| 1. |
- Rodriguez-Lorenzo, Andres, et al.
(författare)
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Superficial peroneal and sural nerve transfer to tibial nerve for restoration of plantar sensation after complex injuries of the tibial nerve: cadaver feasibility study.
- 2011
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Ingår i: Journal of plastic, reconstructive & aesthetic surgery : JPRAS. - : Elsevier BV. - 1878-0539 .- 1748-6815. ; 64:11, s. 1512-6
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Tidskriftsartikel (refereegranskat)abstract
- Nerve reconstruction following lower-extremity nerve injuries usually leads to worse outcomes in comparison with upper-extremity injuries due to the long distances of nerve regeneration. This study was performed to consider the clinical application of distal nerve transfer for the treatment of long gaps of the tibial nerve (TN) and in established compartment syndrome. It aimed to determine the anatomic suitability of transferring the sural nerve (SN) in combination with the superficial peroneal nerve (SPN) to the TN at the level of the tarsal tunnel for restoration of plantar sensation.Nine fresh above-knee amputated limbs were dissected with the aid of loupe magnification. We focussed on the detailed anatomy of the course of the SN and the SPN from its emergence proximally at the knee level to the foot. Two different regions, suprafascial and subfascial, were described for each nerve. The maximum length of dissection and the length of the nerves in each region were measured. In all dissections, we assessed the feasibility of directly transferring the SN and SPN to the TN at the level of the tarsal tunnel.The average length of the course of the SN was 20.6 cm (SD ± 2.3 cm) subfascially and 16.4 cm (SD ± 0.9 cm) suprafascially. For the SPN, the average length was 19.4 cm (SD ± 1.9 cm) subfascially and 18 cm (SD ± 2.5 cm) suprafascially. The point of emergence of the nerve from the subfascial course to the suprafascial course was defined as the pivot point for its transfer to the TN. Both the SN and the SPN reached the TN comfortably at the level of the tarsal tunnel, allowing direct co-aptation.Distal nerve transfer using the SN in combination with the SPN is an anatomically reliable procedure, being a potential alternative to the use of nerve grafts in reconstruction of long gaps of the TN. In addition, selected patients with compartment syndrome may also benefit from this transfer to restore plantar sensation.
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| 2. |
- Bevilacqua, Ruggero, et al.
(författare)
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Challenges in the Management of Kidney Allograft Herniation With a Single-stage Pedicled Anterolateral Thigh Flap
- 2022
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Ingår i: Transplantation direct. - : Wolters Kluwer. - 2373-8731. ; 8:9
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Tidskriftsartikel (refereegranskat)abstract
- Wound complications are the most common surgical complication after kidney allograft transplantation. Total wound rupture exposing the entire kidney is a rare and not well-described event. We present a successful treatment of this complication in a patient admitted to our unit. A single-stage procedure was performed combining debridement and reconstruction with a pedicled anterolateral thigh flap and an iliotibial band transferring. A short literature review is performed comparing the different treatment strategies and results.
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| 3. |
- de Lecea, Cristina Gomez-Martinez, et al.
(författare)
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Five-Step Scapula Tip Flap Harvesting for Oromaxillofacial Defects Reconstruction
- 2022
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Ingår i: Plastic and reconstructive surgery (1963). - : Ovid Technologies (Wolters Kluwer Health). - 0032-1052 .- 1529-4242. ; 150:2, s. 416e-418e
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Tidskriftsartikel (refereegranskat)abstract
- In the last 10 years, there has been an increased focus on the scapula tip free flap for head and neck reconstructions. Its several advantages make it a versatile and reliable reconstructive option for patients with orofacial compound defects. The aim of this article is to present a systematic surgical approach for the harvesting of the scapula tip free flap. Herein, a step-by-step surgical approach and some technical tips are described to make the scapula tip flap dissection simpler, safer, and more straightforward.
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| 4. |
- Janik, Stefan, et al.
