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Conjoined twinning is a rare medical phenomenon, and numerous challenges remain with respect to surgical separation and reconstruction. The purpose of this study is to present a detailed discussion of the authors' institutional experience with eight conjoined twin separations over the past three decades, focusing on challenges and lessons gleaned from these cases.The records of all patients who underwent conjoined twin separation at The Hospital for Sick Children in Toronto, Ontario, Canada, from 1984 to 2018 were retrospectively reviewed.Eight sets of conjoined twins were analyzed. Half of the sets [ n = 4 (50 percent)] were female. There were four sets (50 percent) of ischiopagus twins, three sets (37.5 percent) of omphalopagus twins, and one set (12.5 percent) of craniopagus twins. The median age at separation was 6.75 months. The mean durations of intensive care unit and hospital stay were 14.1 ± 12.9 days and 4.9 ± 4.8 months, respectively. Mean length of follow-up was 6.7 ± 4.4 years. Three deaths occurred in our series, with an overall survival rate of 81 percent. Two sets of twins experienced expander-related complications such as infection and bowel perforation. Three twins required reoperation because of flap necrosis or dehiscence after separation.The authors' results highlight the unique nature of each operation and the great ingenuity required in managing the particular considerations of each case and also adhering to a systematic approach of evaluation and planning. A number of novel strategies were used at the authors' center and have now become commonplace. The lessons learned from such procedures may improve care for future generations of patients.Therapeutic, V.

A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptations to cleft care protocols during and after COVID-19 as a priority learning area of need. A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptations to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organizations involved in comprehensive cleft care. Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinized and COVID-19 adaptations, specifically in the pre- and perioperative periods, were highlighted. Second, surgical procedures and cleft care services were prioritized according to their relationship to functional outcomes and time-sensitivity. The surgical procedures assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft care services assigned the highest priority were new-born assessments, pediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention. A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

Facial paralysis may result in significant functional, esthetic, and psychological morbidity. Mobius syndrome is a form of bilateral congenital facial paralysis that is particularly difficult to treat owing to the lack of readily available donor nerves, particularly in the upper face. In this study, we evaluate the feasibility of using the deep temporal nerves as donors for the innervation of free muscle grafts in the periorbital region. Preserved and fresh cadaver facial halves are dissected, and the course of the deep temporal nerves delineated. We find the middle branch of the deep temporal nerve to be located consistently 4.6 cm from the posterior edge of the tragus along the zygomatic arch, giving an easily identifiable surface landmark for our donor. Finally, we outline a proposed surgical approach for using the middle deep temporal nerve to innervate a free muscle graft to the eyelids through an interpositional nerve graft.

Cross-face nerve grafting enables the reanimation of the contralateral hemiface in unilateral facial palsy and may recover a spontaneous smile. This chapter discusses various clinically applicable strategies to increase the chances for good functional outcomes by maintaining the viability of the neural pathway and target muscle, increasing the number of reinnervating nerve fibers and selecting functionally compatible donor nerve branches. Adopting those strategies may help to further improve patient outcomes in facial reanimation surgery.

The success of conjoined twin separation has increased since the 1950s, notwithstanding the numerous technical and physiologic challenges encountered in such procedures. Together with improvements in our understanding of conjoined twin physiology and the accumulation of surgical expertise, technological advances have largely paralleled the improvement in outcomes. In particular, advances in imaging modalities, adjuncts to abdominal wall closure such as mesh and tissue expansion, and three-dimensional modeling have been instrumental in advancing care for these patients. Considered together, these domains have allowed multidisciplinary teams to better delineate conjoined anatomy, facilitated improved surgical planning and decision-making, and assisted in overcoming the frequent challenges associated with soft-tissue closure. This review delineates the improvements in these modalities and their relationship to increasingly successful conjoined twin separation in recent years.

Since 1998, over 120 upper extremity transplants have been successfully performed around the world; however, the field of vascularized composite allotransplantation (VCA) continues to face various medical challenges and ethical controversies. This article summarizes the worldwide experience with transplantation of vascularized composite upper extremities in children and discusses the unique considerations facing potential pediatric VCA recipients. Three children have successfully received composite upper or lower extremity transplants, of which two involved isografts and one involved allografts. Numerous research and clinical advances relevant to VCA have been made, including patient screening, perioperative rehabilitation, allograft preservation and transportation, enhancement of nerve regeneration, understanding of cortical plasticity, and immunomodulatory strategies. Ethical and psychosocial issues remain at the forefront when evaluating potential pediatric VCA recipients. For ethically and rigorously screened pediatric patients with debilitating upper extremity absence, VCA is a compelling option to restore form and function and has a promising future.

