SPECIAL TOPIC

Functional Free Muscle Transfer for Upper

Extremity Reconstruction
Milan Stevanovic, M.D.
Frances Sharpe, M.D.
Los Angeles, Calif.
Background: Functional losses in the upper extremity that cannot be restored
by nerve or tendon transfer present a treatment dilemma to the reconstructive
surgeon. Common indications for functional free muscle transfer include late
reconstruction of brachial plexus injuries, traumatic muscle loss, Volkmann
ischemic contracture, loss resulting from oncologic resection, and congenital
absence of motor function as seen in arthrogryposis.
Methods: This article reviews the authors’ experience in upper extremity re-
construction using functional free muscle transfer. The indications and tech-
nique for functional free muscle transfer in the upper extremity are reviewed.
Surgical details for sites of reconstruction and the nuances of harvesting the
main donor muscles are presented.
Results: Specific cases and outcome reviews for several series of functional free
muscle transfers are presented.
Conclusion: Functional free muscle transfer is the best and final option for
restoring function in an otherwise nonreconstructible limb.  (Plast. Reconstr.
Surg. 134: 257e, 2014.)

F
unctional losses in the upper extremity
have traditionally been reconstructed with
tendon transfers and functional rotational
muscle transfers. More recently, nerve trans-
fers have expanded the choice of reconstruc-
tive methods available. When presented with
patients who are not candidates for those pro-
cedures, because of late presentation or absence
of local donor muscles or nerves, functional
free muscle transfer is the best means of restor-
ing function in an otherwise nonreconstructible
limb. Common scenarios where there is a role
for functional free muscle transfer include late
reconstruction of brachial plexus injuries, trau-
matic muscle loss, Volkmann ischemic contrac-
ture, loss resulting from oncologic resection, and
congenital absence of motor function as seen in
arthrogryposis.
HISTORICAL PERSPECTIVE
Functional restoration using a transferred
muscle was first investigated in a canine model
by Tamai et al. in 1970.1,2 Clinical application of
From the Department of Orthopedics, University of Southern
California Keck School of Medicine.
Received for publication August 26, 2013; accepted
November 27, 2013.
Copyright © 2014 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000000405
functional free muscle transfer was first reported
in 1976 at several centers: Harii and colleagues
used a free gracilis muscle for facial reanima-
tion3; surgeons at Sixth People’s Hospital in the
People’s Republic of China used pectoralis major
muscle to restore finger flexion in a patient with
Volkmann ischemic contracture4; and Ikuta et al.
also used the pectoralis major muscle for the same
indication. Manktelow5 and Zuker6 popularized
use of functional free muscle transfer in North
America for upper extremity reconstruction.5
Improvements in microsurgical equipment, mag-
nification, and technique led to the expansion of
indications for functional free muscle transfer.
Japanese surgeons have been at the forefront of
application of these techniques to restore upper
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
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www.PRSJournal.com 257e
 Plastic and Reconstructive Surgery • August 2014
Table 1.  Patient Selection
Relative
Indications Contraindications
No other options for reconstruction Age >45 yr
(e.g., tendon or nerve transfer) Obesity (weight of limb to be disease, autoimmune disease, cardiac disease
Motivated patient moved by the transferred
Age <45 yr muscle)
extremity function, including the first applica-
tion of a single functional free muscle transfer to
restore two separate functions, and Doi and col-
leagues’ use of a double functional free muscle
transfer to restore multiple functions.7–13
PATIENT SELECTION
One of the most important factors leading to
a successful operation is a motivated patient who
has appropriate expectations from surgery and
has demonstrated compliance with medical care.
The patient must be committed to a prolonged
rehabilitation program that may be complex and
time consuming.
Age is the next critical component of successful
transfers. Successful recovery of motor function is
better in children. However, later results in children
are compromised by ongoing growth. The trans-
ferred muscle may not grow at the same rate as the
bony skeleton, potentially leading to recurrent con-
tracture across joints. This may be counteracted with
ongoing night-time splinting until the child reaches
skeletal maturity. In the authors’ experience, the
most successful functional free muscle transfers
have been in patients younger than 45 years. Other
authors have reported excellent outcomes in those
as old as 65 years and recommend 70 years as their
cutoff for functional free muscle transfer.14,15
Medical conditions such as diabetes, autoim-
mune diseases, severe chronic viral infections,
heart or peripheral vascular disease, and smok-
ing can all compromise microcirculation and
reinnervation of the transplanted muscle and
Table 2.  Skeletal Muscle Architecture*
Pennate Parallel
Muscle types Unipennate, Strap (gracilis),
bipennate, fusiform
or ­multipennate (gastrocnemius),
(e.g., rectus fan (latissimus)
femoris)
Typical Greater cross- Longer fiber length =
characteristics sectional area; greater excursion
higher mass =
greater force
*From Lieber RL, Friden J. Clinical significance of skeletal muscle
architecture. Clin Orthop Relat Res. 2001;383:140–151.
258e
Absolute
Contraindications
Medical comorbidities: diabetes mellitus, vascular
are contraindications to this procedure. Another
increasingly common problem is patient obesity.
Even a young healthy patient with available donor
muscles will not gain sufficient power in a trans-
ferred muscle to overcome the weight of a very
heavy limb, especially for shoulder abduction and
elbow flexion (Table 1).
PRINCIPLES OF FUNCTIONAL FREE
MUSCLE TRANSFER
Muscle Physiology
Skeletal muscle is a unique biological tissue
capable of transforming chemical into mechani-
cal energy. When considering a functional free
muscle transfer, properties of muscle physiology,
including force and excursion, must be consid-
ered to achieve sufficient functional benefit at
the recipient site.
The principal force-generating components
of skeletal muscle are myosin and actin molecules,
known as thick and thin filaments, respectively.
Myofilaments are arranged in interdigitating
matrices that slide across each other to produce
a muscle contraction. The force generated by a
muscle is in direct relationship to the number of
filaments and the overlap of the actin and myosin
proteins.16
Muscle resting length is defined as the length
of the muscle in its most physiologically elon-
gated position. In this position, there is maximal
overlap of the actin and myosin fibers. This rep-
resents the peak of the muscle length-tension
curve. Overstretching of a transferred muscle
decreases the amount of overlap between the
actin and myosin fibers, resulting in a weakened
muscle contraction. Similarly, undertensioning of
the transferred muscle also results in decreased
filament overlap and suboptimal muscle force
production. Intraoperative restoration of muscle
resting length is of critical importance in achiev-
ing maximal function of the transplanted muscle.
Muscle force can be calculated based on the
physiologic cross-sectional area of the muscle, with
a larger cross-sectional area representing a greater
number of myofilaments. Muscle mass can be used
Volume 134, Number 2 • Upper Extremity Reconstruction

