This article discusses the use of the sternohyoid muscle for facial reanimation. The report outlines the rationale for use, the technical aspects of flap harvest, and early clinical outcomes. The utility of the flap and its comparative attributes relative to the gracilis flap are discussed.

ABSTRACT Background Donor site morbidity is an important consideration in the overall decision‐making algorithm for fasciocutaneous free flap reconstruction of the head and neck. Methods A retrospective case series was conducted of donor site complications occurring within 30 days of surgery among 226 consecutive anterolateral thigh (ALT) or radial forearm free flap (RFFF) microvascular free tissue transfers performed by multiple reconstructive surgeons between 2005 and 2010. Results A greater number of donor site complications occurred among patients undergoing RFFF versus ALT free flaps (40; 35.4%; vs 14; 12.4%; p < .001). Wound dehiscence occurred significantly more frequently among patients undergoing RFFF versus ALT free flap reconstruction (34; 30%; vs 6; 5%; p < .001). Tendon exposure occurred in 16 of the 113 RFFFs (14.1%). Seromas occurred more commonly in the ALT group (6; 5%; vs 2; 1.7%; p = .280). Conclusion Although short‐term donor site morbidity was low in both groups, the ALT was associated with a significantly lower incidence of wound dehiscence with or without tendon exposure. © 2015 Wiley Periodicals, Inc. Head Neck 38 : E945–E948, 2016

This article describes the challenges of facial reconstruction and the role of facial transplantation in certain facial defects and injuries. This information is of value to surgeons assessing facial injuries with massive soft tissue loss or injury.

Objectives/HypothesisPatients undergoing laryngopharyngectomy with extensive pharyngeal mucosal resection or those failing chemoradiation protocols are commonly reconstructed using free tissue transfer. Radial forearm free flaps (RFFFs) and anterolateral thigh free flaps (ALTs) are two of the most commonly used free flaps for laryngopharyngectomy reconstruction. It has been suggested that alaryngeal tracheoesophageal prosthesis (TEP) speech outcomes in patients undergoing ALT reconstruction may be inferior due to the possibly bulkier neopharynx. We report the results of patients treated with ALT and RFFF with regard to postoperative TEP voice outcomes.Study DesignRetrospective cohort study.MethodsWe identified 42 consecutive patients who were treated with total laryngopharyngectomy and free flap reconstruction utilizing either RFFFs (20 patients) or ALTs (22 patients) between April 2001 and August 2010. Evaluations with statistical analysis of standard TEP speech outcome measures (maximal sustained phonation, fluent count, syllable count) and qualitative variables were conducted.ResultsPatient demographics were similar between the RFFF and ALT groups, and 95% and 91% of RFFF and ALT patients received radiation therapy, respectively. Subjective voice quality did not significantly differ between the groups. Differences in outcomes of intelligibility, maximal sustained phonation time, maximum number of syllables, and fluent count, as evaluated by a single speech pathologist, were not statistically significant between RFFF and ALT patients. There was no difference in postoperative complications.ConclusionsThese data indicate that reconstruction of laryngopharyngectomy defects using either the ALT or RFFF technique can produce similarly acceptable TEP voice results. Level of Evidence: 2b. Laryngoscope, 124:397-400, 2014

IMPORTANCENeuromuscular reanimation of the face provides the correct specific neural functional input and thereby prevents synkinesis. Unfortunately, this ideal situation is rarely encountered in the clinical setting.OBJECTIVESTo assess the technical feasibility of and define the surgical procedure for harvesting the sternohyoid muscle as a novel free flap for use in facial reanimation indications.DESIGN, SETTING, AND PARTICIPANTSFresh, postmortem, nonfixed cadavers were used to define the anatomy and perform the flap harvest procedures. Twenty-four flap harvests were performed. Angiography was performed on the pedicle of the harvested flaps to assess potential flap perfusion. Adenosine triphosphatase staining was performed on the muscle specimens to establish fiber type.MAIN OUTCOME MEASURESThe harvest technique, pedicle (arterial or venous), nerve length, and flap geometry parameters were characterized.RESULTSThe sternohyoid muscle was found to be reliably vascularized by the superior thyroid artery in all cases with an appropriate arterial and venous pedicle for vascular anastomosis. The mean arterial (5.5 cm) and venous (5.9 cm) pedicle lengths are comparable with gracilis flaps. The mean motor nerve length was 10.7 cm. The inclusion of the hyoid bone allows rigid fixation, and the muscle size, fiber type, and volume profiles all compare favorably to the gracilis flap for use in the indication of facial reanimation. Mock surgical procedures were performed to define inset parameters. This flap potentially allows single-stage cross-facial neurorrhaphies to be performed.CONCLUSIONS AND RELEVANCEThis is the first article, to our knowledge, of the sternohyoid muscle as a potential donor site for free-tissue transfer. This muscle has a predictable vascular pedicle and neural innervation along with size and fiber type parameters that make it an ideal potential free flap for facial reanimation.LEVEL OF EVIDENCENA.

