Microsurgical Reconstruction Techniques in Facial ... · The facial nerve takes signals from the brain to the move the muscles of the face. It powers all the movement of the face

Report by Jennifer Roy, Churchill Fellow. for the

2018 Dr Lena Elizabeth McEwan and Dame Joyce Daws Churchill Fellowship, to learn new techniques in the field of Plastic and Reconstructive Surgery.

Microsurgical Reconstruction Techniques in Facial Paralysis, Lymphoedema and Head and Neck Surgery.

Awarded by the Winston Churchill Memorial Trust. May 2019

Jennifer Roy - Churchill Fellowship Report Page i

INDEMNITY CLAUSE

THE WINSTON CHURCHILL MEMORIAL TRUST

Microsurgical reconstruction techniques in facial paralysis, lymphoedema and

head and neck surgery.

Report by Jennifer Roy Churchill Fellow

2018

Churchill Fellowship to learn new techniques in the field of Plastic and

Reconstructive Surgery

I understand that the Churchill Trust may publish this Report, either in hard copy

or on the internet or both, and consent to such publication.

I indemnify the Churchill Trust against any loss, costs or damages it may suffer

arising out of any claim or proceedings made against the Trust in respect of or

arising out of the publication of any Report Submitted to the Trust and which the

Trust places on a website for access over the internet.

I also warrant that my Final Report is original and does not infringe the copyright

of any person, or contain anything which is, or the incorporation of which into

the Final Report is, actionable for defamation, a breach of any privacy law or

obligation, breach of confidence, contempt of court, passing-off or contravention

of any other private right or of any law.

Signed ...................................................................................

Date. 28/4/2019

Jennifer Roy - Churchill Fellowship Report Page ii

ACKNOWLEDGEMENTS

I would like to thank the Churchill Trust and its employees for their financial support

and mentorship. I am thankful to Dr. Lena McEwan and Dame Joyce Daws both in

receiving the scholarship they created and in their contribution to women in the

field of surgery. I am grateful to Dr. Luc Morris, Dr. Joe Dayan, Dr. Michelle Corridi

and all those at Memorial Sloan Kettering Cancer Center and to Dr. Patrick Byrne, Dr.

Kofi Boahene and the staff at the Facial Plastic and Reconstructive Surgery Unit at

Johns Hopkins University School of Medicine for their hospitality and education.

Special thanks to my amazing wife, Wendy, and my family, who enabled me to travel

on my Fellowship and have supported my training for many years.

CONTACT DETAILS

Dr. Jennifer Roy Plastic and Reconstructive Surgeon Royal Adelaide Hospital, South Australia [email protected]

ITINERARY

3rd – 15th March 2019: Memorial Sloan Kettering Cancer Centre, New York, USA

18th – 29th March 2019: Johns Hopkins University School of Medicine, Baltimore,

USA.

Jennifer Roy - Churchill Fellowship Report Page iii

KEYWORDS

Plastic and Reconstructive Surgery

Lymphoedema

Facial paralysis

Facial reanimation

Head and neck cancer

Head and neck reconstruction

Jennifer Roy - Churchill Fellowship Report Page iv

Contents 1 Executive Summary ................................................................................................................ 1

2 Introduction ............................................................................................................................... 4

3 Lymphoedema Surgery ......................................................................................................... 5

3.1 MSKCC Lymphoedema unit ......................................................................................... 6

3.2 Patient flow ........................................................................................................................ 6

3.3 Clinical assessment ......................................................................................................... 7

3.4 Imaging ................................................................................................................................ 7

3.5 Surgical procedures ........................................................................................................ 8

3.5.1 Vascularized omental lymph node transfer ................................................. 8

3.5.2 Lymphovenous bypass ...................................................................................... 10

3.6 Surgery selection .......................................................................................................... 11

3.7 Follow up.......................................................................................................................... 11

3.8 Outcomes and recommendations .......................................................................... 11

4 Head and neck reconstruction......................................................................................... 12

4.1 Short fibula resection .................................................................................................. 12

4.2 Mandible virtual surgical planning ........................................................................ 13


5 Facial nerve reconstruction .............................................................................................. 14

5.1 Commissure movement and tooth show ............................................................ 16

5.1.1 Innervated free gracilis transfer .................................................................... 17

5.1.2 Nerve transfer ....................................................................................................... 18

5.2 Eye protection and lid movement management .............................................. 19

5.2.1 Upper eyelid weight ............................................................................................ 19

5.2.2 Lower lid ectropion repair ............................................................................... 20

5.2.3 Free muscle grafting or innervated muscle............................................... 20

5.3 Treatment of Synkinesis ............................................................................................ 20

5.4 Vascularised nerve grafts .......................................................................................... 21


6 Conclusions ............................................................................................................................. 22

7 Dissemination and Implementation .............................................................................. 23

8 Glossary/Abbreviations/Definitions ............................................................................ 24

9 Bibliography ........................................................................................................................... 26

10 Appendices .............................................................................................................................. 27

10.1 Appendix 1: Facial nerve paralysis assessment ........................................... 27

10.2 Appendix 2: Gracilis facial reanimation .......................................................... 29

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10.2.1 Dual innervated gracilis free functioning muscle transfer ................. 29

10.2.2 Cross facial nerve graft (CFNG): ..................................................................... 30

10.2.3 Multivector gracilis flap (Boahene, 2018) ................................................. 31

10.3 Appendix 3: Nerve transfer procedures.......................................................... 36

10.3.1 Masseteric nerve transfer operative points .............................................. 36

10.3.2 Hypoglossal nerve transfer points ................................................................ 37

10.4 Appendix 4: Lymphoedema Clinical Assessment ........................................ 38

10.4.1 History ...................................................................................................................... 38

10.4.2 Physical examination .......................................................................................... 38

10.5 Appendix 5: Limb volume and bioimpedence measurements ............... 39

10.5.1 Truncated cone ..................................................................................................... 39

10.5.2 Perometer ............................................................................................................... 39

10.5.3 L-Dex bio impedance measurements........................................................... 39

10.6 Appendix 6: Vascularized lymph node transfer ........................................... 40

10.6.1 Vascularized Omental Lymph node Transfer (VOLT) ........................... 40

10.6.2 Axillary placement of nodes ............................................................................ 40

10.6.3 Post-operative regime........................................................................................ 41

Jennifer Roy - Churchill Fellowship Report Page 1

1 Executive Summary Plastic and Reconstructive Surgery is well known for being a field of innovation.

The term plastic surgery derives from the Greek word plastikē, meaning “the art

of modelling” and from its beginnings in 800 BC, Plastic Surgeons have developed

techniques which mold and alter the human body to reconstruct tissues and cure

disease.

The primary purpose of this Fellowship was to further develop my skills in

head and neck cancer reconstruction, lymphoedema and facial paralysis surgery.

These three different conditions share a need for microsurgical skills, complex

reconstructive techniques and the treatment of cancer related disease.

Lymphoedema is a debilitating progression of fluid build up, usually in the limbs,

following removal of lymph nodes during the treatment of cancer.

Lymphoedema causes swelling, pain, heaviness and sometimes infections. It

significantly reduces the quality of life of those affected. Traditionally, the

condition has only been alleviated by the use of specific message techniques and

compressions garments.

The loss of facial nerve function is a significant disability and is seen as a

consequence of head and neck tumours, viral and congenital conditions. Facial

movement can be restored in a variety of ways but the results are typically

unpredictable.

