Utilization of the depressor anguli oris musculocutaneous flap for lip reconstruction

The authors describe the anatomic aspects and surgical technique of the depressor anguli oris musculocutaneous flap for reconstruction of the upper and lower lips. Twenty patients were submitted to surgical treatment, 19 for carcinoma and for upper lip scar deformity. In all patients the repair was performed with the depressor anguli oris musculocutaneous island flap. At the follow-up, lip function was satisfactory in 19 patients and unsatisfactory in 1 patient. The aesthetic results were considered satisfactory in all patients. The depressor anguli oris musculocutaneous island flap is safe for upper and lower lip reconstruction, with good functional and aesthetic results, and can be added as a new flap for lip reconstruction.     

Total reconstruction of upper lip and columella with bipedicled depressor anguli oris island musculocutaneous flap.

The authors present the case report of a patient exhibiting upper lip deformity and total columella loss with cosmetic and functional impairment as a result of multiple previous facial carcinomata resections. Repair was achieved with bipedicled depressor anguli oris musculocutaneous island flap.     

Vertical suture plication of the orbicularis oris muscle: a simple procedure for the correction of unilateral marginal mandibular nerve paralysis

Injury to the marginal mandibular nerve is present as an adverse outcome in many surgical procedures. The resultant cosmetic deficit, manifesting lower lip asymmetry and imbalance, is readily noticeable especially during opening of the mouth. Multiple techniques to correct this deformity have been described, but most involve obvious scars or major procedures. A simple, one-step outpatient procedure, which can be performed under local anesthesia with a camouflaged scar, is described to correct the lip malposition.     

Evoked electromyography of the eleventh nerve and trapezius muscle

Values and criteria for abnormality of the eleventh nerve evoked electromyography (EEMG) have been determined. The nerve conduction velocity and duration appear to be relatively consistent from subject to subject. Amplitude of response, while varying significantly from subject to subject, remains relatively constant when the right shoulder is compared to the left shoulder and when a retest is performed.     

Evoked electromyography to rocuronium in orbicularis oris and gastrocnemius in facial nerve injury in rabbits

Background

Muscles innervated by the facial nerve show different sensitivities to muscle relaxants than muscles innervated by somatic nerves, especially in the presence of facial nerve injury. We compared the evoked electromyography (EEMG) response of orbicularis oris and gastrocnemius in with and without a non-depolarizing muscle relaxant in a rabbit model of graded facial nerve injury.

Methods

Differences in EEMG response and inhibition by rocuronium were measured in the orbicularis oris and gastrocnemius muscles 7 to 42 d after different levels of facial nerve crush injuries in adult rabbits.

Results

Baseline EEMG of orbicularis oris was significantly smaller than those of the gastrocnemius. Gastrocnemius was more sensitive to rocuronium than the facial muscles (P < 0.05). Baseline EEMG and EEMG amplitude of orbicularis oris in the presence of rocuronium was negatively correlated with the magnitude of facial nerve injury but the sensitivity to rocuronium was not. No significant difference was found in the onset time and the recovery time of rocuronium among gastrocnemius and normal or damaged facial muscles.

Conclusions

Muscles innervated by somatic nerves are more sensitive to rocuronium than those innervated by the facial nerve, but while facial nerve injury reduced EEMG responses, the sensitivity to rocuronium is not altered. Partial neuromuscular blockade may be a suitable technique for conducting anesthesia and surgery safely when EEMG monitoring is needed to preserve and protect the facial nerve. Additional caution should be used if there is a risk of preexisting facial nerve injury.     

Paralysis of the marginal mandibular branch of the facial nerve: treatment options.

Isolated paralysis of the marginal mandibular branch of the facial nerve results in an asymmetrical smile with elevation of the lower lip on the affected side. We discuss the surgical options for its correction and present a series of 26 patients who underwent either botulinum toxin injection, anterior belly of digastric transfer or free extensor digitorum brevis transfer as treatment. Botulinum toxin injection provided satisfactory results although these were temporary. Anterior belly of digastric transfer was the surgical procedure of choice. It yielded superior cosmetic results, less donor-site morbidity and required a shorter operating time. In more complex congenital facial hypoplastic syndromes, or following extensive surgery in the digastric triangle, the anterior belly of the digastric muscle may be absent or damaged. Extensor digitorum brevis transfer is the preferred option in these cases.     