Objective After nerve injury, an exaggerated neuroinflammatory process may hinder neuron regeneration and recovery. Immunomodulation using glucocorticoids may therefore improve facial nerve injury outcomes. This study aims to examine the effect of both local and systemic dexamethasone administration on facial nerve functional recovery after axotomy in a rat model. Study Design Randomized, placebo-controlled, blinded animal study. Setting Animal laboratory. Subjects and Methods Seventy-four Wistar rats underwent facial nerve axotomy with immediate neurorrhaphy. Rats were randomly assigned a postoperative group: control (no therapy); systemic dexamethasone 0.5, 1, 5, or 10 mg/kg for 3 administrations; or topically applied dexamethasone at 2 or 4 mg/mL. Blinded, standardized facial assessments and nerve conduction studies (NCS) were performed. Gross facial motion assessments were corroborated with vibrissae frequency video analysis. Results At 8 weeks, rats receiving systemic dexamethasone at 5 mg/kg attained greater eye blink closure (P = .004) and vibrissae motion (P = .012) compared with controls. Systemic dexamethasone at 0.5, 1, and 10 mg/kg and intraoperative topical application of dexamethasone at 2 or 4 mg/mL did not produce a significant improvement in facial motion compared with controls. Nerve conduction studies show a trend of increased return of compound muscle action potential amplitude levels compared with baseline among rats that received systemic dexamethasone 5 mg/kg but do not achieve statistical significance. Conclusion In a rat facial nerve axotomy model, high-dose systemic dexamethasone therapy may improve functional recovery when administered in the immediate period following neurorrhaphy.

 ABSTRACT Upper airway manifestations, particularly sinonasal manifestations, are encountered frequently in granulomatosis with polyangiitis (GPA). Nasal endoscopy often reveals crusting, friable erythematous mucosa, and granulation. Up to 25% of patients may have a “saddle-nose” deformity as cartilage destruction worsens. Treatment is often compli-cated by loss of mucociliary function and necrosis, leading to refractory symptoms. Culture-directed antibiotics, topical antibiotic and saline irrigations, and occasional debridement of adherent crusts can reduce the frequency of sinonasal exacerbations and improve obstructive symptoms. Surgery should be reserved for patients unresponsive to maximal medical therapy. Saddle-nose reconstruction is possible in highly selected patients and can improve nasal breathing and resolve anosmia. Up to 20% of patients with GPA have subglottic stenosis; patients with respiratory symptoms should undergo laryngoscopy to assess the presence of subglottic narrowing. Although systemic manifestations of GPA are managed by immunosuppressive therapy, most patients with subglottic stenosis of GPA require surgical management (ie, endoscopic dilation, endoscopic or laser excision, surgical resection followed by  ABSTRACT Glomerulonephritis (GN) is a common manifestation of the antineutrophil cytoplasmic antibody–associated systemic vasculitides (AASV), which include granulomatosis with polyangiitis and microscopic polyangiitis. The level of renal involvement at presentation is highly predictive of survival and should be assessed early so that kidney function can be preserved. AASV patients with urinary sediment but normal function have a twofold greater risk of death than those with no renal involvement. Those with impaired renal function at diagnosis have a fi vefold greater risk of death. Renal vasculitis is most prevalent in older patients, who have more severe disease and poorer prognoses. Renal biopsy not only establishes diagnosis but provides information on severity of renal-function impairment and prognosis. Induction of remission with cyclophosphamide is standard treatment. For patients with crescentic, rapidly progressive GN, adjunctive plasma exchange can promote renal recovery. Renal failure occurs in one-fourth of AASV patients after 3 to 4 years; 60% of patients receiving dialysis for acute GN can recover independent renal function. Renal transplant patients with vasculitis fare as well as renal transplant patients without vasculitis. Lastly, renal vasculitis is an independent risk factor for cardiovascular  ABSTRACT Diagnosis of the pulmonary manifestations of small-vessel vasculitis requires attention to detail, judicious use of imaging technology, and awareness of disorders that can mimic or masquerade as pulmonary vasculitis. Treatment should begin with pharmacologic intervention to manage the underlying infl ammatory disorder. Dilation procedures and, in rare cases, surgery may be needed to resolve airway  ABSTRACT Ophthalmic manifestations of vasculitis can be orbital, ocular (affecting the globe), or intraocular. Orbital infl ammation manifests as sudden onset of pain, erythema, and proptosis, and can be sight-threatening. In the globe, red eye is typical in both episcleritis and scleritis. Episcleritis is usually otherwise asymptomatic with blanching upon instillation of topical phenylephrine, whereas scleritis is painful and does not blanch. Infectious and rheumatic diseases are present in nearly 50% of patients with scleritis. The symptoms of keratitis are similar to those of scleritis; superfi cial keratitis is benign but peripheral ulcerative keratitis can be sight-threatening. Anterior uveitis is the most frequent ocular manifestation of Behçet disease. Approximately 30% of patients with granulomatosis with polyangiitis (Wegener’s granulomatosis) have ocular involvement, with orbital disease being most common. With ophthalmic manifestations of vasculitis, tissue biopsy of any site that is amenable to biopsy is recommended. Biopsy must be interpreted within the context of

