Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 18:
Vascularized Muscle Transplantation and Gracilis Muscle Transplantation
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  The motor nerve is easily identified and dissected, if necessary, just proximal to the dominant vascular pedicle. Ten to 12 cm of nerve are easily available.

Operative Sequence

PLATE XVIII-1. Anatomy

A. The bony landmarks for this muscle are the pubic symphysis, the inferior ramus of the pubis, the ischial tuberosity, and the medial condyle of the knee. The muscle runs from the inferior ramus to the medial condyle area and is bounded anteriorly by the sartorius and posteriorly by the semimembranosus and semitendinosus. The saphenous vein crosses this area in a lateral-to-medial direction. With the thigh held in marked abduction, the muscle lies in the posterior third of the medial surface of the thigh. The proximal incision should be started halfway between the pubic symphysis and the ischial tuberosity and extend distally to the medial condyle. One can pick up the tendon portion of the muscle distally, put it under tension, and draw the line for the incision in this manner. In the distal area, the fibers from the sartorius approach the knee from a lateral-to-medial direction, whereas the gracilis fibers go directly up the medial aspect of the thigh. One can rapidly develop the distal third or half of the muscle circumferentially, isolating and identifying the minor

  pedicle as it comes off the terminal superficial femoral vessel. The major pedicle usually reaches the undersurface of the muscle about 9 cm below the anterior superior iliac spine. The vessels come out from under the adductor longus, which must be retracted medially to gain adequate length to the pedicle. The pedicle can be traced medially and superiorly to the medial circumflex femoral artery, providing a pedicle 6 to 8 cm long. The nerve reaches the muscle superior to the vessels at about the same angle. The nerve often bifurcates or trifurcates just as it reaches the muscle. Manktelow has pointed out that the muscle can be separated into different neurovascular territories by stimulating the individual fascicles. The proximal portion of the muscle can be separated from the pubic ramus by sharp dissection. The muscle must be completely isolated circumferentially down to the bone before this is attempted, to prevent bleeding from the multiple vessels in the area.

PLATE XVIII-2

A. The skin incision has been made and the anterior skin flap has been elevated, exposing the adductor longus and the sartorius.


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