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The Surgical Management of Facial Nerve Injury
Abstract
The surgical management of facial nerve injuries is dependent upon a thorough understanding of facial nerve anatomy, nerve physiology, and microsurgical techniques. When possible, primary neurorrhaphy is the "gold standard" repair technique. Injuries resulting in long nerve gaps or a significant delay between the time of injury and repair requires alterative techniques, such as nerve grafts, nerve transfers, regional muscle transfers, free tissue transfers, and static procedures. Scrupulous technique, selection of the appropriate surgical management, and aggressive physiotherapy with motor reeducation are all critical to obtaining a functionally and aesthetically acceptable result while minimizing synkinesis and facial asymmetry. This review of the literature provides an overview of current concepts in the surgical management of facial nerve injuries.
... In the case of unexpected facial nerve damage, our treatment is immediate primary neurorrhaphy and steroid treatment [1][2][3][4][5][6][7][8][9]. If the facial nerve is unexpected resected, immediate reconstruction is essential to limit functional and aesthetic deficits [1][2][3][4][5]. ...
... If the facial nerve is unexpected resected, immediate reconstruction is essential to limit functional and aesthetic deficits [1][2][3][4][5]. The best method is tension-free primary neurorrhaphy when the proximal and distal cut stumps of the facial nerve are available for repair [8,9]. If primary neurorrhaphy is impossible, nerve grafts using a donor nerve, such as a sural nerve, great auricular nerve, antebrachial cutaneous nerve, and thoracodorsal, nerve have replaced the facial nerve [1,2,4,8]. ...
... The best method is tension-free primary neurorrhaphy when the proximal and distal cut stumps of the facial nerve are available for repair [8,9]. If primary neurorrhaphy is impossible, nerve grafts using a donor nerve, such as a sural nerve, great auricular nerve, antebrachial cutaneous nerve, and thoracodorsal, nerve have replaced the facial nerve [1,2,4,8]. We performed tensionfree primary neurorrhaphy by detaching facial nerves from surrounding tissues after finishing parotid gland tumor surgery. ...
Background
Unexpected facial nerve damage can occur during parotid gland tumor surgery. We sought to determine the incidence and treatment outcomes of unexpected facial nerve injuries in patients with parotid gland tumor surgery.Methods
We retrospectively enrolled in this study five patients, who underwent facial nerve neurorrhaphy due to unexpected facial nerve injury during parotid gland tumor surgery January 2012–August 2019.ResultsThere were five patients (0.008%) with unexpected facial nerve injuries during the parotid gland tumor surgery of 577 patients in our hospital for approximately 8 years. The most common injury site of facial nerve was the marginal mandibular branch (n = 3), followed by the buccal branch (n = 1), and the cervicofacial division (n = 1). In the case of unexpected facial nerve damage, our treatment is immediate primary neurorrhaphy and steroid treatment. Three patients of five recovered and two did not worsen immediately after surgery.Conclusion
Unexpected facial nerve injury during parotid gland tumor surgery is extremely unfortunate. In this case, immediate primary neurorrhaphy and systemic steroids are recommended to restore facial function and reduce cosmetic deficits.
... 9,10 Para su tratamiento se han intentado diferentes estrategias quirúrgicas, como la neurorrafia primaria, colocación de injertos e incluso se ha probado con la ingeniería de tejidos, pero no han tenido el éxito deseado. 11,12 También se ha recurrido a los factores de crecimiento para favorecer la cicatrización adecuada y regeneración del nervio facial porque favorecen la regeneración axonal y la supervivencia neuronal. 13 En este estudio, con respecto a la evaluación clínica del nervio facial con el cierre palpebral, se obtuvo una mejor y más rápida recuperación en los animales tratados con factor neurotrófico derivado del cerebro porque ésta mejora la neurogénesis y la neurotrasmisión a través de las sinapsis, promueve el crecimiento sináptico y modula la plasticidad sináptica como lo observaron Shi y su grupo 14 al estudiar la aplicación de este factor de crecimiento en la anastomosis del nervio ciático y observaron que hay mejor regeneración de su funcionalidad a las 8 semanas posquirúrgicas. ...
OBJECTIVE: To evaluate the clinical, macroscopic and histological changes and in the expression of myelin basic protein and glial fibrillary acidic protein postneurorraphy of the facial nerve combined with the application of brain derived neurotrophic factor or placement of a sural nerve graft in guinea pigs.
MATERIALS AND METHODS: An experimental, prospective, longitudinal and comparative study was done at Unit of Experimental Lung Transplant of National Institute of Respiratory Diseases Ismael Cosio Villegas, Mexico City. In 18 guinea pigs, divided into 3 groups of 6 each one, neurorraphy of the left facial nerve was performed and they were treated as follows: Group I: Facial nerve neurorraphy without treatment. Group II: sural nerve graft placement without treatment. Group III: Facial nerve neurorraphy and brain derived neurotrophic factor. The study lasted 12 weeks and eyelid closure, vibrissa movements, infection, necrosis, adhesions and fibrosis of
the anastomosis were evaluated. Study was done from January 1st, 2022 to January 31, 2023.
RESULTS: Group III showed better clinical evolution in a shorter time, less macroscopic and microscopic fibrosis, better axonal regeneration and neovascularization. The 3 groups showed similar expression of myelin basic protein and glial fibrillary acidic protein.
CONCLUSIONS: Facial nerve neurorraphy in guinea pigs combined with the application of brain derived neurotrophic factor reduces the degree of facial paralysis in a shorter time and favors the healing of the neurorraphy with less fibrosis and better axonal regeneration than the neurorraphy without treatment and sural graft placement without treatment, but it does not originate changes in the production of basic protein and glial fibrillary acidic protein.
... Traumatic FN injury may occur due to accidental trauma or in the surgical practice of otology and head and neck surgery, either as a complication or as a part of the procedure [2,5,12,13] . If both the proximal and distal segments of the transected nerve are available, tension-free end-to-end anastomosis is considered as the gold standard for repair [14] . However, the results following end-to-end anastomosis are not satisfactory mainly due to poor axonal regeneration and synkinesis [1,7] . ...
Objectives:
To investigate the effects of topical and systemic administrations of melatonin and dexamethasone on facial nerve regeneration.
Materials and methods:
In total, 50 male albino Wistar rats underwent facial nerve axotomy and neurorrhaphy. The animals were divided into 5 groups: control, topical melatonin, systemic melatonin, topical dexamethasone, and systemic dexamethasone. Nerve conduction studies were performed preoperatively and at 3, 6, 9, and 12 weeks after drug administrations. Amplitude and latency of the compound muscle action potentials were recorded. Coapted facial nerves were investigated under light and electron microscopy. Nerve diameter, axon diameter, and myelin thickness were recorded quantitatively.
Results:
Amplitudes decreased and latencies increased in both the melatonin and dexamethasone groups. At the final examination, the electrophysiological evidence of facial nerve degeneration was not significantly different between the groups. Histopathological examinations revealed the largest nerve diameter in the melatonin groups, followed by the dexamethasone and control groups (p<0.05). Axon diameter of the control group was smaller than those of the melatonin (topical and systemic) and topical dexamethasone groups (p<0.05). The melatonin groups had almost normal myelin ultrastructure.
Conclusion:
Electrophysiological evaluation did not reveal any potential benefit of dexamethasone and melatonin in contrast to histopathological examination, which revealed beneficial effects of melatonin in particular. These agents may increase the regeneration of facial nerves, but electrophysiological evidence of regeneration may appear later.
... nerve grafting between the facial nerve trunk and its branches is a treatment option. However, these patients universally develop distressing synkinesis (Rovak et al., 2004). We prefer to reanimate the upper, middle and lower thirds of the face separately, as described. ...
BACKGROUND: Upper eyelid paralysis leads to lagophthalmos with the risk of exposure keratitis, corneal ulceration and blindness. METHODS: Consecutive patients undergoing gold weight implantation and/or lateral tarsorrhaphy were identified from our prospective database and reviewed. RESULTS: Sixty-three patients were identified, 36 of whom underwent immediate reanimation procedure either during cancer excision (n = 35) or repair of facial laceration (n = 1). Twenty-seven patients had a delayed procedure either following tumour excision (n = 21) or unresolved Bell's palsy (n = 3), or facial palsy due to complex craniofacial fracture (n = 3). Nine patients required revision to achieve optimal weight. Fifty-two patients had full eye closure. The remaining 11 patients had almost complete eye closure. CONCLUSIONS: Facial paralysis is devastating for the patient and immediate facial reanimation should be performed. We have demonstrated that gold weight implantation and lateral tarsorrhaphy are simple and effective in achieving eye closure.
