The surgical management of frontal branch of the facial nerve injuries

Aim:The frontal branch of the facial nerve is particularly vulnerable to traumatic injury or during surgery.While the larger branches of the facial nerve,such as the buccal branch,are more easily identifiable and amenable to repair,the repair of the frontal branch is not common due to its complex branching pattern and smaller size.The description of the surgical approach to repair the frontal branch of the facial nerve is limited in the literature.In this study,we aim to explore the outcomes of patients who underwent frontal branch facial nerve repair in our centre.Method:In a retrospective case review at a single,tertiary Plastic Surgery centre,we performed frontal branch repair for eight patients(n=8)who sustained complete or partial division of the frontal branch of the facial nerves.These patients were followed up postoperatively and assessed with the Sunnybrook Facial Grading System.Results:Using super microsurgical techniques,primary nerve coaptations,fascicular nerve flaps,and direct neurotisations were performed.All eight patients(100%)demonstrated improvements in terms of resting brow symmetry.There was a significant improvement in brow and frontalis function following surgical repair of the frontal branch,with 87.5%(seven patients)demonstrating improvement in forehead movement.Conclusion:In this case series,we demonstrated that the repair of the frontal branch of the facial nerve is relevant,with reasonably good functional outcomes.Repair of the frontal branch of the facial nerve should ideally be done as early as possible following the injury.Nevertheless,delayed repair may still be beneficial within 18 months after the injury.

The labio-mandibular flap for upper lip and peri-commissural defects

Aim: Peri-commisural defect reconstruction using the Abbe or Estlander flaps tend to pilfer tissue from the lower lip, contributing to microstomia, with its attendant problems. In this study, we aim to design a flap for more superficial defects, in which the underlying orbicularis oris muscle can be preserved when resecting peri-commisural skin malignancies whilst also ensuring completeness of excision. Methods: In a retrospective case review of 7 cases at our institution over a 12-month period (2016-2017), we conceptually designed a perforator-plus fascio-cutaneous flap from within the labio-mandibular fold with a 6-month follow-up in terms of oncological clearance and aesthetic outcome. The cohort was composed of patients with skin cancers e.g. basal and squamous cell carcinomas, presenting to a tertiary care facial plastic surgery centre. The technique involved raising a flap from within the peri-oral area, with a scar disguised along the labio-mandibular and naso-labial folds which allows for both an aesthetic reconstruction and the preservation of the oral sphincter mechanism, by avoiding microstomia. The outcomes measured were (1) to ascertain whether this procedure is oncologically safe, (2) there were instances of microstomia and (3) aesthetic appearance. Results: All oncological lesions were completely excised in all cases and at up to six months' follow-up, there were no instances of recurrence. Functionally, oral sphincter function was preserved in all instances as was aesthetic appearance. Conclusion: The labio-mandibular flap is an oncologically safe procedure for skin cancers whilstpreserving oral sphincter function and maintaining aesthetics. It is hence, a superior alternative to Abbe and Estlander flaps, for more superficial defects, not requiring mucosal excision.