Depressor labii inferioris resection: an effective treatment for marginal mandibular nerve paralysis.

In patients who show their lower teeth during smiling and facial animation, paralysis of the marginal mandibular nerve (MMN) causes a noticeable asymmetry of the lower lip due to the absence of depressor function. This paper presents a balancing technique for this lower lip asymmetry that involves resection of the depressor labii inferioris (DLI) on the nonparalysed side. The anatomy of the muscle, the operative technique, and the effectiveness of the procedure are outlined. A retrospective chart review was performed for 42 adult patients who were treated for MMN palsy with a DLI resection. Seven cases had only the MMN involved, and 35 cases had unilateral facial nerve paralysis. Thirty-six of these patients were available for a follow-up telephone survey. Of the 42 primary DLI resections performed, 36 cases had successful outcomes. Of the six patients who failed to achieve the expected results, five patients had repeat DLI resection and three of these achieved the desired result; the other two patients required a third resection. One patient continued to have DLI action with smiling and subsequently had a Botox injection into the DLI with good results. Of the 36 survey respondents, 21 patients felt their lower lip was asymmetrical at rest prior to DLI resection and 18 of these patients were improved by the procedure (P = 0.0001). Twenty-nine of the 36 patients reported that their lower lip was more symmetrical when they smiled following the DLI resection (P < 0.0001). The bilateral lack of movement in the lower lip when expressing emotions, such as anger and sorrow, was not as important to the patient as the lack of symmetry when expressing these emotions. Patients' speech either improved or showed no change, the amount patients bit their lower lip significantly improved (P = 007) whereas oral continence showed no significant changes (P = 0.147) following the DLI resection. DLI resection is a simple and effective procedure for the treatment of MMN palsy. The results are permanent and predictable. Lower lip symmetry is produced both at rest and with facial animation, without causing a functional deficit. The expected results of surgery can be trialed by local anaesthetic or botulinum toxin to block the activity of the DLI.

Toe-to-finger transfer for post-traumatic reconstruction of the fingerless hand.

OBJECTIVE: To assess the utility of toe-to-finger transfers (TFTs) for post-traumatic reconstruction of the fingerless hand. DESIGN: A case series. SETTING: A regional trauma centre. PATIENTS: Eight men, mean age was 36 years (range from 25-59 yr), who had lost all the fingers from a hand due to a crush-degloving injury (6 patients), frostbite (1 patient) or a burn injury (1 patient). INTERVENTION: TFT. Twelve TFTs were cone and the mean time from injury to reconstruction was 17.2 months. MAIN OUTCOME MEASURES: Objective (range of motion, moving 2-point discrimination, grip strength, key pinch, Jebsen-Taylor hand assessment, return to work) and subjective (activities of daily living and a questionnaire) measures. RESULTS: Eleven of the 12 transfers survived. Six of the 7 in whom the transfer was successful were available for follow-up (mean 45 mo). Range of motion was 10 degrees at the distal interphalangeal joint, 18 degrees at the proximal interphalangeal joint and 59 degrees at the metacarpophalangeal joint. Sensation was protective in all. Grip strength and key pinch were 26.1% and 70.2% of the contralateral hand respectively. Jebsen-Taylor assessment indicated that basic activities were possible but slowed. All 6 patients returned to work and could perform 92.6% of the activities of daily living unassisted. Hand and foot symptoms were mild. Two-thirds were appearance conscious, 5 of the 6 went on to altered vocations and all reported overall satisfaction as high. CONCLUSION: This study supports TFT for reconstruction of the fingerless hand in that, although transferred toe function may be poorer than a normal finger, the hand is restored to a useful, sensate and versatile functional unit, such that global hand and patient function, as well as patient satisfaction, are very good.

Facial animation in children with Möbius syndrome after segmental gracilis muscle transplant.

