RESUMO
BACKGROUND: This work aimed to investigate the change in fingerprint depth and the recovery rule of fingerprint biological recognition function after repairing finger abdominal defects and rebuilding fingerprint with a free flap. METHOD: From April 2018 to March 2023, we collected a total of 43 cases of repairing finger pulp defects using the free flap of the fibular side of the great toe with the digital nerve. After surgery, irregular follow-up visits were conducted to observe fingerprint clarity, perform the ninhydrin test or detect visible sweating with the naked eye. We recorded fingerprint clarity, nail shape, two-point discrimination, cold perception, warm perception and fingerprint recognition using smartphones. The reconstruction process of the repaired finger was recorded to understand the changes in various observation indicators and their relationship with the depth of the fingerprint. The correlation between fingerprint depth and neural repair was determined, and the process of fingerprint biological recognition function repair was elucidated. RESULT: All flaps survived, and we observed various manifestations in different stages of nerve recovery. The reconstructed fingerprint had a clear fuzzy process, and the depth changes of the fingerprint were consistent with the changes in the biological recognition function curve. CONCLUSION: The free flap with the digital nerve is used to repair finger pulp defects. The reconstructed fingerprint has a biological recognition function, and the depth of the fingerprint is correlated with the process of nerve repair. The fingerprint morphology has a dynamic recovery process, and it can reach a stable state after 6-8 months.
Assuntos
Traumatismos dos Dedos , Retalhos de Tecido Biológico , Lesões dos Tecidos Moles , Humanos , Masculino , Feminino , Adulto , Retalhos de Tecido Biológico/transplante , Retalhos de Tecido Biológico/inervação , Pessoa de Meia-Idade , Traumatismos dos Dedos/cirurgia , Lesões dos Tecidos Moles/cirurgia , Adulto Jovem , Recuperação de Função Fisiológica , Procedimentos de Cirurgia Plástica/métodos , Dedos do Pé/cirurgia , Dedos do Pé/inervação , Dedos/inervação , Dedos/cirurgia , Resultado do Tratamento , Fíbula/transplante , Fíbula/cirurgia , Adolescente , IdosoRESUMO
BACKGROUND: In facial reanimation, dual-innervated gracilis free functional muscle transfers (FFMTs) may have amalgamated increases in tone, excursion, synchroneity, and potentially spontaneity when compared with single innervation. The ideal staging of dual-innervated gracilis FFMTs has not been investigated. We aim to compare objective long-term outcomes following one- and two-stage dual-innervated gracilis FFMTs. METHODS: Included were adult patients with facial paralysis who underwent either one- (one-stage group) or two-stage (two-stage group) dual-innervated gracilis FFMT with ≥1 year of postoperative follow-up. Facial measurements were obtained from standardized photographs of patients in repose, closed-mouth smile, and open-mouth smile taken preoperatively, 1 year postoperatively, and 3 years postoperatively. Symmetry was calculated from the absolute difference between the paralyzed and healthy hemiface; a lower value indicates greater symmetry. RESULTS: Of 553 facial paralysis patients, 14 were included. Five and nine patients were in the one- and two-stage groups, with mean follow-up time, respectively, being 2.5 and 2.6 years. Within-group analysis of both groups, most paralyzed-side and symmetry measurements significantly improved over time with maintained significance at 3 years postoperatively in closed and open-mouth smile (all p ≤ 0.05). However, only the two-stage group had maintained significance in improvements at 3 years postoperatively in paralyzed-side and symmetry measurements in repose with commissure position (median change [interquartile range, IQR], 7.62 [6.00-10.56] mm), commissure angle (median change [IQR], 8.92 [6.18-13.69] degrees), commissure position symmetry (median change [IQR], -5.18 [-10.48 to -1.80] mm), commissure angle symmetry (median change [IQR], -9.78 [-11.73 to -7.32] degrees), and commissure height deviation (median change [IQR], -5.70 [-7.19 to -1.64] mm; all p ≤ 0.05). In the between-group analysis, all measurements were comparable in repose, closed-mouth smile, and open-mouth smile (all p > 0.05). CONCLUSION: Long-term outcomes demonstrate that both one- and two-stage dual-innervated gracilis FFMTs significantly improve excursion, but only two-stage reconstruction significantly improves resting tone.
