Plastic and Reconstructive Surgery Board Review Pearls of Wisdom 3th

CHAPTER 44 oe-to-Hand rans er
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A patient has an index nger amputation at the middle o the proximal phalanx. Is she a good candidate or
a second toe-to-index nger trans er?
No. At this level the reconstructed nger will be noticeably shorter than the rest o the intact ngers. In hands
with single nger loss the best reconstructive outcome is obtained when the amputation level is rom the middle o
the middle phalanx to the base o the distal phalanx.

When using the second toe to reconstruct a distal nger, how is unnecessary bulkiness o the reconstructed
digit avoided?
Care ul skeletonization o the vessels prevents bulky so t-tissue marring the aesthetic result and precludes unsightly
skin gra ting. Removal o the thick plantar subcutaneous at at the M P joint level will not only improve the
appearance, but will also allow greater range o motion or the trans erred digit.

What is a “cobra de ormity” and how can it be avoided?
T is term is used to describe an objectionable bulbous so t-tissue junction between a trans erred toe and the
amputation stump because it resembles the head and are o a threatened cobra. It can be avoided by creating our
equal triangular aps through a cruciate incision at the amputation stump tip, undermining them so that they can
reely move over the underlying skeleton o the stump and trans erred toe, and by care ully interdigitating them
with the aps o the trans erred toe.

What are indications or toe-to-hand trans er in a mutilated hand?
o improve or provide pulp-to-pulp, chuck, lateral pinch and hook grip and there ore overall hand unction.

What is a metacarpal hand?
A hand that is unable to achieve any type o pinch or grip (no prehensile capacity) owing to amputation o all
ngers. T e thumb may or may not be preserved.

How should a metacarpal hand be reconstructed?
T e variety and complexity o the metacarpal hand injuries demand care ul planning to ensure proper use o
limited donor tissues and to correctly address the most important de ciencies. Classi cation o the metacarpal
hand helps determine the most appropriate reconstructive method, which may include two second toe trans ers,
combined second and third toe trans er, and great toe trans er.

What should one do i positioning o the toe trans ers is ound to be erroneous immediately ollowing
metacarpal hand reconstruction with poor prehensile positioning?
Prehensile positioning should be set as accurately as possible or any toe trans er, whether multiple (as in
metacarpal hand reconstruction) or singleton (as in thumb reconstruction). However, slight adjustments are o ten
required during the early stages o rehabilitation to per ect positioning. I rigid xation is used, this may not be
possible without an additional general anesthetic. Instead, i parallel intraosseous wiring is used or bony xation
at the osteotomy site, slight rotational and angular adjustments are easible at the bedside within at least the rst
2 weeks postoperatively without jeopardizing toe vascularity. T is can be urther optimized a ter 2 weeks by serial
splinting.

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Classi y the metacarpal hand.
ype I: thumb preserved, all ngers amputated below the middle o the proximal phalanx. T e level o nger
amputation may be used to urther subdivide patients into subtypes A, B, or C.
ype I metacarpal hand
Subtype
Level of Finger Am putation

Recom m endations
I A
Proximal to middle of proximal phalanx

Two second toes or combined second/third
I B

Through MCP joint (intact proximal
articular surface)
Combined second/third as composite joint
transfer
I C

Proximal to MCP

Combined second/third
ype II: metacarpal hands have all ngers amputated proximal to the middle o the proximal phalanx plus
a thumb amputation. Subtypes A, B, C, and D depend on the level o thumb amputation and status o two
important structures: the thenar muscles and carpometacarpal (CMC) joint. Reconstruction o the ngers may be
carried out concurrently or separately rom the thumb reconstruction depending on the subtype.
ype II metacarpal hand
Subtype Level of Thum b Am putation Recom m endations
II A

Distal to metacarpal neck

Great toe transfer
II B

Proximal to metacarpal neck,
adequate thenar function
Preliminary procedure to lengthen thumb followed by great
toe transfer or second toe transfer
Concurrent transfer of combined second/third toe or two
second toes
II C

Inadequate thenar function

Two-stage reconstruction
Opponensplasty
II D

CMC joint damage

Thumb reconstructed as an immobile post

What is the vascular supply or a combined second and third toe trans er?
T e FDMA and/or a plantar digital metatarsal artery provide the vascular pedicle. T ere is no di erence in early
outcome between using one versus two arterial pedicles.

What are the advantages o providing a hand with two adjacent digits?
T is construct allows use ul tripod (chuck) pinch, enhances lateral stability, provides a stronger hook grip, and
allows a wider span or grasping larger objects.

Is a combined second/third toe transplant appropriate to reconstruct the ngers or a type I A metacarpal
hand with a preserved web space? Why or why not?
No, two second toes should be used when the amputation is distal to the web space to avoid a long palm–short
nger appearance.

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How many veins are required to drain the trans erred toe(s) adequately?
Even though all single- and double-toe trans ers can be adequately drained by a single venous anastomosis, it
is sa e practice to harvest at least two good-sized dorsal veins at the oot (pre erably draining separately). T e
pre erred venous anastomosis should be allowed to drain the toe rst; i inadequate (which is unusual) then the
second vein can still be used to augment drainage.

List the late donor-site complications speci c to combined second/third toe trans er.
Pain with ambulation and scissor de ormity (migration o the ourth toe toward the great toe).

What range o motion can be obtained using a vascularized joint or nger arthroplasty?
Generally less than 40 degrees, o ten due to signi cant extensor lag o the trans erred toe joint. I the extensor lag
is improved, however, average range o motion can be increased to approximately 54 degrees.

How can the extensor lag o vascularized joint trans er or proximal interphalangeal joint reconstruction be
minimized?
wo arrangements o the toe central slip have recently been described: type I is an attenuated central slip and
type II is a distinct central slip. For a type I toe with suf cient recipient lateral bands, a centralization procedure
is recommended and this should be repaired to the donor extensor tendon. I the lateral bands are insuf cient,
a modi ed Stack procedure is recommended (this involves passing one distally based slip o exor digitorum
super cialis through to the dorsal side via a drilled tunnel in the base o the toe middle phalanx, and repair
to the recipient extensor tendon). In type II toe joints, a tight repair o the corresponding extensor tendons is
recommended.

What are the indications or vascularized joint trans er?
A pain ul joint with posttraumatic arthritis, instability and/or de ormity. Patients must be highly motivated,
young, and have unctioning exor/extensor tendons.

What advantages do vascularized joints have over other arthroplasty methods?
Vascularized joint trans ers utilize autologous tissue; growth potential in children; allow reconstruction o
compound de ects involving joint, bone, skin, and tendon in a single procedure.

Describe a motor rehabilitation program or a neo-thumb reconstructed by toe trans er.
Rehabilitation begins on the rst postoperative day (Protective Stage) with planning and psychological support
to the patient. By day 4, the vascularity o the transplanted toe can withstand gentle passive joint movements
o 15 degrees (Early Mobilization Stage). T is is gradually increased until ull range o motion is achieved at the
joint immediately distal to the osteotomy; the wrist should be kept in neutral. Near- ull range o motion can be
achieved between weeks 3 and 4 at joints proximal to the osteotomy. Active mobilization exercises commence
a ter week 4 (Active Mobilization Stage), with blocking exion/extension once tendons have healed. By week 7,
rehabilitation can start to be tailored toward the precise requirements o the patient’s dexterous needs to improve
strength and joint motion (Activities o Daily Living Stage). From week 8, the nal stage o rehabilitation
commences (Prevocational raining), which is aimed at improving coordination and maximizing power according
to vocational needs.

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Can toe transplantation be use ul in a patient with hand amputation at wrist level?
Yes. T e concept o toe trans er to the wrist or prehension has existed or nearly a century. Oehlecker, inspired
by Nicoladoni’s work, success ully per ormed a distal orearm stump plasty using a pedicled great toe trans er in
1919. Nowadays, selected, highly motivated patients requiring key-grip to assist the other hand who do not want
hand transplantation, and have not achieved satis actory bene t rom a prosthetic alternative, may be candidates
or three-jointed second toe with great toe pulp ap transplantation to the antebrachial stump. O ten termed the
Vilkki procedure a ter the surgeon who described it, this involves osteoplastic moulding o the distal radius stump,
osteosynthesis o the second toe metatarsal to the radius, insetting o the adjoined sensate great toe pulp ap to the
distal radius stump, care ul prehensile alignment o toe with pulp ap, and microvascular anastomoses.

How should one instruct the patient to take care o the donor oot ollowing toe harvest?
T e patient should only start taking steps on the hind oot rom 2 weeks postoperatively; trans er o weight to the
anterior oot is orbidden. T e patient should then slowly begin to shi t a little weight to the lateral and then the anterior
oot as the next 2 weeks progress. Only once the oot has completed wound healing, a ter about 4 weeks, should the
patient progress toward a more normal gait. It is critical that wound breakdown is avoided at the oot, as in ection and
subsequent dehiscence o the wound may ensue. Normal ootwear can be used a ter approximately 6 weeks.
REFERENCES
Bannister LH. Integumental system: skin and breasts. In: Williams PL, ed. Gray’s Anatomy. 38th ed. oronto, Ontario, Canada:
Churchill Livingstone; 1999:375–424.
Berry MM, Standring SM, Bannister LH. Nervous system. In: Williams PL, ed. Gray’s Anatomy. 38th ed. oronto, Ontario, Canada:
Churchill Livingstone; 1999: 901–1398.
Buncke HJ Jr, Buncke CM, Schulz WP. Immediate Nicoladoni procedure in the Rhesus monkey, or hallux to-hand transplantation,
utilising microminiature vascular anastomoses. Br J Plast Surg. 1966;19:332–337.
Cheng MH, Wei FC, Santamaria E, Cheng SL, Lin CH, Chen SH. Single versus double arterial anastomoses in combined second- and
third-toe transplantation. Plast Reconstr Surg. 1998;108:2408–2412.
Chung KC, Wei FC. An outcome study o thumb reconstruction using microvascular toe trans er. J Hand Surg. 2000;25:651–658.
Dongyue Y, Yudong G. T umb reconstruction utilizing second toe transplantation by microvascular anastomosis: report o 78 cases.
Chin Med J Engl. 1979;92:295–309.
Eaton CJ, Lister GD. oe trans er or congenital hand de ects. Microsurgery. 1991;12:186–195.
Foucher G, Binhammer P. Free vascularized toe trans er. In: Foucher G, ed. Reconstructive Surgery in Hand Mutilation. London, UK:
Mosby; 1997:57–66.
Frykman GK, O’Brien BM, Morrison WA, MacLeod AM. Functional evaluation o the hand and oot a ter one-stage toe-to-hand
trans er. J Hand Surg. 1986;11:9–17.
Gilbert A. Congenital absence o the thumb and digits. J Hand Surg Br. 1989;14:6–17.
Gilbert A. oe trans ers or congenital hand de ects. J Hand Surg Am. 1982;7:118–124.
Gilbert A. Vascular anatomy o the rst web space o the oot. In: Landi A, ed. Reconstruction of the T umb. London, UK: Chapman
and Hall; 1989:199–204.
Gordon L. oe-to-thumb transplantation. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery. 4th ed.
Philadelphia, PA: Churchill Livingstone; 1999:1299–1326.
Ju JH, Hou RX. One-stage cosmetic nger reconstruction using a second toe island ap containing terminal branches o the toe artery.
Orthop raumatol Surg Res. 2015;101(3):345–351.
Kato H, Ogino , Minami A, Usai M. Restoration o sensibility in ngers repaired with ree sensory aps rom the toe. J Hand Surg
Am. 1989;14:49–54.
Kleinman WB, Strickland JW. T umb reconstruction. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery.
4th ed. Philadelphia, PA: Churchill Livingstone; 1999: 2068–2170.
Lam WL, Waughlock N, Hsu CC, Lin Y , Wei FC. Improving the extensor lag and range o motion ollowing ree vascularized joint
trans er to the proximal interphalangeal joint: Part 2—A clinical series. Plast Reconstr Surg. 2013;132:271e–280e.
Leung PC. Sensory recovery in transplanted toes. Microsurgery. 1989;10:242–244.