INTRODUCTION Facial paralysis impairs the mimetic functions of the facial musculature. In pediatric patients, free functioning muscle transfer neurotized with an intact contralateral facial nerve is the gold standard for smile reanimation. In response to requests from families of children with facial paralysis, the Division of Plastic and Reconstructive Surgery at the Hospital for Sick Children hosted an inaugural "Facial Paralysis Family Day." The objective was to create an opportunity for families to meet, exchange stories, and build support networks. METHODS This study was a quality improvement project to conduct a needs assessment and evaluate the feasibility and satisfaction of implementing a family support intervention for individuals living with facial paralysis. RESULTS The needs assessment demonstrated that families were most interested in advances in medicine, therapy and coping sessions and meeting other families. The post-event evaluation questionnaire indicated that attendees enjoyed the event, would attend again and found it highly valuable connecting and networking other families. It also indicated that key needs identified were addressed, with excellent ratings for the presentation discussing advances in medicine (100% rated "good" or "very good"), the therapy sessions (92% rated "good" or "very good") and the presentations by patients and their families (100% rated "good" or "very good.") DISCUSSION:: Two areas of improvement highlighted were elaborating further on medical advances and facilitating interactions between families. Overall, this event was well regarded and will likely be repeated at our institution and serve as a valuable resource for other hospitals planning to organize a similar event.

Craniofacial microsomia is associated with maxillomandibular hypoplasia, microtia, soft-tissue deficiency, and variable severity of cranial nerve dysfunction, most often of the facial nerve. This study evaluated the incidence of facial paralysis in patients with craniofacial microsomia and outcomes after free functioning muscle transfer for dynamic smile reconstruction.A single-center, retrospective, cross-sectional study was performed from 1985 to 2018 to identify pediatric patients with craniofacial microsomia and severe facial nerve dysfunction who underwent dynamic smile reconstruction with free functioning muscle transfer. Preoperative and postoperative facial symmetry and oral commissure excursion during maximal smile were measured using photogrammetric facial analysis software.This study included 186 patients with craniofacial microsomia; 41 patients (21 male patients, 20 female patients) had documented facial nerve dysfunction (22 percent) affecting all branches (51 percent) or the mandibular branch only (24 percent). Patients with severe facial paralysis (n = 8) underwent smile reconstruction with a free functioning muscle transfer neurotized either with a cross-face nerve graft (n = 7) or with the ipsilateral motor nerve to masseter (n =1). All patients achieved volitional muscle contraction with improvement in lip symmetry and oral commissure excursion (median, 8 mm; interquartile range, 3 to 10 mm). The timing of orthognathic surgery and facial paralysis reconstruction was an important consideration in optimizing patient outcomes.The authors' institution's incidence of facial nerve dysfunction in children with craniofacial microsomia is 22 percent. Free functioning muscle transfer is a reliable option for smile reconstruction in children with craniofacial microsomia. To optimize outcomes, a novel treatment algorithm is proposed for craniofacial microsomia patients likely to require both orthognathic surgery and facial paralysis reconstruction.Therapeutic, IV.

Children with facial paralysis face challenges which are both functional as well as psychosocial in nature. Numerous methods have been employed to restore facial movement using various regional and distant muscle transfers. Two-stage facial reanimation is a reliable technique for restoring midface motion in patients with unilateral facial paralysis with minimal donor morbidity. Unlike muscle transfers innervated by other cranial nerves, such as the motor nerve to masseter, powering the muscle transfer with the contralateral facial nerve provides patients with the ability to generate a spontaneous smile congruent with their emotions. In the first stage, a donor facial nerve branch is selected from the unaffected side to provide neural input for the proposed free muscle transfer. A sural nerve graft is used to permit axonal sprouting from the donor motor branch across the face to the contralateral upper buccal sulcus. Six to 12 months later, the second stage procedure is performed, whereby a gracilis muscle transplant is performed, neurotized by the cross face nerve graft. Through meticulous attention to detail and techniques, as outlined in this chapter, clinicians can consistently provide excellent outcomes for patients suffering from unilateral facial paralysis.

Facial palsy can cause the impairment of eye closure and affect blink, ocular health, communication, and esthetics. Dynamic surgical procedures can restore eye closure in patients with decreased facial nerve function. There are no standardized measures of voluntary and spontaneous eye closure that are used to evaluate the outcomes of blink restoration procedures. The purpose of this systematic literature review was to identify the measures used to assess normal and abnormal eye closure and blinking in patients with facial palsy. A literature search of the PubMed database using the keyword “facial nerve/surgery” was conducted. Only English language articles that pertain to the use of facial paralysis assessment systems published in the past 20 years, which involve eyelid closure were included. There were 57 articles that used a facial paralysis classification system with an eyelid closure component: House-Brackmann Facial Nerve Grading Scale (n = 43, 67%); Sunnybrook Facial Grading Scale (n = 9); palpebral fissure heights (n = 4), and the electronic clinician-graded facial function tool (n = 3) and three additional measures were reported once. Although the Terzis and Bruno Scoring System, blink ratio, and electronic, clinician-graded facial function scale(eFACE) Clinician-Graded Scoring System were valid measures of eyelid closure, there was no one comprehensive eye assessment that demonstrated all aspects of eye closure in facial palsy, which include closure amplitude, spontaneity, and quality of life. For blink assessment, eFACE is the most comprehensive tool currently available and recommended to be used with a patient-reported quality of life supplement that captures the specific domains related to facial nerve dysfunction.

