Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 807814

A modied longitudinally split segmental rectus femoris muscle ap transfer for facial reanimation: Anatomic basis and clinical applications
Daping Yanga,*, Steven F. Morrisb, Maolin Tangb, Christopher R. Geddesb
a

Division of Plastic Surgery, Department of Surgery, The 2nd Hospital of Harbin Medical University, Harbin HLJ 150086, China b Department of Anatomy and Neurobiology and Department of Surgery, Dalhousie University Halifax, Nova Scotia, Canada
Received 25 April 2005; accepted 19 October 2005

KEYWORDS
Rectus femoris muscle; Facial reanimation; Surgical ap; Neurovascular anatomy

Summary The present study was conducted to investigate the intra-muscular neurovascular anatomy and the intra-muscular tendon distribution of the rectus femoris muscle to reassess the reliability of technique of harvesting a longitudinally split segmental muscle ap, and to present our clinical experience on usefulness of the longitudinally split segmental rectus femoris muscle ap as a method for reconstruction of the paralysed face in a series of 25 patients. Twenty fresh cadavers were systemically injected with lead oxide, gelatin and water. Based on the anatomy of intra-muscular neurovascular structure in the rectus femoris muscle, 25 consecutive patients with established facial paralysis were treated by using a twostage method combining neurovascular free-muscle transfer with cross-face nerve grafting. Follow-ups were 1524 months. All of the 25 patients showed signicantly improvement in the appearance of the oral commissure and oral competence. Satisfactory results of facial reanimation were obtained in 23 patients. Among these cases, near-natural facial expression was achieved. Recovery continued up to 2 years postoperatively. There were two cases having poor movement of transferred muscle 2 years postoperatively. No complications occurred in the donor site. In conclusion, the present study has demonstrated the suitability for subdivision of the segment muscle ap of the rectus femoris into two functional units with a common neurovascular pedicle. This series has further demonstrated the safety and reliability of using the rectus femoris muscle ap for facial reanimation. q 2006 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons.

* Corresponding author. E-mail address: dapingyang@hotmail.com (D. Yang).

Since, Harii et al. rst reported free gracilis muscle transfer for facial reanimation,1 the technique of the free gracilis muscle transfer has been adopted

S0007-1226/$ - see front matter q 2006 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons. doi:10.1016/j.bjps.2005.10.015

808 and rened by others to achieve both an aesthetic and a functional reconstruction.27 The modied methods included substantial debulking, thinning, and splitting of the muscle to achieve satisfactory results. However, these additional procedures carried the risk of denervation and devascularisation of the muscle ap. Hemostasis control with cautery tends to cause excessive muscle injury. Another problem with the gracilis muscle that surgeons faced was lack of an adequate and strong tendon for attachment to the recipient site during the muscle ap inset, so that many patients required a subsequent procedure to shorten the muscle or adjust its insertion.7,8 To overcome these drawbacks, Taylor et al. has proposed the coracobrachialis muscle as an ideal donor muscle because they considered certain features of the muscle would allow it to improve on the overall result. These features include its long proximal tendon, the thick intermuscular septum along its lateral surface, and the ligament of Struthers.8 The rectus femoris muscle has been used for onestage reconstruction of the established paralysed face.9,10 Our previous anatomical study of the rectus femoris muscles has been conducted to assess the potential of the rectus femoris as an alternative donor muscle for facial reanimation.11 In the present study, our attention was focused on the intramuscular neurovascular anatomy and the intramuscular tendon distribution to reassess the reliability of the technique of harvesting a longitudinally split segmental muscle ap. Our clinical experience on usefulness of combining the longitudinally split segmental rectus femoris muscle ap transfer with cross-face nerve grafting as a two-stage method for reconstruction of the paralysed face in a series of 25 patients is also presented in this paper.

D. Yang et al. tendon) to harvest a segment of muscle ap with a dominant neurovascular pedicle and the intramuscular tendon from the mid-third of the muscle. The segment muscle ap was radiographed. The second radiograph revealed the intra-muscular vascular branches of the segment muscle ap. Finally, careful dissection was performed by subdividing the segment muscle ap into two functional units through the neurovascular hilum of the medial border of the muscle, each with its neurovascular supply. The supercial segment consists of the supercial branch of the dominant neurovascular pedicle and the intra-muscular tendon; the other deep segment contains the posterior branch of the dominant neurovascular pedicle and the posterior aponeurosis (Fig. 1). Both longitudinally split segmental rectus femoris muscle aps were radiographed again. All radiographs were then analysed.

