BACKGROUND:Facial paralysis and postparalysis facial synkinesis both cause severe functional and aesthetic deficits. Functioning free muscle transplantation is the authors’ preferred method for ...reconstructing both deformities.
METHODS:From 1985 to 2017, a total of 392 patients underwent 403 gracilis functioning free muscle transplantations for facial reanimation. Different motor neurotizers were usedcross-face nerve graft (74 percent), spinal accessory nerve (17 percent), and masseter nerve (8 percent). Smile excursion score, cortical adaptation stage, patient questionnaire, Hadlock lip excursion, and the Terzis evaluation systems were used to assess outcomes.
RESULTS:For smile excursion score, the spinal accessory and masseter nerve groups showed higher scores than the cross-face nerve graft group in the first 2 years, but no difference by 3-year follow-up. For cortical adaptation stage, nearly all cross-face nerve graft patients achieved stage IV or V spontaneity, the spinal accessory nerve group achieved at least stage III (independent) movement, but individuals in the masseter nerve group achieved only stage III or less. The cross-face nerve graft group also achieved higher scores according to the Hadlock system and the Terzis evaluation system compared with the other two groups.
CONCLUSIONS:The concept of “sugarcane chewing” where the sweetness is the least at the tail but the most at the head can be simply applied for surgeons and patients in weighing the benefits and drawbacks during the motor neurotizer selection. Cross-face nerve graft–innervated gracilis is analogous to chewing sugarcane from tail to head; despite lower outcome measures earlier, it yields the highest scores at 3 years postoperatively. Masseter-innervated gracilis is akin to chewing sugarcane from head to tail, with greater outcome scores initially but little improvement at longer follow-up. Spinal accessory–innervated gracilis results fall in between these two groups.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.
Introduction: Concomitant nerve injuries with musculoskeletal injuries present a challenging problem. The goals of nerve reconstruction for the shoulder include shoulder abduction and external ...rotation. When patients fail to achieve acceptable shoulder external rotation and shoulder abduction, tendon transfers such as trapezius transfer offer a reliable option in the subsequent stage. Case Presentation: A 32-year-old male presented with weak external rotation in his left shoulder, after previous axillary nerve reconstruction. He received the ipsilateral lower trapezius transfer with the aim of improving the external rotation. Discussion: The lower trapezius restores a better joint reaction force in both the compressive–distractive and anterior–posterior balancing and provides a centering force through the restoration of the anterior–posterior force couple. Conclusion: We believe that the ipsilateral lower trapezius transfer to the infraspinatus is a good outcome and is effective in improving overall shoulder stability and the shoulder external rotation moment arm or at least maintaining in neutral position with the arm fully adducted in patients with post axillary nerve injuries post unsatisfactory nerve reconstruction to increase the quality of life and activities of daily living.
Nerve transfer is the gold standard to restore shoulder abduction in acute brachial plexus injuries. The aim of this study was to compare the phrenic nerve (Ph) to the spinal accessory nerve (XI) as ...the donor nerve for this purpose.
A retrospective chart review was performed on 136 patients with acute brachial plexus injuries who received a nerve transfer of the shoulder with either the Ph (94 patients) or XI (42 patients). Each group was divided into 3 subgroups based on the recipient nerve. The maximum degree of shoulder abduction was recorded after 2 years of postoperative follow-up. A generalized estimating equation model was performed to examine the variables affecting shoulder abduction over time.
The maximum degrees of shoulder abduction achieved were 61.9° ± 38.7° in patients with Ph and 51.1° ± 37.3° in patients with XI. More than M3 shoulder abduction was achieved by 67% of patients with Ph versus 59% of patients with XI. The regression analysis showed that the age at the time of surgery correlated more with the functional outcome over time than the choice of donor nerve.
In multiple root brachial plexus injuries, the Ph exhibited similar outcomes to the XI for shoulder abduction. Our routine exploration of the supraclavicular plexus exposes the Ph conveniently for nerve transfer. The phrenic nerve should be considered as an alternative when the XI is not available or is reserved for secondary reconstruction.
Therapeutic IV.