Objective: To test the feasibility of implementing a high-fidelity cleft palate simulator during a workshop in Santiago, Chile, using a novel video endoscope to assess technical performance. Design: Sixteen cleft surgeons from South America participated in a 2-day cleft training workshop. All 16 participants performed a simulated repair, and 13 of them performed a second simulated repair. The repairs were recorded using a low-cost video camera and a newly designed camera mouth retractor attachment. Twenty-nine videos were assessed by 3 cleft surgeons using a previously developed cleft palate objective structured assessment of technical skill (CLOSATS with embedded overall score assessment) and global rating scale. The reliability of the ratings and technical performance in relation to minimum acceptable scores and previous experience was assessed. Results: The video setup provided acceptable recording quality for the purpose of assessment. Average intraclass correlation coefficient for the CLOSATS, global, and overall performance score was 0.69, 0.75, and 0.82, respectively. None of the novice surgeons passed the CLOSATS and global score for both sessions. One participant in the intermediate group, and 2 participants in the advanced group passed the CLOSATS and global score for both sessions. There were highly experienced participants who failed to pass the CLOSATS and global score for both sessions. Conclusions: The cleft palate simulator can be practically implemented with video-recording capability to assess performance in cleft palate repair. This technology may be of assistance in assessing surgical competence in cleft palate repair.

Living donor liver transplantation is an important strategy of procuring segmental liver allografts for pediatric patients with liver failure, as suitably sized whole donor organs are scarce. The early pediatric living donor liver transplantation experience was associated with high rates of hepatic artery thrombosis, graft loss, and mortality. Collaboration with microsurgeons for hepatic artery anastomosis in pediatric living donor liver transplantation has decreased rates of arterial complications; however, reported outcomes are limited.A 14-year retrospective review was undertaken of children at the authors' institution who underwent living donor liver transplantation with hepatic artery anastomosis performed by a single microsurgeon using an operating microscope. Data were collected on demographics, cause of liver failure, graft donor, vessel caliber, vessel anastomosis, arterial complications, and long-term follow-up.Seventy-three children with end-stage liver failure underwent living donor liver transplantation with microvascular hepatic artery anastomosis. The commonest cause for liver failure was biliary atresia (63 percent). A total of 83 end-to-end hepatic artery anastomoses were completed using an operating microscope. Hepatic artery complications occurred in five patients, consisting of three cases of kinked anastomoses that were revised without complications and two cases of hepatic artery thrombosis (3 percent), of which one resulted in graft loss and patient death. Patient survival was 94 percent at 1 year and 90 percent at 5 years.Microvascular hepatic artery anastomosis in pediatric patients undergoing living donor liver transplantation is associated with a low hepatic artery complication rate and excellent long-term liver graft function. Collaboration between microsurgeons and transplant surgeons can significantly reduce technical complications and improve patient outcomes.Therapeutic, IV.

Background The reconstructive approach for incomplete facial paralysis is not yet determined. In this article, the authors present a new surgical approach for patients with incomplete facial paralysis in which residual, ineffective movement is detected preoperatively in the ipsilateral buccozygomatic territory of the paretic facial nerve. Methods Sixteen patients with incomplete facial paralysis were found eligible for the procedure and underwent one-stage facial reanimation performed by the senior author (E.G.). Reanimation was performed using free gracilis muscle transfer with neural coaptation to an active facial nerve branch(es) responsible for the predetected buccozygomatic residual movement. Patients were reviewed in a systematic fashion using a combined still photographic and video scoring scale for symmetry at rest and at dynamic states. Results Following surgery, improved symmetry was observed in the majority of observations of the mouth region at rest and while smiling and of the nasolabial fold region while smiling. There was no significant change in symmetry in the majority of observations of the eye region at rest and while smiling and the nasolabial fold region at rest. Video assessment of dynamic facial symmetry while smiling demonstrated improved symmetry in 91 percent of the observations (n = 191 observations). Comparison of mean scores for dynamic smile symmetry produced a statistically significant improvement of 1.68 points following surgery (p Conclusion Based on this series, the authors recommend that use of the ipsilateral facial nerve buccozygomatic residual branch be considered as a donor nerve for facial reanimation using a free gracilis muscle transfer in patients with incomplete facial paralysis with residual preoperative movement in the midface. Clinical question/level of evidence Therapeutic, IV.

