Effect of Deep Learning Reconstruction on Respiratory-triggered T2-weighted MR Imaging of the Liver: A Comparison between the Single-shot Fast Spin-echo and Fast Spin-echo Sequences.

PURPOSE: To compare the effects of deep learning reconstruction (DLR) on respiratory-triggered T2-weighted MRI of the liver between single-shot fast spin-echo (SSFSE) and fast spin-echo (FSE) sequences. METHODS: Respiratory-triggered fat-suppressed liver T2-weighted MRI was obtained with the FSE and SSFSE sequences at the same spatial resolution in 55 patients. Conventional reconstruction (CR) and DLR were applied to each sequence, and the SNR and liver-to-lesion contrast were measured on FSE-CR, FSE-DLR, SSFSE-CR, and SSFSE-DLR images. Image quality was independently assessed by three radiologists. The results of the qualitative and quantitative analyses were compared among the four types of images using repeated-measures analysis of variance or Friedman's test for normally and non-normally distributed data, respectively, and a visual grading characteristics (VGC) analysis was performed to evaluate the image quality improvement by DLR on the FSE and SSFSE sequences. RESULTS: The liver SNR was lowest on SSFSE-CR and highest on FSE-DLR and SSFSE-DLR (P < 0.01). The liver-to-lesion contrast did not differ significantly among the four types of images. Qualitatively, noise scores were worst on SSFSE-CR but best on SSFSE-DLR because DLR significantly reduced noise (P < 0.01). In contrast, artifact scores were worst both on FSE-CR and FSE-DLR (P < 0.01) because DLR did not reduce the artifacts. Lesion conspicuity was significantly improved by DLR compared with CR in the SSFSE (P < 0.01) but not in FSE sequences for all readers. Overall image quality was significantly improved by DLR compared with CR for all readers in the SSFSE (P < 0.01) but only one reader in the FSE (P < 0.01). The mean area under the VGC curve values for the FSE-DLR and SSFSE-DLR sequences were 0.65 and 0.94, respectively. CONCLUSION: In liver T2-weighted MRI, DLR produced more marked improvements in image quality in SSFSE than in FSE.

Image Quality and Lesion Detectability of Pancreatic Phase Thin-Slice Computed Tomography Images With a Deep Learning-Based Reconstruction Algorithm.

OBJECTIVE: To evaluate the image quality and lesion detectability of pancreatic phase thin-slice computed tomography (CT) images reconstructed with a deep learning-based reconstruction (DLR) algorithm compared with filtered-back projection (FBP) and hybrid iterative reconstruction (IR) algorithms. METHODS: Fifty-three patients who underwent dynamic contrast-enhanced CT including pancreatic phase were enrolled in this retrospective study. Pancreatic phase thin-slice (0.625 mm) images were reconstructed with each FBP, hybrid IR, and DLR. Objective image quality and signal-to-noise ratio of the pancreatic parenchyma, and contrast-to-noise ratio of pancreatic lesions were compared between the 3 reconstruction algorithms. Two radiologists independently assessed the image quality of all images. The diagnostic performance for the detection of pancreatic lesions was compared among the reconstruction algorithms using jackknife alternative free-response receiver operating characteristic analysis. RESULTS: Deep learning-based reconstruction resulted in significantly lower image noise and higher signal-to-noise ratio and contrast-to-noise ratio than hybrid IR and FBP ( P < 0.001). Deep learning-based reconstruction also yielded significantly higher visual scores than hybrid IR and FBP ( P < 0.01). The diagnostic performance of DLR for detecting pancreatic lesions was highest for both readers, although a significant difference was found only between DLR and FBP in one reader ( P = 0.02). CONCLUSIONS: Deep learning-based reconstruction showed improved objective and subjective image quality of pancreatic phase thin-slice CT relative to other reconstruction algorithms and has potential for improving lesion detectability.

Cap analogs with a hydrophobic photocleavable tag enable facile purification of fully capped mRNA with various cap structures.

Starting with the clinical application of two vaccines in 2020, mRNA therapeutics are currently being investigated for a variety of applications. Removing immunogenic uncapped mRNA from transcribed mRNA is critical in mRNA research and clinical applications. Commonly used capping methods provide maximum capping efficiency of around 80-90% for widely used Cap-0- and Cap-1-type mRNAs. However, uncapped and capped mRNA possesses almost identical physicochemical properties, posing challenges to their physical separation. In this work, we develop hydrophobic photocaged tag-modified cap analogs, which separate capped mRNA from uncapped mRNA by reversed-phase high-performance liquid chromatography. Subsequent photo-irradiation recovers footprint-free native capped mRNA. This approach provides 100% capping efficiency even in Cap-2-type mRNA with versatility applicable to 650 nt and 4,247 nt mRNA. We find that the Cap-2-type mRNA shows up to 3- to 4-fold higher translation activity in cultured cells and animals than the Cap-1-type mRNA prepared by the standard capping method.