to roughly estimate force generation. That is, mus- Reconstructive Ladder

cles of similar mass can produce similar force.
Muscle excursion affects the amount of
motion that can be produced across a joint and
is another factor in selecting a donor muscle.
The amount of muscle excursion or shortening
along a muscle is based on both fiber length
and vector. Longer fiber length and parallel
fiber direction result in greater muscle excur-
sion (Table 2).17
Functional free muscle transfers are often
used in the setting of brachial plexus injuries.
Functional free muscle transfer in this setting is
limited by the number of available donor nerves.
The first reconstructive goal in functional upper
extremity reconstruction is restoration of elbow
flexion, finger flexion, and finger extension. To
accomplish multiple functions with limited donor
nerves, Doi et al. first described the use of a single

Table 3.  Technique Summary for Anterior Deltoid, Biceps, and Triceps Reconstruction
Donor muscle options
New origin
New insertion
Recipient vessels (options)
Recipient nerve (options)
Position for restoration
of resting length†
Postoperatively
Special considerations
*Preferred muscles.
†Resting length is established in this position; however, the repair is performed with the muscle not on tension.
Shoulder Flexion
(Anterior Deltoid) (Fig. 1)
•  Gracilis*
•  Tensor fasciae latae
•  Latissimus dorsi
•  Medial gastrocnemius
• Lateral half of the clavicle
to the acromion
• Anatomical insertion
of the deltoid on the hu-
merus
Artery:
•  Thoracoacromial
Vein:
•  Venae comitantes
•  Tributary of cephalic
• Spinal accessory nerve
(terminal branch)
• Arm in hyperextension at
the shoulder
• Arm immobilized in flexion
and abduction for 8 wk
• Gunslinger or customized
brace
• Alternatively, a thoracic cast
with arm spica and struts can
be used to control arm position
Elbow Flexion
(Fig. 2; Video 1)
•  Gracilis*
•  Latissimus dorsi
•  Tensor fasciae latae
•  Medial gastrocnemius
• Distal half of clavicle
(gracilis)
•  Coracoid (latissimus)
•  Distal biceps tendon
•  Bone at radial tuberosity
• Bone at ulna—level of
tuberosity
Artery:
•  Thoracoacromial
•  Thoracodorsal
Vein:
•  Venae comitantes
•  Cephalic vein branch
• Musculocutaneous
nerve
• Spinal accessory nerve
(terminal branch)
•  Intercostal nerves
• Medial pectoral nerve (not
preferred because of size)
•  Full elbow extension
• Immobilization at 90
degrees of elbow
flexion for 8 wk
• The latissimus muscle
origin does not have
a tendinous portion;
securing the muscle to
the biceps tendon can
be difficult; the muscle
can be wrapped around
the tendon if present;
alternatively, the muscle
can be anchored to the
medial ulna
Elbow Extension
(Fig. 3)
•  Gracilis*
•  Latissimus dorsi
•  Tensor fasciae latae
• Lateral third of the
scapular spine
•  Posterior acromion
• Remnant of triceps
tendon
• Directly to
olecranon
Artery:
•  Profunda brachii
•  Thoracodorsal
Vein:
•  Venae comitantes
•  Vein graft to cephalic
•  Transposed cephalic vein
• Branches of radial
nerve
•  Nerve graft to intercostals
• Terminal branch of
spinal accessory nerve
with or without graft
•  Full elbow flexion
• Immobilization in
full extension
for 8 wk

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 Plastic and Reconstructive Surgery • August 2014

