Andres Rodriguez-Lorenzo

Haptics-assisted Virtual Planning of Bone, Soft Tissue, and Vessels in Fibula Osteocutaneous Free Flaps.

Background: Virtual surgery planning has proven useful for reconstructing head and neck defects by fibula osteocutaneous free flaps (FOFF). Benefits include improved healing, function, and aesthetics, as well as cost savings. But available virtual surgery planning systems incorporating fibula in craniomaxillofacial reconstruction simulate only bone reconstruction without considering vessels and soft tissue. Methods: The Haptics-Assisted Surgery Planning (HASP) system incorporates bone, vessels, and soft tissue of the FOFF in craniomaxillofacial defect reconstruction. Two surgeons tested HASP on 4 cases they had previously operated on: 3 with composite mandibular defects and 1 with a composite cervical spine defect. With the HASP stereographics and haptic feedback, using patient-specific computed tomography angiogram data, the surgeons planned the 4 cases, including bone resection, fibula design, recipient vessels selection, pedicle and perforator location selection, and skin paddle configuration. Results: Some problems encountered during the actual surgery could have been avoided as they became evident with HASP. In one case, the fibula reconstruction was incomplete because the fibula had to be reversed and thus did not reach the temporal fossa. In another case, the fibula had to be rotated 180 degrees to correct the plate and screw placement in relation to the perforator. In the spinal case, difficulty in finding the optimal fibula shape and position required extra ischemia time. Conclusions: The surgeons found HASP to be an efficient planning tool for FOFF reconstructions. The testing of alternative reconstructions to arrive at an optimal FOFF solution preoperatively potentially improves patient function and aesthetics and reduces operating room time.

Nerve transfers for facial transplantation: a cadaveric study for motor and sensory restoration.

Background: Restoration of facial animation and sensation is highly important for the outcome after facial allotransplantation. The identification of healthy nerves for neurotization is of particular importance for successful nerve regeneration within the allograft. However, because of the severity of the initial injury and resultant scar formation, a lack of healthy nerve stumps in the recipient is a commonly encountered problem. In this study, the authors evaluate the technical feasibility of performing nerve transfers in facial transplantation for both sensory and motor neurotization. Methods: Fifteen fresh cadaver heads were used in this study. The study was divided into two parts. First, the technical feasibility of nerve transfer from the cervical plexus to the mental nerve and the masseter nerve to the buccal branches of the facial nerve was assessed. Next, the authors performed nerve transfers in simulated face transplants to describe the surgical technique, focusing on sensory restoration of the midface and upper lip by neurotization of the infraorbital nerve, sensory restoration of the lower lip by neurotization of the mental nerve, and smile reanimation by neurotization of the buccal branches of the facial nerve. Results: In all specimens, coaptation of at least one of the branches of the cervical plexus to the mental nerve and between the masseter nerve to the buccal branch of the facial nerve was possible. In simulated face transplant procedures, nerve transfers of the supraorbital nerve to the infraorbital nerve, cervical plexus branches to the mental nerve, and masseter nerve to facial nerve are all technically possible. Conclusions: Nerve transfers are a technically feasible option that could theoretically be used in face transplantation either as a primary nerve reconstruction when there are no available healthy nerves, or as a secondary procedure for enhancement of functional outcomes.

Supraorbitary to infraorbitary nerve transfer for restoration of midface sensation in face transplantation: cadaver feasibility study.

The collected experience from facial allotransplantations has shown that the recovery of sensory function of the face graft is unpredictable. Unavailability of healthy donor nerves, especially in central face defects may contribute to this fact. Herein, the technical feasibility of transferring the supraorbitary nerve (SO) to the infraorbitary nerve (IO) in a model of central facial transplantation was investigated.

Benefits of two or more senior microsurgeons operating simultaneously in microsurgical breast reconstruction: Experience in a swedish medical center

The aim of this study is to evaluate how the number of senior microsurgeons, performing autologous microvascular breast reconstruction together, influences operating time and postoperative complications.

Vastus lateralis vascularized nerve graft in facial nerve reconstruction: An anatomical cadaveric study and clinical implications

The present study investigates the vascular anatomy of the vastus lateralis motor nerve (VLMN) to be used as a vascularized nerve graft in facial nerve reconstruction. We evaluated the maximum length of the nerve that can be included in the flap and its vascular pedicle. In addition, we discuss its adequacy for use in early reconstruction of the facial nerve both as ipsilateral facial nerve reconstruction and as cross‐facial nerve graft.

Superficial peroneal and sural nerve transfer to tibial nerve for restoration of plantar sensation after complex injuries of the tibial nerve: cadaver feasibility study.