... Facial synkinesis is used to describe such uncontrolled abnormal facial muscle contractions which usually accompany the voluntary contraction of another group of facial muscles and is reserved for pathologic conditions following facial nerve lesion. 1 Three mechanisms have been described as primarily responsible for post-facial paralysis synkinesis: aberrant axonal regeneration, peripheral ephaptic transmissions between neighboring regenerating axons and synaptic reorganization and hyperexcitability of the facial nerve nucleus. 2 Types of abnormal facial muscle activity following facial paralysis may include oral to ocular synkinesis (eye closure with mouth movement), ocular to oral synkinesis (oral commissure raising with eye closure), oral and/or ocular to mentalis synkinesis (chin movement with mouth movement and/or eye closure), oral to platysma synkinesis (cordlike platysma contractures with mouth movements), depressor anguli oris tightness with smile and levator labii superioris over-activity at rest. 3 The first two types are the most frequently encountered patterns. 4 The aim of this study is to present a series of pediatric patients that presented in our Center with post-facial paralysis synkinesis and to investigate the efficacy and the reliability of their treatment. ...
Synkinetic movements comprise abnormal involuntary contractions of one or more facial muscle groups which follow the desired contraction of another facial muscle group. They are frequently encountered in patients with long standing facial paralysis and seriously affect their psychological status due to the impairment of their facial appearance, function and emotional expressivity.
Eleven pediatric patients (2 male and 9 female) presenting with post-facial paralysis synkinesis were included in the study. Mean age was 10.3±4 years and mean denervation time 72.5 months.
Patients underwent the following types of treatment: --Cross facial nerve grafting (CFNG) and secondary microcoaptations with botulinum toxin injection which had an improvement of 100% (3 in the 3 grade synkinesis scale) (n=2). --Cross facial nerve grafting (CFNG) and secondary microcoaptations without botulinum toxin injection which had an improvement of 66%(2 in the 3 grade synkinesis scale) (n=5). --CFNG and direct muscle neurotization with (n=2) or without (n=1) botulinum toxin injection where the improvement was 33%. --Contralateral nasalis muscle myectomy was performed in one patient along with CFNG and secondary microcoaptations which resulted in 66% synkinesis improvement. Biofeedback was invariably undertaken by all patients. Postoperative improvement in eye closure and smile was also noted in the respective cases treated for synkinesis ranging from 25 to 50%, with all patients achieving optimum functional return.
CFNG with secondary microcoaptations and botulinum toxin injections was found to be a very efficient surgical modality addressing post-facial palsy synkinesis with high improvement in facial function and symmetry. Facial neuromuscular re-education contributes considerably in the treatment.
... Synkinesis is defined as the abnormal, simultaneous contraction of a group of muscles with voluntary or involuntary facial expression. This phenomenon occurs when regenerating axons innervate unintended targets (Rovak et al, 2004a). Nowadays, microneurovascular reanimation of the face can be carried out also in one stage (Chuang, 2002). ...
Microneurovascular free muscle transfer with cross-over nerve grafts in facial reanimation Loss of facial symmetry and mimetic function as seen in facial paralysis has an enormous impact on the psychosocial conditions of the patients. Patients with severe long-term facial paralysis are often reanimated with a two-stage procedure combining cross-facial nerve grafting, and 6 to 8 months later with microneurovascular (MNV) muscle transfer. In this thesis, we recorded the long-term results of MNV surgery in facial paralysis and observed the possible contributing factors to final functional and aesthetic outcome after this procedure. Twenty-seven out of forty patients operated on were interviewed, and the functional outcome was graded. Magnetic resonance imaging (MRI) of MNV muscle flaps was done, and nerve graft samples (n=37) were obtained in second stage of the operation and muscle biopsies (n=18) were taken during secondary operations.. The structure of MNV muscles and nerve grafts was evaluated using histological and immunohistochemical methods ( Ki-67, anti-myosin fast, S-100, NF-200, CD-31, p75NGFR, VEGF, Flt-1, Flk-1). Statistical analysis was performed. In our studies, we found that almost two-thirds of the patients achieved good result in facial reanimation. The longer the follow-up time after muscle transfer the weaker was the muscle function. A majority of the patients (78%) defined their quality of life improved after surgery. In MRI study, the free MNV flaps were significantly smaller than originally. A correlation was found between good functional outcome and normal muscle structure in MRI. In muscle biopsies, the mean muscle fiber diameter was diminished to 40% compared to control values. Proliferative activity of satellite cells was seen in 60% of the samples and it tended to decline with an increase of follow-up time. All samples showed intramuscular innervation. Severe muscle atrophy correlated with prolonged intraoperative ischaemia. The good long-term functional outcome correlated with dominance of fast fibers in muscle grafts. In nerve grafts, the mean number of viable axons amounted to 38% of that in control samples. The grafted nerves characterized by fibrosis and regenerated axons were thinner than in control samples although they were well vascularized. A longer time between cross facial nerve grafting and biopsy sampling correlated with a higher number of viable axons. P75Nerve Growth Factor Receptor (p75NGFR) was expressed in every nerve graft sample. The expression of p75NGFR was lower in older than in younger patients. A high expression of p75NGFR was often seen with better function of the transplanted muscle. In grafted nerve Vascular Endothelial Growth Factor (VEGF) and its receptors were expressed in nervous tissue. In conclusion, most of the patients achieved good result in facial reanimation and were satisfied with the functional outcome. The mimic function was poorer in patients with longer follow-up time. MRI can be used to evaluate the structure of the microneurovascular muscle flaps. Regeneration of the muscle flaps was still going on many years after the transplantation and reinnervation was seen in all muscle samples. Grafted nerves were characterized by fibrosis and fewer, thinner axons compared to control nerves although they were well vascularized. P75NGFR and VEGF were expressed in human nerve grafts with higher intensity than in control nerves which is described for the first time. Kasvohermohalvauksen kirurginen hoito hermotetulla lihassiirteellä Pitkäaikainen kasvohermohalvaus on potilaalle henkisesti raskas ja kuormittava sairaus, sillä se vaikeuttaa merkittävästi sosiaalista kanssakäymistä ja aiheuttaa suuren kosmeettisen ja toiminnallisen haitan näille potilaille. Osa näistä potilaista hyötyy leikkaushoidosta, ja lisätiedon saanti leikkaustulokseen vaikuttavista tekijöistä on ensiarvoisen tärkeää, jotta oikeat potilaat voidaan valita ja leikkausmenetelmiä parantaa. Pitkäaikaisen kasvohermohalvauksen paras tunnettu hoitomuoto on hermotettu vapaa lihassiirre. Se mahdollistaa kasvojen lihasten toiminnan ja tunteiden ilmaisun.Tässä kaksivaiheisessa leikkauksessa tuodaan ensin vastakkaiselta puolelta kasvoja terveestä kasvohermosta hermosiirrettä käyttäen hermotus halvaantuneelle puolelle. Toisessa leikkauksessa noin puoli vuotta myöhemmin siirretään muualta kehosta vapaa lihassiirre. Tämän lihassiirteen oma hermo yhdistetään aiemmin halvaantuneelle puolelle tuotuun hermosiirteeseen ja verisuonet yhdistetään paikalla oleviin verisuoniin. Optimaalisessa tapauksessa tämä hermotettu lihassiirre alkaa toimia korvaten halvaantuneet kasvojen lihakset, ja potilas saa ilmeensä ja hymynsä takaisin. Tässä väitöskirjatyössä selvitettiin tämän leikkaushoidon pitkäaikaistuloksia ja potilastyytyväisyyttä sekä niitä tekijöitä, jotka vaikuttavat toiminnalliseen lopputulokseen. Potilaista noin 60% saavutti hyvän kasvojen lihassymmetrian ja toiminnallisen tuloksen, ja 78% koki elämänlaatunsa parantuneen selvästi. Pitkä seuranta-aika leikkauksen jälkeen heikensi toiminnallista tulosta. Magneettikuvauksen perusteella lihassiirre kutistui merkittävästi. Magneettikuvauksessa normaalilta näyttävä lihassiirre myös toimi hyvin. Lihas- ja hermossiirteen koepaloista selvitimme, että sekä lihassiirteen säikeet että hermosiirteen toimivien hermojen määrä oli merkittävästi vähentynyt myös silloin, kun lihassiirteen toiminta oli hyvä. Kaikista hermossiirteistä löysimme hermokasvutekijäreseptoria (p75NGFR) ja verisuonikasvutekijää (VEGF), mutta terveistä hermoista näitä ei löytynyt.Hermokasvutekijäreseptorin ilmeneminen oli yhteydessä hyvään toiminnalliseen tulokseen. Aiemmin näiden kasvutekijöiden ilmenemistä ei ole kuvattu ihmisen hermosiirteissä. Tässä väitöskirjatyössä etsimme selittäviä tekijöitä hyvälle tai heikolle lihastoiminnalle vapaassa, hermotetussa lihassiirteessä. Lisäksi tutkimustuloksemme valottavat yleisimminkin vapaan hermosiirteen sekä vapaan hermotetun lihassiirteen piirteitä ja kasvutekijöiden ilmenemistä niissä. Tulevaisuudessa kasvutekijähoidot saattavat auttaa hermoston sairauksista tai vammoista kärsiviä potilaita.
