NEUROVASCULAR MUSCULOCUTANEOUS LATISSIMUS DORSIFREE-FLAP TRANSFER FOR RECONSTRUCTION OF A MAJORCHEEK DEFECT WITH FACIAL PALSY IN A 14-MONTH-OLD CHILD

CARLOS OLVERA-CABALLERO, M.D.,1* and PABLO HIDALGO-MONROY, M.D.2

This report deals with a female infant 14 months old at time of surgery. Three weeks before admission, she suffered a direct blow to the leftcheek by hitting a table. Within 24 h, she developed a hematoma involving the whole cheek. Ten days later, she developed an eschar on thecheek and was referred to us. Three weeks after the initial trauma, the damaged tissues were debrided, including the skin, subcutaneoustissue, and muscle. The buccal mucosa remained intact. Facial palsy involving the territory of the buccal and mandibular branches wasalready evident at 3 weeks, as well as facial asymmetry. Consequently, a free musculocutaneous neurovascular latissimus dorsi free flap wasproposed to restore the volume, shape, and function of the left half of the face. We present the surgical technique and the results 3.5 yearslater. ª 2005 Wiley-Liss, Inc. Microsurgery 25:373�377, 2005.

This report deals with a female infant 14 months old attime of surgery. Three weeks before admission, shesuffered a direct blow to the left cheek by hitting a table.Within 24 h, she developed a hematoma involving thewhole cheek. She was taken to a physician, who per-formed a puncture and draining. Five days later, thepatient had reddening, swelling, and pain on the left halfof the face, accompanied by fever (39�C). She wasadmitted to a hospital, where she was given antibiotics(cephalosporins) and analgesics. A culture taken onadmission found Staphylococcus aureus. Ten days later,she developed an eschar on the cheek and was referredto us.

On presentation, the patient was stable and nonfe-brile, with an eschar on the cheek and purulent dis-charge. Three weeks after the initial trauma, thedamaged tissues were debrided, including the skin,subcutaneous tissue, and muscle. The buccal mucosaremained intact.

Facial palsy involving the territory of the buccal andmandibular branches was already evident at 3 weeks, aswell as facial asymmetry (Figs. 1�3). Consequently, afree musculocutaneous neurovascular latissimus dorsifree flap was proposed in order to restore the volume,shape, and function of the left half of the face.

SURGICAL TECHNIQUE

With the patient in dorsal decubitus, the borders ofthe facial injury were trimmed, and a superolateral skin-and-subcutaneous-tissue flap was dissected through a

Figure 1. Preoperative view. Facial palsy is evident.

1Plastic and Reconstructive Surgery Service, Hospital para el Nino, Poblano,Puebla, Mexico2Plastic and Reconstructive Surgery Service, Hospital General de Mexico,Mexico City, Mexico

*Correspondence to: Carlos Olvera-Caballero, M.D., 25 Oriente 1809, Pue-bla, Puebla 72540, Mexico.E-mail: carlosolvera@puebla.megared.net.mx

Received 30 September 2004; Accepted 20 November 2004

Published online 12 July 2005 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/micr.20143

ª 2005 Wiley-Liss, Inc.

preauricular incision (similar to a rhytidectomy),bringing this area into wide communication with thetissue defect. Next, flaps were elevated from the lower

border of the cheek defect toward the upper and lowerlips, to make room for the transplanted muscle. Due tofibrosis surrounding the lesion, the internal jugular vein,the external carotid artery, and the transverse nerve ofthe neck (branch of the superficial cervical plexus) thatrun over the anterior surface of the sternocleidomastoidmuscle were dissected in the neck, making them readyfor vascular and nerve microanastomoses.

The patient was turned on the right lateral decubitus,and the latissimus dorsi was dissected in three portions:upper muscular, middle musculocutaneous, and lower

Figure 2. Preoperative view. Tissue defect in face. Only oral mucosa

is intact.

Figure 3. Preoperative view. Tissue defect, with facial asymmetry.

Figure 4. Latissimus dorsi neurovascular free flap. Distal portion

was split.

Figure 5. Immediate postoperative result.

374 Olvera-Caballero and Hidalgo-Monroy

muscular (Fig. 4). The flap’s neurovascular pedicle wasdissected long enough to allow for unencumberedanastomoses. The donor area was sutured, leavingnegative-pressure drainage.

The patient was once again placed in dorsal decub-itus, with the neck in hyperextension in order to performthe anastomoses. These were terminolateral for the ar-tery and vein, with 9-0 nylon sutures, and terminoter-minal by fascicular groups for the nerve with 10-0 nylonunder the operating microscope. Once revascularized,the flap was sutured along its contraction axis. Thus, theproximal portion of the muscle was attached to thezygomatic arch and the preauricular region, and thelower portion was divided into two slips: one for theupper lip, and one for the lower lip beyond the midline.The flap was oriented toward its normal resting posi-tion, with no deforming tension on the site. The islandof skin was sutured to the borders of the wound in thecheek (Fig. 5, with schematic representation in Fig. 6).