Part B. Patients and surgical technique

Patient proles Between 1999 and 2004, 25 patients with established facial paralysis underwent surgical correction using the rectus femoris muscle transplantation. Nine were male patients and 16 were female patients. Patients ranged in age from 15 to 54-year-old (mean 27-year-old). Facial paralysis was incomplete in four of the 25 patients, and the remaining patients had complete facial paralysis. The mean duration of facial paralysis was 8 years (range 1.512 years). Causes of facial paralysis include complication of tumour surgery (such as acoustic neuroma or preauricular or infraauricular tumour excision), unresolved Bells palsy, intra-cranial seventh nerve damage, trauma, or congenital dysfunction. All patients received a classic two-stage procedure: cross-face nerve grafting followed by the rectus femoris functioning muscle ap transplantation. Photographs and videotapes were obtained for all patients before and after surgery and every 6 months thereafter. Outcome was assessed by clinical examination and patient questionnaire for facial appearance at rest and during voluntary and involuntary movements and muscle tone. Surgical technique The operative procedure is divided into two stages. The rst stage consists in a classic cross-face nerve graft. A modied parotidectomy incision with submandibular extension is used to expose the branches of the facial nerve on the nonparalysed side. Two of these branches is divided and joined to

Materials and methods

Part A. Anatomical study
The study was carried out on 20 fresh human cadavers (18 men, 2 women; mean age 74 years). The cadaver underwent arterial injection by means of the carotid artery with a lead-oxide, gelatin, and water mixture. Thereafter, the rectus femoris muscle was dissected. The muscle was radiographed. Radiographs revealed the intra-muscular arterial pattern. Further dissection was then carried out by longitudinally splitting the muscle through the midline of the bipennate structure (landmark of intra-muscular

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Figure 1 The anterior (A) and the posterior (B) view of the rectus femoris muscle show the intra-muscular tendon and the aponeurosis are included with the supercial and deep sections of segment muscle aps. (1) Rectus femoris muscle; (2) supercial section of segment muscle; (3) deep section of segment muscle ap; (4) dominant vascular pedicle; (5) neural branch; ap; (6) intra-muscular tendon; and (7) aponeurosis.

the nerve graft. Making sure that the buccal branch is one of these donor branches. Simultaneously, the sural nerve graft is harvested using multiple small transverse incisions. The sural nerve graft is anastomosed to the donor facial nerve branches and is tunnelled through the upper lip to the paralysed side. The graft is anchored to the dermis by silk suture. Tinels sign is followed, and about 812 months later the vascularized muscle is transferred and its neural branch is sutured to the distal end of the cross-face nerve graft. For the second stage, the two-team approach is used. One team prepares the facial nerve graft and recipient vessels, and the other harvests and prepares the donor muscle on its neurovascular pedicle. The patients are placed in the supine position. An s-shaped skin incision is made on the anterior thigh from the midpoint of the inguinal ligament to the point of 15 cm proximal to the superior pole of the patellar. The femoral triangle area is dissected to identify the branches of the femoral nerve and the lateral circumex femoral artery. The motor branch of the rectus femoris is identied through careful dissection from the femoral nerve trunk. Dissection proximally along the femoral nerve trunk increases the length of the nerve pedicle to 1215 cm. The rectus femoris is longitudinally split through the midline of the bipennate structure for harvesting a segment of muscle ap with a dominant neurovascular pedicle (68 cm in length) and the intra-muscular tendon from the mid-portion of the muscle. The remaining part of the muscle is then left in the thigh, having its blood supply from the other minor vascular

