Reconstruction Of Facial Paralysis Research Articles

Long-term Follow-up of Secondary Reconstruction of Facial Paralysis and Depressive Deformities After Subtotal Temporal Bone Resection.

Subtotal temporal bone resection (STBR) frequently results in facial paralysis and depression, making reconstruction challenging due to significant tissue loss. This study aimed to evaluate the effectiveness of a procedure designed for simultaneous smile and soft tissue reconstruction after STBR. The authors included 3 patients who underwent latissimus dorsi (LD) neuromuscular flap combined with adipose flap transfer after STBR at the Tokyo Medical and Dental University Hospital between 2010 and 2016. Among these patients, 2 had facial vessels unsuitable for anastomosis due to prior neck dissection, and their masseteric nerves were unavailable for neurorrhaphy due to STBR. The thoracodorsal nerve was coaptated to the contralateral facial nerve in all patients and to the ipsilateral masseter nerve in one patient. Follow-up periods ranged from 7 to 13 years, with all patients achieving spontaneous smiles within 12 months post-surgery. Although depressive deformities improved, long-term follow-up revealed buccal muscle bulging due to unstable LD muscle fixation from a zygomatic arch defect caused by STBR. Revision surgeries, including muscle refixation with a tensor fasciae lata graft, muscle reduction, eyebrow lifting, blepharoplasty, and adipose tissue repositioning, were performed as needed. Ultimately, all patients achieved satisfactory facial contours and spontaneous smiles. This study demonstrates that free LD muscle with adipose flap transfer is effective for post-STBR reconstruction. However, detailed surgical planning and multistage reconstruction are often necessary due to the complexities involved.

D155. Exploring the Efficacy of a Novel Platysma Muscle Flap in Rat Models for Advancing Facial Paralysis Reconstruction Research

D155. Exploring the Efficacy of a Novel Platysma Muscle Flap in Rat Models for Advancing Facial Paralysis Reconstruction Research

Optimizing Facial Function in Patients With High-Risk Recurrent Pleomorphic Adenoma and a History of Facial Nerve Injury.

Parotid pleomorphic adenoma (PA) patients present significant diagnostic and surgical challenges rendering them high risk for facial nerve injury. Recurrent PA patients often present with history of facial nerve injury or previous reanimations making salvage of the facial nerve or previous reanimations significantly more complex. The study aim is to share our experience with this high risk for facial nerve injury population and review the literature. Adult patients with recurrent PA and history of facial nerve injury with at least 3 months of follow-up were analyzed for demographics, facial palsy history, previous head and neck surgeries, previous facial paralysis reconstruction, preoperative imaging, surgical approach, and postoperative outcomes. Four female patients were identified with an average age of 62 years. All patients underwent an initial protective dissection of the facial nerve or previous reanimation reconstruction by the facial nerve reconstructive team followed by the extirpative team. The average number of previous head and neck surgeries was 5, the number of recurrences was 2, and follow-up was 20 months. Half had prior dynamic facial reanimation. Two patients underwent complete preextirpative dissection of the facial nerve resulting in neuropraxia, which recovered completely after an average of 143 days. A third patient presented with 2 recurrences, both during and after reanimation with a dually innervated free functional muscle transfer. The reconstruction was salvaged, and motion was achieved. A fourth patient presented with benign preoperative findings, but intraoperative findings confirmed malignancy, necessitating facial nerve sacrifice, followed by immediate intratemporal grafting of the facial nerve and masseteric nerve transfer. Motion appeared 139 days postoperatively. A multidisciplinary effort should be implemented in this high risk for facial nerve injury population with the primary goal of protecting the facial nerve or any previous reanimation procedures, yet with preparedness to apply any reconstructive strategy based on intraoperative findings.

Commentary on: "Measuring Patient-Reported Outcomes After Facial Paralysis Reconstruction Surgery Using the Face-Q" by Vicente-Ruiz et al.

Commentary on: "Measuring Patient-Reported Outcomes After Facial Paralysis Reconstruction Surgery Using the Face-Q" by Vicente-Ruiz et al.

