Dynamic Surgical Restoration of Mid and Lower Facial Paralysis: A Single-Greek-Centre Experience.

Background Facial palsy detrimentally impacts an individual's quality of life due to its effects on function and appearance. There are several reconstructive surgical techniques available that aim to restore facial symmetry. Techniques such as direct neurorrhaphy, nerve grafts, dual reanimation, and reinnervation have the potential to enable varying motor functions, including the re-establishment of a dynamic smile. This study aimed to assess the outcomes of facial palsy reconstructive surgeries undertaken at a tertiary care centre for facial nerve reconstruction in Athens. Methods This study consisted of a comprehensive case series showcasing the outcomes of facial palsy reconstructive surgeries on 29 patients at our Tertiary General Oncological Anti-Cancer Hospital of Athens 'Agios Savvas'. The surgical procedures from October 2004 to December 2023 included reinnervation, nerve grafting, free muscle transfer, and myoplasties following our recommended algorithm. We categorized the patients into two groups: Group A and Group B based on the timing of the reconstruction: delayed or immediate. The House-Brackmann grading scale evaluated the degree and improvement of facial paralysis. Results In Group A, two of the seven patients exhibited activation of the mimetic musculature immediately postsurgery, while the remaining five experienced enhanced facial nerve function in the subsequent months. Adverse outcomes were temporalis dysfunction in one case and tongue atrophy in another. Conversely, in Group B, 21 of 22 patients demonstrated facial activation immediately postsurgery. Only one patient from this group did not show any facial nerve function postoperatively. Two of the 22 patients in Group B encountered complications: one with trismus and another with temporalis dysfunction. All patients were observed for a minimum of 12 months postsurgery. Conclusion With the exception of one patient, all participants showed improved postoperative results, which were satisfactory when weighed against the observed morbidity rate. While our case analysis did not reveal any clear indication of one particular technique being superior, the selection of methods should be based on several factors, and this algorithm could serve as a useful aid in that regard. A comprehensive and standardized clinical assessment of facial palsy, both before and after surgery, is crucial to establish a consensus and plan individualized therapy.

How can I treat calcified chronic pleural empyema in African context: A case report.

INTRODUCTION AND IMPORTANCE: Despite the chance of a complete cure that surgery offers for patients seen early, the management of some complicated forms of chronic pyothorax with calcified pleural pockets of tuberculosis origin is risky, if not impossible. In these conditions, thoracomyoplasty with complete effacement of the pleural pocket is an effective alternative in the surgical management of these pockets. CASE PRESENTATION: We report the case of a 37-year-old male African Arab who was treated for a chronic, calcified pleural pocket of tuberculous origin and in whom low thoracomyoplasty was performed because of the impossibility of performing a left pleuropneumonectomy. The operating courses were uneventful with full pocket closures. REVIEW: 1 year later, the patient reported having resumed his active professional life. CLINICAL DISCUSSION: Pleural decortication associated or not with a pulmonary resection is the main surgical procedure used to manage chronic pyothorax. However, this procedure remains difficult with the risk of death, if not impossible, in cases of long-term chronicity with calcification of the pleural poche wall. In these cases, thoracomyoplasty constitutes a viable alternative in the surgical management of these pleural pockets. CONCLUSION: In the context of tuberculosis and chronic pleural empyema, thoracomyoplasty can be an alternative with satisfactory results when performed by an experienced team using this technique.

Features of the use of ladder myoplasty of a gunshot wound to the laryngopharynx: Case report.

INTRODUCTION AND IMPORTANCE: The laryngopharynx wound is considered to be one of the most severe wounds of neck both in war and in peace, as it may cause life threatening changes in the whole body (asphyxia, bleeding, shock). Important aspects of surgical treatment are to ensure full breathing, acceptable ways of feeding, and the use of reliable wound closure techniques aimed to prevent digestive tract failure and to maintain the framework and aerostasis of the laryngotracheal region. CASE PRESENTATION: A case of unilateral multiple wounds of the laryngopharynx was described in the article. The features of diagnostics, surgical treatment and conservative therapy in the postoperative period with this injury were presented. The wounded man was urgently operated. During surgery the pharynx was mobilized. The metal fragment was removed. The wound of the pharynx was sutured with a two-row suture. The next stage of the surgical treatment was myoplasty. In the case of the patient, the purpose of myoplasty was additional sealing of the pharyngeal suture and myoplasty of the thyroid cartilage injury zone for the purpose of aerostasis. Because of the size of the wounds and their anatomical localization, we used the mobilized lower edge of the Musculus sternocleidomastoideus for myoplasty and proposed the method of ladder myoplasty developed by us. CLINICAL DISCUSSION: In myoplasty method the following criteria must be followed: the muscle flap must be of sufficient length and width, so as not to cause excessive tension in the myoplasty area; the flap must be thick enough to avoid necrosis that may cause subsequent infectious complications; when taking the flap, the most sparing operative access should be used to avoid functional and anatomical disorders; the volume of the taken muscle flap must not lead to functional and anatomical disorders. CONCLUSION: The proposed method of ladder myoplasty using Musculus sternocleidomastoideus is unique, and proves its high efficiency in unilateral multiple laryngopharyngeal injuries, and can be recommended for wide clinical implementation in such clinical situations.

