Douglas H. Harrison

The instep island flap to resurface plantar defects

Abstract An instep island neurovascular flap is described based on the medial plantar artery of the foot. It is simple to elevate, transposes easily into calcaneal defects and provides a new nerve supply. The donor site may be skin grafted and since it does not lie on the weightbearing surface of the foot, there have been no difficulties with walking.

The pectoralis minor vascularized muscle graft for the treatment of unilateral facial palsy.

A series of 10 pectoralis minor vascularized muscle transfers to reanimate the face in unilateral facial palsy are presented. The procedure is carried out in two stages. The first stage constitutes a nerve graft from the functional contralateral facial nerve to the preauricular region of the paralyzed side. Six months later, the pectoralis minor is transferred to the denervated side of the face with restoration of its neurovascular pedicle. The muscle is well suited to its new position with respect to length and bulk, as well as its fanlike shape. The diameter of its vascular pedicle is comparable with the facial vessels. The results demonstrate function in 8 of the 10 grafts, the two failures relating to early vascular thrombosis rather than an inability to reinnervate the muscle grafts.

Morbidity after gold weight insertion into the upper eyelid in facial palsy

Morbidity and outcome after gold weight insertion into the upper eyelid in patients with lagophthalmos were assessed retrospectively by patient questionnaire and case-note review. Results indicated that although satisfaction with the lid and overall facial appearance was high, complications and symptoms attributable to the gold weights were not uncommon.

Free microvascular and microneural transfer of the extensor digitorum brevis muscle for the treatment of unilateral facial palsy.

The operation of transfer of the extensor digitorum brevis muscle to the face in the treatment of unilateral facial palsy (Thompson and Gustavson, 1976) has been further modified by immediate anastomosis of its vascular pedicle to the superficial temporal vessels. Six of our ten patients showed some new movement but in only three did this approach symmetry with the other side. Long term follow-up showed that improvement can be expected for up to two years after transfer. Our technique is assessed critically and suggestions are made for further improvement.

The treatment of unilateral and bilateral facial palsy using free muscle transfers.

A 25-year experience in the treatment of unilateral and bilateral facial palsies is presented. The advent of crossed facial nerve grafts and revascularized muscle grafts gives a high proportion of facial reanimation. The choice for the muscle graft is the pectoralis minor. The latissimus dorsi can be used in unfavorable cirumstances or in bilateral facial palsies. Although recovery of movement is high, the search for refinement and symmetry continues. This article encapsulates the authors philosophy in trying to achieve these goals.

The stiff proximal interphalangeal joint.

The anatomical factors causing stillness at the proximal interphalangeal joint are considered, a rational approach to the surgical treatment is proposed, and the results in thirty joints are presented.

The Phenomenon of the Late Recovered Bell’s Palsy: Treatment Options to Improve Facial Symmetry

Background: Bell’s palsy is an idiopathic neuropathy of cranial nerve VII, and the incidence ranges from 15 to 40 per 100,000. The majority of patients recover, but up to 16 percent of patients have significant sequelae. The phenomenon of the “late recovered” Bell’s palsy has the following specific features and has not formerly been described: (1) tightening of the facial muscles, with a deepening nasolabial fold and reduced palpebral fissure; (2) blepharospasm; and (3) incomplete recovery of peripheral VIIth nerve branches, with ipsilateral forehead paralysis, reduced depressor anguli oris function, and poor excursion of the angle of the mouth on smiling. Methods: Nonsurgical treatment involved four monthly botulinum toxin injections. Patients had injections to paralyze the ipsilateral orbicularis oculi, contralateral forehead rhytides, and depressor anguli oris and to treat blepharospasm and muscle tightness. The effectiveness of the botulinum toxin injections on facial symmetry and patient appreciation of this were assessed by measuring brow height and teeth exposure before and 3 weeks after injection. Results: Twenty-three patients were followed up for a mean period of 37 months. The difference in brow height and teeth exposure after injection was less than preinjection measurements, but this did not reach statistical significance. Patient self-assessments showed improvements in their appreciation of the facial symmetry, ability to go out in public, and feelings of self-worth (visual analogue scale). Surgical treatment options include ipsilateral brow lift, division of the contralateral frontal branch, contralateral tarsorrhaphy to equalize the palpebral fissures, and bilateral upper blepharoplasty. Conclusions: The true benefit of botulinum toxin injections was more apparent during facial animation and not when the face was static. The patients greatly appreciated the improvement in facial symmetry. Various treatment options are available to improve the quality of life for patients with late recovered Bell’s palsy.

Pectoralis minor muscle transfer for unilateral facial palsy reanimation: An experience of 35 years and 637 cases☆

BACKGROUND Free functional muscle transfers are often the treatment of choice for facial reanimation. We describe our experience with 637 cases over a 35-year period. METHODS Data was collected prospectively on all case undergoing functional muscle transfer for unilateral facial paralysis. Results were judged by the operating surgeon and an Independent panel of four observers. RESULTS 354 patients had an excellent result as judged by the surgeon. An independent panel rated patients to have a significant change pre- and post-operatively comparing their Hays scores (p < 0.001, t-test). 27.2% of patients required revisional procedures. 13.3% of patients developed late onset tightness of the transferred muscle. CONCLUSIONS Facial reanimation with functional muscle transfers is a complex procedure and provides a significant improvement for the patient to display humour and emotion.

The abnormal nucleus as a cause of congenital facial palsy

BACKGROUND Congenital facial palsy (CFP) is clinically defined as facial palsy present at birth. It is associated with considerable disfigurement and causes functional and emotional problems for the affected child. The aetiology of the majority of cases however, remains elusive. AIMS To investigate the role of a neuroanatomical abnormality as a cause of unilateral CFP. METHODS Magnetic resonance imaging (MRI) scans were performed on 21 patients with unilateral CFP. Fifteen patients had unilateral CFP only; six suffered from syndromes which can include unilateral CFP. RESULTS Of the 15 patients with unilateral CFP only, four (27%) had an abnormal nucleus or an abnormal weighting of this area on the MRI scan, compared to one (17%) of the remaining six patients. CONCLUSION Developmental abnormalities of the facial nucleus itself constitute an important, and previously ignored, cause of monosymptomatic unilateral CFP.

The exposed total knee replacement prosthesis: a new classification and treatment algorithm

The increased frequency of total knee replacement arthroplasty (TKRA) has been reflected in the number of patients with exposed prostheses referred to this unit. An algorithm has been developed to assist in the preoperative assessment of the wound and this has been tested on 25 patients with wound breakdown following TKRA. The grade of exposure so derived predicts the most appropriate surgical management. The algorithm, grading system and proposed management are described.