Assuntos
Paralisia Facial , Retalhos de Tecido Biológico , Músculo Grácil , Humanos , Paralisia Facial/cirurgia , Paralisia Facial/fisiopatologia , Masculino , Feminino , Músculo Grácil/transplante , Músculo Grácil/inervação , Adulto , Pessoa de Meia-Idade , Resultado do Tratamento , Retalhos de Tecido Biológico/inervação , Procedimentos de Cirurgia Plástica/métodos , Sorriso/fisiologia , Seguimentos , Estudos Retrospectivos , Adulto Jovem , IdosoRESUMO
Facial paralysis (FP) is a devastating condition that can lead to significant aesthetic, social, and emotional morbidities for patients. For some patients with FP, free gracilis muscle transfer (FGMT) is the best option for smile restoration. Masseteric-driven FGMT produces a reliable voluntary smile. Cross-face nerve graft-driven FGMT can produce a spontaneous smile, but this technique has higher failure rates. Early studies suggest dual-innervation FGMT can produce a spontaneous smile while maintaining the reliability of masseteric-driven procedures. Great care should be taken during FGMT surgery to minimize facial bulk and place medial inset sutures that create a natural-appearing smile.
Assuntos
Paralisia Facial , Retalhos de Tecido Biológico , Músculo Grácil , Procedimentos de Cirurgia Plástica , Humanos , Músculo Grácil/cirurgia , Músculo Grácil/transplante , Retalhos de Tecido Biológico/inervação , Retalhos de Tecido Biológico/cirurgia , Reprodutibilidade dos Testes , Estética Dentária , Paralisia Facial/cirurgiaRESUMO
PURPOSE: In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle transplantation are often scarce. We present the results of a potential strategy using the phrenic nerve with staged free gracilis transplantation for upper extremity reanimation in these scenarios. METHODS: A retrospective review was performed on an institutional database of brachial plexus injury or patients with palsy. All patients underwent a staged reconstruction in which the ipsilateral phrenic nerve was extended by an autogenous nerve graft (PhNG), followed by free-functioning gracilis transplantation (PhNG-gracilis). RESULTS: Nine patients (6 cases of late brachial plexus birth injuries, 2 of acute flaccid myelitis, and 1 of adult chronic brachial plexus injury) were included in this study. The median follow-up period following the PhNG-gracilis procedure was 27 months (range, 12-72 months). The goals of the staged PhNG and PhNG-gracilis were primarily finger extension or finger flexion. In some patients, the technique was used to improve both elbow and finger function, tunneling the muscle through the flexor compartment of the upper arm and under the mobile wad at the elbow. All patients exhibited improvement of muscle strength, including in finger extension (4 patients) from M0 to M2; finger flexion (3 patients) from M0 to M3; elbow extension (1 patient) from M0 to M2; and elbow flexion (1 patient) from M2 to M4. CONCLUSIONS: A 2-stage PhNG-gracilis may restore or enhance the residual elbow and/or finger paralysis in chronic brachial plexus injuries. A minimum follow-up period of 3 years is recommended. This technique may remain useful as one of the last reconstructive options to increase power in patients with scarce donor nerves. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.
Assuntos
Traumatismos do Nascimento , Neuropatias do Plexo Braquial , Plexo Braquial , Articulação do Cotovelo , Retalhos de Tecido Biológico , Músculo Grácil , Expansão do Nervo , Transferência de Nervo , Adulto , Humanos , Músculo Grácil/transplante , Nervo Frênico/cirurgia , Nervo Frênico/lesões , Neuropatias do Plexo Braquial/cirurgia , Transferência de Nervo/métodos , Plexo Braquial/lesões , Articulação do Cotovelo/cirurgia , Estudos Retrospectivos , Retalhos de Tecido Biológico/inervação , Traumatismos do Nascimento/cirurgia , Amplitude de Movimento Articular/fisiologia , Resultado do Tratamento , Recuperação de Função Fisiológica/fisiologiaRESUMO
BACKGROUND: The posterior aspect of the leg is an ideal donor site for flap surgery. In this study, the anatomy was investigated of the lateral sural cutaneous nerve (LSCN) and its accompanying artery, superficial lateral sural artery (SLSA), and a lateral sural neurocutaneous flap was designed. METHODS: Five fresh adult cadaver legs perfused with red latex were dissected to observe the course and relationship between LSCN and SLSA. The outer diameter of SLSA at its origin was measured. Then a lateral sural neurocutaneous flap was designed and used to repair soft tissue defects in six patients. RESULTS: The anatomic results showed that the SLSA gave rise to branches that followed the LSCN and ramified into terminals at the ramification of the nerve. It originated directly from the popliteal artery 4.2 ± 0.2 mm above the fibular head, where its outer diameter was 0.96 ± 0.23 mm. Several perforators penetrated from the crural fascia and anastomosed to the SLSA, creating a fine anastomotic network. The clinical results showed that the size of the flap ranged from 12 × 6 cm to 25 × 8 cm. All six flaps survived completely without complications. Follow-up ranged from 6 to 18 months with 11 months on average. The overall contour and sensory recovery of the flap were satisfied. CONCLUSION: A free innervated flap may be elevated safely based on the LSCN and its accompanying vessels. It provides an alternative in reconstruction of soft tissue defects where sensory recovery is important.
