Outcomes of gracilis muscle interposition for rectourethral fistulas caused by treatment of prostate cancer.

BACKGROUND: Gracilis muscle interposition (GMI) has been associated with favorable outcomes in treating complex perianal fistulas. Outcomes of GMI may vary according to the fistula etiology, particularly between rectovaginal fistulas in women and rectourethral fistulas (RUF) in men. The aim of this study was to assess the outcome of GMI to treat RUF acquired after prostate cancer treatment. METHODS: This retrospective cohort study included male patients treated with GMI for RUF acquired after prostate cancer treatment between January 2000 and December 2018 in the Department of Colorectal Surgery, Cleveland Clinic Florida. The primary outcome was the success of GMI, defined as complete healing of RUF without recurrence. Secondary outcomes were length of hospital stay and postoperative complications. RESULTS: This study included 53 male patients with a median age of 68 (range, 46-85) years. Patients developed RUF after treatment of prostate cancer with radiation (52.8%), surgery (34%), or transurethral resection of the prostate (TURP) (13.2%). Median hospital stay was 5 (IQR, 4-7) days. Twenty (37.7%) patients experienced 25 complications, the most common being wound infection and dehiscence. Primary healing after GMI was achieved in 28 (52.8%) patients. Fifteen additional patients experienced successful healing of RUF after additional procedures, for a total success rate of 81.1%. Median time to complete healing was 8 (range, 4-56) weeks. The only significant factor associated with outcome of GMI was wound dehiscence (p = 0.008). CONCLUSIONS: Although the initial success rate of GMI was approximately 53%, it increased to 81% after additional procedures. Complications after GMI were mostly minor, with wound complications being the most common. Perianal wound dehiscence was significantly associated with failure of healing of RUF after GMI.

Gracilis transplantation and temporalis transposition in longstanding facial palsy in adults: Patient-reported and aesthetic outcomes.

BACKGROUND: In longstanding facial palsy, gracilis free functional muscle transfer (FFMT) is currently considered to be the gold standard in smile reanimation. An alternative to muscle free flaps is local muscle transposition, with the temporalis muscle transposition being the preferred procedure, because of its direction of pull when transposed. The present study aimed to compare outcomes of gracilis FFMT neurotised by the masseteric nerve and temporalis muscle transposition in longstanding facial palsy using patient-reported and aesthetic outcomes. METHODS: A cross-sectional comparison of gracilis FFMT and temporalis muscle transpositions was performed. Pre- and postoperative excursion measures were obtained. Patients were asked to answer a satisfaction questionnaire, quality of life questionnaire (FaCE scale) and a depression and anxiety questionnaire (HADS). Laypeople were asked to rate the pre- and postoperative aesthetic appearance. RESULTS: Of 28 eligible patients, 10 gracilis and 12 temporalis patients participated. No significant differences were found between both groups in postoperative quality of life or depression/anxiety. Layperson observers judged the aesthetic appearance to be similar. CONCLUSION: In the present study, gracilis FFMT did not lead to superior quality of life and aesthetic outcomes compared to temporalis muscle transpositions. The facial nerve specialist should perform the procedure he or she expects to lead to optimal results for the patient.

Dietary fats modify vascular fat composition, eNOS localization within lipid rafts and vascular function in obesity.

We tested whether dietary fatty acids alter membrane composition shifting localization of signaling pathways within caveolae to determine their role in vascular function. Wild type (WT) and caveolin-1-deficient mice (cav-1 KO), required for vascular caveolae formation, were fed low fat (LF), high saturated fat (HF, 60% kcal from lard), or high-fat diet with 50:50 lard and n-3 polyunsaturated fatty acid-enriched menhaden oil (MO). HF and MO increased body weight and fat in WT but had less effect in cav-1 KO. MO increased unsaturated fatty acids and the unsaturation index of aorta from WT and cav-1 KO. In LF WT aorta, endothelial nitric oxide synthase (eNOS) was localized to cav-1-enriched low-density fractions which shifted to actin-enriched high-density fractions with acetylcholine (ACh). HF and MO shifted eNOS to high-density fractions in WT aorta which was not affected by ACh. In cav-1 KO aorta, eNOS was localized in low-density non-caveolar fractions but not shifted by ACh or diet. Inducible NOS and cyclooxygenase 1/2 were not localized in low-density fractions or affected by diet, ACh or genotype. ACh-induced dilation of gracilis arteries from HF WT was similar to dilation in LF but the NOS component was reduced. In WT and cav-1 KO, dilation to ACh was enhanced by MO through increased role for NOS and cyclooxygenase. We conclude that dietary fats affect vascular fatty acid composition and membrane localization of eNOS but the contribution of eNOS and cyclooxygenase in ACh-mediated vascular responses is independent of lipid rafts.

Experiences with functional gracilis muscle flap in lower lip reconstruction.