Measuring Patient-Reported Outcomes After Facial Paralysis Reconstruction Surgery Using the FACE-Q.

Background: Patients affected by facial paralysis often experience significant psychosocial impairment, it is, therefore, essential to incorporate their perspective when assessing surgical outcomes. Objective: To study the effect of various patient- and treatment-specific factors on patient satisfaction after facial paralysis reconstruction as measured by FACE-Q. Methods: Seventy-two patients who underwent facial paralysis procedures by our senior author from 2000 to 2020 received the FACE-Q by email. Patient characteristics, duration of paralysis before surgery, type of surgery, complications, and secondary procedures were recorded. Results: Forty-one patients successfully completed the questionnaire. We found that men were significantly more satisfied with the decision to undergo surgery, older patients had significantly lower satisfaction scores with their face and psychosocial well-being, and uninsured patients had higher satisfaction scores with their face and their social and psychosocial well-being, whereas those items were significantly lower in patients with a long-standing facial paralysis. No differences were found between static and dynamic techniques, the presence of complications or the need for secondary procedures. Conclusions: This study found that decreased patient satisfaction was associated with older age, female sex, insured patients, and longer duration of the paralysis before treatment for facial paralysis reconstruction.

Integrated Approaches for Reconstruction of Facial Paralysis.

Facial paralysis can affect periorbital muscles, oral competence, and facial expressions with significant facial deformities, which could occur in either children or adults with variable severity, duration, and degree of recovery. The present study was aimed to delineate treatment plans for facial paralysis with different clinical scenarios and to report the results of these patients. Patients were grouped according to different presentations as follows: (1) facial paralysis with incomplete recovery; (2) young patients of facial paralysis without recovery; (3) senile patients of facial palsy without recovery; (4) combined facial palsy with mandibular deficiency, vascularized bone reconstruction for mandible with (a) subsequent muscle transfer or (b) simultaneous sling operation or (c) simultaneous facial nerve exploration and cross nerve grafting; (5) palsy of frontal branch of facial nerve; (6) palsy of zygomatic-buccal branch of facial nerve; (7) palsy of marginal mandibular branch of facial nerve; (8) partial recovery with dyskinesia; and (9) facial paralysis with dynamic asymmetry and muscle atrophy. According to clinical scenarios, different treatment plans were provided, and clinical outcomes were evaluated and presented. All patient groups achieved fair or satisfactory outcomes. Revisions using sling procedures, botulinum toxin injection, and filler or fat graft as supplement further refined the ultimate outcomes. For reconstruction of facial paralysis, individualized integrated treatment plans are mandatory according to the presentation and condition of the patient. Comprehensive considerations and strategic solutions for the existing disabilities have been appreciated by the patients. The least numbers of operations with considerate correction of asymmetry were the major concerns of the patients.

Surgical Therapeutic Algorithm in Facial Paralysis

Facial nerve paralysis is a debilitating condition with multiple etiologies, with aesthetic, functional, psychological and social impact. Given the complex multitude of causes that may generate such condition, a therapeutic algorithm is mandatory when attempting reconstruction. Severity, timing, patient adherence to a rehabilitation program, status of ipsilateral and contralateral facial nerves and particularities of each patient are all criteria which should be accounted when choosing a treatment option. After initial assessment, a variable treatment panel is available based on condition type include medicamentous therapy, rehabilitation program, dynamic and static procedures surgical procedures, having as primary aim functional restoration achieving aesthetic balanced facial features. This paper summarizes current knowledge in facial paralysis reconstruction and presents an algorithmic approach that eases decision making and therapeutic strategy.

