Technical refinements of the scapular tip-free flap for mandibular reconstruction.

BACKGROUND: The use of scapular tip chimeric free flaps (STFFs) for reconstructing mandibular defects has recently become popular, but its utility relative to other bone-containing free flaps remains debatable. The aim of the report is to describe how technical modification of STFF impacted in its use for mandibular reconstruction also commenting results obtained in a unicentric series of patients. PATIENTS AND METHODS: Patients undergoing mandibular reconstruction using an STFF from January 1, 2014 to June 1, 2022 were retrospectively enrolled in this report. We collected data on chimeric flap type, bone management, vascular pedicles, and the final outcomes. In total, 31 patients (13 men and 18 women) with a mean age of 68 years were enrolled. According to the classification system of Urken, 15 patients had body defects, while 7 had ramus defects, another 7 had symphysis defects, and 2 had both ramus and bodily defects. STFF was always harvested working in two equips simultaneously, in supine position. Dissection included preparation of chimeric components of the flap as latissimus dorsi, serratus and scapular tip. After pedicle dissection scapular bone was cut basing on reconstructive needing with a rectangular (stick) shape including the border of the scapula. In cases of longer bone harvesting, circumflex pedicle was also included to perfuse the upper portion of the scapular border. In five cases, the STFF was harvested with only the scapular angle component, and was thus a composite osteomuscular flap; for the remaining 26 cases, a chimeric STFF was used. Circumflex pedicle was included for eight patients. Six of the seven patients with symphyseal defects underwent a single osteotomy. RESULTS: The average length of the harvested was 69.92 mm (maximum length = 104 mm). The average height of transplanted bone was 26.78 mm (maximum height = 44.2 mm). Mouth-opening was normal in 25 patients, limited in 6 patients, and severely impaired in no patients. The cosmetic results were rated as excellent by 20 patients, good by 8 patients, and poor by 3 patients. CONCLUSION: The STFF is an excellent option for mandibular reconstruction when other flaps are not available and for patients in poor general condition. Technical innovations here presented made possible to harvest long bone segments with accurate shape thanks to osteotomies if needed and with adequate soft tissues components of the chimeric flap, ensuring satisfactory functional and cosmetic results.

Skin Expander for Scalp Reconstruction: Reappraisal of a Reconstructive Procedure for Aplasia Cutis Congenita.

PURPOSE: Aplasia cutis congenita (ACC) is a heterogeneous group of congenital disorders characterized by the absence of epidermis, dermis, appendages, subcutaneous tissue, and bone. The aim of the study is to describe a clinical report of ACC of the scalp treated with skin expanders. CLINICAL REPORT: In October 2019, a 16-year-old female patient underwent scalp expansion with 2 rectangular devices (150 and 250 cm3; Radovan Mentor-Johnson&Johnson). The inflation started 30 days after surgery and continued once every 7 to 10 days to gain 10% of overexpansion. After 3 months, the patient underwent the second surgical step with the expanded scalp transposed to close the defect. Clinical examination 6 months after surgery revealed an acceptable cosmetic result with a hidden surgical scar and hair growth in the previous area of frontoparietal alopecia. CONCLUSION: Skin expander for the reconstruction of extensive ACC defects of the scalp is a valid procedure.

Modified Preauricular Transparotid Approach for Treating Mandibular Condylar Fractures.

AIM OF THE STUDY: We introduce a technical variant of the standard preauricular approach to treat intracapsular and condylar neck fractures: the modified preauricular transparotid approach (MPTA). The main modification, when compared with the conventional submandibular approach, is that the incision of the superficial musculoaponeurotic system is performed directly above the parotid gland, and the buccal branch of the facial nerve is dissected in a retrograde way within the parotid gland. CASE SERIES: Between January 2019 and December 2020 at the Maxillofacial Departments of "Ospedale Maggiore" of Parma and "Policlinico San Martino" of Genoa 6 patients affected by intracapsular and condylar neck fractures underwent open reduction and internal with MPTA. Surgery was uneventful in all patients; no infections occurred in any of the cases; the mean procedure duration was 85 minutes, ranging from 75 to 115 minutes. At the 1-year follow-up, all patients had stable occlusion with a natural, well-balanced morphology of the face and adequate dynamic excursion of the mandible. CONCLUSION: MPTA is particularly suited for intracapsular and condylar neck fractures. Morbidity is negligible in terms of damage to the facial nerve, vascular injuries, and esthetic deformity.