Churchill Fellowships are awarded for overseas research to gain knowledge that

can be useful to the Australian community. I have chosen to investigate areas

that will be used in the clinical work in South Australian hospitals; be taught to

Plastic and Reconstructive Surgical trainees; and be disseminated to the wider

surgical community in Australia through teaching at professional conferences.


The Fellowship included visits to Memorial Sloan Kettering Cancer Centre

(MSKCC), New York, USA; and Johns Hopkins University School of Medicine (JH),

Baltimore, USA.

At MSKCC, I was a part of the international observer program and was able to

visit both the Head and Neck Cancer Surgery and Plastic and Reconstructive

Surgery Units. At Johns Hopkins, I observed in the Facial Plastic and

Reconstructive Surgery Unit. I observed operations, attended clinics and

participated in the multidisciplinary team meetings and teaching.

The most important outcomes of these experiences were:

Lymphoedema Surgery

o A systematic prospective approach to data collection and monitoring

outcomes is important in all new surgical techniques.

o Successful lymphoedema procedures provide good relief of tightness and

heaviness symptoms and often reduce number of infections.

o Vascularized lymph node transfer is used in reversible lymphoedema with

a fibrofatty component.

o Lymphovenous bypass is used in early stage disease with majority of

lymphoedema being fluid based.

Mandible reconstruction

• A short fibula technique allows a second fibula free flap to be taken from

the same leg, reduces the operative time and amount of dissection

required for smaller bone reconstructions.

• Virtual surgical planning can reduce then operative time, increase

precision of osteotomies and allow immediate dental implants to be

placed during a mandible reconstruction.

Facial paralysis treatment

• Assessment for facial asymmetry, the components of smile and

identifying the patient’s priorities are important in tailoring the approach


for each patient.

• Dual innervation of gracilis free flaps provides reliable muscle movement

in most patients with facial weakness.

• Multivector gracilis free flaps provide a more natural smile by restoring

both tooth show and commissure excursion.

• Treatments for unwanted facial muscle movements are important

adjuncts to improve facial weakness symptoms.

Innovative techniques are the basis of the field of Plastic and Reconstructive

Surgery. The knowledge I obtained during my observations at MSKCC and Johns

Hopkins in the areas of lymphoedema, facial paralysis and head and neck

reconstruction, will enable improved management and improved surgical

techniques to be brought to the people of Australia.

Churchill Fellowship Report Page 4

2 Introduction

The following is a report of my observations whilst visiting the Memorial Sloan

Kettering Cancer Centre (MSKCC), New York and Johns Hopkins University Medical

Centre (JHUMC), Baltimore. It outlines innovative techniques in Plastic and

Reconstructive Surgery particularly in the areas of lymphoedema, facial nerve

paralysis and head and neck cancer reconstruction. These techniques and their

clinical application will be adopted into my clinical practice and disseminated to

health professionals within Australia.

Plastic and Reconstructive Surgery is a field of constant innovation with new

techniques being developed to use microsurgery and tissue transfer to treat

previously untreatable diseases. Both the MCKCC and Johns Hopkins have large

academic programs and highly sub-specialised surgeons, who, through research and

clinical application are constantly trying to improve treatments. I was fortunate to

visit the reconstructive surgeons and gain great insight into their techniques and

management of patients with these complex conditions.

Lymphoedema is a debilitating progression of fluid build up, usually in the limbs,

following removal of lymph nodes during the treatment of cancer. Lymphoedema

causes swelling, pain, heaviness and sometimes infections. It significantly reduces

the quality of life of those affected. Lymphoedema has not traditionally been treated

with surgery, with the management being supportive care in the form of specific

fluid reducing lymphatic massage and wearing of compression garments. Recently,

microsurgery has been used to perform free tissue transfer of lymph nodes to the

lymphoedema affected limb (vascularised lymph node transfer) or join damaged

lymphatic vessels to veins (lymphovenous bypass) in an attempt to change the

physiology of the lymphatic drainage and improve the fluid trapped in the limb. At


MSKCC, I was able to meet with surgeons instrumental in progressing the field of

lymphoedema surgery and medical management. They shared their experiences in

surgical techniques and philosophies in treating this poorly understood disease

process.

The facial nerve takes signals from the brain to the move the muscles of the face. It

powers all the movement of the face allowing facial expressions (eg. smile, frown,

surprise), eye closure and keeping food inside then mouth. Loss of facial nerve

function is a significant disability and is seen as a consequence of head and neck

tumours, viral and congenital conditions. Facial movement can be restored in a

variety of ways that typically have had unpredictable results. The Facial Plastic and

Reconstructive Surgery Unit at Johns Hopkins have developed some robust

techniques to improve the appearance and function of the face in those with facial

paralysis

3 Lymphoedema Surgery Lymphoedema is a chronic progressive condition of fluid retention then fibrofatty

infiltration due to lymphatic drainage dysfunction. Although congenital conditions

can lead to this dysfunction, the majority of patients develop lymphoedema

secondary to resection or damage to lymph nodes during cancer treatment. In

Australia, 1 in 8 women develop breast cancer and 20-50% of patients who have

axillary lymph node dissection for breast cancer develop lymphoedema (Petrek,

1998).

Traditionally, lymphoedema has been treated with supportive therapies such as

lymphatic drainage massage and compression therapy. More recently, improved

microsurgical techniques have allowed development of lymphatic tissue transfer and

lymphovenous bypass which can improve the lymphatic drainage and reduce

lymphoedema.

Surgery for lymphoedema has unpredictable results and further research is


continuing to assess who are good surgical candidates, which procedures provide

the most improvement in lymphatic drainage and reduce complications. To this end I

visited MSKCC to learn from their surgical techniques and management of

lymphoedema.

MSKCC has been treating patients with lymphoedema for over 10 years. They

perform various procedures to treat lymphoedema including liposuction,

vascularised lymph node transfer (VLNT) and lymphovenous bypass (LVB). Patient

selection is paramount in identifying good operative candidates and their referral

triage process is outlined below. Clinical assessment and imaging allow for staging of

lymphoedema and suitability for surgery. Post operative follow up and ongoing

monitoring in a prospective research trial gives ongoing information about the

success of any surgical procedures and monitors non-surgical patients and their

outcomes.

3.1 MSKCC Lymphoedema unit The MSKCC Lymphoedema unit is run by three surgeons, and is part of the Plastic

and Reconstructive Surgery Department. Referrals are primarily from general

practitioners and occasionally from breast surgeons or lymphoedema therapists.

Each referral is triaged by nursing coordinators who assess each patient for

suitability for lymphoedema surgical procedures. The triage guidelines are as

follows:

• Body mass index less than 30.

• Compliant with compression treatment.

• No history of circulation or clotting disorder (which are contraindications for

microsurgical procedures).

3.2 Patient flow Patients are seen within a few months of referral in an outpatient clinic by a

surgeon. Depending on the surgeon’s preference, patients have indocyanine green

(ICG) testing to evaluate the lymphatics in the affected limb at the initial or a


separately scheduled appointment. Assessment questionnaires and measurements

are made at the first appointment (see below for details). A magnetic resonance

angiogram test (MRA) is usually ordered after the first appointment.

At a second clinic appointment an assessment of the surgical suitability is made in

conjunction with an explanation of the likely outcomes and risks of the procedure.

If the patient is a surgical candidate, they are usually booked within 3 months and

undergo a course of compressive decongestive therapy with a lymphoedema

therapist prior to surgery. Post operatively they are discharged after 1 night for LVB

and 3-4 nights for VLNT. Follow up is at 1 week post surgery.