Important anatomic structures can be severed in cheek trauma. Injuries to parotid gland and duct are infrequent; however, diagnosis and treatment are very important in order to avoid post-traumatic fistulas or sialoceles. The most important structures of the cheek are the branches of the fourth part of the facial nerve. Immediate repair of a nerve injury has consistently been the largest predictive factor to successful outcomes in traumatic facial nerve transection. Direct end-to-end coaptation should be attempted for gaps up to 1 cm. When the gap is wider, interpositional nerve autografts ought to be used. Allografts, although providing suboptimal results, are still a feasible option when an autograft is not available. Cheek defects necessitate the use of replacement tissue. Local tissue advancement has been historically preferred; however, recent advances in microrsurgical techniques have permitted free tissue transfer, which eventually improves cosmesis and function in cases of large defects.
The repair of complex soft tissue trauma requires debridement, irrigation, exploration, and the repair of involved structures using a layered closure technique. This chapter focuses on indications, contraindications, anatomy, technique: complex facial laceration repair, postoperative management, and complications. All complex soft tissue lacerations should be explored to rule out injury to underlying vital structures prior to closure. The scalp is highly vascularized and can be associated with significant blood loss over a short period of time. The scalp should be closed in a layered fashion to eliminate potential dead space and hematoma formation. Nasal hematomas present as a reddish‐blue elevation of the nasal soft tissue mucosa and require immediate drainage with an incisional parallel to the nasal floor. The chapter provides several case reports with high‐quality images.
Background: Facial palsy (FP) impacts verbal and nonverbal communication, but the effect of synkinesis on communicative ability is unknown. Objective: Among patients with nonflaccid FP, or synkinesis, is there a correlation between disease-specific quality-of-life and communicative ability or dysfunction? Methods: Retrospective study of a series of adult patients with unilateral synkinesis. Subjects were evaluated using the Communicative Participation Item Bank (CPIB) Short Form, Facial Clinimetric Evaluation (FaCE) scale, and Synkinesis Assessment Questionnaire (SAQ). Associations between these scales were evaluated by computing Pearson correlation coefficients. Results: A total of 69 confirmed synkinesis patients were included. Synkinesis patient mean (standard deviation) CPIB score was 20.68 (±8.27; range of scale 0-30), indicative of communication restriction. A strong correlation was observed between total CPIB and FaCE scores (r = 0.66), indicating patients with synkinesis who reported better facial function also reported greater communicative ability. There was a weak correlation between CPIB and SAQ scores (r = -0.27). Conclusion: Synkinesis is associated with significant deficits in communicative ability. Communication restrictions track strongly with the FaCE scale.
In the area of craniomaxillofacial trauma, neurosensory disturbances are encountered commonly, especially with regard to the trigeminal and facial nerve systems. This article reviews the specific microanatomy of both cranial nerves V and VII, and evaluates contemporary neurosensory testing, current imaging modalities, and available nerve injury classification systems. In addition, the article proposes treatment paradigms for management of trigeminal and facial nerve injuries, specifically with regard to the craniomaxillofacial trauma setting.
Facial soft tissue injury is a challenging and complex problem for the facial plastic and reconstructive surgeon for cosmetic and functional reasons. This article will focus on the management of soft tissue injuries of the cheek, one of the most important presenting areas of the face. The cheek, like any other part of the face, is susceptible to several types of injury and any of these injuries have the potential to disfigure and debilitate. Knowledge of anatomical structures and wound healing principles is critical to devising an appropriate management plan and achieving superior patient outcomes in scar revision cases. Multiple techniques to improve long-term scarring from facial soft tissue injuries are available.
With the advancement in surgical techniques and instrumentation, especially after the introduction of operating microscopes and neuromonitoring, the incidence of iatrogenic facial nerve (FN) injury has decreased dramatically. However, the incidence of trauma and the traumatic injuries to the temporal bone/skull base have been increasing steadily, resulting in debilitating injury to the FN. Therefore, there has been a renewed interest among surgeons for various facial reanimation procedures. The backbone of these procedures is the hypoglossal-facial nerve anastomosis, which was introduced by Korte al [1]. However, this classical hypoglossal-facial nerve anastomosis leads to hemiglossal atrophy. To prevent hemiglossal atrophy and improve the quality of life, this classical procedure had undergone several modifications. In this review article, in addition to the description of classical hypoglossal-facial nerve anastomosis and its various modifications, we will discuss the management issues in patients with FN injuries. Abstract Keywords ► facial nerve ► hypoglossal nerve ► anastomosis ► split ► reanimation
Background:
Closed temporal bone fractures due to cranial trauma often result in facial nerve injury, frequently inducing incomplete facial paralysis. Conventional hypoglossal-facial nerve end-to-end neurorrhaphy may not be suitable for these injuries because sacrifice of the lesioned facial nerve for neurorrhaphy destroys the remnant axons and/or potential spontaneous innervation.
Objective:
we modified the classical method by hypoglossal-facial nerve "side"-to-side neurorrhaphy using an interpositional predegenerated nerve graft to treat these injuries.
Methods:
Five patients who experienced facial paralysis resulting from closed temporal bone fractures due to cranial trauma were treated with the "side"-to-side neurorrhaphy. An additional 4 patients did not receive the neurorrhaphy and served as controls.
Results:
Before treatment, all patients had suffered House-Brackmann (H-B) grade V or VI facial paralysis for a mean of 5 months. During the 12-30 months of follow-up period, no further detectable deficits were observed, but an improvement in facial nerve function was evidenced over time in the 5 neurorrhaphy-treated patients. At the end of follow-up, the improved facial function reached H-B grade II in 3, grade III in 1 and grade IV in 1 of the 5 patients, consistent with the electrophysiological examinations. In the control group, two patients showed slightly spontaneous innervation with facial function improved from H-B grade VI to V, and the other patients remained unchanged at H-B grade V or VI.
Conclusions:
We concluded that the hypoglossal-facial nerve "side"-to-side neurorrhaphy can preserve the injured facial nerve and is suitable for treating significant incomplete facial paralysis resulting from closed temporal bone fractures, providing an evident beneficial effect. Moreover, this treatment may be performed earlier after the onset of facial paralysis in order to reduce the unfavorable changes to the injured facial nerve and atrophy of its target muscles due to long-term denervation and allow axonal regrowth in a rich supportive environment.
Background:
Head and neck arteriovenous malformations (AVMs) involving branches of the facial nerve often cause tremendous cosmetic, functional, and psychological problems that are challenging to treat. We proposed an algorithm to obtain the optimal treatment and esthetic outcome.
Methods:
Medical records of 24 patients were reviewed between 2002 and 2015. The lesions were classified into 4 types: type 1, involving no more than 2 facial nerve branches, with a maximal diameter of lesion of 5 cm or less (n = 7); type 2, involving no less than 2 facial nerve branches, with a maximal diameter of lesion of greater than 5 cm (type 2a, facial nerve preservation, n = 8; type 2b, facial reanimation, n = 5); and type 3, involving the mastoid segments or the trunk of the facial nerve (n = 4). Treatment efficacy was assessed and facial function was evaluated using the regional House-Brackmann Facial Nerve Grading System.