Outcome of using the spinal accessory nerve for functional muscle innervation in facial paralysis reconstruction: The first two cases in Vietnam and literature review

Abstract Facial nerve injuries with various causes, such as after trauma, tumor dissection, radiotherapy, etc., resulting the patient's functional, aesthetic, and psychological sequelae. For many decades, plastic surgeons have introduced numerous different nerve sources to overcome the above sequelae, such as contralateral facial nerve, the hypoglosal nerve, the masseter nerve, and the spinal accessory nerve (CN XI). There were various advantages and disadvantages of donor nerves sources. However, the use of ipsilateral donor nerve is said to have many benefits. In this report, we would like to present preliminary results of using the CN XI source in treatment of subacute and chronic VII nerve injury. These were the first two cases of successful surgery using this nerve source in Vietnam. Keywords: Facial nerve injury, facial paralysis, nerve transfer, spinal accessory nerve.

Surgical Treatment for Postparalytic Facial Synkinesis: A 35-Year Experience.

Surgical intervention with combined myectomy and neurectomy followed by functioning free muscle transplantation has been proposed to effectively resolve the problem of postparalytic facial synkinesis since 1985, and it continues to be the authors' standard of care. The authors aim to provide evidence that this surgical strategy is effective for treatment of synkinesis and smile quality. One hundred three patients with postparalytic facial synkinesis were investigated (1985 to 2020). They all underwent extensive removal of the synkinetic muscles and triggered facial nerve branches in the cheek, nose, and neck regions, followed by gracilis functioning free muscle transplantation for facial reanimation. Ninety-four patients (50 with type II and 44 with type III postparalytic facial synkinesis), all of whom had at least 1 year of postoperative follow-up, were included in the study. Patient demographics and functional and aesthetic evaluations before and after surgery were collected. In the yearly distribution of the facial paralysis reconstruction, the incidence of surgical intervention increased from 15 percent before 2012 up to 24 percent in the years after. Young adults (79 percent) and female patients (63 percent) were the dominant population. Results showed a significant improvement of the facial smile quality, with more teeth visible while smiling, and a long-lasting decrease of facial synkinesis. Ninety-six percent of patients did not require botulinum toxin type A injection after surgery. Revision surgery for secondary deformity was 53 percent. Combined myectomy and neurectomy followed by functioning free muscle transplantation for type II and III synkinetic patients leads to promising and long-lasting results despite high revision rates. Refined techniques to decrease the revision rates are needed in the future. Therapeutic, IV.

105. Long Term Surgical and Patient Reported Outcomes After Cross Face Nerve Graft Reconstruction in Pediatric Facial Paralysis

Purpose: Free functioning muscle transfer is the gold standard for pediatric facial paralysis reconstruction and using the contralateral facial nerve for neurotization via a cross face nerve graft enables spontaneous smile restoration. Outcomes of pediatric facial reanimation beyond 10 years are not known, including how smiles change with aging and how adult patients report their facial function and quality of life. This study evaluated long term surgical and patient-reported outcomes for adults who underwent facial reanimation as children. Methods: This cross-sectional study enrolled patients who underwent facial reanimation with a staged cross face nerve graft and free gracilis muscle transfer as children at least 10 years ago. FACE-Gram software was used to quantify commissure excursion on frontal photographs in repose and maximal smile at three time points: preoperative, early postoperative within 2 years, and current (long term follow up). Patient-reported outcomes were evaluated quantitatively using the FaCE Scale and FACE-Q instruments for patient satisfaction, and qualitatively with semi-structured interviews. Results are reported as mean ± SD and parametric statistical analysis was performed with alpha of 0.05. Results: Eighteen patients who underwent facial reanimation as children more than 10 years ago were included (14 females, 5 males; 10 congenital, 8 acquired; age at stage 1 surgery 7.4 ± 3.6 years). Commissure excursion was measured as -1.3 ± 3.5 mm preoperatively, 5.9 ± 2.3 mm postoperatively within 2 years, and 7.6 ± 3.5 mm at long term follow up (mean 20.5 ± 6.9 years). Commissure excursion increased 7.2 ± 4.9 mm from preoperative to early postoperative time points (p<0.0001) and did not significantly increase or decrease at long term follow up (p>0.05). For patient reported outcomes, mean FaCE scale score for facial movement was 44/100 when including eyebrow function and 79/100 when excluding eyebrow function. Mean FaCE scale scores were 63/100 for eye comfort and 81/100 for social function. On the FACE-Q Satisfaction with Outcome scale, 17/18 respondents somewhat agreed or definitely agreed with the statement, “I am pleased with the result.” On the FACE-Q Social Function scale, 16/18 respondents somewhat agreed or definitely agreed with the statement, “I feel confident when I meet a new person.” Conclusions: Pediatric facial reanimation with cross face nerve grafting improves commissure excursion and this is maintained with aging. Adult patients report overall high satisfaction and social functioning. Ongoing ocular issues remains a problem for many patients, underscoring the importance of refining techniques for reanimation of the eye.

