Free Reverse Gracilis Muscle Combined With Steindler Flexorplasty for Elbow Flexion Reconstruction After Failed Primary Repair of Extended Upper-Type Paralysis of the Brachial Plexus

Bertelli, Jayme Augusto

doi:10.1016/j.jhsa.2018.05.016

Cited by 10 publications

(4 citation statements)

References 29 publications

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“…The inverted orientation of the gracilis muscle free flap has been described to restore elbow flexion in patients affected by brachial plexus injuries (Bertelli, 2019; Chin et al, 2013; Wade et al, 2020). As described by the authors, the original orientation simplifies the coaptation of the recipient nerve to reanimate the muscle flap.…”

Section: Discussionmentioning

confidence: 99%

Inverted gracilis muscle free flap with intraoral vascular anastomoses for facial reanimation in vessel depleted neck: A case report

De Cicco,

Bottini,

Lizambri

et al. 2023

Microsurgery

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The reinnervated gracilis muscle free flap represents a workhorse of facial reanimation. This procedure is carried out secondarily to parotid resections, due to advanced tumors that spread to the surrounding structures. Finding recipient vessels might be problematic if other reconstructive procedures are needed to address the defects. This paper describes a procedure to inset a reinnervated gracilis muscle free flap in a vessel depleted patient, through intraoral anastomoses to avoid venous interposition grafts. A 52‐year‐old man developed an advanced adenocarcinoma of the deep parotid lobe and underwent radical surgical excision including the mandibular ramus, condyle, and facial soft tissues (defect size: 8 cm × 4 cm). A secondary double‐flap reconstruction restored the mandibular defect and inset a cross‐face nerve graft. A third intervention finalized the facial reanimation with a 10 cm reinnervated gracilis muscle free flap. The gracilis flap inset was inverted resulting in the proximal flap (pedicle side) lying on the buccal aspect. This allowed vessel joining from the contralateral side via intraoral anastomoses. No complications occurred within and after the intervention. However, the adenocarcinoma relapsed before reinnervation of the gracilis. The patient also had distant brain and lung metastases and received best supportive care. The inverted gracilis muscle free flap may represent an option for attaining facial reanimation in vessel‐depleted patients avoiding long interposition venous grafts.

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Section: Discussionmentioning

confidence: 99%

Inverted gracilis muscle free flap with intraoral vascular anastomoses for facial reanimation in vessel depleted neck: A case report

De Cicco,

Bottini,

Lizambri

et al. 2023

Microsurgery

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“…We can speculate that previous vascular surgery does not affect flap survival, but it makes the operation technically difficult. Reverse FGMT described by Bertelli[ 30 ] can be performed in these patients. In this surgical method, the gracilis tendon is fixed to the acromion and the muscle core is sutured to the biceps distal tendon.…”

Section: Discussionmentioning

confidence: 99%

Outcome of free gracilis muscle transfer for the restoration of elbow flexion in traumatic brachial plexus palsy