CHAPTER 44 oe-to-Hand rans er
427
Leung PC. T umb reconstruction using the second toe. In: Landi A, ed. Reconstruction of the T umb. London, UK: Chapman and Hall;
1989: 205–212.
Leung PC, Wong WL. T e vessels o the rst metatarsal web space. An operative and radiographic study. J Bone Joint Surg Am.
1983;65:235–239.
Lin CH, Lo S, Lin CH, Lin Y . Opponensplasty provides predictable opposable tripod pinch in toe trans er or proximal thumb ray
de ect reconstruction. Plast Reconstr Surg. 2012;130:810e–818e.
Lin Y , Su S , Lo S, Hu CH, Lin CH, Wei FC. Risk actors or reexploration in toe-to-hand trans er: a multivariate analysis o 363
cases. Plast Reconstr Surg. 2015;135:501–506.
Lipton HA, May JW, Simon SR. Preoperative and postoperative gait analyses o patients undergoing great toe-to-thumb trans er. J Hand
Surg. 1987;12:66–69.
Lister GD, Kalisman M, sai M. Reconstruction o the hand with ree microneurovascular toe-to-hand trans er: experience with 54
toe trans ers. Plast Reconstr Surg. 1983;71:372–386.
Ma HS, el-Gammal , Wei FC. Current concepts o toe-to-hand trans er: surgery and rehabilitation. J Hand T er. 1996;9:41–46.
Mathes SJ. Great toe (hallux) ap. In: Mathes SJ, Nahai F, eds. Reconstructive Surgery: Principles, Anatomy, and echnique. New York,
NY: Churchill Livingstone; 1997:891–925.
May JW. Microvascular great toe to hand trans er or reconstruction o the amputated thumb. In: McCarthy JG, May JW, Littler JW,
eds. Plastic Surgery. Philadelphia, PA: WB Saunders; 1990:5183–5185.
May JW Jr, Chait LA, Cohen BE, O’Brien BM. Free neurovascular ap rom the rst web o the oot in hand reconstruction. J Hand
Surg Am. 1977;2:387–393.
Morrison WA. T e great toe wrap-around ap. In: Sera n D, ed. Atlas of Microsurgical Composite issue ransplantation. Philadelphia,
PA: WB Saunders; 1996:131–135.
Nicoladoni C. Daumenplastik und organischer Ersatz des Fingerspitze (Anticheiroplastik und Daktyloplastik). Archiv für klinische
Chirurgie. 1900; 61:606–628. [T is article has been reprinted in translated orm as ollows: “T e classic—plastic surgery o the
thumb and organic substitution o the ngertip (anticheiroplastic surgery and nger plastic surgery)”. By Carl Nicoladoni, 1900
( ranslated in English by Arthur Lietze). Clin Orthop Relat Res. 1985;195:3–6.]
O’Brien B, Brennen MD, MacLeod AM. Microvascular ree toe trans er. Clin Plast Surg. 1978;5:223–237.
Salmins S. In: Williams PL, ed. Gray’s Anatomy. 38th ed. oronto, Ontario, Canada: Churchill Livingstone; 1999:375–424.
an JS, u YK. Comparative study o outcomes between pollicization and microsurgical second toe-metatarsal bone trans er or
congenital radial de ciency with hypoplastic thumb. J Reconstr Microsurg. 2013;29:587–592.
sai M, Wang WZ. Vascularized joint trans ers. Hand Clin. 1992;8:525–536.
Vilkki SK, Kotkansalo . Present technique and long-term results o toe-to-antebrachial stump transplantation. J Plast Reconstr Aesth
Surg. 2007;60:835–848.
Wallace CG, Wei FC. Further aesthetic re nement or great toe trans ers. J Plast Reconstr Aesthet Surg. 2010;63:e109–110.
Wei FC. issue preservation in hand injury: the rst step to toe-to-hand transplantation. Plast Reconstr Surg. 1998;102:2497–2501.
Wei FC, Chen HC, Chuang CC, Chen SH. Microsurgical thumb reconstruction with toe trans er: selection o various techniques. Plast
Reconstr Surg. 1994;93:345–357; discussion 352–357.
Wei FC, Chen HC, Chuang CC, Noordho MS. Reconstruction o the thumb with a trimmed-toe trans er. Plast Reconstr Surg.
1988;82:506–513.
Wei FC, Colony LH. Microsurgical reconstruction i opposable digits in mutilating hand injuries. Clin Plast Surg. 1989;16:491–504.
Wei FC, Colony LH, Chen HC, Chuang CC, Noordho MS. Combined second and third toe trans er. Plast Reconstr Surg. 1989;
86:651–661.
Wei FC, El-Gammal A. oe-to-hand trans er. Clin Plast Surg. 1996;23:103–116.
Wei FC, El-Gammal A, Lin CH, Chung CC, Chen HC, Chen SH. Metacarpal hand: classi cation and guidelines or microsurgical
reconstruction with toe trans ers. Plast Reconstr Surg. 1997;99:122–128.
Wei FC, Ma HS. Delayed sensory reeducation a ter toe-to-hand trans er. Microsurgery. 1995;16:583–585.
Wei FC, Santamaria E. oe-to- nger reconstruction. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand Surgery.
4th ed. Philadelphia, PA: Churchill Livingstone; 1999:1327–1353.
Wei FC, Silverman R , Hsu WM. Retrograde dissection o the vascular pedicle in toe harvest. Plast Reconstr Surg. 1995;96:1211–1214.
Wei FC, Yim KK. Pulp plasty a ter toe-to-hand transplantation. Plast Reconstr Surg. 1995;96:661–666.
Woo SH, Kim JS, Seul JH. Immediate toe-to-hand trans er in acute hand injuries: overall results, compared with results or elective
cases. Plast Reconstr Surg. 2004;113:882–892.
Yim KK, Wei FC. Secondary procedures to improve unction a ter toe-to-hand trans ers. Br J Plast Surg. 1995;48:487–491.
Yim KK, Wei FC, Lin CH. A comparison between primary and secondary toe-to-hand transplantation. Plast Reconstr Surg. 2004;114:
107–112.

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429
Pieter G.L. Koolen, MD,
John B. Hijjawi, MD, FACS, and
Samuel J. Lin, MD, MBA, FACS
ANATOMY OF PERIPHERAL NERVES

What are the basic elements o the peripheral nerves?
Internal epineurium
External epineurium
Perineurium
Endoneurium

What are the unctions o the internal and external epineurium?
T e external epineurium surrounds the entire nerve and the internal epineurium surrounds groups o ascicles.

Which layer is an extension o the blood–brain barrier?
T e perineurium. T is layer has closely packed cells and surrounds individual ascicle that unctions to block the
spread o in ection and to maintain a positive intra ascicular pressure.

T e layer that surrounds individual axons is termed?
T e endoneurium.

What is a ascicular plexus?
A region o interconnections between ascicles.

Name three blood supply sources or peripheral nerves.
1. Arteriae nervosum (vaso nervosus) (epineurium)
2. Extrinsic blood vessels (perineurium)
3. Capillary plexus (endoneurium)
Nerve Injury/Repair
CHAPTER 45

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Plastic & Reconstructive Surgery Board Review

How is the nerve potential propagated down the nerve?
Depolarizing current achieving the threshold membrane potential leads to activation o voltage-gated sodium channels.

What is a node o Ranvier?
A gap that represents a space between adjacent Schwann cells along the length o the axon.

What is saltatory conduction?
Propagation o the action potential via depolarization at the nodes o Ranvier (myelinated bers 3–150 m/s).

What is Wallerian degeneration?
A process by which axoplasm and myelin are degraded and removed by phagocytosis.

What are the key eatures o Wallerian degeneration?
1. Granular disintegration o axoplasmic microtubules and neuro laments.
2. Disappearance o myelin sheath and axons distal to a nerve lesion.
3. Loss o neural conductance within 48 to 96 hours.
4. Axonotmesis (Sunderland second degree).

A ter laceration or injury to the nerve, Wallerian degeneration occurs in which segment?
Distal segment.

What are the bands o Büngner?
Collapsed columns o Schwann cells in the distal segment o a complete nerve injury.

What is neurotrophism?
T e ability o appropriate distal receptors to enhance the maturation o nerve bers, which includes the
production o a gradient o di usible substances that direct axonal growth during regeneration.
NERVE REPAIR CLASSIFICATION AND ASSESSMENT

How are nerve injuries classi ed (Sunderland based)?
First-degree or Neuropraxia
Segm ental
Demyelination
Second-degree or axonotmesis

Axonal injury
Third-degree combined with f brosis o the endoneurium Wallerian degeneration
Fourth-degree

Complete scar block
Fi th-degree or neurotmesis

Transection
Sixth-degree

Combination o IV injuries

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How is brosis resulting rom nerve injuries classi ed (Millesi)?
ype I: brosis o the epineurium
ype II: inter ascicular brosis
ype III: intra ascicular brosis

Which types o injuries can be expected to have complete recovery?
Neuropraxia and axonotmesis.

Nerve ber regeneration occurs at what rate?
1 mm/day or 1 in/month.

What are clinical measurements o motor nerve injury?
Weakness, loss o unction, and atrophy.

What are clinical measurements o sensory nerve injury?
Moving and static two-point discrimination or innervation density and number o bers.
Semmes–Weinstein mono laments and vibration instruments as threshold tests or per ormance levels.

Describe and classi y the six levels o motor recovery ollowing motor nerve injury.
M0: no contraction
M1: contraction in proximal muscles
M2: contraction in distal muscles
M3: contraction su cient to resist gravity
M4: contraction against strong resistance
M5: return to ull muscle strength

Describe and classi y the six levels o sensory recovery ollowing sensory nerve injury.
S0: absence o sensibility
S1: deep-pain sensibility
S2: super cial sensibility
S3: ull recovery o pain and touch (moving 2PD > 15 mm)
S3+ : localization o stimulus (moving and static 2PD 7–15 mm)
S4: complete recovery (2PD 3–6 mm)

What does an “advancing inel sign” a ter nerve injury signi y?
E ect o triggered electric-current–like pain represents outgrowing axon sprout ends.

What is the most sensitive test or eliciting nerve compression syndromes with demyelination?
Nerve conduction velocity (NCV) tests.

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Plastic & Reconstructive Surgery Board Review

What is the most help ul test or eliciting a denervation with axonal loss?
Electromyography (EMG)

What is the earliest that EM studies will be help ul to evaluate a patient or a suspected peripheral nerve
injury?
3 weeks.

Which imaging study is help ul in diagnosing injuries to peripheral nerves?
Magnetic resonance imaging (MRI) neurograms.

Which test is use ul in helping to distinguish proximal and distal injuries?
Somatosensory evoked potentials (SSEP).

