Anatomic and histomorphometric study of the nerve to the vastus lateralis in cadaver for its clinical application in facial reanimation.

BACKGROUND: The innervated vastus lateralis flap (IVLF) is a barely used possibility for facial palsy reconstruction because of its thickness compared to the gracilis, latissimus dorsi, and pectoralis minor flaps. The aim of this study is to perform a precise description of the intramuscular distribution of the nerve motor branches and its relationship with the vascular pedicle in order to harvest a segmental muscle flap with the best contractile strength to restore facial reanimation. METHODS: The study was performed on 16 adult cadaver thighs identifying the vastus lateralis muscle and the distribution and relationships of its neurovascular pedicle and branches. We evaluated where the nerve pierced the muscle and the course of the nerve within it. Transverse segments of the nerve were obtained from the proximal and distal ends of the nerve and stained using anti-ChAT (Choline acetyltransferase) antibodies which are specific of motor neurons. RESULTS: A nerve for the vastus lateralis from the posterior division of the femoral nerve divided into 2 branches in 56% of cases; the principal branch coursed along the vascular pedicle and pierced the muscle more proximally than the respective vessels, and a minor branch that pierced the muscle 25-60 mm proximally. There were 3 main intramuscular branches. The nerve length (mean 132.65 ± 22.89 mm) allowed to reach the contralateral side of the face in almost all cases (95%). The mean ChAT positive fibers was 351.0 ± 92.4/mm2 at the proximal end, and 270.3 ± 87.9/mm2 at the distal end (p = 0.49). The number of ChAT negative fibers was higher than ChAT positive in both proximal and distal ends of the nerve. CONCLUSION: We propose the IVLF as a one-step surgical flap for facial paralysis reanimation due to the constant neurovascular pattern and lengthy pedicle. The amount of motor fibers in several segments of the nerve is appropriate to produce a powerful contraction for dynamic reconstruction.

Salvage Procedures for Facial Reanimation With Neurovascular Flaps When Previous Surgeries Failed: Is Homolateral Vessel or Nerve Depletion a Contraindication?

BACKGROUND: Facial paralysis reconstruction can be difficult in extensive defects after complex facial or cranial base tumor resection and radiotherapy or when primary smile reanimation attempt has failed. The surgical challenge is more complicated when defects are associated with recipient vessels or nerves depletion. This scenario has not been well described in the literature, and the present article will address the alternatives that plastic surgeons may use in these circumstances. METHODS: Seventy-five patients operated in the Hospital Gregorio Marañon between 2008 and 2020, for dynamic reconstruction of facial paralysis, were retrospectively evaluated, collecting data about previous facial nerve surgeries, radiotherapy, chemotherapy, recipient nerve for motor restoration and vessels used for free flaps, type of neurovascular free flap (NVFF), and functional score before and after the facial reanimation surgery. Patients presenting recipient vessel and/or nerve depletion after several facial surgeries requiring a variation from the common NVFF surgical protocol were included in this study. RESULTS: Six cases (8%) with facial paralysis and absent recipient homolateral vessels or nerves after severe cranial base surgery, parotid malignancies, or schwannoma surgery were included. Two patients had an immediate functional reconstruction during the oncologic resection surgery, and 4 patients had a delayed reconstruction. Three patients had previous reconstruction with free flaps, and the vascular pedicles of previous flaps were used for the new NVFF. In the other 3 cases, interposition vein grafts to the contralateral recipient vessels were required to perform NVFF. Masseteric nerve in 4 cases, hypoglossal nerve and posterior branch of the deep temporal nerve in 1 case each, were used as recipient nerves. House-Brackmann score improved in all patients after surgery. CONCLUSIONS: Neurovascular free flap can be successfully performed to restore facial motion after depletion of homolateral recipient vessels or nerves after previous facial or cranial base surgeries. In these cases, interposition vascular grafts or the pedicle of previous flaps are essential to provide vascularization as well as an optimal orientation of flaps, to reach recipient nerves in a 1-step procedure.

Efficacy of Povidone Iodine Against Microbial Biofilms in Breast Implants With Different Textures: Results From an in vitro Study.

