Free Vascularized Scapula tip Flap to L5-S1 Vertebral Defect After Chronic Infection Related to Interbody Fusion Cage: A Case Report.

Septic nonunion after vertebral fusion can lead to significant patient disability. The management of septic nonunions usually involves surgical debridement, bone fixation, and antibiotic therapy. Particularly challenging is lumbosacral vertebral nonunions, which necessitate a difficult surgical approach. We present a novel approach using a scapula tip free flap through an intra-abdominal approach to reconstruct a L5-S1 vertebral defect after a septic nonunion. Our patient, 31-year-old man, with no medical conditions, had a fusion of L5-S1 due to severe lower back pain secondary to isthmic spondylolysis and spondylolisthesis. Despite multiple attempts of surgical fusion, postoperatively the patient developed a septic nonunion. Following a modified DAIR, the nonunion was reconstructed with a scapula tip bone flap 4 × 3 × 2 cm. The subscapular vessels were anastomosed to the deep inferior epigastric vessels after an intra-abdominal inset. The patient was discharged at 15 days postoperatively without any complications. At 1-year follow-up the patient is pain-free, off opiate analgesia with radiological evidence of fusion between the scapula tip, L5 and the S1 vertebral body. This case report describes the use, for the first time, of a free scapula tip, to a lumbosacral spinal defect. The use of the free scapula tip flap may be considered for reconstruction of osseous spinal defects due to its long pedicle and the unique bone shape.

Rethinking Oncologic Facial Nerve Reconstruction in the Acute Phase Through Classification of the Level of Injury.

Early facial nerve reconstruction should be offered in every patient with oncological resections of the facial nerve due to the debilitating functional and psychosocial consequences of facial nerve palsy. Oncologic pathology or oncologic resection accounts for the second most common cause of facial nerve palsy. In the case of these acute injuries, selecting an adequate method for reconstruction to optimize functional and psychosocial well-being is paramount. Authors advocate consideration of the level of injury as a framework for approaching the viable options of reconstruction systematically. Authors breakdown oncologic injuries to the facial nerve in three levels in relation to their nerve reconstruction methods and strategies: Level I (intracranial to intratemporal), Level II (intratemporal to extratemporal and intraparotid), and Level III (extratemporal and extraparotid). Clinical features, common clinical scenarios, donor nerves available, recipient nerve, and reconstruction priorities will be present at each level. Additionally, examples of clinical cases will be shared to illustrate the utility of framing acute facial nerve injuries within injury levels. Selecting donor nerves is critical in successful facial nerve reconstruction in oncological patients. Usually, a combination of facial and nonfacial donor nerves (hybrid) is necessary to achieve maximal reinnervation of the mimetic muscles. Our proposed classification of three levels of facial nerve injuries provides a selection guide, which prioritizes methods for function nerve reconstruction in relation of the injury level in oncologic patients while prioritizing functional outcomes.

Selective ansa cervicalis nerve transfer to the marginal mandibular nerve for lower lip reanimation: An anatomical study in cadavers and a case report.

BACKGROUND: Donor nerve options for lower lip reanimation are limited in patients undergoing oncological resection of the facial nerve. The ansa cervicalis nerve (ACN) is an advantageously situated donor with great potential but has not been examined in detail. In the current study, the anatomical technical feasibility of selective ACN to marginal mandibular nerve (MMN) transfer for restoration of lower lip tone and symmetry was explored. A clinical case is presented. METHODS: Dissections were conducted in 21 hemifaces in non-embalmed human cadavers. The maximal harvestable length of ACN was measured and transfer to MMN was simulated. A 28-year-old male underwent ACN-MMN transfer after parotidectomy (carcinoma) and was evaluated 12 months post-operatively (modified Terzis' Lower Lip Grading Scale [25 observers] and photogrammetry). RESULTS: The harvestable length of ACN was 100 ± 12 mm. A clinically significant anatomical variant ("short ansa") was present in 33% of cases (length: 37 ± 12 mm). Tensionless coaptation was possible in all cases only when using a modification of the surgical technique in "short ansa" cases (using an infrahyoid muscle nerve branch as an extension). The post-operative course of the clinical case was uneventful without complications, with improvement in tone, symmetry, and function at the lower lip at 12-month post-operative follow-up. CONCLUSIONS: Selective ACN-MMN nerve transfer is anatomically feasible in facial paralysis following oncological ablative procedures. It allows direct nerve coaptation without significant donor site morbidity. The clinical case showed good outcomes 12 months post-operatively. A strategy when encountering the "short ansa" anatomical variant in clinical cases is proposed.