What are the normal values or static and moving two-point discrimination?
1. Static 2PD: up to 6 mm
2. Moving 2PD: 2 to 3 mm

Clinical tests or nerve unction
Function

Radial Nerve

Median Nerve

Ulnar Nerve
Extrinsic motor Wrist extension

Pro undus index f nger

Pro undus small f nger
Intrinsic motor None

Abductor pollicis brevis
First dorsal interosseous
Sensory

Dorsal f rst web space Pulp o index f nger

Pulp o small f nger
TREATMENT OF NERVE INJURIES

What repair method is used when a nerve is partially transected and landmarks are preserved?
Epineural repair.

What repair method is generally used when a nerve injury includes a crushing component?
Group ascicular repair.

What repair method is generally used when there is a delayed repair requiring trimming o the nerve ends?
Group ascicular repair.

In an acute crush injury setting with evidence o transection and contusion o a peripheral nerve, what is the
recommended treatment?
agging the proximal and distal nerve endings ollowed by delayed repair a ter 3 weeks or until the wound
permits.

CHAPTER 45 Nerve Injury/Repair
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What is the advantage o early secondary nerve repair?
Allows or terminated scar reaction along the nerve which the surgeon can estimate and gra t.

Have clinical studies demonstrated that ascicular repair is superior to epineural repair?
No.

Nerve elongation in secondary nerve repairs can provide how much additional length?
Approximately 10%.

How ast do nerves regenerate?
Nerve advance in general at a rate o 1 mm/day or 1 in/month. Many clinical studies have reported nerve repair
rates o 2 mm/day.

Name six di erent types o nerve gra ts.
1. runk gra t
2. Cable gra t
3. Pedicle nerve gra t
4. Inter ascicular nerve gra t
5. Fascicular nerve gra t
6. Free vascularized nerve gra t

What is the best way to treat segmental peripheral nerve injuries?
Autogenous nerve gra ts.

Sural nerve gra ts can be harvested up to how many centimeters?
35 to 40 cm.

Harvest o the sural nerve results in a sensory de cit in which region?
Lateral aspect o dorsum o oot.

Reverse vein autogra t conduits can be used or de ects less than how many centimeters in the orearm?
Up to 3 cm.

Name our commonly harvested donor nerves or nerve gra ting.
1. Sural nerve
2. Lateral antebrachial cutaneous nerve
3. Medial antebrachial cutaneous nerve
4. Posterior interosseous nerve

What is a nonsuture method used in nerve coaptation?
Fibrin glue.

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Plastic & Reconstructive Surgery Board Review

Collagen conduits can be used or de ects less than how many centimeters in the orearm?
2 cm.

Synthetic gra ts that incorporate combinations o synthetic hydrogels, biologic materials, extracellular
matrix components, and neurotrophic actors are also termed?
Axonal guidance channels.

Failure o the nerve growth cone to reach its peripheral targets causes which conditions?
erminal neuroma or neuroma in situ.

T e major treatment methods or treating neuromas include?
• Excision and repair
• Embedding in muscle
• Proximal ligation

T e overall success rate or burying neuromas is?
Approximately 75%.

What is a nerve trans er?
rans er o the proximal portion o an intact donor nerve to reinnervate the distal portion o a more important
injured nerve.
PERIPHERAL NERVE ENTRAPMENT SYNDROMES

What does the surgical treatment o entrapment syndromes consist o ?
Decompression and/or neurolysis.

What is the term given to compression o structure at the thoracic outlet?
T oracic outlet syndrome.

T e interscalene triangle borders consist o which structures?
• Anterior scalene muscle anteriorly
• Middle scalene muscle posteriorly
• Medial sur ace o the rst rib in eriorly

T e most common brachial plexus trunks involved in thoracic outlet syndrome?
C8 and 1.

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435

Clinical maneuvers to diagnose thoracic outlet syndrome include?
• Adson or Scalene test
• Costoclavicular or Military test
• Hyperabduction test
• Roos test

T e supraclavicular approach or surgical treatment o thoracic outlet syndrome endangers which nerve?
T e phrenic nerve.

T e transaxillary approach or surgical treatment o thoracic outlet syndrome endangers which nerve?
T e C8 or 1 nerve root.

Suprascapular nerve entrapment may cause pain, weakness, and even atrophy o which muscles?
Supraspinatus and in raspinatus.

What is the most common anatomic site or suprascapular nerve entrapment?
Suprascapular notch.

T e surgical treatment o suprascapular nerve entrapment consists o the release o which structure?
ransverse scapular ligament.

T e two most common sites o ulnar nerve entrapment are located where?
1. Cubital tunnel proximal to the elbow
2. Guyon canal in the wrist

Inability to adduct the thumb without exing the tip o the thumb is termed?
Froment sign.

Inability to adduct the little nger secondary to hypothenar and interossei atrophy is termed?
Wartenberg sign.

Hypothenar atrophy is secondary to compression or palsy o which nerve?
Ulnar nerve.

Surgical options or release o ulnar nerve compression at the elbow include?
• Simple decompression
• Medial epicondylectomy
• Anterior transposition (subcutaneous vs. intramuscular vs. submuscular)
• Endoscopic decompression
• Combinations o the above

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As the ulnar nerve travels down the orearm, where is it positioned?
Between the FDS and the FDP muscle bellies.

T e motor ascicular group o the ulnar nerve at the wrist is located in which position?
Ulnar and dorsal.
Just remember that the motor branch o the ulnar nerve is the deep branch; so deep = more dorsal.

Fractures rom which bone can impinge on the ulnar nerve at Guyon canal?
Hamate via racture o the hook segment (hamulus).

Laceration o the ulnar nerve in the distal orearm will result in the loss o which muscle groups?
• Interossei
• Ulnar two lumbricals
• Hypothenar muscles
• T umb adductor
• Hal o the thumb f exor brevis

Clawing o the hand is ound with which types o ulnar nerve injuries?
Low (distal) ulnar nerve injuries.

Why does the hand claw with low ulnar nerve injuries?
Unopposed FDP f exion o the IP joints and unopposed extension o the MP joints.

What nding distinguishes a neuropathy o the ulnar nerve at the elbow rom that at the wrist?
Decreased sensation in the dorso-ulnar hand.

What is the anatomic basis or the decreased sensation on the dorso-ulnar hand?
T e dorsal sensory branch o the ulnar nerve branches at approximately 8 cm proximal to the pisi orm. T us, it is
una ected by compression at the wrist but its ascicles are still with the main ulnar nerve at the elbow.

What are sites o compression o the median nerve that cause pronator syndrome?
• Ligament o Struthers
• Lacertus brosus (bicipital aponeurosis)
• Pronator teres (musculo ascial band or compression between two muscular heads)
• FDS proximal arch

What are the anatomic borders o the carpal tunnel?
• Carpal bones (f oor)
• ransverse carpal ligament (roo )
• Scaphoid and trapezium radially
• Pisi orm and hook o the hamate ulnarly

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T e motor ascicular group o the median nerve at the wrist is located in which position?
Radial and volar. Just remember that the recurrent motor (muscular) branch branches o radially toward the
thenar muscle group.

T enar atrophy is secondary to compression or palsy o which nerve?
Median nerve.

What is an important symptom to help distinguish the pronator syndrome rom the carpal tunnel
syndrome?
Pain in the proximal palm. Patients will have abnormal sensibility over the thenar eminence in pronator syndrome.

What is the anatomic basis or the above di erence?
T e palmar cutaneous branch o the median nerve branches proximal to the wrist and is thus spared compression
by the transverse carpal ligament.

A splint to minimize pressure within the carpal canal would be designed with how much wrist and nger
extension/ exion?
Wrist neutral and ngers in extension.

A characteristic symptom o anterior interosseous syndrome is?
Inability to orm a circle by pinching the thumb and index nger (O sign).

What is the anatomic basis or the above nding?
T e AIN provides motor innervation to the FPL (thumb IP f exion) and the index and ling FDP (index DIP
f exion). You cannot make an “O” without thumb IP and index DIP f exion. Incidentally, AIN also innervates the
PQ.

Does the anterior interosseous syndrome have any sensory component?
No, motor only.

What is Gantzer muscle?
Accessory head o the FPL.

What is innervation through a Martin-Gruber anastomosis?
Median to ulnar nerve in the orearm. Remember FMG or Foreign Medical Graduate (Forearm-Martin-Gruber).

What is innervation through a Riche–Cannieu anastomosis?
Median to ulnar nerve in the hand.

T e radial nerve is derived rom which cord o the brachial plexus?
Posterior cord.

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T e most common site o compression o the radial nerve occurs at?
T e arcade o Frohse, proximal brous edge o the supinator muscle. Remember the RAF o Royal Air Force
(Radial Nerve-Arcade o Frohse).

Other sites o compression o the radial nerve include?
• Fibrous ascia over the radiocapitellar joint.
• Vascular leash o Henry (radial recurrent artery). Remember RVH or Right Ventricular Hypertrophy
(Radial Nerve-Vascular leash o Henry).
• Medial border o ECRB.
• Distal border o the supinator.

Pain and tenderness in the dorsal lateral orearm is most consistently associated with which compression
syndrome?
Radial tunnel syndrome.

What are symptoms commonly associated with posterior interosseous nerve syndrome?
• Pain in the upper extensor orearm
• Dysesthesias in a super cial radial nerve distribution
• Weakening o the extension o the ngers, thumb, or wrist

Compression o the super cial radial nerve as it emerges rom under the brachioradialis is termed?
Wartenberg’s syndrome.

What structures pass through the tarsal tunnel?
• endons o the f exor hallucis longus muscle
• Flexor digitorum longus muscle
• ibialis posterior muscle
• Posterior tibial nerve
• Posterior tibial artery

Release o which structure is per ormed to decompress the tarsal tunnel?
Flexor retinaculum (which is the roo o the tunnel).

Erectile dys unction ollowing radical prostatectomy is considered to be largely neurogenic in origin; what is
the origin o the bers o the cavernous nerves?
Parasympathetic bers rom S2 to S4.

What is the location o the cavernous nerves in relation to the prostate?
Within the cavernous nerve bundles along the posterolateral sur ace o the prostate, which corresponds
anatomically to the peripheral zone, the most common site o prostate carcinogenesis.

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What are common strategies to preserve erectile unction a ter radical prostatectomy?
1. Nerve-sparing radical prostatectomy
2. Cavernous nerve interposition gra ting
3. Neurotrophic treatment

What is the most common nerve gra t used in cavernous nerve interposition gra ting?
Sural nerve.

What is the reported ef cacy, or return o erectile unction, or unilateral cavernous interposition nerve
gra ting? For bilateral cavernous interposition nerve gra ting?
Unilateral: approximately 50%
Bilateral: approximately 25%

Spontaneous erectile activity ollowing cavernous nerve regeneration has been observed how many months
ollowing surgery?
• 5 to 8 months or mild tumescence.
• 14 to 18 months or erectile activity.

What is the estimated probability o being able to have intercourse at 16 months?
25%.

What is the most requent and avoidable complication a ter peripheral nerve decompression?
Carpal tunnel: neuroma o the palmar cutaneous branch
Cubital tunnel: neuroma o the medial antebrachial cutaneous nerve
arsal tunnel: neuroma o posterior branch o saphenous nerve
REFERENCES
Chang DW, Wood CG, Kroll SS, et al. Cavernous nerve reconstruction to preserve erectile unction ollowing nonnerve-sparing radical
retropubic prostatectomy: a prospective study. Plast Reconstr Surg. 2003;111:1174–1181.
Mackinnon SE, Novak CB. T oracic outlet syndrome. Curr Probl Surg. 2002;39:1070–1145.
Mackinnon SE. Pathophysiology o nerve compression. Hand Clin. 2002;18:231–241.
Penkert G, Fansa H. Peripheral Nerve Lesions: Nerve Surgery and Secondary Reconstructive Repair. 1st ed. New York, NY: Springer-Verlag;
2004.
Rummler LS, Gupta R. Peripheral nerve repair: a review. Curr Opin Orthop. 2004;15:215–219.
Szabo RM. Entrapment and compression neuropathies. In: Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative Hand
Surgery. 4th ed. New York, NY: Churchill Livingstone; 1999.