pedicle. Careful dissection is performed by subdividing the segment muscle ap into two functional units through the neurovascular hilum of the medial border of the muscle. The supercial segment ap consists of the supercial branch of the dominant neurovascular pedicle and the intramuscular tendon; the other deep segment ap contains the posterior branch of the inferior dominant neurovascular pedicle and posterior aponeurosis. Dimensions of the muscle ap are 23 cm in width and approximately 810 cm in length. A preauricular incision is performed on the paralysed side to create a subcutaneous cheek pocket to accept subsequent neurovascular muscle transfer. The facial vessels and the cross-face nerve graft are identied and prepared for anastomosis. The split segmental muscle aps are then transferred to the malar pocket of the paralysed face. The supercial segment ap is used to reconstruct paralysed face muscle. The proximal end of the intra-muscular tendon and muscle are, respectively, anchored to the periosteum of the zygomatic prominence and to the fascia deep to the submuscular aponeurotic system; its distal intramuscular tendon is sutured to oral commissure and the distal end of the muscle ap is then separated into two equal sections that are, respectively, anchored to the paralysed orbicularis oris muscle in the upper and lower lip. The deep segment ap is used to reconstruct the paralysed orbicularis oculi muscle and the nasolabial fold. The proximal end of the deep segment ap is sutured to the temporal muscle. The distal

810 aponeurosis is also divided into two strips. One strip is xed to the inner canthal ligament through a lower eyelid incision, and the other to the paralysed nasolabial fold. The transferred muscle is placed in enough tension so that under anaesthesia it is tight enough to place the paralysed oral commissure in balance with 1 cm higher than the normal side. The common vascular pedicle of two muscle grafts is anastomosed to the facial vessels. Its neural branch is sutured to the distal end of the cross-face nerve graft.

D. Yang et al. The most of the rectus femoris muscles (80%) were classied as type II, with a dominant vascular pedicle and a minor pedicle from the different branches of the lateral circumex femoral artery. A minor pedicle arose from an ascending branch or the transverse branch, which entered the deep surface of the rectus femoris and supplied the proximal muscle. The dominant vascular pedicle arose from the descending branch and entered the muscle at the junction of the upper and middle thirds. Within the muscle, it divided into two main branches that ran straight down to supply the distal two-thirds of the muscle. The supercial branch of the dominant vascular pedicle ran supercially along the medial border of the rectus femoris, and the other posterior branch coursed behind the intra-muscular tendon. There were few anastomoses between the dominant artery and the minor artery (Fig. 2). Twelve percent rectus femoris muscles were classied as type I, having a single vascular pedicle, without regard to some tiny branches supplying the

Results
Part A. Anatomical study
Intra-muscular neurovascular supply Three different vascular patterns in 40 muscles were observed based on Mathes classication.

Figure 2 Arteriogram showing that the rectus femoris muscle receives a dominant vascular pedicle and one minor pedicle (A). A segment of muscle ap is separated from the muscle (B). The segment of muscle ap is subdivided into two functional units through the neurovascular hilum (C).

Segmental rectus femoris muscle ap transfer for facial reanimation tendons of origin and insertion. This vascular pedicle was derived from the descending branch of the lateral circumex femoral artery. Before entering the muscle, the vascular pedicle generally divided into a superior minor branch and an inferior dominant branch. Eight percent muscles received two dominant vascular pedicles from two different branches of the lateral circumex femoral artery as type III. The superior dominant arterial pedicle arose from the ascending branch or the transverse branch of the lateral circumex femoral artery, and the inferior dominant pedicle stemmed from the descending branches of the lateral circumex femoral artery. In general, the intra-muscular vascular pattern in type I or type III was similar to that in type II. The three different vascular patterns were presented only based on the number of vascular pedicles, whether or not arising from different branches of the lateral circumex femoral artery, and their relative dominance within the muscle. The rectus femoris was innervated by a branch from the posterior division of the femoral nerve. The neural branch divided into two branches before it reached the muscle. These branches were, respectively, accompanied by arterial branches to form two neurovascular hila. The superior branch entered the muscle on its proximal posterior surface with the superior vascular pedicle. The inferior branch entered the medial border of the muscle with the inferior dominant vascular pedicle, and split into two branches, respectively, accompanying the supercial branch and the posterior branch of the dominant vascular pedicle before or after entering the muscle. The intra-muscular neural pattern, like the vascular pattern, is oriented longitudinally. Once the nerve separated into two individual fascicles within the muscle, they run parallel to the muscle bers and vascular branches. Intra-muscular structure related to segment muscle ap harvesting The rectus femoris is a fusiform muscle with its supercial bers arranged in a bipennate pattern, and its deep bers run parallel to the long axis of the muscle. Its straight tendinous head is attached to the anterior inferior iliac spine and formed the supercial tendon on the muscles anterior aspect of the proximal third. The intra-muscular tendon arose from the tendon of the reected head. Distal to the supercial tendon, the bipennate structure was formed by the muscle bers arising from the intra-muscular tendon. From the cross-section view, the intra-muscular tendon lay in the anterior portion of the middle muscle belly, and travelled