The postoperative period was uneventful, and thepatient was discharged 1 week after surgery.

Six months later, an electromyography was per-formed, showing active muscular motility. Photographstaken 3.5 years later showed an achieved full recovery of

the lost mobility, and no disturbances in facial growthhave been observed (Figs. 7�10).

Figure 6. Schematic representation of free flap in face. Thoracor-

dorsal artery was anastomosed to external carotid artery, and tho-

racodorsal vein to internal yugular vein, both in Termino-Lateral (TL)

fashion. Thoracodorsal nerve was anastomosed by fascicular

groups, to transverse nerve of neck in Termino-Terminal (TT) fash-

ion. Muscle was fixed on its proximal portion to zygomatic arc and

preauricular parotid fascia. Distal portion was split and fixed to

hemisuperior and inferior left lip. Axis of latissimus dorsi muscle

contraction is inferior to superior (lip to cheek).

Figure 7. Three and a half years postoperative forward lip motion.

Figure 8. Three and a half years postoperative full lip motion.

Latissimus Dorsi Free-Flap Transfer in Child 375

DISCUSSION

Neuromuscular transplantation is a commonly usedprocedure for the treatment of facial palsy. The muscleshave been used for this condition include the gracilis,1

pectoralis minor,2,3 serratus anterior,4 rectus abdomin-is,5 and latissimus dorsi,6 as reported in this paper. Eachone has unique features, advantages, and drawbacks.The choice for treating facial palsy depends on thesurgeon’s preferences.

In this particular case, a latissimus dorsi musculo-cutaneous flap was chosen, since its transplantationmakes it possible to reactivate facial mobility in a singleoperative stage.7 Furthermore, volume and symmetrywere needed due to the tissue loss the patient had sus-tained.

The latissimus dorsi offers such advantages as easydissection, the long pedicle that may be obtained, the factthat it may be transplanted in segments due to its uniqueintramuscular neurovascular distribution,6 the feasibility

of attaching different segments to specific sites, and inthis particular case, other than achieving volume, pro-viding skin cover for the tissue defect with an island ofskin. Moreover, muscle transplantation in one singlesurgical stage is especially convenient in children, since itmakes it unnecessary to perform several surgeries andthus spares them the psychological sequelae.

Reinnervation using a cross-nerve anastomosis or across-nerve graft to the contralateral facial nerve bran-ches was not performed in this case because the diameterof the left transverse nerve of the neck was very similarto the thoracodorsal nerve; the possible different sizesdiameter between the contralateral facial nerve branchesand thoracodorsal nerve and also to avoid more dis-section in the face of the child. Moreover, as describedby Harii et al.,7 reinnervation is faster after the one-stage transplant, in contrast to transplantation using across-nerve graft, since preserving the vascularity ofnerves promotes faster axonal growth. This was noted inour patient: as early as 6 months after the transplanta-

Figure 9. Three and a half years postoperative frontal view. Figure 10. Three and a half years postoperative facial symmetry and

lip motion.

376 Olvera-Caballero and Hidalgo-Monroy

tion, there was already movement in paralyzed areas ofthe face.

CONCLUSIONS

This case report points out that transplantation ofthe latissimus dorsi is ideal for the one-stage treatmentof facial palsy requiring volume for symmetry, skin torepair cutaneous losses, and a functional muscle to re-store mobility to the face.

REFERENCES

1. Harii K. Microneurovascular free muscle transplantation forreanimation of facial paralysis. Clin Plast Surg 1979;6:361�375.

2. O’Brien BM, Franklin JD, Morrison WA. Cross facial nerve graftsand microneurovascular free muscle transfer for long establishedfacial palsy. Br J Plast Surg 1980;33:202�215.

3. Harrison DH. The pectoralis minor vascularized muscle graft forthe treatment of unilateral facial palsy. Plast Reconstr Surg1985;75:206�213.

4. Terzis JK. Pectoralis minor: a unique muscle for correction offacial palsy. Plast Reconstr Surg 1989;83:767�776.

5. HataY, Yano K, Matsuka K, Ito O, Matsuda H, Hosokawa K.Treatment of chronic facial palsy by transplantation of the neu-rovascularized free rectus abdominis muscle. Plast Reconstr Surg1990;86:1178�1187.

6. Tobin GR, Shusterman BA, Peterson GH, Nichols G, Bland KI.The intramuscular neurovascular anatomy of the latissimus dorsimuscle: the basis for splitting the flap. Plast Reconstr Surg1981;67:637�641.

7. Harii K, Asato H, Yoshimura K, Sugawara Y, Nakatsuka T, UedaK. One stage transfer of the latissimus dorsi muscle for reanima-tion of a paralyzed face: a new alternative. Plast Reconstr Surg1998;102:941�951.

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