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HEAD AND NECK
Section IV

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443
Jonathan Black, MD and
John N. Jensen, MD
GENERAL

What are the bones o the orbit?
Facial Trauma
CHAPTER 46
Roo : Frontal, lesser wing o sphenoid.
Medial wall: Ethmoid, lacrimal, rontal process o maxilla.
Lateral wall: Zygoma, greater wing o sphenoid.
Floor: Zygoma, maxilla.
Fro, Frontal bone; Sph, Sphenoid; Zyg, Zygoma; Pal, Palatine bone; Max, Maxilla; Lac, Lacrimal bone;
Eth, Ethmoid bone.

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What are the buttresses o the acial skeleton?
Vertical: Nasomaxillary (medial), zygomatico-maxillary/lateral orbit (lateral), mandibular ramus (posterior).
Horizontal: Fronto-orbital, in erior orbital rims, maxillary arch, mandibular arch, zygomatic arches.

What is the most common acial racture in children?
A relatively recent study strati es by age (0–6, 6–12, 12–18 years) and demonstrated a downward trend over time
across age groups in skull and orbital ractures, and a concomitant upward trend in mid ace (maxillary, nasal,
NOE, ZMC) ractures, mandible, and dentoalveolar ractures, as a percentage o total ractures remained stable
rom in ancy through adolescence; in this study, orbital ractures were most common, ollowed by mandible or
nasal, depending on the age.

What is the current consensus o use o resorbable plates in acial ractures?
Some studies show comparable results to titanium, but their use is not commonly employed, and remains controversial.

What is the standard imaging or acial ractures?
C scan with axial and (reconstructed) coronal images are the minimum necessary; o ten sagittal and/or 3D
reconstruction are critical to ully de ne the extent o injury.

When is consideration made or tracheostomy in acial ractures?
Unstable airway (bilateral mandible ractures and altered LOC); pan acial ractures with maxillary and mandibular
ractures, especially with concomitant thoracic trauma and pulmonary contusion or brain injury.

Is IMF an indication or gastrostomy?
No. A liquid diet can be managed e ectively per os (through a straw) in most cases.

What nding should raise concerns with skull base ractures?
Pulsatile proptosis, headache, visual loss, diplopia and periorbital and ocular erythema are signs o posttraumatic
carotid-cavernous stula. It may occur with ractures extending into the cranial ossa rom either posterior or
anterior cranial ossae. It is con rmed with angiography, and initially managed with VIR techniques.

In acial nerve transection, how long be ore the distal segments lose the ability to be located with a nerve
stimulator?
24 to 48 hours.

What general anatomic landmark may be used to determine the easibility o acial nerve exploration and repair?
Injuries medial to the lateral canthus are unlikely to be success ully repaired surgically.

How o ten do patients with acial ractures rom high-speed motor vehicle crashes sustain cervical spine injury?
10%.

How are parotid duct injuries managed acutely?
Cannulation with a 5F pediatric eeding tube, with instillation o dye to locate laceration or transaction. Repair
with ne suture (8-0 mono lament) acutely over the stent is advised.

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How e ective is external carotid artery ligation in controlling acial hemorrhage ollowing traumatic injury?
Because o rich collateralization between internal and external carotid artery vascular territories, ligation is usually
not very e ective. Packing oral and nasal cavities is more likely to stem the hemorrhage and allow or coagulation
and hemostasis.

What is a “growing” skull racture?
Usually encountered in children under age 3 years, it occurs when a skull racture is accompanied by an underlying
dural tear that is untreated. Herniation o the underlying brain, sometimes re erred to as a leptomeningeal cyst,
prevents spontaneous bone healing, and the racture appears to widen over time. It is managed with dural repair
and cranioplasty.

How does one approach the pan acial racture?
From stable to unstable; with concomitant maxillary and mandibular ractures, usually occlusion is established,
ollowed by mandible, then maxilla ORIF.

In cases o ORIF o the maxilla and/or mandible, what are the most likely causes o malocclusion a ter
removal o intraoperative IMF?
Inadequate reduction leading to inaccurate placement o miniplate xation.
FRONTAL SINUS

How o ten do rontal sinus ractures present with CSF leak?
About 20%

What is the cause o a CSF leak in this setting?
A dural tear (likely rom a posterior table bone ragment or cribri orm plate disruption) combined with a racture
pattern allowing the CSF to enter the paranasal sinuses.

What are the conditions in rontal sinus racture that warrant conservative management?
Minimal displacement o ractures (anterior and posterior tables), even when CSF leak is present, are initially
managed with observation. I CSF leak persists, a lumbar drain may be considered to reduce the ow across the
dural tear, and allow or secondary healing.

What are the eatures in rontal sinus racture that determine which operative intervention is indicated?
T ere are three: integrity o the barrier between the brain and rontal sinus, contour o the anterior table, and
patency o naso rontal ducts. T e (colonized) sinus mucosa must be removed i there is communication with the
dura/brain; there ore, cranialization is usually employed when there is a displaced posterior table racture with or
without CSF leak. ORIF o the anterior table addresses contour de ormity, and outlet obstruction (assessed with
instillation o dye in sinus, with patency con rmed with appearance o dye in nasal cavity) with intact posterior
table is addressed by sinus obliteration or endoscopic sinus surgery.

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How is the rontal sinus cranialized?
A coronal approach is generally employed, in the subpericranial plane. T e ragments o the anterior table
are marked or replacement, and additional osteotomy per ormed i necessary. T e posterior table, usually
comminuted, is removed, the dura repaired, the mucosa o the sinus thoroughly stripped, the sinus bony sur ace
burred, and a pericranial ap raised rom the rontal scalp, and placed in the base o the sinus to orm a barrier
between the intracranial space and rontonasal ducts. T e anterior table is replaced with internal xation, leaving a
small gap above the brow to accommodate the pericranial ap.

How is the rontal sinus obliterated?
T e anterior table ragments are recovered, the mucosa stripped and the bony cavity burred, the pericranial ap raised
and inset, and the sinus cavity lled with at, muscle, or bone. T e anterior table is replaced with internal xation.

How is the mucosa properly stripped?
All visible mucosa is manually removed. A ne burr is used over the entire bony sur ace o the sinus to remove the
remaining mucosal invaginations (pits o Breschet).

How do you test or CSF?
Beta-2-trans errin is most speci c; halo sign on lter paper is unreliable.

What are the early complications o rontal sinus racture?
CSF leak, epistaxis, meningitis, intracranial bleed.

What are the late complications o rontal sinus racture?
Osteomyelitis, mucocoele ( rom retained mucosa), intracranial abscess. T ese can occur years later; current
recommendations are or annual surveillance imaging or 5 years, though there are many cases o mucocoele
presenting more than 10 years post-injury.
NASAL

What is the sensory innervation o the nose?
External branches o the anterior ethmoidal nerve (V1), in ratrochlear nerve (V1) supply superior portion and tip;
branches o in raorbital nerve (V2) supply in erior and lateral nasal skin.

Why must a septal hematoma be drained?
Failure to recognize and treat a septal hematoma may result in necrosis o the septal cartilage and per oration. It is
most e ectively accomplished with early intervention (at presentation) and apposition o mucosa to cartilage must
be con rmed.

What are the common eatures o a naso-orbital-ethmoid racture?
elecanthus, epiphora, attened nasal bridge, upturned nasal tip.

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What is the Markowitz–Manson classi cation schema or NOE ractures?
Related to the ragment with the medial canthal insertion:
ype 1: large central ragment
ype 2: small ragment within comminuted segment
ype 3: extensive comminution/avulsion

What is the key to minimizing postreduction nasal de ormities requiring uture septorhinoplasty?
Addressing septal injury by primary reduction in a controlled setting with general anesthesia available.
ORBIT

What is the depth o the orbital f oor?
It varies according to size and age o patient, but generally about 40 to 45 mm in adults.

Where is Whitnall’s tubercle?
T e rontal process o the zygoma, about 5 to 10 mm deep to the lateral rim within the bony orbit. T e lateral
canthal ligament attaches here.

Where does the medial canthal ligament attach?
T e rontal process o the maxilla; the thicker posterior portion inserts on the posterior lacrimal crest.

What are the anatomic cues or xation o the medial canthal ligament?
T e transnasal wire should be placed posterior and superior to the posterior lacrimal crest.

What are the signs o orbital entrapment?
Diplopia on upward gaze is the classic clinical nding, but may be present secondary to periorbital edema in
the absence o entrapment ollowing orbital racture; C scan has emerged as the most reliable sign in common
practice, but a orced duction test remains a reliable tool as well.

What is the Marcus–Gunn pupil and what is its signi cance?
Also known as the a erent papillary de ect (APD), it is an indication o optic nerve injury. It is present when
there is no papillary constriction to direct light, but the consensual response is preserved, as the e erent (CN III
parasympathetics) pathway remains intact. When a pupil remains dilated in response to direct light stimulation
and the consensual response is absent, it is most likely a de ect in the e erent pathway.

What technical choices can be made to minimize the incidence o entropion ollowing a transconjunctival
approach to the in erior orbital rim?
Avoid detachment o the lateral canthal tendon, which reduces the risk or misalignment/rotation o the lid
margin when being reattached.

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What is the “trap door” pattern o orbital f oor racture?
When the mechanism o injury is such that a de ect in the orbital oor is transient, like a hinged trap door, and
periorbita is entrapped, though in the absence o obvious orbital oor bony de ect on imaging. In some cases it
can induce the oculocardiac re ex.

What is the Aschner phenomenon?
Also known as the oculocardiac re ex, it occurs with traction o extraocular muscles (entrapment ollowing
blowout racture) or compression o globe (during reconstruction o the orbital oor. Communications between
V1 and the vagus nerve in the brainstem account or it, and can result in bradycardia, junctional rhythm, or
asystole; it is a potentially li e-threatening condition. When detected in the evaluation o a patient with acial
injuries, it is an indication or immediate intervention.

Which method o access to the orbital f oor has the lowest risk o ectropion?
It is widely reported that the transconjunctival approach has a lower incidence o postoperative ectropion, though
probably it depends on the operator.

How is ectropion initially treated?
Conservatively with several weeks/months o scar massage.

When is the lacrimal system explored?
When there is visible sign o disruption o the duct, as with laceration.

What is the proper plane o dissection in the transconjuctival approach to the orbital f oor?
Preseptal (between the orbicularis oculi and septum), ollowing incision o the capsulopalpebral ascia.

What are Jones I and II tests?
T ey are used to detect obstruction o the lacrimal system. Jones I tests physiologic conditions and involves
instillation o 2% uorescein into the tear meniscus o the a ected eye, insert a cotton swab under the anterior
middle turbinate, wait 5 minutes, and check swab. I uorescein is evident, there is no obstruction or only partial
obstruction. I absent, it may mean obstruction at any point rom the punctum to the nasal cavity. A Jones II
test is then done by cannulating the punctum, and injecting saline (nonphysiologic conditions). It will overcome
partial obstruction, or edema, or obstruction at the punctum. I re ux is encountered or no ow is evident, there
is complete obstruction.

