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Updated: May 26, 2026
Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer
Published on: March 1, 2015
Free functional muscle transfer in children: A long-term case series from a single microsurgical unit
Tarek Abdalla El-Gammal1, Amr El-Sayed2, Mohamed Mostafa Kotb2
1Department of Orthopedics, Division of Hand and Upper Extremity, University of Florida, Gainesville, FL, USA.
Insights
Free functional muscle transfer (FFMT) effectively restores arm motion in children. Gracilis FFMT provides durable results, with strength and functional recovery significantly impacting patient satisfaction and bimanual use.
Area of Science:
- Pediatric reconstructive surgery
- Microsurgery
- Orthopedic surgery
Background:
- Restoring active motion in children with upper-limb paralysis or muscle loss is challenging.
- Free functional muscle transfer (FFMT) is an option for limb reconstruction when local muscles are unavailable.
- Optimal timing, donor nerve selection, and long-term growth effects for FFMT in children require further investigation.
Purpose of the Study:
- To report a single-institution experience with gracilis FFMT in pediatric patients.
- To evaluate the outcomes of FFMT for upper-limb reconstruction in children.
- To identify factors influencing functional recovery and patient satisfaction after FFMT.
Main Methods:
- Retrospective review of 35 children (<18 years) undergoing upper-limb FFMT with ≥24 months follow-up.
- Gracilis muscle used for finger/elbow flexion, elbow extension, or combined functions.
- Outcomes assessed: time to activation, range of motion, Medical Research Council (MRC) strength, secondary procedures, complications, bimanual use, and satisfaction.
Main Results:
- 100% flap survival with initial muscle activation at a mean of 4.1 months.
- Significant improvements in motion and strength (p < 0.001), with ≥4 MRC strength in 78-80% of reconstructions.
- Finger-flexion transfers showed better bimanual use and recovery; satisfaction correlated with final strength and reconstruction completeness.
Conclusions:
- Gracilis FFMT offers durable restoration of active motion and strength in pediatric patients.
- Functional outcomes depend on the indication and reconstructed function, not solely donor nerve choice.
- FFMT is a valuable component of staged reconstructive strategies for pediatric upper-limb deficits.
Background:
Restoration of active motion in children with upper-limb paralysis or muscle loss remains challenging. Free functional muscle transfer (FFMT) is a reconstructive option when local muscle donors are unavailable, but uncertainties persist regarding optimal timing, donor nerve selection, and long-term effects of growth and secondary deformities. This study reports a single-institution experience addressing these issues.
Methods:
A retrospective review was conducted of 35 children (<18 years) who underwent upper-limb FFMT with a minimum follow-up of 24 months. All reconstructions used the gracilis muscle to restore finger flexion, elbow flexion, elbow extension, or combined functions. Donor nerves included the anterior interosseous nerve (AIN) with or without median nerve fascicles, intercostal nerves, spinal accessory nerve, and phrenic nerve. Outcomes included time to muscle activation, range of motion, Medical Research Council (MRC) strength, secondary procedures, complications, bimanual use, and patient or caregiver-reported satisfaction. Pre- and postoperative outcomes were compared using paired and groupwise statistical tests.
Results:
Mean age at surgery was 7.6 years, with a mean follow-up of 68 months (range, 24-166 months). Flap survival was 100%. Initial muscle activation occurred at a mean of 4.1 months. Significant improvements in motion and strength were observed across all functions (p < 0.001). MRC grade ≥4 strength was achieved in 80.0% of elbow-flexion reconstructions and 78.3% of finger-flexion reconstructions. Finger-flexion reconstructions demonstrated higher bimanual use and more consistent recovery than elbow-flexion reconstructions. In construct-level analysis, single-function transfers showed clearly superior finger-flexion outcomes, whereas elbow-flexion results differed by endpoint: single-function transfers achieved greater ROM, while all dual-function elbow-flexion transfers reached MRC grade ≥4 in this small subgroup. Secondary procedures were required in 51.4% of patients. Overall satisfaction was reported by 71.4% and correlated more strongly with final strength and completion of reconstruction than with range of motion.
Conclusions:
Gracilis FFMT provides durable restoration of active motion and strength in children. Outcomes are influenced by indication and reconstructed function rather than donor nerve selection alone. Strength recovery and functional integration are primary determinants of bimanual use and satisfaction. Findings support the use of FFMT as part of a staged reconstructive strategy in pediatric patients.
