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Marsden et al. Plast Aesthet Res 2019;6:24 I http://dx.doi.org/10.20517/2347-9264.2019.14 Page 5 of 11

A B

C D

E F

Figure 3. Clinical images of an example of upper limb functional reconstruction with an innervated medial gastrocnemius myocutaneous
flap, following left deltoid excision for recurrent sarcoma (previous partial deltoid resection and ALT flap). A: planned excision of
previous ALT flap and remaining deltoid; B: defect following total deltoid resection, with exposed humerus; C: right medial gastrocnemius
myocutaneous flap planning; D: flap islanded with its neurovascular bundle dissected prior to division; E: result at one year showing
excellent flap contour; F: M5 power of shoulder abduction and flexion, equal to the contralateral side (see Video 4). ALT: antero-lateral
thigh

However, there may be circumstances following more extensive resections where longer length is required
to perform reinnervation. The senior author has successfully performed FFMT with long nerve harvest in
both rectus abdominis and gracillis transfer. Free or pedicled rectus abdominis myocutaneous flaps can be
raised with long dissection of over 10 cm of intercostal nerves [Figure 5].

We have had excellent results with pedicled, innervated rectus abdominis flaps in quadriceps
reconstruction, with evidence of motor function in the donor muscle within three months and MRC 5/5
[24]
return of power at seven months . The most commonly used free functioning flap for both oncologic
and trauma reconstruction is the gracillis flap. One of the limitations to its use is the relatively short
neurovascular pedicle, usually allowing around 6-8 cm of length to be harvested. When longer lengths of
donor nerve are required, long nerve gracillis flaps can be harvested through the obturator foramen, via a
combined intra-abdominal approach, allowing up to 30 cm of donor nerve to be harvested with the muscle.
Time to reinnervation is increased due to the longer distances for regeneration, but full function can be
achieved successfully with these techniques.