Results:
Cure was achieved in 11 (45.8%) patients, and improvement was achieved in 12 (50.0%) patients, with a follow-up of 36.3 ± 32.9 months (range, 12-144 months). There was no significant difference of the regional House-Brackmann Facial Nerve Grading System score before and after treatment (type 1, unchanged; type 2a, P = 0.356; type 2b, P = 0.423; type 3, unchanged). Treatment outcomes were not significantly related to the type of nerve involvement (P = 1.000) and the facial reanimation procedure (P = 1.000).
Conclusions:
Surgical excision or ethanol embolization alone is efficient for type 1 AVMs. The optimal approach for type 2a AVMs was surgery, followed by well-vascularized tissue transfer. In type 2b AVMs, the satisfied treatment results are achieved by lesion excision and immediate facial reanimation. A 2-stage strategy may result in contented treatment outcome in type 3 AVMs.
The functional and psychosocial impact of facial paralysis on the patient is significant. In response, a broad spectrum of treatment options exist and are provided by a multitude of health care practitioners. The cause and duration of the facial weakness can vary widely and the optimal care pathway varies. To optimize patient outcome, those involved in the care of patients with facial palsy should collaborate within comprehensive multidisciplinary teams (MDTs). At an international level, those involved in the care of patients with facial paralysis should aim to create standardized guidelines on which outcome domains matter most to patients to aid the identification of high quality care. This review summarizes the causes and treatment options for facial paralysis and discusses the subsequent importance of multidisciplinary care in the management of patients with this condition. Further discussion is given to the extended role of the MDT in determining what constitutes quality in facial palsy care to aid the creation of accepted care pathways and delineate best practice.
Soft tissue injuries represent the most common manifestation of craniomaxillofacial trauma seen and evaluated by emergency medical as well as surgical personnel. These soft tissue injuries of the head and neck frequently pose challenging reconstructive problems for the craniomaxillofacial surgeon, and their management entails careful evaluation and planning for optimal treatment. This chapter provides an overview of craniomaxillofacial soft tissue injuries and highlights the major considerations in their management. The reader is provided with a basic framework for analysis of the respective injuries by anatomic region as well as a guiding set of principles for repair. The chapter concludes with special considerations for bite wounds, pediatric soft tissue injuries, and soft tissue injuries associated with craniomaxillofacial fractures to give the reader additional information on these commonly encountered entities.
Facial paralysis can lead to dysfunctions in eyelid closure, which is called lagophthalmos. A number of surgical procedures, both dynamic and static, have been described to restore the innervation of the orbicularis oculi muscle that closes the eyelids. This cadaver-based anatomical study aimed to evaluate the anatomy of the anterior, middle, and posterior deep temporal nerves; nerves to the temporalis muscle; and their availability for direct muscle neurotization of the orbicularis oculi. A total of 10 hemisectioned head specimens from 5 adult cadavers (2 men and 3 women) were used in this study. The adequacy of the length of the anterior deep temporal nerve was assessed for direct neorotization of the orbicularis oculi muscle. The mean distances between the originating point of the deep temporal nerves from the mandibular nerve in the infratemporal fossa and their terminal entry points into the muscle were 46.4 (42-51 mm), 42.2 (38-46 mm), and 33.4 mm (26-40 mm) for the anterior, middle and posterior branches of the nerves, respectively. We conclude that the anterior deep temporal nerve is a versatile nerve that can be used for direct muscle neurotization, nerve transfer, and babysitter procedures in selective blinking restoration. Before proceeding with any further clinical use, an anatomical study should be performed with fresh specimens from cadavers.
A thorough clinical examination is performed to evaluate facial nerve function as parotid duct injuries frequently occur in conjunction with facial nerve injuries. Short-acting paralytics are used to allow for further facial nerve stimulation with a nerve stimulator. Primary anastomosis is performed over the cannulated ends of the duct using nonresorbable nylon (9-0, 10-0) or silk (7-0, 8-0) sutures. All deep facial lacerations involving the parotid gland should have the parotid duct cannulated in order to evaluate the integrity of Stensen's duct. The choice of ductal repair is dependent upon the location of injury and the ability to identify both proximal and distal ends of the parotid duct. All hard and soft tissue injuries require meticulous debridement and closure, with special emphasis placed on aligning the vermilion border of the lip if involved. After definitive treatment of ductal discontinuity, the parotid capsule is closed in order to minimize sialocele formation.
Background:
Reinnervation of target tissues determines functional outcomes after nerve grafting, which is important in traumatic injury caused by accidents or consequences resulting from surgical removal of tumors. Previous studies documented the influences of nerve repair mainly based on nerve morphometry but rarely compared the final outcomes according to target reinnervation patterns by nerve fibers of different categories.
Methods:
In a mouse model of nerve grafting, the authors analyzed the innervation indexes of different target tissues after transection-reimplantation on the sciatic nerve, which were defined as a parameter on the operated side normalized to that on the control side.
Results:
Muscle reinnervation appeared to be the best compared with skin reinnervation (p < 0.0001) and sweat gland reinnervation (p < 0.0001) at postoperative month 3. The sudomotor reinnervation was relatively higher than the cutaneous reinnervation (p = 0.014). The abundance of trophin transcripts for brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic factor (GDNF), and neurotrophin 3 (NT3) was higher in plantar muscles on the operated side than those on the control side. In contrast, transcripts of BDNF, GDNF, nerve growth factor, and NT3 were all similar in the footpad skin between the operated and control sides.
Conclusions:
The results suggested that, compared with the skin, muscles achieved the best reinnervation after nerve grafting, which was related to higher expression of BDNF, GDNF, and NT3 in muscles than in the skin.
Purpose:
This report summarizes our experience in the management of extratemporal facial paralysis with a variety of reconstructive techniques and explores those parameters which are considered to be useful in achieving better outcomes.
Methods:
In all, 56 patients with extratemporal facial paralysis were studied. All the patients had a mean follow-up of 5 years (standard deviation: 3.5). Video evaluation was performed by 3 independent assessors at the required follow-up intervals.
Results:
The final median score for the partial facial paralysis group was significantly higher (4.175) compared with the complete facial paralysis (3.3), P = 0.007. In this series, the only other factor that appeared to influence the final outcome was the denervation time and not the age group, type of facial nerve injury, or method of repair.
Conclusion:
The concept of dynamic panfacial reconstruction with an individual and tailored to patient's needs approach is demonstrated in all and particularly in bilateral cases.
The motor components of local cranial nerves provide a series of options for the surgical rehabilitation of the paralyzed face. Nerve donor sites vary with respect to their motor power, functional deficit, and synergy with facial expression. A thorough understanding of each donor nerve's strengths and weaknesses facilitates the selection process. Technical modifications to reduce donor site morbidity and the emerging role of the masseter nerve are examined.
The anastomosis between the two facial nerves for the treatment of facial paralysis, in which the proximal stump of the severed facial nerve is not accessible, was utilized in eleven patients. The palsy was secondary to resection of an acoustic tumor in nine patients, sarcoma of the petrous bone was the cause in one and an automobile accident in the other. The original concept of anastomosing a branch of the normal pes anserinus to the trunk of the paralyzed facial nerve, as first presented by the author at the Second International Symposium on Facial Nerve Surgery held in Japan in September, 1970, has been modified. The technique of anastomosing the cervico-facial division of the normal facial nerve, and directing it to the temporo-facial division of the paralyzed facial nerve via a sural autograft 20-22 cm long, was combined with the utilization of the ipsilateral descendens cervicalis (hypoglossi). This nerve was anastomosed to the cervico-facial division of the paralyzed facial nerve and utilized in four patients. The technique is illustrated in detail.
On account of the complex anatomy at the base of skull, surgery here may result in post operative cranial n. deficits. Facial palsy is often feared and its effects upon the patient's psychological and emotional well-being can be catastrophic. The modest results and the side effects of the facio-hypoglossal anastomosis used for facial rehabilitation have led us to consider an anastomosis between a motor branch of the trigeminal n. and the facial n. Dissection has allowed us to demonstrate that the masseteric n. offers the characteristics and the relationships which should make such an anastomosis feasible.