Background Gracilis muscle transplant is the standard of care for smile reconstruction in children with Mobius syndrome. The authors describe the long-term clinical efficacy, durability, and psychosocial impact of this approach at a mean follow-up of 20 years. Methods Patients with Mobius syndrome who underwent gracilis muscle transfer between 1985 and 2005 were included in the study. The authors assessed midfacial movements using photographs and Scaled Measurement of Improvement in Lip Excursion measure, administered the patient-reported Facial Clinimetric Evaluation Scale, and used semistructured interviews. Results The mean age at surgery was 13.2 ±10.6 years and the mean follow-up was 20.4 ± 4.4 years postoperatively. Twenty-two gracilis muscle transplants were performed, all innervated by the motor nerve to the masseter. Photographic analysis using Scaled Measurement of Improvement in Lip Excursion software demonstrated that movement of the muscle was unchanged 20 years after surgery. Smile symmetry was stable long term. The overall mean Facial Clinimetric Evaluation score of the cohort was 62.3 ± 12.0. Facial comfort (86.4 ± 21.2) and social function (69.9 ± 18.5) subdomains were the highest. Although the facial movement subdomain score was 35.6 ± 12.4, the score related to smiling alone was 84.1 ± 20.2, indicating satisfaction with the midfacial reconstruction. Interview responses indicated high satisfaction with surgery; fulfilled expectations of social acceptance; improved communication; enhanced self-confidence; and a sense of increased facial symmetry, spontaneity, and smile excursion. Conclusion Segmental gracilis muscle transplantation provides long-lasting, durable improvements in objective and patient-reported measures of facial function.

Purpose To document the presence and location of new sensory nerve fibers after corneal neurotization using in vivo confocal microscopy (IVCM) in 2 patients with neurotrophic keratopathy (NK). Methods Two patients with unilateral advanced NK received corneal neurotization to surgically reinnervate the cornea. IVCM was used to identify subbasal nerve fibers and document corneal reinnervation. In 1 patient (case 1), IVCM was performed before and after corneal neurotization; in the second patient (case 2), IVCM was performed after neurotization and corneal transplantation. Results In case 1, who had hand motion visual acuity due to NK-associated corneal perforation that necessitated cyanoacrylate gluing, preoperative IVCM identified no subbasal nerves; however, subbasal nerves were identified 6 months after corneal neurotization, and there were no further episodes of persistent epithelial defects. In case 2, in whom NK with a total absence of corneal sensation was the result of treated basal skull meningioma, corneal sensation, visual acuity, and ocular surface health improved after corneal neurotization. Deep anterior lamellar keratoplasty was performed 2.5 years after corneal sensation was reestablished. IVCM demonstrated corneal reinnervation at the stromal and subbasal level in a pattern different from the normal cornea. Conclusions Corneal neurotization restores corneal sensation by reinnervating the stromal and subbasal layers of the cornea. In doing so, corneal neurotization may halt the process of NK and prevent further visual loss.

Background Pediatric forearm compartment syndrome can lead to severe functional disability. Although it is known that earlier presentation with decompression leads to better outcomes, it is not known when presentation after injury leads to significant loss of function requiring microsurgical intervention. The authors describe the rate of microsurgical reconstruction after pediatric forearm compartment syndrome as related to timing of presentation. Methods A retrospective chart review was conducted of pediatric patients with forearm compartment syndrome between January 1, 2000, and March 22, 2013, after a traumatic upper extremity injury. Demographic information, cause, time to decompression, complications, and functional outcome were recorded. Results Thirty-five patients aged between 2 and 16 years (8.97 ± 4.12 years) met inclusion criteria. The majority (74 percent) were boys. The right upper extremity was predominantly involved (54 percent), with a predilection for ulnar fractures (66 percent). Fasciotomies were completed for 32 patients (91 percent). Two patients had no decompression (6 percent) because of late presentation. The average time to fasciotomy was less than 12 hours after injury in 16 patients (46 percent), 12 to 48 hours in 15 patients (43 percent), and greater than 48 hours in four patients (11 percent). Complications (63 percent) included nerve injury (40 percent), skin graft (37 percent), scar revision (11 percent), and long flexor tightness requiring serial casting (17 percent). Forearm muscle necrosis requiring microsurgical reconstructive surgery with a gracilis muscle flap occurred in two patients (6 percent). Increased time to decompression was statistically associated with long flexor tightness and gracilis reconstructive surgery. Conclusion Presentation after 48 hours resulted in significant functional deficits requiring reconstructive surgery (gracilis muscle flap reconstruction) or long-term conservative management (serial casting).

