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Vakhshori et al. Plast Aesthet Res 2023;10:36 https://dx.doi.org/10.20517/2347-9264.2022.78 Page 9 of 22

[3]
The surgical technique for free gracilis transfer has been well described in the literature . The patient is
placed in a frog leg position and an incision is created along a line from the pubic tubercle to the medial
femoral condyle [Figure 7]. If a skin paddle is used, it is created in the proximal third of the incision and just
posterior to the line. The gracilis is the most posterior adductor muscle of the thigh, and is differentiated
from the sartorius by its origin on the pubic tubercle, rather than anterior superior iliac spine. The medial
thigh fascia is incised and kept with the gracilis muscle to improve independent gliding during contraction.
The distal tendon is identified and separated from the other tendons of the pes anserinus. As with the
latissimus transfer described above, marking sutures may be used at fixed intervals to help define resting
length. Proximally, the neurovascular pedicle is identified 8 to 12 cm distal to the pubic tubercle [Figure 8].
The pedicle is divided after exposure of the recipient site and division of origin and insertion of the muscle
[3]
to minimize ischemia time . Prolonged ischemia time should be avoided -- Martins-Filho et al.
demonstrated a trend towards improved results in terms of muscle strength with decreased ischemia
[48]
time . Additionally, they noted a trend towards poorer functional outcomes with only one venous
anastomosis compared to two .
[48]
The recipient site is prepared with an extensile anterior arm approach including exposure of the lateral
clavicle, acromion, and coracoid proximally, and the medial epicondyle and antecubital fossa distally
[Figure 9]. The gracilis is attached proximally to the lateral clavicle and acromion or coracoid via suture
anchors or bone tunnels. By fixing the muscle proximally first, the muscle can then be stretched to its
resting length and the position of arterial anastomosis can be planned to avoid undue tension on the
pedicle. Arterial anastomosis may be performed with the thoracoacromial, lateral thoracic, or subscapular
arteries in an end-to-end fashion, or the brachial artery in an end-to-side fashion [Figures 10] . After
[3]
anastomosis, distal gracilis is secured to the distal biceps tendon or the radius or ulna, with the restoration
of the distance between the previously placed marking sutures while the elbow is held in extension
[49]
[Figure 11] . The orientation of the gracilis may be reversed in the event of prior surgery near the brachial
plexus, which allows the anastomosis and nerve coaptation to be performed more distally, out of the region
of prior scarring [50,51] .The gracilis may also be used for finger flexion when attached distally to the flexor
digitorum profundus (FDP) and flexor pollicis longus (FPL), or finger extension when attached distally to
the extensor digitorum communis (EDC). Maldonado et al. showed that distal tendon attachment (to FDP
or FPL tendons with flexor carpi radialis [FCR] tendon autograft) was associated with superior elbow
flexion strength and range of motion compared to biceps tendon reattachment . Bertelli showed the
[52]
gracilis muscle flap can be combined with a Steindler flexorplasty, wherein the flexor-pronator mass origin
is transferred proximally to the anterior humerus to improve elbow flexion, to increase strength and
decrease time to elbow flexion .
[51]
Following distal fixation, nerve coaptation is performed. The gracilis may be innervated by a variety of
donor nerves, including the distal spinal accessory nerve, intercostal nerves, fascicles of the ulnar or median
nerve, the phrenic nerve, or contralateral medial pectoral nerve . In cases where elbow flexion was lost due
[3]
to anterior compartment trauma or resection, the original musculocutaneous nerve may be used. The
authors prefer neurotization with the distal spinal accessory nerve. The spinal accessory nerve is identified
after detaching the trapezius insertion from the clavicle and the acromion. The distal branch of the spinal
accessory nerve is divided and a coaptation is performed to the motor branch of the gracilis with
microsurgical technique.

Reported outcomes are shown in Table 3. The majority of patients, 79% of those reported, achieved
antigravity strength or stronger with free gracilis transfer, with a low rate of reported complications.