If the patient is not a surgical candidate, they are in an observation arm of a

prospective research trial and continue with follow up appointments and

measurements.

3.3 Clinical assessment At the initial or baseline outpatient clinic appointment, a clinical assessment is made

by the nurse and surgeon (See Appendix 4). Three validated questionnaires are used

to assess severity of lymphoedema and quality of life (lymphedema life impact scale

LLIS; upper limb lymphedema ULL-27; Lymphedema quality of life LYMQOL – Leg).

Height, weight and body mass index are documented. Limb measurements are made

using the truncated cone method and a perometer. Bioimpedence is measured with

the L-Dex monitor (See Appendix 5). Clinical photos are taken of the affected and not

affected limbs.

3.4 Imaging ICG, lymphoscintigraphy and MRA were performed in all patients (regardless of

surgery) at baseline and 12 months.


3.5 Surgical procedures Surgery for lymphoedema can be divided into reductive or physiological techniques.

Reductive techniques reduce the fibrous fatty layer of tissue beneath the skin

(fibroadipose tissue) either by excision or liposuction. Liposuction is favored over

excisional procedures, as it doesn’t leave large wounds to heal. Liposuction can

reduce the weight of a limb and the associated symptoms but these procedures are

only occasionally performed at MSKCC due to the limited long term benefit. They

require lifelong compression and will rapidly recur if compression is removed.

The MSKCC lymphoedema surgeons focus on physiological procedures, in particular

vascularized omental lymph node transfer (VOLT) and lymphovenous bypass (also

known as lymphovenous anastomosis or LVA).

3.5.1 Vascularized omental lymph node transfer Vascularised lymph node transfer procedures have been performed for 10 years at

MSKCC. Initial procedures used groin, axillary (armpit) or cervical (neck) lymph

nodes, however the omentum is now the favoured choice of donor lymph nodes.

The omentum is a layer of lymph nodes and fat which lies over the bowel within the

abdominal cavity. This donor site has been found to reduce complications as

removing lymph nodes can cause lymphoedema in the donor limb and cervical

nodes are nearby large and important structures in the neck. Blood supply for the

omentum comes from the right gastroepiploic artery and the lymph nodes are raised

on this blood supply and used to transfer as a free flap into the lymphoedema

affected limb. Microsurgery is used to attach the omentum to recipient blood vessels

and in many patients this allows new lymphatic channels to grow towards the

imported vascularized lymph nodes and drain lymphatic fluid out of the limb via the

veins.

The rate of a successful operation can be measured in several ways and following

the VOLT procedure 83% of patients have subjective improvement in their upper-

extremity limb symptoms and 22% reduction in mean volume of limb (Nguyen,

2017).

The position that nodes are place in the affected limb (recipient site) is evaluated in


each patient. There are several considerations including:

• Level of obstruction: ICG is used to visualise in real time the lymphatic flow

and places that obstruction of lymphatic flow occurs. If functioning

lymphatics are found to drain into the axilla or groin, then they are unlikely to

benefit from additional lymph node placement. If obstructed lymphatics are

distal then lymph nodes are placed in the distal part of the limb (conversely

for proximally obstructed lymphatics).

• Quality of soft tissues: Often lymphoedematous limbs have very tight skin

and soft tissues, making insertion of nodes difficult. In these cases, lymph

nodes may be placed more proximally or require a small skin graft overlying

the nodal tissue.

• Venous outflow obstruction: Following lymph node dissection tight scar often

occurs around the large veins, causing obstruction of the venous blood flow

out of the limb. This can reduce the ability to drain fluid from the limb and

lead to high venous pressure. Removal of scar from around the large veins

reduces this pressure allowing fluid drainage to improve and reducing limb

swelling. If the patient has symptoms of shoulder pain, reduced range of

shoulder movement or, venous obstruction on MRI, scar removal should be

performed.

The venous outflow of the VLNT is carefully assessed to ensure there is no

back pressure on the draining lymph nodes. This is thought to be particularly

important when using omental donor nodes as they are on a vascular circuit.

Surgeons at MSKCC used two techniques to improve venous outflow:

o Two venous anastomoses where possible.

o Flow through artery anastomosis.

Lymph nodes are often placed in the axilla as a second recipient site when

the axilla is opened to perform scar removal.

• Avoiding primary draining nodes: In cases where some lymphatic drainage is

still present in the lymphoedematous limb or when using donor nodes from a

limb, the primary draining lymph node is identified and preserved. The

technique of reverse lymphatic mapping can be used to identify the primary


draining node in the limb and avoid it, thereby limiting the risk of worsening

or developing lymphoedema. This technique involves using pre-operative

radioactive dye injected into the limb, to identify the primary draining node

(lymphoscintigraphy and intraoperative gamma probe), in conjunction with

ICG injection into the adjacent trunk. Primary draining nodes were avoided

when raising lymph nodes (eg in the axilla chest wall nodes on the

thoracodorsal vessels were usually found to drain chest wall and used for

donor axillary lymph nodes).

Harvesting omentum does have some risks and the complications seen by the

surgeons at MSKCC are one patient with pancreatitis (felt to be due to dissecting the

blood vessels too close to the pancreas) and more commonly ileus (temporary lack

of movement of the bowel). Only two cases of ileus had lasted for longer than 2

days, requiring a nasogastric tube to be placed. To reduce the risk of ileus, a pain

relief that has reduced effect on the bowel movement is used (alvimopan – a

gastrointestinal mu-receptor antagonist opioid analgesic).

Further details of this procedure are in Appendix 6.

3.5.2 Lymphovenous bypass LVB or lymphovenous anastomosis (LVA) is a procedure that connects lymphatic

vessels to veins in an attempt to get lymphatic fluid to bypass lymphatic obstructed

vessels and drain into the venous system.

This procedure involved identifying the lymphatics using ICG study intraoperatively

and identifying where they are adjacent to subcutaneous veins. At these junctions,

small incisions are made into the subcutaneous fat and the two vessels are joined.

The lymphatic vessels are often only 0.3 to 0.5mm in diameter and require

additional magnification and finer instruments than regular microsurgery.

At MSKCC, usually between 3 and 5 anastomoses are performed on each patient.

The patients are then placed in a compressive garment and discharged the following

day.

Post operatively, ICG studies show improved drainage of lymph into the venous


system and a reduction in limb volume. Commonly patients can cease wearing their

compression garments and have decreased symptoms of heaviness, tightness and

infections.

3.6 Surgery selection Although this surgery has been performed for over a decade, surgeons are still trying

to identify who will benefit from a surgical procedure and which procedure to offer.

A detailed discussion with each patient explains the potential that they may have no

improvement or possible worsening of their symptoms. The surgeons at MSKCC also

explain that the majority of patients will continue to need long term compression.

LVB is used when the swollen limb mostly contains fluid. MRA is used to identify the

ratio of fat to fluid. This usually occurs early in the disease process before the

fibrous fatty tissue has had a chance to develop.

When the limb has a significant component of fibrofatty tissue on MRA, but still can

get reduction in limb volume with compression, the patient is a candidate for VLNT.

Once the fibrofatty tissue of the swollen limb becomes woody and non-pitting, the

chance of success with a physiological procedure is poor and at MSKCC these

patients are not offered a surgical procedure.