Tracheal injury from dog bite in a child.

BACKGROUND: Dog bites associated with the head and neck area in children are a common problem. Most of the lacerations are found in the upper lip and the nose region, and tracheal injury is rare [1]. Tracheal injury requires prompt and accurate diagnosis and treatment to rescue the patient. Especially in children, securing the airway is often more difficult than in adults because of their short neck and narrow trachea. In this report, we experienced a pediatric case of multiple dog bites with tracheal injuries in the neck. CASE PRESENTATION: We report the case of a 3-year-old girl who presented with multiple dog bites. There were multiple wounds on the head, face, neck, and anterior chest, and air leakage was observed from the cervical wound at the time of transfer. It was difficult to perform oral endotracheal intubation, therefore, we extended the neck wound, probed the trachea with finger, and inserted a tracheal tube directly from the cervical wound in the emergency room. Tracheoplasty and another wound cleansing were performed in the operating room. The patient was discharged on the 18th day after surgery, without further complications. CONCLUSION: Tracheal injury from a dog bite is rare. It is important to prompt and accurate diagnosis and treatment. Children should be especially careful because of their short necks and narrow tracheas.

A Case of Cochlear Implant Replacement Requiring Full-Thickness Skin Grafting.

Cochlear implants improve the quality of life of patients with bilateral severe sensorineural hearing loss. Normally, patients with cochlear implants can continue to use the devices for years without any complications. However, equipment failure or infection at the implant site could develop in some patients, and this might often necessitate implant replacement. Although cochlear implant replacement surgery itself is not a major risk in most cases, extensive tissue resection will be required in cases involving infection, and the insertion site of the temporal bone implant will need to be changed. We encountered a case of skin necrosis at the temporal bone implant site caused by constant external irritation from the temple of an eyeglass frame. The patient underwent cochlear implant replacement surgery involving full-thickness skin grafting from the abdomen. Thereafter, the patient's condition improved. Full-thickness skin grafting can be useful in cases of extensive skin defects encountered during cochlear implant replacement.

Effect of pentavalent inorganic arsenic salt on erythropoietin production and autophagy induction.

Arsenic is abundant in the environment and takes the form of trivalent and pentavalent arsenic compounds. Arsenite has been reported to both promote and suppress erythropoietin (EPO) production and autophagy induction. EPO production is involved in hematopoiesis, and autophagy induction is involved in cytoprotection, both of which are thought to be cellular responses to arsenic stress. While there are reports that show the effects of EPO on autophagy induction, the relationship between EPO production and autophagy induction is unclear. Therefore, this study analyzed the effect of the pentavalent inorganic arsenic salt arsenate on EPO production in vitro and in vivo and EPO-induced autophagy in HepG2 cells. Exposure of HepG2 cells to low-concentration arsenate was observed to increase EPO production and induced autophagy. Moreover, a ROS scavenger suppressed the arsenate-induced increase in autophagy and EPO mRNA levels. Both EPO production and autophagy induction contributed to protection from arsenate-induced cytotoxic stress. HepG2 cells expressed the EPO receptor and production of EPO by HepG2 cells acted in an autoregulatory manner to suppress autophagy induction. In vivo administration of low-concentration arsenate to rats increased EPO mRNA levels in the liver and kidney. These results suggested that low-concentration arsenate promotes EPO production and autophagy induction in HepG2 cells, and the resultant EPO production contributes to cytoprotection of cultured cells via EPO receptor activation.

Do mothers pick up a phone? A cross-sectional study on delivery of MCH voice messages in Lagos, Nigeria.