Assuntos
Artérias/anatomia & histologia , Retalhos de Tecido Biológico/irrigação sanguínea , Retalhos de Tecido Biológico/inervação , Nervo Sural/anatomia & histologia , Adulto , Artérias/transplante , Cadáver , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nervo Sural/transplante , Adulto JovemRESUMO
Breast reconstruction often renders the chest skin and nipple areolar complex (NAC) insensate. We propose a new technique of preserving the intercostal nerves during mastectomy and using them to reinnervate the NAC following mastectomy and immediate autologous tissue reconstruction. The technique involves preservation of the lateral intercostal nerves during mastectomy, dissection of the lateral intercostal nerves to length, coaptation of the intercostal nerves to a nerve graft which is then tunneled through the free flap and the distal nerve graft is then coapted to the nerve stumps at the base of the NAC. We performed a retrospective analysis of 14 breasts, which underwent nipple reinnervation during immediate autologous breast reconstruction. Mean age was 49 years (range: 32-61 years). Sensory outcomes, as tested with Semmes-Weinstein monofilaments, were compared to a cohort of breasts that underwent nipple sparing mastectomy without neurotization. Compared to control patients, there was no statistically significant difference (pâ¯=â¯0.0969) in sensation between pre-operative and post-operative nipple sensation at final follow-up. This proof-of-concept study suggests that immediate re-innervation of the NAC in the setting of immediate breast reconstruction enhances recovery of the NAC sensation.
Assuntos
Neoplasias da Mama/cirurgia , Nervos Intercostais , Mamoplastia/métodos , Mamilos/inervação , Mamilos/cirurgia , Adolescente , Adulto , Feminino , Retalhos de Tecido Biológico/inervação , Humanos , Mastectomia , Pessoa de Meia-Idade , Satisfação do Paciente , Estudos RetrospectivosAssuntos
Músculos Abdominais Oblíquos , Parede Abdominal , Retalhos de Tecido Biológico , Mamoplastia/métodos , Transferência de Nervo/métodos , Reto do Abdome , Músculos Abdominais Oblíquos/irrigação sanguínea , Músculos Abdominais Oblíquos/inervação , Músculos Abdominais Oblíquos/cirurgia , Parede Abdominal/inervação , Parede Abdominal/cirurgia , Anatomia Regional , Retalhos de Tecido Biológico/inervação , Retalhos de Tecido Biológico/transplante , Humanos , Reto do Abdome/irrigação sanguínea , Reto do Abdome/inervação , Reto do Abdome/cirurgiaRESUMO
OBJECTIVE: This prospective study was performed to investigate the distribution of proximal ulnar artery perforating vessels through three-dimensional blood vessel reconstruction and examine the presence and consistency of the perforating vessels intraoperatively. METHODS: For anatomical guidance, three-dimensional blood vessel reconstruction was performed to determine the consistent presence of perforating vessels in the proximal ulnar artery. A free proximal ulnar artery perforator flap was then transferred in 17 patients to resurface skin defects on the hands. Color Doppler ultrasound was used to identify and mark the perforating vessels. Intraoperative evaluation was conducted to check for anastomosis of the perforating vessels at the marked sites and assess the vessel anastomosis conditions. RESULTS: No vascular crisis, flap necrosis, or wound infection occurred after surgery in 15 patients. Postoperative follow-up was conducted for 6 to 36 months. The appearance of the flap was satisfactory, the texture of the flap was soft, sensation was well restored, and hand function was not limited. The mean two-point discrimination of the flap was 7.6 ± 2.2 mm. CONCLUSIONS: Free sensory proximal ulnar artery perforator flap transfer is a safe and reliable surgical technique with respect to restoration of both the appearance and sensory function of the hand.