3.7 Follow up Patients are followed in a prospective research trial for long term monitoring

regardless of surgery. They have appointments at initial outpatient appointment

(baseline), 6 months, 1 year, 2 years and 3 years.

3.8 Outcomes and recommendations o A systematic prospective, long term approach to data collection and

monitoring outcomes is important in lymphoedema surgery, to assess

critically its usefulness and which specific patients will benefit.


o A combination of patient history, ICG, lymphoscintigraphy and MRA are used

to decide on which surgical procedure may be effective.

o Omental vascularized lymph nodes have low morbidity and provide ample

lymphatic tissue.

o Lymphovenous bypass is used in early stage disease with majority of

lymphoedema being fluid based.

o Vascularized lymph node transfer is used in reversible lymphoedema with a

fibrofatty component.

o Successful procedures provide good relief of tightness and heaviness

symptoms and often reduce number of infections.

o Explanation of the potential for no improvement or worsening of symptoms

is required with each patient.

o The vast majority of patients will continue to need compression of some kind

after surgery.

4 Head and neck reconstruction

Head and neck cancer requires reconstruction of various structures including the

jaw, teeth, eyes, mouth, nose and tongue. During my visits to MSKCC and Johns

Hopkins, I observed some innovative techniques in head and neck reconstruction.

4.1 Short fibula resection The fibula (lower leg) bone is used for reconstruction of various bony structures as a

free tissue transfer. Usually, the entire fibula bone is resected even if only a short

piece of bone is required. Dr Kofi Boahene at Johns Hopkins uses a short fibula

resection technique to allow the remaining fibula bone to be taken for a second

reconstruction in the future. The procedure also has a smaller incision and

dissection area allowing quicker recovery from surgery. He dissects the fibula in the

usual manner but once the bone is ready for cutting (osteotomies), measures the

exact amount of bone and length of vessels (pedicle) required and uses this as a


guide for the distance of the bone to be removed. Once fully dissected, the pedicle is

then divided at the bone cut closest to the knee (proximal osteotomy). This allows

the remaining peroneal vessels supplying the fibula that can be harvested in the

future.

4.2 Mandible virtual surgical planning The lower jawbone (mandible) is often resected due to oral cancer. It is a complex

three dimensional structure, that contains the lower teeth and provides the

structure to hold floor of mouth muscles and tongue. The mandible is usually

reconstructed with bone taken from another part of the body. The fibula (lower leg

bone) is used for reconstruction of the mandible. The long straight fibula bone must

be cut into a 3 dimensional structure resembling the mandible and attached to any

remaining native mandible with a plate and screws. Traditionally, the shaping of the

fibula bone is done by free-hand plating techniques and dental implants performed

at a second stage procedure many months or years later.

At MSKCC a technique using 3D virtual surgical planning is used to precisely cut the

fibula bone into segments with exact angles that allows them to be screwed into a

preplanned reconstruction plate. This can reduce the time that the bone is not

attached to its blood supply and allow for immediate dental implants to be placed.

The 3D printed cutting guides are placed over the fibula bone, the dental implants

and screw holes are drilled into the bone using a drilling guide, then the bone is cut

into segments and predrilled holes used to attach the bone to the pre-bent plate.

Once the fibula is plated the blood supply is divided and it is taken to the jaw and

attached via predrilled holes in the native mandible.

This technique allows for all the bone cutting and plating to be performed before

disconnecting its blood supply, this reduces the de-oxygenated time to the bone. It

also allows dental implants to be placed at the time of the reconstruction. A second

stage procedure is required 1 month later to create a gutter between the lip and

new mandible (vestibuloplasty) and teeth are placed soon after.


4.3 Outcomes and recommendations • A short fibula technique allows a second fibula free flap to be taken from the

same leg, reduces the operative time and amount of dissection required for

smaller bone reconstructions.

• Virtual surgical planning can reduce then operative time, increase precision

of osteotomies and allow immediate dental implants to be placed during a

mandible reconstruction.

5 Facial nerve reconstruction

Treatment of facial weakness is by the Facial Plastic and Reconstructive Surgery Unit

at the Johns Hopkins. Dr. Patrick Byrne and Dr. Kofi Boahene are sub-specialists in

the area of facial reanimation and allowed me to observe in their clinics and surgery

over a two-week period.

The unit has a close relationship with neurologists, neurosurgeons and head and

neck surgeons who refer patients with facial nerve pathologies of various

aetiologies. Facial weakness occurs when the facial nerve is damaged either by

nearby or nerve tumour or viral causes. The facial nerve powers (innervates) the

muscles of facial expression allowing smile, frown, eyebrow raising and eye closure.

Once the nerve is permanently damaged these muscle become weak and if left de-

innervated for longer than 12-24 months will waste and become unable to move.

The Facial Plastic Surgeons at Johns Hopkins attempt to intervene as early as

possible in facial nerve damage to reduce the long-term muscle weakness.

To do this they have developed good working relations with the doctors who first

see these patients to establish early referral patterns. For example, neurologists are

encouraged to refer patients with Bell’s palsy (facial nerve weakness caused by a

viral illness). Typically most people with Bell’s palsy recover all movement with non-


surgical treatment (steroids and antiviral medications). However, a small proportion

have permanent weakness with either partial or complete paralysis of the facial

muscles. There is a bimodal distribution of facial nerve recovery in Bell’s palsy that

occurs at 3 weeks or 3 months (Devriese PP, 1990). The surgeons at JH have noticed

that the patients in the 3 month group tend to be more likely to have long-term

weakness. Patients who develop Bell’s palsy that has not partially recovered within 6

weeks are seen in the Facial Plastic Surgery clinic for assessment.

Clinic assessment involves history taking, examination and documentation of facial

movement by measurement, photography and video. History points are [used] to

document the cause of facial nerve injury and timeline and any previous treatment.

The patients’ expectations are investigated in detail to ascertain their perceptions of

their appearance and goals of treatment. History and examination details are shown

in detail in Appendix 1. Smile assessment is performed and the four elements of

smile are examined in detail:

1. Malar mound (cheek shape)

2. Nasolabial fold (depression running from nose to corner of mouth)

3. Commissure excursion (amount of movement of the corner of the mouth

during wide smile)

4. Tooth show (number of teeth showing on each side of mouth during wide

smile).

Various methods of reconstruction can be used for facial nerve weakness and each

patient is assessed for type of weakness and the likely benefits of the reconstructive

options. During my time at JH I was able to observe the surgeons assessing different

conditions and in this report I will explain some of the rationale behind their choice

of reconstruction and novel reconstructive techniques. To explain all the disease

processes and operations of facial nerve reconstruction is beyond the scope of this

report, so I have included details where required for explanation.


5.1 Commissure movement and tooth show Treatment for commissure movement and tooth show can be divided into the

following options:

1. Neuromyectomy: Nerve and muscle resection of the depressor anguli oris

(DAO). Reduces the downward pull of the lower lip thereby increasing smile

excursion and tooth show. A reversible test of the effectiveness of this

procedure is to inject 1mL of lignocaine into the DAO (being careful not to

inject into depressor labii inferioris (DLI)). 15 minutes after injection the

paralysis of this muscle gives a good indication of the amount of extra tooth

show and commissure excursion that can be expected following

neuromyectomy of the DAO. This procedure is indicated in patients with

asymmetry where the upper lip movement is restricted by downward pull of

the lower lip and have a good result with the lignocaine test. The procedure

can be performed and results observed prior to gracilis muscle transfer.