Background Mobius syndrome is a complex congenital disorder of unclear cause involving multiple cranial nerves and typically presenting with bilateral facial and abducens nerves palsies. At The Hospital for Sick Children, Toronto, Ontario, Canada, microneurovascular transfer of free-muscle transplant is the procedure of choice for midfacial animation. The primary aim of this study was to investigate surgical outcomes of the procedure in terms of complications, secondary revisions, and smile excursion gains. Methods A retrospective 29-year review was performed using patient records from a single tertiary care center. The authors included children with Mobius syndrome who had undergone facial animation surgery with a free segmental gracilis muscle transfer and microneurovascular repair between January 1, 1985, and August 31, 2014. Smile excursion measures were obtained using the Facial Assessment by Computer Evaluation-Gram on a subset of the included patients. Results A total of 107 patients undergoing 197 reconstructive procedures met inclusion criteria. Most reconstructions relied on the motor nerve branch to the masseter for innervation [n = 174 (88 percent)]. Thirteen complications were reported, of which six required surgical interventions. Three revision procedures were performed: scar revision, muscle repositioning, and removal of infected permanent suture material. The use of the motor nerve branch to the masseter resulted in good commissure excursion gains (average, 4.61 mm for bilateral cases and 9.34 mm for unilateral reconstructions). Conclusion Midfacial animation with segmental gracilis muscle transfer for patients with Mobius syndrome provides gains in the amplitude and symmetry of oral commissure excursion and carries a reasonably low complication rate. Clinical question/level of evidence Therapeutic, IV.

Purpose: Pediatric facial paralysis has substantial functional consequences in a growing child including impaired quality of life. Microneurovascular facial reanimation is the gold standard for smile reconstruction; however, quantitative data are lacking regarding long-term outcomes, particularly beyond 10 years. The primary objective of this study was to evaluate the long-term surgical and patient-reported outcomes after dynamic reconstruction of unilateral facial paralysis in childhood. Methods: A cross-sectional study was performed of patients in our institutional facial paralysis database (1978-2008) who underwent dynamic reconstruction of unilateral facial paralysis 20 or more years ago. All patients were treated as children with a staged cross face nerve graft and free functioning muscle transfer. Frontal facial photographs in repose and maximal smile prior to surgery, within 2 years post-surgery, and at long term follow-up were analyzed using the MEEI Face-Gram software for commissure excursion. Patient-reported outcomes were obtained using the FaCE Scale for subjective facial impairment and disability, as well as the FACE-Q Satisfaction with Outcome and FACE-Q Social Function scales. Results are reported as median [IQR] and non-parametric statistical analysis was performed with alpha of 0.05. Results: Eleven patients were included with long term follow-up of 23.7 [5.6] years (6 females, 5 males; 5 congenital, 6 acquired; age at surgery 7.3 [6.3] years). For surgical quantitative measures, commissure excursion significantly improved from prior to surgery (-1.3 [7.4] mm) compared to follow up within 2 years post-surgery (7.0 [1.7] mm) (p0.05). For patient-reported outcomes, median FaCE Scale scores showed good function for social function (81/100), oral function (88/100), facial comfort (92/100), and overall score (75/100). On the FACE-Q Satisfaction with Outcome scale, 10/11 respondents somewhat agreed or definitely agreed with the statement, “I am pleased with the result.” On the FACE-Q Social Function scale, 10/11 respondents somewhat agreed or definitely agreed with the statements, “I make a good first impression” and “I feel confident when I participate in group situations.” Conclusion: Dynamic reconstruction of unilateral facial paralysis in young children improves commissure excursion that is maintained at long-term follow up. As adults, these patients report a high level of satisfaction and social functioning with their smile reconstruction.

Summary Background Smiling is a fundamental component of social interactions. Significant challenges arise for patients with facial palsy. One of the key procedures for dynamic smile restoration is the microneurovascular transfer of a gracilis muscle. We aimed to assess the effectiveness and safety of dynamic smile reanimation surgery using the free gracilis muscle unit in patients with facial palsy. Methods We conducted a systematic review and meta-analysis of studies reporting surgical outcomes of dynamic smile restoration using free gracilis muscles identified from EMBASE, Medline, and Web of Science databases from their inception to March 15, 2018. Two-stage screening and data extraction were performed by two independent reviewers. Pooled proportions were calculated using random-effects models. Results Thirty-one studies including 1647 patients who underwent 1739 free gracilis flaps were included. Twelve (38.7%) studies measured perioperative smile excursion change using six different tools. Six of these studies were homogeneous and were used in meta-analyses of smile excursion improvement, which revealed a mean change of 7.5 mm (95% CI 6.0–9.0 mm, I2 86.7%) perioperatively. Twenty (64.5%) studies reported perioperative complications, and pooled proportions of flap failures were of 2.9% (95% CI 1.3–4.5%, I2 47.7%). Conclusions Dynamic smile restoration using a free gracilis muscle may represent an effective procedure to regain oral commissure motion and is associated with an approximately 3% rate of flap failure. Masseteric nerve coaptations lead to larger improvements in perioperative smile excursion (10 mm) than cross-facial nerve grafts (6.8 mm). Future studies with homogeneous reporting of smile excursion and patient-reported outcome measures are needed.