We report free serratus transplantation in 100 consecutive patients, 10 in combination with the latissimus muscle and 2 with rib. Transplantation was performed for extremity soft-tissue coverage, contour correction, and facial reanimation. Twenty-two patients received serratus transplantation as part of complex reconstruction requiring multiple microvascular transplants. Overall success was 99 percent, with a single flap failure. Four patients suffered partial flap loss. Emergent reexploration for suspected vascular occlusion was infrequent, required in six flaps (6.0 percent), with an 83 percent salvage rate. Significant complications occurred in 18 percent of recipient sites and 12 percent of donor sites, with eight patients developing seroma/hematoma. No scapular winging was noted, and all patients retained full shoulder range of motion. The serratus muscle flap is a highly reliable flap characterized by a consistently long pedicle, excellent malleability, and multipennate anatomy permitting coverage of complex three-dimensional wounds and consistent performance as a functional transplant. Underlying rib can be included as a myo-osseous flap to expand the versatility of this flap.
A case of traumatic peripheral facial palsy incurred during the removal of an acoustic neuroma via a sub-occipital craniectomy is presented.
The palsy was rehabilitated by using the ingenious method of Dott with a modification. In this, the second anastomosis between the distal end of the peripheral (sural) nerve graft and the distal trunk of the paralyzed facial nerve was performed within the mastoid rather than in the neck. The result obtained is remarkable. The technique is described and illustrated in detail.
Lipomas and fibrolipomas of the larynx and hypopharynx are rare. Indeed, by 1934 Birkett was able to report only 42 extrinsic and 5 intrinsic cases. Additional occurrences have been reported since then and it has been emphasized that these tumors although histologically benign ore clinically malignant.
A case of recurrent fibrolipoma of the pyriform sinuses requiring right transthyroid lateral pharyngotomy in 1951 and 1966 and left transthyroid lateral pharyngotomy in 1961 is reported. The patient has been followed by one observer for the last 35 years and is at present in her 84th year. There has been neither histopathological evidence of liposarcomatous transformation nor recurrence since 1966. Previous recurrences appeared on the contralateral side from first observance after 10 years and on the same side after 15 years.
The use of the gold weight for lagophthalmos is a simple procedure that is usually successful. The important technical points are firm suture fixation to the tarsal plate and placement of the weight high on the plate. The smallest weight, which will provide good coverage of the cornea, should be used because large weights are more likely to migrate. A bulge will not be seen if the weight is placed on a portion of the upper eyelid that recedes into the lidfold on opening the eye. The amount of upper eyelid that is exposed on opening the eye will determine whether this is possible. In some patients, it is not possible to hide the weight and the bulge is unsightly.
In some muscles, distinct and separate portions of the muscle are each under the control of a different fascicle of the motor nerve. Although there is some slight overlap in areas, this unit, a single fascicle muscle territory, is present in the gracilis muscle. Microneurovascular techniques have improved the reliability of muscle transplantation for the reconstruction of facial paralysis. The amount of movement obtained depends on many factors, including the amount of muscle transplanted and the adequacy of its reinnervation. The ability to transplant a small segment of a muscle based on the fascicular territory enables the surgeon to supply the amount of movement that each individual patient requires.
During the general advancement of science which has lately taken place in this country, observations have been gradually accumulating in the schools of the metropolis, which prove that the department of Anatomy has not been stationary. The nervous system, hitherto the most unsatisfactory part of a physiologist's studies, has assumed a new character. The intricacies of that system have been unravelled, and the peculiar structure and functions of the individual nerves ascertained; so that the absolute confusion in which this department was involved has disappeared, and the natural and simple order has been discovered. In proceeding to give some account of these new observations, the Author of this paper had conceived, that it would be more suitable to the scientific body he had to address, to lay the subject before them in the precise manner in which it first presented itself to his enquiries, and to detail his observations and experiments in the succession in which they were made; but he has been persuaded by some of the Members of this Society to change that form, and to present the subject in the manner to which he has been accustomed, in teaching these doctrines; and they were pleased to say, that in this way, a new subject would be more readily comprehended.
Masseter and temporalis muscle transpositions may be considered in cases of longstanding facial paralysis and in the congenital absence of the facial nerve or muscles. The basic advantage of this technique is the introduction of a large volume of living and dynamic muscle into the face. Additional advantages include simplicity, the support provided, enhancement of the possibility of myoneurotization, and no loss of other significant function. In many instances, facial movement improves for a period of approximately two years, and the long-range effect would suggest some degree of rehabilitation of the facial muscles. Our combined experience with over 100 muscle transpositions indicates the efficacy and success of this technique in selected patients.
The hypoglossal-facial nerve crossover is a valuable surgical procedure for the treatment of certain types of facial paralysis. It is most effective when used as an integral part of a primary ablative operation for the treatment of cancer in this region. In the treatment of long-standing facial paralysis, its application requires an intact peripheral facial nerve system and some functioning mimetic muscles with an obliterated proximal facial nerve segment. It is recognized that other procedures are available for repair in patients who meet essentially these same criteria. The disadvantages are minimal intraoral crippling, mass movements of the face and, in some instances, hypertonia of the face. The advantages are improved facial tone, protection of the eye, intentional facial movements controlled by the tongue, and movements associated with physiological functions of the tongue.
The difficulties encountered in extratemporial facial nerve reconstruction after extensive trauma or following resection of parotid tumors often lead to unsatisfactory functional and cosmetic results. So far it has been common practice to use as a "regenerative nerve," the original facial nerve. Using this procedure, however, frequently only a portion of the peripheral branches can be reanastomosed. Above all, the "autoparalytic syndrome" develops in this situation owing to undirected outgrowth of axons, and an aberration of the blinking-reflex motoneurons occurs. Experience has shown that the isolated use of a cross-face transplant is not suitable for satisfactory functional regeneration. Depending on the individual anatomic situation, a number of possibilities are therefore recommended for a combined approach using several "regenerative nerves." In this connection, the particular physiologic properties of these nerves have to be taken into account which can help to improve considerably the functional and cosmetic results.
The two stage principle is one of the most important features of the procedure. It allows starting the operation at a very early stage (one to six months). The donor area in the periphery is very well supplied, therefore as many facial fascicles as necessary can be sacrificed on the healthy side. We have never noticed any functional disturbances. The nerves leading to the buccinator muscle and those which innervate the lateral pull of the mouth are especially suitable. This weakening of the strong pull of the mouth is of great value for symmetry but unfortunately relapse to the original state is common. The selection of the nerve fascicles on the healthy side must be executed in a deep layer below the muscles because all large branches are located here. The end of the sural grafts should positioned far back on the paralyzed side to enable easy anastomoses at the second stage. A face lift incision on the paralyzed side and tightening of the skin are of additional value and provide some support to the elongated muscles. The combination of cross-face nerve transplant with other substitutional methods in which muscles are used for reinnervation is very promising. In our experience physiotherapy is a very important measure. It should be started after the onset of the palsy and continued until restoration of the face is complete. It is usually applied three times a week with exponential current and at a strength of 20 to 60 milliamperes. Each group of muscles receives a 2 to 3 minutes dosage. It is helpful if the patient can use a stimulation apparatus at home daily for short treatments.
A clinical operative technique for free muscle transplantation by microneurovascular anastomoses is presented. Two cases of free transfer of the gracilis muscle for dynamic reconstruction of facial paralysis are described, including a follow-up study with electromyography, light microscopy, and electron microscopy. We feel this new technique will have a wide range of application in reconstructive surgery.
The present study on the anatomy of the human facial nerve is based on the results of a series of gross dissections, and histologieal and electro-diagnostic examinations. From our findings it follows that there is a definite spatial orientation of the peripheral branches in the facial nerve trunk. The results of the morphologic studies are in agreement with those obtained by electric stimulation combined with electromyography. © 1976 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.
After study of local anatomy in fresh cadaver the authors carried out free abductor hallucis muscle transplantation successfully in three patients with facial paralysis. In one patient the plantaris medialis vessels were anastomosed to the contralateral facial vessels and the plantaris medialis nerve was anastomosed to buccal branch of the contralateral facial nerve. In two patients the plantaris medialis vessels were anastomosed to the ipsilateral facial vessels and the plantaris medialis nerve was anastomosed to the myloidens branch from ipsilateral trigeminal nerve. The authors described the local anatomy and operative methods in details. The advantages of this operative method were also discussed.