2. Botox injection: Botulinum toxin injection can be performed on the opposite

(contralateral) side to the facial weakness. It is placed as 3 injections into the

DAO and smaller amounts into the DLI and mentalis. The botox blocks the

neuromuscular junctions and paralyses the muscles. The reduction of muscle

movement of the unaffected side can make asymmetries appear less

obvious. This technique is used for milder asymmetry.

3. Temporalis tendon transfer (T3): A procedure that moves the action of the

temporalis muscle from closing the jaw and reroutes it to move the corner of

the mouth. It is used in patients who have asymmetry at rest.

4. Gracilis tissue transfer: The gracilis muscle is moved from the leg and

transferred to the face where its blood vessels and nerve are attached with

microsurgery to those in the face. Once transferred, the muscle is inset to

replicate movement of the facial muscles that lift the corner of the mouth. At

JH the average movement obtained with this operation is 8-10mm. It is used

when there is resting symmetry but not enough movement.

5. Nerve transfer procedures: The nerves that clench the jaw (masseteric nerve)

and move the tongue (hypoglossal nerve) can be used to power the facial

nerve. This procedure is performed in two situations:


a. In the case of no viable facial muscles the nerve can be transferred to

power a gracilis tissue transfer.

b. The nerve can be transferred directly to the facial nerve in cases

where the facial muscles are still working or have recently been

deinnervated.

5.1.1 Innervated free gracilis transfer The gracilis muscle can be harvested and inset in a variety of ways. The two main

variables in the gracilis transfer are the method of nerve innervation and the

placement of the muscle and the direction it pulls (vector).

Nerve innervation: Traditionally, either a masseter nerve transfer or cross facial

nerve graft (CFNG) is used as the innervation for the gracilis functional muscle

transfer. The nerve to masseter has many more axons than CFNG. It therefore

produces stronger movement of the gracilis than CFNG. However, movement

produced by activating masseter (clenching teeth) which must be learnt. CFNG

innervation can produce spontaneous but usually weaker movement.

CFNG is usually performed as a two-stage procedure where donor sural nerve is

harvested and placed across the face between a buccal branch of the

contralateral facial nerve and the proposed placement of the gracilis. The nerve

growth is then monitored and usually at about 9 months the second stage

gracilis transfer is performed, when the nerve axons have grown to the end of

the graft.

Surgeons at JH now perform dual innervation gracilis transfer. This involves

innervating the gracilis with both the masseter nerve transfer and a CFNG.

Usually performed in two stages, the CFNG is placed as usual in the first stage

and then coapted in the second stage to the gracilis, along with the transferred

nerve to masseter. They occasionally perform the CFNG, nerve to masseter

transfer and gracilis transfer in the one procedure. In this case the axons from

the contralateral facial nerve grow through the CFNG over the following 9

months and ideally then begin to allow spontaneous movement. The surgeons at


JH have been collecting outcomes data on the one stage procedure and feel that

similar results are being obtained to the two stage. Further details of the

procedures are seen in Appendix 2.

Gracilis vector placement: The placement of the muscle within the face and

direction of pull is essential to maximizing the commissure movement and tooth

show. Traditionally, the gracilis muscle was placed in the face as one piece of

muscle and attached between the oral commissure and the zygoma. JH has

developed a method of placing the muscle paddles to more accurately mimic the

native facial expression musculature. Described as a multivector gracilis free

functional muscle, it splits the gracilis muscle into two parts (paddles) and

attaches them in two directions of pull (vectors). One paddle (distal) is placed

between the upper lip and bone beneath the eye (infraorbital rim) to enable

elevation of the upper lip and increase tooth show. The second paddle

(proximal) is placed between the oral commissure and arch of the cheek (lateral

zygomatic arch). Specific surgical details can be seen in Appendix 2.

5.1.2 Nerve transfer Traditionally, transfer of either the masseteric or hypoglossal nerves were used in a

situation where there was complete loss of the facial nerve function (eg cancer

resection or nerve tumour). Nerves once damaged can have very slow and

unpredictable recovery. In these cases, the amount of recovery of the facial

movement is variable. The longer that a muscle is left without nerve input, the more

likely that it will never recover as the nerve connections (motor end plates) begin to

die and cannot be recovered even if a nerve regenerates and reaches the muscle.

The surgeons at JH have started to use nerve transfer in these patients at an earlier

stage so as not to lose the function of the deinnervated facial muscles. This was

evident in their practice in two particular cohort of patients.

Bell’s palsy: As mentioned above, Bell’s palsy patients are referred early to the Facial

plastic and reconstructive surgery unit at JH. This allows the surgeon to assess the

patient at around 6 weeks following the illness onset and over a few clinic


appointments, gage the recovery of the nerve. If at 3 to 6 months there is no

recovery, a nerve transfer is suggested to give additional innervation of the facial

musculature. Careful assessment must be performed in these cases as patients with

partial nerve recovery can develop over active muscle tone (i.e. excessive

contraction of the facial muscles). In these cases, using a nerve transfer to power up

the nerve to the facial muscles will produce little outcome as they are already

contracted. In these situations, a gracilis muscle transfer will bring new muscle to

improve contractility. In select cases, division and lengthening of the upper lip

(zygomaticus) muscle or removal of this muscle when the gracilis is inserted can

improve the tension produced by the excessively contracted muscle.

Facial nerve tumour: Tumours of the facial nerve can cause a progressive

deterioration of the nerve function and weakness of the facial muscles. These

tumours are often slow growing and non-cancerous (benign) and there is a difficult

decision as to whether resect as this will certainly result in complete facial nerve

weakness. Most commonly, these patients delay resection of their tumour until the

facial weakness becomes severe to give the maximum time with movement of the

facial muscles. The surgeons at JH have begun treating these patients much earlier,

offering nerve transfer and /or CFNG prior to tumour resection to allow improved

muscle movement and reduce the attrition of the de-innervated muscles.

5.2 Eye protection and lid movement management Incomplete eye closure due to weakness of the muscles surrounding the eye is an

urgent issue. The cornea can become ulcerated if a protective layer of tears is not

available to moisten the globe. Both the upper and lower lids can be affected by

facial nerve paralysis with the upper lid not able to completely close and the lower

lid falling away from the globe. Several procedures can be performed to aid eye

closure including upper lid weight insertion, lower lid ectropion repair and muscle.

5.2.1 Upper eyelid weight Gold or platinum weights can be inserted just under the skin of the upper eyelid to


aid closure of the eyelid. The weight gives gravitational assistance to close the upper

eyelid. Several techniques are used by the surgeons at JH to aid in the correct weight

placement.

• The weight is sized by placing a trial weight on the lid. The correct weight is

just enough to cover the pupil. By inserting lighter weights it allows quicker

and more physiological eye closure.

• Local anaesthetic injection can be performed at exact cc equal to weight to

examine how the eyelid will close with weight.

• Hyaluronic acid (a temporary tissue filler) can also be used to give same

effect for approximately 6-9 months.

• Weight placement is medial on the lid just over the tarsal plate and the

weight sutured in place with 7-0 prolene so as not to migrate.

5.2.2 Lower lid ectropion repair

• Duragen collagen matrix is used as a spacer in the lower lid to raise the lid

and reduce exposure.

5.2.3 Free muscle grafting or innervated muscle

• New literature is indicating that muscle can be grafted onto the orbicularis

and develop the same contractile characteristics as the native muscle.

• A segment of vascularized platysma (innervated by CFNG) can also be used to

facilitate eye closure.