Anatomical Features in Lower-Lip Depressor Muscles for Optimization of Myectomies in Marginal Mandibular Nerve Palsy.

INTRODUCTION: Myectomies of the lower-lip depressor muscles, with the aim to improve facial balance in unilateral facial paralysis, have unexplained high recurrence rates. A potential explanation is that these recurrences are due to inadequate resection through the muscle width, leaving lateral muscle fibers intact. AIM: Revisit the anatomy of the lower-lip depressor muscles and suggest an optimization of the surgical technique. Perform a literature review to identify recurrence rates and surgical technique of the procedure. MATERIALS AND METHODS: Ten fresh hemifaces were dissected. The following measurements of depressor labii inferioris and depressor anguli oris were made: the widths of the muscles, the distance from the mandibular midline to the lateral borders of the muscles, and the intraoral distance from the lateral canine to the lateral border of depressor anguli oris. A literature review was performed. RESULTS: The width of depressor labii inferioris was 20 ±â€Š4 mm and depressor anguli oris 14 ±â€Š3 mm. The distance from the midline to the lateral border of depressor labii inferioris was 32 ±â€Š4 mm and 54 ±â€Š4 mm for depressor anguli oris. The literature review revealed a mean recurrence rate of 21%. DISCUSSION: A potential optimization of the surgical technique in lower-lip depressor myectomies is to extend the muscle resection laterally. To ensure inclusion of the whole width of the depressor muscles and decrease the recurrence rates of the procedure, the measurements presented in this study should be kept in mind during surgery.

Microsurgical Salvage of Acute Lower Limb Ischemia after Iatrogenic Femoral Injury during Orthopedic Surgery in a Pediatric Patient.

Acute lower limb ischemia (ALLI) in the pediatric population is rare but may lead to limb loss and life-long complications. We report the technique and outcomes of microsurgical salvage of ALLI in a preterm newborn after open reduction of congenital hip dysplasia. A 2-month-old girl was born premature at week 36 with congenital bilateral hip dysplasia. The initial management attempted was conservative and entailed placement of bilateral Von Rosen splints. The treatment was successful on the left side, but the patient had recurrent unstable hip dislocation on the right side. Subsequently, 2 attempts at close reduction under general anesthesia were done and both were unsuccessful in maintaining the right hip in the acetabulum. Therefore, an open reduction of the right hip was planned through a medial/obturator approach. During the surgical procedure, the neurovascular femoral bundle (including the superficial femoral artery [SFA], femoral vein [FV], and femoral nerve) was accidently transected with subsequent development of ALLI. Therefore, the FV was harvested distally to the injury site and a 4-cm long healthy segment was obtained. It was reversed, flushed with heparin, spatulated at both extremities, and interposed to the SFA in end-to-end fashion using two 9/0 polypropylene interrupted sutures under microscope. Reperfusion of the limb was noted immediately after releasing the vascular clamps. The final ischemia time at completion of the surgical procedure was 6 hr. Thereby, prophylactic 4-compartment fasciotomies were performed in the right leg. The patient tolerated the procedure well and the postoperative clinical course was free from adverse events. Duplex ultrasound examination at 6 weeks after the intervention confirmed sustained clinical success and showed no signs of venous thromboembolism. At the same time, X-ray examination of the right hip confirmed adequate and stable reduction of the joint in the acetabulum. ALLI due to accidental arterial injury during orthopedic surgical procedures for congenital defects in newborns is a rare but potentially devastating complication. Microsurgical salvage is a safe, feasible, and effective option to restore limb flow. Multidisciplinary expertise and meticulous technique are mandatory in order to achieve satisfactory and durable outcomes.

Endoscopic assisted insetting of free flaps in anterior skull base reconstruction: A preliminary report of five cases.