Fourteen functionally relevant mimic muscles of nine human bodies were analyzed with respect to their muscle fiber sizes and their histochemical fiber type composition. In cryostat sections stained for actomyosin ATPase, type 1 and type 2 fibers were evaluated separately by means of computer-assisted image analysis. The fiber diameters varied between 20.24 and 41.45 microns. According to the proportions of the fiber types, the mimic muscles could be classified into three groups: (1) phasic muscles, with 14 to 15 percent type 1 fibers, (2) intermediate muscles, with 28 to 37 percent type 1 fibers, and (3) tonic muscles, containing 41 to 67 percent type 1 fibers. It is concluded that one has to consider this diversity of mimic muscles when planning the surgical reconstruction of facial paralysis.
The hemitongue paralysis that occurs as a result of a classic hypoglossal-facial nerve crossover procedure can result in profound functional deficits in speech, mastication, and swallowing. The procedure is not an option in patients with bilateral facial paralysis or those at risk for combined cranial nerve deficits. To address some of the drawbacks and limitations of this classic procedure, we developed the hypoglossal-facial nerve interpositional jump graft (12-7 jump graft) procedure. This procedure involves interposing a nerve graft between a partially severed but functionally intact twelfth cranial nerve and the degenerated seventh cranial nerve, and is often combined with other reanimation procedures. To date, we have performed 33 12-7 jump graft procedures in 30 patients (three were treated for bilateral facial paralysis); this report describes the procedure and its indications, and details the results of 23 procedures performed in 20 patients for whom 24-month follow-up data are available. Twelfth nerve deficits occurred in only three patients in this report. Recovery of facial function began between 3 and 24 months postoperatively. Facial tone and symmetry were achieved in every patient, no patient had significant mass movement, and 13 patients (two of whom were treated for bilateral facial paralysis) had excellent and three had superb restoration of facial movement. These results show the 12-7 jump graft to be a valuable adjunct for facial reanimation in selected patients.
We performed neurovascularized free rectus abdominis muscle transplantations in two patients with chronic facial palsy. In one patient, the postoperative course was uneventful, but the patient died from rupture of esophageal varices. In the other patient, both morphologic and functional results were satisfactory. Therefore, the rectus abdominis muscle is considered to be a suitable donor for muscle transplantation for the treatment of chronic facial palsy. The rectus abdominis muscle is advantageous in that (1) simultaneous operations by two teams are possible with the patient in the supine position, (2) it is supplied by long nerves and long and large vessels, (3) it is flat and consists of segments with appropriate lengths, (4) the force and distance of contraction are appropriate, and (5) the tendinous intersections are suitable for anchoring sutures.
Surgical repair of facial nerve deficits may be marred by lack of muscle control and donor region paresis. Using New Zealand white rabbits, a study was undertaken to evaluate facial muscle reanimation with a donor source not previously used: the motor division of the trigeminal nerve. The results were compared with the severed facial nerve and hypoglossal-facial coaptation. An atrophy scale was calibrated for facial muscles of the rabbit. Clinical, electromyographic, and histomorphometric findings confirmed that the trigeminal nerve was a suitable donor source. The neurorrhaphy produced an exponential rate of repair.
This study retrospectively identifies and characterizes patients with facial palsy related to birth trauma and describes the natural history of this disorder. The records of infants born with facial weakness or paralysis over a 5-year period at Brigham and Women's Hospital were reviewed, and criteria were defined to assign a diagnosis of acquired facial palsy based on birth history and documented physical examinations. The majority of patients were followed up by interview with a family member. Among 44,292 infants born between October 1, 1982 and July 31, 1987, there were 92 recorded cases of congenital seventh nerve palsy. Of these, 81 were acquired, for an incidence of 1.8 per 1000. Seventy-four of the 81 (91 percent) were associated with forceps delivery. By contrast, obstetric forceps were used in 19 percent of all deliveries during the period of the study. The average weight of subjects was 3.55 kg, versus a mean overall birth weight of 3.23 kg. Fifty-nine percent of mothers of affected children and 37 percent of controls were prima gravidas. Forceps delivery, birth weight of 3500 gm or more, and primiparity were all significant risk factors for acquired facial palsy. The incidence of additional birth injuries also was substantially higher among affected subjects than among the general population of newborns. Sixty-six of 81 patients had adequate follow-up. Recovery has been complete for 59 patients (89 percent) and incomplete for the remaining 7 (mean follow-up 34 months). In summary, congenital traumatic facial palsy has definable risk factors and a predictably favorable outcome.
The author introduced this muscle for the first time almost a decade ago, and this is the first extensive description of the intricate microanatomy of this complex but unique microneurovascular muscle unit. Advantages and disadvantages and indications and contraindications for its use in facial paralysis are presented in detail from an extensive clinical experience of almost 50 such microneurovascular transfers. Pitfalls that the reconstructive microsurgeon should beware and strengths in using this muscle for facial palsy are highlighted. The detailed operative approach is presented, with promise of undetectable scars and minimal functional loss. The strategies for how to inset this muscle unit in the new recipient site are given, along with the thought processes involved in selecting the actual sites of anchoring the muscle to reproduce a mirror image of the contralateral normal face. Finally, an exemplary clinical case demonstrating the use of the pectoralis minor muscle for both eye and lower face reanimation is presented in detail, demonstrating the dual nerve supply and the resulting independent eye and smile movements with total lack of mass action and/or synkinesis. Restorations of eye blink and of a symmetrical and coordinated smile are the frequent rewards of using this unique muscle for the correction of facial palsy.
One of the primary causes of labial wrinkling is soft-tissue volume loss. I suggest combining the various ancillary procedures with substantial tissue augmentation using autologous dermis grafts.
Forty-four patients with idiopathic facial (Bell's) palsy were studied. They were assessed by the eventual clinical outcome and on this basis 3 groups were formed. Various clinical parameters were studied and those factors associated with a poor prognosis were identified. The factors of significance include age, initial severity of the palsy and the time taken for spontaneous improvement. All other parameters fail to show any statistically significant correlation with prognosis.
In spite of its reliable and long neurovascular pedicle, the latissimus dorsi muscle is generally considered unsuitable for facial reanimation, largely due to its size and bulk. We describe the anatomic dissections and clinical experience using a small segmentally innervated portion of the latissimus dorsi muscle to restore facial animation.
Purified botulinum A exotoxin was used to treat 9 adults with strabismus, 22 adults with incapacitating essential blepharospasm and 1 adult with "senile" spastic lower-eyelid entropion. Eight of the strabismus patients received one injection each into one horizontal extraocular muscle under electromyographic control in the outpatient clinic; the ninth patient received two injections. One week after the injection there was an 81% change on average in the angle of deviation. In the three patients followed up for 4 to 9 months the average change was 66%. For the patients with blepharospasm the toxin was injected into the orbicularis oculi. Relief of spasm lasted an average of 12 weeks after the first treatment and 15 weeks after the second. In the patient with spastic entropion the symptoms resolved with repeated injection of the lower-lid orbicularis. In all three groups the injections were well tolerated. The main complication was transient ptosis, which occurred in about 30% of the first two groups.
When a cut nerve, which has been repaired, does not function properly it is usually due to the regenerating axons failing to cross the site of the anastomosis. The axonal regrowth may be blocked either by the presence of granulation tissue between the cut ends of the nerve, or to poor stabilization of the nerve stumps with resultant movement and torsion.
In the past, many substances have been utilized to protect these anastomosis, most with unfavorable results. The most popular material used today for nerve protection is silastic sheeting which appears to offer some protection without having any major undesirable side effects.
Gibb in a previous article, suggested that autogenous vein may be an excellent material for the protection of facial nerve anastomosis. It is readily available, easily tailored and completely physiologic. We felt his proposal had merit, but that it first should be evaluated in an animal model before embarking on a clinical trial.