Armangil

Ünsal

Yıldırım³

et al. 2021

Jt Dis Relat Surg

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Traumatic brachial plexus palsy (TBPP) is a devastating injury that significantly affects the upper extremity functions and results in serious disability. Surgical reconstruction is closely related to the severity of the injury and the time elapsed after the trauma. Microneural and/or free functional muscle transfer reconstruction can be performed in patients admitted in the early period. [1][2][3] Tendon transfers, pedicle or free muscle transfers are the treatment options in patients with delayed TBPP and reserved for cases where nerve repair or reconstruction fails. [1,4] Doi et al. [5] reported successful results using free muscle transfer to restore limb functions in TBPP patients in 1991. The same team defined double free muscle transfer in 1995. [6] Objectives: The aim of this study was to evaluate the functional outcomes of patients with free gracilis muscle transfer (FGMT) for the restoration of elbow flexion.Patients and methods: Between January 2012 and January 2019, a total of 16 patients (13 males, 3 females; mean age: 27.3±11.7 years; range: 18 to 53 years) who underwent FGMF to achieve elbow flexion after traumatic brachial plexus palsy (TBPP) were retrospectively analyzed. Data including demographic and clinical characteristics of the patients, etiology, affected side, injury level, accompanying injuries, time between injury and surgery, follow-up time, complications, whether nerve reconstruction and artery repair were performed previously, and details of the procedure were recorded. The outcome measures were elbow range of motion in degrees, muscle strength, and Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-36 (SF-36) scores. Results:The mean follow-up was 30±11.5 (range, 24 to 42) months. Two patients had C5-C8 injuries, two patients had C6-T1 injuries, and all other patients had injuries to the C5-T1 roots. Muscle strength was M3/M4 in 11 (68.8%) patients, M2 in two (12.5%) patients, and M0 in one (6.2%) patient. The median active range of motion of the elbow joint in patients with successful results (M3 and above) was measured as 75 (range, 30 to 100) degrees. A statistically significant improvement was observed in the pre-and postoperative DASH scores and in some SF-36 subscale scores of patients with successful results. Conclusion:Free gracilis muscle flap is a reliable option in the restoration of elbow flexion in patients with TBPP. Although there is an improvement in functional results, disability, and quality of life, there may be no change in patients' mental status and pain.

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“…11,[22][23][24][25][26][27][28] Hattori et al 8 reported on FFMT in three patients with subclavian injury, but who had intact thoracodorsal and thoracoacromial arteries and had not undergone any previous nerve reconstruction. Bertelli 29 and Chin et al 30 presented series of patients with partial brachial plexus injuries in which the gracilis was reversed, so that its motor branch could be innervated by motor branches of the median or ulnar nerve in the distal aspect of the arm, and revascularized by the radial artery and cephalic vein, with good results. Although none of the authors reported the use of the technique in patients with proximal vascular injury, the procedure could be used in those instances, if the radial artery has good blood flow through collateral circulation and the hand function permitted the use of median/ulnar fascicles as donor nerves.…”

Section: Discussionmentioning

confidence: 99%

Use of the Facial Artery for Free Functioning Muscle Transfers: An Alternative Pedicle for Salvage in Brachial Plexus Lesions with Vascular Injuries

Bhatia

Prabhune

Carvalho

2020

Indian J Plast Surg

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Free functional muscle transfer (FFMT) is a salvage procedure recommended in cases of brachial plexus injury with late presentations or failures of primary nerve reconstruction. The workhorse for most authors is the gracilis, and the most common indication is the restoration of elbow flexion. For successful revascularization of the muscle, donor vessels must be in proximity of the site of the muscle fixation and allow direct coaptation to a donor nerve, ideally without the use of nerve grafts. A major problem occurs when patients have sustained concomitant vascular injuries to the subclavian and/or axillary arteries and had previous surgical dissections in the area where the most common vascular pedicles are located. The authors report the use of the rerouted facial vessels as donors in these complex cases. The surgical technique is presented, along with three cases where the procedure was used. The flaps survived in all the patients and grade > 3/5 muscle contraction was observed in the two patients who had adequate follow-up. Conclusion: the use of the facial vessels as donor vessels is an option to revascularize a FFMT in the setting of severe vascular injury to the subclavian and axillary arteries.

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Free Reverse Gracilis Muscle Combined With Steindler Flexorplasty for Elbow Flexion Reconstruction After Failed Primary Repair of Extended Upper-Type Paralysis of the Brachial Plexus

Cited by 10 publications

References 29 publications

Inverted gracilis muscle free flap with intraoral vascular anastomoses for facial reanimation in vessel depleted neck: A case report

Inverted gracilis muscle free flap with intraoral vascular anastomoses for facial reanimation in vessel depleted neck: A case report

Outcome of free gracilis muscle transfer for the restoration of elbow flexion in traumatic brachial plexus palsy

Use of the Facial Artery for Free Functioning Muscle Transfers: An Alternative Pedicle for Salvage in Brachial Plexus Lesions with Vascular Injuries

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