Table 4.  Technique Summary for Finger Extension, Finger Flexion, and Thenar Reconstruction
Finger Extension Finger Flexion Thenar Reconstruction
(Fig. 4) (Figs. 5–9; Video 2) (Fig. 10)
Donor muscle options •  Gracilis* •  Gracilis* • Distal two slips of serratus
•  Latissimus dorsi •  Latissimus dorsi anterior*
•  Tensor fasciae latae •  Tensor fasciae latae • Gracilis (portion using a
single neuromuscular terri-
tory only)*
•  Abductor hallucis muscle
New origin • Lateral epicondyle and • Medial epicondyle of hu- • Ulnar side of fifth metacarpal
­common extensor fascia merus and flexor-pronator (superficial to hypothenar
fascia muscles)
New insertion • Tendons of EDC; EPL can • Tendons of flexor • Distal third of first metacar-
also be included digitorum profundus at pal and proximal third of
the distal forearm the proximal phalanx (radial
side)
Recipient vessels (options) Artery: Artery: Artery:
•  Radial artery •  Anterior interosseous •  Radial artery (end-to-side)
•  Branch of radial artery •  Radial artery (end-to-end) Vein:
Vein: •  Ulnar artery (end-to-side) •  Venae comitantes
•  Venae comitantes •  Brachial artery (end-to-side)
Vein:
•  Venae comitantes
• Local superficial veins to aug-
ment drainage of skin flap
Recipient nerve (options) • Posterior interosseous nerve •  Anterior interosseous •  Median recurrent nerve
• Motor branch to pronator • Median nerve motor
teres ­fascicles†
Position for restoration •  Full elbow extension • Elbow, wrist, and fingers in • Full thumb planar abduction
of resting length‡ • Wrist flexion at 20–30 full extension and MCP joint extension
degrees
• Finger metacarpophalangeal
joint flexion at 90 degrees
Postoperatively • Immobilization for 6 wk • Immobilization for 4–5 wk • Immobilization in palmar
with elbow at 90 degrees of • Elbow at 90 degrees of abduction and MCP joint
flexion, wrist at 30 degrees flexion, wrist at 30 degrees flexion
of extension, and full of flexion, MCP joints at 90 for 5–6 wk
MCP extension degrees of flexion
•  IP joints can be left free • Thumb in palmar abduction
and IP joint flexion
Special considerations • EDC tendons are sewn • The gracilis muscle can • Some authors have used the
together using a side-to-side be separated into separate transverse carpal ligament
technique neuromuscular territories to as the neomuscle origin; we
• Pulvertaft weave is used to provide independent thumb find this too short a distance
secure transferred muscle flexion; this requires two to adequately reestablish
to EDC separate donor fascicles muscle resting length and
•  EPL reconstruction • If thumb flexion is restored provide sufficient abduction
• Included in functional as a single unit, the FPL power
transfer tendon must not be as tight • Median motor branch must
• Rerouted to radial side of as the finger flexors, to that be functional for this transfer
first metacarpal finger flexion occurs before
• Pulley reconstruction to the thumb flexes
provide abduction moment
and prevent bowstringing
• Separately secured to
transferred muscle along the
radial side
EDC, extensor digitorum communis; EPL, extensor pollicis longus; FPL, flexor pollicis longus; MCP, metacarpophalangeal; IP, interphalangeal.
*Preferred muscles.
†Separate fascicles should be used for independent FPL reconstruction when necessary.
‡Resting length is established in this position; however, the repair is performed with the muscle not on tension.

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Volume 134, Number 2 • Upper Extremity Reconstruction

Fig. 1. Diagrammatic representation of the gracilis muscle used Fig. 3. Diagrammatic representation of the gracilis muscle used
for anterior deltoid reconstruction. (Copyright © Timothy C. for triceps reconstruction for elbow extension. (Copyright ©
Hengst, printed with permission.) Timothy C. Hengst, printed with permission.)

muscle to restore two separate functions.8,9,11,12 Recipient-Site Considerations

Better outcomes are generally achieved when
a single muscle is used for a single function.
However, when facing global functional losses,
a single muscle providing two functions may be
the best choice. Doi et al. were also the first to
describe double free functional muscle transfers,
with the first muscle used to provide combined
elbow flexion and finger extension and the sec-
ond muscle used to provide finger flexion.9
Common requirements that apply to all tendon
transfers also apply to functional free muscle trans-
fer. These include (1) full (or nearly full) passive
range of motion of the joint that the transfer will
act across; (2) suitable soft-tissue bed allowing ten-
don gliding; and (3) adequate antagonist muscle
function. Requirements specific to functional free
muscle transfer are the presence of a healthy pure
motor donor nerve and healthy recipient vessels.

Fig. 2. (Left) Diagrammatic representation of the gracilis muscle used for biceps reconstruction. This 19-year-
old college student sustained an upper trunk injury to the brachial plexus. He presented 2 years after injury
with minimal shoulder girdle function and absent elbow flexion. Hand function was normal. He under-
went a functional free muscle transfer using the ipsilateral gracilis muscle. (Copyright © Timothy C. Hengst,
printed with permission. Previously published by Slutsky D. The Art of Microsurgical Hand Reconstruction.
New York: Thieme; 2013.) (Right) Elbow flexion 18 months after functional free muscle transfer, rated as
Medical Research Council grade 4 flexion strength. (Authors retain copyright.)

