber
diameter [37].
Muscle fatigue
A complex array of physiological and neurological
factors affect the rate at which a muscle fatigues.
There is some evidence that mechanisms of fatigue
may be muscle-specific and/or exercise duration-spe-
cific [38]. Within a given muscle, fiber type composi-
tion and the pattern of motor unit activation play a role
in determining the rate at which a muscle fatigues.
Transplanted muscle easily fatigues, depending on the
donor motor nerve [20].
Ultrasound monitoring of muscle hypertrophy
Watanabe and Ohno [39] measured muscle thick-
ness and cross-sectional area (CSA) of transferred
gracilis with static compound B ultrasound scanning
between 1 month and 1.5 years postoperatively. The
gracilis is a strap muscle and showed less change of
muscle thickness and CSA between resting and con-
traction, however, their serial measurement showed
gradual decrease of muscle thickness and CSA
(atrophy) until 15 to 20 weeks postoperatively, and
the values increased proportional to amplitude of
motor action potentials by electromyography. Con-
traction rate, that is values of muscle thickness at
maximum contraction divided by muscle thickness at
rest, also increased proportional to innervation and
training. Contraction rate is significantly related to
range of elbow joint. Serial and quantitative ultra-
sonography of transferred muscle is a good indicator
for muscle strengthening postoperatively.
Quantitative recovery of strength of
transferred muscle
Watanabe et al [40] measured the transplanted
muscle strength, which reconstructed elbow flexion
following complete paralysis of brachial plexus,
using quantitative analysis with peak torque by
KIN-COM (isokinetic machine). Gracilis reinner-
vated from spinal accessory nerve achieved ob-
tained 5.8 Nm of peak torque in concentric
contraction (13.9% of contralateral normal side),
and 10.2 Nm of peak torque in eccentric contraction
(19.7% of normal). The patient can lift objects
weighing from 1 to 6 kg on the forearm. These
values are same as those of intercostals nerve to
musculocutaneous nerve crossing. Even if excellent
recovery of muscle strength by free muscle transfer
494 K. Doi et al. / Clin Plastic Surg 29 (2002) 483–495
is achieved, quantitative value is about one-fifth of
the normal and never returns to normal (Manual
muscle test 5) [41].
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