Möbius syndrome is a complex congenital anomaly involving multiple cranial nerves, including the abducens (VI) and facial (II) nerves, and often associated with limb anomalies. Muscle transplantation has been used to address the lack of facial animation, lack of lower lip support, and speech difficulties these patients experience. The purpose of this study was to investigate the results of bilateral, segmental gracilis muscle transplantation to the face using the facial vessels for revascularization and the motor nerve to the masseter for reinnervation. The outcome of the two-stage procedure was assessed in 10 consecutive children with Möbius syndrome by direct interview, speech assessment, and oral commissure movement. Preoperative data were collected from direct questioning, viewing of preoperative videotapes, notes from prior medical evaluations, and rehabilitation medicine and speech pathology assessments. All of the patients developed reinnervation and muscle movement. The children who described self-esteem to be an issue preoperatively reported a significant posttransplant improvement. The muscle transplants produced a smile with an average commissure excursion of 1.37 cm. The frequency and severity of drooling and drinking difficulties decreased postoperatively in the seven symptomatic children. Speech difficulties improved in all children. Specifically, of the six children with bilabial incompetence, three received complete correction and three had significant improvement. Despite the length and complexity of these procedures, complications were minimal. Muscle transplantation had positive effects in all problematic areas, with a high degree of patient satisfaction and improvement in drooling, drinking, speech, and facial animation. The surgical technique is described in detail and the advantages over regional muscle transfers are outlined. Segmental gracilis muscle transplantation innervated by the motor nerve to the masseter is an effective method of treating patients with Möbius syndrome.

Factors influencing use of digital prostheses in workers' compensation recipients.

The purposes of this study were to retrospectively identify factors associated with decreased use of digital prostheses in workers' compensation recipients 6 months after fitting and to identify characteristics of those individuals who requested and received a second set of prostheses after demonstrating consistent use of the first set. One hundred seventy-eight patients fitted with 281 digital prostheses completed a questionnaire 6 months after fitting. Forty-nine patients (28%) stated they never or occasionally used their prosthesis (low utilization) and 42 (24%) stated they used them more than 4 hours per day (high utilization). One hundred ten patients (62%) reported stump problems; 37 (21%) stated that the problem interfered with the use of the prosthesis. High utilization was associated with nonmanual employment after the injury. Low utilization was associated with male gender, stump problems, and a distal amputation level. Ring finger prostheses were least likely to be used; small finger prostheses, most likely. The country of origin of the patient was not associated with frequency of use. One hundred sixty-one patients had received the prostheses at least 3 years before the end of the study; 45% of these patients had requested and received a second set of prostheses. Women were more likely to request and receive a second set than men. We could not accurately predict future use of digital prostheses. Each case must be evaluated on an individual basis. (J Hand Surg 2000; 25A:80-85.

Lower extremity free flaps: a review.

OBJECTIVE: To identify factors related to free-flap coverage of lower extremity fractures that are linked to a negative outcome. DESIGN: A chart review. SETTING: A large microsurgical referral centre. PATIENTS: From 1981 to 1989, the records of all patients who underwent free-tissue transfer to the lower extremity with more than 1 year of follow-up were selected. From this was drawn a subgroup of 49 patients (mean age, 36 years) who had tibial fractures (55% were motor vehicle injuries) and in almost all cases established soft-tissue or bony defects. They formed the study group. INTERVENTION: Free-flap transfer. OUTCOME MEASURES: Factors that might be associated with free-flap failure: mechanism of injury, grade of tibial fracture, history of smoking, diabetes, peripheral vascular disease, ischemic heart disease, vascular compromise in the leg preoperatively, recipient artery used, type of anastomosis, and hypertension or hypotension intraoperatively. RESULTS: Type IIIB tibial fractures were the most frequent (67%) and carried a significantly (p = 0.02) higher risk of free-flap failure than other types of fracture. Patients underwent a mean of four procedures before referral for free-tissue transfer. The mean time from injury to flap coverage was 1006 days. Stable, long-term coverage of the free flaps was achieved in 78% of patients. Wound breakdown was most often caused by recurrent osteomyelitis (65%). Seventy-four percent of the fractures healed. The amputation rate was 10%. Four patients required repeat free-flap transfer for limb salvage. CONCLUSIONS: Only the grade of tibial fracture could be significantly related to postoperative free-flap failure.

Gracilis donor site morbidity.

Donor site morbidity in 104 cases of gracilis free tissue transfer was examined through a retrospective chart review and mail survey. Fifty-one females and 53 males with an average age of 23 years comprised the study group. Forty-three were under age 18. In-hospital donor site complications occurred in 10 patients. There was excessive pain in 4, wound infections in 3, hemorrhage in 2, and temporary nerve palsy in 1. Early complications were more common in the pediatric group. Sixty-two surveys were returned from patients detailing late complications where they graded parameters between 0 and 10 where 0 was "none" and 10 was "worst imaginable." The highest average score was 5.12 reported for noticeability of the scar. There was a significant difference between adults and children for sensitivity, tightness, notice-ability, and ugliness of the scar. More than half the respondents had no complaints about their donor site scar. Fifteen percent of patients reported temporary reduction of leg strength with a men duration of 6 months.

