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Vakhshori et al. Plast Aesthet Res 2023;10:36 https://dx.doi.org/10.20517/2347-9264.2022.78 Page 17 of 22

Figure 11. Dissection of the distal biceps tendon for the distal attachment of the transferred gracilis muscle.

accessory nerve transfer and 55% of those with ulnar nerve fascicles reaching M3 strength or greater, but the
difference was not statistically significant . Chuang et al. showed that transferring three intercostal nerves
[74]
leads to earlier recovery of muscle strength and higher final power compared to those with two transferred
intercostal nerves . This group showed poorer results with the use of the spinal accessory nerve to
[49]
innervate the free functional muscle transfer -- 0% achieving M4 strength (compared to 78% of those with
three intercostal nerves treated). However, they note the use of a nerve graft interposition when using the
spinal accessory nerve to achieve the appropriate length of the transferred nerve . Kimura et al. also noted
[49]
a higher number of patients reaching M4 strength when the nerve transfer was performed without an
interpositional nerve graft . Terzis and Kostopoulos prefer the use of latissimus dorsi or rectus femoris
[76]