Bilateral facial paralysis is a rare entity that occurs in both pediatric and adult patients and can have congenital or acquired causes. When paralysis does not resolve with conservative or medical management, surgical intervention may be indicated. This article presents the authors' preferred technique for facial reanimation in patients with bilateral congenital facial paralysis. Specifically, a staged bilateral segmental gracilis transfer to ipsilateral nerve to masseter is discussed.

AimTo report clinical outcomes and evidence of corneal innervation in patients with neurotrophic keratopathy (NK) treated with minimally invasive corneal neurotisation (MICN) using a sural nerve graft and donor sensory nerves from the face.MethodsPatients undergoing MICN at The Hospital for Sick Children, Toronto, Canada were prospectively recruited. Data on central corneal sensation (CCS, measured with Cochet-Bonnet aesthesiometer), best-corrected visual acuity (BCVA) and corneal epithelial integrity were collected. In four patients who subsequently underwent keratoplasty, immunohistochemical analysis was performed on the corneal explants. One patient underwent magnetoencephalography (MEG) after MICN to characterise the neurophysiological pathways involved.ResultsBetween November 2012 and February 2017, 19 eyes of 16 patients underwent MICN. Mean follow-up was 24.0±16.1 months (range, 6–53). Mean CCS significantly improved from 0.8±2.5 mm to 49.7±15.5 mm at final follow-up (pConclusionsBy providing an alternative source of innervation, MICN improves corneal sensation and stabilises the corneal epithelium, permitting optical keratoplasty for patients with NK-related corneal opacity.

BACKGROUND: Corneal denervation can lead to opacification and blindness. A new treatment technique, surgical corneal neurotization, transfers healthy donor nerve, (most commonly contralateral supratrochlear or supraorbital) to the affected limbus to prevent corneal destruction and improve healing potential of the cornea following insult. We examine gross and histomorphometric anatomy of the supratrochlear and supraorbital nerves relevant to their use in corneal neurotization. METHODS: For each of nine adult cadaver heads, bilateral supraorbital and supratrochlear nerves were dissected from the supraorbital rim to the anterior hairline. The following data were recorded for each nerve: exit from the orbit through a notch versus foramen; horizontal distance from midline at the supraorbital rim; and distance from orbital exit to first branching point. Samples of all left supraorbital and supratrochlear nerves were obtained at the level of the supraorbital rim and at points 3 cm and 6 cm distally for histomorphometric analysis. Myelinated axon counts were determined for each sample. RESULTS: Four supraorbital foramina, 14 supraorbital notches, two supratrochlear foramina, and 15 supratrochlear notches were identified. Average supraorbital and supratrochlear distances to midline were 26.5 mm and 21 mm respectively. Average myelinated axon counts for both nerves were greater at the orbital rim (supraorbital: 6018, supratrochlear: 2533) than at 6 cm distally (supraorbital: 1621, supratrochlear: 1112). CONCLUSIONS: Anatomic dissection shows relative close approximation of the supraorbital and supratrochlear nerves, with a high proportion of both nerves exiting the orbit through foramina. The supraorbital nerve at the orbital rim contains the greatest number of myelinated axons.

The sural nerve is a common donor site for nerve reconstruction. The only study describing outcomes in paediatric patients was following bilateral sural nerve harvest before the age of 1 year. Bilateral nerve harvest at such a young age may limit patients' ability to perceive a sensory difference. The objective of this study was to understand the sensory and functional deficit after unilateral sural nerve harvest in paediatric patients.A prospective case series was performed in children (age 6-18 years) following unilateral sural nerve harvest. The contralateral foot was used as a control. Sensory Threshold Evaluation was performed by Weinstein Enhanced Sensory Test (WEST) - Foot, and a Functional Sensory and Pain Questionnaire was administered. Sural nerve harvest was performed by a minimally invasive technique using a nerve stripper.Twenty-eight feet of 14 patients that underwent unilateral sural nerve harvest were assessed. As a group, the 14 feet with sural nerve harvest demonstrated significantly higher thresholds in the four areas tested (p0.05), thus identifying objective sensory loss at each location. The location of sensory loss in each patient was variable, with heavier sensory thresholds detected in 69.6% of areas tested than those in the corresponding location in the contralateral foot. Greater sensory loss was detected at the proximal lateral foot than at the distal lateral foot. Responses to the questionnaire revealed that only one patient perceived a sensory loss that affected their function.Unilateral sural nerve harvest in paediatric patients resulted in measurable sensory loss. Despite loss of innervation, only two patients reported intermittent dysaesthesia or cold sensitivity, and the majority of the patients reported no functional deficit.