[Staged reconstructive surgery for bronchopleural fistula]. / Etapnaya rekonstruktivno-vosstanovitel'naya khirurgiya pri bronkhoplevral'nom svishche.

Treatment of bronchopleural fistula after pneumonectomy is still an urgent problem for thoracic surgeons. Transsternal bronchial stump occlusion should be preferable if possible. However, this is not enough for curing in some cases. We present a patient with concomitant cancer and tuberculosis of lungs whose postoperative period was complicated by bronchial stump failure. Preoperative diagnostic data are presented. We describe the indications for surgeries and main surgical stages. Some interventions including reconstructive surgery using a muscle flap led to recovery. Latissimus dorsi muscle flap on thoracodorsal artery is the best option for reconstructive surgical treatment in patients with extensive chest wall defects and thoracostomy.

Case report: Single-stage facial reanimation with bilateral lengthening temporalis myoplasties for immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome related developmental facial palsy.

Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare primary immunodeficiency, typically associated with clinical features of intractable diarrhoea, type 1 diabetes mellitus and eczema. We present a case of IPEX syndrome referred to our regional facial palsy service for smile restoration surgery. The patient presented with dissatisfaction of facial appearance, including mask-like facies and no functional smile. Pre-operative electromyography confirmed normal temporalis muscle activation. Consequently, the patient was offered single-stage bilateral lengthening temporalis myoplasties. The patient reported improved satisfaction with facial appearance. Surgery resulted in good early resting and voluntary symmetry. Oral commissures were elevated at rest improving oral incompetence. This is the first description of facial animation surgery in the context of IPEX syndrome. With careful consideration and patient selection, successful surgical restoration of resting symmetry and dynamic commissural smile can be achieved in this complex cohort of patients.

Surgical Anatomy of Temporalis Muscle Transfer with Fascia Lata Augmentation for the Reanimation of the Paralyzed Face: A Cadaveric Study.

Background The temporalis muscle flap transfer with fascia lata augmentation (FLA) is a promising method for smile reconstruction after facial palsy. International literature lacks a detailed anatomical analysis of the temporalis muscle (TPM) combined with fascia lata (FL) augmentation. This study aims to describe the muscle's properties and calculate the length of FL needed to perform the temporalis muscle flap transfer with FLA. Methods Twenty nonembalmed male (m) and female (f) hemifacial cadavers were dissected to investigate the temporalis muscle's anatomy. Results The calculated minimum length of FL needed is 7.03cm (f) and 5.99cm (m). The length of the harvested tendon is 3.16cm/± 1.32cm (f) and 3.18/± 0.73cm (m). The length of the anterior part of the temporalis muscle (aTPM) is 4.16/± 0.80cm (f) and 5.30/± 0.85cm (m). The length of the posterior part (pTPM) is 5.24/± 1.51cm (f) and 6.62/± 1.03cm (m). The length from the most anterior to the most posterior point (aTPMpTPM) is 8.60/± 0.98cm (f) and 10.18/± 0.79cm (m). The length from the most cranial point to the distal tendon (cTPMdT) is 7.90/± 0.43cm (f) and 9.79/± 1.11cm (m). Conclusions This study gives basic information about the temporalis muscle and its anatomy to support existing and future surgical procedures in their performance. The recommended minimum length of FL to perform a temporalis muscle transfer with FLA is 7.03cm for female and 5.99cm for male, and minimum width of 3 cm. We recommend harvesting some extra centimeters to allow adjusting afterward.

Public and patients' perceptions of facial reanimation using lengthening temporalis myoplasty.