5.3 Treatment of Synkinesis Synkinesis is the involuntary movement of muscles linked by facial nerve. A common

example is when smiling causes unwanted squinting of the eye or eye closure can

cause the mouth to twitch. These synkinetic movements are not only distracting to

the facial symmetry but can become annoying to the patient. Synkinesis is commonly

seen following recovery of Bell’s palsy and following reanimation procedures. Botox

can be used into the excitable muscles to dampen down the twitching. A lignocaine


injection into the muscle will mimic the effects of botox and assist in deciding how

much benefit may be gained.

Overactive muscles can cause uncomfortable tension in the face. This can also be

treated with removal, deinnervation or lengthening procedures if botox alone is not

sufficient.

5.4 Vascularised nerve grafts Facial nerve resection following tumour removal can sometimes leave the facial

nerve available at both ends and require a nerve graft as a conduit for the nerve to

grow along as nerves regenerate. Traditionally, a sural nerve graft is taken from the

leg. However, at MSKCC the surgeons use a technique using vascularized nerve with

the hope that this will provide a better environment for nerve to regenerate. The

nerve to vastus lateralis muscle can be taken with an anterolateral thigh facial free

flap (a thick connective tissue from the thigh which gets its blood supply from the

lateral circumflex femoral artery). This technique was used in conjunction with nerve

transfers (massteric and hypoglossal) to provide additional power to the facial

muscles.

5.5 Outcomes and recommendations • Assessment for facial asymmetry, the components of smile and identifying

the patient’s priorities are important in tailoring the approach for each

patient.

• Dual innervation of gracilis free flaps with cross facial nerve graft and

masseteric nerve, provides reliable muscle movement in most patients with

facial weakness.

• Multivector gracilis free flaps give a more natural smile by restoring both

tooth show and commissure excursion.

• Nerve transfers can be used early in progressive facial weakness to limit the

deterioration of the facial muscles.

• Eyelid weight size should be carefully selected to allow quick lid movement.

• Lignocaine injection can be useful quick and reversible tool in assessing the


likely response to botox injection.

• Synkinesis and asymmetry are often well treated with botox.

6 Conclusions My Fellowship at MSKCC and JH allowed me to meet surgeons who are performing

highly specialized surgery using innovative techniques and collecting robust

outcomes data. I was privileged to be taught about and observe their practices and

learnt many new techniques and ways of approaching patients with lymphoedema

and facial weakness.

Surgery is a very schedule dependent field and unfortunately, I didn’t get the

opportunity to see every procedure available in each unit. Despite this, I was able to

learn a great deal from many dedicated and talented surgeons.

My recommendations are not only useful to surgeons, during my Fellowship I have

realized that by educating the wider medical field (doctors, allied health, nurses)

many patients with lymphoedema or facial nerve weakness could benefit from these

procedures.

Lymphoedema is a debilitating consequence of some cancer treatments and can be a

constant ongoing reminder of past treatment as well as reducing quality of life. By

developing new surgical techniques with reduced morbidity and greater efficacy, we

can provide better long term outcomes for patients with lymphoedema.

The field of facial paralysis surgery is constantly changing with exciting and more

reliable techniques which can benefit a much larger group of patients than was

previously thought. By tailoring our techniques to each patient we can improve the

lives of many patients with facial weakness.


7 Dissemination and Implementation Initial implementation of the findings in this report, will be used by myself in practice

as a Plastic and Reconstructive Surgeon in Adelaide, South Australia. I will be

disseminating these techniques via a series of educational presentations to my

Plastic and Reconstructive Surgery colleagues at the Royal Adelaide Hospital and

other hospitals throughout South Australia.

Plastic and Reconstructive Surgery trainees in South Australia have teaching

provided by the Australian Society of Plastic Surgeons, at which I will teach these

new techniques and ideas.

The wider medical field will be important to engage with in disseminating this

information including general practitioners, neurologist, neurosurgeons, ear nose

throat surgeons, breast surgeons, and lymphoedema therapists.


8 Glossary/Abbreviations/Definitions Aetiology: cause of disease.

Axon: nerve cell body running within nerve.

Bell’s palsy: Facial weakness caused by viral illness damaging the facial nerve.

Coaptation: joining of two nerves with microsurgery.

CFNG: cross facial nerve graft, where a nerve graft is placed across the face from

a branch of the facial nerve on the unaffected side to the affected side.

DAO: depressor anguli oris (muscle that depresses angle of mouth)

DLI: depressor labii inferioris (muscle that depresses the lower lip).

De-innervated: muscle with damaged nerve input.

Facial reanimation: restoring the movement of the facial expression muscles

supplied by the facial nerve.

Free tissue transfer (free flap): transfer of tissue from one part of the body

(donor site) to an area that requires reconstruction or repair (recipient site).

ICG: indocyanine green (a dye used to visualize lymphatic and blood vessels).

Ileus: temporary lack of movement of the bowel.

Innervated: muscle with nerve input

JHUMC: Johns Hopkins University Hospital.

LND: lymph node dissection (removal of lymph nodes)

Lymphoedema: the swelling of a limb with fluid and fibrofatty tissue.

Lymphovenous bypass: rerouting of lymphatic vessels to nearby veins allowing

lymphatic fluid to bypass the damaged lymph system.

Malar: area of face over the cheek bone.


Microsurgery: surgery with the use of a microscope to visualise and operate on

small structures, such as blood vessels and nerves.

Microvascular reconstruction: microsurgery is used to connect blood vessels to

give blood supply to the transferred tissue at the recipient site.

Morbidity: complication caused by a treatment.

Motor end plates: ends of nerves as they attach to muscle.

MSKCC: Memorial Sloan Kettering Cancer Centre.

Oral commissure: corner of mouth.

Paralysis: weakness or loss of muscle movement.

Sural nerve: nerve bringing feeling from the lateral foot, commonly used as a

donor nerve for grafting.

Synkinesis: involuntary movement of muscles linked by facial nerve.

Vascularised lymph node transfer: microvascular tissue transfer of lymph nodes.

Zygoma: cheek bone.


9 Bibliography

1. Australian Institute of Health and Welfare. ACIM (Australian Cancer Incidence

and Mortality) Books. Canberra: AIHW.

2. Boahene, K 2018 The Multivector Gracilis Free Functional Muscle Flap for

Facial Reanimation JAMA Facial Plas Surg 20 (4): 300.

3. Devriese PP, Schumacher T, Scheide A, et al. Incidence, prognosis and

recovery of Bell's palsy. A survey of about 1000 patients (1974–1983). Clin

Otolaryngol Allied Sci. 1990;15(1):15–27.

4. Nguyen, AT, Suami H, Hanasono MM, et al. Long-term outcomes of the

minimally invasive free vascularized omental lymphatic flap for the

treatments of lymphedema. J Surg Oncol. 2017 Jan; 115 (1): 84-89.


10 Appendices

10.1 Appendix 1: Facial nerve paralysis assessment History

• weakness history (start date, cause, progression, any recovery and when),

• what is affected (brow droop, eye dryness or watering, resting symmetry,

smile, speech, oral competence, compensatory over activity of good side,

synkinesis)

• treatment (medications, surgery, eye protection)

• how does the patient feel about their face, what bothers them (droop,

smile size, asymmetry, eye closure, synkinesis)

• what is the order of importance to the patient of the problem areas.