Maxillomandibular Advancement for Obstructive Sleep Apnea Syndrome: Long-Term Results of Respiratory Function and Reverse Face-Lift.

PURPOSE: Scientific literature considers maxillomandibular advancement (MMA) as the most effective surgical treatment for the management of adult obstructive sleep apnea syndrome (OSAS). Maxillomandibular advancement enlarges the pharyngeal space by expanding the skeletal framework. Moreover, it projects the soft tissue of the cheeks, the mouth, and the nose in the aging face, which is characterized by multiple signs affecting the middle third and the lower third. The potential of orthognathic surgery (double jaw surgical advancement) of expanding the skeletal foundation to increase the facial drape support and to rejuvenate the face by a "reverse face-lift" is now recognized. The aim of this study was to review the surgical outcomes after MMA in terms of respiratory function and assessment of facial esthetics. METHODS: We retrospectively reviewed the charts of all patients affected by OSAS who underwent maxillomandibular advancement between January 2010 and December 2015 in 2 tertiary hospitals (IRCCS Policlinico San Martino of Genoa and IRCCS Policlinico Ca' Granda of Milan). During the postoperative follow-up examination, all patients underwent polysomnographic examination and esthetic assessment to evaluate the respiratory function and facial rejuvenation after double jaw surgical advancement. RESULTS: The final study sample included 25 patients (5 females, 20 males). The overall success rate of the surgical treatment (apnea/hypopnea index, AHI <20) was 79%; the overall rate of surgical cure (AHI <5) was 47%. Twenty-three patients (92%) showed a degree of rejuvenation after MMA. CONCLUSIONS: Maxillomandibular advancement is currently the most effective surgical treatment for the management of OSAS in adult patients who are not responders to medical treatment. "Reverse face-lift" is the consequence of the double jaw surgical advancement.

Analysis of the High Submandibular Approach: A Critical Reapprasail of a Transfacial Access to the Mandibular Skeleton.

AIM: In 2006 following the development of dedicated osteosynthesis plates, Meyer and colleagues reported a successful clinical study of condylar fractures treated by a modified submandibular approach; it was called high submandibular approach or "Strasbourg approach." The aim of this study is to describe the high submandibular approach step by step. CASE SERIES: Between January 2010 and December 2015 at the Maxillofacial Unit of the Hospital "Policlinico San Martino" 13 patients affected by subcondylar fracture underwent open reduction and internal with high submandibular approach. Surgery was uneventful in all patients; no infections occurred in any of the cases; the mean procedure duration was 89 minutes, ranging from 66 to 125 minutes. The mean hospital stay was 2.9 days, ranging from 2 to 6 days. At the 1-year follow-up, all patients had stable occlusion with a natural, well-balanced morphology of the face and adequate dynamic excursion of the mandible. CONCLUSIONS: The morbidity is negligible in terms of damage to the facial nerve, vascular injuries, and aesthetic deformity. The authors think that further prospective clinical trials are necessary to assess and eventually develop this approach.

Double Arterialized Scapular Tip Free Flap for Mandibular Reconstruction.

