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Free Functional Gracilis Muscle Opponensplasty for Thenar Reconstruction: Indications, Technique, and Long Term Outcomes
Emmanuel M Nageeb, MD
1, John M. Felder, MD
2, Zvezdana Mila?ek, MD
3, Marina Ninkovic, MD
3; Milomir Ninkovic, MD, PhD
4(1)Corewell Health East William Beaumont University Hospital, Royal Oak, MI, (2)Plastic Surgery, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, (3)Bogenhausen Academic Hospital, Munich, Bavaria, Germany, (4)Scientific Unit for Medical Research, International Medical Center Priora, ?epin, ?epin, Croatia
Background: Loss of thumb opposition due to thenar muscle damage significantly impairs hand function. While traditional opponensplasty via tendon transfers is commonly employed, it often yields suboptimal functional outcomes and lacks intuitive cortical control. This study evaluates the efficacy of free functional gracilis muscle transfer (FFMT) for thenar reconstruction in patients with preserved median nerve function but damaged thenar musculature.
Methods: We present a retrospective case series of two patients with complex thenar injuries-one from burn-induced compartment syndrome and the other from a high-energy blast injury-who underwent gracilis FFMT innervated by the recurrent motor branch of the median nerve. Surgical technique, perioperative management, and postoperative rehabilitation protocols are described. Long-term outcomes were assessed through clinical examination, functional metrics, and videographic documentation over follow-up periods of 3 and 9 years.
Results: Both patients achieved Medical Research Council (MRC) grade M4 muscle power and regained meaningful thumb opposition, allowing precision pinch and improved hand function. No donor site morbidity or flap failure was observed. Simultaneous soft tissue reconstruction of the first web space effectively addressed accompanying contractures.
Conclusions: Gracilis FFMT provides a reliable and functionally superior alternative to tendon transfers for thenar reconstruction in select patients. The procedure enables restoration of dynamic, intuitive thumb opposition and simultaneous correction of first web space contracture. These long-term outcomes support broader consideration of this technique in cases of isolated thenar muscle loss with intact distal median nerve function.
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