Color Doppler ultrasound: effective monitoring of the buried free flap in facial reanimation

OBJECTIVE

The gracilis muscle free flap has become a reliable means for smile reanimation for patients with facial paralysis. Because it is a buried flap, it presents a postoperative monitoring challenge. We sought to evaluate our experience with color Doppler ultrasound in the monitoring of gracilis free flap viability in the immediate postoperative setting.

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary medical center.

METHODS

Patients with facial paralysis treated with gracilis muscle free flap for smile reanimation performed between March 2009 and November 2010 were evaluated by color Doppler ultrasound and included in the study. Our experience with the use of the color Doppler ultrasound to monitor the gracilis muscle flap is presented.

RESULTS

Forty-six patients were identified. In all cases, color Doppler ultrasound was used postoperatively to assess flow through the vascular pedicle. Outcomes included an early flap survival rate of 100%, with no instances of equivocal or absent flow on either the arterial or venous side. Color Doppler ultrasound provided important objective information regarding muscle perfusion postoperatively in several instances of equivocal postoperative perfusion of the flap.

CONCLUSION

Color Doppler ultrasound is a safe, noninvasive method that can be performed serially to evaluate a buried free flap. We have had success in verifying normal arterial and venous flow through the pedicle using this method of monitoring of the gracilis muscle free flap during facial reanimation, and in 3 instances, it eliminated the need for wound exploration to verify appropriate muscle perfusion.

Comparing Facial Nerve Grading Systems: House-Brackmann to Automated

Objective: 1) Evaluate the feasibility of an automated zonal facial function grading system through comparison with the House-Brackmann II (HBII) scale. 2) Determine whether such a computerized tool for facial analysis patients can provide objective, accurate, and reproducible assessment in both global and zonal regions of the face.

Method: A prospective clinical trial was performed with 77 consecutive new facial paralysis patients undergoing standardized facial videography. Videos were independently scored by 3 facial nerve specialists using the HBII scale. Subsequent digital analysis was performed with Facogram software, and computer-generated scores were recorded and compared.

Results: Interobserver correlation was high using the HBII scale, with correlation coefficients of 0.81, 0.86, and 0.84. Automated Facogram scores correlated well with manual HBII (scores were within 1.0 ± 0.59, 1.4 ± 1.1, 1.1 ± 1.0, 1.1 ± 0.8, and 1.4 ± 0.8 for overall grade, brow, eye closure, nasolabial fold, and oral commissure, respectively). The HBII required more clinician time to calculate, with an average of 72 ± 21 seconds per case, compared with the Facogram which did not require any clinician time. Specific patient characteristics and video techniques that improved accuracy of the software were identified.

Conclusion: An automated, zone-specific facial analysis tool would eliminate inter-rater subjectivity and allow assessment of facial paralysis patients in a standardized manner across geographic regions and medical specialties. Facogram correlates well with the HBII system. Clinicians should understand the ideal patient population and videotaping technique to optimize accuracy of the program.

Infections after Gracilis Free Flap Reconstruction

Objective: Investigate the incidence, bacteriology, and clinical outcomes of surgical site infection (SSI) after gracilis transfer for facial reanimation, with a focus on determining the optimal perioperative antibiotics in these clean-contaminated cases.

Method: A retrospective chart review was performed for facial paralysis patients who underwent gracilis free flap reconstruction from 2003 to 2010. Microbiology, medication allergies, type and duration of perioperative prophylactic antibiotics, surgery length, and ASA status were reviewed. Functional smile outcomes were compared between those who developed infections and those who were infection-free.

Results: Since 2003, 110 patients have undergone 116 gracilis free flap operations for facial reanimation, with 6 SSIs. All of the infections occurred in patients receiving clindamycin, levofloxacin, and/or cefazolin perioperative antibiotics. None of the patients who received ampicillin/sulbactam developed a SSI. Surgical site cultures from infected patients grew alpha-hemolytic streptococci, Haemophilus parainfluenzae, Fusobacterium, coagulase-negative staphylococci, and Neisseria. Notably, there were no methicillin-resistant Staphylococcus aureus (MRSA) infections. In the patients with SSIs, the mean oral commissure excursion improved by 7.49 ± 3.83 mm, which was not significantly different from noninfected patients with subjective excellent outcomes of 11.4 ± 7.1 mm.

Conclusion: In gracilis flap infections, the organisms identified were consistent with oral flora. Infections occurred in patients receiving prophylactic clindamycin, levaquin, and/or cefazolin, but not in those receiving prophylactic ampicillin/sulbactam. Infections were not associated with decreased functional outcome. These data may have implications for the optimal choice of prophylactic antibiotics.