Figure 1: Anatomy of the latissimus dorsi neurovascular pedicle. (A) An intraoperative photograph of the arrangement of the neurovascular pedicle showing the organisation of the two branches of the thoracodorsal nerve (TDN); The medial branch (TDN(Med)) and the lateral branch (TDN(Lat)) can be seen in relation to the thoracodorsal artery and vein (TDA&V).

Figure 1 (B): A diagrammatic representation of the neurovascular pedicle before and after the TDN (Lat) has been separated from the main trunk.

Figure 2: Insetting of the latissimus dorsi free functional muscle flap.(A) An intraoperative photograph depicting the insetting of the latissimus dorsi muscle and the joining of the two branches of the thoracodorsal nerve (TDN). The TDN (Med) was coapted to the cross facial nerve graft (CFNG) and the TDN (Lat) was joined to the nerve to the masseter muscle (MN) and thus ‘super-innervating’ the muscle flap.

Figure 2(B): A diagrammatic illustration showing the inset of the flap, in addition to the above, showing the thoracodorsal artery and vein (TDA&V) being anastomosed to the facial artery and vein (FA&V). Note that the CFNG passes beneath the lower lip due to the patient having previous cleft surgery.

Figure 3: Pre and postoperative photographs. (A) Pre operative photography of a patient with CHARGE syndrome and complete right sided facial paralysis.

Figure 3(B): A 1 yr post operative photograph showing facial reanimation with good excursion of the muscle when both smiling and biting.

Major Criteria
Minor Criteria
Characteristic facial dysmorphology
Choanal atresia
Facial clefting
Cranial nerve abnormalities
Traceoesophageal fistula
Auditory anomalies
Congenital heart defects
Genitourinary anomalies
Developmental delay
Short stature
Table 1: Clinical features of Charge Syndrome