UNLABELLED Although treating facial palsy is considered debilitating for patients, trigeminal nerve palsy and sensory deficits of the face are overlooked components of disability. Complete anesthesia leaves patients susceptible to occult injury, and facial sensation is an important component of interaction and activities of daily living. Sensory reconstruction is well established in the restoration of hand sensation; however, only one previous report proposed a surgical strategy for sensory nerve reconstruction of the face with use of nerve transfers. Nerve transfers, when used alone, have limited application because of their restricted arc of rotation in the face; extending their arc by adding nerve grafts greatly expands their utility. The following cases demonstrate the early results after V2 and V3 reconstruction with cross-face nerve grafts in three patients with acquired trigeminal nerve palsy. Cross-face nerve grafts using the sural nerve permit more proximal reconstruction of the infraorbital and mental nerves, which allows reinnervation of their entire cutaneous distribution. All patients demonstrated improved sensation in the reconstructed dermatomes, and no patients reported donor-site abnormalities. Cross-face nerve grafts result in minimal donor-site morbidity and are promising as a surgical strategy to address sensory deficits of the face. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.

Botulinum toxin A has been described as an effective adjunct treatment for achieving symmetry in adults with facial paralysis. Few investigators have described the use of botulinum toxin A in pediatric patients with facial paralysis.To present our preliminary experience with botulinum toxin A in pediatric patients presenting with asymmetry of the lower lip.We performed a retrospective medical record review of all pediatric patients (age range, 4-17 years; mean [SD] age, 11.2 [4.7] years) with facial paralysis who were treated with botulinum toxin A injections from January 1, 2004, through December 31, 2012. Patients presented for treatment at The Hospital for Sick Children, Toronto, Ontario, Canada, or the Massachusetts Eye and Ear Infirmary, Boston.Using facial analysis software, we measured lower lip asymmetry in the patients' photographs before and after treatment, at rest, and in a dynamic state. We performed analysis of variance to assess for improvement in symmetry.We identified 18 patients with the following 3 primary indications for treatment: focal lip asymmetry (n = 11), extensive hemifacial asymmetry (n = 5), and focal synkinesis (n = 2). We found no complications related to botulinum toxin A treatment. The mean (SD) dynamic deviation before the injection was 3.5 (1.7) mm, whereas the mean dynamic deviation after the injection was 1.5 (0.8) mm. The mean (SD) deviation correction was evaluated at 61% (6%) and was statistically significant (P = .04).Botulinum toxin A injection is a safe procedure for improving localized asymmetry in pediatric patients with facial paralysis. Preliminary results indicate that botulinum toxin A may be an effective treatment for lower lip asymmetry in children and adolescents.4.

Corneal anesthesia is a debilitating condition which can ultimately lead to blindness from repetitive corneal injury and scarring. We have developed a minimally invasive technique for corneal re-innervation that we have used with excellent results in ten eyes. This article and accompanying video describes the relevant anatomy and demonstrates the technique in detail.

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Objectives Paediatric coronary artery bypass grafting is indicated in cases of clinically significant and symptomatic coronary stenosis, with frequent complications occurring in the perioperative period. To reduce complications and improve outcomes of these procedures, surgical microscopes have been used at our centre with the anastomosis performed by a microvascular surgeon. The purpose of this article is to report our institutional experience in all patients who have undergone paediatric coronary artery bypass grafting procedures with and without microvascular techniques. Methods Twenty-four patients who underwent coronary artery bypass grafting from January 2000 to May 2017 were retrospectively reviewed. Results Eighteen patients underwent bypass without microvascular involvement and 6 patients required the use of microsurgical techniques. Median age at the time of operation was 9.79 and 2.02 years for the 2 groups, respectively. The median weight at the time of operation was 41.2 and 10.75 kg for the 2 groups, respectively. Procedures were performed emergently in 4 patients. Three major anastomotic complications occurred requiring reoperation, although none occurred in the microvascular group. The median follow-up was 3.40 years and 5.25 years for the 2 groups, respectively. Three patients were symptomatic at last follow-up and 2 deaths occurred, all in the non-microvascular group. All grafts were patent in both groups. There were no statistically significant differences between preoperative and postoperative ejection fraction between the groups. Conclusions Our results highlight the potential positive impact of collaboration between cardiac and microvascular surgeons during paediatric coronary artery bypass grafting procedures and the subsequent reduction in complications that may be expected.