(författare)
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Using the serratus anterior free flap for dynamic facial reanimation : Systematic review
- 2023
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Ingår i: Head and Neck. - : John Wiley & Sons. - 1043-3074 .- 1097-0347. ; 45:1, s. 266-274
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Forskningsöversikt (refereegranskat)abstract
- It was the purpose of this study to evaluate the role of the serratus anterior free flap (SAFF) with its long thoracic nerve (LTN) as composite flap for dynamic facial reanimation. A total of 10 studies, published between 2004 and 2021, met inclusion criteria. Clinical data of 48 patients were used for the systematic review and analysis. One to three slips were used, mainly as one-stage procedures (n = 39; 81.3%), to create different force vectors. Single or double innervated muscle transfers were utilized in 32 (66.7%) and 16 (33.3%) cases with additionally harvested skin paddles in 4 (8.3%) patients. The LTN was mostly anastomosed to the ipsilateral masseteric nerve (45.8%; n = 22) or to remaining facial nerve branches (37.5%; n = 18), while cross-facial-nerve-grafting was rarely used (16.7%; n = 8). The SAFF as composite flap with different force vectors proved to be a good candidate for immediate dynamic facial reanimation after any midface defects.
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| 5. |
- Oldén, Alexandra, et al.
(författare)
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Factors Affecting Complete Oral Rehabilitation in Patients With Vascularized Free Fibula Flap Mandibular Reconstruction : A 10-Year Retrospective Study
- 2023
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Ingår i: The Journal of Craniofacial Surgery. - : Wolters Kluwer. - 1049-2275 .- 1536-3732. ; 34:6, s. 1635-1639
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Tidskriftsartikel (refereegranskat)abstract
- The fibula is the preferred bone flap for mandibular reconstructions due to its many advantages, including the possibility to insert dental implants. All patients who received a mandibular reconstruction with a vascularized free fibula flap at the Uppsala University Hospital between 2009 and 2019 were retrospectively examined regarding the proportion of implant insertion and factors that affected implant outcome. Forty-one patients had 42 fibula flap reconstructions. Eleven patients (27%) received dental implants and 8 (20%) completed dental rehabilitation. Patient death and cancer recurrence were the main reasons for not receiving implants. The survival rates of implants placed in irradiated and nonirradiated fibulas were 15% and 76%, respectively. Less than 20% of reconstructed patients received an implant-supported prosthesis. Implants placed in an irradiated fibula should be considered at high risk for implant loss.
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| 6. |
- Stefansdottir, Andrea B., et al.
(författare)
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Comparison of Pain Management Strategies to Reduce Opioid Use Postoperatively in Free Flap Breast Reconstruction : Pain Catheter versus Nerve Block in Addition to Refinements in the Oral Pain Management Regime
- 2024
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Ingår i: ARCHIVES OF PLASTIC SURGERY-APS. - : Georg Thieme Verlag KG. - 2234-6163 .- 2234-6171. ; 51:02, s. 156-162
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Tidskriftsartikel (refereegranskat)abstract
- Background: Perioperative management in autologous breast reconstruction has gained focus in recent years. This study compares two pain management protocols in patients undergoing abdominal-based free flap breast reconstruction: a past protocol (PP) and a current protocol (CP)-both intended to reduce opioid consumption postoperatively. The PP entails use of a pain catheter in the abdominal wound and the CP consists of an intraoperative nerve block in addition to refinements in the oral pain management. We hypothesize that the CP reduces opioid consumption compared to PP.Methods: From December 2017 to January 2020, 102 patients underwent breast reconstruction with an abdominal-based free flap. Two postoperative pain management strategies were used during the period; from December 2017 to September 2018, the PP was used which entailed the use of a pain catheter with ropivacaine applied in the abdominal wound with continuous distribution postoperatively in addition to paracetamol orally and oxycodone orally pro re nata (PRN). From October 2018 to January 2020, the CP was used. This protocol included a combination of intraoperative subfascial nerve block and a postoperative oral pain management regime that consisted of paracetamol, celecoxib, and gabapentin as well as oxycodone PRN.Results: The CP group ( n = 63) had lower opioid consumption compared to the PP group ( n = 39) when examining all aspects of opioid consumption, including daily opioid usage in morphine milligram equivalents and total opioid usage during the stay ( p < 0.001). The CP group had shorter length of hospital stay (LOS).Conclusion: Introduction of the CP reduced opioid use and LOS was shorter.
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| 7. |
- 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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| 8. |
- 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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| 9. |
- 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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| 10. |
- 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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| 11. |
- 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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