Dynamic Reconstruction of Facial Paralysis in Craniofacial Microsomia.

Craniofacial microsomia is associated with maxillomandibular hypoplasia, microtia, soft-tissue deficiency, and variable severity of cranial nerve dysfunction, most often of the facial nerve. This study evaluated the incidence of facial paralysis in patients with craniofacial microsomia and outcomes after free functioning muscle transfer for dynamic smile reconstruction. A single-center, retrospective, cross-sectional study was performed from 1985 to 2018 to identify pediatric patients with craniofacial microsomia and severe facial nerve dysfunction who underwent dynamic smile reconstruction with free functioning muscle transfer. Preoperative and postoperative facial symmetry and oral commissure excursion during maximal smile were measured using photogrammetric facial analysis software. This study included 186 patients with craniofacial microsomia; 41 patients (21 male patients, 20 female patients) had documented facial nerve dysfunction (22 percent) affecting all branches (51 percent) or the mandibular branch only (24 percent). Patients with severe facial paralysis (n = 8) underwent smile reconstruction with a free functioning muscle transfer neurotized either with a cross-face nerve graft (n = 7) or with the ipsilateral motor nerve to masseter (n =1). All patients achieved volitional muscle contraction with improvement in lip symmetry and oral commissure excursion (median, 8 mm; interquartile range, 3 to 10 mm). The timing of orthognathic surgery and facial paralysis reconstruction was an important consideration in optimizing patient outcomes. The authors' institution's incidence of facial nerve dysfunction in children with craniofacial microsomia is 22 percent. Free functioning muscle transfer is a reliable option for smile reconstruction in children with craniofacial microsomia. To optimize outcomes, a novel treatment algorithm is proposed for craniofacial microsomia patients likely to require both orthognathic surgery and facial paralysis reconstruction. Therapeutic, IV.

Salvage Procedures for Facial Reanimation With Neurovascular Flaps When Previous Surgeries Failed: Is Homolateral Vessel or Nerve Depletion a Contraindication?

Facial paralysis reconstruction can be difficult in extensive defects after complex facial or cranial base tumor resection and radiotherapy or when primary smile reanimation attempt has failed. The surgical challenge is more complicated when defects are associated with recipient vessels or nerves depletion. This scenario has not been well described in the literature, and the present article will address the alternatives that plastic surgeons may use in these circumstances. Seventy-five patients operated in the Hospital Gregorio Marañon between 2008 and 2020, for dynamic reconstruction of facial paralysis, were retrospectively evaluated, collecting data about previous facial nerve surgeries, radiotherapy, chemotherapy, recipient nerve for motor restoration and vessels used for free flaps, type of neurovascular free flap (NVFF), and functional score before and after the facial reanimation surgery. Patients presenting recipient vessel and/or nerve depletion after several facial surgeries requiring a variation from the common NVFF surgical protocol were included in this study. Six cases (8%) with facial paralysis and absent recipient homolateral vessels or nerves after severe cranial base surgery, parotid malignancies, or schwannoma surgery were included. Two patients had an immediate functional reconstruction during the oncologic resection surgery, and 4 patients had a delayed reconstruction. Three patients had previous reconstruction with free flaps, and the vascular pedicles of previous flaps were used for the new NVFF. In the other 3 cases, interposition vein grafts to the contralateral recipient vessels were required to perform NVFF. Masseteric nerve in 4 cases, hypoglossal nerve and posterior branch of the deep temporal nerve in 1 case each, were used as recipient nerves. House-Brackmann score improved in all patients after surgery. Neurovascular free flap can be successfully performed to restore facial motion after depletion of homolateral recipient vessels or nerves after previous facial or cranial base surgeries. In these cases, interposition vascular grafts or the pedicle of previous flaps are essential to provide vascularization as well as an optimal orientation of flaps, to reach recipient nerves in a 1-step procedure.