BACKGROUND: Voice messages have been employed as an effective and efficient approach for increasing health service utilization and health promotion in low- and middle-income countries. However, unlike SMS, voice message services require their users to pick up a phone call at its delivery time. Furthermore, voice messages are difficult for the users to review their contents afterward. While recognizing that voice messages are more friendly to specific groups (eg, illiterate or less literate populations), there should be several challenges in successfully operationalizing its intervention program. OBJECTIVE: This study is aimed to estimate the extent to which voice message service users pick up the phone calls of voice messages and complete listening up to or beyond the core part of voice messages. METHODS: A voice message service program composed of 14 episodes on maternal, newborn, and child health was piloted in Lagos, Nigeria, from 2018 to 2019. A voice message call of each of 14 episodes was delivered to the mobile phones of the program participants per day for 14 consecutive days. A total of 513 participants in the voice message service chose one of five locally spoken languages as the language to be used for voice messages. Two multilevel logistic regression models were created to understand participants' adherence to the voice message: (a) Model 1 for testing whether a voice message call is picked up; and (b) Model 2 for testing whether a voice message call having been picked up is listened to up to the core messaging part. RESULTS: The greater the voice message episode number became, the smaller proportion of the participants picked up the phone calls of voice message (aOR: 0.98; 95% CI: 0.97-0.99; P = .01). Only 854 of 3765 voice message calls having been picked up by the participants (22.7%) were listened to up to their core message parts. It was found that picking up a phone call did not necessarily ensure listening up to the core message part. This indicates a discontinuity between these two actions. CONCLUSIONS: The participants were likely to stop picking up the phone as the episode number of voice messages progressed. In view of the discontinuity between picking up a phone call and listening up to the core message part, we should not assume that those picking up the phone would automatically complete listening to the entire or core voice message.

Three-dimensional conditional generative adversarial network-based virtual thin-slice technique for the morphological evaluation of the spine.

Virtual thin-slice (VTS) technique is a generative adversarial network-based algorithm that can generate virtual 1-mm-thick CT images from images of 3-10-mm thickness. We evaluated the performance of VTS technique for assessment of the spine. VTS was applied to 4-mm-thick CT images of 73 patients, and the visibility of intervertebral spaces was evaluated on the 4-mm-thick and VTS images. The heights of vertebrae measured on sagittal images reconstructed from the 4-mm-thick images and VTS images were compared with those measured on images reconstructed from 1-mm-thick images. Diagnostic performance for the detection of compression fractures was also compared. The intervertebral spaces were significantly more visible on the VTS images than on the 4-mm-thick images (P < 0.001). The absolute value of the measured difference in mean vertebral height between the VTS and 1-mm-thick images was smaller than that between the 4-mm-thick and 1-mm-thick images (P < 0.01-0.54). The diagnostic performance of the VTS images for detecting compression fracture was significantly lower than that of the 4-mm-thick images for one reader (P = 0.02). VTS technique enabled the identification of each vertebral body, and enabled accurate measurement of vertebral height. However, this technique is not suitable for diagnosing compression fractures.

Effects of Atezolizumab and Bevacizumab on Adrenal Gland Metastasis of Hepatocellular Carcinoma: A Case Report and Review of Literature.

Regarding the prognosis of cases with advanced-stage hepatocellular carcinoma (HCC), a recent clinical study showed that the immune checkpoint inhibitors atezolizumab plus bevacizumab have superior efficacy to sorafenib. However, only a few reports have focused on their effects on extrahepatic metastases. We herein report a case of HCC in a 59-year-old man with intrahepatic lesions treated successfully by hepatic arterial chemoembolization, radiotherapy, and sorafenib; the extrahepatic lesion in the adrenal gland was treated by atezolizumab plus bevacizumab. The patient showed a tumor-free condition for one year. We have summarized the clinical course and reviewed the literature to underscore the efficacy of atezolizumab plus bevacizumab for treating extrahepatic lesions of HCC.

Impact of Deep Learning Reconstruction Combined With a Sharpening Filter on Single-Shot Fast Spin-Echo T2-Weighted Magnetic Resonance Imaging of the Uterus.