Neuronal loss after transsection of the facial nerve: a morphological and neurophysiological study in monkeys.

Functional recovery after nerve lesions seems to depend on peripheral as well as central factors. To investigate the central neuronal loss after transsection of a pure motor nerve, the middle branch of the facial nerve on one side was transsected and immediately repaired microsurgically by epineural suturing. After a period of 6-15 months, a quantitative neurophysiological recording was made to estimate muscle response. A nerve tracer was injected into the mimic muscles innervated by the nerve to label the surviving motor neurons within the facial nucleus. The opposite side was used as the control in all cases. After the regenerative period, a mean loss of 15% of the total cell number was observed within the facial nucleus compared with the opposite side. The cell loss comprised all types of neurons. This amount of neuronal loss was followed by an even greater loss of muscle response when a quantitative neurophysiological recording was made after nerve regeneration. The results are discussed in relation to loss of nerve elements after nerve lesions and its effect on functional recovery.     

面神经颊支和下颌缘支的解剖学研究及应用

目的 观察面神经颊支与下颌缘支肌外、肌内走行分布情况，为面瘫整复术中受区神经的选择和预防神经支损伤提供依据。方法 在24侧头部标本中，分别观测颊支和下颌缘支的分支数目、吻合情况、走行中的层次、颊支与腮腺导管以及下颌缘支与下颌骨下缘、面血管的关系，结合Sihler’s肌内神经染色，明确其支配肌肉和在肌内的分布规律；并在40例面瘫手术患者受区面神经分支的寻找和选择中进行验证。结果 腮腺导管体表投影较恒定，面神经颊支以2～3支为主，占87．5％，多数分布在导管上方10．7mm和下方9．3mm的范围内，支配中面部表情肌。下颌缘支以1～2支为主，占95．9％，多数分布在下颌骨下缘上方13．4mm和下方4．8mm的范围内，跨面动脉浅面，支配下唇诸肌。结论 面神经颊支与腮腺导管、下颌缘支与面动脉及下颌骨下缘有着紧密的关系。应用改良Sihler法，可以更为清晰的显示人面部表情肌的肌内神经分布情况。     

下颌缘全长截骨治疗单侧下颌骨过度发育

目的：探讨下颌缘全长截骨治疗单侧下颌骨过度发育的疗效。方法：因美容需要进行单侧下颌骨过度发育整形手术患者5例,术前根据头颅X线正侧位片、下颌全景牙片及下颌骨CT三维重建检查对患者的下颌骨形态进行分析,并征求患者需要分别采用不同手术方法：5例全部采用下颌缘全长截骨,3例同时行双侧下颌角区外板截除。结果：所有患者手术顺利,手术时间3h左右,未发生手术并发症,经过6月～2年随防,所有患者面部轮廓改善明显,双侧基本对称,咬合关系正常,疗效明显。结论：下颌缘全长截骨对单侧下颌骨过度发育有很好的疗效。     

环甲肌肌电图对喉上神经阻滞效果的评估作用

目的通过观察喉肌电图中环甲肌肌电募集相对喉上神经阻滞效果评估的准确性,探讨环甲肌肌电图对清醒气管插管评估的准确性。方法困难气道患者14例,麻醉诱导前在舌骨大角平面行喉上神经阻滞,双侧各注入1%利多卡因2ml,口咽部及经环甲膜穿刺气管内1%丁卡因表面麻醉各2ml,后行纤维支气管镜清醒气管插管。喉上神经阻滞效果以临床诊断作判别标准,同时肌电图电极经皮肤检测喉上神经支配的环甲肌肌电募集相。以临床诊断喉上神经阻滞效果佳(阳性)作为评判标准,通过受试者工作特征曲线(ROC曲线)分析环甲肌肌电募集相对喉上神经阻滞效果反应的敏感性和特异性,寻找诊断临界值(cutoff点);采用Spearman检验分析募集相与阻滞效果的相关性。结果环甲肌肌电募集相对喉上神经阻滞效果反应的ROC曲线下面积(AUC)为:0.927(95%CI 0.799~1.000);当肌电募集为减弱++相时,敏感度与特异度之和值最大,其敏感性为75.0%,特异性为91.7%;Spearman相关系数r=0.659(95%CI 0.525~0.779,P=0.002)。结论应用环甲肌肌电募集模式对喉上神经阻滞术效果进行评估有很高的准确性。当环甲肌肌电募集减弱为++相或以下时,相应侧的声门上黏膜感觉消失,神经阻滞效果佳,可作为判别清醒气管插管时机的指标。     