INTRODUCTION: Free vascularized tissue may provide a robust reconstruction after anterior skull base surgery. We report our technique and outcomes of the endoscopic inset of free flaps in anterior skull base reconstructions. METHODS: Between 2016 and 2018, endoscopic tumor removal and reconstruction of anterior skull base pathology was performed in five patients aged 20-72 years old (four male, one female). The tumors included three neuroblastomas, a carcinoma, an adenoma, and a melanoma. The median size of the defect was 3.7 × 6.6 cm. Transmaxillary access was gained through the upper sulcus and an anterior and medial maxillectomy. The flap inset was facilitated by the endoscope. The donor vessels were tunneled through the sinus and through the cheek to the facial vessels without the use of the endoscope. RESULTS: In three cases a vastus lateralis flap was used, in one case an adipofascial ALT flap and in one case an adipofascial radial forearm flap. Separation of intracranial and sinonasal spaces was confirmed by radiological and endoscopic examinations. There was no flap failure and one case with partial necrosis. One of the flaps needed to be trimmed as it obliterated the nasal cavity and in one of the cases the flap was repositioned postoperatively. Two cases had infectious complications. The mean follow-up of the patients was 13.8 months. CONCLUSIONS: Endoscopic assisted inset of a free flap in the anterior skull base was feasible in the five cases we present. A dedicated, multidisciplinary approach is mandatory for surgical innovation like this.

Usefulness of a template-based anterolateral thigh flap for reconstruction of head and neck defects.

BACKGROUND: One of the challenges in head and neck reconstruction is to have an adequate understanding of the three-dimensionalities of the defects created after resections due to the high variability of clinical scenarios. Consequently, it is essential to design the flap to match the requirements of the defect in order to facilitate the insetting and to achieve a successful outcome. The anterolateral thigh flap (ALT) is a robust and versatile flap commonly used in head and neck reconstruction. In this study the authors use a hand-made template as a tool to customize ALT flaps and its variations to fit more accurately the different shapes, volume, and components of the resulting defects. The aim of this study is to describe in detail this surgical approach and present the clinical experience in 100 consecutive cases using a template-based ALT flaps in head and neck reconstruction. METHODS: A retrospective review was performed on all microvascular head and neck reconstruction cases between January 2013 and December 2017 in our institution where a template-based ALT flap design was performed. We describe in detail the surgical technique used and present the clinical outcomes. In addition, we analyzed the use of different designs of the ALT flaps including different flap components in relation to the location of the defect. RESULTS: One hundred reconstructions for head and neck defects were performed in 97 patients. Seven types of ALT free flaps were performed: fasciocutaneous (46%), suprafascial (8%), adipofascial (9%), vastus lateralis muscle (3%), composite fasciocutaneous/adipofascial (9%), chimeric flaps (21%), and vascularized nerve grafts (4%). Oropharyngeal and periauricular defects were mostly reconstructed with fasciocutanoues design. In more complex three-dimensional defects such as skull base or midface defects, a chimeric flap was selected. In all cases the used of template facilitated the insetting of the free flap. The total flap loss was 2%. CONCLUSIONS: Customization of ALT flaps using intraoperative templates is a useful method for flap design which facilitates fitting of the flap to a variety of defects in head and neck reconstruction.

Oculo-zygomatic nerve transfer for facial synkinesis: An anatomical feasibility study.