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through the majority of the muscle length. Its anatomic landmark was the midline of the bipennate structure. A broad aponeurosis was seen on the posterior aspect of the muscles distal two-thirds. Taken together, these ndings could provide some potential insights regarding the segmental rectus femoris muscle transfer as follows. 1. The lengths of the intra-muscular tendon of the rectus femoris and the aponeurosis along its posterior surface enable them to be included with any segment of muscle located along the medial surface of the muscle (Fig. 1). 2. The longitudinally oriented pattern of neurovascular supply of the muscle makes it an ideal choice for longitudinal subdivision (Fig. 2). 3. The supercial and deep sections of the muscle can be easily identied at the dominant neurovascular hilum, as its supercial bers arrange in a bipennate pattern and its deep bers run parallel to the long axis of the muscle. Dissection through the neurovascular hilum can subdivide a segmental muscle ap into two functional units, each with its neurovascular supply.

Part B. Clinical study

All of the 25 patients underwent transfer of the muscle without any complications. No muscle necrosis was observed. All of the 25 patients showed signicantly improvement in the appearance of the oral commissure and oral competence. Satisfactory results of facial reanimation were obtained in 23 patients, evaluated at 15 months to 2 years after second operation. Among these cases, near-natural facial expression was achieved. Recovery continued up to 2 years postoperatively. There were two cases out of 25 cases only with static symmetry of the lips and without the movement of transferred muscle 2 years postoperatively.

Case reports
Case 1
A 24-year-old man presented with left complete facial paralysis resulting from intra-cranial damage 2 years previously. The rectus femoris muscle was transplanted for facial reanimation combined with cross-face nerve grafting which was joined to two contralateral buccal branches. Seven months after the surgery, the patient felt a weak contraction of the transferred muscle, and 2 years after surgery,

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Figure 3 A 24-year-old man presented with left facial paralysis resulting from intra-cranial damage 2 years previously. Seven months after the surgery, the patient felt a weak contraction of the transferred muscle, and 2 years after surgery, the muscle contracted with considerable power. Smiling before treatment (A); 2 years after muscle ap transfer at rest (B), and 2 years after muscle ap transfer with muscle contraction (C).

the muscle contracted with considerable power (Fig. 3).

Case 2
A 31-year-old woman presented with a left complete facial paralysis of 4 years duration that resulted from resection of a recurrent intra-cranial cholesteatoma. Two-stage method combining neurovascular free-muscle transfer with cross-face nerve grafting was performed. A strip from aponeurosis of rectus femoris muscle was used to suspend the left lower eyelid, because the left temporal muscle had already been used to ll in a dead space when the cholesteatoma was removed. Muscle contraction was not observed 2 years after neurovascular free muscle transfer. Only static symmetry of the face was shown (Fig. 4).

Case 3
A 23-year-old man with left complete facial paralysis 2 years after a left acoustic neuroma previously removed was treated by cross-face nerve grafting and split segmental rectus femoris muscle transfer. The patient felt voluntary movement of the transferred muscle 8 months after the surgery, and the muscle obtained considerable contraction 2 years after the operation. A distal aponeurosis strip was used to suspend the left lower eyelid (Fig. 5).