OBJECTIVES: To answer the clinical research questions: "Among facial paralysis patients (FPPs), did lengthening temporalis myoplasty (LTM) improve public's perceptions, patients' perceptions, as well as objective oral measurements of post-operative outcomes?" METHODS: To answer the research questions, we designed and implemented a hybrid cross-sectional and retrospective cohort study enrolling a cohort of laypersons and FPPs treated at a tertiary care center from 2011 to 2020. The primary predictor variables were LTM in FPPs (before/after) and medical background on medical care (FPPs/laypersons). The main outcome variable was post-operative outcomes (from a public's perspective, FPPs' perspective, and with objective measurements). Descriptive and univariate statistics were computed as appropriate, and P ≤ 0.05 was considered statistically significant. RESULTS: The sample consisted of 203 lay volunteers and 15 FPPs. After LTM, public perception voted the significant improvements in disfigured, important to repair, bothersome, severity (DIBS) score, and facial attractiveness. Patients' perspective was also significantly improved for global severity, oral function, and facial movement. Objective measurements of deviation at the oral commissure and the smile angle also significantly improved after LTM. CONCLUSION: Despite no control groups (i.e., other techniques to be compared) in this study, our study results suggest that LTM can be used to improve public's perception, patient's perception, and objective oral measurement of post-operative outcomes in FPPs. Because different questionnaires were used, it is unknown whether public and patient's perceptions are compatible.

Vastus lateralis versus rectus femoris muscle flaps for recalcitrant hip joint infection: An anatomical study comparing the effectiveness of acetabular dead space control.

Eliminating recalcitrant prosthetic hip joint infections remains one of the greatest challenges in orthopedic surgery. In such cases, the salvage procedure of femoral head excision (the Girdlestone procedure) is often performed. There has been emerging surgical interest in filling the resulting acetabular dead space with a pedicled muscle flap, to enable antibiotic delivery. Both vastus lateralis (VL) and rectus femoris (RF) muscle flaps have been described for this purpose with good success. This study is the first anatomical investigation comparing VL and RF as candidates for interposition myoplasty following hip joint excision. Following standard surgical technique, the Girdlestone procedure and interposition myoplasty of both RF and VL were performed on 10 cadavers. The primary aim was to determine which muscle flap eliminated a greater volume of acetabular dead space. Secondary aims were to characterize the blood supply to RF and assess additional metrics indicative of the likelihood of flap success. The VL flap eliminated more dead space than RF. However, the use of the RF flap was feasible in all cases and has several benefits, including ease of harvest, mobility, and aesthetics. The location of the inferior vascular pedicle into RF was relatively consistent and the most effective predictor of flap success. Both VL and RF are effective in reducing acetabular dead space. While VL can fill a greater volume, the RF flap has technical advantages, related to the predictability of the blood supply.

[New approaches in surgery for osteomyelitis of the femoral neck and head via anterior access]. / Perednii dostup v khirurgii osteomielita sheiki i golovki bedra.

OBJECTIVE: To analyze an effectiveness of anterior approach to the hip joint for sequestrectomy with myoplasty. MATERIAL AND METHODS: We have developed anterior surgical access for osteomyelitis of the femoral neck and head. Semi-oval incision is made in projection of the femoral head. Tendons of sartorius muscle and rectus femoris muscle are cut off from anterior spine of the iliac wing. Surgical field ensures sequestrectomy for osteomyelitis of the hip joint. Closure of osteomyelitis cavity is performed by the proximal parts of two anterior iliacus muscles. Surgical field may be enlarged by temporary intersection of iliopsoas muscle tendon. RESULTS: The key to anterior surgical approach to the hip joint is sartorius muscle and rectus femoris muscle. The length of surgical wound reaches 17-22 cm, width - 16-18 cm. The mobilized proximal part of sartorius muscle is used for closure of the entire bone cavity in femoral neck and head. Stable long-term remission was observed in 11 (91.7±7.6%) out of 12 patients. CONCLUSION: Original surgical approach is less traumatic and ensured manipulations under an angle of about 90°. This access complements the advantages of the well-known anterior approaches and has no their disadvantages.

Rehabilitation of facial palsy by the lengthening temporalis myoplastie: A case report.

