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Page 18 of 22 Vakhshori et al. Plast Aesthet Res 2023;10:36 https://dx.doi.org/10.20517/2347-9264.2022.78

transfers in most patients because of the increased strength at recovery and inadequate muscle bulk of the
[44]
gracilis .Similar to Chuang et al., Terzis and Kostopoulos also demonstrated increased strength after
[44]
latissimus dorsi neurotization with three intercostal nerves compared to two .
Oliver et al. performed a systematic review and meta-analysis to compare free functional muscle transfers
(gracilis, rectus femoris, and latissimus dorsi) innervated by either intercostal or spinal accessory nerves.
They found no difference in success rate or muscle strength, with nearly 65% achieving at least grade M3
strength . Despite the success seen with these nerve transfers, one should consider potential risks and
[84]
complications. Though the use of intercostal nerves is commonly reported, the proximity to vital structures
should be noted, as there have been reported pleural tears and effusions, acute respiratory distress
syndrome, seroma formation, and rib fractures .
[85]

POSTOPERATIVE PROTOCOL
Following functional muscle transfer, patients are monitored closely for signs of flap failure, whether the
transfer is pedicled or free. A skin paddle is useful in determining if early signs of flap failure are present,
[86]
and may provide more successful flap salvage in the event of arterial thrombosis or venous congestion .
After functional muscle transfer, rehabilitation is vital to optimizing patient outcome. Typically, patients are
placed in a splint postoperatively with the elbow in flexion for 1-6 weeks, following which patients begin
passive therapy exercises to avoid contracture . Doi et al. performed a trial with patients undergoing double
[3]
free gracilis muscle transfer, comparing those with 6 weeks of immobilization to those with early passive
mobilization after 1 week of splinting. They showed that none of the patients in the latter group required
tenolysis, compared to 32% in the immobilization group, but the final range of motion was similar .
[62]
Following muscle reinnervation, retraining is required to train the patient to use the new elbow flexor
properly.

CONCLUSIONS
Functional muscle transfer is a viable option to restore elbow flexion in the setting of brachial plexus injury,
traumatic muscle loss, oncologic treatment, poliomyelitis, or congenital absence of motor function. Options
include pedicled or free functional muscle transfers. Functional muscle transfer has the potential to
significantly improve upper extremity function.

DECLARATIONS
Authors’ contributions
Performed literature review: Vakhshori V
Prepared manuscript: Vakhshori V, Azad A

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.