A Novel Method of Spinal Accessory Nerve Banking Using Silicone Catheter for Functioning Free Muscle Transfer

In secondary brachial plexus reconstruction, exploring an area that has already been operated on is challenging and time-consuming for a surgeon, especially in centers with a single-team approach. Due to their inertness and lack of adverse effects, silicone Foley catheters were used successfully during the reconstruction of flexor tendons. Based on the concept, we have achieved an acceptable functional outcome by banking the spinal accessory nerve in a silicon catheter for gracilis reanimation, which permits smooth dissection, maintains the length, and shortens the operating time for subsequent reconstruction. Level of Evidence: Level V.

Long-term outcomes of dual innervation in functional muscle transfers for facial palsy

BACKGROUND

This study describes a different approach with a 2-stage facial reanimation in patients with long-standing unilateral facial paralysis using free gracilis muscle transfer, innervated by both cross-facial nerve graft and masseteric nerve. The authors present their rationale, surgical technique, and long-term outcomes.

METHODS

Between August 2012 and March 2016, 11 patients (6 female and 5 male patients) underwent a 2-staged dually innervated gracilis muscle transfer. Patients were evaluated with physical examination and needle electromyography. A standardized assessment of preoperative and postoperative photographs and videos was performed using Terzis' smile functional grading system at 48 months following surgery and the Emotrics software to assess improvement in symmetry over a 36-month postoperative period.

RESULTS

Voluntary contraction of the gracilis muscle was observed in all patients at a mean of 4 months and 4 days following muscle transfer. A spontaneous smile produced without teeth clenching was developed in all patients by 18 months postoperatively. Six patients achieved excellent and 5 good results. The difference between the averaged pre- and postoperative scores was statistically significant. With Emotrics, there were significant improvements in the smile angle, upper lip elevation, commissural excursion, and commissural height, with continuous improvement over 36 months. The postoperative electromyography (EMG) confirmed dual innervation of the gracilis muscle by the facial and masseteric donor motor neural sources. We present our results at minimum 48 months postoperatively.

CONCLUSIONS

Dual innervated two-stage gracilis transfer is an effective method for reanimation in long-standing unilateral facial paralysis, providing both rapid reinnervation of the transferred muscle, together with a powerful, synchronous smile.

Powering the Gracilis for Facial Reanimation: A Systematic Review and Meta-analysis of Outcomes Based on Donor Nerve

Importance

Free gracilis transfer for dynamic reanimation in chronic facial paralysis is the gold standard, but there remains a need to better understand outcomes with respect to the donor nerve.

Objective

To characterize outcomes in adults undergoing primary gracilis transfer for facial paralysis stratified by donor nerve used for neurotization.

Data Sources

Search strategies were used in Ovid MEDLINE (1946-2019), Embase (1947-2019), Scopus (1823-2019), Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov (1997-2019).

Study Selection

Inclusion and exclusion criteria were designed to capture studies in adults with unilateral chronic facial paralysis undergoing single-paddle free gracilis transfer. All study types were included except case reports. Abstracts and full texts were reviewed in duplicate. Of 130 unique citations, 10 studies including 295 patients were included after applying inclusion and exclusion criteria. Data were analyzed between November 2018 and December 2019.

Data Extraction and Synthesis

PRISMA guidelines were followed. The Newcastle-Ottawa scale was used to assess study quality, and the Cochrane Risk of Bias tool was used to assess risk of bias. Independent extraction by 2 authors (P.M.V. and J.J.C.) was performed. Data were pooled using a random-effects model.

Main Outcomes and Measures

Owing to heterogeneity in reporting of facial reanimation outcomes, we first performed a systematic review, and then compiled available outcomes for meta-analysis. Outcomes studied for meta-analysis were oral commissure excursion and facial symmetry.