INTRODUCTION: Scapular tip free flap (STFF) has become today one of the workhorse flaps for maxillary reconstruction; recently, the possibility of extending the vascular supply by adding to the angular branch of the circumflex pedicle up to its periosteal entrance in the lateral border of the scapula has been proposed as a reliable technique to improve the length of perfused bone when STFF is used for mandibular reconstruction. The purpose of this study was to evaluate the patients who had received microvascular reconstruction of the mandible with STFF vascularized by both the circumflex scapular artery via the periosteal branch and the thoracodorsal artery via the angular artery. METHODS: A retrospective chart review was conducted for all patients who underwent reconstruction with an STFF for mandibular defect between January 2016 and December 2020 at the University Hospital of Parma. The outcome was evaluated by assessing dietary intake (unrestricted, soft, liquid, and tube feed) and speech (normal, intelligible, partially intelligible, and unintelligible). RESULTS: The final study sample included 9 patients (5 men and 4 women). The average patient age was 68.9 years (range, 59.9-74.8 y) at the time of surgery. There was no flap loss. A 1-year postoperative computed tomography scan revealed full osteointegration of the flap. CONCLUSIONS: Our results show that the STFF is a valuable reconstructive option, especially in patients with complex head and neck defects requiring soft and hard tissues.

Supercharged massetric-facial cross-graft for gracilis reinnervation in unilateral facial palsy treatment.

BACKGROUND: The choice of neurotization source for gracilis neuromuscular transplant is a key point in the treatment of unilateral long-standing paralysis. To combine the advantages of different donor nerves and overcome their disadvantages, mixed neurotization sources have been described with encouraging results. The authors present a preliminary report of a novel technique, the "supercharged" cross-graft, a two-step technique consisting of a double powered cross nerve graft provided by a zygomatic branch of the healthy facial nerve and the masseter nerve of the healthy side. PATIENTS AND METHODS: From January 2015 to December 2019 eight patients, aged between 19 and 61 years old (mean age at surgery 33.62) suffering unilateral established paralysis (congenital or acquired, >24 months) underwent gracilis reinnervation with the supercharged cross grafting technique. Subjects underwent a two-step surgical rehabilitation: in the first operation sural nerve was harvested and used as cross-graft cooptated by healthy side facial nerve branch and masseteric nerve. During second procedure gracilis neuromuscular transplant was performed reinnervarting the muscle with the cross-graft. Patients were evaluated using Emotrics software, which allowed for automated facial measurements on post-operative pictures taken at the last follow-up. The results of the different poses were compared to assess the contribution to smile excursion by the masseter and facial nerve, together and separately. Finally, we analyzed spontaneous smile to assess whether masseteric contribution is used in daily life. RESULTS: No major or minor complications occurred. Follow-up time ranged from 12 to 41 months, with a mean of 22.75 months. A good commissure excursion (mean 33.84 mm) was obtained during smile with no teeth clenching (without masseter activation), as well as during teeth clenching without smiling (activation of gracilis only - mean 32.55). When smiling and biting simultaneously the excursion was greater than the single two components (mean 35.91). In spontaneous smile, commissure excursion was higher (mean 34.23) than that provided by only the facial nerve (smile only) in most patients. CONCLUSIONS: This novel technique of mixed neurotization for gracilis transplant shows consistent results with powerful contraction and good smile coordination. It also allows us to extend the indications for mixed neurotization techniques.

A New Neurorehabilitative Postsurgery Intervention for Facial Palsy Based on Smile Observation and Hand-Mouth Motor Synergies.

Objective: To perform a preliminary test of a new rehabilitation treatment (FIT-SAT), based on mirror mechanisms, for gracile muscles after smile surgery. Method: A pre- and postsurgery longitudinal design was adopted to study the efficacy of FIT-SAT. Four patients with bilateral facial nerve paralysis (Moebius syndrome) were included. They underwent two surgeries with free muscle transfers, one year apart from each other. The side of the face first operated on was rehabilitated with the traditional treatment, while the second side was rehabilitated with FIT-SAT. The FIT-SAT treatment includes video clips of an actor performing a unilateral or a bilateral smile to be imitated (FIT condition). In addition to this, while smiling, the participants close their hand in order to exploit the overlapped cortical motor representation of the hand and the mouth, which may facilitate the synergistic activity of the two effectors during the early phases of recruitment of the transplanted muscles (SAT). The treatment was also aimed at avoiding undesired movements such as teeth grinding. Discussion. Results support FIT-SAT as a viable alternative for smile rehabilitation after free muscle transfer. We propose that the treatment potentiates the effect of smile observation by activating the same neural structures responsible for the execution of the smile and therefore by facilitating its production. Closing of the hand induces cortical recruitment of hand motor neurons, recruiting the transplanted muscles, and reducing the risk of associating other unwanted movements such as teeth clenching to the smile movements.

