The Subzygomatic Triangle: Rapid, Minimally Invasive Identification of the Masseteric Nerve for Facial Reanimation
Johns Hopkins Medicine, Baltimore, Maryland, United StatesPlastic and Reconstructive Surgery (Impact Factor: 2.99). 03/2013; 132(1). DOI: 10.1097/PRS.0b013e318290f6dc
BACKGROUND:: The masseteric nerve is a valuable donor nerve in the management of facial paralysis, however its location is less familiar to surgeons because this motor nerve is not commonly exposed in other head and neck procedures. Current techniques for masseteric nerve identification rely on physical measurements from surface or bony landmarks that may be unpredictable across patient age, ethnicity and size. We sought to identify a rapid and minimally invasive technique based on surgical anatomy independent of intra-operative physical measurements. METHODS:: A two phase fresh frozen cadaver study was performed followed by a clinical application that included 11 consecutive patients undergoing facial reanimation procedures between May 2012 and October 2012. RESULTS:: Ten cadavers were dissected and 11 clinical applications are reported. In all dissections the masseteric nerve was identified through the newly described "Subzygomatic Triangle". This triangle is formed by the zygomatic arch superiorly, the temporomandibular joint posteriorly, and the frontal branch of the facial nerve inferiorly and anteriorly. This finding was consistent across patient ages (8-49 years) and ethnicities. Through using the short scar, minimal dissection approach described in the study, average time to nerve identification was 10.2 minutes during the clinical application. CONCLUSION:: The subzygomatic triangle is a consistent anatomic landmark for rapid, reliable and minimally invasive identification of the masseteric nerve. The use of the subzygomatic triangle obviates the need for extensive dissection and surgeon reliance upon soft tissue measurements that may vary between patients of different size, gender or ethnicity. LEVEL OF EVIDENCE:: IV.
Article: Traumatic Facial Nerve Injury[Show abstract] [Hide abstract]
ABSTRACT: Facial nerve trauma can be a devastating injury resulting in functional deficits and psychological distress. Deciding on the optimal course of treatment for patients with traumatic facial nerve injuries can be challenging, as there are many critical factors to be considered for each patient. Choosing from the great array of therapeutic options available can become overwhelming to both patients and physicians, and in this article, the authors present a systematic approach to help organize the physician's thought process.Otolaryngologic Clinics of North America 10/2013; 46(5):825-39. DOI:10.1016/j.otc.2013.07.001 · 1.49 Impact Factor
Article: Reanimating the paralyzed face[Show abstract] [Hide abstract]
ABSTRACT: Facial animation is an essential part of human communication and one of the main means of expressing emotions, indexing our physiologic state and providing nonverbal cues. The loss of this important human quality due to facial paralysis can be devastating and is often associated with depression, social isolation and poor quality of life. Interruption of the neuromuscular pathway from the facial motor cortex to the facial muscles is the common causative factor in facial paralysis resulting from various etiologies. Restoring tone, symmetry and movement to the paralyzed face requires timely nerve grafting intervention in cases of reversible paralysis and the transfer of functional muscle units in irreversible paralysis. We review recent advances in these techniques.F1000 Prime Reports 11/2013; 5:49. DOI:10.12703/P5-49
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ABSTRACT: Objectives/HypothesisEvaluation of long-term patient-perceived functional outcomes and quality of life (QOL) related to communication and eating with an emphasis on voice, speech production, and swallowing after cerebello-pontine angle (CPA) surgery. Study DesignProspective cross-sectional study. Methods The MD Anderson Dysphagia Inventory (MDADI), Voice Handicap Index (VHI), and Facial Clinimetric Evaluation (FaCE) surveys were distributed to patients who underwent CPA surgery between January 2008 and December 2010. Immediate postoperative cranial nerve function extracted from medical records was compared to long-term patient-perceived function and associated QOL. ResultsThere was a 61% response rate with a mean postoperative period of 31.6 months (range 15-49). The presence of facial palsy in the postoperative period and the corresponding House-Brackmann (H-B) score were the strongest predictors of patient-perceived long-term function and QOL in all three domains (P<.005). Postoperative vagal palsy by comparison was not associated with long-term disturbance of voice or speech function. Postoperative dysphagia had a particularly large association with perceived long-term facial function and related QOL (P<.0005), with a smaller but significant impact on perceived swallow outcome (P<.05). After adjusting for other variables, the postoperative H-B score remained a significant predictor of perceived long-term facial and voice function and related QOL. Conclusions Patients with severe facial dysfunction following surgery to the CPA are at increased risk for long-term self-reported difficulties with communication and eating, even with improvement of vagal function. Speech and swallow therapy should therefore be provided to these patients whether or not they also have pharyngeal dysphagia or voice disturbance. Level of Evidence2b. Laryngoscope, 124:476-480, 2014The Laryngoscope 02/2014; 124(2). DOI:10.1002/lary.24252 · 2.14 Impact Factor
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