Selective fascicular coaptation of free functioning gracilis transfer for restoration of independent thumb and finger flexion following Volkmann ischemic contracture.

Children are prone to developing moderate to severe Volkmann ischemic contracture following a supracondylar fracture of the humerus or its treatment. Given the variable extent of forearm muscle damage, tendon transfers and tenodeses are often unavailable. To address these contractures, intensive hand therapy and a free functioning muscle transfer are required. Despite functional improvement following free muscle transplantation, reconstructed patients with severe Volkmann ischemic contracture tend to have persistent difficulty with fine motor activities owing to the losses of intrinsic muscle function and independence of thumb and finger flexion. The authors demonstrate how selective coaptation of separate fascicular territories of the gracilis nerve branches to the branches of the anterior interosseous nerve that innervate flexor pollicis longus and flexor digitorum profundus may be performed to establish a degree of independent thumb and finger flexion with a single free gracilis transfer. This technical refinement as well as its long-term outcomes in a series of three patients is presented.

Functioning free muscle transfers.

Functioning free muscle transfer to the upper extremity is an extremely complex and difficult procedure. It is useful only in selected cases that require significant skeletal muscle replacement and fulfill stringent criteria. The operation itself is performed by means of a two-team approach. Attention to detail is paramount if success is to be achieved. Careful placement of the muscle origin and insertion under appropriate tension is a key feature of the procedure. Precise microvascular anastomoses and microneural coaptations must be done. A time-intensive rehabilitation program is needed to gain as much function from the muscle as possible. Although not perfect, free muscle transfer does provide substantial improvement from a functional standpoint for these unfortunate patients.

Plasticity of the human motor system following muscle reconstruction: a magnetic stimulation and functional magnetic resonance imaging study.

OBJECTIVE: Although motor system plasticity in response to neuromuscular injury has been documented, few studies have examined recovered and functioning muscles in the human. We examined brain changes in a group of patients who had a muscle transfer. METHODS: Transcranial magnetic stimulation (TMS) was used to study a unique group of 9 patients who had upper extremity motor function restored using microneurovascular transfer of the gracilis muscle. The findings from the reconstructed muscle were compared to the homologous muscle of the intact arm. One patient was also studied with functional magnetic resonance imaging (fMRI). RESULTS: TMS showed that the motor threshold and short interval intracortical inhibition was reduced on the transplanted side while at rest but not during muscle activation. The difference in motor threshold decreased with the time since surgery. TMS mapping showed no significant difference in the location and size of the representation of the reconstructed muscle in the motor cortex compared to the intact side. In one patient with reconstructed biceps muscle innervated by the intercostal nerves, both TMS mapping and fMRI showed that the upper limb area rather than the trunk area of the motor cortex controlled the reconstructed muscle. CONCLUSIONS: Plasticity occurs in cortical areas projecting to functionally relevant muscles. Changes in the neuronal level are not necessarily accompanied by changes in motor representation. Brain reorganization may involve multiple processes mediated by different mechanisms and continues to evolve long after the initial injury. SIGNIFICANCE: Central nervous system plasticity following neuromuscular injury may have functional relevance.

Surface anatomy of the middle division of the facial nerve: Zuker's point.

BACKGROUND: The anatomy of the facial nerve and its branches has been well documented. The course of the extratemporal facial nerve, its anatomical planes, and the surface landmarks of the temporal division and marginal mandibular division are well known. However, the surface landmark of the middle division of the facial nerve has not been studied to date. METHODS: Eighteen hemifacial dissections in 10 fresh human cadavers were performed through a preauricular face-lift incision. An 18-gauge needle with brilliant green dye was used to mark the nerve through the skin before dissection. The exact location of the middle division branches of the facial nerve was documented in relation to the transcutaneous marking. RESULTS: The middle division branches of the facial nerve were found to lie at a mean of 2.3 mm from the tattooed point, with a range of 0 to 6 mm. A nerve branch was found directly tattooed by the needle seven of 18 times, inferior to the tattoo five of 18 times, and superior to the tattoo six of 18 times. CONCLUSIONS: The zygomatic/buccal motor branch that innervates the zygomaticus major muscle can be reliably found at the midway point on a line drawn from the root of the helix and the lateral commissure of the mouth. This study will help guide surgeons to the middle division of the facial nerve as it applies to facial surgery.

Facial palsy and reconstruction.

This article outlines a thorough approach to facial nerve palsy and reconstruction.

Facial paralysis measurement with a handheld ruler.