INTRODUCTION: The lengthening temporalis myoplasty (LTM) is defined as a transfer of the entire temporal muscle from the coronoid process to the labial commissure reinserted into the orbicularis muscle. PRESENTATION OF CASE: a 60-year-old man with grade III longstanding facial paralysis of the right hemi-face secondary to a right total parotidectomy. The surgery was performed for the rehabilitation of the right hemi-facial side by the lengthening temporalis myoplasty. The follow-up was favorable with improvement of the facial dynamics. DISCUSSION: Surgical management of the longstanding facial palsy is a real challenge. The lengthening temporalis myoplasty offers several advantages; technically is a simple. This technique was demonstrated in severe neglected facial palsy and is performed when there is a definitive complete, or almost complete, loss of the facial nerve and the trigeminal is preserved. Effective rehabilitation through training and physical therapy is necessary to optimize results. CONCLUSION: Facial palsy should no longer be permanent, surgical techniques as lengthening temporalis myoplasty with early postoperative physiotherapy leads to good results. Preoperative planning and early recognition of issues can avoid postoperative complications.

The temporalis muscle and its relationship to the accessory attachments and the main pedicle-a cadaveric study.

Lengthening temporalis myoplasty, described by Daniel Labbe in 1997, is a facial reanimation procedure for the treatment of facial nerve palsy. It involves the mobilization of temporalis muscle antero-inferiorly, and the insertion of its tendon at the nasolabial fold-oral commissure region. Knowledge of the temporalis muscle is crucial in performing this procedure; however, previous anatomical studies are limited. This study on cadavers, aimed to describe the anatomical location of the temporalis muscle insertion in relation to the adjacent structures, and its main pedicle to aid surgeons in performing this procedure. Twenty-four temporalis muscles were dissected in 12 fresh frozen cadavers. The anatomical location of the temporalis muscle insertion, accessory attachments, the emergence of the posterior deep temporal artery, and the distance of sliding movements from the coronoid process to the nasolabial fold were recorded. In addition to its origin from the temporalis fossa and its insertion at the coronoid process, the temporalis muscle was found to have multiple accessory attachments to adjacent structures. These findings explain the challenges in performing the sliding action without releasing the accessory attachments to the masseter and pterygoid muscles. The deep posterior temporal artery is located inferoposteriorly in relation to the muscle. Therefore, the muscle elevation maneuver performed without direct vision can be done with minimal risk to the muscle pedicle. The knowledge of temporalis muscle insertion, its accessory attachments, and its main pedicle will facilitate surgeons in performing the lengthening temporalis myoplasty more confidently.

[Facial paralysis sequelae: Long term follow-up revision surgery, redo, continuing care]. / Séquelles de paralysie faciale : un suivi au long court reprises, retouches, poursuite de prise en charge.

Facial paralysis sequelae have an intense psycho-social impact which imposes an optimal care in the long run. The surgical challenges are numerous, and the therapeutic weapons are multiple. We propose an analysis of these treatments by the prism of their pitfalls and their limits. The complications of the main surgical procedures are described as well as the details of the rework necessary to cope with them or to quickly correct the defects. Moreover, the result limits are detailed with suggestions to improve them. Finally, we develop the necessary iterative treatments or new therapeutic proposals that are essential for the long-term care of these patients whose sequelae of facial paralysis evolve with time and aging. The surgery of facial paralysis is not unequivocal. It requires humility, patience and tenacity to support the patient throughout his life.

McLaughlin's legacy in the current treatment of facial palsy.

Charles Redmond McLaughlin was a pioneer in both facial palsy surgery and in facial plastic surgery (East Grinstead, 1946-1969). Thanks to his work, the personalised treatment of facial palsy was begun.

Lengthening temporalis myoplasty and reduction of the swallowing oral phase dysfunction in facial palsy patients.

INTRODUCTION: Facial palsy can cause dysfunction in the oral phase of swallowing. Lengthening temporalis myoplasty is a widely used technique for correction of facial asymmetry in facial palsy. The aim of this study was to determine whether lengthening temporalis myoplasty could reduce the dysfunction in the oral phase of swallowing in patients with facial palsy. MATERIALS AND METHODS: This prospective study enrolled 13 patients undergoing lengthening temporalis myoplasty. Lip continence, bolus residue, and perceived disability before surgery and at 3 months and 6 months after surgery were compared. Lip force was evaluated with a manometric test and drooling with a self-administered questionnaire. Bolus residue was assessed visually. Perceived disability was evaluated using a self-administered questionnaire. RESULTS: Lip force improved significantly (from 58.23 ± 23.35 mmHg to 91.15 ± 18.36 mmHg; p = 0.001). Drooling showed a corresponding reduction, with the score decreasing from 4.31 ± 1.8 to 3 ±â€¯1.41; p = 0.025. A decrease in bolus residue was also noted; the score decreased from 1.39 ± 0.77 to 0.46 ± 0.66; p < 0.001. These changes contributed to a significant reduction in perceived physical disability; the score decreased from 6.15 ± 3.74 to 3.46 ± 5.70; p = 0.004). CONCLUSION: Lengthening temporalis myoplasty, in addition to providing smile reanimation, may also reduce the dysfunction of the oral phase of swallowing in patients with facial palsy.