BACKGROUND Nerve reconstruction following lower-extremity nerve injuries usually leads to worse outcomes in comparison with upper-extremity injuries due to the long distances of nerve regeneration. This study was performed to consider the clinical application of distal nerve transfer for the treatment of long gaps of the tibial nerve (TN) and in established compartment syndrome. It aimed to determine the anatomic suitability of transferring the sural nerve (SN) in combination with the superficial peroneal nerve (SPN) to the TN at the level of the tarsal tunnel for restoration of plantar sensation. METHODS Nine fresh above-knee amputated limbs were dissected with the aid of loupe magnification. We focussed on the detailed anatomy of the course of the SN and the SPN from its emergence proximally at the knee level to the foot. Two different regions, suprafascial and subfascial, were described for each nerve. The maximum length of dissection and the length of the nerves in each region were measured. In all dissections, we assessed the feasibility of directly transferring the SN and SPN to the TN at the level of the tarsal tunnel. RESULTS The average length of the course of the SN was 20.6 cm (SD ± 2.3 cm) subfascially and 16.4 cm (SD ± 0.9 cm) suprafascially. For the SPN, the average length was 19.4 cm (SD ± 1.9 cm) subfascially and 18 cm (SD ± 2.5 cm) suprafascially. The point of emergence of the nerve from the subfascial course to the suprafascial course was defined as the pivot point for its transfer to the TN. Both the SN and the SPN reached the TN comfortably at the level of the tarsal tunnel, allowing direct co-aptation. CONCLUSION Distal nerve transfer using the SN in combination with the SPN is an anatomically reliable procedure, being a potential alternative to the use of nerve grafts in reconstruction of long gaps of the TN. In addition, selected patients with compartment syndrome may also benefit from this transfer to restore plantar sensation.

A reliable anatomic approach for identification of the masseteric nerve

The masseteric nerve remains a reliable option in facial reanimation procedures in patients whom have no facial nerve donor (i.e. Moebius syndrome), previously failed cross-facial nerve grafts, prefer a one-stage procedure, or have a guarded lifespan. There is minimal donor site morbidity, it is conveniently located within the region of dissection, and has a shorter distance for re-innervation with a more rapid and powerful clinical recovery of function. However, surgeons encounter difficulty locating the nerve due to a variety of described branching patterns and variability of facial measurements on which some surgical approaches are based upon. We present a technique to identify the nerve in a 1.5 cm area defined by constant anatomical landmarks e the zygomatic arch, condyle, coronoid process, and mandibular notch. To demonstrate variability of the nerve location based on facial measurements, cadaveric dissections were performed and compared to previous studies. Since facial measurements were occasionally unreliable, mainly in the anterioreposterior dimension, an alternative surgical approach was developed. A pre-tragal incision is used to elevate a cheek flap in the subcutaneous plane for approximately 1 cm and then transition into the sub-SMAS plane to expose the parotid-masseteric fascia, facial vessels, modiolus, and zygomatic arch. Palpation of the anatomic landmarks, zygomatic arch, coronoid process, and mandibular condyle, helps identifying the triangular zone. The mandibular or sigmoid notch is also confirmed as the caudal apex of the triangular zone. Opening and closing the mouth may facilitate identification of the coronoid. Dissection begins in the center of this triangular region. If the parotid gland extends over this area (not uncommon), dissection proceeds gently through the parotid with fine hemostats directed in an anterior posterior course, while preserving the facial nerve branches. An assistant gently

Predictors of Reoperations in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

Background: The deep inferior epigastric perforator (DIEP) procedure is regarded a safe option for autologous breast reconstruction. Reoperations, however, may occur, and there is no consensus in the literature regarding the risk factors. The aim of this study was to identify factors associated with reoperations in DIEP procedure. Patients and Methods: A retrospective study of consecutive patients undergoing DIEP breast reconstruction 2007 to 2014 was performed and included a review of 433 medical charts. Surgical outcome was defined as any unanticipated reoperation requiring return to the operating room. Multivariate regression analysis was utilized to identify predictors of reoperation. The following factors were considered: age, body mass index, comorbidity, childbearing history, previous abdominal surgery, adjuvant therapy, reconstruction laterality and timing, flap and perforator characteristics, and number and size of veins. Results: In total, 503 free flaps were performed in 433 patients, 363 (83.8%) unilateral and 70 (16.2%) bilateral procedures. Mean age was 51 years; 15.0% were obese; 13.4% had hypertension; 2.3% had diabetes; 42.6% received tamoxifen; 58.8% had preoperative radiotherapy; 45.6% had abdominal scars. Reoperation rate was 15.9% (80/503) and included flap failure, 2.0%; partial flap loss, 1.2%; arterial thrombosis, 2.0%; venous thrombosis, 0.8%; venous congestion, 1.2%; vein kinking, 0.6%. Other complications included bleeding, 2.2%; hematoma, 3.0%; fat necrosis, 2.8%, and infection, 0.2%. Factors negatively associated with reoperation were childbearing history (odds ratio [OR]: 3.18, P = 0.001) and dual venous drainage (OR: 1.91, P = 0.016); however, only childbearing remained significant in the multivariate analyses (OR: 4.56, P = 0.023). Conclusions: The history of childbearing was found to be protective against reoperation. Number of venous anastomoses may also affect reoperation incidence, and dual venous drainage could be beneficial in nulliparous patients.

Fibula osteo‐adipofascial flap for reconstruction of a cervical spine and posterior pharyngeal wall defect

When reconstructing combined defects of the cervical spine and the posterior pharyngeal wall the goals are bone stability along with continuity of the aerodigestive tract. We present a case of a patient with a cervical spine defect, including C1 to C3, associated with a posterior pharyngeal wall defect after excision of a chordoma and postoperative radiotherapy. The situation was successfully solved with a free fibula osteo‐adipofascial flap. The reconstruction with a fibula osteo‐adipofascial flap provided several benefits in comparison with a fibula osteo‐cutaneous flap in our case, including an easier insetting of the soft tissue component at the pharyngeal level and less bulkiness of the flap allowing our patient to resume normal deglutition.

Synkinesis in Bell's palsy in a randomised controlled trial

To study the development of synkinesis in Bells palsy. Frequency, severity, gender aspects and predictors were analysed.