One-Stage Simultaneous Augmentation of 2 Regions of 3 Facial Reanimations After Mid Skull Base Surgery by Using a Neurovascular Latissimus Dorsi Chimeric Flap

Abstract

We report a patient who underwent secondary reconstruction for facial paralysis involving 2 regions of augmentation and 3 facial reanimations using a neurovascular latissimus dorsi (LD) chimeric flap.A 53-year-old man underwent mid-skull base surgery for a chondrosarcoma at the temporomandibular joint and primary reconstruction using a free anterolateral thigh flap. At 28 months after surgery, he showed temporal and buccal depression and incomplete facial paralysis. We planned 1-stage reconstruction using a neurovascular LD chimeric flap, which was divided into dual compounds of the neurovascular muscle with soft tissue along the descending and transverse bifurcation of the thoracodorsal neurovascular bundle. We added adipose tissue to the muscle belly of the transverse branch using microperforators. We cut the transverse nerve 2.7 cm from the hilus and about 5 cm from the bifurcation, enabling the proximal stump of the transverse branch to be sutured to the ipsilateral buccal branch and function as a cross-face nerve graft. The transverse branch compound was placed on the temporal region and its neural pedicle was sutured to the zygomatic branch. The descending branch compound was placed in the buccal region and sutured to the contralateral buccal branch.At 58 months after surgery, good contour remained, and smiling was voluntary and natural. On needle electromyography, the zygomatic major muscle and the muscle transferred to the buccal region showed good contraction, and the muscle transferred to the temporal region provided tonus to the lower eyelid. The versatility of the neurovascular chimeric flap facilitated multiple augmentations and 3 reanimations.