Factors associated with poor outcome following primary carpal tunnel release in non-diabetic patients.

A retrospective study was performed of 112 non-diabetic patients (133 hands) who had open surgical treatment for carpal tunnel syndrome, to determine the factors associated with poor outcome. None of the patients had a previous carpal tunnel release and all had a positive nerve conduction study to confirm the clinical diagnosis of carpal tunnel syndrome. Outcome was assessed at least 18 months after surgery and classified as excellent, good or poor. Outcome was deemed poor when symptoms were minimally improved, unchanged or worse after surgery. This occurred in 13.5% of treated hands. There was a higher chance of poor outcome in patients with physically strenuous work activities. All these heavy or repetitive manual workers were also involved in compensation and their poor outcome correlated with their inability to return to their original work. Other predisposing factors, associated hand conditions, duration of symptoms prior to surgery, the presence of bilateral or nocturnal symptoms, and the severity of the pre-operative nerve conduction deficit did not affect the final outcome after surgery.

Outcome of carpal tunnel release in diabetic patients.

A retrospective study of 15 diabetic patients (20 hands), who underwent carpal tunnel release, was performed to determine the outcome. All patients had a minimum of 18 months of follow-up. Outcome was considered excellent if there was complete resolution of symptoms and this occurred in 35% of the treated hands. Eight hands (40%) had a good outcome with significant improvement of pre-operative symptoms. Outcome was considered poor when symptoms were minimally improved, unchanged, or worse after surgery and this occurred in 25% of treated hands. All hands with a poor final result had either no electrodiagnostic evidence of localized compression or only mild compression in pre-operative nerve conduction studies. It was postulated that the contribution of localized compression to pre-operative hand symptoms was less than the contribution of peripheral neuropathy in these hands.

Pregnancy-induced carpal tunnel syndrome requiring surgical release longer than 2 years after delivery.

OBJECTIVE: To determine the percentage of patients in whom carpal tunnel syndrome was induced by pregnancy, the presence of any risk factors causing persistent symptoms after delivery, and the outcome of surgical decompression in these patients. METHODS: We reviewed retrospectively the records of 100 consecutive women treated by carpal tunnel release in our unit from 1988-1991. RESULTS: Seven patients had the onset of hand symptoms during pregnancy. One patient was diabetic and worked as a machine operator, but none of the others had predisposing factors that could have led to persistent postpartum symptoms. The hand symptoms persisting after delivery initially required conservative treatment only. However, 2-16 years later, symptoms became severe enough to warrant surgical release of the carpal tunnel. All patients had resolution of symptoms after surgery. CONCLUSION: Some patients with mild residual hand symptoms due to carpal tunnel syndrome may initially respond to conservative treatment, but 2-16 years later, symptoms may become severe enough to warrant surgical release. We recommend long-term follow-up of patients with residual postpartum hand symptoms.

Tuberculosis of the hand.

Three cases of tuberculosis of the hand are presented. There was a significant delay between the onset of symptoms and the correct diagnosis. Several observations are made to increase the awareness of this condition.

The shape of a normal smile: implications for facial paralysis reconstruction.

Sophisticated smile reconstruction for facial paralysis requires an understanding of the facial movements during a normal smile. This study analyzes the direction and extent of movement of the upper and lower lips, nasal labial folds, and nasal base during smiling. Twenty normal subjects were analyzed using cine studies. A stop frame vector analysis was done on reference points on the lips and lower face. The greatest movement occurred at the commissure and upper lip. Intersubject variation in direction and extent of movement is great. Intrasubject variation in movement in comparing left and right sides was also quite large. Techniques of facial paralysis reconstruction that apply forces to the mouth, which mimic the vectors of movement on the patients' normal side, are most likely to provide a symmetrical smile reconstruction.

Wound-healing complications after soft-tissue sarcoma surgery.