Long nerve grafts are prone to chronic denervation, often resulting in unsatisfactory clinical outcomes. The authors aim to investigate whether supercharge end-to-side (SETS) motor nerve transfers to ...a long nerve graft can potentially enhance nerve regeneration and functional outcomes.
A reversed long nerve graft was interposed between the C6 and the musculocutaneous nerve in 48 rats. The motor nerves near the C6 proximally and the musculocutaneous nerve distally were chosen for SETS transfer to the long nerve graft. There were four groups: (A) nerve graft only, (B) proximal SETS transfer, (C) distal SETS transfer, and (D) proximal and distal double SETS transfers. A grooming test was assessed at 4, 8, 12, and 16 weeks postoperatively. Biceps weight, compound muscle action potential amplitude, tetanic contraction force, and histomorphometric analysis of the musculocutaneous nerve were evaluated at 16 weeks.
Long nerve grafts that received SETS transfers (groups B, C, and D) showed superior results compared with the control group. Proximal SETS transfer had significantly better outcomes than distal SETS transfer in electrodiagnostic parameters, whereas double SETS transfer had the highest axonal count and biceps compound muscle action potential amplitude.
SETS motor transfers to long nerve grafts can effectively improve functional outcome and optimize nerve graft regeneration to the target nerve.
Long nerve grafts yield suboptimal functional results. The experimental study showed that SETS motor transfer to a long nerve graft improves muscle functional outcomes. A double motor SETS transfer provides the best results. Proximal SETS transfer might have more benefits over distal transfer.
Obstetric brachial plexus palsy (OBPP) can cause deformities of the upper extremity in up to 92% (S-OBPP). Reconstruction of the elbow is difficult because co-contraction of the elbow flexor (EF) and ...extensor (EE) muscles makes the traditional strategy of treatment ineffective. We propose a novel strategy to minimize the effect of co-contraction, comprising of transfer of an EF to the triceps, followed by a staged gracilis muscle transplantation (FFMT) to augment EF. We hypothesize this will lead to improved EE, maintaining the EF, as well as decrease elbow flexion contracture.
A single-center retrospective review of patients who received a gracilis FFMT for EF after EF-to-EE transfer was performed. EF/EE strength and range of motion were collected from the last clinical visit. Patients were excluded if they had less than 1.5 years of follow-up. A control group who had S-OBPP but non-surgical treatment was used for comparison.
Twenty-one patients were included. Average age at muscle transfer was 7.6 ±5.5 (3-22) Y/O and at gracilis FFMT was 10.4 ± 6.0 (5-26) Y/O. Average follow-up was 7.3 ± 6.5 (1.5-14.8) years. After EF-to-EE transfer, EE strength increased significantly from MRC 2.2 ± 0.4 to 3.4 ± 0.5 (p<0.0001) and EF decreased from 3.2 ± 1.1 to 1.1 ± 1.1 (p<0.0001) and recovered to MRC grade 3.3 ± 0.7 after gracilis FFMT. EF contracture was significantly less compared to non-surgical cohort (p=0.029).
Patients who undergo EF-to-EE, followed by gracilis FFMT have equivalent EF strength with significantly improved EE and improved elbow flexion contracture.
A newly introduced pan-immune-inflammation value (PIV) was not evaluated for its role in oral cavity squamous cell carcinoma (OSCC). In this study, the PIV was calculated with the following equation ...(neutrophil count × platelet count × monocyte count)/lymphocyte count from the results of the automated hematology analyzers in 853 OSCC patients from 2005 to 2017. The optimal cutoff for the preoperative PIV was 268, as determined by a receiver operating characteristic curve. Significant differences were observed for alcohol consumption, smoking, pT status, pN status, overall pathological status, extranodal extension, cell differentiation, depth of invasion, and perineural invasion between higher and lower PIV patients (all p values < 0.05). Kaplan-Meier and univariate regression analyses indicated that higher PIV was associated with worse overall survival, disease-free survival, locoregional recurrence-free survival, and distant metastasis-free survival (all p values < 0.001). Multivariate analyses adjusted by various factors further demonstrated that PIV was an independent prognostic factor for overall and distant metastasis-free survival (p = 0.027, HR: 1.281 and p = 0.031, HR: 1.274, respectively). In conclusion, a higher PIV level was associated with poor clinicopathological factors in OSCC patients and could be used to predict poor posttreatment outcomes, especially for overall and distant metastasis-free survival.
