Ralph T. Manktelow

Orofacial and mandibular reconstruction with the iliac crest free flap: a review of 60 cases and a new method of classification.

Sixty vascularized iliac crest free-tissue transfers were used for oromandibular reconstruction, 46 as osteocutaneous and 14 as osseous flaps. Forty-one patients had preoperative radiotherapy, and 8 had failed previous attempts at reconstruction. Forty-nine of the 60 reconstructions were carried out primarily, most commonly following ablative surgery for radiorecurrent squamous carcinoma. Ages ranged from 19 to 85 years, and follow-up ranged from 2 months to 5 years. Flap survival was 95 percent. Eight-six percent of patients returned to their previous activities. There were 2 perioperative deaths, and 31 patients were alive at follow-up. Horizontal defects from 5 to 16 cm were reconstructed, and in 22 patients, both oral lining and skin coverage were replaced. Radiographic evidence of bone union was noted in 96 percent of synostoses, and clinical union was seen in all but one patient. One patient required bilateral hemimandibular reconstructions for sequential primaries at different operative sittings. Functional and cosmetic results were generally satisfactory and were excellent in bone-only reconstructions. Several surgical principles evolved to minimize bulk and eliminate the need for intermaxillary fixation or external fixation postoperatively. To improve results in large or more lateral through-and-through defects, an accessory pectoralis musculocutaneous flap proved advantageous. Cosmetic and functional results depend largely on three factors: the extent of the surgery, the leanness of the patient, and his or her position on the surgical learning curve.

Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve : Effectiveness and cerebral adaptation

Background: This study assesses the ability of the masseter motor nerve–innervated microneurovascular muscle transfer to produce an effective smile in adult patients with bilateral and unilateral facial paralysis. Methods: The operation consists of a one-stage microneurovascular transfer of a portion of the gracilis muscle that is innervated with the masseter motor nerve. The muscle is inserted into the cheek and attached to the mouth to produce a smile. The outcomes assessed were the amount of movement of the transferred muscle; the aesthetic quality of the smile; the control, use, and spontaneity of the smile; and the functional effects on eating, drinking, and speech. The study included 27 patients aged 16 to 61 years who received 45 muscle transfers. Results: All 45 muscle transfers developed movement. The commissure movement averaged 13.0 ± 4.7 mm at an angle of 47 ± 15 degrees above the horizontal, and the mid upper lip movement averaged 8.3 ± 3.0 mm at 42 ± 17 degrees. Age did not affect the amount of movement. Patients older than 50 years had the same amount of movement as patients younger than 26 years (p = 0.605). Ninety-six percent of patients were satisfied with their smile. Conclusions: A spontaneous smile, the ability to smile without thinking about it, occurred routinely in 59 percent and occasionally in 29 percent of patients. Eighty-five percent of patients learned to smile without biting. Age did not affect the degree of spontaneity of smiling or the patients ability to smile without biting.

Facial animation in children with Möbius syndrome after segmental gracilis muscle transplant.

&NA; Möbius syndrome is a complex congenital anomaly involving multiple cranial nerves, including the abducens (VI) and facial (VII) nerves, and often associated with limb anomalies. Muscle transplantation has been used to address the lack of facial animation, lack of lower lip support, and speech difficulties these patients experience. The purpose of this study was to investigate the results of bilateral, segmental gracilis muscle transplantation to the face using the facial vessels for revascularization and the motor nerve to the masseter for reinnervation. The outcome of the two‐stage procedure was assessed in 10 consecutive children with Möbius syndrome by direct interview, speech assessment, and oral commissure movement. Preoperative data were collected from direct questioning, viewing of preoperative videotapes, notes from prior medical evaluations, and rehabilitation medicine and speech pathology assessments. All of the patients developed reinnervation and muscle movement. The children who described self‐esteem to be an issue preoperatively reported a significant posttransplant improvement. The muscle transplants produced a smile with an average commissure excursion of 1.37 cm. The frequency and severity of drooling and drinking difficulties decreased postoperatively in the seven symptomatic children. Speech difficulties improved in all children. Specifically, of the six children with bilabial incompetence, three received complete correction and three had significant improvement. Despite the length and complexity of these procedures, complications were minimal. Muscle transplantation had positive effects in all problematic areas, with a high degree of patient satisfaction and improvement in drooling, drinking, speech, and facial animation. The surgical technique is described in detail and the advantages over regional muscle transfers are outlined. Segmental gracilis muscle transplantation innervated by the motor nerve to the masseter is an effective method of treating patients with Möbius syndrome. (Plast. Reconstr. Surg. 106: 1, 2000.)

A comparison of commissure excursion following gracilis muscle transplantation for facial paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve.

Background: The microneurovascular transfer of a free muscle transplant is the procedure of choice for facial animation in a child with facial paralysis. One of the critical factors of this procedure is the selection of a motor nerve to innervate the transplanted muscle. Methods: From 1989 to 1999, 166 free segmental gracilis muscle transfers were performed in 121 children for facial animation. The cross-face nerve graft was used in 70 procedures (cross-face nerve graft group) to innervate the muscle by branches of the seventh nerve for the normal side. The ipsilateral masseteric nerve was used in 94 procedures (50 patients, masseter group) and the ipsilateral accessory nerve was used in two procedures (one patient). To compare the operative procedures between the first two groups, all charts were reviewed. The extent of oral commissure movement was determined by measurements taken from the tragion to the oral commissure, both at rest and with full smile. In the cross-face nerve graft group (n = 20), the extents were measured on both the normal side and the reconstructed side; in the masseter group (n = 16), they were measured on the left and right sides. Results: No significant difference was found between the two groups (p < 0.05) for the mean age at the time of muscle transplantation, for the total operation time for muscle transplantation, and for the length of the muscle used or for the fraction of circumference of the segment of gracilis muscle used. Although the operative variables were similar between two groups, the muscle excursion differed. Excursion in the cross-face nerve graft group was less than that on the right (p = 0.0006) or left (p = 0.0000) in the masseter group. It was also less than on the normal side (p = 0.0000) of the cross-face nerve graft group. Also, there was no significant difference between the left and right sides within the masseter group (p < 0.05). Furthermore, the extent of oral commissure movement in the masseter group was similar to that of the normal side in the cross-face nerve graft group (p = 0.35, p = 0.61). Conclusion: These results indicate that segmental gracilis muscle transplantation using the motor nerve to the masseter nerve for facial animation in children is a very reproducible operation and provides a commissure excursion in the range of normal.