Examination

• Movement and tone of muscles innervated by facial nerve branches

o Temporal – frontalis movement, brow position, compensatory

activity in opposite brow.

o Zygomatic – orbicularis oculi, lower lid position, eye closure (is

pupil covered)

o Buccal – naso labial fold, cheek mound, resting position of mouth,

o Marginal mandibular – lower lip movement

o Cervical – platysma

• Synkinesis

o Eye twitching, platysma activity, lip depressors overactivity when

trying to activate other branches.

• Smile

o Assessment of smile components:

1. Malar mound

2. Nasolabial fold

3. Commissure excursion (measured in milimetres and compared

to other side)

4. Teeth show (number of teeth)


NB. Both tooth show and commissure excursion are asymmetrical in

individuals with working facial nerves. Can be up to 8mm difference in

excursion.


10.2 Appendix 2: Gracilis facial reanimation

10.2.1 Dual innervated gracilis free functioning muscle transfer o Gracilis is used for increasing commissure excursion and tooth show.

o Average of 8-10mm of increased commissure excursion.

o Initially used to use either masseter nerve transfer or cross facial nerve graft

(CFNG) for innervation.

o Masseteric nerve has many more axons than CFNG (due to requiring 2

coaptations, each time losing about half the axons). It therefore produces

stronger movement of the gracilis than CFNG. However, movement produced

by activating masseter (clenching teeth) which must be learnt.

o CFNG innervation can produce spontaneous but usually weaker movement.

o CFNG is usually performed as a two stage procedure where donor sural nerve

is harvested and placed across the face between a buccal branch of the

contralateral facial nerve and the proposed placement of the gracilis. Then

the nerve growth is monitored and usually at about 9 months the second

stage gracilis transfer is performed.

o Notes on CFNG can be seen below.

o Surgeons at JH now perform dual innervation gracilis transfer. This involves

innervating the gracilis with both the masseter nerve transfer and a CFNG.

Usually performed in two stages, the CFNG is placed as usual in the first stage

and then coapted in the second stage to the gracilis.

o In the dual innervation gracilis, the masseteric nerve is coapted end to end on

the obturator nerve and the CFNG is coapted in geometric fashion end to side

on a place distal to the end to end coaptation close to the gracilis muscle. The

idea is to get axons to grow from the CFNG into the motor end plates first

before masseter axons grow through.

o Nerve coaptations are performed with 10-0 nylon sutures, reinforced with

fibrin glue and covered with a collagen matrix (Medtronic Durepair dura

regeneration matrix).

o The dual innervated gracilis can also be done as a one stage operation.

Where the CFNG is placed at the same time as the free muscle transfer and


coapted in the above manner. The outcomes of this one stage procedure

have yet to be analysed, but the feeling of the surgeons was that it would

produce similar overall outcome to a two stage procedure.

10.2.2 Cross facial nerve graft (CFNG): o NIMS set up on unaffected side to harvest contralateral facial nerve branch.

o Electrodes placed on orbicularis oculi (lower lid) and orbicularis oris (upper

lip).

o 1 in 100,000 adrenaline solution is injected into the incision line and

subcutaneous tissues.

o Sural nerve graft taken through 2 incisions. Placement of incisions is at

roughly 1/3rd and 2/3rds of the way along the nerve graft. Nerve initially

found at distal incision (between tendon and subcutaneous fat). Blunt

dissection above and below nerve with narrow malleable retractor then

whilst nerve is on tension, its course is palpated with a finger and proximal

cut made over nerve.

o Nerve is marked and examined for branching at distal end.

o Inset of nerve is often reversed (distal end coapted to facial nerve). However,

it can be placed either way depending on branching pattern, so as to capture

all axon pathways along the nerve graft.

o A suture is placed at the end of the graft not being coapted with 4/0 prolene.

o Graft length must reach from facial nerve branch to opposite temple.

o Preauricular skin incision is in a modified facelift manner with extension

anteriorly horizontal into the hairline and around the ear lobule.

o Flap is raised in a supraSMAS plane until anterior of parotid.

o Facial nerve branches are identified and mapped to facial muscle

movements.

o A donor facial nerve branch is decided on by, assessing the movement of the

unaffected side and deciding where to weaken facial muscles to provide

improved asymmetry. For example, if the unaffected side has a large

commissure excursion then a branch that has more mouth excursion is used.


Conversely, if the unaffected side has large tooth show then a branch that

mainly moves the upper lip will be used. The branch used does not need to

mimic the movement you wish to produce on the affected side, as this will be

determined by the vector of the gracilis muscle.

o Once the facial nerve branch is chosen, the nerve graft is tunneled through

the subcutaneous tissue. A stab incision is made at the centre of the upper lip

(frenulum) and a narrow tendon retriever tunneled between the facial nerve

branch and the lip and the nerve pulled through. A second stab incision is

then made within the hairline of the temple on the affected side. This is along

the path of the temple extension of the preauricular incision, which will be

made for placing the gracilis. The tendon retriever is then tunneled from

temple to upper lip and the prolene suture grasped and nerve pulled

through. A small clip is placed on the prolene suture to hold in place.

o The sural nerve is then coapted to the facial nerve branch with two 9/0 nylon

sutures (just to hold the ends of the nerve in position). Duragen is used under

the nerves during the coaptation. Fibrin glue is placed over the coaptation

and the duragen folded over and / or a small square placed to overlie the

glue. More glue is used over the duragen and under the skin flap during

closure.

o The preauricular and stab incisions are closed, with prolene left about 7mm

to allow easy visibility at the second stage.

o A facelift garment is used for the first day.

o No drain is placed.

10.2.3 Multivector gracilis flap (Boahene, 2018) o Traditionally gracilis muscle was inset to oral commissure and zygoma.

o Multivector gracilis splits the gracilis muscle into 2 parts, allowing one part to

pull laterally and one medially.

o This is thought to mimic the natural smile movement by elevating both

commissure and upper lip.

The technique used at JH is as follows:


o Contralateral leg is used as this aligns the gracilis pedicle with the facial artery

and the tendious portion of the muscle with the lip.

o Vascular pedicle and obturator nerve identified in usual fashion. The gracilis

muscle is innervated by the obturator nerve and blood supply is from the

profunda femoris vessels.

o Vessels and nerve are identified entering the muscle 8-10cm from the pubic

tubercle.

o Length-tension relationship is guided by using marking sutures placed on the

gracilis surface at measured intervals.

o Obturator nerve enters the muscle in association with the vascular pedicle

and then splits into 2-3 branches that run longitudinally parallel to the

arterial braches and muscle fibres. This positioning of the vessels and nerve

allow the muscle to be split longitudinally supplied by these branches.

o Proximal paddle is taken from the anterior 1/3rd of the muscle and the distal

paddle taken from the posterior 1/3rd.

o The central 1/3rd is resected around the bridging neurovascular pedicles.

o Proximal paddle is larger (2.5 to 3cm) with the nerve running in centre of

flap.

o The muscle bellies are dissected with the aid of a Doppler and nerve

stimulator (NIMS or checkpoint).

o A layer of myomysium and gliding fascia is maintained on the muscle.

o Distal paddle is smaller (1 to 1.5cm) with the nerve running into the medial

aspect of the flap.

o Once dissected the Doppler signals and independent muscle contraction is

verified.

o Modified facelift incision is made with relaxing hair tuft incision that gives

good access to the subzygomatic triangle for dissection of the masseteric

nerve, malar eminence, zygomatic arch and temporalis fascia. The flap is

raised in a deep plane (sub-SMAS) level and extended beyond the nasolabial

fold (exposing orbicularis oris).

o CFNG is identified, masseteric nerve identified and prepared.

o A trough is created by removing some buccal fat and masseter muscle.


o Facial or other recipient vessels are prepared.

o Anchoring sutures with 2/0 PDS are placed on orbicularis free lip margin

superiorly for the distal muscle paddle and in 3 points on the oral

commissure for the proximally paddle.

o Proximal paddle becomes the lateral vector and is sutured from the oral

commissure to lateral zygomatic arch.

o Distal paddle becomes the medial vector and is sutured from upper lip to

infraorbital rim lateral aspect.

o A pseudotendon is created with a running vicryl suture if the tendinous

portion of the muscle is insufficient.

o Tension is set close to passive length but made slightly tighter to allow for

secondary slippage.

o Muscle vascularized then nerves coapted.

o Dual innervation as seen above.

o Proximal muscle is secured at the desired tension to the periosteum of the

zygomatic arch and deep temporal fascia.

o SMAS flap is suspended as in facelift to support muscle flap.

o Incision closed over drain.


