Comparison of Functional Results After Cross-Face Nerve Graft-, Spinal Accessory Nerve-, and Masseter Nerve-Innervated Gracilis for Facial Paralysis Reconstruction: The Chang Gung Experience.

BACKGROUND: Using functioning free muscle transplantation (FFMT) for facial paralysis and postparalysis facial synkinesis reconstruction is our preferred technique. Gracilis was the first choice of muscle. Three motor neurotizers: cross-face nerve graft (CFNG), spinal accessory nerve (XI) and masseter nerve (V3) have been used as neurotizers for different indications. METHODS: A total of 362 cases of facial reanimation with FFMT were performed between 1986 and 2015. Of these, 350 patients with 361 FFMT were enrolled: 272 (78%) patients were treated by CFNG-gracilis, 56 (15%) by XI-gracilis, and 22 (6%) by V3-gracilis. Smile excursion score, cortical adaptation stage with tickle test for spontaneous smile, facial synkinesis, satisfaction score by questionnaire, and functional facial grading were used for outcome assessment. RESULTS: The CFNG-gracilis in a 2-stage procedure achieved most natural and spontaneous smile when longer observation (≥2 years) was followed. The single-stage procedure using the XI-gracilis has proven a good alternative. V3-gracilis provided high smile excursion score in the shortest rehabilitation period, but never obtained spontaneous smile. CONCLUSIONS: The CFNG-gracilis remains our first choice for facial paralysis reconstruction which can achieve natural and spontaneous smile. XI- or V3-gracilis can be selected as a save procedure when CFNG-gracilis fails. The V3-gracilis is indicated in some specific conditions, such as bilateral Möbius syndrome, older patients (age, >70 years), or patients with malignant disease.

Chimeric Free Vascularized Metatarsophalangeal Joint With Toe Fillet Flap: A Technique for Reconstruction of the Posttraumatic Metacarpophalangeal Joint With Concomitant Soft Tissue Defect.

For painful, dysfunctional, posttraumatic metacarpophalangeal (MCP) joints, the free vascularized toe joint transfer may represent a good solution. Successful reconstruction is potentially limited, however, by 2 features of the traditional vascularized metatarsophalangeal (MTP) transfer: inadequate arc of flexion and insufficient soft tissue coverage. The solution to both of these dilemmas lies in the manner of utilizing the donor site. Because of its innate hyperextensibility, rotating the MTP 180° volar to dorsal provides the greatest arc of flexion in the reconstructed MCP. Excellent soft tissue coverage can be provided by elevating the skin paddle of the transferred second toe as a chimeric fillet flap, based on the tibial plantar digital artery.

Surgical correction of pixie-ear defect without an exposed incision on the lobe.

Pixie ear is a condition in which the posterior edge of the helix extends straight down to the cheek-jaw intersection, without sweeping back up anteriorly to form a lobe. It occurs congenitally, but more commonly is a postoperative condition, following facelift surgery. Over the years, a handful of methods have been proposed to restore a normal earlobe contour in patients with pixie-ear defects, regardless of etiology. However, virtually all either result in an exposed scar or have limited or undocumented follow-up. The technique described here, resulting in a hidden scar on the mastoid-facing portion of the newly formed lobe and at the mastoid, behind the lobe, has been performed 26 times, with follow-up as long as 20 years.

Comparison of Surgical Strategies between Proximal Nerve Graft and/or Nerve Transfer and Distal Nerve Transfer Based on Functional Restoration of Elbow Flexion: A Retrospective Review of 147 Patients.

BACKGROUND: Surgical strategy to treat incomplete brachial plexus injury with palsies of the shoulder and elbow by using proximal nerve graft/transfer or distal nerve transfer is still debated. The aim of this study was to compare both strategies with respect to the recovery of elbow flexion. METHODS: One hundred forty-seven patients were enrolled: 76 patients underwent reconstruction using proximal nerve graft/transfer, and 71 patients underwent reconstruction using distal nerve transfer. All patients were evaluated preoperatively and postoperatively to assess the recovery rate and muscle strength of elbow flexion. Shoulder abduction and hand grip power were also recorded to assess any concomitant postoperative changes between the two methods. RESULTS: The best recovery rate for functional elbow flexion (p = 0.006) and the fastest recovery to M3 strength (p < 0.001) were found in the double fascicular transfer group. However, recovery of shoulder abduction with proximal nerve graft/transfer was significantly better than with distal nerve transfer (80.3 percent versus 66.2 percent in shoulder abduction ≥60 degrees; and 56.6 percent versus 38.0 percent in shoulder abduction ≥90 degrees). A significant decrease in grip strength between the operative and nonoperative hands was also found in patients undergoing distal nerve transfer (p = 0.001). CONCLUSIONS: Proximal nerve graft/transfer offers more accurate diagnosis and proper treatment to restore shoulder and elbow function simultaneously. Distal nerve transfer can offer more efficient elbow flexion. Combined, both strategies in primary nerve reconstruction are especially recommended when there is no healthy or not enough donor nerve available. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.