What eature o orbital trauma is worrisome or optic nerve injury?
Blunt orce to superolateral aspect o orbit.

What are the signs o retrobulbar hematoma?
Eye pain, decreased visual acuity, proptosis, chemosis, intraocular hypertension, lid ecchymosis/hematoma,
paralyzed extraocular muscles.

What is the proper acute management o increased intraorbital pressure rom a retrobulbar hematoma?
Lateral canthotomy/cantholysis per ormed immediately (in ER); permanent visual loss can occur with delayed
treatment.

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What are indications or ORIF o orbital f oor ractures?
De ect > 2 cm (or > 50% o orbital oor), entrapment o periorbital contents, enophthalmos.

What are not indications or ORIF o orbital ractures?
Diplopia, in raorbital nerve hypesthesia/anesthesia, and subconjunctival hemorrhage are common and o ten
resolve without intervention.

What is superior orbital ssure syndrome?
Disruption o the our nerves passing through the superior orbital ssure: CN III, IV, VI and V1, giving
extraocular muscle paralysis (ophthalmoplegia), ptosis, a xed, dilated pupil with normal consensual response, and
numbness o the orehead/brow/upper eyelid.

What is orbital apex syndrome?
Superior orbital ssure syndrome + optic nerve injury; presents with blindness.

What are the surgical approaches to the orbit?
ransconjunctival, subciliary, subtarsal, superior lid crease, brow, and transcaruncular.

What is the mechanism o posttraumatic enophthalmos?
Increased orbital volume is the predominant cause, possibly by inadequate oor reconstruction; posttraumatic at
atrophy, among other eatures, may contribute to a lesser degree.
ZYGOMATICOMAXILLARY COMPLEX

In the Gillies approach or zygomatic arch racture reduction, what is the correct plane o dissection?
Between the deep temporal ascia and temporalis muscle bers; dissection in this plane allows sa e placement o
the instrument deep (medial) to the impacted racture.

Why is the lateral orbital wall a use ul anatomic landmark to judge ZMC racture reduction?
In the standard racture pattern with posterior and medial impaction o the zygomatic body, there usually is
overlap o the ragments on the relatively at sur ace o the lateral orbit (zygomaticosphenoid articulation),
and alignment here is dif cult to achieve without correction o the position o the zygomas. Reduction is still
con rmed by visualization o anatomic alignment at the zygomatico rontal suture, in erior orbital rim, and lateral
buttress. However, use o these three areas alone can result in inadequate reduction as residual rotation is dif cult
to appreciate, especially i there is comminution o the lateral buttress.

What are the our extensions alluded to in a “tetrapod” racture?
In erior orbital rim, zygomatico- rontal suture (lateral orbit), zygomaticomaxillary buttress (lateral buttress),
zygomatic arch.

What are the indications or ORIF o a ZMC racture?
Unstable ractures. Complete ractures through the entire tetrapod, even i minimally displaced, have the potential
to displace through the action o the masseter. Incomplete ractures that are displaced (usually medial and
posteriorly) should be xed. In nondisplaced incomplete ractures, in raorbital nerve anesthesia and malocclusion
may resolve and may be observed. Comorbidity also plays a role in the decision to intervene.

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What are the additional indications or repairing a ZMC racture?
Malar attening, enophthalmos.

What are the indications to operatively repair an isolated zygomatic arch racture?
rismus (inability to close the mandible) and aesthetic change rom arch displacement.

How does trismus occur in a ZMC racture?
Medial displacement o the arch portion impedes the coronoid process o the mandible rom moving superiorly
during elevation o the mandible.

How can you prevent malar at pad ptosis secondary to zygoma racture reduction?
It can be prevented by resuspension o overlying mid ace so t tissue a ter reduction o the racture at the in erior
orbital rim, or preservation o the periosteal attachments during dissection.
MAXILLARY FRACTURE

What are the classic mid ace racture patterns, as described by Rene LeFort?
LeFort 1: Horizontal racture across both medial and lateral maxillary buttresses near base o piri orm, and
pterygoid plates.
LeFort 2: Pyramidal pattern across lateral buttresses but crosses medial buttresses more superiorly, and pterygoid
plates.
LeFort 3: Cranio acial disjunction, with maintenance o lateral and medial buttresses, but racture across
zygomatic arches, orbital oors, naso rontal junction, and pterygoid plates (Fig. 46-1).
Figure 46-1 Classic mid ace racture patterns (Le Fort racture classi cation).

CHAPTER 46 Facial rauma
451

In actual practice, how o ten are these patterns encountered?
Commonly it is a combination o these patterns, usually with signi cant comminution, usually with high-energy
blunt orce trauma.

In the surgical approach to maxillary ractures, what is the guiding principle?
Reestablishment o a normal occlusive relationship; ailure to do so is usually secondary to inadequate reduction o
the ractures.

How are palatal ractures managed?
Because o the inelastic quality o the palatal mucoperiosteum, these ractures are usually stabilized with ORIF
along the standard mid ace buttresses, as well as IMF, with suture repair o the mucoperiosteum assisting in
stabilizing the ragments i necessary. Low-pro le plates may be used on occasion, but o ten become exposed and
necessitate removal. In severely comminuted cases, use o a custom-made splint should be considered.
MANDIBLE

What are the absolute indications or open reduction o a mandibular condylar neck racture?
Displacement o the condyle into the middle cranial ossa, bilateral injury with loss o posterior acial height,
lateral displacement out o the glenoid ossa, and oreign body in the joint.

What is an appropriate period o time to maintain a patient in intermaxillary xation?
Depends on the patient’s age and comorbidity, and nature o the injury. I the injury extends into the joint,
immobilization o more than 2 or 3 weeks is risky or ankylosis. Older patients are at greater risk as well. A
standard o care is or IMF or 3 to 6 weeks, ollowed by several weeks o elastics i healing is incomplete.

Is it true that most mandibular ractures are bilateral?
No; about hal are.

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What is the proper technique o placement o an Ivy loop?
See Figure 46-2.
Figure 46-2 Ivy loop placement.
A 26-gauge wire is olded on itsel , a ew twists made at the bend, and the ree ends passed rom buccal to lingual
at the site o the racture. Each wire is brought around a tooth bordering the racture, one end passed immediately
inside the twists, and the ends twisted together to roughly bridal the border teeth. T e central twisted segment
is then urther twisted to secure the circumdental xation as a kind o weave. It is a good temporary x to open,
bleeding, displaced ractures in patients with li e-threatening injuries precluding early operative intervention.

What special considerations must be made or the pediatric population?
Use o plate xation requires periosteal stripping, and concomitant reduction o blood supply, which may
adversely impact growth; additionally, in children in primary and mixed dentition, developing tooth ollicles
occupy much o the maxilla and mandible, and are at risk with ORIF. T e unerupted permanent canine is
traditionally thought to be at greatest risk.

In children in primary and mixed dentition, how are mandible ractures managed?
I the periosteal sleeve is essentially intact, mandible ractures o ten heal and remodel avorably in growing
children. Subcondylar ractures are the most common in children, and are o ten treated conservatively with a so t
diet. Immobilization (IMF) can a ord com ort in some cases, and can be placed by crossing wire loops anteriorly
anchored by piri orm wires placed in an open manner, connected to circummandibular wires placed in a closed
technique.

In the classic case o unilateral subcondylar racture with contralateral parasymphyseal racture, what is the
standard approach?
ORIF o the parasymphyseal racture with IMF.

What are the two equivalent techniques or ORIF o noncomminuted mandibular angle racture?
Champy plate at the superior border with/without a short course o MMF OR two-plate xation through an
external approach.

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What is the Champy plate, and the principle behind it?
It is a plate that wraps around the oblique line at the anterior junction o the ramus and body, placed through
an intraoral approach. T e notion is that some mandibular angle ractures are “ avorable,” and are essentially
stabilized against rotation by the action o the masseteric/medial pterygoid sling, and require minimal xation to
heal well. Mesial to canines, the risk or rotation requires the standard two-plate ( xation plate + tension band)
approach.

Why do condylar neck ractures usually displace medially?
T e lateral pterygoid muscle inserts into the condylar neck; it displaces the neck medially when acting unopposed.

What is a Joe Hall Morris device?
A device or external xation used to align badly comminuted mandibular ractures with signi cant so t tissue
disruption is present (like gunshot wounds). Its advantage is minimal subperiosteal dissection to preserve blood
supply.

How does one manage a mandible racture in the edentulous patient?
ORIF i possible; otherwise, intermaxillary xation must be managed either with a splint or the patient’s dentures,
i intact.

In the treatment o early postoperative in ection ollowing mandible ORIF, when is it appropriate to leave
the hardware in place?
Usually it is appropriate, unless there is clear evidence o osteomyelitis. Most early post-op in ections are related to
diseased dentition, and i the underlying source is removed and the abscess drained, the hardware may be le t in
place and the patient observed.

When are teeth extracted in managing mandible ractures?
When they inter ere with reduction, are comminuted, or clearly devitalized or decayed.

In dental ractures, what is the signi cance o hot and cold sensitivity?
Exposure o dentin, and possibly pulp (vascular supply).

When mental nerve anesthesia is detected, what is the usual racture pattern?
Mandibular body, with displacement, a ecting the in erior alveolar nerve; ractures through the mental nerve
oramen can also cause anesthesia.
REFERENCES
Bite U, Jackson I , Forbes GS, et al. Orbital volume measurements in enophthalmos using 3-D C imaging. Plast Reconstr Surg.
1985;75:502–508.
Crawley WA, Sandel AJ. Fractures o the mandible. In: Ferraro JW, ed. Fundamentals of Maxillofacial Surgery. New York, NY: Springer-
Verlag; 1997:192–202.
Du resne CR, Manson PN. Pediatric acial trauma. In: McCarthy JG, ed. Plastic Surgery. Vol 2. Philadelphia, PA: WB Saunders;
1990:1142–1187.

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Ellis E. A prospective study o 3 treatment methods or isolated ractures o the mandibular angle. J Oral Maxillofac Surg. 2010;68:
2743–2754.
Kelly KJ. Pediatric acial trauma. In: Achauer BM, Eriksson E, Guyuron B, et al., eds. Plastic Surgery: Indications, Operations, and
Outcomes. Vol 2. St Louis, MO: Mosby D Year Book; 2000:941–969.
Lettieri S. Facial trauma. In: Achauer BM, Eriksson E, Guyuron B, et al., eds. Plastic Surgery: Indications, Operations, and Outcomes.
Vol 2. St Louis, MO: Mosby D Year Book; 2000:923–940.
Manson PN. Facial ractures. In: Aston SJ, Beasley RW, T orne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia, PA:
Lippincott-Raven; 1997:383–412.
Markowitz BL, Manson PN, Sargent L, et al. Management o the medial canthal tendon in nasoethmoid orbital ractures: the importance
o the central ragment in classi cation and treatment. Plast Reconstr Surg. 1991;87:843–853.
McGuirt WF, Salisbury PL III. Mandibular ractures: their e ect on growth and dentition. Arch Otolaryngol Head Neck Surg. 1987;
113:257–261.
Pollock RA. Nasal trauma: pathomechanics and surgical management o acute injuries. Clin Plast Surg Am. 1992;19:133–147.
Rohrich RJ, Adams WP. Nasal racture management: Minimizing secondary nasal de ormities. Plast Reconstr Surg. 2000;106:266–273.
Rohrich RJ, Hollier LH. Management o rontal sinus ractures: changing concepts. Clin Plast Surg Am. 1992;19:219–232.
Rohrich RJ, Hollier LH, Watamull D. Optimizing the management o orbitozygomatic ractures. Clin Plast Surg Am. 1992;19:149–165.
Rohrich RJ, Shewmake KB. Evolving concepts o craniomaxillo acial racture management. Clin Plast Surg Am. 1992;19:1–10.
Schendel SA. Vertical maxillary de ects. In: Ferraro JW, ed. Fundamentals of Maxillofacial Surgery. New York, NY: Springer-Verlag;
1997:284–286.
Smith ML, Williams JK, Gruss JS. Management o orbital ractures. Oper Tech Plast Reconstr Surg. 1998;5:312–324.
Wol e SA, Johnson P. Frontal sinus injuries: primary care and management o late complications. Plast Reconstr Surg. 1988;82:781–791.
Wexler A. Anatomy o the head and neck. In: Ferraro JW, ed. Fundamentals of Maxillofacial Surgery. New York, NY: Springer-Verlag;
1997:53–113.
Yaremchuk MJ. Fractures o the maxilla. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Vol 2. Boston, MA: Little Brown
& Co; 1994:1156–1164.
Zide BM. T e temporomandibular joint. In: McCarthy JG, ed. Plastic Surgery. Vol 2. Philadelphia, PA: WB Saunders; 1990:1474–1513.