Results

Meta-analysis of masseteric nerve (MN) (n = 56) vs cross-facial nerve graft (CFNG) (n = 52) in 3 retrospective studies showed no statistical heterogeneity between these studies (I2 = 0%), and the standardized mean difference (SMD) was greater for MN (0.55; 95% CI, 0.17 to 0.94). Meta-analysis of angles of symmetry in 2 retrospective studies comparing MN (n = 51) to CFNG (n = 47) both at rest (-0.22; 95% CI, -0.63 to 0.18) and with smiling (-0.14; 95% CI, -0.73 to 0.46) were better with MN, though the difference was not statistically significant.

Conclusions and Relevance

Owing to heterogeneity in reported outcomes from facial reanimation, we were unable to make definitive conclusions regarding the optimal donor nerve. Establishing a reporting standard at peer-reviewed journals to improve results reporting is one method to allow for improved collaboration in the future. Standardizing follow-up times, assessing spontaneity in an objective and reproducible fashion, and use of consistent outcome measures would allow for future meta-analyses and better understanding of options for facial reanimation.

Body proportions as possible predictors for free gracilis one-stage facial reanimation

BACKGROUND

Gracilis muscle and its motor nerve belongs to most commonly used flap for facial reanimation. However, it is performed in two steps, which is time consuming. One stage technique can be also performed, but the length of the motor nerve cannot be currently determined before surgery.

AIM

The present study was conducted in order to evaluate the body composition on the length and suitability of the motor nerve of gracilis muscle for one stage facial reanimation.

METHODS

The gracilis flaps along with the motoric nerve were dissected from 20 fresh cadavers (6 females, 14 males). The length of the lower extremity from superior iliac anterior spine to the bottom of the heel and BMI were measured. Regression analysis of lower extremity length and BMI to the actual length of the motor nerve of gracilis flap was performed.

RESULTS

The linear regression analysis showed a positive correlation between the length of the lower limb and the size of the motor nerve length (r = 0.5060, p < 0.05), as well as between the BMI and the size of the motor nerve length (r = 0.5073, p < 0.05). Also, the males had longer motor nerve when compared to females by 13 % (p < 0.05). No difference between females and males in BMI was observed.

CONCLUSION

The length from the superior iliac anterior spine, BMI and gender seemed to be potential factors that could help to predict the length of the gracilis flap motor nerve for the one stage facial reanimation. However, further studies evaluating other anatomical factors and validating the possible prediction rule for one stage reanimation success are needed (Fig. 3, Ref. 14).

Neurotization of free gracilis transfer with the brachialis branch of the musculocutaneous nerve to restore finger and thumb flexion in lower trunk brachial plexus injury: an anatomical study and case report

OBJECTIVE

To investigate the feasibility of using free gracilis muscle transfer along with the brachialis muscle branch of the musculocutaneous nerve to restore finger and thumb flexion in lower trunk brachial plexus injury according to an anatomical study and a case report.

METHODS

Thirty formalin-fixed upper extremities from 15 adult cadavers were used in this study. The distance from the point at which the brachialis muscle branch of the musculocutaneous nerve originates to the midpoint of the humeral condylar was measured, as well as the length, diameter, course and branch type of the brachialis muscle branch of the musculocutaneous nerve. An 18-year-old male who sustained an injury to the left brachial plexus underwent free gracilis transfer using the brachialis muscle branch of the musculocutaneous nerve as the donor nerve to restore finger and thumb flexion. Elbow flexion power and hand grip strength were recorded according to British Medical Research Council standards. Postoperative measures of the total active motion of the fingers were obtained monthly.

RESULTS

The mean length and diameter of the brachialis muscle branch of the musculocutaneous nerve were 52.66±6.45 and 1.39±0.09 mm, respectively, and three branching types were observed. For the patient, the first gracilis contraction occurred during the 4th month. A noticeable improvement was observed in digit flexion one year later; the muscle power was M4, and the total active motion of the fingers was 209°.

CONCLUSIONS

Repairing injury to the lower trunk of the brachial plexus by transferring the brachialis muscle branch of the musculocutaneous nerve to the anterior branch of the obturator nerve using a tension-free direct suture is technically feasible, and the clinical outcome was satisfactory in a single surgical patient.