Assuntos
Retalhos de Tecido Biológico/transplante , Traumatismos da Mão/cirurgia , Retalho Perfurante/transplante , Transplante de Pele/métodos , Artéria Ulnar/transplante , Adolescente , Adulto , Feminino , Seguimentos , Retalhos de Tecido Biológico/efeitos adversos , Retalhos de Tecido Biológico/irrigação sanguínea , Retalhos de Tecido Biológico/inervação , Humanos , Masculino , Pessoa de Meia-Idade , Retalho Perfurante/efeitos adversos , Retalho Perfurante/irrigação sanguínea , Retalho Perfurante/inervação , Estudos Prospectivos , Pele/irrigação sanguínea , Pele/inervação , Transplante de Pele/efeitos adversos , Resultado do Tratamento , Adulto JovemRESUMO
Microneurovascular free muscle transfer is the gold-standard surgical procedure for the reanimation of established facial paralysis. However, the innervation of the transferred muscle by the contralateral facial nerve is usually insufficient to produce a stable smile. Besides, the corner of the mouth sometimes moves unnaturally as if it were being pulled up because of the single-direction movement. Thus, we propose one-stage facial reanimation using free latissimus dorsi (LD)-serratus anterior (SA) combined muscle flap transfer with dual innervation. The LD-SA combined muscle flap was harvested with the thoracodorsal artery and vein as common vessels to move the corner of the mouth bidirectionally for natural smiling. The LD muscle was located in the same direction as the zygomaticus major muscle and reinnervated by dual innervation. The contralateral facial nerve was coapted with the thoracodorsal nerve, and the ipsilateral masseter motor nerve was inserted into the LD muscle by intramuscular neurotization. The 6th or 7th SA muscle was located in the same direction as the risorius muscle and reinnervated by neurorrhaphy of the long thoracic nerve and the thin branch of the ipsilateral masseter motor nerve. Since 2015, seven patients have been treated with this method without complications. On average, SA muscle movement was detected in voluntary biting at 3.1 months, and spontaneous smiling occurred 7.7 months after surgery. All patients developed a spontaneous natural smile. This method for established facial paralysis has the potential to improve the quality of the reconstructed smile and the unstable results of conventional single-innervation-single-muscle transfer.
Assuntos
Músculos Faciais/cirurgia , Paralisia Facial/cirurgia , Retalhos de Tecido Biológico/cirurgia , Sorriso , Adulto , Idoso , Músculos Faciais/inervação , Feminino , Retalhos de Tecido Biológico/inervação , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Recent attempts have been made to direct the sensory neurotisation of free superficial circumflex iliac artery (SCIA) flaps. However, donor nerves enabling sensory recovery are limited. We report our findings in fifteen patients who underwent distal limb defect reconstruction using a sensate SCIA flap, including the lateral cutaneous branch of the subcostal nerve (LCSN), between August 2017 and September 2018. The distance from the anterosuperior iliac spine to the point where the LCSN crossed the iliac crest ranged between 6.5 and 10 cm. The diameter ranged between 1.5 and 4.0 mm. The flap size ranged between 8 × 4 and 13 × 10 cm2. All of the flaps survived uneventfully. Tests of sensory modalities, including the Semmes-Weinstein (SW) touch, vibration, pinprick, temperature and static two-point discrimination (s2PD) tests were applied in nine regions of each flap post-operatively. One or more modalities were present in at least one region at 6 months post-operatively, and the recovery of vibration perception was more consistent than that of SW touch and pinprick perception. The recovery of s2PD was noted in 4 cases over a follow-up period of more than 12 months. A reliable sensate flap with the LCSN can be considered as an attractive option for the sensory reconstruction of distal limb defects of moderate size.