We reviewed our institutional experience of patients (pts) with salivary gland cancers who were treated definitively to identify risk factors associated with disease recurrence. An IRB approved registry was queried for pts with salivary gland cancers treated between 1994 and 2011 with surgery ± adjuvant radiation (RT), or adjuvant chemoradiation therapy (CRT). Adjuvant RT was generally given for pts with high grade disease, T3/4 tumors, or lymph node involvement (N+). Adjuvant CRT was typically used for pts with + margins or extracapsular extension. Kaplan-Meier analysis was used to calculate disease-free (DFS) and overall survival (OS). Univariate analysis (UV) and two separate multivariate models (MV) were generated using Cox proportional hazards regression to identify patient, tumor and treatment related variables associated with any disease recurrence including loco-regional (LRF) or distant failures (DF). One MV was done in a stepwise fashion (MV1) and the other was performed with all variables included simultaneously (MV2). Variables included age, Karnofsky performance status (KPS), cell differentiation (well [WD], moderate [MD], poor [PD]), T stage, N+, histology, perineural invasion (PNI), angiolymphatic invasion (ALI) and the use of surgery monotherapy. Of the 147 pts (59% male; 92% white) included in this study, the median age at treatment was 59 years (range: 16-100) and median KPS was 90. Primary sites were parotid gland in 116 (79%) pts, submandibular gland in 29 (20%) and minor salivary gland in 2 (1%). The most common histology was adenocarcinoma (36%) followed by mucoepidermoid (25%), adenoid cystic (17%) and other (22%). T1, T2, T3 and T4 tumors were found in 25%, 29%, 18%, and 28% of pts, respectively; 33% of pts had N+ disease. Surgery alone was performed in 29% of pts, while 67% and 10% were treated with adjuvant RT and adjuvant CRT, respectively. With a median follow-up of 25.4 months, the median OS was 33.1 months (range 1.2 - 205.5). 21 (14%) pts had LRF and 25 (17%) had DF. These rates were consistent across histologies. 5yr DFS and OS were 62.2% and 65.9%, respectively. On MV1, N+ disease (HR 3.18; p=0.0003) and older age showed significantly higher risk of disease recurrence. MV2 showed that older age (HR 1.03; p=0.005), T4 disease (HR 2.66; p=0.0056) and PD tumors (HR 15.6; p=0.0077) were also significantly associated with higher rates of disease recurrence. Despite high incidences of PNI (total 47%; named nerve 25%) and ALI (25%), these were not associated with inferior outcomes. Older pts, high grade tumors, T4 disease, and N+ are factors associated with a higher risk of disease recurrence in salivary gland cancers. Efforts to intensify treatment in this population are indicated and are being tested in RTOG 1008.