OBJECTIVE: Reconstruction of the lips is pivotal because the lips play an essential role in facial aesthetics and have unique functional properties. We presented our experience in reconstruction of total or subtotal lower lip defects with functional gracillis muscle flap covered split-thickness skin graft (STSG) in patients. METHODS: Between 2009 and 2011, seven patients underwent resection of lower lip squamous cell carcinoma and lip reconstruction. Gracillis muscle flap was performed for reconstruction. Recipient vessels were the facial artery and vein. Motor nerve of the gracillis muscle was coapted to the marginal branch of the facial nerve. Gracillis muscle was covered with STSG. Patients were evaluated about mouth opening, oral competence, word articulation, the color match of the graft, the contraction of the muscle by physical examination. Electromyographic studies and sensation tests were performed. RESULTS: Postoperative course was uneventful for all of the flaps. No microvascular revisions were needed. One patient was reoperated because of wound dehiscence under local anaesthesia. Mean follow up period was 15 months. After three months, movement of the reconstructed lip was observed. Color of the grafted skin was matched with the skin of the face. The patients had no problems with word articulation, oral continence, or mouth opening. The electromyographic study showed recovery of motor innervation. After 1 year, the patients demonstrated recovered sensitivity with the sensation test. CONCLUSION: Considering functional results, superior aesthetic appearance, and minimal donor-site morbidity of the functional gracillis transfer covered skin graft, we think that this method may be an alternative for reconstruction of large full-thickness defects of the lower lip. © 2015 Wiley Periodicals, Inc. Microsurgery 37:487-493, 2017.

Lengthening temporalis myoplasty versus free muscle transfer with the gracilis flap for long-standing facial paralysis: A systematic review of outcomes.

BACKGROUND: Our aim was to compare the outcomes of reconstructive surgery for long-standing facial paralysis by gracilis free flap transfer versus lengthening temporalis myoplasty (LTM) according to Daniel Labbé. MATERIALS AND METHODS: PubMed, Web of Science, Wiley Online Library, Cochrane Library, Directory of Open Access Journals, and SAGE Premier 2011 database were electronically searched. Randomized controlled trials (RCTs), controlled clinical trials (CCTs), and case series with a sample size > 5 were sought. Data were extracted by a single investigator. RESULTS: Sixteen articles met the selection criteria. All of these studies were retrospective case series. Efficacy outcomes were analyzed by assessing mouth symmetry both at rest and upon smiling, as well as the quality and the spontaneanity of the smile. Commissural displacement in patients operated by the gracilis flap was greater after surgery involving masseteric nerve reinnervation than a cross-facial nerve graft reinnervation. Patients with double innervation had similar results to those who had surgery involving only masseteric nerve reinnervation. These results are in accordance with the subjective evaluations. Patients operated by the lengthening temporalis myoplasty achieve less lateral movement of the commissure, with controversial evidence of spontaneity (only "automatic"). CONCLUSIONS: There are currently no published RCTs or CCTs regarding facial reanimation surgery. Thus, only very weak evidence is available to support the use of one type of surgery over another. However, our review suggests that LTM achieves results that are at least equal to those obtained with gracilis transfer, but LTM is a less extensive procedure that provides quicker results without the need for more than one operation. LTM, therefore, seems a good alternative to free muscle flap. LEVEL OF EVIDENCE: IV.

Graciloplasty, electrostimulation, electromyography. Clinical implications of electrophysiological phenomena in the neo-sphincter created from the gracilis muscle.

UNLABELLED: The aim of the study was to compare the electrophysiological phenomena occurring in the gracilis muscle, transposed into the pelvic floor during the graciloplasty procedure, subjected to continuous electrical stimulation by means of implanted stimulator, or regular stimulation by means of an external device, as well as the long-term functional results of the graciloplasty procedure. MATERIAL AND METHODS: A total of 27 patients were included in the analysis. The study group consisted of 7 patients after dynamic graciloplasty, 11 patients after graciloplasty followed by transrectal stimulation, 4 patients after graciloplasty with transcutaneous stimulation, and 5 patients after graciloplasty without any stimulation. All patients had a surface electromyographic examination of the transposed gracilis muscle performed, the signal for each patient was compared to the signal acquisited from a non-transposed gracilis in the same patient. In addition, each subject underwent a clinical operation results assessment, as well as an anorectal manometry examination. RESULTS: In the electromiographic examination, the mean frequency of motor units action potentials of the gracilis muscle in the thigh was 64 Hz, and in the muscle after transposition and stimulation period mean frequency was 62 Hz. There was no statistically significant difference in the frequency of action potentials before and after treatment in any of the analyzed groups, or between groups with different methods of stimulation (p> 0.05). We found a significant correlation between the clinical outcome of the procedure, and the average amplitude of the EMG signal from the transposed muscle, as well as between the amplitude of the EMG signal and the basal pressure in the anal canal in manometric examination. There were no significant correlations in the remaining manometric parameters. CONCLUSIONS: Despite the different methods of postoperative stimulation, including expensive implantable stimulators, there was no difference in the electrical activity between the transposed gracilis muscle, and the gracilis muscle left in situ. There was no signoficant advantage of the dynamic graciloplasty procedure over the graciloplasty with transanal or transcutaneous stimulation.