BACKGROUND: Patients with severe oro-ocular synkinesis often present with concomitant inefficient smile excursion on the affected site. In theory, oculo-zygomatic nerve transfer may decrease synkinesis and improve smile by redirecting nerve fibers to their target muscle. The aim of this study was to explore the feasibility of nerve transfer in human cadavers between a caudal branch innervating the orbicularis oculi to a cephalad branch innervating the zygomaticus major muscles. METHODS: Eighteen hemi-faces were dissected. Reach for direct coaptation of a caudal nerve branch innervating the orbicularis oculi muscle to a cephalad nerve branch innervating the zygomaticus major muscle was assessed. Measurements included total number of nerve branches as well as maximum dissection length. Nerve samples were taken from both branches at the site of coaptation and histomorphometric analysis for axonal count was performed. RESULTS: The number of sub-branches to the orbicularis oculi muscle was 3.1 ± 1.0 and to the zygomaticus major muscle 4.7 ± 1.2. The maximal length of dissection of the caudal nerve branch to the orbicularis oculi muscle was 28.3 ± 7.3 mm and for the cranial nerve branch to the zygomaticus major muscle 23.8 ± 6.5 mm. Transection and tension-free coaptation was possible in all cases but one. The average myelinated fiber counts per mm2 was of 5,173 ± 2,293 for the caudal orbicularis oculi branch and 5,256 ± 1,774 for the cephalad zygomaticus major branch. CONCLUSION: Oculo-zygomatic nerve transfer is an anatomically feasible procedure. The clinical value of this procedure, however, remains to be proven.

Contemporary Concepts of Primary Dynamic Facial Nerve Reconstruction in the Oncologic Patient.

Transection of the facial nerve and its branches during extensive ablative procedures in the oncologic patient causes loss of control of facial mimetic muscles with severe functional and aesthetic sequelae. In such patients with advanced tumorous disease, copious comorbidities, and poor prognosis, rehabilitation of the facial nerve has long been considered of secondary priority. However, recent advances in primary facial nerve reconstruction after extensive resection demonstrated encouraging results focusing on rapid and reliable restoration of facial functions. The authors summarize 3 innovative approaches of primary dynamic facial nerve reconstruction by using vascularized nerve grafts, dual innervation concepts, and intra-facial nerve transfers.

Relational Anatomy of the Mimetic Muscles and Its Implications on Free Functional Muscle Inset in Facial Reanimation.

BACKGROUND: The human smile is a complex coordinated activity of mimetic muscles predominantly recognizable by a superolateral pull at the commissure and elevation of the upper lip. The aim of this study was to revisit the muscles of facial expression responsible for these motions, evaluate their relational anatomy and orientation, and relate this to optimal positioning of free muscle transfer in smile reanimation. METHODS: Nineteen hemifaces from fresh cadaveric specimens were dissected. A subsuperficial muscular aponeurotic system skin flap was elevated to expose the zygomaticus major, zygomaticus minor, levator labii superioris, and levator labii superioris alaeque nasi. Muscle location, length, width, angle of pull, and any anatomic variation were noted. RESULTS: All specimens had zygomaticus major, levator labii superioris, and levator labii superioris alaeque nasi muscles present bilaterally. Conversely, the zygomaticus minor was present in only 10 of 19 hemifaces. There was no significant difference in muscle length, width, or line of pull between specimen sides. Of all the assessed muscles, the zygomaticus minor had the most transverse line of pull, at 31.6°; the zygomaticus major was more oblique with a line of pull of 55.5°; and the levator labii superioris and levator labii superioris alaeque nasi were oriented almost vertically with angles of 74.7° and 79.0°, respectively. CONCLUSIONS: The mimetic muscle vector is quite vertical in comparison to the angle obtained by traditional dynamic smile reconstruction surgeries. A more vertical vector, especially at the upper lip, should be considered in smile reconstruction.

Free anterolateral thigh flap and masseter nerve transfer for reconstruction of extensive periauricular defects: Surgical technique and clinical outcomes.

BACKGROUND: Radical tumor ablation in the periauricular area often results in extensive soft tissue defects, including facial nerve sacrifice, bone and/or dura defects. Reconstruction of these defects should aim at restoring facial reanimation, wound closure, and facial and neck contours. We present our experience using free anterolateral thigh flap (ALT) in combination with masseter nerve to facial nerve transfer in managing complex defects in the periauricular area. METHODS: Between 2011 and 2015 six patients underwent a combined procedure of ALT flap reconstruction and masseter nerve transfer, to reconstruct extensive, post tumor resection, periauricular defects. The ALT flap was customized according to the defect. For smile restoration, the masseter nerve was transferred to the buccal branch of the facial nerve. If the facial nerve stump was preserved, interposition of nerve grafts to the zygomatic and frontal branches was performed to provide separate eye closure. The outcomes were analyzed by assessing wound closure, contour deformity, symmetry of the face, and facial nerve function. RESULTS: There were no partial or total flap losses. Stable wound closure and adequate volume replacement in the neck was achieved in all cases, as well as good facial tonus and symmetry. The mean follow-up time of clinical outcomes was 16.8 months. Smile restoration was graded as good or excellent in four cases, moderate in one and fair in one. CONCLUSION: Extensive periauricular defects following oncologic resection could be adequately reconstructed in a combined procedure of free ALT flap and masseter nerve transfer to the facial nerve for smile restoration.