Maximizing the Smile Symmetry in Facial Paralysis Reconstruction: An Algorithm Based on Twenty Years' Experience

Over the last two decades, the senior author (B.H.) has had an extensive experience with facial paralysis reconstruction. During this period, the techniques have evolved substantially based on the experience and after observing and analyzing the surgical outcomes. The purpose of this article is to relay the lessons learned from the 20 years' experience and suggest an algorithm. In this retrospective study, we have included 343 cases of facial paralysis cases. Complete facial paralysis cases were 285 and 58 were incomplete facial paralyses, both requiring surgical procedures. Complete facial paralyses were divided in to short term (n = 83) and long term (n = 202). In total, 58% of the patients were women and 42% were men. The age range was 6 to 82 years. The techniques employed were direct suture, nerve grafts, cross-facial nerve grafts (CFNGs), masseteric-to-facial nerve transference, hypoglossal-to-facial nerve transference, free muscle transplants, and lengthening temporal myoplasty to achieve the best symmetry after reanimation of unilateral, bilateral, complete, and incomplete facial paralysis. The type of paralysis, objective measurements, the personal patient's smile, and the gender are key concepts to be considered before scheduling a dynamic facial paralysis reconstruction. For unilateral facial paralysis, the time of onset, the type of paralysis, the patient's comorbidities, and the healthy side status are some of the determining factors when selecting the correct technique. The preferred techniques for unilateral facial paralysis are direct repair, CFNG, masseteric-to-facial transposition, and free gracilis transfer. For incomplete facial paralysis, the masseteric-to-facial nerve transference is preferred. In bilateral facial paralysis, bilateral free gracilis transfer is performed in two stages using the nerve of the masseter muscle as the source of innervation. The authors provide an algorithm which simplifies facial paralysis reconstruction to achieve the greatest facial symmetry while thinking about the potential comorbidities and developing spontaneity smile according to the gender of the patient.

Tips and Pearls for Recovering Symmetry After Facial Palsy Using a Tendon Sling: Our 20-Year Experience

Background: In facial palsy reconstruction, static techniques with the use of slings can improve the appearance and functionality of the paralyzed face and may be used in patients who cannot undergo complex surgeries or as an ancillary procedure to a dynamic reconstruction. The objective of this study was to assess the improvement in facial symmetry and quality of life among older patients with flaccid facial palsy with the use of a plantaris tendon sling. Methods: A total of 46 patients who had undergone a static reconstruction with the plantaris tendon sling were studied. The surgical technique is detailed emphasizing the tips and pearls. Results: The displacement of the oral commissure was assessed with the FACIAL CLIMA demonstrating a mean elevation of 1.5 ± 0.4 cm and an improvement of 97 ± 7% in the recovery of oral commissure symmetry 2 years after the surgery, whereas the Sunnybrook Facial Grading System showed an improvement of symmetry at rest (-15 ± 5) at 2 years. The Facial Disability Score indicated an improvement of the physical disability (+73.5 ± 14) as well as the social impairment (+21 ± 7) at 1 year postoperatively. Patients were followed for a median of 2 years (range 2-6 years). Conclusions: The use of tendon slings for static facial paralysis reconstruction is a reliable technique with no functional sequelae and good long-term results.