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 Plastic and Reconstructive Surgery • August 2014
Video 1. Supplemental Digital Content 1 shows a 14-year-old
boy who had experienced a traumatic global brachial plexus
palsy at age 6. He had undergone previous wrist fusion. At age
14, he underwent free functional gracilis transfer to restore
elbow flexion, http://links.lww.com/PRS/B49. The patient is
shown here 14 months after the procedure.
Before functional free muscle transfer, addi-
tional procedures may be necessary to prepare the
recipient site. These include contracture release,
tenolysis (distal to the planned tenorrhaphy site),
and soft-tissue coverage to ensure a proper envi-
ronment for tendon gliding.
At the time of functional free muscle transfer,
surgical incisions are planned to provide the best
soft-tissue coverage over the transferred muscle
and tenorrhaphy site. The recipient site should be
prepared before the donor muscle is harvested. A
two-team approach is frequently used, but division
of the tendon insertion should not be completed
until recipient vessels and motor nerve are identi-
fied. This is particularly important when using a
Fig. 4. Diagrammatic representation of the gracilis muscle used for recon-
struction of finger extension. (Copyright © Timothy C. Hengst, printed with
permission.)
262e
Video 2. Supplemental Digital Content 2 shows a 22-year-old
man who had prolonged compression to his right forearm
resulting in partial necrosis of volar forearm skin and all of the
flexor compartment muscles. He underwent functional free
muscle transfer to restore finger flexion and extensor carpi radi-
alis longus tendon transfer to restore independent thumb func-
tion, http://links.lww.com/PRS/B50. The patient is shown here
2 years after functional free muscle transfer.
functional free muscle transfer for reconstruction
in patients with Volkmann contracture. In these
cases, it is often necessary to obtain intraoperative
frozen sections to identify healthy fascicles of the
recipient motor nerve. In addition, the vascular
anastomosis should be performed proximal to the
ischemic tissue bed. Even though an adequate arte-
rial inflow may be found within the reconstruction
site, the venous outflow is unreliable. The vascular
pedicle and recipient nerve should be mobilized
as much as possible to obtain sufficient length for
proper positioning of the transplanted muscle.
The vascular anastomosis is completed first, and
the muscle is allowed to perfuse for 10 to 15 minutes
until the venous outflow does not appear overly dark.
The anastomosis is completed as quickly as possible
Volume 134, Number 2 • Upper Extremity Reconstruction

Fig. 6. Clinical views of patient described in Figure 5. (Above)

Preoperative finger extension. (Below) Preoperative finger flex-
ion. (Authors retain copyright.)

Fig. 5. (Above) Diagrammatic representation of the gracilis mus-

cle used for reconstruction of finger flexion. (Below) Diagram-
matic representation of the latissimus dorsi muscle used for
reconstruction of finger flexion. This 8-year-old boy developed
a Volkmann contracture of the forearm after a supracondylar
humerus fracture at age 6. Before his presentation to our ser-
vice, he had undergone a flexor tendon lengthening in the dis-
tal forearm, with minimal functional improvement. He also had
diminished sensory and motor function in the median nerve
distribution. Two years after injury, he underwent functional
free muscle transfer for finger flexor reconstruction using an
ipsilateral gracilis muscle. The anterior interosseous nerve was
the recipient nerve, which was coapted very close to the gracilis
muscle. The median nerve was markedly constricted in the most
fibrotic portion of the flexor muscle mass. Simultaneous median
nerve reconstruction was performed using a sural nerve donor.
(Copyright © Timothy C. Hengst, printed with permission.)

to minimize permanent ischemic changes to the

muscle. Irreversible muscle loss increases with time
in a nonlinear relationship.18,19 It is our experience
that if the muscle ischemia time exceeds 2 hours,
the muscle will likely survive, but the function will
never be good. If the cause of the prolonged isch-
emia time can be identified (usually, compromised
venous outflow leading to reperfusion problems)
and rectified (e.g., vein grafting to different recipi- Fig. 7. Clinical views of patient described in Figure 5. Intraop-
ent vessels), one can consider harvesting a different erative dissection with excision of the fibrotic muscle. (Authors
donor muscle at the same procedure. retain copyright.)

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 Plastic and Reconstructive Surgery • August 2014
Fig. 8. Clinical views of patient described in Figure 5. (Above) Postoperative finger
extension. (Below) Postoperative finger flexion. (Authors retain copyright.)
The muscle is secured to its new origin site
using nonabsorbable suture. The origin may be
secured to periosteum and surrounding fascia,
bone tunnels, or suture anchors as needed. The
new muscle origin should be spread out as much as
possible to match the width of the old origin. The
muscle is stretched to restore its resting length,
and the distal tenorrhaphy is performed. When
possible, a Pulvertaft weave provides a strong
tenorrhaphy site. The neurorrhaphy is completed
last, placing the neurorrhaphy site as close as pos-
sible to the transplanted muscle.
Wound closure should be performed with
attention to avoiding compression of the vascular
pedicles. Tight skin closure should be avoided, as
Fig. 9. Clinical view of patient described in Figure 5.
Constricted median nerve. (Authors retain copyright.)
264e
a compartment-like syndrome can occur when the
reperfused muscle swells postoperatively.
Details of site-specific reconstruction are
listed in Tables 3 and 4 ( Figs. 1 through 10).
(See Video, Supplemental Digital Content 1,
which demonstrates the results of free func-
tional gracilis transfer 14 months after the pro-
cedure. This 14-year-old boy had a traumatic
global brachial plexus palsy at age 6. He had
undergone previous wrist fusion. At age 14, he
underwent free functional gracilis transfer to
restore elbow flexion, http://links.lww.com/PRS/
B49. See Video, Supplemental Digital Content
2, which demonstrates the results shown at 2
years from functional free muscle transfer. The
patient is a 22-year-old man who had prolonged
compression to his right forearm resulting in
partial necrosis of volar forearm skin and all
of the flexor compartment muscles. He under-
went functional free muscle transfer to restore
finger flexion and extensor carpi radialis longus
tendon transfer to restore independent thumb
function, http://links.lww.com/PRS/B50.)
Donor Muscle Considerations
Desirable characteristics of the donor
muscle include neurovascular anatomy that
allows for transplantation, adequate length
and excursion for its new function, sufficient
force to power the recipient-site function, and
acceptable donor-site morbidity. The muscle
Volume 134, Number 2 • Upper Extremity Reconstruction