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Douglas M. Sidle, MD, FACS and
Rakesh K. Chandra, MD
EMBRYOLOGY AND ANATOMY

What branchial arch does the acial nerve innervate?
T e second (hyoid) arch.

What cartilage is associated with the second branchial arch?
Reichert’s cartilage.

How many muscles does the acial nerve innervate?
23 muscles per side:
Facial Nerve Anatomy
and Paralysis
CHAPTER 47
• Occipito rontalis
• Procerus
• Nasalis muscle
• Depressor septi nasi
• Orbicularis oculi
• Corrugator supercilii
• Depressor supercilii
• Auricular muscles (anterior, superior, posterior)
• Orbicularis oris
• Depressor anguli oris
• Risorius
• Zygomaticus major
• Zygomaticus minor
• Levator labii superioris
• Levator labii superioris alaeque nasi
• Depressor labii in erioris
• Levator anguli oris
• Buccinator
• Mentalis
T e platysma in the neck is innervated by the acial nerve.
T e stylohyoid muscle, stapedius and posterior belly o the digastric muscle are also innervated by the acial nerve,
but are not considered muscles o acial expression.

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T rough which oramen does the acial nerve exit the skull?
Stylomastoid.

What term is used to describe the network o anastomoses o the extratemporal acial nerve?
T e pes anserinus, and arborization.

What does pes anserinus mean?
T e oot o a goose.

What are the three major landmarks used to identi y the acial nerve as it exits the stylomastoid oramen?
1. T e tympanomastoid ssure: 6 to 8 mm in erior to the drop-o o the ssure.
2. T e tragal pointer: 1 cm anterior and 1 cm in erior to the point.
3. Retrograde dissection o the posterior belly o the digastric muscle.
T e acial nerve is almost invariably ound at a point where the tip o the mastoid, cartilaginous process o the
auditory canal, and superior border o the posterior belly o the digastrics muscle meet.

Where does the posterior belly o the digastric muscle insert on the skull?
T e medial aspect o the mastoid portion o the temporal bone.

What are the extratemporal branches o the acial nerve?
emporal, Zygomatic, Buccal, Marginal Mandibular, Cervical (Mnemonic: o Zanzibar By Motor Car). Some
patients have a branch to the postauricular musculature, but this is considered vestigial.

What unctional f ber types comprise the acial nerve?
SVA: taste rom anterior two-thirds o tongue via chorda tympani to the nucleus solitarius.
SVE: motor branches to muscles o acial expression, digastric, stapedius, and stylohyoid rom the motor nucleus
in the pons.
GSA: sensation rom the conchal bowl and part o the external auditory canal. Possibly some V3 contribution to
middle ear.
GVE: parasympathetic stimulation o lacrimal, submandibular, sublingual gland, and minor salivary glands (all
glands in the head but the parotid).

What is the blood supply to the acial nerve?
Stylomastoid artery branch o posterior auricular artery. Greater super cial petrosal artery rom the middle
meningeal artery.

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What is SMAS?
SMAS is an abbreviation or the submuscular aponeurotic system. T e SMAS is a layer o tissue which covers the
deeper structures o the cheek area and is linked to the super cial muscle covering the lower ace and neck, called
the platysma. Some techniques or aceli t surgery, li t and reposition the SMAS along with the skin. In doing so,
the jowls are li ted, the neck is tightened, and the cheeks are elevated.
Also known as the super cial musculo aponeurotic system, it is an inelastic brous tissue immediately below
the skin and subcutaneous at o the ace into which the acial muscles insert. It is contiguous with the platysma
in eriorly and the super cial temporal ascia and the galea superiorly.

Where does the acial nerve course in the parotid region?
T rough the substance o the gland deep to the parotid ascia and SMAS.

Where do the nerve branches exit the parotid ascia to course superf cially?
Branches exit at the anterior limit o the parotid gland, continuing deep to the SMAS.

What is the most commonly permanently injured branch o the acial nerve during rhytidectomy?
T e temporal branch at the zygomatic arch.

Where does the temporal branch cross the zygomatic arch?
Hal way between the lateral canthus and the root o the auricular helix. Near McGregor’s patch (zygomatic
ligaments anchoring cheek).

What is Pitanguy’s line?
It is a theoretical line re ecting the course o the temporal branch o the acial nerve. It is drawn rom a point
0.5 cm below the tragus to a point 1.5 cm lateral to the superior orbital rim.

Between which ascial layers does the temporal branch o the nerve course as it crosses the zygomatic arch?
T e branch courses deep to the SMAS and immediately super cial to the super cial layer o deep temporal ascia.

A stroke patient may maintain unction o the rontalis muscle even though all o the other acial muscles on
the ipsilateral side are paralyzed. Why?
Because the nerve bers that project to the part o the acial nucleus in the pons that innervates the orehead
project bilaterally, but those that project to the part o the nucleus that innervates the remaining acial muscles
project only contralaterally.

What ascial layer does the marginal mandibular nerve lay deep to as it crosses the mandible?
T e nerve lies immediately beneath the super cial layer o the deep cervical ascia.

What branch o the acial nerve innervates the buccinator muscle?
Buccal branch o the acial nerve.

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At what site is the primary action o botulinum toxin?
Botulinum toxins block acetylcholine release at the presynaptic cell sur ace, causing a chemical denervation. T e
light chain, which has zinc metalloprotease activity, cleaves SNAP-25, which is involved in vesicle usion and
release o acetylcholine.

What are the botulinum toxin subtypes?
T ere are seven serologically distinct subtypes o botulinum toxin A through G. Only botulinum toxin type A is
FDA approved or cosmetic use.
FACIAL NERVE PATHOLOGY

Why does a lesion proximal to the motor nucleus o VII produce paralysis o only the lower ace, whereas a
lesion below the motor nucleus produce complete acial paralysis?
T e lower ace receives input rom motor tract bers that have crossed only once in the pons, while the upper ace
receives input rom crossed and uncrossed bers rom the motor tract.

What is the House–Brackmann grading system?
A standard system to evaluate the degree o recovery o acial nerve unction rom 1 (normal) to 6 (complete
paralysis). See Figure 47-1.
Figure 47-1 T e House–Brackmann grading system.

What is the most common orm o idiopathic acial paralysis?
Bell’s palsy, 15 to 40 per 100,000.

What percentage o Bell palsy is recurrent?
10% to 14%.

What is Bell palsy?
A diagnosis o exclusion, it is idiopathic acial paralysis with sudden onset and spontaneous resolution.

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What percentage o Bell palsy presents with complete paralysis?
66%.

Over what time period do the majority o Bell palsies resolve?
4 to 6 months.

What proportion o Bell palsy presenting with House–Brackmann grade 6 resolve completely?
70%. More than 90% presenting with incomplete paralysis resolve.

What other symptoms do patients with Bell palsy o ten present with?
Viral prodrome, numbness o the ear, ace, neck, dysgeusia, hyperacusis, and decreased tearing.

I a Bell palsy patient is seen in the f rst ew days, what medications can be prescribed?
A prednisolone taper has been shown to improve outcomes. Less evidence supports antivirals, such as acyclovir,
but they are commonly prescribed in conjunction with the prednisolone taper.

What is Bell phenomenon?
Upward/outward rotation o the eye with attempted eye closure. T is is an unconscious movement to protect the
cornea. It is a positive prognostic sign in regard to corneal protection. See Figure 47-2.
Figure 47-2 T e Bell phenomenon.

What percentage o patients with Lyme disease develop acial paralysis?
10%. Paralysis may be bilateral. All resolve with appropriate Lyme disease treatment.

What is the most common cause o bilateral acial paralysis?
Guillain–Barrè syndrome.

What is Melkersson–Rosenthal syndrome?
Syndrome o unknown etiology characterized by recurrent acial nerve paralysis, woody acial edema, and a deeply
ssured tongue.

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What is neuropraxia?
Compression o a nerve resulting in decreased transmission without disruption o axons.

What is axonotmesis?
Disruption o axons resulting in Wallerian degeneration distal to the lesion with preservation o the neural sheaths
(complete recovery expected).

What is neurotmesis?
Disruption o axons and support cells leading to Wallerian degeneration and uncertain return to unction.

What is synkinesis?
Synkinesis is abnormal synchronization o movement, occurring with voluntary and re ex activity o muscles
that normally do not contract together. T is phenomenon occurs rom aulty remyelination o regenerating nerve
bers.

What is Bogorad syndrome?
Nerves originally destined or the submandibular gland innervate the lacrimal gland leading to tearing during
gustation. Also known as “crocodile tears.”

Where is the site o lesion leading to “crocodile tears”?
T e site o lesion must be at or proximal to the geniculate ganglion as the greater petrosal nerve segregates rom
the acial nerve at that point.

What is Frey syndrome?
Gustatory sweating is secondary to autonomic branches meant to drive parotid secretion cross-innervating sweat
glands and blood vessels in the cheek.

What are the most common causes o acial paralysis in children?
Bell palsy (37%). rauma (20%).

What is the most common cause o acial paralysis in neonates?
Birth trauma.

What are the most common causes o acial nerve disorders in adults?
Bell palsy (51%). rauma (23%). umor (5%).

T e acial nerve should be electrically monitored when dissecting and extirpating which branchial cle t
abnormality?
Branchial cle t type I.

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461
FACIAL NERVE EVALUATION AND REHABILITATION

In the recovery suite immediately a ter a aceli t, one side o the ace is paralyzed. What should you do?
Reassess the patient in 2 to 3 hours. Local anesthesia may still be a ecting the nerve. T en consider steroids and
nerve testing, since complete acial nerve injury a ter rhytidectomy is extremely rare.

What is an EMG?
EMG stands or ElectroMyoGraphy. It is a tool to measure voluntary nerve and muscle unction. Probes are
placed into the test muscles (in this case, acial muscles) and the patient volitionally tries to contract those muscles.

What is the signif cance o f brillation potentials on EMG?
Fibrillation potentials are spontaneous muscle action potentials that occur 1 to 2 weeks a ter injury and signi y
denervation o the muscle. T is signi es a poor prognosis. T us, practitioners o ten wait 2 to 3 weeks to get an
EMG.