Maxillary reconstruction with scapular tip chimeric free flap.

PURPOSE: Purpose of the article is to discuss the use of the scapular tip free flap (STFF) for the reconstruction of maxillary defects. METHODS: A retrospective evaluation of patients who underwent maxillary reconstruction with STFF is presented. Patients were evaluated with respect to complications, function, and cosmesis. RESULTS: Study population consisted of 53 patients. All flaps survived and partial bone resorption only occurred in a young patient. Minor complications included two instances of partial muscular necrosis. The donor site was primarily closed in all patients. Mouth opening was assessed as good (>3 cm) in 41 patients, partially limited (2-3 cm) in 9 patients, and limited (<2 cm) in 3 patients. Dental rehabilitation was achieved in 35 patients; esthetic results were assessed by patient as excellent in 19 patients, good in 28 patients, and poor in 6 patients. CONCLUSIONS: The scapular tip chimeric free flap represents an indispensable tool for reconstructive head and neck microsurgery. The main advantages of this technique are very low donor site morbidity and a long pedicle, as well as the potential for harvesting multiple flaps in a chimeric design; STFF represents the first choice for treatment of small postero-lateral defects of the maxilla, and of wide and complex through-and-through defects involving all components of the midface.

Autonomic Responses to Emotional Stimuli in Children Affected by Facial Palsy: The Case of Moebius Syndrome.

According to embodied simulation theories, others' emotions are recognized by the unconscious mimicking of observed facial expressions, which requires the implicit activation of the motor programs that produce a specific expression. Motor responses performed during the expression of a given emotion are hypothesized to be directly linked to autonomic responses associated with that emotional behavior. We tested this hypothesis in 9 children (M age = 5.66) affected by Moebius syndrome (MBS) and 15 control children (M age = 6.6). MBS is a neurological congenital disorder characterized by underdevelopment of the VI and VII cranial nerves, which results in paralysis of the face. Moebius patients' inability to produce facial expressions impairs their capacity to communicate emotions through the face. We therefore assessed Moebius children's autonomic response to emotional stimuli (video cartoons) by means of functional infrared thermal (fIRT) imaging. Patients showed weaker temperature changes compared to controls, suggesting impaired autonomic activity. They also showed difficulties in recognizing facial emotions from static illustrations. These findings reveal that the impairment of facial movement attenuates the intensity of emotional experience, probably through the diminished activation of autonomic responses associated with emotional stimuli. The current study is the first to investigate emotional responses in MBS children, providing important insights into the role of facial expressions in emotional processing during early development.

Perioperative pain management after fibular free flap harvesting for head-and-neck reconstruction using mini-catheters to inject local anesthetic: A pilot study.