Assuntos
Pé/cirurgia , Retalhos de Tecido Biológico/cirurgia , Mãos/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Adulto , Lesões por Esmagamento/cirurgia , Feminino , Pé/inervação , Traumatismos do Pé/cirurgia , Retalhos de Tecido Biológico/inervação , Mãos/inervação , Traumatismos da Mão/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , SensaçãoRESUMO
BACKGROUND: Soft tissue reconstruction of the foot represents a complex reconstructive challenge given the unique anatomical properties of the glabrous plantar skin. For large soft tissue defects and/or complex injuries, free tissue transfer is often the optimal reconstructive modality. The decision to pursue a neurotized free flap remains controversial and an area of debate. Given the trend toward increasing use of neurotized free flaps, we performed a systematic review to determine if nerve coaptation is a beneficial adjunct to free tissue transfer. METHODS: A systematic search of the English literature using PubMed and Web of Science was performed. Studies were identified between 1985 and 2018. Manuscripts were eligible if they contained original clinical outcomes research of patients who underwent free tissue transfer to the foot or heel with neurotization. RESULTS: A total of 189 studies were identified with initial screening and 19 studies were included in our analysis. A total of 175 patients underwent free flap reconstruction to the foot; of these, 107 patients had a nerve coaptation performed. Patients who underwent neurotization had improved sensory characteristics (two-point discrimination, light touch, and pain sensation), quicker return to ambulation and activities of daily living, and decreased ulcer formation compared with those who did not. Overall complications were infrequent, with ulceration being the most common. CONCLUSION: Neurotized free flaps appear to have an overall decreased rate of ulceration, improved sensory discrimination, and quicker return to ambulation/activities of daily living in comparison to nonneurotized free flaps. However, when examining free anterolateral thigh (ALT) and free medial plantar artery (MPA) fasciocutaneous flaps, durability (i.e., frequency of ulcer formation) and functionality (ambulation and return to activities of daily living) do not appear to be significantly different between neurotized and nonneurotized flaps.
Assuntos
Traumatismos do Pé/cirurgia , Pé/cirurgia , Retalhos de Tecido Biológico , Transferência de Nervo/métodos , Procedimentos de Cirurgia Plástica/métodos , Lesões dos Tecidos Moles/cirurgia , Retalhos de Tecido Biológico/inervação , Humanos , MicrocirurgiaRESUMO
BACKGROUND/AIM: Large full thickness abdominal wall defects following malignancies can be a reconstructive challenge. The purpose of this study was to analyze long-term outcomes and complications following abdominal wall reconstruction using composite antero-lateral thigh (ALT) flaps. PATIENTS AND METHODS: The study retrospectively investigated 16 consecutive patients who underwent abdominal wall reconstruction with autologous flap between May 2003 and March 2018. Volumetric flap analysis was used to assess flap atrophy over time, evaluating the role of denervation and reinnervation. The long-term outcome was assessed to compare the two groups (free vs. pedicled ALT flap reconstructions). RESULTS: All flaps successfully covered the defects. We found a significant increase in flap resorption in free flaps when compared to pedicled ones. Abdominal bulging was seen in 3 out of 16 (19%) patients after more than 12 months follow-up, in close correlation with mesh absence. CONCLUSION: Free flaps were shown to be equally effective as their pedicled counterparts, without significant increase in complication rate.
Assuntos
Parede Abdominal/cirurgia , Retalhos Cirúrgicos/transplante , Autoenxertos , Feminino , Retalhos de Tecido Biológico/efeitos adversos , Retalhos de Tecido Biológico/inervação , Retalhos de Tecido Biológico/transplante , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Procedimentos de Cirurgia Plástica/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Estudos Retrospectivos , Retalhos Cirúrgicos/efeitos adversos , Retalhos Cirúrgicos/inervação , Coxa da Perna , Resultado do TratamentoAssuntos
Neoplasias da Mama/cirurgia , Retalhos de Tecido Biológico/inervação , Mamoplastia/métodos , Mastectomia/métodos , Mamilos/cirurgia , Adulto , Neoplasias da Mama/patologia , Feminino , Seguimentos , Retalhos de Tecido Biológico/transplante , Humanos , Mamilos/inervação , Recuperação de Função Fisiológica/fisiologia , Medição de Risco , Resultado do TratamentoRESUMO
A frequently encountered anatomical structure in the elevation of a radial forearm free flap is the superficial branch of the radial nerve. This structure has a relatively consistent anatomic location, but variations do occur. We present a case where the superficial branch of the radial nerve was in an usual position but remained superficial to the brachioradialis throughout its course. Two previous reports also describe the superficial branch of the radial nerve remaining superficial to the brachioradialis, although, in these reports, the nerve was more medial than is typical. We postulate that one of the most common anatomic variations of the superficial branch of the radial nerve is for it to remain superficial to the brachioradialis. As this variation could potentially be confused with the medial or lateral antebrachial cutaneous nerves, it is important for the reconstructive surgeon to be aware of this to prevent inadvertent injury.