Reconstruction of late esophagus perforation after anterior cervical spine fusion with an adipofascial anterolateral thigh free flap: A case report.

Reconstruction of late esophageal perforation usually requires flap surgery to achieve wound healing. However, restoring the continuity between the digestive tract and retropharyngeal space to allow for normal swallowing remains a technical challenge. In this report, we describe the use of a thin and pliable free adipofascial anterolateral thigh (ALT) flap in a 47-year-old tetraplegic man with a history of C5-C6 fracture presented with a large posterior esophagus wall perforation allowing an easier flap insetting for a successful wound closure. The postoperative course was uneventful and mucosalization of the flap was confirmed by esophagoscopy 4 weeks postsurgery. The patient tolerated normal diet and maintained normal swallowing during a follow-up of 3 years postoperatively. The adipofascial ALT flap may provide easier insetting due to the thin and pliable layer of adipofascial tissue for reconstructing large defects of the posterior wall of the esophagus by filling the retroesophageal space.

Benefits of two or more senior microsurgeons operating simultaneously in microsurgical breast reconstruction: Experience in a swedish medical center.

BACKGROUND: The aim of this study is to evaluate how the number of senior microsurgeons, performing autologous microvascular breast reconstruction together, influences operating time and postoperative complications. METHODS: A retrospective study was carried out in one hundred consecutive patients who underwent unilateral delayed deep inferior epigastric perforator flap reconstruction at a single institution. All patients followed our institution's surgical protocol and were divided into groups depending on the number of senior microsurgeons that simultaneously performed the procedure. Operating time and complications were compared between the groups. RESULTS: Sixteen of the patients were operated by one single microsurgically trained specialist, 64 by two and 20 by three specialists. The mean operating time for the one microsurgeon's group was 286 ± 84 min, for the two-microsurgeons' group 265 ± 57 min and for the three-microsurgeons' group 251 ± 59 min. There was a trend of decreasing operating times when more microsurgeons performed surgery together, however the difference between groups was not statistically significant (P = 0.251). Total flap failure rate was 2% (2/100). Both cases occurred in the group operated by one single microsurgeon (2/16) compared with two microsurgeon's group (0/64) and three microsurgeon's group (0/20; P < 0.005). CONCLUSIONS: By optimising the surgical experience available during microvascular breast reconstruction, operating time can be reduced and efficiency improved. In the current setting, two microsurgically trained surgeons achieved optimal operation flow with the lowest complication rate. © 2016 Wiley Periodicals, Inc. Microsurgery 37:416-420, 2017.

Vastus lateralis vascularized nerve graft in facial nerve reconstruction: an anatomical cadaveric study and clinical implications.

BACKGROUND: The present study investigates the vascular anatomy of the vastus lateralis motor nerve (VLMN) to be used as a vascularized nerve graft in facial nerve reconstruction. We evaluated the maximum length of the nerve that can be included in the flap and its vascular pedicle. In addition, we discuss its adequacy for use in early reconstruction of the facial nerve both as ipsilateral facial nerve reconstruction and as cross-facial nerve graft. METHODS: Five fresh cadavers were used in this study. In all specimens, the VLMN and its vascular pedicle were dissected, photodocumented and measured using calipers. In addition, two vascularized VLMN were injected with a radiopaque contrast and underwent CT angiography and three dimensional reconstructions were scanned to illustrate the vascular supply of the nerve using OsiriX Software. RESULTS: The VLMN was divided into two divisions, an oblique proximal and a descending distal, in 70% of the dissections with a mean maximal length of 8.4 ± 4.5 cm for the oblique division and 15.03 ± 3.87 cm for the descending division. The length of the oblique division, when present, was shorter than the length of the descending branch in all specimens. The mean length of the pedicle was 2.93 ± 1.69 cm, and 3.27 ± 1.49 cm until crossing the oblique and the descending division of the nerve respectively. The mean caliber of the nerve was 2.4 ± 0.62 mm. Three-dimensional computed tomography angiography demonstrated perfusion throughout the entire VLMN by branches from the descending branch of the lateral femoral circumflex artery which ran parallel to the descending division of the VLMN. Additionally, we observed that technically it was possible to preserve the oblique branch of the VLMN. CONCLUSION: This study confirms that VLMN presents adequate anatomic features to be used as a vascularized nerve graft for facial nerve reconstruction in terms of length, pedicle, and caliber.