BACKGROUND: Fibular donor site pain management in the early postoperative period can help minimize complications, patient discomfort, and agitation. Traditional management of postoperative pain consists of systemic administration of opioids and NSAIDS. The use of local anesthetics in addition to systemic analgesics has the potential to improve pain control. Purpose of the study is to evaluate the efficacy of mini-catheters used to inject local anesthetic into the fibular donor site after flap harvesting for reconstruction of the head-and-neck area. METHODS: Prospective study on 31 patients (mean age 52 years) treated for head and neck reconstruction with fibula free flap using minicatheter for local anesthetic injection in the early postoperative time. A bolus of chirochaine (0.125% w/v; 20 mL) was injected through the catheter before the patient regained consciousness. Postoperatively, three consecutive injections (20 mL each) were administered 8, 16, and 24 h after surgery. Pain evaluation before and after local anesthetic injection is used to assess efficacy and overall pain control. RESULTS: No major or minor complication occurred. Mean pain value was 1.69. At 8 h, the pain scores before injection ranged from 0 to 10 (mean 4.13 ± 3.06). After injection, the pain scores ranged from 0 to 5 (mean 1 ± 1.34). Similarly, at 16 h, the pain scores ranged from 0 to 8 (mean 2.77 ± 2.42) before injection and from 0 to 6 (mean 0.42 ± 1.2) thereafter. At 24 h, the initial pain score ranged from 0 to 6 (mean 1.71 ± 1.74) and from 0 to 1 (mean 0.1 ± 0.3) after drug administration. Pre and postinjection pain scores differences were statistically significant after all three injections (P < .001). CONCLUSIONS: Minicatheter seems to be easy, safe, and efficient when used to control pain after fibular free-flap harvesting.

Bilateral Harvesting of a Fibula Free Flap: Assessment of Morbidity.

PURPOSE: To investigate morbidity related to harversting of bilateral fibula free flap for head and neck reconstruction using subjective and functional tests. METHODS: Patients were retrospectively evaluated using point evaluation system (PES) and balance evaluation systems test (BESTest) questionnaires to assess morbidity related to surgery. RESULTS: Five patients were enrolled in the study. Mean PES scores was 22.2 over 24. Mean overall function assessed with BESTest was 77.6%, and the results were poorest for section I. Sections V and VI had scores of 88% and 83%, respectively, indicating that the sensory balance and gait stability of the patients were compromised only minimally. CONCLUSION: Bilateral harvesting of the fibula free flap is not associated with an increase in long-term morbidity and does not lead to significant functional impairments. Therefore, this procedure should be considered safe, and can be performed without concern regarding morbidity, when bone reconstruction with a fibula free flap is indicated.

Microsurgical Decompression of Inferior Alveolar Nerve After Endodontic Treatment Complications.

Iatrogenic injury in oral surgery is the most frequent cause of sensory disturbance in the distribution of the inferior alveolar nerve (IAN) and mental nerve.Inferior alveolar nerve damage can occur during third molar extraction, implant location, orthognathic surgery, preprosthetic surgery, salivary gland surgery, local anesthetic injections or during the resection of benign or malignant tumors.Injuries to the IAN can be caused also by endodontic treatment of mandibular molars and premolars when filling material is forced into the tooth and mandibular canal.The sensory disturbances that could follow a damage of the IAN could be hypoesthesia, dysesthesia, hyperesthesia, anesthesia, and sometimes a painful anesthesia that strike ipsilateral lower lip, chin, and teeth. These can undermine life quality by affecting speech, chewing, and social interaction.Treatment of these complications is sometimes difficult and could consist in observation or in surgical decompression of the involved nerve to relieve the patient's symptoms and improve sensory recovery. The most debated points are the timing of intervention and the effective role of decompression in clinical outcome-improvement.The purpose of this article is to show authors' experience with 2 patients treated with microsurgical nerve decompression to remove endodontic material from the mandibular canal and providing also a comprehensive review of the literature.

Stereophotogrammetric Evaluation of Labial Symmetry After Surgical Treatment of a Lymphatic Malformation.

Lymphatic malformations (LMs) are rare, nonmalignant masses, frequently involving the head and neck, potentially causing impairment to the surrounding anatomical structures. Major LMs frequently cause facial disfigurement with obvious consequences on self-esteem and social functioning. The attempt to restore symmetry is thus one of the main goals of treatment. In this study, the authors present a not-invasive method to objectively quantify the symmetry of the labial area before and after surgical treatment of a LM, affecting a 16-year-old woman. This was done with sequential three-dimensional stereophotogrammetric imaging and morphometric measurements. The method showed a high reproducibility and supplied quantitative indicators of the local degree of symmetry, helping clinicians in its objective assessment, and facilitating treatment planning and evaluation. A quantitative appraisal of the results can additionally improve patient adherence to a usually multistage therapy.