The role of sartorius muscle flaps in the management of complex groin wounds.

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether sartorius muscle flaps (SMF) can be effectively used in the setting of complex groin wounds with exposed prosthetic grafts for graft salvage and limb salvage. The literature review identified 33 articles reporting on the use of SMF for complex vascular wounds. Of these, 7 articles reporting on the use of 539 SMFs were considered the best evidence to answer the clinical question. Indications included surgical site infections with or without wound dehiscence, lymph leaks, graft infection and groin pseudoaneurysms, whereas in 98 of the included 539 cases, the flaps were performed prophylactically. Vacuum-assisted closure systems were used in 25 cases to promote healing. The use of an SMF is associated with low rates of muscle flap and graft complications, whereas outcomes seem to be independent of the presence of occlusive disease in the superficial femoral artery. They can be effectively combined with aggressive debridement strategies and vacuum-assisted closure devices to optimize outcomes. The published literature supports the use of SMF in the management of complex groin wounds following vascular reconstruction and is associated with encouraging flap, limb and graft salvage rates.

Rectus abdominis detrusor myoplasty (RADM) for acontractile/hypocontractile bladder in spinal cord injury patients: Preliminary report.

BACKGROUND: Urinary bladder dysfunction in the form of acontractile/hypocontractile bladder is very common after spinal cord injury and it may lead to recurrent urinary tract infection (UTI), stones formation, and deteriorating renal function. Conventionally, these patients evacuate their bladders by life-long clean intermittent catheterization (CIC) or an indwelling catheter (IC). For these patients, another option is to use innervated skeletal muscle wrap around the bladder to augment detrusor function and voluntary evacuation of bladder. METHODS: We selected 5 patients with acontractile/hypocontractile bladder following spinal cord trauma. These patients were assessed by urodynamic study for post void residual volume (PVRV), detrusor pressure (Pdet), urine flow rate (Vmax), and bladder contractility index (BCI). All five patients underwent Rectus Abdominis Detrusor Myoplasty (RADM). RESULTS: Complete spontaneous voiding was achieved in all patients. Rectus abdominis detrusor myoplasty (RADM) elicits a statistically significant reduction in PVRV and statistically significant increase in urine flow rate, bladder contractility and detrusor pressure after 6 months. Recurrent UTIs ceased in all patients. There were no immediate or late complications. CONCLUSION: RADM appears to be a promising option in a patient with acontractile/hypocontractile bladder to restore the bladder function. It avoids CIC in all patients leading to improvement in quality of life in select group of patients.

Lengthening Temporalis Myoplasty: Objective Outcomes and Site-Specific Quality-of-Life Assessment.

Objective Evaluate outcomes of the lengthening temporalis myoplasty in facial reanimations. Study Design Case series with planned data collection. Setting Ospedali Riuniti, Bergamo, and AOUC Careggi, Florence, Italy. Subjects and Methods From 2011 to 2016, 11 patients underwent lengthening temporalis myoplasty; demographic data were collected for each. Pre- and postoperative photographs and videos were recorded and used to measure the smile angle and the excursion of the oral commissure, according to the SMILE system (Scaled Measurements of Improvement in Lip Excursion). All patients were tested with the Facial Disability Index, and they also completed a questionnaire about the adherence to physiotherapy indications. Results All patients demonstrated a significant improvement in functional parameters and in quality of life. On the reanimated side, the mean z-line and a-value, measured when smiling, significantly improved in all patients: from 22.6 mm (95% CI, 20.23-25.05) before surgery to 30.9 mm (95% CI, 27.82-33.99) after surgery ( P < .001) and from 100.5° (95% CI, 93.96°-107.13°) to 111.6° (95% CI, 105.63°-117.64°; P < .001), respectively. The mean postoperative dynamic gain, passing from rest to a full smile at the reanimated side, was 3.1 mm (95% CI, 1.30-4.88) for the z-line and 3.3° (95% CI, 1.26°-5.29°) for the a-value. The Facial Disability Index score increased from a preoperative mean of 33.4 points (95% CI, 28.25-38.66) to 49.9 points (95% CI, 47.21-52.60) postoperatively ( P < .001). Conclusions The lengthening temporalis myoplasty can be successfully used for smile reanimation, with satisfying functional and quality-of-life outcomes.