Influence of flap prefabrication on seeding of subcutaneously injected mesenchymal stem cells in microvascular beds in rats.

BACKGROUND: In this article, the authors investigated whether the prefabrication of an autologous pedicled flap by isolation from the surrounding with artificial skin substitutes would increase mesenchymal stem cell (MSC) seeding. METHODS: Mesenchymal stem cells were isolated from human umbilical cords and were cultured and characterized by fluorescence-activated cell sorting. Oxacarbocyanine and its green fluorescence emission were used to label the MSCs population.Sixteen adult Wistar rats were randomized in 4 groups (n = 4 animals per group). In group 1, a prefabricated groin flap (GF) with skin substitutes was harvested without cell injection; in group 2, 1 million MSCs were injected subcutaneously in the area corresponding to the GF without flap harvesting; in Group 3, a prefabricated GF with skin substitutes was harvested and 1 million MSCs were injected subcutaneously; and in Group 4, a prefabricated GF with skin substitutes was harvested and 2 million MSCs were injected subcutaneously. All procedures were performed bilaterally in each animal. Animals were sacrificed 2 weeks after the surgery. Flap viability was then assessed by clinical inspection and histology, and seeding of MSCs was observed. RESULTS: All flaps survived 2 weeks after the surgery. Oxacarbocyanine-labeled cells were found in all prefabricated flaps injected (Groups 3 and 4) in higher number in comparison with the group where subcutaneous injection without flap harvesting was performed (Group 2). This difference was statistically significant (P < 0.05). CONCLUSIONS: Prefabricated skin flaps with skin substitutes may provide a useful vehicle for the implantation of MSCs to serve as an autologous microvascular bioscaffold.

Fibula osteo-adipofascial flap for reconstruction of a cervical spine and posterior pharyngeal wall defect.

When reconstructing combined defects of the cervical spine and the posterior pharyngeal wall the goals are bone stability along with continuity of the aerodigestive tract. We present a case of a patient with a cervical spine defect, including C1 to C3, associated with a posterior pharyngeal wall defect after excision of a chordoma and postoperative radiotherapy. The situation was successfully solved with a free fibula osteo-adipofascial flap. The reconstruction with a fibula osteo-adipofascial flap provided several benefits in comparison with a fibula osteo-cutaneous flap in our case, including an easier insetting of the soft tissue component at the pharyngeal level and less bulkiness of the flap allowing our patient to resume normal deglutition.

The Role of Deep Inferior Epigastric Perforator and Thoracodorsal Artery Perforator Flaps in Head and Neck Reconstruction.

Head and neck reconstruction has evolved to a more accurate replacement of the missing tissues for aesthetic and functional benefits, besides a concern with the morbidity caused in the donor site. This has led us to the use of perforator flaps. Deep inferior epigastric perforator flap allows the harvest of a large well-vascularized skin paddle with adequate bulk for large and voluminous defects reconstruction. Its main uses described in the literature are: tongue reconstruction, orbitomaxillary reconstruction, and scalp reconstruction. Thoracodorsal artery perforator flap is derived from the subscapular system and allows the harvest of a large array of chimeric flaps.

Tips to Virtually Plan Your Free Scapula Flap.

