Citations

Background: Dynamic facial reanimation is the gold standard treatment for a paralyzed face. The use of the cross-face nerve graft (CFNG) in combination with the masseteric nerve to innervate the free gracilis muscle has been reported to provide both spontaneity and strong neural input. We report a case series of dual innervation, using a novel method where the branch to masseter is coapted to the side of the CFNG. Methods: Eight patients received free gracilis muscle transfer using the new dual innervation method between September 2014 and December 2017. The CFNG, which was performed nine months prior, was sutured in an end-to-end fashion to the obturator nerve. A nerve graft was coapted to the ipsilateral masseteric nerve and then sutured in an end-to-side fashion to the CFNG proximal to its coaptation to the obturator nerve. Results: All patients recovered smile function with and without teeth clenching around the same time period. Smiles without teeth clenching appeared later in two of eight patients and earlier in one of eight patients, being noted at an average of 8.25 months of follow-up versus 7.6 months. The estimate of true attainment is limited by the spacing of follow-up dates. Average follow-up time was 36.07 months (range: 10–71.5). FACE-Gram software smile analysis with and without biting demonstrated similar excursion on average (7.64 mm versus 8.6 mm respectively, P = 0.93), both of which are significantly improved from preoperation. Conclusion: This novel method of a dual-innervated free gracilis muscle transfer offers a viable technique that achieves a symmetric, strong, and emotional smile.

ImportanceLip, oral, and pharyngeal cancers are important contributors to cancer burden worldwide, and a comprehensive evaluation of their burden globally, regionally, and nationally is crucial for effective policy planning.ObjectiveTo analyze the total and risk-attributable burden of lip and oral cavity cancer (LOC) and other pharyngeal cancer (OPC) for 204 countries and territories and by Socio-demographic Index (SDI) using 2019 Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study estimates.Evidence ReviewThe incidence, mortality, and disability-adjusted life years (DALYs) due to LOC and OPC from 1990 to 2019 were estimated using GBD 2019 methods. The GBD 2019 comparative risk assessment framework was used to estimate the proportion of deaths and DALYs for LOC and OPC attributable to smoking, tobacco, and alcohol consumption in 2019.FindingsIn 2019, 370 000 (95% uncertainty interval [UI], 338 000-401 000) cases and 199 000 (95% UI, 181 000-217 000) deaths for LOC and 167 000 (95% UI, 153 000-180 000) cases and 114 000 (95% UI, 103 000-126 000) deaths for OPC were estimated to occur globally, contributing 5.5 million (95% UI, 5.0-6.0 million) and 3.2 million (95% UI, 2.9-3.6 million) DALYs, respectively. From 1990 to 2019, low-middle and low SDI regions consistently showed the highest age-standardized mortality rates due to LOC and OPC, while the high SDI strata exhibited age-standardized incidence rates decreasing for LOC and increasing for OPC. Globally in 2019, smoking had the greatest contribution to risk-attributable OPC deaths for both sexes (55.8% [95% UI, 49.2%-62.0%] of all OPC deaths in male individuals and 17.4% [95% UI, 13.8%-21.2%] of all OPC deaths in female individuals). Smoking and alcohol both contributed to substantial LOC deaths globally among male individuals (42.3% [95% UI, 35.2%-48.6%] and 40.2% [95% UI, 33.3%-46.8%] of all risk-attributable cancer deaths, respectively), while chewing tobacco contributed to the greatest attributable LOC deaths among female individuals (27.6% [95% UI, 21.5%-33.8%]), driven by high risk-attributable burden in South and Southeast Asia.Conclusions and RelevanceIn this systematic analysis, disparities in LOC and OPC burden existed across the SDI spectrum, and a considerable percentage of burden was attributable to tobacco and alcohol use. These estimates can contribute to an understanding of the distribution and disparities in LOC and OPC burden globally and support cancer control planning efforts.