Smiling is an important aspect of emotional expression and social interaction, leaving facial palsy patients with impaired social functioning and decreased overall quality of life. Although there are several techniques available for facial reanimation, staged facial reanimation using donor nerve branches from the contralateral, functioning facial nerve connected to a cross-face nerve graft (CFNG) is the only technique that can reliably reproduce an emotionally spontaneous smile. Although CFNGs provide spontaneity, they typically produce less smile excursion than when the subsequent free functioning muscle flap is innervated with the motor nerve to the masseter muscle. This may be explained in part by the larger number of donor motor axons when using the masseter nerve, as studies have shown that only 20% to 50% of facial nerve donor axons successfully cross the nerve graft to innervate their targets. As demonstrated in our animal studies, increasing the number of donor axons that grow into and traverse the CFNG to innervate the free muscle transfer increases muscle movement, and this phenomenon may provide patients with the benefit of improved smile excursion. We have previously shown in animal studies that sensory nerves, when coapted to a nerve graft, improve axonal growth through the nerve graft and improve muscle excursion. Here, we describe the feasibility of and our experience in translating these results clinically by coapting the distal portion of the CFNG to branches of the infraorbital nerve.

We illustrate the case of a brachial pseudoaneurysm in a 32-week preterm baby male who presented with a large pulsatile mass in the right antecubital fossa, with no clear aetiologic factor. The management of this type of lesion has been controversial and based mainly on case reports. In this case, after obtaining partial response with two thrombin injections, it spontaneously regressed during expectant management. This combination of therapeutic options may be an alternative for the management of complex lesions and, to the best of our knowledge, has not been previously reported.

Facial paralysis in children is a disabling functional and aesthetic issue. In cases where recovery is not expected, there are numerous options for reconstruction of the midface "smile." At the Hospital for Sick Children in Toronto, Canada, we have been using a free functional gracilis muscle transfer. In this article, we review the technical details of the procedure, which we have refined over the past 30 years, and also briefly discuss secondary and adjunctive procedures.

Proximal forearm replantation presents with multiple challenges. In this paper, we present the unique advantages of transplantation at the level of proximal forearm and contrast this to replantation. We describe the rationale for transplantation following below elbow amputation: the bone level allows fixation and preservation of the functioning elbow joint, and the muscle can be reconstructed above the elbow. The surgical procedure including anatomic dissections is also illustrated.

Vascularized Composite Allotransplantation (VCA) enables improved function and quality of life for those who have lost anatomical parts such as a limb and the relief of profound suffering for those with severe facial disfiguration. VCA differs from vital organ transplantation in two important ways: (1) these transplants are not necessary for recipient survival, impacting risk-benefit ratios; and (2) face and limb transplants are visible and touchable, leading to issues of identity changes, social interaction and psychological adjustments. This chapter will consider the ethical implications of VCA in pediatrics. This chapter will be divided into the following six sections: (1) introduction; (2) the state of the science and experience with VCA; (3) risk-benefit assessment; (4) informed consent (i) donors and donor surrogate decision makers (ii) recipients and recipient surrogate decision makers; (5) establishing a pediatric program (i) recipient selection (ii) allocation; (iii) accountability for surgical innovation and (6) conclusion.

PURPOSE OF REVIEW In this review article, aimed at those likely to encounter but relatively unfamiliar with paediatric facial paralysis, we summarize reconstructive options in its surgical management. RECENT FINDINGS The article looks at static and dynamic reconstructions available to address the problems encountered in the different anatomical regions of paralyzed face. SUMMARY Although multiple surgical options are available for each anatomical region, decision-making should be taken in a multidisciplinary environment, and take into account the individual requirements of the family and patients.

Free functional muscle transfer to the face is a standard of facial animation. The contralateral facial nerve, via a cross-face nerve graft, provides spontaneous innervation for the transferred muscle, but is not universally available and has additional shortcomings. The motor nerve to the masseter provides an alternative innervation source. In this study, the authors compared donor nerve histomorphometry and clinical outcomes in a single patient population undergoing free muscle transfer to the face.Pediatric patients undergoing dynamic facial (re-)animation with intraoperative nerve biopsies and gracilis transfer to the face powered by either the contralateral facial nerve via a cross-face nerve graft or the motor nerve to the masseter were reviewed over a 7-year period. Myelinated nerve counts were assessed histomorphometrically, and functional outcomes were evaluated with the Scaled Measurement of Improvement in Lip Excursion software.From 2004 to 2011, 91 facial (re-)animation procedures satisfied study inclusion criteria. Average myelinated fiber counts were 6757 per mm2 in the donor facial nerve branch, 1647 per mm in the downstream cross-face nerve graft at the second stage, and 5289 per mm in the masseteric nerve. Reconstructions with either innervation source resulted in improvements in oral commissure excursion and smile symmetry, with the greatest amounts of oral commissure excursion noted in the masseteric nerve group.Facial (re-)animation procedures with use of the cross-face nerve graft or masseteric nerve are effective and result in symmetric smiles. The masseteric nerve provides a more robust innervation source and results in greater commissure excursion.Therapeutic, III.

Intravascular pyogenic granuloma is a rare tumour, with approximately 30 cases presented previously in the literature. It most commonly occurs in the veins of the head and neck and upper extremity in middle-age patients. There is a paucity of reports detailing this lesion the pediatric literature. A case involving a 14-year-old boy with an intravenous pyogenic granuloma is presented.