Measuring 3D facial displacement of increasing smile expressions.

BACKGROUND: Following paralysis, facial reanimation surgery can restore movement by nerve and/or muscle transfer within the face. The subtleties of lip and cheek movements during smiling are important aspects in assessing reanimation. This study quantifies average 3D movement vectors of the face during smiling based on the diverse Binghamton University 3D facial expression database to yield normative measures of lip and cheek movement. METHODS: The analysis was conducted on 100 subjects with 3D facial scans in a neutral and 4 increasing smile intensities, as well as associated labeled 3D landmark points. Each subject set of 3D scans was rigidly registered to measure average displacement vectors (distance, azimuth, and elevation) between the neutral and happy expressions. RESULTS: The average lip commissure displacement was found to be 9.2, 11.4, 13.5, and 16.0 mm for increasing smile levels 1-4, respectively. Similarly, the average commissure azimuth angle across all 4 smile levels is ∼44 ± 21 degrees, and the average elevation angle across all 4 smile levels is ∼37 ± 15 degrees. The maximum cheek displacement from the neutral expression was 4.5, 5.7, 6.8, and 7.9 mm for the smile levels 1-4, respectively. The average cheek movement azimuth angle is outward (increasing 1-13 degrees), and the elevation angle is upward (increasing 51-59 degrees) from the face. CONCLUSIONS: These data quantifying 3D lip and cheek smile displacements improve the understanding of facial movement and may be applicable to future assessment/planning of facial reanimation surgeries.

Facial paralysis and the role of free muscle transplantation.

Facial paralysis can have significant functional, psychological and aesthetic concerns that alter the lives of our patients. These effects can be functional, affecting the eye, nose and mouth, or aesthetic, affecting the symmetry of the face and particularly the mimetic function of smile. Several reanimation procedures have been described to address this. In this chapter, we will outline our technique for reanimation utilizing segmental gracilis muscle transplants to the face. These are innervated either by the contralateral normal 7th nerve via a cross face nerve graft, or a different ipsilateral motor where no 7th nerve is available or would not produce the required result. The other ipsilateral motor that we have found extremely effective is the motor nerve to masseter. This can power a segmental gracilis muscle transplant and lead to excursion that is near normal. These techniques will be described in detail.

A three-dimensional study of the musculotendinous and neurovascular architecture of the gracilis muscle: application to functional muscle transfer.

INTRODUCTION: Muscle transfer is used to restore function typically using a single vector of contraction. Although its use with two independently functional muscular units has been employed, in order to refine this concept we endeavoured to detail the intramuscular anatomy of gracilis, a muscle commonly used for transfer. A novel method to capture intramuscular fibre bundle and neurovascular arrangement was used to create a three-dimensional (3D) digital model that allowed for accurate representation of the relationships between all the intramuscular structures to facilitate flap planning. METHODS: Twenty gracilis muscles were harvested from 15 cadavers. All components of the muscle were digitised using a Microscribe G2 Digitiser. The data were exported to the 3D animation software Autodesk(®) Maya(®) 2012 whereupon it was rendered into a 3D model that can be exported as static images or videos. Neurovascular anatomy and muscle architecture were analysed from these models, and fibre bundle length, pennation angle and physiological cross-sectional area were calculated from digitised data. RESULTS: The muscle is composed of a variable number of distinct longitudinal segments with muscle fibres spiralling onto the tendon. The main artery to the muscle has three main intramuscular patterns of distribution. The venae comitantes drain discrete zones without intramuscular macroscopic anastomoses. The minor pedicles form an anastomotic chain along the anterior border of the muscle and all vessels were biased to the deep surface. The nerve is related to the vessels in a variable manner and both run between longitudinal muscular compartments. CONCLUSIONS: The digitisation technique may be used to advance knowledge of intramuscular architecture and it demonstrated that the gracilis muscle is comprised of four to seven muscular compartments, each representing a functional unit that may theoretically be differentially activated and could be harnessed for more sophisticated muscle transfers.

The first successful lower extremity transplantation: 6-year follow-up and implications for cortical plasticity.