The use of virtual surgical planning (VSP) and computer-aided design and manufacturing to assist in osseous reconstruction has become the standard of care in head and neck reconstruction. The use of the free fibula flap with VSP remains the most common flap for osseous reconstruction, and as such, it is well described in the published literature. The scapular free flap (SFF) based on the angular branch has not yet garnered the same attention. The popularity of the SFF osseus head and neck reconstruction is increasing due to the flaps' inherently different properties and indications it can fulfill; the natural curvature of the bone, the reduced incidence of atheroscelerosis in the donor vessels and the earlier postoperative mobilization of the patient. In the preoperative planning process, the SFF presents several unique challenges and considerations that differ from the free fibula flap. It is important for surgeons already using, or considering using the SFF, that VSP is used correctly to achieve optimal outcomes. The authors aim to describe and clarify aspects of VSP use in SFF reconstruction in the head and neck area with a specific focus on: (1) The perforator-like vascular anatomy of the scapula; (2) How to maximize the shape of the scapula to minimize osteotomies; (3) Fine-tuning of scapula osteotomies on side table; (4) How to plan cutting guide placement and fit on the scapula. The authors hope that this article will help reconstructive microsurgeons plan and perform the SFF in conjunction with VSP.

Feasibility of a cross-face reconstruction of the mental nerve-A cadaveric simulation study with histomorphometric analysis.

INTRODUCTION: The inevitable sacrifice of the inferior alveolar nerve during oncologic resections results in substantial sensory impairment, impacting crucial functions such as speech, saliva retention, and mastication. This study investigated the feasibility of sensory restoration through cross-face reconstruction of the mental nerve via a contralateral mental nerve branch. METHODS: The cross-face reconstruction procedure was simulated in five formalin-fixed cadavers in both sides to evaluate the anatomic fundamentals and the nerve gap between the mental nerve main trunk and transferred contralateral mental nerve branch. Furthermore, a histomorphometric analysis was performed to assess the cross-sectional area and axon counts. RESULTS: The mean gap distance between the main mental nerve trunk and transferred contralateral branch was 15.3 mm. End-to-end coaptation was achieved in nine out of ten simulations. The mean cross-sectional area was 0.996 mm2 at the main mental nerve trunk and 0.253 mm2 at the coaptation site of the nerve branch. The mean donor-to-recipient axon ratio was found to be 0.3:1. CONCLUSION: The cadaveric simulation demonstrates the feasibility of a cross-face reconstruction of the mental nerve with only minimal gapping. Advantages of the proposed technique include the use of shorter nerve grafts, to minimize donor site morbidity and enable fast reinnervation. This technique may offer a promising method to enhance the quality of life in patients by increasing survival rates and life expectancy.

Preoperative assessment of depressor anguli oris to prevent myectomy failure: An anatomical study using high-resolution ultrasound.

BACKGROUND: Myectomies of the lower lip depressor muscles have unexplained high failure rates. This study aimed to examine the depressor anguli oris (DAO) muscle using high-resolution ultrasound to identify potential anatomical explanations for surgical failures and to determine the accuracy of utilizing preoperative ultrasound assessment to improve myectomies. METHODS: Anatomical features of DAO and the surrounding anatomy were examined in 38 hemifaces of human body donors using high-resolution ultrasound and dissection. RESULTS: The ultrasound and dissection measurements showed the DAO muscle width to be 16.2 ± 2.9 versus 14.5 ± 2.5 mm, respectively, and the location of the lateral muscle border 54.4 ± 5.7 versus 52.3 ± 5.4 mm lateral to the midline. In 60% of the cases, the facial artery was either completely covered by lateral DAO muscle fibers or was found to be in direct contact with the lateral border. Significant muscle fiber continuity was present between the DAO and surrounding muscles in 5% of cases, whereas continuity between the depressor labii inferioris and surrounding muscles was considerably more common and pronounced. CONCLUSIONS: High-resolution ultrasound can accurately reveal important preoperative anatomical information in myectomies. Two potential explanations for the surgical failures were discovered: an overlap of lateral DAO muscle fibers over the facial artery could lead to inadequate resections and continuity with the surrounding muscles might lead to muscle function takeover despite adequate resections. Both can be uncovered preoperatively by the surgeon through a brief, directed ultrasound examination, which may allow for modification of the surgical plan to reduce surgical failure.