OBJECTIVE: This study aimed to evaluate the effects of deep learning (DL) reconstruction and a postprocessing sharpening filter on the image quality of single-shot fast spin-echo (SSFSE) T2-weighted imaging (T2WI) of the uterus. MATERIALS AND METHODS: Fifty consecutive patients who underwent pelvic magnetic resonance imaging were included. Parasagittal T2WI with a slice thickness of 4 mm was obtained with the periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) and SSFSE sequences (mean scan time, 204 and 22 seconds, respectively). The following 3 types of SSFSE images were reconstructed, and the signal-to-noise ratio (SNR) and tissue contrast were assessed: conventional reconstruction (SSFSE-C), DL reconstruction (SSFSE-DL), and DL with a sharpening filter (SSFSE-DLF). Three radiologists independently assessed image quality, and area under the visual grading characteristics curve (AUCVGC) analysis was performed to compare the SSFSE and PROPELLER images. RESULTS: Compared with that of the PROPELLER images, the SNR of the SSFSE-C, SSFSE-DL, and SSFSE-DLF images was significantly lower (P < 0.05), significantly higher (P < 0.05), and equivalent, respectively. The SSFSE-DL images exhibited significantly lower contrast between the junctional zone and myometrium than those obtained with the other sequences (P < 0.05). In qualitative comparisons with the PROPELLER images, all 3 SSFSE sequences, SSFSE-DL, and SSFSE-DLF demonstrated significantly higher scores for artifacts, noise, and sharpness, respectively (P < 0.01). The overall image quality of SSFSE-C (mean AUCVGC, 0.03; P < 0.01) and SSFSE-DL (mean AUCVGC, 0.23; P < 0.01) was rated as significantly inferior, whereas that of SSFSE-DLF (mean AUCVGC, 0.69) was equivalent or significantly higher (P < 0.01). CONCLUSION: Using a combination of DL and a sharpening filter markedly increases the image quality of SSFSE of the uterus to the level of the PROPELLER sequence.

The Impact of Brow-Lift on Eyelid Closure in Patients with Facial Paralysis.

Background: Brow-lift-induced eyelid closure impairment is commonly discussed in patients with facial paralysis but has not been well quantified. Objective: To measure the limitation of eyelid closure in patients with facial paralysis using simulated brow-lift with tape. Design, Setting, and Participants: For 50 facial paralysis patients with brow ptosis who visited our institution from October 2017 to December 2020, brow-lift was simulated by elevating the paralyzed-side brow using surgical tape, and closed palpebral fissure heights in spontaneous blinking were measured using high-speed videography. The effect of several factors on the change in closed palpebral fissure height was evaluated by multiple linear regression analysis. Results: Greater patient age (p = 0.021), single eyelids (p = 0.003), higher value of closed palpebral fissure height before simulation (p = 0.004), and higher value of brow elevation (p = 0.013) were significant for the increase of closed palpebral fissure height. Conclusions: Brow elevation to the degree that achieves symmetrical brow height could be detrimental to eyelid closure in patients with facial paralysis, especially who are elderly, have single eyelids, or present with preoperative decreased lid-closure function. UMIN Clinical Trials (UMIN Registry No. 000042974).

Comparative Blink Analysis in Patients With Established Facial Paralysis Using High-Speed Video Analysis.

ABSTRACT: This study analyzed the blink characteristics of patients with incomplete and complete facial paralysis. The authors measured and compared the palpebral distance, eyelid movement distance, and the eye-closing ratio of blinks in 55 patients with Bell's palsy or Ramsay Hunt syndrome (Bell & Hunt group) and 14 with complete paralysis (Complete Paralysis group). in the Bell & Hunt group, the palpebral distance (7.94 mm) was smaller on the paralyzed side than on the non-paralyzed side (9.61 mm). The eyeclosing ratio and the upper eyelid movement were reduced on the paralyzed side (65.3% versus 93.7%, 4.61 versus 7.97 mm) and in the Complete Paralysis group (25.3% versus 94.7%, 2.10 versus 8.49 mm). In the Bell & Hunt group, movement of the upper eyelid on the paralyzed side was weakened despite palpebral contracture. The Complete Paralysis group exhibited highly reduced movement in both the upper and lower eyelids.

Change in Eyelid Closure in Spontaneous Blinking After Static Eyelid Reconstruction Surgery for Patients With Facial Paralysis.

BACKGROUND: Static eyelid reconstruction surgery, such as ptosis repair or brow lift, is widely performed for patients with facial paralysis. Complications include exposure keratitis and possible vision loss mainly due to eyelid closure impairment in spontaneous blinking. However, no quantitative evaluation data has been available regarding postoperative closure deterioration. METHODS: To elucidate factors associated with postoperative eyelid closure impairment, a retrospective study was performed for 51 patients who underwent an initial static eyelid reconstruction surgery from October 2017 to August 2020. A static eyelid reconstruction surgery consisted of either 1 or more of the following: (1) levator advancement, (2) brow lift, and (3) orbicularis oculi myectomy. Eyelid closure ratios (0% for complete closure impairment and 100% for perfect closure) at spontaneous blinks were measured on 6 occasions: before operation and at postoperative 1, 3, 6, 9, and 12 months. Comparison was made between preoperative and postoperative values by using mixed-effects model. RESULTS: Overall, average closure ratio was significantly increased. However, 10 patients had >10% closure ratio decreases at at least 1 postoperative measurement point, and all those patients had undergone brow lift procedures. CONCLUSIONS: Although eyelid closure at spontaneous blinks may, contrary to assumptions, generally be improved after static eyelid reconstruction surgery, brow lift was suggested to be associated with eyelid closure impairment.