Anatomy of the orbicularis oris muscle in cleft lip

The anatomy of the orbicularis oris muscle was studied using histological sections of 18 operative specimens of unilateral cleft lip (14 incomplete and 4 complete). In incomplete clefts the intrinsic part of the orbicularis, located in the vermilion, is simply interrupted without distortion. The extrinsic part, lying higher in the lip, crosses the cleft but is distorted vertically according to the degree of the nasal deformity. In complete clefts the intrinsic bundle ends in the submucosa of the vermilion as in incomplete clefts. The extrinsic bundle is deviated towards the ala nasi on the lateral side. On the medial side, the fibres are rarer and more horizontal. Conclusions are drawn regarding reorientation of the muscle fibres during cheiloplasty.     

Depressor labii inferioris resection: an effective treatment for marginal mandibular nerve paralysis.

In patients who show their lower teeth during smiling and facial animation, paralysis of the marginal mandibular nerve (MMN) causes a noticeable asymmetry of the lower lip due to the absence of depressor function. This paper presents a balancing technique for this lower lip asymmetry that involves resection of the depressor labii inferioris (DLI) on the nonparalysed side. The anatomy of the muscle, the operative technique, and the effectiveness of the procedure are outlined. A retrospective chart review was performed for 42 adult patients who were treated for MMN palsy with a DLI resection. Seven cases had only the MMN involved, and 35 cases had unilateral facial nerve paralysis. Thirty-six of these patients were available for a follow-up telephone survey. Of the 42 primary DLI resections performed, 36 cases had successful outcomes. Of the six patients who failed to achieve the expected results, five patients had repeat DLI resection and three of these achieved the desired result; the other two patients required a third resection. One patient continued to have DLI action with smiling and subsequently had a Botox injection into the DLI with good results. Of the 36 survey respondents, 21 patients felt their lower lip was asymmetrical at rest prior to DLI resection and 18 of these patients were improved by the procedure (P = 0.0001). Twenty-nine of the 36 patients reported that their lower lip was more symmetrical when they smiled following the DLI resection (P < 0.0001). The bilateral lack of movement in the lower lip when expressing emotions, such as anger and sorrow, was not as important to the patient as the lack of symmetry when expressing these emotions. Patients' speech either improved or showed no change, the amount patients bit their lower lip significantly improved (P = 007) whereas oral continence showed no significant changes (P = 0.147) following the DLI resection. DLI resection is a simple and effective procedure for the treatment of MMN palsy. The results are permanent and predictable. Lower lip symmetry is produced both at rest and with facial animation, without causing a functional deficit. The expected results of surgery can be trialed by local anaesthetic or botulinum toxin to block the activity of the DLI.     

Preserving the marginal mandibular branch of the facial nerve during submandibular region surgery: a cadaveric safety study

Background

The marginal mandibular branch of the facial nerve is vulnerable to iatrogenic injuries during surgeries involving the submandibular region. This leads to significant post-operative morbidity. Studies assessing accurate anatomical landmarks of the marginal mandibular branch are sparse in South Asian countries. Present study was conducted to assess the relationship between the marginal mandibular branch and the inferior border of the body of mandible.

Methods

Twenty-two preserved cadavers of Sri Lankan nationality were selected. Cadavers were positioned dorsal decubitus with necks in extension. The maximum perpendicular distance between the inferior/caudal most ramus of the marginal mandibular branch and the inferior border of the body of the mandible was recorded on both hemi faces.

Results

Recorded maximum distance was 17.65 mm on left side and 10.80 mm on right side. Mean maximum distance, was 7.12?±?2.97 mm. There was no statistically significant difference in the maximum deviation on left (7.84?±?3.41 mm) and right sides (6.44?±?2.37 mm).

Conclusion

Course of the marginal mandibular nerve is complex. If the distance of the incision in the posterior submandibular approach is less than 2 cm from the inferior border of the mandible, there is a high probability of damaging the inferior ramus of the marginal mandibular branch of the facial nerve.