Daniel P. Butler

A multidisciplinary cleft palate team in the developing world: Performance and challenges

Although volunteering surgical teams have enjoyed success in improving the capabilities of health care professionals in the developing world to perform cleft palate repairs, there remains a lack of any integrated post-operative care pathway. As a result the focus on enhancing the care of patients born with a cleft palate in the developing world is now moving towards generating the skills and resources required to form local multidisciplinary cleft care teams. The Children’s Surgical Centre (CSC) is a charitable organisation and one of the leading surgical centres in Cambodia capable of performing cleft palate repairs. In 2008 there were no locally-trained speech and language therapists in Cambodia. In consideration of this, a project commenced to train one of the health care professionals working at CSC to become a speech and language therapist. We aim to report on two factors affecting the outcome of patients presenting to CSC with a cleft palate: timing of surgical repair and return for SLT. We have also considered the patient-specific variables that may delay the time to surgical repair and impact upon whether a patient returns for SLT.

The axillary approach to raising the latissimus dorsi free flap for facial re-animation: a descriptive surgical technique.

The latissimus dorsi flap is popular due to the versatile nature of its applications. When used as a pedicled flap it provides a robust solution when soft tissue coverage is required following breast, thoracic and head and neck surgery. Its utilization as a free flap is extensive due to the muscles size, constant anatomy, large caliber of the pedicle and the fact it can be used for functional muscle transfers. In facial palsy it provides the surgeon with a long neurovascular pedicle that is invaluable in situations where commonly used facial vessels are not available, in congenital cases or where previous free functional muscle transfers have been attempted, or patients where a one-stage procedure is indicated and a long nerve is required to reach the contra-lateral side. Although some facial palsy surgeons use the trans-axillary approach, an operative guide of raising the flap by this method has not been provided. A clear guide of raising the flap with the patient in the supine position is described in detail and offers the benefits of reducing the risk of potential brachial plexus injury and allows two surgical teams to work synchronously to reduce operative time.

Lengthening temporalis myoplasty: Outcome and radiographic anatomical evaluation of length required

There are numerous options available to reanimate the middle third of the face with great debate regarding the optimal treatment solution. The temporalis muscle was first used in reanimation of the face by Gillies in 1934. With the advent of microneurovascular muscle transfers in the 1970s, focus moved towards free tissue transfer to reanimate the smile. In 1996, Labbè and Huault described the lengthening temporalis myoplasty (LTM) technique. The major advantages of this regional muscle transfer technique over free-tissue transfer procedures are that it is relatively fast and technically easier. A potential concern of the LTM technique is that insufficient length will be gained to facilitate transfer of the temporalis tendon from the coronoid to the oral commissure without undue tension on the point of inset. In this study we evaluate the outcomes of ten patients who have undergone LTM to reanimate the middle third of their face and perform radiological assessment of the length required to facilitate tension-free inset. All patients that underwent LTM for facial reanimation in the treatment of facial palsy between November 2006 and August 2014 were identified retrospectively. All operations were performed by a single surgeon using the type 1 Labbè technique. The incidence of tendon inset dehiscence and excess tension were recorded. In the second part of this study, evaluation of the distance between the coronoid process of the mandible to the oral commissure was performed using computerised tomography (CT). Twenty consecutive adult outpatients (forty hemi-faces) that had undergone routine CT evaluation of the paranasal sinuses and had no pathology of the maxilla or mandible were included. Images were reformatted to produce axial, coronal and sagittal slices of 0.625 mm. The oral commissure was identified as the meeting point of zygomaticus major, buccinators, levator anguli oris and orbicularis oris. Of the ten patients that underwent LTM for facial reanimation three had a tight, contracted appearance postoperatively. In one patient there was complete dehiscence of the temporalis tendon from the oral commissure requiring re-operation with interposition of a fascial sling. CT analysis was performed on 13 male and seven female patients. The distance between the coronoid process of the mandible and the desired site of inset for the advanced temporalis tendon, the oral commissure, showed an overall mean distance of 58 mm (standard deviation Z 6.2 mm). The average distance in female patients was 55 mm and 59 mm in male patients. We propose that the high rate of contracture/dehiscence observed in our patient group is due to insufficient length being gained in the temporalis muscle to allow the tendon to pass the 58 mm from the coronoid process of the mandible to the oral commissure without excessive tension. In Labbè’s original description, they describe a 40 mm gain in length from the type 1 LTM, which is markedly lower than the length we have calculated to be required. Furthermore, evaluation of endoscopic LTM demonstrated a maximum gain in length of 3 cm. In response to these findings, we advocate the use of interpositional fascial/tendon grafts to extend the temporalis tendon to the oral commissure without undue tension at the point of inset.

The incidence of facial vessel agenesis in patients with syndromic congenital facial palsy.