Background: In the practice of breast augmentation and reconstruction, implant irrigation with various solutions has been widely used to prevent infection and capsular contracture, but to date, there is no consensus on the optimal protocol to use. Recently, application of povidone iodine (PI) for 30 min has shown in vitro to be the most effective irrigating formula in reducing contamination in smooth breast implants. However, as 30 min is not feasible intraoperatively, it is necessary to determine whether shorter times could be equally effective as well as to test it in both smooth and textured implants. Methods: We tested the efficacy of 10% PI at 1', 3', and 5' against biofilms of 8 strains (2 ATCC and 6 clinical) of Staphylococcus spp. on silicone disks obtained from Mentor® and Polytech® implants of different textures. We analyzed the percentage reduction of cfu counts, cell viability and bacterial density between treatment (PI) and control (sterile saline, SS) groups for each time of application. We consider clinical significance when > 25% reduction was observed in cell viability or bacterial density. Results: All textured implants treated with PI at any of the 3 exposure times reduced 100% bacterial load by culture. However, none of the implants reached enough clinical significance in percentage reduction of living cells. Regarding bacterial density, only 25-50 µm Polytxt® Polytech® implants showed significant reduction at the three PI exposure times. Conclusion: PI is able to inhibit bacterial growth applied on the surface of breast implants regardless of the exposure time. However, no significant reduction on living cells or bacterial density was observed. This lack of correlation may be caused by differences in texture that directly affect PI absorption.

Restoration of Neck Extension after Severe Oncological Surgery of the Posterior Cervical Trunk.

Reconstruction of posterior cervical trunk defects secondary to tumor resection carries significant morbidity when vertebral hardware or the spinal cord is exposed, and neck extension is interrupted. Complete reconstruction includes the coverage and obliteration of dead spaces, but functional outcomes are necessary to prevent the head dropping. This report documents the first known technique, using a free latissimus dorsi neurovascular flap to provide neck extension after ablative oncological surgery affecting trapezium and paraspinal muscles of the neck. The author explains the method by using a branch of the accessory nerve as the donor nerve. While keeping the head in a neutral position, the tendinous part of the neurovascular flap was firmly attached to the occipital periosteum and to the cephalad remnants of the trapezius, splenius capitis, and semispinalis muscles. At the caudal portion of the defect, cardinal notches were used to set the muscle at rest, avoiding excessive fiber tension. The maximal length of the muscle at rest was measured before flap elevation, calculated via the anatomical 3D print model. The thoracodorsal nerve was stimulated until the muscle shortened its length to 50%. Head extension was tested several times via neurostimulation and electromyographic control. The described procedure may provide neck extension and circumvent the problem with donor nerve providing synergy to the desired function.

The Effect of Intraoperative Radiotherapy on Healing and Complications After Sacrectomy and Immediate Reconstruction.

INTRODUCTION: Sacropelvic resection is the treatment of choice for pelvic bone tumors and can be associated with intraoperative electron radiotherapy (IOERT) to optimize local control of the disease. Reconstruction with flaps also is essential to avoid pelvic complications. There is scarcity of publications evaluating outcomes of reconstructive procedures associated with IOERT. METHODS: A prospective study in 53 patients between 2005 and 2018 was performed. Thirty-four patients received IOERT (group I [GI]) and 19 did not (GII). We examined demographic characteristics, tumor pathology, type of resection and volume of surgical specimen, timing of surgery, IOERT doses, postoperative stay, and complications. We used it for reconstruction rectus abdominis, gluteal, omental and gracilis, superior gluteal artery perforator flap, and free flaps. RESULTS: Colonic adenocarcinoma and chordoma were the most frequent tumors. The median (interquartile range) IOERT dose was 1250 (1000-1250) cGy; operating time was 10.15 (8.6-14.0) hours versus 6.0 (5.0-13.0) hours, hospital stay was 37 (21.2-63.0) days versus 26.0 (12.0-60.0) days, and volume of surgical specimen was 480.5 (88.7-1488.0) mL versus 400 (220.0-6700.0) mL in GI and GII, respectively. Operating time was significantly longer in GI (P < 0.03). There were significant positive correlations between operating time, hospital stay, and volume of surgical specimen. Main complications were exudative wounds (50% vs 31.5%), wound dehiscence (41.1% vs 31.5%), and seroma (29.4% vs 26.3%) in GI and GII, respectively. Complications were similar to previous studies with or without radiotherapy. CONCLUSIONS: Under a reconstructive approach, IOERT did not harm flap survival nor increased pelvic complications when compared with similar cases without IOERT.

Anastomosis linfático-venosa mediante técnica de supramicrocirugía / Supermicrosurgical lymphovenous anastomosis

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Anatomical study of the masseteric and obturator nerves: Application to face transplant and reanimation procedures.

The masseteric nerve (MN) and the anterior branch of the obturator nerve (ON) that innervate the transferred gracilis muscle have proved highly efficient for reanimating paralyzed facial muscles when muscle transfer is required. Previous researchers have published the total axonal load for myelinated fibers in both nerves. However, the real motor axonal load has not been established. We performed the study on 20 MN and 13 ON. The segments of the MN and the ON were embedded in paraffin, sectioned at 10 µm, and stained following a standard immunohistochemical procedure using anti-choline acetyltransferase to visualize the motor fibers. The MN has a higher axonal load than the ON. There were statistically significant differences between the axonal load of the proximal segment of the MN and the ON. These findings confirm that end-to-end anastomoses between the MN and the ON should preferably use the proximal segment. However, MN neurotomy should ideally be performed between the proximal and distal segments, preserving innervation to the deep fascicles. Our results show that the MN is ideal as a donor motor nerve for reinnervating transplanted muscle for dynamic reanimation of the paralyzed face. The neurotomy should ideally be performed between the first and second collateral branches of the MN. Clin. Anat. 32:612-617, 2019. © 2019 Wiley Periodicals, Inc.

