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Page 2 of 10 Nguyen et al. Plast Aesthet Res 2019;6:31 I http://dx.doi.org/10.20517/2347-9264.2019.42

navigate stairs, and are able to ambulate without a brace. The fourth patient unfortunately was deceased in under
three months following his tumor resection.

Conclusion: Despite its small size in comparison to the quadriceps muscles, with physiotherapy and training, the
gracilis muscle demonstrates the capacity to hypertrophy and replace quadriceps function following limb salvage
surgery.

Keywords: Knee extension, re-animation, functional muscle transfer, free flap, pedicled flap, sarcoma, microsurgery,
quadriceps, reconstruction

INTRODUCTION
It is not uncommon to have to resect one or more components of the four quadriceps muscles during
[1]
[2]
sarcoma resection from the anterior compartment of the thigh . Pritsc et al. examined postoperative
isometric strength and found that the strength of the quadriceps decreased by 22%, 33%, 55%, and 76%,
[2,3]
respectively, when one, two, three, or more components of the quadriceps were resected . Functional
thresholds of quadriceps strength below which essential quadriceps functions are impaired have been
difficult to determine as there are many other factors in addition to muscle strength that affect ambulatory
[4]
ability .
At our institution, in the setting of anterior compartment resections of the thigh for malignant soft tissue
tumors, we do not routinely proceed with functional reconstruction or augmentation of the quadriceps
muscles if at least one of the four quadriceps muscle groups remain intact. In those patients who undergo
complete resection or complete loss of continuity (central wide resections) and/or denervation of all four
quadriceps, we have been successful in restoring essential quadriceps function utilizing a single gracilis
muscle transfer, either as a free flap from the contralateral leg, or, more recently, as a simple pedicled
gracilis muscle from the ipsilateral leg. With either technique, the gracilis muscle is transferred into the
rectus femoris position. With training, the gracilis is able to hypertrophy enough to perform essential
quadriceps function.

METHODS
Institutional research ethics approval was obtained for the study (Ethics #: HS23291). We retrospectively
reviewed all patients at our institution who underwent complete resection and/or had complete denervation
of all four quadriceps muscles as part of their sarcoma resection of the anterior thigh and reconstruction
with a single gracilis muscle. All cases were performed by a single surgeon (Hayakawa TEJ). Patient
demographics, surgical technique, and clinical outcomes such as British Medical Research Council (MRC)
grading, knee extension, and ambulatory status is reported.

Surgical technique
The choice of free or pedicled gracilis is usually determined by the degree of cutaneous soft tissue
reconstruction required. If there is a relatively small cutaneous defect, then both the functional quadriceps
reconstruction and soft tissue reconstruction are accomplished by a single free contralateral gracilis
myocutaneous flap. If the soft tissue or skin defect is too large for the gracilis skin paddle, then an
ipsilateral pedicled gracilis is transferred into the rectus femoris position for the functional component of
the reconstruction, and a larger cutaneous free tissue transfer such as an anterolateral thigh (ALT) or deep
inferior epigastric perforator (DIEP) flap is added for coverage of the soft tissue defect.

In both scenarios, the inset of the gracilis is identical, and into the rectus femoris position. The gracilis
will become the only “quadriceps” muscle and will provide both hip flexion and knee extension, which