Upper airway manifestations, particularly sinonasal manifestations, are encountered frequently in granulomatosis with polyangiitis (GPA). Nasal endoscopy often reveals crusting, friable erythematous mucosa, and granulation. Up to 25% of patients may have a “saddle-nose” deformity as cartilage destruction worsens. Treatment is often complicated by loss of mucociliary function and necrosis, leading to refractory symptoms. Culture-directed antibiotics, topical antibiotic and saline irrigations, and occasional debridement of adherent crusts can reduce the frequency of sinonasal exacerbations and improve obstructive symptoms. Surgery should be reserved for patients unresponsive to maximal medical therapy. Saddle-nose reconstruction is possible in highly selected patients and can improve nasal breathing and resolve anosmia. Up to 20% of patients with GPA have subglottic stenosis; patients with respiratory symptoms should undergo laryngoscopy to assess the presence of subglottic narrowing. Although systemic manifestations of GPA are managed by immunosuppressive therapy, most patients with subglottic stenosis of GPA require surgical management (ie, endoscopic dilation, endoscopic or laser excision, surgical resection followed by reconstruction).

Background: Several methods of neural rehabilitation for facial paralysis using 12-7 transfers have been described. The purpose of this study is to report on a series for dynamic reinnervation of the paralyzed face by using a split 12-7 nerve transposition. The goals of this procedure are to minimize tongue morbidity and to provide good facial reinnervation.Methods: Prospective case series. Melolabial crease discursion, overall facial movement, and degree of tongue atrophy and mobility were recorded.Results: Thirteen patients underwent facial reanimation using a split hypoelossal-facial nerve transfer with postoperative follow-up to 58 months (range, 6-58 months). All patients achieved excellent rest symmetry and facial tone. Of 13 patients, 10 had measurable coordinated movement and discursion of their melolabial crease. Of 13 patients, 12 had mild to moderate ipsilateral tongue atrophy. The mean time to onset of visible reinnervation was 3 months.Conclusion: Split hypoglossal-facial nerve transposition provides good rehabilitation of facial nerve paralysis with reduced lingual morbidity. Long-term rest symmetry and potential learned movement can be achieved. This technique may provide a favorable alternative to the traditional method of complete hypoglossal sacrifice or jump grafting. (C) 2011 Published by Elsevier Inc.

Background: Free muscle transfer for facial reanimation has become the standard of care in recent decades and is now the cornerstone intervention for dynamic smile reanimation. We sought to quantify smile excursion and quality-of-life (QOL) changes in our pediatric free gracilis recipients following reanimation.Methods: We quantified gracilis muscle excursion in 17 pediatric patients undergoing 19 consecutive pediatric free gracilis transplantation operations, using our validated SMILE program, as an objective measure of functional outcome. These were compared against excursion measured the same way in a cohort of 17 adults with 19 free gracilis operations. In addition, we prospectively evaluated QOL outcomes in these children using the Facial Clinimetric Evaluation (FaCE) instrument.Results: The mean gracilis excursion in our pediatric free gracilis recipients was 8.8 mm ± 5 mm, which matched adult results, but with fewer complete failures of less than 2-mm excursion, with 2 (11%) and 4 (21%), respectively. Quality-of-life measures indicated statistically significant improvements following dynamic smile reanimation (P = .01).Conclusions: Dynamic facial reanimation using free gracilis transfer in children has an acceptable success rate, yields improved commissure excursion, and improves QOL in the pediatric population. It should be considered first-line therapy for children with lack of a meaningful smile secondary to facial paralysis.

OBJECTIVE The anterolateral thigh (ALT) flap has become a frequently used free flap for head and neck reconstruction. Widespread use has been based on literature of ALT flap thickness performed primarily in Asian populations. To our knowledge, to date there has not been a comprehensive analysis of the anthropomorphic parameters of this flap in the Western population, in which it is often much thicker, thereby potentially limiting its utility. METHODS Computed tomographic angiograms of 106 patients were assessed, yielding 196 lower-extremity scans examined for volumetric characteristics and vascular anatomical variations. RESULTS Perforator vessels were located in 88.8% of scans, and most commonly located were a hybrid musculoseptocutaneous vessel (52.3%) followed by septocutaneous (33.9%) and musculocutaneous (13.8%) vessels. The midpoint perforator was located within ±2% of the midpoint of the total thigh length in only 47% of legs. The proximal and distal perforators were located 52.7 and 58.6 mm from the midpoint, respectively. Subcutaneous fat thickness differed significantly by sex, with mean male and female thicknesses of 9.9 mm and 19.9 mm (P < .001), respectively. Thickness increased with increasing body mass index, especially in women. CONCLUSION This study used computed tomographic angiography to characterize the ALT flap vasculature and thickness, providing a degree of predictability to these 2 highly variable flap characteristics.

