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Vakhshori et al. Plast Aesthet Res 2023;10:36 https://dx.doi.org/10.20517/2347-9264.2022.78 Page 7 of 22

Figure 5. Inset of the pedicled latissimus dorsi flap.

nerve root, contralateral lateral pectoral nerve, or intact ipsilateral cervical nerve roots or intraplexal nerve
branches [9,44] . Terzis et al. demonstrated increased postoperative mean muscle grade after neurotization of
[44]
three intercostal nerves compared to two intercostals . The thoracodorsal artery of the transferred
latissimus may be anastomosed to the thoracoacromial artery, and the venae comitantes or cephalic vein
may be used for venous outflow .
[9]

Reported outcomes are shown in Table 2. In the studies reporting individual patient motor grades, 83%
achieved at least antigravity elbow flexion strength. Mean elbow flexion was 72°.

Gracilis
The gracilis muscle is a commonly used donor muscle for a variety of upper extremity reconstruction
indications. Either the ipsilateral or the contralateral gracilis may be used. In cases of double free functional
muscle transfer used to restore multiple functions in the extremity, bilateral gracilis can be harvested.
However, the direction of the vascular pedicle makes the contralateral gracilis a more desirable option. The
gracilis provides knee flexion, internal rotation, and thigh adduction, but is redundant and does not lead to
functional deficits in the leg when harvested. Additionally, it may be harvested with a skin paddle, and its
length and excursion provide an ideal replacement for elbow flexors. One important aspect to consider
when harvesting the gracilis is the short pedicle length. Determining the estimated pedicle length prior to
flap harvest is of utmost importance to determine if the gracilis is a viable option. In the event that the
pedicle length is insufficient, a vein graft may be utilized.