Vascularized composite allotransplantation as a viable reconstructive option is gaining recognition and new cases are being reported with increasing frequency including hand, face and laryngeal transplantation. However, only one successful complete lower limb transplantation has been reported to date, in which a functioning limb from one ischiopagus twin with a lethal cardiac anomaly was transplanted to the other. Six years later, the patient is mobilizing well and engaging in sporting activities with her peers in a mainstream school. Clinical evaluation of motor and sensory modalities demonstrated a good functional result. Quality of life was assessed using the short form-36 health survey and lower extremity functional scale disclosing a high level of social and physical capacity. Functional magnetic resonance imaging was performed and showed cortical integration of the limb; the implications of cortical plasticity and vascularized composite allotransplantation for the correction of congenital limb anomalies are presented.

Use of a mechanical leech in a reverse-flow radial forearm flap: case report.

The reverse-flow radial forearm flap provides excellent coverage for distal upper-limb defects. It is simply raised and does not require microsurgical skills. However, since its vascular pedicle is reversed, its venous outflow can be significantly diminished because of the venous valves. The authors present the case of a 16-year-old patient with a sagittal amputation of the radial aspect of the right thumb, who manifested at the time of surgery marked venous engorgement of a reverse-flow radial forearm flap. This was successfully relieved by the placement of a mechanical leech consisting of a Silastic rubber catheter--of the kind used to gain central vascular access in newborns--introduced in the lumen of the reversed vein at the extremity of the flap. This permitted intermittent evacuation of blood from the flap postoperatively, contributing to the success of this procedure. The technique used is detailed and pertinent literature is reviewed.

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.

Complex facial nevi: a surgical algorithm.

Sixty-six children with large congenital nevi of the face were surgically managed in our center during the last 8 years. All patients with a lesion that posed a reconstructive challenge were included in the study. None could be effectively dealt with by excision and simple primary closure. To simplify description and evaluation, the patients were divided into three groups. Group I had 15 patients with relatively small lesions (1- to 3-cm maximal diameter) that were confined to one aesthetic unit of the face and could be reconstructed in one stage. Reconstruction was usually achieved by using local skin flaps or with full-thickness skin grafting. Group II had 28 patients with medium-sized lesions (3- to 12-cm maximal diameter) that involved one or two aesthetic units and required not more than two stages for reconstruction. These patients usually needed either serial excisions and/or skin grafting or a two-stage tissue expansion procedure (insertion of tissue expanders and reconstruction). Group III had 23 patients with very large lesions (over 12 cm in maximal diameter), some covering half of the face and thus involving several aesthetic units and requiring multiple stages for reconstruction. These patients required a combination of tissue expansion procedures, large faciocervical and scalp/forehead skin flaps, full-thickness skin grafting, and serial excisions for reconstruction. The anatomic distribution of the lesions over the various aesthetic units is described, as are the reconstructive techniques with advantages and disadvantages of each, reflecting on outcome. The approach to the larger complex lesions is detailed. Based on our experience, a reconstructive algorithm is proposed.

The diamond vermilion flap--a new technique for vermilion augmentation in cleft lip repair.

OBJECTIVE: In most cleft lips patients, the vermilion on the medial aspect of the repair is deficient in height. Not many surgeons have dealt with ways to augment the height of the vermilion at this location. In the unilateral cleft lip, the repair may include the insertion of a small triangular vermilion flap from the cleft side into an incision made for it in the muco-vermilion junction of the noncleft side. We have developed a new technique to further augment the vermilion in incomplete cleft lip patients. METHOD: Vermilion remnants may be present in these patients on the scar tissue between the margins of the cleft. A diamond-shaped vermilion flap based on its attachments to the orbicularis oris muscle may be transposed into the noncleft side to an incision made caudal and parallel to the muco-vermilion border. Then the triangular vermilion flap may be inserted just distal to the island flap. Using this method, the vermilion is augmented and the muco-vermilion line parallels more the white skin roll.

Mandibular reconstruction in children using the vascularized fibula.