Fig. 10. Diagrammatic representation of the distal two slips of the serratus anterior muscle used for thenar muscle reconstruc-
tion for thumb opposition. (Copyright © Timothy C. Hengst, printed with permission. Previously published by Slutsky D. The Art of
Microsurgical Hand Reconstruction. New York: Thieme; 2013.)

should have adequate fascia and tendon to
support secure attachments to the new origin
and insertion sites. Several muscles meet these
criteria and are suitable for use as functional
free muscles. These include the gracilis, latissi-
mus dorsi, tensor fasciae latae, rectus femoris,
medial gastrocnemius, serratus anterior, pecto-
ralis major, and combined gracilis with adduc-
tor longus. Of these muscles, the gracilis has
proved to be the workhorse of most functional
free muscle transfer in the upper extremity
(Table 5).
The donor muscle should have adequate
power to support the planned function. It is
difficult to determine the exact force of a mus-
cle. Estimates based on cross-sectional area or
weight give a rough estimate of force potential
of a muscle. Excursion can also be difficult to
assess. Six to 7 cm of excursion is required to
restore adequate elbow and finger flexion. The
donor muscle should be innervated by a single

Table 5.   Donor Muscles for Functional Free Muscle Transfer

Mathes and ­Nahai
­Classification
Muscle Muscle Type (Vascular) Comments
Gracilis Parallel (strap) Type 2 Workhorse of upper extremity reconstruction
Latissimus dorsi Parallel (fan) Type 5 Bulky at recipient site; lacks distal tendinous portion
Tensor fasciae latae Parallel (fan) Type 1 Limited excursion because of short muscle length
Serratus anterior Parallel Type 5 No tendinous portions; indications only for thenar
muscle reconstruction; can use a portion of the
muscle for reconstruction
Medial gastrocnemius Parallel (fusiform) Type 1 Powerful muscle, but short excursion
Rectus femoris Pennate Type 1 Bulky, donor-site morbidity (weakness of knee extension)
Pectoralis major Parallel (fan) Type 5 Powerful muscle, but short excursion; donor-site morbid-
ity high, especially in female patients

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 Plastic and Reconstructive Surgery • August 2014

Fig. 11. (Above) Necrosis of the median nerve. Although the nerve was
not constricted in this case of Volkmann contracture, the nerve was not
functioning in the preoperative examination. The whitish area of nerve
was sclerotic and dysvascular over a 7-cm section. (Below) Median nerve
reconstruction using sural nerve autograft. The obturator nerve of the
gracilis muscle was coapted to the anterior interosseous nerve after his-
tologic analysis demonstrated normal fascicles in the area of nerve repair.
(Authors retain copyright.)

Table 6.   Surgical Technique for the Gracilis Muscle

Key Points
Position • Frog lateral
Dissection • Skin paddle is important for muscle tendon gliding
• A long skin paddle extending the length of the muscle can be harvested if the entire medial
fascia is included in the dissection
• Incorporate medial fascia of the thigh from just posterior to the sartorius to the posterior edge
of the gracilis
• Gracilis is harvested within its fascial sleeve; at completion of dissection, the entire muscle
should be ensheathed in fascia (Figs. 12 through 14)
• Length of the distal tendon can be extended by a separate incision at the pes anserine and
releasing the tendon at its insertion
Resting length • Marked with the leg in full hip abduction and knee extension
Obturator nerve • Enters muscle proximal to the vascular pedicle
• Should be checked with a nerve stimulator to ensure function before harvest (0.5–1.0 Hz)
• If muscle does not contract, it cannot be used; especially important in setting of previous pelvic
trauma
• Contains two separate fascicles that can be divided to provide independent function based on
separate neurovascular territories of the gracilis (Fig. 15)
• This can be used to restore independent thumb flexion
Vascular pedicle • Origin from the profunda femoris
• Enters the anterior deep surface 5–8 cm proximal to the muscle origin
• Greater pedicle length achieved by dissection back toward the profunda femoris artery and
ligation of branches to the adductor longus

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Fig. 12. The gracilis muscle is harvested with fascia of the thigh. The subcutaneous
tissue is elevated widely above the level of the fascia both anteriorly and posteriorly.
Anteriorly, the fascia is incised along the posterior border of the sartorius, taking a wide
harvest of fascia anterior to the gracilis muscle. Posteriorly, the fascia is less robust and
can be incised along the posterior border of the gracilis. (Above) Diagrammatic repre-
sentation of harvesting of the gracilis muscle. The vascular pedicle arises from the femo-
ral artery. The obturator nerve enters the muscle just proximal to the vascular pedicle.
(Below) Harvested gracilis muscle ensheathed in fascia. (Copyright © Timothy C. Hengst,
printed with permission. Previously published in Seal A, Stevanovic M. Free functional
muscle transfer for the upper extremity. Clin Plast Surg. 2011;38:561–575.)

