Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 18:
Vascularized Muscle Transplantation and Gracilis Muscle Transplantation
  The dominant vascular pedicle of the gracilis consists of one artery and two accompanying veins. In a small percentage of patients, the two veins join to become one common vein proximally in the inner thigh before emptying into the medial femoral circumflex venous system. Most commonly, however, having two recipient veins for use in gracilis muscle transplantation is desirable. Both the anterior and posterior tibial arteries commonly have two accompanying veins usable as recipients for the gracilis veins. Branches of the greater or lesser saphenous venous systems may also be used as recipient veins, in which case they may have to be dissected a distance to be rerouted to the area of dominant recipient artery. Branches of the cephalic and basilic venous systems in the upper extremity are usable as recipient veins. The facial and superficial temporal arteries have only one accompanying vein each, and in the latter it is often small. Use of other venous systems in the head and neck, such as the external jugular vein, may be required in these cases.

In functional gracilis muscle transplantation to the upper extremity or to the head and neck, the appropriate recipient motor nerves must be identified. In the forearm, the motor branches of the median nerve to the superficialis or long flexor musculature may be used. Ulnar nerve branches to the flexor carpi ulnaris and the two ulnar profundi are also possibilities. The appropriate recipient flexor tendons at the wrist or in the hand must also be identified.


To use the gracilis muscle to repair facial paralysis, the previously placed crossfacial sural nerve graft must be identified and documented as having sprouting axons at its cut end. Viable nerve bundles are identifiable under the operating microscope, and can be confirmed by frozen section evaluation.

Anatomic landmarks allow preoperative marking to identify the locations of all critical structures involved in harvesting the gracilis muscle. Markings are placed with the hip flexed and abducted and the knee flexed. Following are the key landmarks and structures.

1. The adductor longus muscle is easily palpated as a prominent band extending from the pubis toward the knee in the medial thigh.

2. The anterior border of the gracilis muscle lies approximately 3 cm inferior and parallel to the palpated adductor longus from the pubis to the knee. The posterior border of the gracilis muscle may be estimated by a line approximately 6 cm posterior to the anterior border, which gradually converges with this as the muscle approaches the knee. The musculotendinous roll of the gracilis at the knee is approximately 2 cm in diameter.

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