Static Suspension of the Paralyzed Face Utilizing the Midfacial Corridor: Anatomic Evaluation and Surgical Technique.

BACKGROUND: Fascia lata and tendon grafts are frequently utilized to support the paralyzed midface and to extend muscular reach in McLaughin style, orthodromic temporalis transfers. The grafts are frequently placed in a deep subcutaneous positioning that can lead to the development of a, bowstring deformity in the cheek. This paper describes insertion of tendon grafts into the midfacial corridor collectively formed by the buccal, submasseteric and superficial temporal spaces. METHODS: Over a seven-year period, all patients that underwent insertion of facia lata and tendon grafts in the midfacial corridor were included. Demographic information, perioperative variables and clinical outcomes were collected and analyzed. RESULTS: A total of 22 patients were included with a mean age of 64.3 years (33-86). There were multiple etiologies for the facial weakness including acoustic neuroma (9.1%), Bell's palsy (13.6%), facial nerve schwannoma (9.1%), temporal bone fracture (4.6%) and malignancy (22.7%). Midfacial corridor grafts were utilized in combination with nerve transfers (V-VII and XII-VII) in nine patients, McLaughin style temporalis transfers in 12 and as a standalone procedure in one individual. During the study period, no patients exhibited a tethering, or concave deformity in the midface. Additionally, no impingement, difficulties with mastication, parotitis or hematoma were encountered. One patient developed a postoperative infection, that was successfully managed. CONCLUSION: Placement of tendon or fascia grafts for static support or tunneling of an orthodromic temporalis transfer through the midfacial corridor can be performed rapidly while providing midfacial support and avoiding the creation of visible cutaneous deformities.

Dual Innervation of Free Functional Muscle Flaps in Facial Paralysis.

Dual innervation in free muscle flap facial reanimation has been used to create a functional synergy between the powerful commissure excursion that can be achieved with the masseter nerve and the spontaneity that can be derived from a cross-face nerve graft. The gracilis has been the most frequently used muscle flap, and multiple combinations of neurorrhaphies have been described, including the masseter to the obturator (end-to-end) combined with a cross-face nerve graft to the obturator (end-to-side) and vice versa. Single and staged approaches have been reported. Minimally, dual innervation is as effective as using the motor nerve to masseter alone.

Use of sternal plate for pectus excavatum repair in adults leads to minimal postoperative pain.

Pectus excavatum is a chest wall deformity that results in caved-in or sunken appearance of lower half of anterior chest. Surgical treatment is favored when functional or cosmetic concerns arise. We present a case and series of six patients (mean haller index: 4.28) who had repair with minimal pleural disruption and sternal plate. After a broad bilateral inframammary skin incision, the anterior aspect of sternum is identified and incised. Next, the surgeon hyperextends and fixates the bone in its desired position by applying manual dorsal pressure through a small intercostal incision. Superior and inferior fasciocutaneous flaps are raised and then advanced to reconstruct the soft tissue defect. All patients had durable repair of the chest wall abnormalities and they had minimal pain during the postoperative period. No analgesia medication was necessary 1 month post-operatively. This may provide significantly less pain compared to the Nuss or Ravitch procedures to fix Pectus excavatum.

Contemporary solutions for the treatment of facial nerve paralysis.

LEARNING OBJECTIVES: After reviewing this article, the participant should be able to: 1. Understand the most modern indications and technique for neurotization, including masseter-to-facial nerve transfer (fifth-to-seventh cranial nerve transfer). 2. Contrast the advantages and limitations associated with contiguous muscle transfers and free-muscle transfers for facial reanimation. 3. Understand the indications for a two-stage and one-stage free gracilis muscle transfer for facial reanimation. 4. Apply nonsurgical adjuvant treatments for acute facial nerve paralysis. SUMMARY: Facial expression is a complex neuromotor and psychomotor process that is disrupted in patients with facial paralysis breaking the link between emotion and physical expression. Contemporary reconstructive options are being implemented in patients with facial paralysis. While static procedures provide facial symmetry at rest, true 'facial reanimation' requires restoration of facial movement. Contemporary treatment options include neurotization procedures (a new motor nerve is used to restore innervation to a viable muscle), contiguous regional muscle transfer (most commonly temporalis muscle transfer), microsurgical free muscle transfer, and nonsurgical adjuvants used to balance facial symmetry. Each approach has advantages and disadvantages along with ongoing controversies and should be individualized for each patient. Treatments for patients with facial paralysis continue to evolve in order to restore the complex psychomotor process of facial expression.

Acellular dermal matrix and negative pressure wound therapy: a tissue-engineered alternative to free tissue transfer in the compromised host.