One-hundred and eighty patients undergoing limb-salvage surgery for soft-tissue sarcoma from 1986 to 1991 were assessed retrospectively for risk factors associated with major wound-healing complications. Twenty-three of 137 patients (16 percent) treated with primary direct wound closure sustained complications. In univariate analysis, the cross-sectional area of tumor resection, the use of preoperative irradiation, the width of the skin excision, a history of smoking, and a history of diabetes and/or vascular disease were associated with wound failure. Multivariate analysis revealed that preoperative irradiation (p = 0.04) and resection diameter (p = 0.017) accounted for the risk of complications. Eighteen additional patients were treated empirically with distant vascularized tissue transfer following preoperative irradiation because of concerns regarding potential wound complications. The lower complication rate in this group suggested that vascularized tissue transfer may be beneficial in lowering wound complication rates.

Pediatric free tissue transfer: an evaluation of 99 cases.

OBJECTIVE: To evaluate the results of free tissue transfers in children who undergo reconstructive surgery. DESIGN: Case series chart review. Mean follow-up longer than 2 years. SETTING: Two tertiary care pediatric hospitals. PATIENTS: Consecutive sample of 99 children. INTERVENTIONS: Free tissue transfers for reconstruction of a variety of defects. MAIN OUTCOME MEASURES: Indications, operations, complications, survival. RESULTS: The most common indications were for restoration of muscle function and for difficulties with soft-tissue coverage. Multiple donor sites were used, with the gracilis muscle, fibula, latissimus dorsi and groin flaps predominating. The overall survival rate was 99.0%. Complications were common, with an overall rate of 59.6%; most were graded as minor or moderate. CONCLUSIONS: Meticulous planning is paramount in achieving a successful outcome. Complications are common but do not include vascular spasm. Free tissue transfers can be successfully completed in small children despite the dimensions of the tissues.

The medical leech: an old treatment revisited.

The treatment modality of choice for venous insufficiency after free tissue transfer or replantation remains surgical repair. When this is not technically possible, the use of medical leeches is a useful adjunct to treatment. This paper reviews the history of the use of leeches in medicine, the anatomy and physiology of Hirudo medicinalis, the techniques of leech therapy, and the complications and contraindications.

Complications and unsatisfactory results in the microsurgical reconstruction of lower extremities.

Complications and unsatisfactory results in the microsurgical reconstruction of lower extremities were reviewed in a chronological sequence. Perioperative complications were grouped into the following categories: improper patient or donor tissue selection, unsatisfactory choice of recipient site vessels, inadequate exposure of recipient site vessels, improper "insetting" of the free tissue transfer, extralumenal obstruction, and miscellaneous adverse factors. Vascular changes in the limb as a result of free tissue transfer are discussed. Discussion of late postoperative problems includes the long-term results of soft tissue and skeletal reconstruction.

A new cause of trigger thumb.

We report a case of severe painful triggering in the thumb caused by intermittent locking of the interphalangeal joint by a sesamoid bone. The triggering was corrected by excision of the interphalangeal joint sesamoid bone.

[Neurovascular transfer of the m. gracilis for the treatment of Volkmann's contracture following supracondylar fracture in childhood]. / Transfert neurovascularisé du gracilis pour le traitement de la contracture de Volkmann suite à une fracture supracondylienne à l'âge pédiatrique.

Children are particularly prone to developing moderate to severe Volkmann's ischemic contracture following a supracondylar fracture of the humerus or its treatment. In order to treat such contractures, intensive hand therapy and a gracilis free muscle transfer to the digital flexors were used in 8 patients at an average age of 6 years 2 months. All transfers were successful. At follow-up (1 to 8 years, average 3 years), despite limited wrist extension in 5/8 patients and mean grip and pinch strengths between 22 and 43% of normal for age and dominance, all patients regained considerable finger flexor excursion (tip to crease distances of 0 to 5.0 cms, average 1.68 cms). Although fine motor assessment using the M.A.N.D. battery of tests placed the patients in the moderate disability range, 7/8 patients became independent in the tested activities of daily living with the exception of buttoning a cuff with the involved hand, which was difficult for 5/8 subjects. Quantifiable measurements underestimated the renewed importance of the operated hand. Compensatory motion at the shoulder allowed positioning the hand which changed from being nearly useless to becoming a functionally non-dominant hand well integrated into daily life.

Surgical management of facial palsy.

Patients with facial palsy present with a multitude of different problems to which individual solutions must be carefully tailored. Although numerous surgical options exist, the results of reconstruction are rarely ideal. This article discusses different surgical procedures for reconstruction of the eye and mouth with special emphasis on the newer technique of microsurgical transfer of muscle tissue for reanimation.