Diffusion-Based Virtual MR Elastography of the Liver: Can It Be Extended beyond Liver Fibrosis?

Background: Strong correlation has been reported between tissue water diffusivity and tissue elasticity in the liver. The purpose of this study is to explore the capability of diffusion-based virtual MR elastography (VMRE) in the characterization of liver tumors by extending beyond liver fibrosis assessments. Methods: Fifty-four patients (56 liver tumors: hepatocellular carcinoma (HCC), 31; metastases, 25) who underwent MRE, diffusion-weighted imaging (DWI) (b: 0, 800 s/mm2), and VMRE (b: 200, 1500 s/mm2) were enrolled. The MRE shear modulus (µMRE), apparent diffusion coefficient (ADC), and shifted ADC (sADC) were obtained. Virtual stiffness (µdiff) was estimated from the relationship between µMRE and sADC. A linear discriminant analysis combining VMRE and MRE to classify HCC and metastases was performed in a training cohort (thirty-two patients) to estimate a classifier (C), and evaluate its accuracy in a testing cohort (twenty-two patients). Pearson's correlations between µMRE, sADC, and ADC were evaluated. In addition to the discriminant analysis, a receiver operating characteristic (ROC) curve was used to assess the discrimination capability between HCC and metastases. Results: The correlations between µMRE and sADC were significant for liver, HCC, and metastases (r = 0.91, 0.68, 0.71; all p < 0.05). Those between µMRE and ADC were weaker and significant only for metastases (r = 0.17, 0.20, 0.55). µdiff values were not significantly different between HCC and metastases (p = 0.56). Areas under the curves (AUC) to differentiate HCC from metastases were as follows: VMRE, 0.46; MRE alone, 0.89; MRE + VMRE, 0.96. The classifier C also provided better performance than MRE alone, in terms of sensitivity (100 vs. 93.5%, respectively) and specificity (92 vs. 76%, respectively, p = 0.046). Conclusions: The correlation between sADC and µMRE was strong both in the liver and in tumors. However, VMRE alone could not classify HCC and metastases. The combination of MRE and VMRE, however, allowed discriminant performance between HCC and metastases.

Visualization of small visceral arteries on abdominal CT angiography using ultra-high-resolution CT scanner.

PURPOSE: To evaluate the image quality and ability to delineate the small visceral arteries of high-resolution (HR) abdominal CT angiography (CTA) using an ultra-high-resolution computed tomography (UHR CT) scanner. MATERIALS AND METHODS: Thirty-seven patients were enrolled who underwent abdominal CTA using a UHR CT scanner. The images were reconstructed with a matrix of 1024 × 1024 and 0.25 mm thickness for HR CTA and with a matrix of 512 × 512 and 0.5 mm thickness for normal resolution (NR) CTA. Maximum CT value, image quality, and delineation of the small arteries were compared between HR CTA and NR CTA. RESULTS: HR CTA showed significantly higher maximum CT value, higher image quality, and better delineation of the small arteries than did NR CTA (P < .005). CONCLUSION: HR CTA using a UHR CT scanner showed higher image quality than NR CTA and enhanced the delineation of visceral arteries.

Multimaterial decomposition algorithm for quantification of fat in hepatocellular carcinoma using rapid kilovoltage-switching dual-energy CT: A comparison with chemical-shift MR imaging.