What is the signif cance o polyphasic potentials on EMG?
Polyphasic potentials are recorded rom nearby nerve bers and signi y reinnervation o the muscle. T ey are the
earliest sign o nerve regeneration. T is reveals good prognosis.

What is ENoG (or EEMG)?
In ElectroNeuroGraphy (or Evoked ElectroMyoGraphy), the nerve is electrically stimulated by a probe. T is
measures and compares the amplitude o summation potentials o the paralyzed ace to the normal side.

Where is the likely site o a acial nerve lesion in a newborn baby with a normal examination, no evidence o
birth trauma, and unilateral acial paralysis?
Likely temporal bone abnormalities. T is is evaluated with a C scan o the head and temporal bones. Likewise,
serial electrical testing is per ormed. No activity on EMG and > 90% reduction on ENoG (EEMG) suggest
congenital cause, not birth trauma.

What is the primary concern when initially managing a patient with acial paralysis?
Protection o the eye rom ophthalmologic sequelae including exposure keratitis, corneal ulcer, and potential
blindness.

What time constraints should you consider when acial nerve reinnervation techniques such as end-to-end
anastomosis, hypoglossal crossover, or cable gra ting ( acial nerve gra ting procedures) are being considered?
Best per ormed in the rst 12 to 18 months be ore muscle atrophy and loss o the motor end plates.

What nonsurgical treatments exist or eye protection in acial paralysis?
Hydrating drops, ointment, moisture chamber, lid taping at night, external eyelid weights, and physical therapy
(using sur ace electromyography or mirror eedback).

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What surgical procedures are available or eye protection?
Lateral canthoplasty, sling procedures, lower-lid shortening, tarsorrhaphy, and lid loading with gold or platinum
weight placement, rarely medial canthoplasty.

Where is an upper eyelid weight placed?
It is placed super cial to the upper tarsal plate and the levator aponeurosis with the in erior edge a ew millimeters
above the lash line. It is generally placed centered over the junction o the central and medial one-third o the
eyelid, generally over the medial limbus.

What is the next alternative or eyelid weight placement in patients with contact allergy to gold?
Platinum weight.

What dynamic reanimation procedures may be accomplished?
emporalis transposition, ree muscle trans er with microneuronal and microvascular anastomoses, masseteric
nerve to acial nerve anastomosis, XII–VII crossover.

What is a static sling procedure?
Suspension o the a ected musculature with Gore- ex, ascia lata, or allogra t dermal tissue.

What procedures are used to restore neural input to the acial muscles?
Primary repair o the nerve or neurorrhaphy, cable gra ting, cross- ace gra ting, XII–VII crossover, XI–VII
crossover, jump gra ts, masseteric nerve to VII crossover.

What proximal nerve can be used to provide a cable gra t o 10 cm or less?
Great auricular nerve.

What nerve is used or cable gra ts requiring > 10 cm?
Sural nerve (up to 35 cm).

What is the technique o neurorrhaphy?
Interrupted sutures o 9-0 nylon placed in the epineurium. A tension- ree closure is essential.

In the case o a severed nerve, what type o nerve repair generally produces the best outcomes?
Generally, a primary repair o the nerve will produce better outcomes than a repair with an interposition, or jump
gra t.

When evaluating a deep acial laceration, what landmark can be used to help determine i a primary nerve
repair is warranted?
A traumatically lacerated acial nerve is generally not repaired i it is torn distal to a line drawn vertically rom
the lateral canthus. T is is in part due to the size o the distal nerve stumps and in part due to the arborization o
distal nerve endings at that point.

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463

When a surgeon provides preoperative counseling to a patient who undergoing a nerve gra t, how long
should the patient told to wait or the procedure to achieve its best outcome postoperatively?
Between 3 months and 2 years.

When counseling your patient, what is the best results you can achieve with a nerve gra ting procedure?
House–Brackmann Grade III.

In what situation should a XII–VII crossover be considered to reanimate a paralyzed ace that is caused by a
acial nerve disruption?
When the proximal acial nerve stump is not available and the peripheral system is viable (less than 2 years rom
the time o the trauma).

What is a XII–VII crossover with jump gra t?
T e hypoglossal nerve is isolated and one-third to hal o the nerve is incised. A great auricular nerve gra t is
sutured to the proximal cut segment o the hypoglossal nerve and is anastomosed to the cut acial nerve. T is
procedure shows comparable outcomes to the direct XII–VII crossover, provided it is per ormed in the rst
30 days ollowing nerve injury.

What unique morbidity can result rom a XII–VII crossover or XII–VII jump gra t procedure?
Disruption o the hypoglossal nerve can result in dif culties with mastication and articulation. o mitigate this
complication, only one-third o the hypoglossal nerve is incised and a jump gra t can be used.

What is cross- acial nerve gra ting?
A nerve gra t is anastamosed with contralateral buccal branches and tunneled to the opposite side o the ace where
it is anastamosed with the cut branches o the paralyzed side. T is technique as primary therapy has largely allen
out o avor and is generally reserved or powering a ree muscle gra t.

How long a ter paralysis may reinnervation techniques prove use ul?
Within 2 years o the onset o paralysis; a ter this point progressive muscle atrophy and brosis o the
neuromuscular junctions precludes the use o reinnervation techniques.

Describe the two-stage technique o microvascular ree tissue trans er.
Sural nerve gra t is tunneled rom an anastomosis with contralateral buccal branches to the involved side o the
ace and is tagged. Approximately 9 to 12 months later, ree tissue trans er o gracilis muscle and neurovascular
pedicle is per ormed, and the cross- acial nerve is anastamosed with the pedicle.

What orientation is the sural nerve gra ted?
Reverse or rotated. However, newer evidence suggests directionality o the gra t does not impact results.

Describe the single-stage technique.
Free muscle trans er is per ormed with cross- acial tunneling o the nerve pedicle to the contralateral buccal nerve
branches. Likewise, nerve anastomosis can be made to the ipsilateral masseteric nerve.

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What is the advantage o single-stage repair?
T e axons need only traverse a single anastomotic line to reach the destination muscle. Less morbidity and quicker
recovery is thus hypothesized.

What are common muscles used in ree tissue trans er acial reanimation procedures?
Gracilis, pectoralis minor, and serratus anterior.

What dynamic reanimation technique can be used to reanimate the paralyzed ace in one-stage and provide
immediate results?
emporalis trans er. Both the trans er o the temporalis tendon and trans er o the muscle are described.
REFERENCES
Bailey BJ. Head and Neck Surgery: Otolaryngology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.
Gantz BJ, Rubinstein J , Gidley P, Woodworth GG. Surgical management o Bell’s palsy. Laryngoscope. 1999;109:1177–1188.
House JW, Brackmann DE. Facial nerve grading system. Arch Otolaryngol Head Neck Surg. 1985;93:146–147.
Lee KJ. Essential Otolaryngology: Head and Neck Surgery. 8th ed. New York, NY: McGraw-Hill; 2003.
May M. T e Facial Nerve. 1st ed. New York, NY: T ieme; 1986.
McCabe BF. Autoimmune sensorineural hearing loss. Ann Otol Rhinol Laryngol. 1979;88(5):585–589.
Papel ID, Frodel JL, Holt GR, et al. Facial Plastic and Reconstructive Surgery. 2nd ed. New York, NY: T ieme; 2002.
Sullivan FM, Swan IR, Donnan P , et al. Early treatment with prednisolone or acyclovir in Bell’s palsy. N Eng J Med. 2007;357(16):
1598–1607.
Sidle DM, Fishman AJ. Modi cation o the orthodromic temporalis tendon trans er technique or reanimation o the paralyzed ace.
Otolaryngol Head Neck Surg. 2011;145(1):18–23.

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Michael J.A. Klebuc, MD and
Bradley Eisemann, MD
ANATOMIC ESSENTIALS

What are the our unctional components o the acial nerve?
1. Somatic motor e erent—muscles o acial expression, auricular muscles, occipitalis, posterior belly digastric,
stylohyoid and stapedius.
2. Special sensory a erent—(chorda tympani nerve running with lingual nerve) taste anterior 2/3 tongue, hard
and so t palate.
3. General sensory somatic a erent—(posterior auricular nerve) sensation to skin o concha, small area behind
ear, posterior ear canal. Arnold’s nerve (CN X)—major contributor to external ear canal sensation.
4. Visceral motor e erent—(greater petrosal nerve) autonomic parasympathetic to mucus glands nose, hard palate,
so t palate and lacrimal gland (chorda tympani nerve) submandibular, sublingual, and minor salivary glands.

What landmarks are commonly utilized to identi y the main trunk o the acial nerve?
T e nerve lies approximately 1 cm deep to the tragal pointer and medial to the posterior belly o the digastric muscle.

What landmarks describe the course o the rontal branch o the acial nerve?
Pitanguy’s line: A line extending 0.5 cm below the tragus to 1.5 cm above the lateral brow with the nerve running
on the undersur ace o the temporoparietal ascia.

What structures can acilitate identi cation and protection o the marginal mandibular nerve branches?
T e branches consistently lie on top o the acial artery and vein 1 to 3 cm below the mandibular border.

Which acial muscles are innervated on their super cial sur ace?
Most muscles o acial expression are innervated on their deep sur ace with the exception o the levator anguli oris,
buccinator, and mentalis.

Why does the anterior belly o the digastric muscle remain unctional with acial nerve injury?
T e anterior belly is innervated by the mylohyoid branch o the in erior alveolar nerve ( rigeminal).
Facial Paralysis: Static
and Dynamic Treatment
CHAPTER 48

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Hyperacusis suggests injury at what level o the acial nerve?
Injury o the acial nerve proximal to the branch o the stapedius muscle (middle ear) o ten produces increased
perception o sound intensity.
FACIAL PARALYSIS ETIOLOGY

A patient presents with the onset o mild u-like symptoms and pain behind the right ear ollowed hours
later by a complete unilateral hemi- acial paralysis. A ter neurologic evaluation to rule out a cerebrovascular
accident what medical treatment is requently prescribed?
T is is a classic presentation o Bell’s palsy that is believed to represent a herpes simplex virus (HSV) type 1
in ection o the acial nerve. A course o oral steroids should be prescribed within 72 hours o the onset o the
paralysis. Antiviral medications (i.e., Acyclovir) are also requently utilized, however, their bene t is less clear.
Facial paralysis and pain ul vesicles involving the ear are associated with varicella zoster in ection (VZV) known
as Ramsay Hunt syndrome. T e treatment or both is the same, however, more limited recoveries are requently
encountered with Ramsay Hunt syndrome when compared to Bell’s palsy.

A patient is re erred by their primary care physician or surgical correction o Bell’s palsy. T e patient
reports a slowly progressive, unilateral weakness o the mid ace and impaired ability to smile. What is the
next step in this patient’s treatment?
Slow onset o acial weakness is highly suspicious or extratemporal causes o acial paralysis such as tumors o the
parotid gland. A thorough head and neck examination ollowed by imaging (C , MRI) should be undertaken
prior to surgery.

A patient presents with unilateral acial paralysis and reports a “bull’s eye” rash, atigue and ever a ter a
hiking trip. What is the suspected diagnosis?
Lyme disease is a spirochete (Borrelia burgdor eri) in ection disseminated by tick bites. T e diagnosis is con rmed
with serologic testing and optimal treatment with antibiotics (ce triaxone, doxycycline, azithromycin).

Postoperative radiation therapy is planned ollowing radical parotidectomy with segmental resection o the
acial nerve. Should nerve gra t reconstruction be delayed?
T ere is no unctional advantage to delaying nerve gra t reconstruction until radiation therapy is completed. In addition,
more accurate identi cation o the transected nerve branches will be possible during the initial surgical procedure.