Background: The goal of this study was to characterize the references provided as supporting evidence of the Plastic Surgery In-service Training Examination (PSITE) syllabi, including those on the novel “core surgical principles” section. Methods: We analyzed the references from five consecutive PSITE Examination syllabi (2016–2020). We collected the following information from each question: question section, total number of references, and source of publication of each reference. Results: We analyzed 1250 questions and 3436 references. Plastic and Reconstruction Surgery was overall the most frequently referenced journal followed by Journal of Hand Surgery (American Volume) and Annals of Plastic Surgery. The most commonly referenced textbooks were Plastic Surgery (by Neligan), Green’s Operative Hand Surgery, and Grabb and Smith’s Plastic Surgery. Regarding the “core surgical principles” section, Plastic and Reconstruction Surgery remained the most frequently cited journal, followed by the Journal of the American Medical Association, New England Journal of Medicine, Annals, and Aesthetic Surgery Journal. “Core surgical principles” contained the largest number of unique journals (n = 209) among all test sections. Within the “core” section, Statistics in Medicine was the most frequently referenced textbook followed by Grabb and Smith’s Plastic Surgery. Conclusions: The main plastic surgery texts and literature were used to support approximately half of the answers within the “core surgical principles” section. The references within this section originated from the largest number of different journals, thus highlighting the breadth and variety of this content and the challenges in preparing for this section.

Background: Osseous reconstruction following total spondylectomy/vertebrectomy in the thoracic spine is indicated to restore spinal stability. To assist with bony reconstruction, vascularized bone flaps including free vascularized fibula flaps and pedicled rib flaps can be used. However, there are limited data comparing various techniques. The authors aimed to evaluate the outcomes of free vascularized fibula flaps and pedicled rib flaps used for thoracic spinal reconstruction. Methods: The authors reviewed 44 vascularized bone flaps [10 anterior pedicled rib flaps, 25 posterior pedicled rib flaps, and nine vascularized fibula flaps] for corpectomy defects spanning T1 to L1 between January of 1999 and June of 2018. Mean age and follow-up were 46 ±17 years and 74 ± 52 months, respectively. Results: The union rate was 93 percent, with a similar mean time to union among the three groups: free vascularized fibula flaps, 9 ± 4 months; anterior pedicled rib flaps, 9 ± 6 months; and posterior pedicled rib flaps, 9 ± 5 months (p = 0.95). Surgical-site complications were found in 27 vascularized bone flaps (61 percent), and reoperations and revisions were performed in 14 (32 percent) and 10 (23 percent) vascularized bone flaps, respectively. No differences were identified among anterior pedicled rib flaps, posterior pedicled rib flaps, and vascularized fibula flaps with regard to complication, reoperation, and revision rates. Conclusions: Free vascularized fibula flaps and pedicled rib flaps provide durable reconstruction for thoracic spinal defects. Union, time to union, revision, and reoperation rates were similar among anterior and posterior pedicled rib flaps and vascularized fibula flaps. Given the variability in indication and defect types among the flap cohorts, the authors’ results should be interpreted carefully as an insight into the outcomes of different vascularized bone flaps for the unique cases of thoracic spinal reconstruction rather than to compare the different flaps used. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Abstract Facial paralysis can impair one'™s ability to form facial expressions that are congruent with internal emotion. This hinders communication and the cognitive processing of emotional experience. Facial reanimation surgery, which aims to restore full facial expressivity is a relatively recent undertaking which is still evolving. Due in large part to published techniques, refinements, and clinical outcomes in the scientific literature, consensus on best practice is gradually emerging, whereas controversies still exist. Taking stock of how the discipline reached its current state can help delineate areas of agreement and debate, and more clearly reveal a path forward. To do this, the authors have analyzed the 50 seminal publications pertaining to facial reanimation surgery. In longstanding cases, the free gracilis transfer emerges as a clear muscle of choice but the nerve selection remains controversial with prevailing philosophies advocating cross facial nerve grafts (with or without the support of an ipsilateral motor donor) or an ipsilateral motor donor only, of which the hypoglossal and nerve to masseter predominate. The alternative orthodoxy has refined the approach popularized by Gillies in 1934 and does not require the deployment of microsurgical principles. Although this citation analysis does not tell the whole story, surgeons with an interest in facial reanimation will find that this is a good place to start.