Assuntos
Retalhos de Tecido Biológico/inervação , Músculo Esquelético/transplante , Procedimentos de Cirurgia Plástica/métodos , Nervo Radial/anatomia & histologia , Carcinoma de Células Escamosas/cirurgia , Antebraço , Humanos , Masculino , Mucosa Bucal/cirurgia , Neoplasias Bucais/cirurgia , Músculo Esquelético/inervaçãoRESUMO
BACKGROUND: We evaluated the time course and differences in the sensory recovery of three commonly used free flaps for lower extremity reconstruction. Furthermore, the sensory recovery of skin-grafted muscle and skin paddle in latissimus dorsi flaps (LDMF) were differentiated. METHODS: In a prospective study, 26 patients who had undergone free flap lower extremity reconstruction were enrolled. Among them, 9 received LDMF, 9 received gracilis muscle flaps (GMF), and 8 received anterior lateral thigh flaps (ALTF). The sensory recovery was investigated by using the Semmes-Weinstein test (SWT) at 6 and 12 months after the surgery. RESULTS: All flaps recorded spontaneous sensory recovery. The GMF showed the smallest anesthetic area after 12 months as compared with the ALTF and LDMF (1 ± 3% vs. 18 ± 39% (p < .05) vs. 35 ± 35% (p < .05), respectively). Qualitatively, ALTF exhibited the best sensory recovery with the lowest SWT values (ALTF 4.57 ± 1.12 vs. GMF 5.01 ± 0.81 8 [p < .05], vs. LDMF 5.84 ± 0.52 [p < .05]). The sensory recovery of skin-grafted muscle was superior to that of the skin paddle in the LDMF (anesthetic area 29 ± 36% vs. 54 ± 33% [p < .05], SWT 5.85 ± 0.60 vs. 6.30 ± 0.18 [p < .05], respectively). CONCLUSION: All flaps displayed spontaneous sensory recovery potential over the investigation period, which appeared to be influenced by the flap type and size. The LDMF skin paddle showed lower potential for sensory recovery as compared with the skin-grafted muscle area of the same flap. The GMF demonstrated a near-complete sensory recovery after 12 months.
Assuntos
Retalhos de Tecido Biológico/inervação , Perna (Membro)/inervação , Perna (Membro)/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/fisiopatologia , Sensação/fisiologia , Idoso , Animais , Músculo Grácil/transplante , Humanos , Masculino , Pessoa de Meia-Idade , Exame Neurológico , Estudos Prospectivos , Ratos , Músculos Superficiais do Dorso/inervação , Músculos Superficiais do Dorso/transplante , Adulto JovemRESUMO
PURPOSE: To report the clinical outcomes of elbow flexion reconstruction using a reverse free gracilis muscle flap plus Steindler flexorplasty in patients with previously failed reconstruction of extended upper-type brachial plexus paralysis. METHODS: Twenty-four male patients were reoperated upon an average of 45 months (SD, ± 45 months) after brachial plexus repair. The gracilis tendon was secured to the acromion, and the muscle belly was sutured to the biceps distal tendon. Vascular repair was performed preferentially end to end to the radial artery and cephalic vein. Nerve repair was achieved by coapting the nerve to the gracilis to motor fascicles of the median or ulnar nerve. The medial epicondyle was osteotomized, proximally advanced by 4 to 5 cm and secured to the anterior side of the humerus. RESULTS: Active elbow flexion was restored in 23 of 24 patients. Sixteen patients ultimately achieved M4 strength, among whom 6 had full range of motion (ROM), and the remaining 10 recovered an average of 110° (95% confidence interval [95% CI], 100°-120°) of elbow flexion. Seven patients exhibited M3 elbow flexion strength recovery, which was associated with weaker hands and incomplete ROM, averaging 94° (95% CI, 86°-102°). There was, on average, a 10° (95% CI, 4.4°-15.6°). elbow flexion contracture. Among the 16 patients with M4 level recovery of elbow flexion, supination was partially restored in 12. CONCLUSIONS: In patients previously operated upon, using a reversed free gracilis muscle flap in association with a Steindler procedure is effective as salvage surgery to restore elbow flexion and partial supination. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
Assuntos
Neuropatias do Plexo Braquial/fisiopatologia , Articulação do Cotovelo/cirurgia , Retalhos de Tecido Biológico , Músculo Grácil/transplante , Procedimentos Ortopédicos , Amplitude de Movimento Articular/fisiologia , Adolescente , Adulto , Plexo Braquial/lesões , Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/cirurgia , Criança , Articulação do Cotovelo/fisiopatologia , Retalhos de Tecido Biológico/irrigação sanguínea , Retalhos de Tecido Biológico/inervação , Humanos , Masculino , Pessoa de Meia-Idade , Força Muscular/fisiologia , Reoperação , Estudos RetrospectivosRESUMO
