Lower Lip Reanimation: Experience Using the Anterior Belly of Digastric Muscle in 2-stage Procedure.

Lower lip depression was historically regarded a neglected area of facial paralysis, but, with refinement of techniques, has gained increasing attention. We present the first detailed description and evaluation of a 2-stage technique, using first cross facial nerve graft and then the anterior belly of digastric muscle (ABDM), innervated by the cross facial nerve graft, to restore dynamic and spontaneous lower lip depression. METHODS: Retrospective analysis of 2-stage lower lip reanimations between 2010 and 2018 was performed. Demographics, etiology, and operative details were recorded. Videos were graded pre/postoperatively using a 5-point Likert scale by 21 independent observers. Objective changes of symmetry were analyzed using Photogrammetry (Emotrics). RESULTS: Twenty-seven patients were identified (median age 34.9 years, range 6-64). The mean duration between the 2 stages was 15.1 months. Follow-up ranged from 18-72 months. There were minor complications in 4 patients, and 1 case was abandoned due to insufficient length of anterior belly of digastric muscle. Average peer-reviewed scores improved from 2.1 to 3.2 (P < 0.05). Emotrics did not show improvement in static symmetry (P > 0.05). However, during open-lip smiling, lower lip height improved significantly (P < 0.05) whilst dental show improvements approached significance (P < 0.08). Lower lip symmetry was also improved during lower lip depression, as shown by improvements in lower lip height (P < 0.05), smile angle, and dental show (both P < 0.05). CONCLUSIONS: These results show the safety and efficacy of 2-stage lower lip reanimation using anterior belly of digastric muscle transposition. This procedure is our choice for longstanding lower lip paralysis and provides coordinated spontaneous lower lip depression, thus enhancing the overall perioral animation and smile.

The retrograde approach to the reverse dorsal metacarpal artery flap.

We present a short communication on the use of a retrograde approach in the DMCA Perforator flap in cases of reconstruction post SCC excision of the hand. We illustrate the anatomy, and present intra- and post-operative findings.

Technical refinements of the free medial sural artery perforator (MSAP) flap in reconstruction of multifaceted ankle soft tissue defects.

BACKGROUND: Peri-ankle defects are difficult to reconstruct due to sharp contours, thin skin, aesthetic value, function and footwear impact. The medial sural artery perforator flap (MSAP) is increasing in popularity as a thin and pliable flap. This study aims to demonstrate its versatility in reconstructing defects around the ankle area and our approach to insetting these flaps in difficult areas around the ankle without the need for subsequent flap revisions. METHODS: A retrospective review of the senior author's series of peri-ankle reconstructions using the MSAP flap was undertaken. RESULTS: Between 2011-2015, 15 patients underwent peri-ankle reconstruction with the MSAP flap. There were 4 dorsal foot, 4 medial malleolar, 4 lateral malleolar, and 3 tendo-achilles defects. All flaps in this series survived. There was one episode of partial flap necrosis in one patient and no incidences of donor site dehiscence. All patients returned to full ambulation and none required subsequent flap revision. CONCLUSIONS: The MSAP flap offers the benefits of a fasciocutaneous flap, whilst providing a thin, pliable, single stage and robust reconstruction for peri-ankle defects, with a cosmetically ideal donor site.

Beyond the L-Strut: Redefining the Biomechanics of Rhinoplasty Using Topographic Optimization Modeling.

Rhinoplasty utilizes cartilage harvested from the nasal septum as autologous graft material. Traditional dogma espouses preservation of the "L-strut" of dorsal and caudal septum, which is less resistant to axial loading than virgin septum. Considering the 90° angle between dorsal and caudal limbs, the traditional L-strut also suffers from localized increases in internal stresses leading to premature septal "cracking," structural-scale deformation, or both. Deformation and failure of the L-strut leads to nasal deviation, saddle deformity, loss of tip support, or restriction of the nasal valve. The balance between cartilage yield and structural integrity is a topographical optimization problem. Guided by finite element (FE) modelling, recent efforts have yielded important modifications including the chamfering of right-angled corners to reduce stress concentrations and the preservation of a minimum width along the inferior portion of the caudal strut. However, all existing FE studies offer simplified assumptions to make the construct easier to model. This review article highlights advances in our understanding of septal engineering and identifies areas that require more work to further refine the balance between the competing interests of graft acquisition and the maintenance of nasal structural integrity.

The Vascularized Medial Femoral Corticoperiosteal Flap for Thumb Reconstruction.

We present an interesting method of shaping a vascularized medial femoral condyle (MFC) flap into a "neophalanx" for phalangeal reconstruction. Our patient presented with limited strength and function secondary to fracture nonunion of the proximal phalanx of the dominant thumb. Following excision of the pseudarthrosis, an MFC corticoperiosteal flap was harvested, sculpted into a prism shape and inset. The superomedial genicular pedicle was anastomosed to the princeps pollicis artery and a cephalic tributary. On follow-up, new bone growth was seen on radiographs and the patient had substantially improved function, with full metacarpophalangeal extension, a Kapandji score of 9, and a markedly reduced Disabilities of the Arm, Shoulder and Hand score of 2.68. The MFC flap is useful for reconstruction of bony defects, with minimal donor morbidity. This versatile vascularized flap can be crafted to requisite shapes and is useful for small defects in the hand, including phalangeal reconstruction.

Diagnostic accuracy of clinical examination and magnetic resonance imaging for common articular wrist pathology.

The authors retrospectively compared the diagnostic accuracy of clinical examination and magnetic resonance imaging for intra-articular wrist pathology (triangular fibrocartilage complex, lunotriquetral and scapholunate injuries), using wrist arthroscopy as the gold standard. Sixty-six patients had clinical examination and arthroscopy; 38 of them also had magnetic resonance imaging. The diagnostic accuracy of clinical examination for all three injuries combined was 56.1%, and the accuracy of MRI was 55.3%. Magnetic resonance imaging was more specific, while clinical examination was more sensitive. Clinical examination was more accurate for specific triangular fibrocartilage complex (TFCC) injuries, while magnetic resonance imaging was more accurate for lunotriquetral (LT) and scapholunate (SL) ligament injuries. The study results suggest that magnetic resonance imaging has a use where clinical examination is ambiguous or where scapholunate damage is suspected.