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 Plastic and Reconstructive Surgery • August 2014
nerve, and only muscles with Mathes and Nahai
types I, II, and V vascular supply can be consid-
ered for transplantation.20,21 The location of the
donor muscle neurovascular pedicle should be
considered to optimize location relative to the
anticipated recipient vessels.
PREOPERATIVE PLANNING
Preoperative planning is a critical compo-
nent of successful functional free muscle trans-
fer. A detailed physical examination should
assess passive range of motion across the joint
for the planned transfer, functioning motor
and sensory nerves proximal and distal to the
area of deficit, vascular assessment of the limb
including in-office Doppler examination when
indicated, and evaluation of the soft-tissue
envelope at the reconstructive site. Also impor-
tant is an evaluation of the entire previous zone
of injury, as this may affect areas of planned
vascular anastomosis and neurorrhaphy. The
planned donor site should be examined to con-
firm there are no previous injuries or scarring
at the donor site and to confirm function of the
donor muscle. Selection of the ipsilateral ver-
sus contralateral donor muscle will depend on
the location of the donor and recipient nerves
and vessels.
Electromyography is not always helpful or
indicated. Magnetic resonance angiography or
angiography can be useful to assess upper extrem-
ity vascularity and potential recipient vessels. In
the forearm, an intact anterior interosseous artery
will frequently correlate with an uninjured ante-
rior interosseous nerve.22 Magnetic resonance
imaging can be useful in showing pathologic sig-
nal alterations in denervated muscles, confirming
clinical examination. Higher strength magnets
with appropriate acquisition and software can
be used to demonstrate nerve abnormality and
may have a future role in helping identify donor
nerves.23
Planning for the operating room includes
adequate microsurgical equipment and magnifi-
cation, and an experienced anesthesiologist who
can keep the patient well-hydrated, perfused, and
normothermic. Short-acting paralytic agents may
be used for the anesthetic induction but should
not be used during surgery. A pathologist experi-
enced in neurohistochemical staining should be
available if there is a question regarding the suit-
ability of the recipient-site donor nerve. Surgical
incisions should be planned to optimize access to
(1) recipient vessels and nerve and (2) new origin
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and insertion sites, and, very importantly, to limit
the need for skin grafts directly over the trans-
ferred muscle belly or tendon.
Sensory deficits can limit the usefulness of
functional reconstruction. Every effort should be
made to restore protective sensation to critical
areas of the hand. Patients with brachial plexus
palsy without sensation may benefit from sensory
reconstruction of the median nerve using sen-
sory fascicles of the intercostal nerves. Patients
with Volkmann contracture without sensation
should undergo primary grafting of the median
nerve at the time of functional reconstruction
(Fig. 11).
DONOR MUSCLE DISSECTION
The two most commonly used muscles for
upper extremity reconstruction are the gracilis
muscle and the latissimus dorsi muscle.
Gracilis
The gracilis muscle is usually harvested with
the patient supine in a frogleg position. Based on
the position of the recipient vessels, the contra-
lateral gracilis is preferred for anterior deltoid,
biceps, and finger extensor reconstruction. The
ipsilateral gracilis is preferred for triceps recon-
struction and thenar reconstruction. Either con-
tralateral or ipsilateral gracilis can be used for
finger flexor reconstruction (Table 6 and Figs. 12
through 15).
Fig. 13. Surgical dissection of the gracilis. A distal incision was
made to identify the tendon of gracilis and help outline the sur-
gical incision for harvesting the gracilis with its overlying skin
paddle. A branch of the saphenous vein is seen in the proximal
portion of the dissection. This can be used to augment venous
outflow if necessary. The gracilis muscle is being reflected pos-
teriorly. The neurovascular pedicle lies in the fat seen just distal
to the branch of the saphenous vein. (Authors retain copyright.)
Volume 134, Number 2 • Upper Extremity Reconstruction

Fig. 14. (Above) The harvested gracilis muscle. The skin edges have been
secured to the underlying fascia to prevent shear injury to the perforating
branches. (Below) The deep surface of the harvested gracilis muscle, which is
encased in fascia. (Authors retain copyright.)

Fig. 15. The gracilis muscle has two distinct neuromuscular territories,
supplied by separate fascicles of the obturator nerve. These can func-
tion independently by using different donor nerves. In the forearm,
this can allow independent function of the thumb. (Authors retain
copyright.)

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 Plastic and Reconstructive Surgery • August 2014

Table 7.   Surgical Technique for the Latissimus Muscle

Key Points
Position • L
 ateral or prone
Dissection • Entire latissimus does not need to be harvested; use length necessary for muscle that is being
reconstructed
• Can be difficult to distinguish fibers of LD and teres major; stimulation of LD can help
­differentiate the boundary
• Fascia overlying the LD is thin, but should be protected and included with the muscle to
­facilitate later muscle-tendon gliding
• Tendon should be divided at the humeral insertion
Resting length • Measured with the arm in full abduction at the shoulder (Fig. 16)
Thoracodorsal nerve • Enters on the deep medial surface
• ~10–15 cm proximal (­ caudad) to humeral insertion
• Has two fascicles supplying independent neurovascular territories and can be used for
­restoration of independent thumb flexion*
• Lateral fascicle supplies the lateral (smaller) area of the latissimus
Vascular pedicle • Can be elongated by ligation of branches to the serratus anterior and other small branches (Fig. 17)
*Theeuwes HP, Gosselink MP, Bruynzeel H, Kleinrensink GJ, Walbeehm ET. An anatomical study of the length of the neural pedicle after the
bifurcation of the thoracodorsal nerve: Implications for innervated free partial latissimus dorsi flaps. Plast Reconstr Surg. 2011;127:210–214.