Figure 1. Multivector gracilis two muscle paddle harvest

Figure 2. Inset of multivector gracilis flap.


Anatomical gracilis flap

o Here the one muscle flap is used to produce one vector.

The flap paddle is split at the superior edge for 1-2 cm to give a slip for

insertion into the infraorbital rim and one to the zygoma.

Figure 3. Anatomical gracilis flap.


10.3 Appendix 3: Nerve transfer procedures

10.3.1 Masseteric nerve transfer operative points o Subzygomatic triangle formed by a vertical line on the anterior border

of TMJ and inferior edge of zygomatic arch. By bisecting these gives

the course of the masseteric nerve.

Figure 4. Subzygomatic triangle and path of masseteric nerve.

o Facial nerve monitor used with stimulator on 0.8.

o Identify the facial nerve recipient branch on anterior border of parotid

by using nerve stimulator.

o Identify a branch that stimulates both zygomatic and buccal branches

ideally.

o Inject subzygomatic triangle muscle with adrenaline (3-5mL 1 in

100,000).

o Identify masseteric nerve superior to facial nerve branches and deep

within the masseter muscle at the level of just inferior to zygomatic

arch.

o Dissect nerve distally and identify branches. One branch is used and

cut distally.

o Duragen is used to position the nerve superficially.


o 9-0 nylon a few milimetres away from end through epineurium is

used to position the nerves before dividing the facial nerve branch.

o Ideally end to end but can be end to side coaptation. Important to see

fascicles within facial nerve.

o Nerves coapted with 10-0 nylon, fibrin glue covered with a square of

Duragen sheet.

10.3.2 Hypoglossal nerve transfer points o Facial nerve can be drilled out at mastoid at second genu.

o Facial nerve is transected at this point and brought down into neck.

o End to side coaptation to the hypoglossal.

o 2/3rds of hypoglossal nerve is cut and facial coapted.

o If facial can’t be brought to hypoglossal, then half of the hypoglossal

can be divided and neurotised to lengthen and coapt to the facial

nerve stump.


10.4 Appendix 4: Lymphoedema Clinical Assessment

10.4.1 History o Age

o Sex

o Presenting complaint (lymphoedema, lipedema, high or future risk).

o Lymphoedema (location, type (primary or secondary), causation (cancer type,

lymph node status), onset and course, symptoms (see below).

o Timing of surgery and treatment.

o Chemotherapy or radiotherapy treatment.

o Lymphatic therapy

o Massage

o Compression (type, grade, occasional / daily / 24 hours)

o Manual lymphatic drainage, pump, wrapping, night compression,

garment type.

o Lymphoedema symptoms

o Heaviness, swelling, infections, pain.

o Relevant past medical history

o Weight, cardiac history, diabetes, DVT or PE, obesity, peripheral

vascular disease.

o Smoking, alcohol, family history, medications and allergies.

10.4.2 Physical examination o International Society of Lymphology staging.

o Pitting oedema

o Range of movement: nil, mild, moderate or severe limitation.

o Venous pathology: varicosities, brawny oedema, venous stasis.

o Pulses


10.5 Appendix 5: Limb volume and bioimpedence measurements

10.5.1 Truncated cone o wrist crease is 0cm, then 4cm increments along arm to shoulder to 44cm

o measurement in centimetres to the half cm.

10.5.2 Perometer o infrared light used to measure volume

o start and end points along arm is made same

o used to calculate the following measurements

o volume,

o volume difference between limbs

o % volume difference.

10.5.3 L-Dex bio impedance measurements. o Impedimed U 400 model.

o Pt lies still supine for 1 to 2 mins.

o 3 nodes are used (both arms and one leg for upper limb, both legs and

one arm for lower limb)

o Skin is cleaned with alcohol wipe and left to dry prior to application of

sensors.


10.6 Appendix 6: Vascularized lymph node transfer

10.6.1 Vascularized Omental Lymph node Transfer (VOLT) o Omentum used as low morbidity and many vascularized nodes readily

available.

o Preoperative bowel preparation.

o Raised through midline upper abdominal incision.

o Adhesions between omentum and bowel carefully divided.

o Ligasure used to divide omentum.

o Right gastroepiploic vessels used as pedicle.

o Care taken not to dissect back too far towards pancreas.

o Once pedicle is isolated, intravenous ICG used to visualise vascularized

portions of omentum.

o IV ICG dose is 4mL then 10mL flush just prior to visualization with SPY camera

(Novadaq pinpoint ICG visulaliser used at MSKCC).

o Post operative IV then oral discharge antibiotics.

10.6.2 Axillary placement of nodes o Transverse incision similar to lymph node dissection.

o Scar removed from around axillary vein to reduce venous outflow

obstruction.

o Circumflex scapular and thoracodorsal arteries identified as assessed as

recipient vessels.

o Large lymph node flap can be placed in axilla so first anastomosis performed

here and then portion of omentum taken as second flap for distal arm.

o Always anastomose a second vein if venous backflow is high (can be assessed

when second lymph node flap divided).

o Fatty tissue should be trimmed to enable axilla closure.

o Omentum hitched to superior point of axilla.

o Deep layers closed to hold omentum high in axilla.

o Drain


10.6.3 Post-operative regime o Usually 4 night inpatient stay.

Leg restrictions:

o First 2 weeks: Non-weight bear, no lymphoedema wraps or

compression, no manual lymphatic drainage.

o For calf recipient: frog leg position.

o For groin recipient: limit hip flexion.

o After 2 weeks: Gradually increase weight bearing over 1 week, visit

lymphoedema therapist for massage and compression, wrap or

bandage distal to incision (up to knee for groin incision, toes and foot

for calf incision).

o 4 weeks: Manual lymphatic drainage over incision site, light exercise,

compression or wrap over incision.

o 6 weeks: All usual activity.

Arm restrictions:

o First 2 weeks: No weight on arm, rest arm away from side, move

elbow as usual, no pressure on incision, no wraps or bandage over

incision, no massage over incision.

o After 2 weeks: visit lymphoedema therapist, start wraps or bandage

over incision, start manual lymphatic drainage on arm but not over

incision.

o 4 weeks: Start manual lymphatic drainage over incision, slowly start

light exercise.

o 6 weeks: All usual activities.

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Microsurgical Reconstruction Techniques in Facial ... · The facial nerve takes signals from the brain to the move the muscles of the face. It powers all the movement of the face