The versatility of the use of free-functioning gracilis muscle flap in the reconstruction of deficient motor unit

Introduction Free gracilis muscle transfer can provide reliable reconstruction of cases of lost motor unit. The aim of this study was to describe the surgical techniques used for harvesting the gracilis muscle used for reconstruction of facial paralysis and brachial plexus palsy. Patients and methods Ten patients underwent free gracilis muscle transfer. Short gracilis muscle transfer was used for facial reanimation. Extended gracilis muscle transfers were used to reconstruct patients with brachial plexus palsy. Results All of the transferred muscles were survived completely except one. The overall success rate was 90%. The average time for the start of reinnervation was 3.74 months (range, from 3 to 5 months). Discussion We used free gracilis flap for reconstruction of delayed cases with deficient motor unit. Tamai was the first to describe free microvascular transfer in dogs. Harii was the first to describe free gracilis flap in humans. The gracilis muscle has a constant anatomy, long tendon, and good excursion with few donor site morbidities. Conclusion The gracilis muscle is recommended for use as a free-functioning muscle flap for reconstruction of delayed cases of motor paralysis as in cases of facial nerve injury and brachial plexus injury.

Bidirectional/double fascia grafting for simple and semi-dynamic reconstruction of lower lip deformity in facial paralysis

For the total aesthetic reconstruction of facial paralysis, treatment of lower lip deformity as "a neglected target in facial reanimation" is important. Although various dynamic reconstruction approaches have been reported for lower lip deformity, these have not been popularly performed due to aggressive surgical invasiveness, long recovery time for reinnervation, and unstable outcomes. To reconstruct the lower lip deformity more simply but semi-dynamically, we modified bidirectional/double fascia grafting methods that have been established as simple and minimally invasive treatments for pediatric congenital lower lip paralysis. Between 2009 and 2011, nine patients were treated using this procedure alone or with combinations of other procedures of facial reanimation such as one-stage free muscle transfer. For outcome assessment, patients were evaluated using a lower lip paralysis grading system, including the objective aesthetics and functional results of the lower lip at rest (score range, 0-1), during smiling (score range, 0-4), and during mouth opening (score range, 0-2). The mean total scores improved from 1.43 (poor) preoperatively to 5.71 (excellent) postoperatively. In all evaluation items, the postoperative scores improved significantly compared to the preoperative scores (p<0.01) with no severe complications. The procedure is simply applied to various types of extensive facial paralysis, as well as congenital lower lip paralysis in combination with other static and dynamic reconstruction methods for facial paralysis, and it is suggested that this approach significantly and semi-dynamically improves the aesthetic function of the lower lip at rest, during smiling, and during mouth opening.

Facial paralysis reconstruction in children and adolescents with central nervous system tumors.

Facial paralysis remains a vexing problem in the treatment of posterior cranial fossa tumors in children. Fortunately, current techniques are available to reconstruct the paralyzed face in restoring balance, symmetry, and amelioration of functional sequelae. The restoration of structure and function of the paralyzed face is tantamount to proper social integration and psychosocial rehabilitation. In addition, the facial nerve is important in preventing drying of the eyes, drooling, and speech abnormalities, among other functions. The most visible evidence of facial paralysis is stark asymmetry, especially with animation. This is perhaps the most troubling aspect of facial paralysis and the one that leads to the greatest amount of psychosocial stress for the child and family members. Management strategies include early and late intervention. Early reconstructive goals focus on preservation and strengthening of intact motor end plates through native stimulatory pathways. Late reconstructive efforts are centered on surgically reconstructing permanently lost function based on each third of the face. Use of adjunct modalities such as chemical or surgical denervation and myectomies are also critical tools in restoring symmetry. Physical therapy plays a large role in both early and late facial nerve paralysis in optimizing cosmetic and functional outcome.