Free muscle transplantation to provide active finger flexion

Free muscle transplatation is a procedure which involves the transfer of a skeletal muscle from one location in the body to another. Viability is maintained by microvascular anastomoses of the muscles artery and vein to a suitable artery and vein in the recipient site. Voluntary muscle contraction is obtained by suturing of the muscles motor nerve to an appropriate motor nerve in the recipient site. Two cases are presented; one using the gracilis and the other using the pectoralis major muscle. The indication for each transplantation was the traumatic loss of long flexor musculature to the digits. In both cases transplanted muscles survived and are functioning well. Excellent grip strength and nearly a full range of finger movement were provided by the transplanted muscle.

Muscle transplantation by fascicular territory.

In some muscles, distinct and separate portions of the muscle are each under the control of a different fascicle of the motor nerve. Although there is some slight overlap in areas, this unit, a single fascicle muscle territory, is present in the gracilis muscle. Microneurovascular techniques have improved the reliability of muscle transplantation for the reconstruction of facial paralysis. The amount of movement obtained depends on many factors, including the amount of muscle transplanted and the adequacy of its reinnervation. The ability to transplant a small segment of a muscle based on the fascicular territory enables the surgeon to supply the amount of movement that each individual patient requires.

Mandibular reconstruction in the radiated patient: the role of osteocutaneous free tissue transfers

This paper discusses our experience with the second metatarsal and iliac crest osteocutaneous transfers for mandibular reconstruction. The prime indication for this type of reconstruction was for anterior mandibular defects when the patient had been previously resected. Midbody to midbody defects were reconstructed with the metatarsal and larger defects with the iliac crest. In most cases, an osteotomy was done to create a mental angle. The evaluation of speech, oral continence, and swallowing revealed good results in all patients unless lip or tongue resection compromised function. Facial contour was excellent in metatarsal reconstructions. The iliac crest cutaneous flap provided a generous supply of skin for both intraoral reconstruction and external skin coverage but tended to be bulky, particularly when used in the submental area. Thirty three of 36 flaps survived completely. Flap losses were due to anastomosis thrombosis (1), pedicle compression (1), and pedicle destruction during exploration for suspected carotid blowout (1). Ninety three percent of bone junctions developed a solid bony union despite the mandible having had a full therapeutic dose of preoperative radiation. Despite wound infections in 8 patients, and intraoral dehiscence with bone exposure in 12 patients, all but one of these transfers went on to good bony union without infection in the bone graft.

An anatomical study of the pectoralis major muscle as related to functioning free muscle transplantation

The prerequisites for a functioning free muscle transplant are reviewed. A method for studying the anatomy of the pectoralis major muscle is presented, giving special attention to the detail of the neurovascular structures. Fifteen meticulous dissections, documented by sketches and photographs, provide the data base. This work is summarized in Table I and Figure 3. The variability is stressed in Table II. None of the variations observed preclude the use of the inferior four-fifths of the sternocostal muscle as a functioning free muscle transplant. The length and bulk of this muscle are advantages for its use in replacing forearm flexors. The multiple innervations may be an advantage or disadvantage, depending on the availability of the motor nerves in the recipient site. The time-consuming dissection is a disadvantage. With this knowledge, the reconstructive surgeon can assess the advisability of using the pectoralis major muscle as a functioning free muscle transplant.

The iliac crest and the radial forearm flap in vascularized oromandibular reconstruction

Sixty cases (59 patients) of oromandibular reconstruction using vascularized iliac crests were compared with 13 in which radial osteocutaneous flaps were used. These patients were reviewed from the standpoint of cosmetic results and function as well as their operative and postoperative courses. In both groups, the results were generally good. However, revisionary surgery was more frequent in those receiving the iliac crest. This group also had a higher incidence of intraoral wound breakdown and bone exposure. Nevertheless, the sheer size of the iliac crest made it ideal for massive oromandibular defects, just as its natural curvature lent itself to precise replication of the mandible in bone-only reconstructions. Its bulk proved a major obstacle in small composite defects. The radial forearm flap carried thin, pliable, well-vascularized skin that was superior to groin skin for oral lining. Bone gaps of up to 9 cm could be handled with ease, thus making it complementary to the iliac crest over the wide spectrum of mandibular reconstruction.

The dorsalis pedis free flap: technique of elevation, foot closure, and flap application.

The dorsalis pedis free flap is an excellent reconstructive tool for thin remote mucosal defects, for heel and hand defects where innervation is critical, and as an osteocutaneous flap with unique application to mandibular and floor of mouth reconstruction. The major criticism with this flap is related to its uncertain vascularity and the donor defect. We have found in our series of 45 cases that the vascular anatomy is exceedingly reliable. Problems with the donor defects are all related to technique. With care in flap elevation and foot closure, which we describe in detail, an acceptable donor site with minimal complications can be achieved. The clinical applications of this flap are illustrated by three case reports. Our experience with the donor site has not been problem-free. However, we do believe that with meticulous technique primary healing will occur without functional disability and with minimal cosmetic deformity.