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Page 8 of 10 Nguyen et al. Plast Aesthet Res 2019;6:31 I http://dx.doi.org/10.20517/2347-9264.2019.42

43 patients. In this series, 9 of the 17 patients that were available for follow up evaluation had resection of
greater than ¾ of the quadriceps or complete femoral nerve loss. All 43 patients in this series attained full
knee extension; however, 41% still required walking aids. Only 14% of all patients underwent pre-operative
[9]
neoadjuvant radiation therapy . Despite its segmental innervation, Grinsell et al. described the use of
the rectus abdominis muscle for complete quadriceps reconstruction. This group described dissecting 1-4
segmental intercostal nerves to the rectus abdominis over 10-12 cm and re-innervating the muscle to motor
[10]
branches of the femoral nerve. They reported MRC Grade 4 power or greater in 6 of 11 patients .
It has been our past practice not to proceed with functional reconstructions in those patients having at
least one of the four quadriceps muscles remaining following tumor resection. Although these patients may
be somewhat initially disabled, we noticed that with training and physiotherapy most are able to achieve
unassisted ambulation, normal to near normal appearing gait, and full or nearly full knee joint extension.
These findings are likely due at least in part to the well-established observation in both bodybuilding and
powerlifting that muscles have the capacity for hypertrophy [11,12] . Based on these findings, we believed the
gracilis would have the ability to replace enough quadriceps function essential for activities of daily living:
sitting, getting up from a chair, and unassisted gait. To be clear, the goal of the transfer was not to replicate
the strength and power of all four quadriceps muscles with a single smaller muscle.

From a surgical perspective, the gracilis is a simple, straight forward transfer, particularly if it is pedicled.
The gracilis is in the same surgical field as the resection and hence there is no additional donor site
morbidity, and no change of positioning or awkward positioning is required. The gracilis flap can be
pedicled into the defect with no ischemia time and no microvascular anastomosis. The stout proximal
fascia and long distal tendon make the gracilis perfectly suited for insertion into the rectus femoris origin
proximally and into the quadriceps tendons distally with a strong Pulvertaft weave. The obturator nerve
can be cut short for more rapid reinnervation if a long femoral nerve stump exists or tailored to be longer
if the nerve was involved with the tumor more proximally. Thus far, we have always reinnervated the
gracilis with the rectus femoris motor nerve branch of the femoral nerve, which is tagged during resection.
Failure of reinnervation has not been a problem. Although not performed for sarcoma surgery, we have
successfully performed pedicled functional gracilis leaving the obturator nerve to gracilis intact. We have
utilized this in combination with a nerve transfer for complete femoral nerve injuries. In this case, the
muscle dissection and placement are the same, but the obturator branch to the gracilis is left intact and the
gracilis is “piggybacked” onto the medial side of rectus femoris. In this case, the obturator branch to the
adductor longus is transected and used as a simultaneous nerve transfer to reinnervate the rectus femoris.
Therefore, simply leaving the motor nerve to the gracilis intact during pedicled gracilis transfer may be
another technique option but we do not have experience utilizing this in our sarcoma reconstructions.

There are advantages to the gracilis over the other free muscle transfers: its donor site functional deficit
is likely less than that of a rectus abdominis, latissimus dorsi, or contralateral rectus femoris, and the
recipient vessel location or the necessity of vein grafts in a radiated vessel depleted field does not become a
factor when trying to accurately position the pedicled muscle transfer as compared to a free tissue transfer.

There are certainly situations in which other muscle transfers should be considered. For example, if the
resection necessitates a femoral prosthesis, a latissimus dorsi or rectus abdominus is probably better suited
to provide more complete coverage of the prosthesis. If the sartorius remains following resection, then it
[8]
[6]
should also be considered in addition to the gracilis as described by Willcox et al. and Innocenti et al. .
Local tendon transfers can certainly be considered in institutions whose protocol does not include pre-
operative neoadjuvant radiation therapy. The risk of post-operative wound dehiscence and lymphedema
with these techniques is not insignificant even in the non-irradiated setting .
[9]