ABSTRACT: Understanding intratumoral fat in hepatocellular carcinoma (HCC) is clinically important to elucidate prognosis. We sought to quantify HCC and liver fat with a multimaterial decomposition (MMD) algorithm with rapid kilovoltage-switching dual-energy computed tomography (DECT) relative to chemical-shift magnetic resonance imaging (CSI).In this retrospective study, 40 consecutive patients with HCC underwent non-contrast-enhanced (non-CE) and four-phases contrast-enhanced (four-CE) DECT (80 and 140 kVp) and abdominal MR imaging (including CSI) between April 2011 and December 2012. Fat volume fraction (FVFDECT) maps were generated by MMD algorithm to quantify HCC and liver fat. Fat fraction measured by CSI (FFCSI) was determined for HCC and liver on dual-echo sequence using 1.5- or 3-Tesla MR systems. The correlation between FVFDECT and FFCSI was evaluated using Pearson correlation test, while non-CE FVFDECT and four-CE FVFDECT were compared by one-way ANOVA and Bland-Altman analysis.Forty patients (mean age, 70.1 years ± 7.8; 25 males) were evaluated. FVFDECT and FFCSI exhibited weak to moderate correlations for HCC in non-CE and four-CE except in equilibrium phase (r = 0.42, 0.44, 0.35, and 0.33; all P < .05), and very strong correlations for liver in all phases (r = 0.86, 0.83, 0.85, 0.87, and 0.84; all P < .05). Those correlation coefficients were significantly higher for liver for each phase (all P < .05). FVFDECT did not differ significantly across scan phases regarding HCC or liver (P = .076 and 0.56). Bland-Altman analysis showed fixed bias in all phases between non- and four-CE FVFDECT in HCC and liver.As compared with liver, correlations between FVF measured by DECT-based MMD and FF measured by CSI were weak in HCC in all phases. FVF is reproducible across all scan phases in HCC and liver. The MMD algorithm requires modification for HCC fat quantification given the heterogeneous components of HCC.

Chimeric Latissimus Dorsi Flap in One-Stage Reconstruction of Depressor Muscle Dysfunction and Depression Deformity in the Perimandibular Area.

BACKGROUND: Depression deformity and paralysis of depressor muscles (DMs) may occur following tumor resection in the perimandibular region. Obtaining satisfactory results is challenging. The authors report 3 cases of 1-stage reconstruction by transferring neurovascular chimeric latissimus dorsi (LD) musculo-adipose flaps, with satisfactory results. METHODS: Three patients with depression deformity and DMs dysfunction after tumor resection in the perimandibular region underwent chimeric LD flap transfer. The flap comprised 1 portion with adipose tissue for augmentation, and the other contained muscle bellies with 1 or 2 neural pedicle (s) for DM reanimation. In case 1, the neural pedicle was sutured to the contralateral marginal mandibular branch. In case 2, the neural pedicle was sutured to the ipsilateral marginal mandibular branch. In case 3, the neural pedicle was sutured to both branches of the facial nerve. RESULTS: All patients were satisfied with the deformity corrections. However, contractions of the transferred muscles varied. Case 1 showed insufficient contraction. Case 2 had excessive muscle contraction. In case 3, the muscle had double innervation, and well-balanced contraction was maintained for 3 years. CONCLUSIONS: Neurovascular chimeric LD flaps are versatile and useful for secondary reconstruction after tumor resection for functional loss of mimetic muscles. The ipsilateral facial nerve may be an effective motor source.

One-Stage Simultaneous Augmentation of 2 Regions of 3 Facial Reanimations After Mid Skull Base Surgery by Using a Neurovascular Latissimus Dorsi Chimeric Flap.

ABSTRACT: We report a patient who underwent secondary reconstruction for facial paralysis involving 2 regions of augmentation and 3 facial reanimations using a neurovascular latissimus dorsi (LD) chimeric flap.A 53-year-old man underwent mid-skull base surgery for a chondrosarcoma at the temporomandibular joint and primary reconstruction using a free anterolateral thigh flap. At 28 months after surgery, he showed temporal and buccal depression and incomplete facial paralysis. We planned 1-stage reconstruction using a neurovascular LD chimeric flap, which was divided into dual compounds of the neurovascular muscle with soft tissue along the descending and transverse bifurcation of the thoracodorsal neurovascular bundle. We added adipose tissue to the muscle belly of the transverse branch using microperforators. We cut the transverse nerve 2.7 cm from the hilus and about 5 cm from the bifurcation, enabling the proximal stump of the transverse branch to be sutured to the ipsilateral buccal branch and function as a cross-face nerve graft. The transverse branch compound was placed on the temporal region and its neural pedicle was sutured to the zygomatic branch. The descending branch compound was placed in the buccal region and sutured to the contralateral buccal branch.At 58 months after surgery, good contour remained, and smiling was voluntary and natural. On needle electromyography, the zygomatic major muscle and the muscle transferred to the buccal region showed good contraction, and the muscle transferred to the temporal region provided tonus to the lower eyelid. The versatility of the neurovascular chimeric flap facilitated multiple augmentations and 3 reanimations.