Cranial Nerves and Nerve Surgery in the Oral and Maxillofacial Region

The head and neck surgeon is confronted with cranial nerves in the course of operations and he or she must know the anatomy and the ways to treat complications should they happen. In this chapter we focus on the subject of cranial nerves and begin with the history and anatomy and then to individual nerves and maladies of these nerves and complications of surgical procedures involving these nerves

Upper extremity resurfacing via an expanded latissimus dorsi musculocutaneus flap for large circumferential defects: the “spiral” reconstruction technique

We present an expanded latissimus dorsi musculocutaneus (LDMC) flap to treat circumferential upper extremity defects via resurfacing and “spiral reconstruction” in 5 patients during a 17-year period. Five patients with different indications for tissue expansion from burns to congenital hairy nevi were operated. The expansion was done in a longitudinal direction, and a rectangular tissue expander (TE) was inserted under the LD muscle to expand the flap in a longitudinal direction thereby forming a “long” flap rather than a “wide” one. After excising the circumferential lesion, the expanded “elongated” flap was wrapped spirally around the extremity to cover the defect; the donor site was closed as usual. The 5 patients we treated via LDMC flaps in a spiral fashion were free of complications, and all were satisfied with the outcome. All the flaps survived and the spiral reconstruction allowed for a tension-free donor site closure and near complete recipient coverage. This technique is indicated for large circumferential extremity skin defects and deformities. Application of expanded LDMC flaps in a spiral fashion can be used by the reconstructive surgeon to resurface large circumferential upper extremity lesions when indicated. The idea of a long and thinned expansion flap must be in a longitudinal direction and we need this long expanded and thin flap to “spiral” it around the extremity to cover a large defect. The “spiral” flap coverage introduced here for large circumferential extremity defects enables the surgeon to cover the defect with simultaneous donor site closure and good results

Soft tissue distraction in hand surgery: the “pentagonal frame” technique

Soft tissue distraction (STD) is an increasingly accepted operation in all fields of hand surgery from elbow contracture release to PIP joint release. Current techniques reported lack the ability to distract the joints of the fingers or the hand, maintain the length of released contractures, and hold them in a position while active and passive physiotherapy is possible. We describe a technique by which STD of the hand and fingers is done with no joint or tendon involvement overcoming the aforementioned drawbacks. Thirty-three patients with hand contractures were treated. In this method, a thin 1–1.5-mm Kirschner wire was passed horizontally at the proximal head of the distal phalanx and bent like a frame around the finger, forming a pentagonal shape for anchorage. The distal distraction was exerted at the distal phalanx. Various forms of external fixation were then used to distract a finger, several fingers, or the hand by placing tension on this frame; the distraction was either static (with a wire exerting pressure) or dynamic (using a rubber band to adjust the tension). After obtaining the desired result, the wire or rubber band was temporarily freed to commence active and passive physiotherapy. We maintained the frame for 3–6 weeks. All 33 patients were successfully treated. No major complications were encountered during the follow-up period (3–5 years). The pentagonal frame allows for effective distraction of soft tissues and joint ligaments and maintains the space needed for healing of fractures of the metacarpals and phalanges

Ectopic major transplantation for salvage of upper and lower extremity amputations

【Abstract】Objective: Ectopic tissue transplanta- tion is not a new idea. Godina and his colleagues pioneered this method in the 1980s. This method is a last resort method of preserving an amputated body part, which consists of banking the amputated segment in an ectopic area and re- turning it to its native place at a later date. In this article we present our experience with this demanding procedure. Methods: Debridement was the mainstay of this procedure. The stump and amputated part are carefully de- brided and the stump was either closed primarily or covered by a flap. The amputated part was transplanted to one of several banking sites in the body and at a later date it will be transferred to its native site in an elective setting. Results: Seven patients meeting the set criteria for ectopic transplantation were enrolled in this study. The over- all success rate was about 70%, lower than expected but these are cases of severe crush injury. Although the func- tional recovery of these patients are very low, all of the successful cases except one could find a job as a janitor or light manual worker. No patient could return to his previous job. Conclusion: Ectopic transplantation of body parts is an accepted method of treatment of severely crushed ex- tremity or finger injuries. In our country an amputee has very little chance of finding a job instead a disabled person can. In addition in Iran cultures amputation is seen as pu- nishment of either the God or the society, so it is not well accepted and many patients persist on saving the limb even with no functional recovery. None of our successful cases could return to his previous occupation but almost all of them could find a job as janitors or light manual workers. Key words: Replantation; Transplantation; Extremities; Amputation, traumati

Reintroducing the Latissimus-Rib Free Flap as a Long Bone Substitute in The Reconstruction of Lower Extremity Injuries

The leg is a complex district with functions of weightbearing support,stability, and motility. The management of extensive and complex defects is more challenging and often results in leg amputation or shortening.Leg amputation is a severe mutilation that alters the patient’s work and social life by limiting ambulation and self-sufficiency.During a 3 years period we treated four patients with leg injury consisting of tibial defect who underwent one-stage surgery for soft tissue and bone reconstruction.The follow-up period was from 31 to 36 months. Time to bony union ranged from 4 to 7 months. Time to full weight bearing was from 5 to 9 months after   operation. All of the transferred tissue showed hypertrophy after weight bearing. Nonunion & abscess occurred in one case.Arterial thrombosis & valgus deformity were other postoperation complications.The limb was shorter by an average of 0.5 cm in three cases,longer by 1.1 cm in one case, and in the last case, it was not measurable.Other disabling complications were not seen. We believe that this forgotten method can be a valuable alternative to other techniques such as free fibula flap in certain cases that the surgeon can reconstruct bone & soft tissue defects in one stage

Soft tissue distraction using pentagonal frame for long-standing traumatic flexion deformity of interphalangeal

【Abstract】Objective: Interphalangeal joint con-tracture is a challenging complication of hand trauma, which reduces the functional capacity of the entire hand. In this study we evaluated the results of soft tissue distraction with no collateral ligament transection or volar plate removal in comparison with traditional operation of contracture re-lease and partial ligament transection and volar plate removal. Methods: In this prospective study, a total of 40 pa-tients in two equal groups (A and B) were studied. Patients suffering from chronic flexion contracture of abrasive trau-matic nature were included. Group A were treated by soft tissue distraction using pentagonal frame technique and in Group B the contracture release was followed by finger splinting. Results: Analyzed data revealed a significant differ-ence between the two groups for range of motion in the proximal interphalangeal joints (P<0.05), while it was not meaningful in the distal interphalangeal joints (P>0.05). There was not a significant difference in the degrees of flexion contracture between groups (P>0.05). Regression analysis showed that using pentagonal frame technique significantly increased the mean improvement in range of motion of proxi-mal interphalangeal joints (P<0.001), while the higher the preoperative flexion contracture was observed in proximal interphalangeal joints, the lower improvement was achieved in range of motion of proximal interphalangeal joints after intervention (P<0.001). Conclusion: Soft tissue distraction using pentagonal frame technique with gradual and continuous collateral liga-ment and surrounding joint tissues distraction combined with skin Z-plasty significantly improves the range of mo-tion in patients with chronic traumatic flexion deformity of proximal and/or distal interphalangeal joints. Key words: Osteogenesis, distraction; Finger joint; Hand deformitie