An ideal donor site for vascularized nerve grafts should have a constant anatomy, minimal functional loss after the nerve has been sacrificed, and a dependable blood supply parallel to the nerve over a relatively long distance. Creating a pedicle for a free vascularized deep peroneal nerve graft with the anterior tibial vessels seems to be a most suitable method for repairing long nerve gaps of over 20 cm and digital nerve defects with severe finger damage. Applications of this nerve graft to digital nerve losses with severely scarred beds created by avulsion injury, and two-stage reconstruction in some partial brachial plexus palsies (free vascularized nerve graft in the first stage and free vascularized muscle graft in the second stage) are well indicated. Advantages of this technique are: (1) A long nerve graft (up to 25 cm) can be obtained, and anomalies are rare (the nerve is absent in only 4 percent of cases). (2) The caliber of the vascular pedicle is large (approximately equal to 3 mm). (3) The nerve has a sufficient blood supply from the collateral blood vessels. (4) The graft can be easily obtained in the supine position. (5) A monitoring skin flap, based on the inferior lateral peroneal artery, can be attached to the nerve graft. (6) Sensory loss resulting from the sacrifice of the nerve covers a minimal area. (7) A donor scar on the anterior aspect of the lower leg is more acceptable than one on the posterior aspect because of less movement in walking. Disadvantages of this technique are: (1) Sacrifice of the large vessels in the lower leg may result in circulatory complications in the donor foot; to avoid this problem, preoperative angiography is recommended. (2) The donor scar is in an exposed area in female patients. (3) There may be temporary postoperative edema and disability in the donor leg.
There are two types of smiling: without exposure of the teeth (usual smile), and with their exposure (square smile). Performance of the former involves use of the major zygomatic muscle, while the latter is created by the major zygomatic and the depressor labii inferior muscles. The function of the depressor labii inferioris muscle cannot be ignored in facial paralysis reconstruction. A double-muscle transfer using a divided rectus femoris muscle for one-stage reconstruction of both the major zygomatic muscle and the depressor labii inferior muscle is described. The patient suffered facial paralysis caused by an extracranial schwannoma originating from the facial nerve. After the tumor was removed, divided rectus femoris muscle segments were transferred to reconstruct the major zygomatic muscle and the depressor labii inferior muscle. After the pedicle vessel of the muscles was anastomosed to the recipient facial vessel, the long motor nerve of the proximal divided muscle was cross-faced and coapted directly to the prepared contralateral buccal branch. The short motor nerve of the distal muscle segment was sutured to the ipsilateral masseteric nerve. The advantages of divided rectus femoris muscle transfers are that (1) independent muscle contraction can be reconstructed; (2) no tongue or trapezius muscle atrophy occurs because the masseteric nerve is used as the motor source of the labial depressor; (3) only one muscle is sacrificed for muscle grafts; and (4) it is a one-stage reconstruction.
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