A technique for facial reanimation: The partial temporalis muscle-tendon transfer with a fascia lata sling.

BACKGROUND: This report describes the results of a surgical procedure for facial reanimation. This single-stage technique involves the orthodromic transfer of only a superficial segment of the temporalis tendon. This is extended with fascia lata to achieve elevation of the oral commissure along the desired vector in the paralysed hemi-face. METHODS: A retrospective case note review was performed. Patients' photographs were objectively evaluated with Facial Assessment by Computer Evaluation (FACE) software. RESULTS: Thirty-nine patients underwent the procedure from 2001 to 2011. Median age at the operation was 57.0 years (interquartile range (IQR) 38.2-66.3 years), and median duration of follow-up was 0.9 years (IQR 0.5-1.8 years). All patients achieved early improvements in appearance and function after surgery. Three patients underwent further, minor procedures for aesthetic and functional adjustments around the oral commissure. Complications occurred in three patients: two minor facial haematomas and one thigh wound infection. The surgery did not disturb natural temporalis muscle function. FACE analysis demonstrated that no significant movement of the oral commissure occurred during attempted smiling in the paralysed hemi-face before surgery. However, symmetry was achieved when the healthy and paralysed hemi-faces were compared post-operatively, both in repose and during controlled smiling. CONCLUSIONS: This modified, single-stage technique for facial reanimation improves commissure mobilisation and has been objectively shown to restore symmetry of the commissure to the reanimated hemi-face.

Microvascular modifications to optimize the transverse upper gracilis flap for breast reconstruction.

BACKGROUND: The free transverse upper gracilis flap is well described for breast reconstruction and is the authors' second choice. Medial thigh soft tissue creates a durable, pliable, aesthetic breast; however, it has been criticized for modest volume and short pedicle. This demands frequent use of bilateral flaps for unilateral reconstructions, sacrifice of thoracodorsal vessels, and/or use of vein grafts. The authors have overcome these issues by modifying their microvascular techniques. METHODS: The authors describe several maneuvers that they have introduced, including excision and replacement of costal cartilage, using nontraditional internal mammary arterial anastomoses, and using adductor branches for flap-to-flap anastomoses to allow double flap reconstructions. The authors describe their case series of 30 transverse upper gracilis flaps to reconstruct 20 breasts in 18 patients. RESULTS: All flaps have survived. Seventy-five percent of the reconstructions were unilateral, although of these, 67 percent used two flaps to reconstruct one breast. The mean reconstructed breast was 360.9 g. Of 10 breasts reconstructed with double flaps, six used available adductor branches, whereas the others used internal mammary perforators, end-to-side anastomoses, or retrograde arterial flow. To complement this clinical approach, an anatomical study of the branching patterns from the gracilis pedicle has been carried out on 33 cadaveric specimens. CONCLUSIONS: The authors' study has allowed a new classification system to be defined and demonstrates suitable branching patterns to allow flap-to-flap anastomoses in 75 percent of patients; in those 25 percent where this is not possible, alternative strategies for double flaps can be sought and have been used successfully in our clinical series. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A reliable parameter for primary closure of the free anterolateral thigh flap donor site.

BACKGROUND: Primary closure of the donor site after flap harvest is key to achieving a satisfactory result. The authors investigated the width of the harvested anterolateral thigh flap allowing primary closure of the donor site. METHODS: Sixty-five consecutive patients undergoing reconstructive procedures using anterolateral thigh flaps were divided into two groups: group A, primary closure of the donor site; and group B, donor site covered with split-thickness skin graft. Maximum flap width and thigh circumference were measured at the midpoint of the line connecting the lateral superior margin of the patella and the anterior superior iliac spine. The maximum flap width-to-thigh circumference ratio was calculated. Patients' body mass index and age were recorded. The outcome was evaluated by the surgeon. RESULTS: Primary closure of the donor site was possible in 56 patients (86 percent), and in nine patients (14 percent) a split-thickness skin graft was necessary. All of the donor sites were closed primarily when the flap width was less than 16 percent of the thigh circumference. There was a significant correlation between body mass index and the ratio (p<0.001, r=-0.573) and between patient age and the ratio (p=0.033, r=0.267). Muscle herniation was significantly higher in group B (p=0.029). CONCLUSIONS: The flap width-to-thigh circumference ratio is a reliable parameter for preoperative planning of primary closure of the anterolateral thigh flap donor site. Primary closure can be achieved if the flap width-to-thigh circumference ratio is less than 16 percent. The patient's body mass index and age have to be taken into consideration.

Free fibula osteocutaneous flap with soleus muscle as a chimeric flap for reconstructing mandibular segmental defect after oral cancer ablation.

In some cases, the fibula osteocutaneous flap may not provide sufficient soft tissue for obliterating dead space after tumor ablation. This report describes a modified fibula osteocutaneous flap using a portion of soleus muscle to reduce postoperative complications. This study analyzed 20 patients who underwent ablative oral cancer surgery with mandibular segmental defect between September 2005 and June 2007. Of total, 17 cases were mandible complex defects and 3 were composite defects. Of total, 18 were men and 2 were women, respectively. Age range was 30 to 74 years, and mean age was 53 years. The procedure entailed harvest of chimeric fibula flap with skin paddle and bone segment composed of a sheet of soleus muscle (7 x 4 to 12 x 5 cm in size) originating from the perforator branch of the peroneal artery. The soleus muscle was used to obliterate the dead space of the mouth floor and cheek-neck area. All flaps survived except 1 failure due to venous insufficiency. The submandibular and chin area exhibited mild swelling at the submandibular area early postoperatively. Patients had achieved satisfactory contour without donor site morbidity at a mean 12-months of follow-up. Complications included 2 flaps requiring reoperation due to the flap pedicle compromised. One flap was successfully salvaged but the other failed. Two cases of orocutaneous fistula-induced infection recovered after conservative treatment. Donor site assessment revealed a satisfactory outcome without major donor site morbidity. This refinement in mandibular reconstructive surgery substantially reduces postoperative complications.