Reconstruction of Wegener Granulomatosis Nose Deformity Using Fascia Lata Graft.

Wegener granulomatosis (WG) is a necrotizing vasculitis that involves the upper respiratory tract, the lungs, and the kidneys. It also causes deformities of the nose in practically all patients, altering the cartilaginous and bony structure as well as the inner lining of the nose.The surgical repair of these nasal distortions is a challenge mainly due to the impairment of wound healing and graft take that is caused both by the disease itself and by the prolonged immunosuppressant treatment.Many different reconstruction plans have been developed, using costal or calvarial bone grafts, cartilage grafts and local skin and mucosa flaps. Results have been diverse.The authors present the case of a 56-year-old patient who suffered from WG and consulted for nasal sequelae. She initially underwent several failed attempts at reconstruction; finally, the authors performed a nasal repair using a double strip of fascia lata as a dorsal graft, with no complications and a good aesthetic result.Fascia lata graft is a new and good option for nasal reconstruction in patients with WG because it is easily obtainable, it can be set in place through closed rhinoplasty and it can achieve good vascularization with low risk of resorption or disease reactivation.

Injection Laryngoplasty Using Autologous Fat Enriched with Adipose-Derived Regenerative Stem Cells: A Safe Therapeutic Option for the Functional Reconstruction of the Glottal Gap after Unilateral Vocal Fold Paralysis.

BACKGROUND: Paralysis of one vocal fold leads to glottal gap and vocal fold insufficiency that has significant impact upon a patient's quality of life. Fillers have been tested to perform intracordal injections, but they do not provide perdurable results. Early data suggest that enriching fat grafts with adipose-derived regenerative cells (ADRCs) promote angiogenesis and modulate the immune response, improving graft survival. The aim of this study is to propose ADRC-enriched adipose tissue grafts as effective filler for the paralyzed vocal fold to use it for functional reconstruction of the glottal gap. METHOD: This is the first phase I-IIA clinical trial (phase I/IIA clinical trial, unicentric, randomized, controlled, and two parallel groups), to evaluate the safety of a new therapy with ADRC-enriched fat grafting (ADRC: group I) for laryngoplasty after unilateral vocal fold paralysis. Control group patients received centrifuged autologous fat (CAF: group II) grafts. Overall mean age is 52.49 ± 16.60 years. Group I (ADRC): 7 patients (3 males and 4 females), 52.28 ± 20.95 year. Group II (CAF): 7 patients (3 males and 4 females), 52.71 ± 12.59 year. RESULTS: VHI-10 test showed that preoperative mean score was 24.21 ± 8.28. Postoperative mean score was 6.71 ± 6.75. Preoperative result in group I was 21.14 ± 3.58 and postoperative result was 3.14 ± 3.53. Preoperative result for group II was 27.29 ± 10.66. Postoperative score in group II was 10.29 ± 7.52. Wilcoxon and the Student t-tests showed that the patient's self-perception of posttreatment improvement is larger when ADRCs are used. Comparing pre- and posttreatment voice quality analysis, group I showed a p = 0.053. Group II showed a p = 0.007. There would be no significant differentiation between pre- and posttreatment results. This is true for group II and limited for group I. CONCLUSIONS: This prospective trial demonstrates the safety and efficacy of the treatment of glottal gap defects utilizing ADRC-enriched fat grafts. This trial is registered with NCT02904824.

Circumferential Pharyngoesophageal Reconstruction and Total Larynx Preservation with Extra-anatomical Free Flaps.

Reconstruction of total circumferential pharyngeal defects following caustic or stenosant lesions of the pharynx present major challenges with respect to minimizing surgical morbidity and restoring functional deficits. With recent advances in microvascular free tissue transfer, the options for pharyngeal reconstruction have multiplied in order to maximize swallowing and voice. There is long experience in the reconstruction of the pharynx and the cervical esophagus in oncological patients after total pharyngolaryngectomy, but there are not many publications concerning circumferential pharyngeal reconstruction preserving the larynx. Here, we discuss 2 new techniques for total circumferential pharyngeal reconstruction respecting swallowing and voice by means of extra-anatomical bypasses (visceral or fasciocutaneous), upholding the larynx in its original placement.