Discussion
Although reanimation of the paralysed face is one of the challenges for the reconstructive surgeon, a considerable progress has been made over the last two decades. Neurovascular free muscle transfer is

now a standard procedure for the dynamic smile reconstruction of longstanding facial paralysis. Surgeons have obtained a good result in the treatment of facial paralysis with cross-facial nerve grafts in combination with free vascularised muscle aps in recent years. Surgeons have favoured the gracilis muscle for its reliable vascular supply, the ease being harvested, and its expendability. In addition to the gracilis, the extensor digitorum brevis,12,13 serratus anterior,14 latissimus dorsi, 15,16 rectus abdominis, 17 and pectoralis minor18,19 muscles have been used in attempts to restore spontaneous symmetrical movements to the face to achieve both an aesthetic and a functional reconstruction. However, inadequate cosmetic result is problematic because many patients require subsequent procedures to debulk the muscle, shorten it, or adjust its insertion.8 An ideal splitting segment muscle ap, therefore, should have not only a consistent neurovascular pedicle, but also include an adequate and strong tendon for attachment to the recipient site. Transfer of the rectus femoris has been performed to improve facial smile function in patients with unilateral established facial paralysis in onestage.9,10 We preferred cross-face nerve graft followed by free-muscle transplantation as a twostage procedure, because of the better results achieved with more synchronous, natural, and symmetric facial movement. We modied Koshimas method to a longitudinally split segmental rectus femoris muscle ap transfer with an intramuscular tendon. The rectus femoris as an alternative donor muscle has the common advantages the same as the gracilis, including a reliable neurovascular supply, minimal donor-site morbidity, and the option of having two teams operate simultaneously. In addition, it has a few unique features, such as the

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Figure 4 A 31-year-old woman presented with a left complete facial paralysis of 4 years duration that resulted from resection of a recurrent intra-cranial cholesteatoma. Muscle contraction was not observed 2 years after neurovascular free muscle transfer. Only static symmetry of the face was shown. Before treatment (left) and after treatment (right).

intra-muscular tendon and broad aponeurosis, which can be included with the split segment of muscle harvested for facial reanimation to facilitate attachment of the muscle in the face to improve the facial asymmetry.

The intra-muscular tendon was found in our experience to be helpful not only for anchoring the muscle ap to the fascia and periosteum, but also for splitting and thinning the segmental muscle ap. Careful dissection through the intra-muscular

Figure 5 A 23-year-old man with left complete facial paralysis 2 years after a left acoustic neuroma previously removed was treated by cross-face nerve grafting and split segmental rectus femoris muscle transfer. Smiling before operation (A). Two years after muscle transfer (B).

814 tendon can reduce the likelihood of tissue injury and ensures that the segment of muscle harvested can be safely performed in an expeditious and reliable manner. Because the rectus femoris is relatively thick compared with the facial muscles, a splitting segment muscle ap is required for facial reanimation. The lengths of the intra-muscular tendon of the rectus femoris and the aponeurosis along its posterior surface enable them to be included with any segment of muscle located along the medial surface of the muscle used for facial reanimation. The intra-muscular tendon is of signicance because it can be used as a fascial sling for static support in the face when it is harvested with the muscle. On the other hand, the technique of harvesting a segmental muscle ap using the intra-muscular tendon as a landmark can minimise the chances of intra-muscular nerve and vessel damage, since there are no vascular anastomoses between the bipennate muscles. However, the risk of vessel damage exists during splitting the supercial and deep segment aps. The success of this procedure depends on precise knowledge of the intra-muscular neurovascular anatomy. Care should be taken when dissecting through the neurovascular hilum, where two sections of the muscle can be easily identied, as its supercial bers arrange in a bipennate pattern and its deep bers run parallel to the long axis of the muscle. Furthermore, this present study has demonstrated that the rectus femoris muscles have poorly developed vascular anastomoses between the vascular territories. The phenomenon could be explained on the basis of our intra-muscular dissection. We have found that the intra-muscular tendon inuence vascular connections between the vascular territories within the muscle, which might be benecial to reduce vessel damage during intramuscular dissection. In conclusion, the present anatomical study has demonstrated the availability of two neurovascular hila in the rectus femoris muscle and its suitability for subdivision of the segment muscle ap into two functional units with a common neurovascular pedicle for functioning muscle transfer. Moreover, this series has further demonstrated the safety and reliability of using the rectus femoris muscle ap for facial reanimation.

D. Yang et al.

References
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