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

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.

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.

Osseointegration implants have revolutionized craniofacial prosthetic reconstruction. Implant placement relies on adequate thickness and quality of bone to permit osseointegration. Positioning the implant is critical in craniofacial reconstruction because surface contours of the prosthesis must be preserved while housing attachment components securely and discretely. Also, the position of the final prosthesis must transition to native tissue smoothly. We report on the use of intraoperative stereotactic image guidance in the placement of implants for orbital, nasal, and auricular prosthetic reconstruction. Clinical data, intraoperative images, and postoperative rehabilitated results are presented to demonstrate the utility of the application of stereotactic image guidance for implant placement. In our experience, stereotactic image guidance facilitates optimal implant site selection if there is abnormal bone quantity or quality.

Management of the brow remains a challenging, important, and gratifying area in the care of facial paralysis patients. Aged facial paralysis patients generally require surgical management of brow ptosis. Young facial paralysis patients occasionally require surgical management of brow ptosis. Indications for surgical management, treatment options, and surgical approach are discussed. Consideration of factors such as age, forehead furrows, skin type, duration of paralysis, and degree of visual impairment are discussed in the context of treatment planning.