BACKGROUND: Single-stage latissimus dorsi neuromuscular transfer has been a valuable option for dynamic smile reanimation. However, there is a paucity of studies evaluating the potential donor morbidity in such cases. The present study aimed to comprehensively analyze the donor morbidity following functional latissimus dorsi muscle transfer. METHODS: Patients who underwent single-stage functional latissimus dorsi muscle transfer for smile reanimation between 2002 and 2016 were reviewed. Postoperative complications and functional impairments at the donor sites were evaluated. The Quick-Disabilities of the Arm, Shoulder and Hand questionnaire was used for assessing postoperative donor-site function. RESULTS: Sixty patients, including 12 pediatric (18 years or younger) patients, were analyzed. Mean length of a harvested thoracodorsal nerve was 14.9 cm. Fourteen patients were treated with a dual innervation technique, in which both a descending and a transverse branch of the thoracodorsal nerve were harvested. Donor complications were observed in seven cases; all of them were seromas and resolved by simple aspiration. No other complications including scoliosis and sensory and/or motor disturbances in the upper extremities were encountered. Fifty patients responded to the Quick-Disabilities of the Arm, Shoulder and Hand questionnaire at a median follow-up of 51 months. The average score was 2.64, and all but three patients scored less than 10. No variables, including patient age (pediatric versus adult) and the use of a dual-innervation technique, affected the donor morbidities, including the functional deficits. CONCLUSION: Single-stage latissimus dorsi neuromuscular transfer for facial reanimation might be associated with a low rate of complications and minimal functional morbidity at the donor site. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Assuntos
Expressão Facial , Músculos Faciais/cirurgia , Retalhos de Tecido Biológico/transplante , Procedimentos de Cirurgia Plástica/métodos , Músculos Superficiais do Dorso/transplante , Sítio Doador de Transplante/fisiopatologia , Adolescente , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Músculos Faciais/inervação , Paralisia Facial/diagnóstico , Paralisia Facial/cirurgia , Feminino , Retalhos de Tecido Biológico/inervação , Humanos , Masculino , Qualidade de Vida , Recuperação de Função Fisiológica/fisiologia , Estudos Retrospectivos , Medição de Risco , Sorriso , Estatísticas não Paramétricas , Músculos Superficiais do Dorso/inervação , Coleta de Tecidos e Órgãos/métodos , Sítio Doador de Transplante/cirurgia , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The reconstructive approach for incomplete facial paralysis is not yet determined. In this article, the authors present a new surgical approach for patients with incomplete facial paralysis in which residual, ineffective movement is detected preoperatively in the ipsilateral buccozygomatic territory of the paretic facial nerve. METHODS: Sixteen patients with incomplete facial paralysis were found eligible for the procedure and underwent one-stage facial reanimation performed by the senior author (E.G.). Reanimation was performed using free gracilis muscle transfer with neural coaptation to an active facial nerve branch(es) responsible for the predetected buccozygomatic residual movement. Patients were reviewed in a systematic fashion using a combined still photographic and video scoring scale for symmetry at rest and at dynamic states. RESULTS: Following surgery, improved symmetry was observed in the majority of observations of the mouth region at rest and while smiling and of the nasolabial fold region while smiling. There was no significant change in symmetry in the majority of observations of the eye region at rest and while smiling and the nasolabial fold region at rest. Video assessment of dynamic facial symmetry while smiling demonstrated improved symmetry in 91 percent of the observations (n = 191 observations). Comparison of mean scores for dynamic smile symmetry produced a statistically significant improvement of 1.68 points following surgery (p < 0.001). CONCLUSION: Based on this series, the authors recommend that use of the ipsilateral facial nerve buccozygomatic residual branch be considered as a donor nerve for facial reanimation using a free gracilis muscle transfer in patients with incomplete facial paralysis with residual preoperative movement in the midface. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.