Summary
Restoration of lost opposition in the context of significant thenar soft tissue defects
represents a tremendous reconstructive challenge. Free functioning muscle transfer
has been described in this context and has the advantage of providing both a functioning
muscle unit as well as soft tissue coverage in a single reconstructive procedure.
It adds to the injured limb, and by sparing donor tendons avoids the need for re-education
of motor function. We describe the use of a free innervated gracilis muscle flap for
functional thenar reconstruction in two unique cases following extensive traumatic
loss of thenar skin and musculature. Crucially, in each case, the recurrent motor
branch of the median nerve had been destroyed at its point of insertion into the thenar
muscle remnants.
Aim
To date, the main reported disadvantages of free functioning muscle transfer in thenar
reconstruction include difficult flap dissections, donor site morbidity, inadequate
strength and excursion of the transplanted muscle and excessively bulky flaps. Our
aim was, as far as possible, to address these issues.
Surgical procedure
Each thenar defect was measured and a corresponding segment of gracilis muscle, measured
in situ, was raised on the proximal neurovascular pedicle. End-side microvascular
anastomosis was performed between the medial circumflex femoral artery and the radial
artery. The venae comitantes of the pedicle were anastomosed end-end with those of
the radial artery and also with the cephalic vein. Epineural anastomosis was performed
between the motor branch of the obturator nerve and the recurrent motor branch of
the median nerve. Each flap was covered with a split thickness skin graft.
Results
Both flaps survived without any complication. Both patients regained excellent voluntary
thumb opposition, sufficient to allow return to full-time employment, and had restoration
of sufficient thenar bulk. This was achieved with minimal donor site morbidity.
Conclusions
Restoration of lost opposition, in the context of significant thenar soft tissue defects,
can be achieved using a free functional gracilis flap. This produces clinically excellent
functional results and can be carried out as a single stage reconstructive procedure.
This is a novel application of a tremendously versatile donor muscle in functioning
free muscle transfer.
Keywords
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Article info
Publication history
Published online: April 24, 2007
Accepted:
March 1,
2007
Received:
October 31,
2006
Footnotes
☆Presented to Federation of the European Societies for Surgery of the Hand, XI Congress, Glasgow, 2006.
☆Presented at joint meeting of British and Spanish Societies for Surgery of the Hand, Valladolid, Spain, April 2005.
☆Prize for best paper presented at joint meeting of Scottish and Irish Plastic Surgeons, Belfast, Oct 2005.
Identification
Copyright
© 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Inc. All rights reserved.