In this study, the authors review their experience with vascularized fibula transfers for mandibular reconstruction in children. They outline the indications for such reconstruction, their method of contouring the fibula to accurately resemble the resected mandible, reconstruction of the temporomandibular joint, and the use of vascularized muscle for the management of associated soft-tissue deficiencies. Ten consecutive patients, 5 to 17 years of age and undergoing this procedure, were assessed from a medical, dental, radiographic, and photographic standpoint. The fibulae were elevated via a lateral approach, osteotomized, as required, and fixation was achieved with titanium miniplates and screws. All transfers survived, with viability confirmed by early postoperative bone scanning. Five patients had temporomandibular joint reconstruction, and five patients required simultaneous reconstruction of soft-tissue defects with associated vascularized muscle. The postoperative follow-up ranged from 3 to 30 months The occlusion of the remaining dentition, mandibular symmetry and projection, adequacy of lining and skin cover, and maximal mouth opening were reassessed. Occlusion was class 1 in all patients, and free-flap stability and function were in the normal range. However, soft-tissue contour was a problem. All wounds healed primarily without donor-site complications and with minimal recipient-site complications.

Decreasing the perioperative complications associated with the superior pharyngeal flap operation.

This outcome study was a continuation of a previously published review. It examined whether there had been a decrease in the number of acute perioperative complications surrounding superior pharyngeal flap operations since a patient's death in 1990. A total of 386 patients were divided into two groups: the early group (July of 1985 to December of 1990) n = 164, and the later group (January of 1991 to June of 1996) n = 222, which were statistically comparable. The patient complication rate decreased from 19.5 to 6.3 percent (chi square, p = 0.0001). Airway obstruction decreased from 11 to 3.2 percent (chi square, p = 0.0012). Bleeding complications decreased from 7.3 to 1.4 percent (chi square, p = 0.0027). The majority of airway complications (72 percent) and bleeding complications (80 percent) occurred in the first 24 hours. Predictive factors for complications included the surgeon involved, patients with associated medical conditions, having an associated procedure performed concurrently, and leaving the donor site open (multiple logistic regression). Hospital stay also decreased from 5.8 +/- 2.5 to 3.8 +/- 1.6 days (Student's t test p = 0.0001). The decrease in complication rate was due to the increased awareness of all staff involved and also due to changes in surgical management, including a decrease in the number of surgeons (from seven to four surgeons), a decrease in the number of associated procedures (10.4 to 4.5 percent, chi square, p = 0.026), a decrease in the number of open donor sites (34.8 to 4.5 percent, chi square, p = 0), and an increase in the use of nasopharyngeal airways (17.1 to 45 percent, chi square, p = 0). The superior pharyngeal flap operation has become a safer procedure in this hospital.

Cranial nerve defects in congenital facial palsy.

METHODS: Cranial nerve defects were enumerated in 29 children with congenital facial palsy presenting for reanimation via chart review with a view to determining unaffected donor nerves. The literature was searched via Medline to reveal 186 additional case reports that were complete enough in their description to allow assessment of cranial nerve defects. RESULTS: The group presenting for reanimation comprised 24 females and 5 males. All of the males had unilateral isolated facial nerve paralysis. Of the females, 9 had isolated unilateral palsy and 14 had bilateral palsy, and half of these were isolated. Six had bilateral abducens nerve palsy, fulfilling the original definition of Möbius syndrome. Of these, 3 had a right-sided hypoglossal weakness, one had a bilateral oculomotor palsy, and one had a bilateral trochlear palsy. One girl had bilateral facial and auditory involvement. The literature review revealed a group that was 60% male, with 85% having bilateral facial palsy. Abducens palsy was present in 68%, glossopharyngeal in 28%, hypoglossal in 26%, and oculomotor in 20%. The group was very heterogeneous in many ways. CONCLUSIONS: There are many theories of pathogenesis of this syndrome. Isolated facial palsy is in concordance with previous findings of nerve lesions within the temporal bone. Multiple cranial nerve defects are more likely to have brainstem lesions, related to prenatal ischemic events. The cranial nerve least likely to be involved was the accessory nerve, suggesting that this may be a reliable donor for reanimation procedures.

Endoscopic sural nerve harvest in the pediatric patient.

A technique of endoscopic sural nerve harvest was devised to minimize the donor-site scarring in pediatric patients requiring peripheral nerve-grafting procedures. The harvests were performed under tourniquet control using two 2-cm incisions for access at the lateral malleolus and the midcalf. Endoscopic visualization and blunt dissection of the nerve were achieved with a 4-mm Hopkins telescope with 30-degree angled lens (Karl Storz GmbH, Tuttlingen, Germany) stabilized in an Emory retractor and attached to a video camera. The medial sural nerve was divided in the popliteal fossa proximally under endoscopic visualization. The lateral sural nerve was identified and harvested when present. Between June of 1994 and March of 1995, 18 patients underwent 27 sural nerve harvests using the endoscopic technique. Mean patient age was 3.3 years (range 4 to 197 months). Indications for surgery included obstetrical brachial plexus palsy (12), facial palsy (5), and ulnar nerve neuroma (1). Nerve-graft length harvested ranged from 13 to 41 cm. Mean tourniquet time per limb was 92 minutes. No nerve graft injury was noted on examination under the operating microscope. Postoperative pain, swelling, and ecchymosis were minimal. Donorsite scarring has been aesthetically satisfactory to date.