Latissimus
The use of the contralateral or ipsilateral latis-
simus is based on the function to be reconstructed
rather than on the position of the recipient vessels.
Typically, if the ipsilateral latissimus is considered
for elbow flexion or extension reconstruction, a
rotational latissimus is used. If this if not an option,
the contralateral free latissimus can be used for
elbow extension or flexion. For reconstruction
of elbow extension, the patient is placed in the

Fig. 17. Dissected latissimus dorsi muscle on the thoracodorsal

pedicle. The scissors are shown below the thoracodorsal branch
to the serratus anterior. This branch is ligated to provide a longer
vascular pedicle. (Authors retain copyright.)

prone position, and access to both the donor and

recipient sites can be achieved with one position-
ing and preparation. Elbow flexion reconstruction
using the contralateral latissimus requires reposi-
tioning from a lateral decubitus or prone position
to a supine position. This should be planned in
advance and performed expediently to limit flap
ischemia time (Table 7 and Figs. 16 and 17).24

Fig. 16. Diagrammatic representation of the dissection of the
latissimus dorsi muscle. The arm is in a position of abduction for
marking of the resting length. (Copyright © Timothy C. Hengst,
printed with permission.)
POSTOPERATIVE MANAGEMENT
Most vascular complications occur within the
first 8 hours after free tissue transfer. This is the most
critical period of monitoring, when flap evaluation
should be performed every 30 minutes by an expe-
rienced nursing staff. Close inpatient monitoring is
continued for 3 to 5 days, with decreasing frequency
of flap evaluation. The flap is monitored for Dop-
pler signal, color, temperature, and turgor. We have
noted that any petechial hemorrhage present in the skin

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Volume 134, Number 2 • Upper Extremity Reconstruction

Fig. 18. Partial skin necrosis of the gracilis skin flap 12 hours after functional free
muscle transfer for restoration of finger flexion. The patient was returned emer-
gently to the operating room. Both the arterial and venous vascular anastomoses
were patent. The necrotic skin was débrided. The underlying muscle was healthy.
Split-thickness skin graft was used to cover the exposed muscle. The patient did
require a tenolysis at scar revision 8 months after surgery. He achieved good
functional recovery with nearly full active finger flexion and Medical Research
Council grade 4 motor function. (Authors retain copyright.) (Above) Necrosis seen
around the margins of the skin paddle. (Center) Necrotic tissue débrided. (Below)
Finger flexion at 18 months postoperatively.

paddle is a harbinger of impending flap failure and
warrants immediate return to the operating room
for exploration. At times, this may represent only a
compromised skin paddle without problems with
the underlying muscle25 (Fig. 18). (See Video, Sup-
plemental Digital Content 3, which demonstrates
that, despite partial skin flap necrosis described in
Figure 18, the patient had excellent finger flexion
18 months after functional free muscle transfer
with gracilis for reconstruction of finger flexion.
This 6-year-old patient sustained a supracondylar
humerus fracture and subsequently developed a
compartment syndrome and later ischemic con-
tracture of the flexor compartment of the forearm,
http://links.lww.com/PRS/B51.) Any vascular com-
promise in the postoperative period may affect final
functional recovery of the transferred muscle.
During the initial recovery phase, the new
muscle origin and insertion need to be protected.
This requires 6 to 8 weeks of relative immobiliza-
tion. Joint mobility and tendon gliding should be
maintained as much as possible with passive range-
of-motion exercises, always with attention to protec-
tion of the tenorrhaphy sites. Removable splinting