Background: Congenital facial palsy can result in significant disfigurement. A potential treatment option is free functional muscle transfer to reanimate the face. For this to be possible, a suitable recipient artery and vein must be present in the affected hemiface. In this study, the authors aim to identify whether patients with syndromic congenital facial palsy have a higher rate of facial vessel agenesis than those with isolated congenital facial palsy. Methods: Patients were identified between November of 2006 and October of 2013. Patients were stratified into two groups: those with syndromic congenital facial palsy and those with isolated congenital facial palsy. The presence or absence of facial vessels was determined intraoperatively. Results: Forty-seven eligible patients were included in the study. Those with syndromic congenital facial palsy were significantly more likely to have an absent facial vein than patients with isolated congenital facial palsy (p = 0.015). There was a strong trend toward those with syndromic facial palsy lacking a facial artery (p = 0.08). Subgroup analysis of patients with Möbius syndrome revealed that these patients were significantly more likely to have facial artery agenesis than those with isolated congenital facial palsy (p = 0.03). Conclusions: Facial vessel agenesis is significantly more common in patients with syndromic congenital facial palsy compared with those with isolated congenital facial palsy. This must be considered in the preoperative planning for facial reanimation with free functional muscle transfer. The operating surgeon should consider vascular studies of the affected hemiface before undertaking the procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

An Algorithm to Guide Recipient Vessel Selection in Cases of Free Functional Muscle Transfer for Facial Reanimation

Background The aim of this study was to review the recipient vessels used in our cases of facial reanimation with free functional muscle transfer and to identify patient variables that may predict when the facial vessels are absent. From this we present a protocol for vessel selection in cases when the facial artery and/or vein are absent. Methods Patients were identified from November 2006 to October 2013. Data was collected on patient demographics, facial palsy aetiology, history of previous facial surgery/trauma and flap/recipient vessels used. A standard operative approach was adopted and performed by a single surgeon. Results Eighty-seven eligible patients were identified for inclusion amongst which 98 hemifaces were operated upon. The facial artery and vein were the most commonly used recipient vessels (90% and 83% of patients, respectively). Commonly used alternative vessels were the transverse facial vein and superficial temporal artery. Those with congenital facial palsy were significantly more likely to lack a suitable facial vein (P=0.03) and those with a history of previous facial surgery or trauma were significantly more likely to have an absent facial artery and vein (P<0.05). Conclusions Our algorithm can help to guide vessel selection cases of facial reanimation with free functional muscle transfer. Amongst patients with congenital facial palsy or in those with a previous history of facial surgery or trauma, the facial vessels are more likely to be absent and so the surgeon should then look towards the transverse facial vein and superficial temporal artery as alternative recipient structures.

Preserving a patent DIEP pedicle to facilitate salvage breast reconstruction with a second free flap: A case report

Surgeons performing free flap breast reconstruction need to have a range of techniques in their armamentarium to successfully salvage cases of flap failure. We present a case of 47‐year‐old patient who suffered near‐total right breast deep inferior epigastric perforator (DIEP) flap failure 3 days post‐bilateral immediate breast reconstruction with DIEP flaps. At debridement, the DIEP pedicle was noted to be patent with preserved perfusion to a small segment of tissue around the origin of the pedicle. This tissue and the DIEP pedicle itself were therefore preserved to facilitate subsequent breast reconstruction using stacked transverse upper gracilis flaps anastomosed end‐to‐end to the original DIEP pedicle. Post‐operatively, both flaps remained viable with no further complications and symmetrical aesthetic result maintained at 2 months follow‐up post‐salvage procedure. This case emphasizes the importance of exercising caution during initial debridement for free flap failure to preserve viable tissue in the flap and pedicle, particularly in circumstances where vascular flow in the pedicle is maintained, to facilitate successful salvage reconstruction.

Facial palsy: what can the multidisciplinary team do?

The functional and psychosocial impact of facial paralysis on the patient is significant. In response, a broad spectrum of treatment options exist and are provided by a multitude of health care practitioners. The cause and duration of the facial weakness can vary widely and the optimal care pathway varies. To optimize patient outcome, those involved in the care of patients with facial palsy should collaborate within comprehensive multidisciplinary teams (MDTs). At an international level, those involved in the care of patients with facial paralysis should aim to create standardized guidelines on which outcome domains matter most to patients to aid the identification of high quality care. This review summarizes the causes and treatment options for facial paralysis and discusses the subsequent importance of multidisciplinary care in the management of patients with this condition. Further discussion is given to the extended role of the MDT in determining what constitutes quality in facial palsy care to aid the creation of accepted care pathways and delineate best practice.

Reanimation surgery in patients with acquired bilateral facial palsy

Acquired bilateral facial palsy is rare and causes difficulty with speech and eating, but dynamic reanimation of the face can reduce the effect of these problems. Of 712 patients who had these procedures during our study period, two had an acquired bilateral facial paralysis. In both, reanimation was completed in a single operation using a free-functional transfer of the latissimus dorsi muscle that was coapted to the masseteric branch of the trigeminal nerve. Both patients achieved excellent non-spontaneous excursion and an improvement in function. Careful evaluation of the available donor nerves including thorough examination and electromyographic testing should always be completed before operation.

The perils of spinning class: An open ankle fracture following a spinning exercise session

Spinning is an increasingly popular form of cycle-based exercise. The workouts are often of high-intensity and participants are intermittently encouraged to achieve a high crank-set-cadence rate. We report a unique case of an open ankle fracture requiring free flap coverage, which highlights the potential perils of spinning class.