One-Stage Procedure Using Spinal Accessory Nerve (XI)–Innervated Free Muscle for Facial Paralysis Reconstruction

For the treatment of facial paralysis, functioning free muscle transplantation has become accepted standard treatment. Choice of donor nerve and number of surgery stages, however, are still matters of great debate. Between 2000 and 2011, 36 patients (out of 329; 11 percent) with 42 functioning free muscle transplantations were treated using spinal accessory nerve (XI)-innervated muscle for facial reanimation as a one-stage procedure. Indications included bilateral or unilateral Möbius syndrome, severe postparetic facial synkinesis, and patient preference. Postoperative smile training was required to achieve spontaneous smile. For outcome assessment, patients were evaluated using multidisciplinary methods, including objective smile excursion score (range, 0 to 4), cortical adaptation stage (range, I to V), tickle test, and subjective patient questionnaire and satisfaction score (range, 1 to 5). Mean smile excursion score improved from 0.5 preoperatively to 3.4 postoperatively. Eighty-three percent of patients were able to perform independent and even spontaneous smile after 1 year of follow-up. Ninety percent of patients had a mean satisfaction score of 3.4 out of 5. However, 50 percent expressed more concern with aesthetic appearance than functional status. There was no functional morbidity of the donor shoulder in daily life. The classic two-stage procedure is still the first choice for facial paralysis reconstruction. However, the effectiveness of XI-innervated free muscle for facial reanimation in a one-stage procedure has proven it to be a good alternative treatment. It has become second in popularity for facial paralysis reconstruction in the authors' center. Therapeutic, IV.

Anatomic basis of interfascicular nerve splitting of innervated partial latissimus dorsi muscle flap

To study the anatomic basis for the interfascicular nerve-splitting technique applied to the innervated latissimus dorsi muscle flap to preserve the remnant muscle function. Cadaveric dissection was performed to study the distribution of the thoracodorsal nerve and artery, and simulation of the surgical technique was also executed. A total of 42 latissimus dorsi muscles from 21 preserved cadavers were dissected, and the distribution of the nerves and arteries were studied. The thoracodorsal neurovascular bundles were identified entering the muscle, and the distance from the upper margin and lateral margin of the muscle, and the distance from the angle of scapula were measured. The distance from the brachial plexus to the branching of the thoracodorsal nerve were measured and the distance between the branching of the nerve and artery were also measured. Interfascicular splitting of the thoracodorsal nerve was performed under operating microscope and the validity of the technique was confirmed by histology. The thoracodorsal neurovascular bundle entered the muscle at a distance of 39.1 ± 8.8 mm from the upper margin, and 23.8 ± 10.3 mm from the lateral margin. In addition, from the angle of scapula, the distance was 47.8 ± 17.8 mm in the transverse axis, and 48.9 ± 13.5 mm in the sagittal axis. The distance from the brachial plexus to the first branching of the thoracodorsal nerve was 78.5 ± 11.0 mm, and distance to the second branching was 96.3 ± 12.9 mm. The thoracodorsal nerve always branched before the artery, and the distance from the first branching of the nerve to the first branching of the artery was 20.4 ± 8.9 mm. Interfascicular dissection of the nerve was performed under operating microscope, by opening the epineurium and splitting the fascicles with utter care not to injure the perineurium. This procedure was very similar to splitting a wire cable. Histological analysis of the dissected nerve confirmed that the interfascicular dissection was performed without injuring the fascicules and the perineurium was intact. We simulated and confirmed that the preservation of the remnant muscle function was possible by using the nerve-splitting technique in the innervated latissimus dorsi muscle flap. It is easy and simple to separate the nerve branch entering the muscle flap from the nerve branch entering the remnant muscle without injury, which results in increasing the nerve length while preserving the muscle function of the donor site. Further, the distribution of the thoracodorsal neurovascular bundle was studied in 42 muscles, which can be used as a reference point during surgery. With this novel technique, preservation of the remnant muscle function is possible when using innervated muscle flaps, which can be applied in areas such as reconstruction of facial paralysis and reconstruction of the chest wall in Poland syndrome.

Assessing Outcomes in Facial Reanimation: Evaluation and Validation of the SMILE System for Measuring Lip Excursion During Smiling

Assessing Outcomes in Facial Reanimation: Evaluation and Validation of the SMILE System for Measuring Lip Excursion During Smiling