A child with bilateral acial paralysis presents or evaluation. What is the second most common cranial nerve
ef ected by this syndrome?
Moebius syndrome is a rare disorder e ecting 1 in 50,000 births. It has a genetic component, however, most cases
are sporadic and multi actorial. T e acial nerve is involved in all cases. T e abducens nerve (CN VI) is the second
most requently involved cranial nerve (approximately 75%) producing a lateral gaze palsy. T e hypoglossal nerve
(CN XII) is a ected in approximately 25% o cases and is associated with a hypoplastic tongue. Cranial nerves
VIII, III, and IV are usually spared. Other associated anomalies include club oot (approximately 30%), hand and
upper limb de ormities, Poland’s anomaly (approximately 15%) and high-arched palate. Intelligence is usually
normal, however, the autistic behavior spectrum is present in approximately 30% o cases.

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467

What is the optimal time or exploration o the acial nerve ollowing sharp laceration?
Exploration should take place within 72 hours. T e transected distal nerve branches continue to conduct during
this period allowing or more straight orward operative identi cation.

Do acial nerve lacerations immediately adjacent to the nasolabial old require repair?
Reasonable recovery can be expected with cheek lacerations medial to the lateral canthus without direct nerve
repair due to the extensive arborization o the buccal and zygomatic branches. However, all transected branches
should be repaired i identi ed.

What clinical presentation o a temporal bone racture avors operative intervention?
Immediate onset o acial paralysis o ten requires surgical exploration, while delayed paralysis is commonly
managed with steroids and observation.

Which acial nerve branch is most requently injured during rhytidectomy?
T e buccal branches. T e clinical sequelae o injury to the buccal branch is less than that seen with injury to the
marginal and rontal branches. T is is due to the extensive arborization o the marginal and rontal branches.
SURGICAL REHABILITATION OF THE PARALYZED FACE
Treatment Goals

What are the cosmetic goals o treating the paralyzed ace?
Restore static and dynamic acial symmetry.

What are the unctional goals o treating the paralyzed brow and periorbital region?
Correct visual obstruction (brow ptosis) and avoid exposure keratitis (corneal protection and restoration o
protective blink).

What are the unctional goals o treating the paralyzed mid ace and perioral region?
Regain oral competence, acilitate speech (plosive and bilabial sounds), restore nonverbal communication (smile)
and maintain a patent nasal airway.

What are the unctional goals o treating the paralyzed lower ace?
Restore lower lip symmetry and motion.

What principle actors in uence surgical planning and technique selection?
1. Duration o paralysis (irreversible muscle atrophy a ter 18–24 months).
2. Availability o the proximal acial nerve trunk.
3. Viability o distal acial nerve branches.
4. Condition o muscles and so t tissue (trauma or radiation injury).
5. Advanced age and medical comorbidities.
6. Presence o additional cranial nerve injuries.

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Regional Approaches

What are the most common surgical treatments or the paralyzed brow?
1. Direct browli t (hairline or via midbrow rhytid)
2. Pretrichial subcutaneous brow li t
3. Open coronal browli t
4. Endoscopic browli t

What surgical procedures are most commonly used to treat acute paralysis (less than 18 months) o the
upper eyelid with lagophthalmos?
1. Nerve repair with or without interposition gra ts
2. Cross- ace nerve gra ts
3. Insertion o upper eyelid weight (potentially temporary)
4. Lateral tarsorrhaphy (potentially temporary)

What surgical procedures can be utilized to treat chronic paralysis (more than 18 months) o the upper
eyelid with lagophthalmos?
1. Insertion o upper eyelid weight (gold, platinum chain)
2. Palpebral spring
3. emporalis trans er (a slip can be elevated rom its origin and rerouted around the lateral orbital rim to the
medial canthal ligament)
4. Free muscle f ap (a ter cross- ace nerve gra ting)

What are the most common surgical treatments or the paralyzed lower eyelid with ectropion?
1. Lateral canthoplasty
2. Sling suspension
3. Horizontal lid shortening
4. Cartilage gra ting

What are the most common surgical treatments or the paralyzed nasal aperture?
1. Static sling suspension
2. Alar base elevation

What are the most common surgical treatments or dynamic reconstruction o acute (less than 18 months)
paralysis o the mid ace and perioral region?
1. Microsurgical nerve repair with or without interposition nerve gra ts.
2. Nerve trans ers (masseter-to- acial nerve, hypoglossal-to- acial nerve, cross- ace nerve gra ts)
3. “Baby sitter”- XII–VII or V–VII trans er combined with cross- ace nerve gra ts

What are the most common surgical techniques or dynamic reconstruction o chronic (greater than 18 months)
paralysis o the mid ace and perioral region?
1. Free unctional muscle f aps (gracilis, pectoralis minor, latissimus dorsi)
2. Regional muscle trans ers (temporalis, masseter)

CHAPTER 48 Facial Paralysis: Static and Dynamic reatment
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What are the most common static techniques employed in the mid ace and perioral region?
1. Static sling suspension ( ascia lata gra t, tendon gra t, suture, Gortex/ADM)
2. Mid ace li t
3. Cervico acial rhytidectomy

What surgical treatments have been described to enhance motion and or symmetry in the chronically
paralyzed lower lip?
1. Myectomy o contralateral lower lip depressors (a ter initial trial o chemodenervation)
2. rans er o anterior belly o digastric muscle (with or without neurotization rom cross- ace nerve gra t)
3. Wedge excision (with or without obicularis oris muscle advancement f ap)
4. Platysma f ap
5. Fascia lata gra ts

What surgical treatments have been described to enhance motion and/or symmetry in acute
(less than 18 months) lower lip paralysis?
1. Microsurgical nerve repair with or without interposition gra ts
2. Cross- ace nerve gra t
3. Mini-hypoglossal trans er
4. Direct muscle neurotization
Brow Paralysis

What structure should be preserved during direct browli t through orehead excision?
T e supraorbital nerve should be preserved to preserve sensation to the orehead and scalp. T is nerve runs just
deep to the rontalis muscle at the lower orehead.

Is there a role or weakening or paralyzing a normal hemi- orehead?
Yes, particularly in younger patients. Improved upper acial symmetry and orehead tone may be obtained with
botulinum toxin or rontal branch resection on a normal hemi-brow, at the variable expense o emotive upper acial
expression. Care must be utilized in the older patient to avoid the production o excessive ptosis and visual obstruction.
Eyelid Closure and Lower Lid Support

Upper eyelid treatments are aimed at balancing the unopposed action o which acial muscle?
Levator palpebrae superioris (cranial nerve III).

What are the most popular implant alloys or upper lid loading?
Gold and platinum, both o which are highly immunoinert. Platinum allows or lower-pro le implants and
platinum chains may produce less visual disturbance and improved cosmesis.

How are lid weights sized?
Preoperatively in an awake patient, 0.8 to 1.8 g sizers are adhered to the upper lid with two-sided tape. T e device
that produces complete or near complete closure without ptosis is selected.

470
Plastic & Reconstructive Surgery Board Review

Where are weights placed in the upper lid?
Deep to the obicularis oculi muscle and directly on top o the tarsal plate with the weight’s in erior boarder
approximately above the lash line. T e weight should be biased slightly medial to center as lateral placement o ten
produces inadequate medial closure (see Fig. 48-1).
Figure 48-1 Lid weight placement in the upper eyelid.

What is the principal method or temporalis trans er to paralyzed upper lid?
An in eriorly based strip o temporalis muscle is elevated rom its origin in the temporal ossa and elongated with a
strip o temporal ascia. T is is then rerouted subcutaneously around the lateral orbital rim, across the tarsal plate,
and inserted into the medial canthal tendon. With temporalis contraction the upper lid is pulled down.

How do you per orm a lateral tarsorrhaphy?
Suture apposition o deepithelialized segments o the lateral upper and lower lids.

What is an advantage o the lateral tarsorrhaphy or corneal protection?
Reliable patient-independent improvement in corneal protection. T is may be particularly use ul in mentally
debilitated or demented patients, in cases o involving an anesthetic cornea, or in cases with severe corneal
exposure. rade-o s include lateral visual obstruction and aesthetic asymmetries.

Over time, with decreased mid acial tone and a paretic orbicularis oculi, a lower lid ectropion with scleral
show can develop. How can this be treated?
Static support o the lower lid (i.e., tendon or tensor ascia latae [ FL] sling, cartilage gra t), lateral canthoplasty
(e.g., dermal pennant or tarsal strip), horizontal lid shortening (e.g., Kuhnt–Szymanowski procedure), and/or
cheek elevation procedures.
Midface and Perioral Restoration

How does nasal airway obstruction develop?
External nasal valve collapse due to external compression arising rom a drooping mid ace as well as loss o
dynamic compensation due to paralysis o the nasalis and levator alaeque nasi musculature. T is is requently
treated with tendon or ascia sling to open the external nasal valve.

When are cranial nerve trans ers used to reanimate the mid ace and perioral region?
Nerve trans ers are employed when the proximal trunk o the acial nerve is not available (intracranial/
intratemporal injury), there are identi able distal nerve branches, and there are viable muscles o acial expression
(not irreversibly atrophied or injured).

CHAPTER 48 Facial Paralysis: Static and Dynamic reatment
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What characteristics make the masseter-to- acial nerve trans er an ef ective technique or smile restoration?
T e descending branch o the masseter nerve can be trans erred to selected zygomatic and buccal branches o the
acial nerve without interposition gra ts. T e descending branch has a dense population o myelinated motor bers
(approximately 1,500) producing strong motion. Cerebral adaptation over time produces an e ortless smile in
the majority o young patients. T ere is limited donor-site morbidity because o unctional overlap between the
masseter and temporalis muscles.

Where can the masseteric branch o the trigeminal nerve be ound?
T e main trunk o the masseter nerve can be identi ed at a point 3 cm in ront o the tragus and 1 cm below
the zygomatic arch (cutaneous landmarks). T e masseter muscle has three lobes. T e nerve lies deep within the
substance o the muscle on the super cial sur ace o the deep lobe (approximately 1.5 cm below the SMAS).

What modi cation o the hypoglossal-to- acial nerve trans er has been made to decrease donor-site morbidity?
Complete transection o the hypoglossal nerve produces hemi-tongue atrophy, mass acial motion, and impairment
o speech and eating in a signi cant number o patients. T ese morbidities are greatly improved by partial transection
o the nerve (approximately one-third) and the use o an interposition jump gra t (usually greater auricular nerve).

What is a “babysitter” procedure?
Part o a staged strategy to restore spontaneous acial animation. Acutely deinnervated mimetic muscles are
initially reinnervated by a local motor nerve (i.e., masseteric or hypoglossal nerve). T is procedure minimizes
mimetic muscular atrophy while a banked cross- acial nerve gra t is allowed to mature.

How can the temporalis muscle be utilized or smile restoration?
T ree variations o the temporalis trans er have been employed or creation o a smile.
1. urning the central portion (approximately 4 cm wide) over the zygomatic arch and using an extension o the
deep temporal ascia to reach the commissure (Gillies technique).
2. Releasing the temporalis insertion rom the coronoid process and utilizing an interposition FL gra t to reach
the corner o the mouth (McLaughlin technique, Fig. 48-2).
3. Releasing the coronoid insertion and mobilizing the entire muscle in the temporal ossa to reach the
commissure without ascial gra ts (lengthening temporalis myoplasty—Labbe technique).
Figure 48-2 McLaughlin technique or smile restoration.