The expanded forehead scalping flap: a new method of total nasal reconstruction.

The challenge of total nasal reconstruction is particularly formidable in the pediatric patient. Forehead skin is taut, and conventional methods of reconstruction, such as the midline forehead flap, provide a paucity of tissue in this age group. Tissue expansion is well-suited modification to overcome this limitation, but as applied to the midline forehead flap, it does not address the resulting vertical forehead scar. We present a new technique for total nasal reconstruction using an expanded, transversely oriented forehead scalping flap in a pediatric patient. This approach not only provides a generous amount of forehead skin but also limits donor-site morbidity and scarring by orienting incisions transversely at the hairline and within the scalp.

Obstetrical brachial plexus palsy: results following neurolysis of conducting neuromas-in-continuity.

Sixteen infants with conducting neuromas-in-continuity at primary brachial plexus exploration underwent microsurgical neurolysis of their lesions. For each patient, the immediate preoperative scores for individual joint movements were compared with scores at the last examination. In the Erb's palsy group (n = 9), significant improvement was seen in shoulder movements, elbow flexion, supination, and wrist extension (paired t test, p < 0.05). Clinically useful improvements in function was seen at the shoulder and elbow (Fisher's exact test, p < 0.05). In the total palsy group (n = 7), significant improvement in shoulder abduction, shoulder adduction, elbow flexion, and extension of the wrist, fingers, and thumb was seen (paired t test, p < 0.05), but there was no significant improvement in the proportion of patients with useful functional outcomes. Neurolysis in Erb's palsy improves both muscle grade and the functional ability of patients. Neurolysis does not provide useful functional recovery in patients with total plexus palsy.

Free gracilis muscle transfer for coverage of severe foot deformities.

The purpose of this study was to describe the gracilis free-tissue transfer for soft-tissue coverage after surgical correction of severe clubfoot and other complex foot deformities in children older than 4 years. Requirements for success include complete correction of deformity, temporary Kirschner-wire fixation to maintain correction, experience in microvascular surgery, and close postoperative monitoring of the tissue transfer. Atrophy of the muscle transfer over the first year precludes the need for debulking procedures. This procedure was used in three children aged 4.5, 7, and 7.3 years with untreated or recurrent equinovarus foot deformities. Postoperatively, these children had flexible, pain-free, plantigrade feet with no donor-site complications. In conclusion, the gracilis free transfer appears to be a safe, effective, and reliable option to cover soft-tissue defects after the treatment of severe clubfeet in older children.

The first elective free flap in a cardiac transplant patient.

A case of free fibula transfer for mandibular reconstruction in a cardiac transplant patient is described. The reconstructive microsurgeon should be aware of the special requirements of these immunosuppressed patients and flap transfer should be performed in specialized centers with the interaction of different specialties to make the procedure safe and successful.

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.

Biceps tendon rupture after successful reinnervation: a case report.

Although rupture of the long head of biceps is a fairly common event, its etiology in young healthy individuals has been assumed to be related to an extraordinarily strong muscle contraction. In this report we describe such a rupture following minor trauma in a reinnervated muscle. The case brings up several points of interest concerning tendon tensile strength and potential for rupture.

The use of a shunting catheter for a ruptured brachial artery following open elbow dislocation.

A rare case of rupture of the brachial artery with distal ischaemia following open elbow dislocation in a child is reported. The use of a shunting catheter successfully maintained the distal circulation until definitive branchial artery reconstruction was performed.

Type 4 median nerve entrapment after elbow dislocation.

A rare case of median nerve entrapment after posterior elbow dislocation is reported. Nerve entrapment was both in the healed medial epicondyle fracture and within the elbow joint and we recommend placing this type of entrapment separately in an extended classification of median nerve entrapment following elbow dislocation.