BACKGROUND: Evaluation of the severity of facial paralysis deformity and the effectiveness of reconstructive surgery requires a measurement tool that is practical and simple enough for daily use. It should be able to objectively measure facial asymmetry at rest and the amount of facial movement during expression. The authors present and assess a simple measurement technique that is readily usable in the clinic. Designed to evaluate smile reconstruction, the technique can be used to evaluate other parts of the paralyzed face, such as the eye, nose, and forehead. METHODS: A standardized handheld ruler measuring technique is described for the assessment of the position and the movement of five points marked on the lips. The measured points are used to characterize the position of the mouth at rest and the movement that occurs with smiling. The technique uses two transparent rulers that are held in the examiner's hand. Using this technique, two experienced examiners separately measured the rest position of 21 unilateral facial paralysis patients twice, creating 84 sets of measurements. Accuracy was assessed by simultaneously measuring the movement of the commissure and mid upper lip during smiling on 10 normal persons using both handheld ruler and a proven technique, the facial reanimation measurement system. RESULTS: The average intraclass correlation coefficients for interrater and intrarater reliability exceed 0.89. The mean difference between the handheld ruler and facial reanimation measurement system measurements was 1.7 mm. CONCLUSION: The handheld ruler technique is simple, reliable, and accurate, providing useful measurements for the evaluation of facial paralysis reconstructions.

Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation.

BACKGROUND: This study assesses the ability of the masseter motor nerve-innervated microneurovascular muscle transfer to produce an effective smile in adult patients with bilateral and unilateral facial paralysis. METHODS: The operation consists of a one-stage microneurovascular transfer of a portion of the gracilis muscle that is innervated with the masseter motor nerve. The muscle is inserted into the cheek and attached to the mouth to produce a smile. The outcomes assessed were the amount of movement of the transferred muscle; the aesthetic quality of the smile; the control, use, and spontaneity of the smile; and the functional effects on eating, drinking, and speech. The study included 27 patients aged 16 to 61 years who received 45 muscle transfers. RESULTS: All 45 muscle transfers developed movement. The commissure movement averaged 13.0 +/- 4.7 mm at an angle of 47 +/- 15 degrees above the horizontal, and the mid upper lip movement averaged 8.3 +/- 3.0 mm at 42 +/- 17 degrees. Age did not affect the amount of movement. Patients older than 50 years had the same amount of movement as patients younger than 26 years (p = 0.605). Ninety-six percent of patients were satisfied with their smile. CONCLUSIONS: A spontaneous smile, the ability to smile without thinking about it, occurred routinely in 59 percent and occasionally in 29 percent of patients. Eighty-five percent of patients learned to smile without biting. Age did not affect the degree of spontaneity of smiling or the patient's ability to smile without biting.

A comparison of commissure excursion following gracilis muscle transplantation for facial paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve.

BACKGROUND: The microneurovascular transfer of a free muscle transplant is the procedure of choice for facial animation in a child with facial paralysis. One of the critical factors of this procedure is the selection of a motor nerve to innervate the transplanted muscle. METHODS: From 1989 to 1999, 166 free segmental gracilis muscle transfers were performed in 121 children for facial animation. The cross-face nerve graft was used in 70 procedures (cross-face nerve graft group) to innervate the muscle by branches of the seventh nerve for the normal side. The ipsilateral masseteric nerve was used in 94 procedures (50 patients, masseter group) and the ipsilateral accessory nerve was used in two procedures (one patient). To compare the operative procedures between the first two groups, all charts were reviewed. The extent of oral commissure movement was determined by measurements taken from the tragion to the oral commissure, both at rest and with full smile. In the cross-face nerve graft group (n = 20), the extents were measured on both the normal side and the reconstructed side; in the masseter group (n = 16), they were measured on the left and right sides. RESULTS: No significant difference was found between the two groups (p < 0.05) for the mean age at the time of muscle transplantation, for the total operation time for muscle transplantation, and for the length of the muscle used or for the fraction of circumference of the segment of gracilis muscle used. Although the operative variables were similar between two groups, the muscle excursion differed. Excursion in the cross-face nerve graft group was less than that on the right (p = 0.0006) or left (p = 0.0000) in the masseter group. It was also less than on the normal side (p = 0.0000) of the cross-face nerve graft group. Also, there was no significant difference between the left and right sides within the masseter group (p < 0.05). Furthermore, the extent of oral commissure movement in the masseter group was similar to that of the normal side in the cross-face nerve graft group (p = 0.35, p = 0.61). CONCLUSION: These results indicate that segmental gracilis muscle transplantation using the motor nerve to the masseter nerve for facial animation in children is a very reproducible operation and provides a commissure excursion in the range of normal.

Evaluation of a new measurement tool for facial paralysis reconstruction.

