| 1. |
- Tee, Richard, et al.
(författare)
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Early Second Free Flap is Required in Osteoradionecrosis-related Nonunion after Primary Mandible Reconstruction
- 2023
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Ingår i: Plastic and Reconstructive Surgery - Global Open. - : Wolters Kluwer. - 2169-7574. ; 11:6
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Tidskriftsartikel (refereegranskat)abstract
- Background: Osteoradionecrosis (ORN) manifested as symptomatic nonunion between primary free flap and native mandible after primary bony reconstruction of the mandible is an entity not included in current conventional ORN staging guidelines. This article reports on and proposes early management of this debilitating condition using a chimeric scapular tip free flap (STFF).Methods: A retrospective review was performed examining cases with bony nonunion at the junction of primary free fibula flap (FFF) and native mandible at a single center over a 10-year duration, which required a second free bone flap. Details of each case (patient demographics, oncological details, primary surgery, presentation, and secondary surgery) were documented and analyzed. Outcomes of the treatment were assessed.Results: Four patients (two men and two women; age range, 42–73 years) out of a total of 46 primary FFF were identified. All patients presented with symptoms of low-grade ORN and radiological signs of nonunion. All cases were reconstructed with chimeric STFF. The duration of follow-up ranged from 5 to 20 months. All patients reported resolution of symptoms and radiological evidence of union. Two of four patients subsequently received osseointegrated dental implants.Conclusions: Institutional rate of nonunion after primary FFF requiring a second free bone flap is 8.7%. All the patients of this cohort presented with a similar clinical entity easily discounted as an infected nonunion postosseous flap reconstruction. There is no ORN grading system that currently guides the management of this cohort. Good outcomes are possible with early surgical intervention with a chimeric STFF.
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| 2. |
- Vejbrink Kildal, Villiam, M.D. 1992-
(författare)
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Advances in the Management of Facial Paralysis Sequelae
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Despite advances in the management of facial paralysis and its associated sequelae, therapies targeting the lower facial region remain underdeveloped. This thesis aimed to improve both the diagnostic and therapeutic modalities for facial paralysis, with a focus on the lower face.Methods: This thesis employed anatomical and retrospective studies across three key areas. First, high-resolution ultrasound was evaluated for its ability to increase the precision of botulinum toxin injections in the treatment of facial synkinesis and gustatory hyperlacrimation (Paper I), as a preoperative tool to reduce surgical failures in lower lip depressor myectomies (Papers III–IV), and as a method for evaluating the platysma muscle in patients with facial paralysis (Paper V). Second, anatomical exploration was conducted to identify new potential nerve donors for reanimating the lower facial region (Paper II). Third, a novel classification system for facial nerve injuries was applied to a retrospective cohort to stratify patients and to propose a management algorithm for marginal mandibular nerve reconstruction (Paper VI).Results: The use of high-resolution ultrasound significantly increased the accuracy of injections into the facial muscles and lacrimal gland (Paper I). High-resolution ultrasound also provided valuable preoperative information for depressor anguli oris myectomy (Paper IV) and allowed for the assessment of the platysma muscle in both the neck and face (Paper V). A literature review revealed a surgical failure rate of 21% for lower-lip depressor myectomies (Paper III). The ansa cervicalis nerve was established as an anatomically reliable nerve donor for selective marginal mandibular nerve grafting, although awareness of a common anatomical variant and the required modification of the surgical technique are crucial for surgical success (Paper II). A new classification system effectively stratified patients based on the severity of facial nerve injury, allowing for the creation of a management algorithm for marginal mandibular nerve reconstruction (Paper VI).Conclusions: Application of the findings of this thesis may contribute to the improved management of patients with facial paralysis and associated sequelae, particularly with regard to the lower face.
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| 3. |
- Vejbrink Kildal, Villiam, et al.
(författare)
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Anatomical features in lower lip depressor muscles for optimization of myectomies in marginal mandibular nerve palsy
- 2021
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Ingår i: The Journal of Craniofacial Surgery. - : Wolters Kluwer. - 1049-2275 .- 1536-3732. ; 32:6, s. 2230-2232
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: Myectomies of the lower-lip depressor muscles, with the aim to improve facial balance in unilateral facial paralysis, have unexplained high recurrence rates. A potential explanation is that these recurrences are due to inadequate resection through the muscle width, leaving lateral muscle fibers intact.Aim: Revisit the anatomy of the lower-lip depressor muscles and suggest an optimization of the surgical technique. Perform a literature review to identify recurrence rates and surgical technique of the procedure.Materials and Methods: Ten fresh hemifaces were dissected. The following measurements of depressor labii inferioris and depressor anguli oris were made: the widths of the muscles, the distance from the mandibular midline to the lateral borders of the muscles, and the intraoral distance from the lateral canine to the lateral border of depressor anguli oris. A literature review was performed.Results: The width of depressor labii inferioris was 20 ± 4 mm and depressor anguli oris 14 ± 3 mm. The distance from the midline to the lateral border of depressor labii inferioris was 32 ± 4 mm and 54 ± 4 mm for depressor anguli oris. The literature review revealed a mean recurrence rate of 21%.Discussion: A potential optimization of the surgical technique in lower-lip depressor myectomies is to extend the muscle resection laterally. To ensure inclusion of the whole width of the depressor muscles and decrease the recurrence rates of the procedure, the measurements presented in this study should be kept in mind during surgery.
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| 4. |
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| 5. |
- Vejbrink Kildal, Villiam, et al.