Head and neck reconstruction using the superiorly based reversed-flow facial artery myomucosal flap.

PURPOSE: The use of myomucosal buccinator flaps in the reconstruction of oral cavity defects is well established in the international literature; however, their use for the reconstruction of defects not in the oral cavity has been largely underestimated. The purpose of this report was to describe and review the applications of the superiorly based facial artery myomucosal (FAMM) flap in head and neck reconstruction. MATERIALS AND METHODS: This study was a retrospective evaluation of 12 patients who underwent reconstruction of the palate, lip, nasal septum, and conjunctiva with reversed-flow FAMM flaps. Mouth opening, speech, reconstruction effectiveness, and esthetic outcomes were analyzed. RESULTS: The patient cohort consisted of 7 men and 5 women 33 to 80 years old (mean, 56.2 yr old). No major complication occurred. Cosmetic results were excellent in most patients. Functionally, the best reconstruction results were obtained in the palate, lip, and conjunctiva. Nasal reconstruction led to mild airway obstruction in 2 cases and severe obstruction in 1 case. CONCLUSION: The superiorly based FAMM flap plays an important role in the reconstruction of particular defects involving the oral cavity and other distant sites of the head and neck area. The reliability, low morbidity, and optimal results that can be achieved using this technique make this flap a good option for such reconstructions.

Donor site morbidity after scapular tip free flaps in head-and-neck reconstruction.

BACKGROUND: Recently, the scapular tip free flap has been popularized as a valuable option for bone reconstruction of the head and neck area. Analyses of perioperative and long-time morbidity are crucial to enable complete comprehension of this technique and will be presented in this paper. METHODS: Perioperative and long-term morbidity of scapular tip flaps harvesting were analyzed in a cohort of 19 patients. Local complications and ambulation-time were used to assess perioperative results, while Constant-Murley and DASH scores were used to evaluate long-term morbidity on shoulder functions. RESULTS: Local perioperative complications were minimal (three cases of seroma and two wound dehiscence). Ambulation time ranged between 2 and 4 days (mean 2.7 days). Constant-Murley scores ranged between 66 and 100 (mean 92.2). The DASH score ranged between 39 and 85 (mean 48.6). CONCLUSION: Harvesting a scapular tip free flap resulted in very low shoulder morbidity, without interfering the patient's daily activities. © 2015 Wiley Periodicals, Inc. Microsurgery 35:447-450, 2015.

Reconstruction of mandibular defects using the scapular tip free flap.

PURPOSE: Purpose of the article is to present the use of the scapular tip free flap (STFF) for the reconstruction of oromandibular defects. PATIENTS: Eleven patients who underwent oromandibular reconstruction with STFF were retrospectively evaluated with regards to form and function assessing mouth opening, dietary intake, and cosmetic outcome. Donor site morbidity was evaluated using the Constant-Murley test for the shoulder unit. RESULTS: Follow-up ranged from 6 to 35 months (mean 20.6 months). Good or excellent results in mouth opening and cosmesis were achieved in eight patients, speech was assessed as intelligible or normal in all but one patient and mean ambulation time after surgery was 2.5 days. Results of Constant score ranged from 45 to 70 (mean 60.6), and the main limitation encountered was elevation of the arm above the head, which was seen in all but one patient confirming the low impact of the technique on the shoulder system. CONCLUSION: Low morbidity, early ambulation time, possibility of simultaneous harvesting with the tumor resection, large musculocutaneous paddles in the chimeric version of the flap are advantages of the STFF and makes it a good choice in elderly patients, when other bone containing free flaps are not indicated because of the related morbidity, when other flaps are not available or when wide composite defects are approached.

Ancillary procedures in facial animation surgery.