Eighteen dog facial nerves were severed. In six animals (control group) the nerve was repaired with three 7/0 silk sutures in neurolemmal sheath. In the second six, after the nerve sheath was repaired, a section of post auricular vein was wrapped around the anastomosis, being held in place with 7/0 silk sutures. In the remaining six animals, prior to repairing the severed nerve, a tube-like section of post-auricular vein was slipped around the proximal segment of the nerve, then after the nerve anastomosis was completed, the vein tube was pulled down over the anastomosis and held in place with 7/0 silk suture.
Animals in each group were sacrificed at one, two and three months, in addition, three animals in each group were kept until maximum return of facial function occurred.
Clinical evaluation revealed that the animals which had their nerve anastomosis protected with the vein tube or vein sheeting, had more complete return of facial function than the control group.
Histological sections showed the vein still to be identifiable during the first two postoperative months, after this is became lost in the general fibrous reaction that occurred around the anastomosis. There was no difference between the groups in the amount of granulation tissue or fibroblasts in the area of the anastomosis. It appears that a careful anastomosis of the neurolemmal sheath will prevent granulations from entering the nerve as effectively as the vein tube; however, we felt that the additional stabilizing effect of the vein tube contributed to the improved results in the sheated animals.
It appears that autogenous vein is a safe substance for the protection of facial nerve anastomosis, and is suitable for clinical use.
The spatial relations of the peripheral branches of the facial nerve within the temporal bone were studied. Five groups of experiments were performed, using 48 adult cats. The topographical anatomy of the horizontal segment was demonstrated by evoked EMG in two cats with injuries to the lateral aspect of the horizontal segment of the facial nerve. The upper face was more severely injured than the lower. The cross sectional spatial anatomy of the horizontal segment of the facial nerve was mapped out in seven cats by histopathologically correlating the lesion site with the peripheral distribution. Gross dissections in 14 cats demonstrated the cross sectional spatial relationships of the peripheral fibers at the stylomastoid foramen and distal portion of the vertical segment. Temporal bone sections in five cats added further to the orientation of the facial nerve.
The following conclusions were drawn from this study:
A technique for placing gold weights in the upperlids to relieve lagophthalmos in patients with facial palsy is described. The indications and other applications of the technique are presented.
In the absence of earlier reported success in the free grafting of autogenous skeletal muscle to orthotopic sites, the present investigation varied the grafting procedure in two ways. First, only complete muscle bellies were transplanted so that the full length of all constituent muscle fibres were included in the graft. Secondly, each complete muscle entity was denervated 14-21 days before transplantation so that the resultant enzyme changes might alter the muscle metabo- ism to a more economic level of aerobic type (increasing vascularity). By this change, the transplant might better survive the initial period of ischaemia and become more effectively vascularized by direct anastomosis of graft and host vessels at the recipient site. In 8 dogs, when 20 free autogenous grafts of skeletal muscle were applied as orthotopic transplants which included the complete muscle belly, microscopic survival occurred in half the grafts but never to more than 5-10% of the original volume of the graft. In 4 dogs, when 8 similar grafts were transplanted 2-3 weeks after preliminary denervation, 6 survived in up to 80% of the original gross volume of the grafts, with histologically normal muscle constituting as much as three-quarters of the surviving graft. A source of innervation limited to one extremity of the graft allowed axonal proliferation to produce reinnervation over a distance of 5 cm of grafted muscle in 6 months. Thereinnervation of muscle grafts was confirmed by histological and histo- chemical investigation, as well as direct electrical stimulation. In a single human patient suffering from facial paralysis, a free graft of the extensor digitorum brevis muscle of the foot was transplanted to the face, 2 weeks after denervation, to reanimate the paralyzed eyelids, with clinically complete success confirmed by electromyography. Histologically normal muscle, the presence of innervating axons, and reinnervated motor end plates were demonstrated in the grafts 8 months after transplantation.
Successful reanimation of the paralyzed face requires a specific yet adaptable procedural armamentarium. Usually, in the treatment of regional paralysis, one distinct technique is deemed most appropriate and dependable. In cases of total hemiparesis secondary to surgical ablation or trauma, however, the simultaneous use of two separate but complementary rehabilitative systems has proved valuable in 15 patients. The reconstructive concept described divides the face into two functional spheres, an upper periorbital area and a lower perioral region. The integral system includes a direct facial nerve-to-cable graft reanastomosis for the upper division combined with a masseter muscle transfer for the lower facial region. The immediate supportive effects of the masseter transposition integrated with its long-term ability to rehabilitate via myoneurotization complement the more physiologically exacting effects of the nerve anastomosis.
This year, 1981, is the 50th anniversary of facial nerve decompression for Bell's palsy. The procedure was first suggested in 1923 but not performed until 1931. From the start, facial nerve decompression has generated disagreement regarding the indication and timing for surgical treatment and the anatomic extent of decompression. In each decade as the postonset time within which to perform surgical intervention has decreased, the anatomic extent of decompression has increased. Otologists continue to disagree, and we need to reevaluate our past and analyze how the difference may be resolved in the future. This critical review, in chronologic order, of the history and present status of facial nerve decompression is the necessary first step in resolving some of the persistent problems in surgical management of patients with Bell's palsy.
A two-stage technique of cross face nerve transplantation in facial palsy is presented. This operation is regarded a substitutional procedure with the mose physiological basis, but beyond the age of 50 other easier operations should be performed unless favourable conditions prevail. The results in 35 patients are reviewed. The cross face nerve transplantation never attain the quality of ipsilateral facial nerve repair, but in case of regeneration the operation is superior to all other substitution operations.
Four patients who had undergone operative procedures, wherein substantial segments of the VIIth cranial nerve had been resected, experienced some degree of reanimation of the muscles of expression despite the fact that no restitutive measures were employed. The site of insult was in the face in two; the temporal bone in one; and the fourth occurred in the cerebellopontine angle.
Teeth-clenching and grimacing were practiced before a mirror by each subject, and one wonders if “re-education” of dormant trigeminal nerve fibers might have facilitated the rehabilitation which was achieved.
Hypoglossal-facial nerve transfer is a standard technique for facial-palsy reconstruction. The fascicular anatomy of the hypoglossal nerve may be important in determining strategies, when attempting to minimize atrophy of the tongue. The present study investigated hypoglossal fascicular anatomy by histomorphometric analysis of 10 human hypoglossal nerves. The nerve demonstrates a monofascicular topography in its proximal third and mid portions, becoming polyfascicular only in its distal third. The mean number of fascicles in the distal portion is 5.0, compared to 1.1 in the proximal and mid portions (p < .01). The mean number of myelinated axons in the hypoglossal nerve is 9200.
Four patients who underwent functioning free muscle transplantation (FFMT) for facial reconstruction developed a progressive disfiguring muscle contracture. This complication has not been previously reported. Three of the patients had longstanding facial paralysis and were reanimated by FFMT. The fourth patient had left hemifacial atrophy but without facial paralysis. She also underwent FFMT for augmentation. All four FFMTs were innervated by the ipsilateral facial nerve. Initially, they all had a normal facial appearance at rest during the first few months after FFMT. However, they all developed a progressive severe muscle contracture from 6 to 12 months after FFMT. Continuous spontaneous electrical impulse activity, which stimulated the transferred muscle day and night, may be responsible for the progressive muscle contracture. From the patients' reported sensations and from clinical evaluation, which included a local xylocaine injection test, over-reinnervation with a synkinesis effect of the transferred muscle is hypothetically the main cause, not over-tension of the muscle itself. This complication may possibly be avoided by limiting or decreasing the number of fascicles from the ipsilateral facial nerve or better by using a cross-facial nerve graft instead of the ipsilateral facial nerve as the innervating motor nerve. The outcome with a cross-facial nerve is likely to be more predictable and reliable.