(författare)
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Preoperative assessment of depressor anguli oris to prevent myectomy failure : An anatomical study using high-resolution ultrasound
- 2024
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Ingår i: Journal of Plastic, Reconstructive & Aesthetic Surgery. - : Elsevier. - 1748-6815 .- 1878-0539. ; 88, s. 296-302
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Tidskriftsartikel (refereegranskat)abstract
- Background: Myectomies of the lower lip depressor muscles have unexplained high failure rates. This study aimed to examine the depressor anguli oris (DAO) muscle using high-resolution ultrasound to identify potential anatomical explanations for surgical failures and to determine the accuracy of utilizing preoperative ultrasound assessment to improve myectomies.Methods: Anatomical features of DAO and the surrounding anatomy were examined in 38 hemifaces of human body donors using high-resolution ultrasound and dissection.Results: The ultrasound and dissection measurements showed the DAO muscle width to be 16.2 ± 2.9 versus 14.5 ± 2.5 mm, respectively, and the location of the lateral muscle border 54.4 ± 5.7 versus 52.3 ± 5.4 mm lateral to the midline. In 60% of the cases, the facial artery was either completely covered by lateral DAO muscle fibers or was found to be in direct contact with the lateral border. Significant muscle fiber continuity was present between the DAO and surrounding muscles in 5% of cases, whereas continuity between the depressor labii inferioris and surrounding muscles was considerably more common and pronounced.Conclusions: High-resolution ultrasound can accurately reveal important preoperative anatomical information in myectomies. Two potential explanations for the surgical failures were discovered: an overlap of lateral DAO muscle fibers over the facial artery could lead to inadequate resections and continuity with the surrounding muscles might lead to muscle function takeover despite adequate resections. Both can be uncovered preoperatively by the surgeon through a brief, directed ultrasound examination, which may allow for modification of the surgical plan to reduce surgical failure.
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| 6. |
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| 7. |
- Vejbrink Kildal, Villiam, et al.
(författare)
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Selective ansa cervicalis nerve transfer to the marginal mandibular nerve for lower lip reanimation : An anatomical study in cadavers and a case report
- 2023
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Ingår i: Microsurgery. - : John Wiley & Sons. - 0738-1085 .- 1098-2752. ; 43:2, s. 142-150
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Tidskriftsartikel (refereegranskat)abstract
- Background:Donor nerve options for lower lip reanimation are limited in patients undergoing oncological resection of the facial nerve. The ansa cervicalis nerve (ACN) is an advantageously situated donor with great potential but has not been examined in detail. In the current study, the anatomical technical feasibility of selective ACN to marginal mandibular nerve (MMN) transfer for restoration of lower lip tone and symmetry was explored. A clinical case is presented.Methods:Dissections were conducted in 21 hemifaces in non-embalmed human cadavers. The maximal harvestable length of ACN was measured and transfer to MMN was simulated. A 28-year-old male underwent ACN-MMN transfer after parotidectomy (carcinoma) and was evaluated 12 months post-operatively (modified Terzis' Lower Lip Grading Scale [25 observers] and photogrammetry).Results:The harvestable length of ACN was 100 & PLUSMN; 12 mm. A clinically significant anatomical variant ( "short ansa ") was present in 33% of cases (length: 37 & PLUSMN; 12 mm). Tensionless coaptation was possible in all cases only when using a modification of the surgical technique in "short ansa " cases (using an infrahyoid muscle nerve branch as an extension). The post-operative course of the clinical case was uneventful without complications, with improvement in tone, symmetry, and function at the lower lip at 12-month post-operative follow-up.Conclusions:Selective ACN-MMN nerve transfer is anatomically feasible in facial paralysis following oncological ablative procedures. It allows direct nerve coaptation without significant donor site morbidity. The clinical case showed good outcomes 12 months post-operatively. A strategy when encountering the "short ansa " anatomical variant in clinical cases is proposed.
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| 8. |
- Vejbrink Kildal, Villiam, M.D., et al.
(författare)
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Ultrasound-guided injections for treatment of facial paralysis sequelae : A randomized study on body donors
- 2024
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Ingår i: Plastic and reconstructive surgery (1963). - : Wolters Kluwer. - 0032-1052 .- 1529-4242. ; 153:3, s. 617e-625e
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Tidskriftsartikel (refereegranskat)abstract
- Background: Botulinum toxin injection is the gold standard treatment of synkinesis and gustatory hyperlacrimation in facial paralysis patients. However, poor injection accuracy may lead to suboptimal treatment results and complications. Diplopia, ptosis, and lagophthalmos are common after lacrimal gland injections. Intra-ocular injections have been reported in the treatment of both synkinesis and excessive tearing. Ultrasound guidance should increase injection accuracy in the facial region, but this has not been proven.Methods: Twenty-six hemifaces of non-embalmed cadavers were studied in a randomized split-face manner. Ink was injected with ultrasound or landmark guidance into the lacrimal gland and three common synkinetic muscles: the orbicularis oculi, depressor anguli oris, and mentalis. Injection accuracy was evaluated through several measures.Results: Using ultrasound guidance, most ink (>50%) was found inside the correct target in 88% of cases, compared with 50% using landmark guidance (p<0.001). This was most pronounced in the lacrimal gland (62% vs. 8%), depressor anguli oris (100% vs. 46%), and mentalis (100% vs. 54%) (p<0.05). All ink was found inside the correct target (no ink outside) in 65% using ultrasound guidance vs. 29% without (p<0.001). Injection accuracy (any ink in target) was 100% when using ultrasound guidance vs. 83% without (p<0.01). Twenty-three percent of landmark-guided depressor anguli oris injections stained the facial artery (p=0.22).Conclusions: Ultrasound guidance significantly increased injection accuracy and reduced the amount of ink lost in surrounding tissue when compared with landmark guidance. Clinical trials are needed to explore the effects of ultrasound guidance on treatment outcome, duration, and complications in facial paralysis patients.
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