In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle transplantation are often ...scarce. We present the results of a potential strategy using the phrenic nerve with staged free gracilis transplantation for upper extremity reanimation in these scenarios.
A retrospective review was performed on an institutional database of brachial plexus injury or patients with palsy. All patients underwent a staged reconstruction in which the ipsilateral phrenic nerve was extended by an autogenous nerve graft (PhNG), followed by free-functioning gracilis transplantation (PhNG-gracilis).
Nine patients (6 cases of late brachial plexus birth injuries, 2 of acute flaccid myelitis, and 1 of adult chronic brachial plexus injury) were included in this study. The median follow-up period following the PhNG-gracilis procedure was 27 months (range, 12–72 months). The goals of the staged PhNG and PhNG-gracilis were primarily finger extension or finger flexion. In some patients, the technique was used to improve both elbow and finger function, tunneling the muscle through the flexor compartment of the upper arm and under the mobile wad at the elbow. All patients exhibited improvement of muscle strength, including in finger extension (4 patients) from M0 to M2; finger flexion (3 patients) from M0 to M3; elbow extension (1 patient) from M0 to M2; and elbow flexion (1 patient) from M2 to M4.
A 2-stage PhNG-gracilis may restore or enhance the residual elbow and/or finger paralysis in chronic brachial plexus injuries. A minimum follow-up period of 3 years is recommended. This technique may remain useful as one of the last reconstructive options to increase power in patients with scarce donor nerves.
Therapeutic V.
Volkmann ischemic contracture (VIC) is a devastating condition that results from neglected compartment syndrome, which leads to prolonged ischemia, irreversible tissue necrosis, and various degrees ...of muscle and nerve damage, causing serious motor and sensory functional implications for the limb and a spectrum of diseases associated with worsening deformities. A thorough understanding of the anatomy and VIC pathophysiology is needed to plan an appropriate strategy. Functioning free muscle transplantation (FFMT) can restore finger movement in a paralyzed limb but requires a three-staged approach to maximize the benefits of FFMT, leading to meaningful finger extrinsic function.
BACKGROUNDUsing 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 neurotizerscross-face nerve graft (CFNG), spinal accessory nerve (XI) and masseter nerve (V3) have been used as neurotizers for different indications.
METHODSA total of 362 cases of facial reanimation with FFMT were performed between 1986 and 2015. Of these, 350 patients with 361 FFMT were enrolled272 (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.
RESULTSThe 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.
CONCLUSIONSThe 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.
Objectives: Loss of smile and inability of eye closure are coexisting features of complete facial paralysis. Both reconstructions are commonly performed separately. In this study, we present an ...option of using one gracilis functioning free muscle transplantation for the simultaneous and combined reconstruction of smile and lagophthalmos. Methods: A retrospective review was performed from an institutional database for facial paralysis. The gracilis for functioning free muscle transplantation was split into three portions, namely the upper gracilis was used for smile, the lower gracilis was used for eye closure, and the central gracilis was used for maintenance of vasculature. Intramuscular dissection of the obturator nerve was performed to create two motor neurotizers. The design was to adopt one muscle with two functioning free muscle transplantations for two functions, i.e., smile and eye closure. Results: A total of five patients with unilaterally complete facial palsy, which resulted from acoustic neuroma resection, were enrolled. All patients had a follow-up of at least 1 year. The smile score improved from 0 (no tooth visible) up to 3+ (at least three teeth visible). The eye closure improved from 9-11 mm to 0-6 mm in interpalpebral distance. Conclusions: Based on the technique of intramuscular nerve dissection and division, one gracilis functioning free muscle transplantation can be split into upper and lower gracilis for two functioning free muscle transplantations with the preservation of the central part of the vasculature. The surgical strategy proves that it is theoretically and clinically applicable for simultaneous and combined reconstruction of smile and eye closure with only one nutrient vessel anastomosis. Level of Evidence: IV
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