Evaluation of facial movement, including distance and direction, is essential for anyone interested in facial paralysis reconstruction. The authors' goal was to develop a measurement system that is simple, uses commercially available equipment, takes little time, and provides meaningful and accurate measurements. This technique is called the facial reanimation measurement system. It involves placing dots around the patient's mouth and video recording the patient performing maximal effort smiles. Using a video editing program, one frame showing the patient at rest is overlaid with a second frame showing the patient's smile. This overlaid image is imported into Adobe PhotoShop, where measurements are obtained using tools available in the program. Twenty patients were used to test interrater and intrarater reliability of the facial reanimation measurement system. The accuracy of the measurement process was tested by comparing 10 known distances and angles with those obtained using the facial reanimation measurement system. Both intrarater and interrater reliability of the distance and angle measurements are highly accurate, with intraclass correlations greater than 0.9. The facial reanimation measurement system is accurate to within 0.6 mm and 2.0 degrees when compared with a "known" distance and angle. The facial reanimation measurement system has been used to measure smile movements of more than 200 patients and has been demonstrated to be valuable for detecting changes of facial movements over time. This system is simple and economical and only requires 20 minutes to perform. Although the authors demonstrated evaluation of smile movement, the system may be used to evaluate other movements, such as mouth puckering, eye closure, and forehead elevation.

Carpal tunnel syndrome: cross-sectional and outcome study in Ontario workers.

PURPOSE: To carry out an analytic cross-sectional study of Ontario workers with carpal tunnel syndrome (CTS) and to assess workers' symptoms, functional disabilities, recreational difficulties, and work capability 4 years after treatment of their CTS. METHODS: Data were obtained by review of Ontario Workers Safety and Insurance Board (WSIB) files and by completion of self-assessment questionnaires. Inclusion criteria included all workers registered with the Ontario WSIB who were off work with newly diagnosed carpal tunnel syndrome in 1996. RESULTS: There are 3 million workers covered by the WSIB in the province of Ontario. In 1996, 964 of them developed work-related CTS that required time off for treatment. Of these patients 53% were women and 75% had bilateral CTS. Eighty-one percent of the unilateral cases involved the dominant extremity. The average age at the time of claim was 41 years and workers were at the same job type for an average of 7.4 years (unilateral) and 8.5 years (bilateral), respectively. Thirty-nine percent of workers had a history of another tendonitis or epicondylitis. Seventy-five percent of workers had surgery and on average returned to work 3 months later. Four years after treatment, outcome was assessed by self-administered questionnaires, for which there was a 73% response rate. Forty-six percent of workers experienced moderate to severe pain, 47% had moderate to severe numbness, and 40% had difficulty grasping and using small objects. Only 14% were symptom free. Successful return to work was considered to be a return to the same job with or without modifications, and it occurred in 64% of cases. Better clinical outcome scores were found to occur with surgery and abnormal nerve conduction study results. Worse clinical outcome scores were present with repeat surgery and surgical complications. Concurrent diagnoses of either tendonitis or epicondylitis also resulted in worse clinical outcome scores and worse return-to-work outcomes. The average total cost in Canadian dollars to the WSIB exceeded $13,700 per worker for a total cost in excess of $13,200,000 per year. (In 1996, $1 Canadian = $1.365 US.) CONCLUSIONS: These outcomes indicate that Canadian workers have a large amount of permanent pain and suffering, a large loss of work productivity, and incur a considerable financial cost as a result of work-related CTS.

The effects of gracilis muscle transplantation on speech in children with Moebius syndrome.

Speech and communication are major problems for children with Moebius syndrome, a congenital anomaly that includes facial and abducens nerve paralysis and, often, other cranial nerve deficits. In addition, these children frequently have severe functional problems such as drooling as well as poor self-esteem. The purpose of this study was to investigate the outcome of speech with bilateral gracilis muscle transplants innervated by the masseteric nerve in children with Moebius syndrome. The outcome of this two-stage procedure was investigated in 12 patients. Assessments were done before and after surgery, and additional data were collected from video records. After surgery, the children showed improved intelligibility of speech with a significantly lower frequency of all compensatory phonemes, including the sounds of /p/, /b/, /m/, /w/, "sh", /f/, and /v/. This procedure had evident positive impact in all problematic areas and is the procedure of choice for these unfortunate children.

Tendon function after replantation: prognostic factors and strategies to enhance total active motion.

The purpose of this study was to determine the important prognostic factors for recovery of tendon function as measured by total active movement (TAM) in patients undergoing digital replantation. More important, the authors wanted to establish which factors may be manipulated to maximize motion. A retrospective review of 48 patients (103 digital rays) who underwent replantation was performed. Average TAM for all digits was 129 deg. Zone 1 and zone 5 injuries had better TAM than injuries in zones 2, 3, and 4, which had TAM values not significantly different from one another. Avulsion injuries fared significantly worse than other mechanisms of injury. TAM values were not affected by age, type of bone fixation, number of arteries repaired, or number of digits injured. Digits with both the profundus and the superficialis tendons repaired had significantly better TAM values relative to one-tendon fingers. Similarly, fingers treated with an "early" mobilization regime also exhibited better movement. Small numbers of injured digits in some groups may have limited our ability to detect significant differences.