PURPOSE: Facial animation surgery with neuromuscular transplants has become a standard procedure for the treatment of facial palsies. However, the forehead, periocular complex, nasal base area, and inferior lip are secondary sites that also need to be considered in the complete rehabilitation of a flaccid facial palsy. MATERIALS AND METHODS: A total of 136 ancillary procedures were performed in 49 patients between 2003 and 2013 and consisted of eyebrow suspensions (11), upper eyelid loading with a platinum chain (39), inferior palpebral suspension with fascia lata (22), nasal base suspension with fascia lata (26), and botulinum toxin injection (38). RESULTS: Cosmetic results were good and excellent in 30.7% and 63.2% of the procedures, respectively. Functionally, periocular complex rehabilitation and nasal base suspension led to excellent improvements in function in 87.2% and 73.1% of the patients, respectively. CONCLUSIONS: The use of ancillary procedures can improve the functional and esthetic results of facial animation surgery.

Mandibular resection and reconstruction in the management of extensive ameloblastoma.

PURPOSE: To present our experience with the management of 31 extensive mandibular ameloblastomas treated with segmental mandibulectomy, reconstruction with free fibula or iliac crest flap, and rehabilitation with immediate or delayed endosteal dental implants. PATIENTS AND METHODS: The study sample comprised 31 patients with histologically confirmed mandibular ameloblastomas. Primary ameloblastomas were treated in 23 patients, and recurrent ameloblastomas affected 8 patients. Mandibular defect sizes ranged from 3.5 to 12.5 cm (mean, 5.6 cm). A free fibula osseous or osteocutaneous flap was used 17 times for reconstruction; in the remaining 14, a free iliac crest osseous or osteomuscular flap was chosen. Dental implants were positioned in 25 patients; implant procedures were performed simultaneously with reconstruction in 21 cases. RESULTS: All flaps were transplanted successfully, and no major complication occurred postoperatively. Final histologic examinations showed 27 multicystic and 4 unicystic ameloblastomas. Free margins were achieved in all patients. The duration of follow-up was 18 to 120 months (mean, 53.6 months). No patient showed clinical or radiologic signs of recurrence. The dental implant success rate was 100%. CONCLUSIONS: Segmental mandibular resection followed by immediate defect reconstruction with bone-containing free flaps with immediate dental implant placement should be considered as the treatment of choice for extensive mandibular ameloblastomas.

Optimizing the results of facial animation surgery: Botulinum toxin injection into free functional gracilis flap transfer.

Although neuromuscular gracilis transplantation is the best choice for facial reanimation in patients with congenital or inveterate palsy, the results are not completely satisfactory. Ancillary procedures developed to achieve better symmetry of the smile and reduce the hypercontractility of the transplanted muscle have been reported. However, the intramuscular injection of botulinum toxin has not been described for this purpose. Patients undergoing gracilis injections of botulinum toxin after facial reanimation surgery between September 1, 2020, and June 1, 2022, were retrospectively enrolled in this study. We collected photographs taken before and 20-30 days after injection and compared the symmetry of the face using software. Nine patients with a mean age of 23.56 years (range, 7-56 years) were enrolled. Reinnervation of the muscle was provided by the contralateral healthy facial nerve via a sural cross-graft (four patients), by the ipsilateral masseteric nerve (three cases), and by the contralateral masseteric and facial nerve (two). Using Emotrics software, we identified differences in the commissure excursion discrepancy of 3.82 mm, the smile angle discrepancy of 0.084°, and the dental show discrepancy of 1.49 mm; the average difference in the commissure height deviation was 2.26 mm (P = 0.02), and those in the upper- and lower-lip height deviation were 1.05 mm and 1.49 mm, respectively. Gracilis injection of botulinum toxin after gracilis transplantation is a safe and feasible procedure that could be applicable to all patients with asymmetric smiles related to excessive transplant contraction. It yields good esthetic results with little to no related morbidity.