Since the introduction of cross-facial nerve grafting and free vascularized muscle transfer for the treatment of longstanding facial paralysis, substantial progress has been made toward restoration of facial expression that is as normal as possible. Much of the focus has remained on the gracilis as a donor muscle. However, its inherent anatomical characteristics may preclude it from ever being more than simply a mass of contractile tissue in the face. The coracobrachialis muscle, which is the analogue in the arm of the lower limb adductor mass, was proposed as an alternative donor muscle because it was thought that certain features would allow it to improve on the overall results that are currently possible with the gracilis. A comparative anatomical study was conducted to gauge this potential. A total of 133 muscles were analyzed, including 96 dissected specimens, 16 arterial and 14 venous study specimens, and seven neurovascular study specimens. Anatomical parameters were recorded for each muscle and later tabulated. Histological analysis of the nerves to 10 gracilis and 10 coracobrachialis muscles was performed, and the findings were confirmed with intraneural dissection of an additional 20 nerves under an operating microscope. The coracobrachialis was observed to be a practical alternative to the gracilis. Indeed, it has many of the attributes that initially drew attention to the gracilis as a possible donor muscle, including a reliable neurovascular supply, minimal donor-site morbidity, and the option of having two teams operate simultaneously. In addition, it has a size, shape, and form that make it an excellent choice for transfer to the face. It could be easily attached in the face to provide static support as well as animation, because of its long proximal tendon, the thick intermuscular septum along its lateral surface, and, when present, the ligament of Struthers.

Reliable information on cost and value in microsurgery is not readily available in the literature. Driving factors for cost, determinants of complications, and cost-reduction strategies have not been elucidated in this population, despite such progress in other areas of medicine. Clearly, the time-consuming and costly nature of this endeavor demands that appropriate indications and patient management be delineated; to operate proactively in this cost-conscious time, financial and outcome determinations are critical. One hundred seven consecutive free-tissue transfers performed from 1991 to 1994 by a single microsurgeon were studied. Retrospective chart review for clinical parameters was combined with analysis of hospital costs and professional charges. Operating room and anesthesia costs were based on a microcost analysis of actual operating room time, materials, labor, and overhead. Other patient level costs were generated by Transition 1, a hospital cost-accounting system. The following issues were addressed: (1) flap survival; (2) total costs and length of stay for all free flaps; (3) payments received from various insurers; (4) breakdown of operating room costs by labor, supplies, and overhead; (5) breakdown of inpatient costs by category; (6) additional costs of complications and takebacks; (7) factors associated with complications and flap takebacks; and (8) cost-reduction strategies. Mean free flap operating room costs (exclusive of professional fees) ranged among case types from $4439 to $6856 and were primarily a function of operating room times. Elective patient cases lasted a mean 440 minutes. There was a large disparity in reimbursement: private insurers covered hospital costs (not charges) completely, whereas Medicare paid 79 percent and Medicaid only 64 percent. Length of stay, operative procedures, and complications had the greatest influence on inpatient costs in this group of free flap patients. Potential cost savings as a result of possible practice changes (e.g., shortening intensive care unit stays and avoiding staged operations) can be predicted. This analysis has caused a revision in these institutions' practice patterns and lays the foundation for planned outcome studies in this population.

Nerves innervating the rectus abdominis are at risk during DIEP flap harvest. Small, type 1 nerves have overlapping innervation from adjacent nerves and may be sacrificed without functional detriment. However, large type 2 nerves at the level of the arcuate line innervate the entire width of rectus muscle without adjacent overlap and may contribute to donor-site morbidity if sacrificed.