The free vascularized rectus femoris muscle graft with a long motor nerve was used for reconstruction of unilateral established facial paralysis in one stage. The pedicle vessels were anastomosed to the recipient vessels in the ipsilateral face, and the motor nerve of the muscle, which was led through the upper lip, was sutured to the contralateral facial nerve. The advantages of this one-stage reconstruction as compared with surgery involving second-stage reconstruction are that the reconstruction can be completed in one stage and that the period required for muscle refunctioning after sugery is short. The vascular supply of the rectus femoris muscle can emanate mainly from the later circumflex femoral artery. In our cadaveric study, five types of variation were found for origination of a nutrient artery of the muscle. The most common type was one in which the artery derived from the descending branch of the lateral circumflex femoral artery (39 percent). The motor nerve of the rectus femoris is derived from the femoral nerve under the inguinal ligament and runs downward through the intermuscular space between the sartorius muscle and the iliopsoas muscle before entering the posteromedial part of the upper third of the rectus muscle. The advantages of using the rectus muscle are as follows: (1) safety and simplicity exist with one main large arterial supply for arterial anastomosis; (2) the length of the femoral nerve (more thant 20 cm) is adequate for reaching the contralateral facial nerve for suturing; (3) a simultaneous operation by two teams is possible with the patient in the supine position; (4) the force and distance of contraction are appropriate to reanimate the face; (5) the rectus muscle can be separated as a segment with appropriate lengths; (6) the tendinous fascia in both ends provides a reliable point for anchoring sutures, which provides firmer attachment; and (7) no loss of donor leg function occurs.
The present study examined the histochemical characteristics of the orbicularis oculi muscle (OOM) in the rat, in order to better understand the target muscle of the blink reflex-specifically, the motor endplate distribution and number in the normal, denervated, and reinnervated OOM. Assessment of the number of endplates needed to accomplish eye closure would provide critical information in the microsurgical restoration of the blink reflex in facial paralysis. Results demonstrated a 50% increase in the number of endplates of reinnervated rats, compared to denervated animals.
One of the most unsettling sequela of facial paralysis (FP) is the loss of the blink reflex, leading to both a functional and aesthetic deformity. A successful method of treating FP and, in particular, loss of eye-sphincter function, is the use of the cross-facial nerve graft (CFNG) to reinnervate the previously denervated orbicularis oculi muscle. The present study examined the histomorphometric aspects of the entire CFNG, with respect to axon diameter and myelin area. The axon profile of the CFNG had a positive correlation with motor end-plate counts and electrophysiologic recordings. These results should help in further understanding the number of motor axons needed to restore adequate function to the paralyzed eye sphincter, and establish more rational reconstructive procedures.
There are two types of smiling: without exposure of the teeth (usual smile), and with their exposure (square smile). Performance of the former involves use of the major zygomatic muscle, while the latter is created by the major zygomatic and the depressor labii inferior muscles. The function of the depressor labii inferioris muscle cannot be ignored in facial paralysis reconstruction. A double-muscle transfer using a divided rectus femoris muscle for one-stage reconstruction of both the major zygomatic muscle and the depressor labii inferior muscle is described. The patient suffered facial paralysis caused by an extracranial schwannoma originating from the facial nerve. After the tumor was removed, divided rectus femoris muscle segments were transferred to reconstruct the major zygomatic muscle and the depressor labii inferior muscle. After the pedicle vessel of the muscles was anastomosed to the recipient facial vessel, the long motor nerve of the proximal divided muscle was cross-faced and coapted directly to the prepared contralateral buccal branch. The short motor nerve of the distal muscle segment was sutured to the ipsilateral masseteric nerve.
The advantages of divided rectus femoris muscle transfers are that (1) independent muscle contraction can be reconstructed; (2) no tongue or trapezius muscle atrophy occurs because the masseteric nerve is used as the motor source of the labial depressor; (3) only one muscle is sacrificed for muscle grafts; and (4) it is a one-stage reconstruction.
Presently available techniques for lip augmentation have an assortment of limitations.
To provide a safe, reliable method of lip augmentation on a long-term basis.
Through a stab incision in each quadrant, chips of human cadaver, banked fascia lata were inserted into intralabial pockets.
Fascia lata grafting proved to be a simple effective technique of lip enhancement. Over the period of follow-up, enhancement was evident in most cases and no allergic reactions or infections occurred. Lip motion was satisfactory and paresthesia were minor.
Fascia lata grafting is a simple, controlled technique for graded lip enhancement.
Extrafusal muscle fibers of human striated skeletal muscles are known to have a uniform innervation pattern. Motor endplates (MEP) of the "en plaque" type are located near the center of muscle fibers and distributed within the muscles in a narrow band. The aim of this study was to evaluate the innervation pattern of human facial muscles and compare it with that of skeletal muscles.
Ten facial muscles from 11 human cadavers were dissected, the nerve entrance points located, and the dimensions measured. All muscles were stained in toto for MEPs using Acetylcholinesterase (AChE) and examined under the microscope to determine their location. Single muscle fibers were teased to evaluate the stained MEPs.
The length of the different facial muscles varied from 29 to 65 mm, which correlated to the length of the corresponding muscle fibers. MEP zones were found on the muscles in the immediate vicinity of the nerves' entrance points and located eccentrically. Numbers and locations varied from muscle to muscle. Three MEP zone distribution patterns were differentiated: numerous small MEP zones were evenly spread over the muscle, a predominant MEP zone and two to three small zones were spread at random, and two to four MEP zones of equal size were randomly scattered. One MEP of the "en plaque" type was found in 73.8% of the muscle fibers and two to five MEPs were found in 26.2%. The distances between the multiple MEPs on one muscle fiber varied from 10 to 500 microm.
This study suggests that facial muscles differ from skeletal muscles regarding distribution and number of MEPs. The eccentric location of MEP zones and multiple MEPs suggests there is an independent mechanism of neural regulation in the facial muscle system.
Complications occurred in six patients after gold weights were implanted into the upper eyelid tissues for fifth and seventh nerve palsies. These complications included implant infection without extrusion (in one patient); entropion with trichiasis and presumed inflammatory reaction to the gold weight material (in one patient); upper eyelid distortion and poor eyelid contour with corneal ulceration and scarring (in one patient); significant residual lagophthalmos with exposure keratitis (in one patient); and blepharoptosis obscuring the pupillary access (in two patients). Resolution of the complications required 1. implant removal in four of six patients without reinsertion of a second weight, 2. recession of the retractors of the upper eyelids with medial and lateral canthoplasty (in four patients), and 3. permanent tarsorrhaphy (in one patient). The authors conclude that complications may be minimized by careful preoperative determination of the optimum implant size, weight, and placement within the eyelid as well as meticulous attention to the surgical technique of implantation. The use of other eyelid protective procedures is often necessary to augment corneal protection especially in patients with combined fifth and seventh cranial nerve palsies. Endogenous implant infection without extrusion of the gold weight may be distinguished from presumed inflammation due to gold allergy by clinical response to antibiotics in the former and requirements of steroids or removal of the implant in the latter.
The authors report their experience with 31 hypoglosso-facial anastomoses mainly carried out after removal of tumours of the cerebello-pontine angle, 26 were available for evaluation: at 18 months there were 5 of grade II, 19 of grade IV and 2 of grade V. Only one patient was dissatisfied with the result. 24 of the patients had received their hypoglosso-facial anastomosis using the clinical technique of Korte. In 3 cases the operation was by the technique of May. The authors suggest a variation of May's technique: it was carried out on the last 4 patients. It consists of a hemi-hypoglosso-facial anastomosis with rerouting of the mastoid portion of the facial nerve, without using a nerve graft. The aim of this technique is to reduce the sequelae of hemi-lingual atrophy and paralysis (which gives trouble with articulation, mastication and deglutition). The authors' experience confirms that these sequelae are greatly reduced, if not abolished. The functional results in terms of facial movements were satisfactory and consistant: 43.7% were quantified--with 3 of grade II and one of grade IV on the House Brackmann scale.
The two-stage method combining neurovascular free-muscle transfer with cross-face nerve grafting is now a widely accepted procedure for dynamic smile reconstruction in cases with long established unilateral facial paralysis. Although the results are promising, the two operations, about 1 year apart, exert an economic burden on the patients and require a lengthy period before obtaining results. Sequelae such as hypoesthesia, paresthesia, and conspicuous scar on the donor leg for harvesting a sural nerve graft also cannot be disregarded. To overcome such drawbacks of the two-stage method, we report a refined technique utilizing one-stage microvascular free transfer of the latissimus dorsi muscle. Its thoracodorsal nerve is crossed through the upper lip and sutured to the contralateral intact facial nerve branches. Reinnervation of the transferred muscle is established at a mean of 7 months postoperatively, which is faster than that of the two-stage method. In our present series with 24 patients, 21 patients (more than 87 percent) believed that their results were excellent or satisfactory, which also compares well with the results of the two-stage method combining free-muscle transfer with cross-face nerve graft.