New Refinements in Greater Omentum Free Flap Transfer for Severe Secondary Lymphedema Surgical Treatment.

Lymphedema is a chronic debilitating disease, affecting a considerable part of the population; it results from impairment of the lymphatic system. It is highly prevalent among patients subjected to axillary and groin nodal dissection after surgery for breast cancer, abdominopelvic surgery, and lymphadenectomy after melanoma surgery. Interestingly, among the surgical treatment options for lymphedema, groin lymph node transfer is gaining popularity; however, in some cases, dissection at this site can cause significant morbidity, including possible development of iatrogenic lymphedema. To avoid these complications, new donor nodal groups are being proposed (eg, submental or supraclavicular). We have used the greater omentum as a lymph node and lymph vessel donor site. Dissection of the omentum is easy to perform and can even be done in patients who have undergone previous abdominal surgeries. We present refinements in the surgical technique for free omentum transfer in the management of secondary lymphedema: the first free omental flap dissection performed laparoscopically and the use of a primary flap as the recipient pedicle of a free greater omentum flap for anatomical repair after chest osteoradionecrosis and simultaneous functional repair of chronic lymphedema.

Invasive basal cell carcinoma in a xeroderma pigmentosum patient: facing secondary and tertiary aggressive recurrences.

Xeroderma pigmentosum (XP) is characterized by photohypersensitivity of sun-exposed tissues and several thousand-fold increased risk of developing malignant neoplasms of the skin and eyes. Inherited molecular defects in nucleotide excision repair genes cause the autosomal recessive condition XP. A 56-year-old woman with XP presented with an extensive multirecurrence basal cell carcinoma in the left naso-orbital region. At the time of the first visit, the patient had already received several interventions with local reconstructive techniques, a full course of radiotherapy, and bilateral neck dissection. A large tumor resection and free flap reconstruction were performed. Three years 9 months afterward, an aggressive recurrence occurred, and a second resection was needed. A new free flap was transferred, and microvascular anastomoses were done to the pedicle of the previously transferred flap. Nine months later, the patient returned with frontal bone tumoral lesions, and third microsurgical intervention was done. At that time, the reconstruction was practiced by a composite chimeric flap with a rib portion. Its pedicle was anastomosed to the one of the second free flaps. The objective of this article was to report the authors' experience concerning a unique case of XP requiring a complex reconstruction of the anterior skull base. Xeroderma pigmentosum patients need an early diagnosis and removal of cutaneous tumor lesions as some of them behave aggressively, especially those affecting the face. Free flaps are good solutions for reconstruction and should proceed from non-sun-exposed areas of the body. If reconstructed areas are highly radiated and/or skin tumors affect deep anatomical areas, complications are frequent.

Practical solutions for lymphaticovenous anastomosis.

Lymphedema is a chronic debilitating disease affecting a considerable part of the population that results from impairment of the lymphatic system. Lymphovenous anastomosis (LVA), a technique that attempts to achieve a physiologic lymphatic load of the edematous limb, is an accepted treatment. Techniques make anastomosis of 0.3 to 0.8 mm lymphatics to subdermal veins possible, but it is a challenge for microsurgeons because it requires a high degree of concentration and skill. An associated problem that we sometimes face when doing LVA is the absence of suitable veins in the proximity of an ideal lymphatic vessel. In situations like this, the presence of large veins with a higher diameter than the lymphatics is an alternative to consider. In these cases, end-to-side anastomosis is recommended. We describe a helpful technique to perform end-to-side LVA, using a thin catheter to create a round hole in the lateral wall of subdermal veins having the same diameter as the neighboring lymphatic that is going to be anastomosed. We also describe our personal modification of the intravascular stenting technique.

Large posterior chest wall defect reconstructed with a de-epithelised trans-thoracic TRAM flap.

Extensive posterior chest wall defects, especially those closer to the midline of the trunk, pose surgical challenges in plastic surgery. In these cases, prior to tissue coverage, the status of the pleural cavity and skeletal support need to be addressed to obtain a functional and anatomical reconstruction. We recently operated upon a patient presenting with an aggressive ossifying fibromyxoid tumour located in the lower dorsal paraspinal region on the right side. After ablative surgery and intra-operative radiotherapy, a broad defect in the chest wall of 15 x 10 cm, including the proximal part of five posterior ribs, was presented. It required immediate bony frame reconstruction, which was resolved with a Goretex patch wrapped with a de-epithelised myocutaneous pedicled transverse rectus abdominus myocutaneous (TRAM) flap, transposed through the right hemithorax. The patient was extubated 2 days after surgery and discharged in 10 days. We describe the use of an intra-thoracic TRAM flap to reach the posterior chest wall defects, and we propose its specific indication for reconstruction of extensive posterior chest wall defects when other options are unavailable.