ObjectiveExamine the effect of both local and systemic dexamethasone administration on facial nerve return of function after complete axotomy and immediate microsurgical repair in a rat model. After nerve injury, an exaggerated neuro‐inflammatory process may hinder regeneration. Therefore, our hypothesis is that glucocorticoid administration will improve nerve recovery.MethodA total of 74 Wistar rats underwent facial nerve axotomy with immediate neurorrhaphy. Blinded and randomized, rats were assigned a postoperative group: control (no therapy), systemic dexamethasone 0.5, 1, 5, or 10 mg/kg for 3 doses, or topical dexamethasone 2 or 4 mg/mL. Standardized facial assessments and nerve conduction studies (NCS) were performed.ResultsAt 8 weeks, rats receiving systemic dexamethasone at 1 and 5 mg/kg attained greater eye blink closure (P =. 014 and P =. 018, respectively) and vibrissae motion (P =. 018 and P =. 023, respectively) compared with controls. Systemic dexamethasone at 0.5 and 10 mg/kg had similar facial motion to controls. Intraoperative topical application of dexamethasone 2 or 4 mg/mL to the neurorrhaphy site was not superior to controls. Gross facial motion assessments were corroborated with vibrissae motion frequency video analysis. NCS’s indicated an increased return of compound muscle action potential amplitude levels to baseline among rats that received systemic dexamethasone 5 mg/kg (P =. 048).ConclusionIn a rat facial nerve axotomy model, postneurorrhaphy systemic dexamethasone therapy improved functional and neurophysiological outcomes at doses of 1 and 5 mg/kg. Locally delivered steroid was not beneficial compared with control groups. Therefore, systemic glucocorticoid administration may provide a substantial recovery benefit after facial nerve injury.

The anterolateral thigh (ALT) flap has great versatility for use in head and neck reconstructive surgery, and is becoming one of the most frequently used free flaps. The ALT flap consists of anterolateral thigh skin and subcutaneous fat with a pedicle that emerges from the descending branch of the lateral circumflex artery, the first major branch of the profunda femoris artery. Two disadvantages are inconsistent perforator vascular anatomy that may lead to difficulties in harvest and variability in flap thickness, which can preclude functionality. Therefore, methods to determine perforator location and course along with flap thickness enhance reconstructive preoperative planning. Our objective was to determine the ease of identifying the vascular anatomy and flap thickness on computed tomography angiograms (CTA) for pre-surgical planning. CTA runoffs of 106 random patients were obtained yielding 196 lower extremity scans. The CTAs were analyzed using a 3D workstation. Measurements were obtained in the axial plane. The lateral circumflex femoral artery (LCFA) was identified and followed to identify the perforators that would potentially supply an ALT free flap. As a perforator with a muscular course is more difficult to dissect, each perforator vessel course was categorized as musculocutaneous, musculoseptocutaneous, or septocutaneous indicating that before reaching cutaneous tissue, the vessel first coursed through the muscle, muscle and septum (intermuscular septum between vastus lateralis and rectus femoris), or septum alone. Flap thickness was measured as the perpendicular distance from the edge of the vastus lateralis to the skin surface. Perforator vessels were identified in 88.8% of scans. 52.3% of perforator vessels were musculoseptocutaneous, 33.9% septocutaneous, and 13.8% musculocutaneous. Mean flap thickness was 9.9mm (SD 5.1mm) in males and 19.9 mm (SD 11.3mm) in females. Perforator vessels and flap thickness was measured in a majority of scans studied (88.8%). CTA can be used for pre-operative planning for ATL flap reconstructions.

Purpose of review Surgical management of facial paralysis continues to undergo evolution. Advances made in management reflect the challenging nature of facial paralysis and the drive to ever improve outcomes. Recent findings Recent advances have been made in neuronal transfers using the masseteric nerve, minimally invasive static procedures, and dynamic transfer of the temporalis tendon. Summary Continued evolution of techniques for the management of facial paralysis is reflected in the current literature. Broader application of neuronal transfers, minimally invasive static procedures, and orthodromic temporalis tendon transfer, among other techniques, indicates a vibrant field of surgeons who pursue ever better results for patients with facial paralysis.