Free tissue transfer has revolutionized lower extremity reconstruction; however, its use in elderly patients with multiple medical problems can be associated with elevated rate s of perioperative morbidity and mortality. This study evaluates the use of acellular dermal matrix (ADM) in conjunction with negative pressure wound therapy (NPWT) and delayed skin graft application as an alternative to free tissue transfer in this compromised population. Bilayer, ADM (Integra, Plainsboro, NJ) was used in conjunction with NPWT (Wound V.A.C, Kinetic Concepts Inc., San Antonio, TX) to achieve vascularized coverage of complex lower extremity wounds with denuded tendon and bone in elderly, medically compromised patients. Following incorporation, the matrix was covered with split-thickness skin graft. Four patients (age range, 50 to 76 years) with multiple medical comorbidities were treated with the above protocol. The average time to complete vascularization of the matrix was 29 days. Definitive closure with split-thickness skin graft was achieved in three patients and one wound healed by secondary intention. No medical or surgical complications were encountered and stable soft tissue coverage was achieved in all patients. This early experience suggests that dermal substitute and NPWT with delayed skin graft application can provide a reasonable tissue-engineered alternative to free tissue transfer in the medically compromised individual.

Facial reanimation using the masseter-to-facial nerve transfer.

BACKGROUND: This article describes facial reanimation using the transfer of the trigeminal motor nerve branch of the masseter muscle (masseter nerve) to the facial nerve (masseter-to-facial nerve transfer). METHODS: A retrospective review was performed of 10 consecutive facial paralysis patients treated with a masseter-to-facial nerve transfer for reanimation of the midface and perioral region over a 7-year period. Patients were evaluated with physical examination, direct measurement of commissure excursion, and video analysis. RESULTS: All patients regained oral competence, good resting tone, and a smile, with a vector and strength comparable to those of the normal side. Motion developed an average of 5.6 months after masseter-to-facial nerve transfer, with 40 percent of patients developing an effortless smile by postoperative month 19. CONCLUSIONS: The masseter-to-facial nerve transfer is an effective method for reanimation of the midface and perioral region in a select group of facial paralysis patients. The technique is advocated for its limited donor-site morbidity, avoidance of interposition nerve grafts, and potential for cerebral adaptation, producing a strong, potentially effortless smile.

Indications and outcomes of free tissue transfer to the lower extremity in children: review.

Thirty-four free tissue transfers for reconstruction of various tissue defects to the lower extremities were performed in 32 children over a 20-year period (1980 to 1999). Patient ages ranged from 3 to 19 years (mean: 10.8 years). Four donor sites were used: gracilis muscle, latissimus dorsi muscle, iliac crest osteocutaneous, and vascularized fibula. Fourteen patients had tissue defects related to trauma: nine received a gracilis flap; five received a latissimus dorsi flap. Five patients had tissue defects related to malignant tumor resection: three patients with Ewing's sarcoma received free fibulae; one patient with an osteogenic sarcoma received a gracilis flap, and another received an iliac crest osteocutaneous flap. Fifteen patients had congenital anomaly-related tissue defects: five with talipes equinovarus received gracilis flaps; ten with congenital tibial pseudoarthrosis received free fibulae. Vascular outcome was assessed based on the achievement of flap perfusion and post-surgical vascular revisions. Complete flap survival was achieved in 32 cases (85.3 percent); partial flap loss in three cases (8.82 percent); and complete flap loss in two cases (5.9 percent). Early revision surgery for the five partial or failed flaps consisted of debridement and split-thickness skin graft or flap removal. No patients required vascular take-backs or experienced vascular spasm. There were no systemic problems associated with the long and complex surgeries. Functional outcome was assessed based on ambulation, post-surgical complications, and whether the flap served its intended purpose. Ambulation was achieved in all cases. Functional surgical revisions were required in 32.4 percent of cases, and included scar revisions, flap debulking, bone grafts, and pin insertion. The most prevalent morbidity was persistent leg-length discrepancy (35.3 percent of cases). Only one successful flap was unable to meet its intended purpose, as a tibial pseudoarthrosis persisted, despite initial excision and a well-perfused reconstruction. Results show that free tissue transfer is safe and dependable for tissue defects of the lower extremity in children. From the authors' experience, free flaps used for the repair of defects from congenital tibial pseudoarthrosis have a high vascular success, but also require an extensive rehabilitation course, with only moderate functional success. There was no significant difference between flap surgeries performed immediately, intermediately, or late after trauma. These procedures have a wide range of indications and, despite the need for surgical revision and an extensive rehabilitation course, functional and vascular success can be achieved.

Persistent cutaneous manifestations of hyperoxaluria after combined hepatorenal transplantation.

A 30-year-old woman with primary hyperoxaluria type I (PHI) developed livedo reticularis with overlying ulcerations on her legs 16 months after receiving a liver-kidney transplant. A skin biopsy of the lesion showed deposits of calcium oxalate. To our knowledge, there have been no reported cases of livedo reticularis in patients with PH1 after a combined liver-kidney transplant.

How to help diabetic patients avoid amputation.

Preview Of the 14 million Americans who have diabetes mellitus, more than 2 million will at some point have foot ulcers. The prevalence of this complication, its impact on the activities of daily living, and the cost of treating it make it a problem of immense magnitude. Primary care physicians who emphasize prevention and early treatment of foot ulcers can greatly reduce the likelihood of serious sequelae. This article tells you what to look for in examining the feet, how to advise patients in foot care, and what to do if ulcers occur despite preventive efforts.