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 Plastic and Reconstructive Surgery • August 2014
Video 3. Supplemental Digital Content 3 demonstrates that,
despite partial skin flap necrosis described in Figure  18, the
patient had excellent finger flexion 18 months after functional
free muscle transfer with gracilis for reconstruction of fin-
ger flexion. This 6-year-old patient sustained a supracondylar
humerus fracture and subsequently developed a compartment
syndrome and later ischemic contracture of the flexor compart-
ment of the forearm, http://links.lww.com/PRS/B51.
is used thereafter to protect the muscle that is not
yet reinnervated from inadvertent overstretching.
Passive range of motion is continued after
immobilization is completed. Although it is some-
what controversial, we begin electrical stimulation
at this time. The time of onset of spontaneous con-
traction depends on the site of neurorrhaphy rela-
tive to the transferred muscle, but typically begins
between 3 and 6 months postoperatively. Essential
to recovery at this time is the role of the therapist in
guiding the patient in muscle contraction, initially
using the previous muscle function of the recipient
nerve to initiate the new muscle contraction. For
example, when a recipient intercostal nerve is used
to reinnervate a muscle transfer for elbow recon-
struction, the patient would be encouraged to take
a deep breath as he or she is attempting to initiate
elbow flexion. Progression of functional recovery
can be seen for up to 2 years after transfer.
Functional transfers in children present the
problem of ongoing skeletal growth. This can lead
to a relative imbalance of the transferred muscle
to the antagonist muscle. For this reason, we rec-
ommend night splinting across the affected joint
through skeletal maturity.
OUTCOMES
Outcomes following functional free muscle
transfer depend on many factors: cause of the
defect, donor muscle strength and excursion rela-
tive to the desired function, muscle ischemia time
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(including postoperative vascular compromise),
motor units available in the donor nerve, patient
age and motivation, postoperative therapy, and
other factors. Even in excellent clinical outcomes,
there is incomplete recovery of nerve regenera-
tion within the muscle and mixed healthy and
degenerative muscle fibers. In a histological study
of muscle biopsies in patients who achieved Medi-
cal Research Council grade 4 or greater func-
tional recovery, only 46 percent of muscle fibers
appeared healthy.18
The most functional free muscle transfers in
the upper extremity are performed for brachial
plexus reconstruction. Donor nerves are limited in
this setting and nerve grafts are often used. These
factors can compromise the clinical outcomes com-
pared with traumatic injuries or Volkmann con-
tracture, where the donor nerve is frequently the
nerve that previously supplied the same motor func-
tion. Several of the functional free muscle trans-
fers in brachial plexus surgery also support more
than one function, which also decreases the power
of the recovered motor function at a single level.
Doi et al. reported on 24 patients who underwent
functional free muscle transfer for dual functional
reconstruction. Most patients recovered Medical
Research Council muscle function greater than or
equal to 3, with time to electromyographic reinner-
vation in uncomplicated cases being approximately
3 months. Final elbow motion was better in gracilis
and latissimus dorsi donor muscles than in rectus
femoris, and the time to reinnervation was shorter
with the spinal accessory donor recipient nerve than
with the intercostal nerve.10,11 Chung et al. reported
on 35 patients who underwent functional free mus-
cle transfer for biceps reconstruction. Intercostal
donor nerves were used in the majority of cases,
and 78 percent of patients achieved greater than or
equal to Medical Research Council grade 4 motor
function.26 Similar results were seen in the Mayo
Clinic experience. When a functional free muscle
transfer was used for a single functional reconstruc-
tion (elbow flexion), 79 percent of patients recov-
ered greater than or equal to Medical Research
Council grade 4 motor function. When two func-
tions were reconstructed with a single muscle, only
63 percent of patients achieved Medical Research
Council grade 4 function.27 Gousheh and Arasteh
reported similar results, but used a staged nerve
graft to the contralateral medial pectoral nerve, fol-
lowed by functional free muscle transfer and a third
stage where the functional free muscle transfer was
extended to provide more distal function.28
Functional reconstruction following Volk-
mann ischemic contracture was the first clinical
Volume 134, Number 2 • Upper Extremity Reconstruction
application of functional free muscle transfer. First
performed at the Sixth People’s Hospital in Shang-
hai in 1973, the lateral portion of the pectoralis
major was used to reconstruct the flexor muscles
of the forearm for a patient with Volkmann isch-
emic contracture.4 Zuker et al. published a series
of functional free muscle transfers using a gracilis
donor muscle in 1991, reporting on seven patients.
All patients achieved less than 2-cm pulp to palm
grip. Grip strength was approximately 25 percent
that of the contralateral side. All patients achieved
an independent functional nondominant hand.6
In 2011, they reported on a modification of their
technique to provide independent thumb flexion
by separating the fascicles of the obturator nerve
and using two donor nerves, providing separate
innervation to the neurovascular territories of the
gracilis muscle.29 Krimmer et al. used the gracilis
muscle in 15 patients with a primary indication
of Volkmann contracture. Thirteen of 15 muscles
demonstrated reinnervation. Ten patients achieved
full active motion.30,31 Liu et al. used the medial gas-
trocnemius muscle in 20 patients, reporting electro-
myographic activity at 6 to 20 months. Functional
outcomes were reported as satisfactory, but the clin-
ical photographs suggest incomplete finger flexion,
likely related to the short excursion of the muscle.32
Reconstruction after tumor resection has been
most frequently reported for lower extremities. In
the upper extremity, good functional recovery has
been reported, with time to reinnervation occur-
ring at approximately 5.5 months.14,15,33–36
Other indications including reconstruction
after trauma and congenital deficits have also
been reported with similar functional outcomes,
typically recovering Medical Research Coun-
cil grade 4 motor recovery.7,37–40 Lin et al. noted
a higher rate of failure of functional recovery
when a functional free muscle transfer was used
in the acute setting to achieve wound coverage
and reconstruct function.40 This has not been our
experience in the acute setting.
COMPLICATIONS
Complications can be divided into acute and
long-term complications, and also donor- and
recipient-site complications. Acute complications
at the recipient site include flap loss, partial flap
loss (either skin paddle or partial muscle loss),
hematoma, and infection. Long-term complica-
tions at the recipient site include scarring and
tendon adhesions requiring revision surgery,
attenuation at the tendon repair site resulting in
a shortened muscle resting length and decreased
excursion and power of the transferred muscle,
inadequate recovery of muscle power for the
desired level of function, and fracture at the site
of new muscle origin. Pediatric patients may expe-
rience bone growth that is more rapid than that
of the transferred muscle. This can lead to joint
contracture with growth. Acute complications at
the donor site include hematoma or seroma for-
mation. The latissimus dorsi donor site frequently
forms a seroma. Quilting and use of fibrin sealant
at the donor site may reduce this complication.41
Several authors have reported transient peroneal
or sciatic nerve palsy related to intraoperative posi-
tioning.42–44 Long-term donor-site complications
include painful unsightly scar, donor-site pain
or dysesthesia, and measurable functional losses
at the donor site. Despite measured decrease in
muscle strength (5 to 10 percent shoulder girdle
strength45 and 11 percent decreased adductor
strength),44 the decreased strength is often not
noted by the patient.
CONCLUSIONS
Functional free muscle transfer is a power-
ful tool in upper extremity reconstruction when
other options are not available. Appropriate
patient selection, a skilled surgical reconstructive
team, and a dedicated postoperative rehabilita-
tion program are essential for restoration of lost
function and patient satisfaction.
Milan Stevanovic, M.D.
Department of Orthopedics
2025 Zonal Avenue
GNH Room 3900
Los Angeles, Calif. 90033
stevanov@usc.edu
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