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Jones K, Taylor SM, Al Afif A. Muscle transposition and free muscle transfer in facial nerve reanimation. Curr Opin Otolaryngol Head Neck Surg 2024; 32:287-293. [PMID: 37902964 DOI: 10.1097/moo.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
PURPOSE OF REVIEW This review highlights recent advances in facial reanimation surgery particularly related to muscle transposition and free functional muscle transfer (FFMT). RECENT FINDINGS FFMT and muscle transposition are mainstays in the treatment of chronic facial paralysis. Recent literature evaluates single versus dual innervated FFMT, reanimation of the periocular region and lower lip depressors, and indications for such methods over gold standard FFMT techniques. New donor sites for muscle transposition and FFMT are also described. SUMMARY Gracilis FFMT (GFMT) continues to be the gold standard in dynamic facial reanimation for patients with chronic facial paralysis. Muscle transposition should be considered in older patients, those medically unfit for long operative procedures, and individuals who prefer more immediate results. With respect to FFMT, described nerve coaptation patterns, surgical stages, and donor muscle choice vary. Standardization of data reporting and outcome measures is needed in future studies.
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Affiliation(s)
- Kia Jones
- Department of Head and Neck, Plastic and Reconstructive Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - S Mark Taylor
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ayham Al Afif
- Department of Head and Neck, Plastic and Reconstructive Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
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Thachil R, Wen YE, Madrazo AZ, Sanchez CV, Reisch JS, Rozen SM. Dual versus Single Innervation of Gracilis Free Functional Muscle Transfer in Facial Paralysis: Long-Term Resting and Dynamic Outcomes. Plast Reconstr Surg 2024; 154:633-648. [PMID: 37607261 DOI: 10.1097/prs.0000000000011005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
BACKGROUND The purpose of this study was to compare long-term tone and excursion in single- versus dual-innervated free functional muscle transfer (FFMT) in patients with longstanding facial paralysis. METHODS Patients with longstanding facial palsy treated with an FFMT innervated either by a nerve-to-masseter graft (single-innervation group) or nerve-to-masseter and cross-facial-nerve grafts (dual-innervation group) were included. One-year minimum follow-up was required. Outcome measures, based on standardized photographs, included excursion, smile angle, teeth exposure, commissure height deviation, and upper lip height deviation in repose and in closed and open-teeth smile preoperatively and at 3 months, 1 year, and 3 years postoperatively. Emotrics software and ImageJ software were used to take measurements. Between-group and within-group longitudinal comparisons were analyzed. RESULTS At 3 years (single, n = 24; dual, n = 13), significance was found between groups in commissure position (single, 26.42 mm versus dual, 31.51 mm; P < 0.0001) and excursion with open-mouth smile (single, 31.32 mm versus dual, 26.59 mm; P < 0.001). Single-innervation FFMT within-group analysis lacked significant improvement in commissure height deviation and upper lip height deviation at 3 years in repose, whereas the dual-innervation group revealed significant improvements (3.67 mm [ P < 0.001], 3.17 mm [ P < 0.001], respectively). Teeth exposure revealed an increase in the dual-innervation group (single, 35.753 mm 2 versus dual, 64.177 mm 2 ), but significance was not observed. CONCLUSION Dual-innervated FFMT revealed improvements in resting tone and teeth exposure with minimal decrease in smile excursion compared with single-innervated FFMT. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
| | | | | | | | - Joan S Reisch
- Population and Data Sciences, University of Texas Southwestern Medical Center
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Wen YE, Thachil RL, Madrazo AZ, Sanchez CV, Reisch JS, Rozen SM. Dual-Innervated Gracilis Free Functional Muscle Transfers in Facial Palsy Patients: Comparing Long-Term Outcomes between One- versus Two-Stage Procedures. J Reconstr Microsurg 2024; 40:511-526. [PMID: 38224967 DOI: 10.1055/a-2245-9795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
BACKGROUND In facial reanimation, dual-innervated gracilis free functional muscle transfers (FFMTs) may have amalgamated increases in tone, excursion, synchroneity, and potentially spontaneity when compared with single innervation. The ideal staging of dual-innervated gracilis FFMTs has not been investigated. We aim to compare objective long-term outcomes following one- and two-stage dual-innervated gracilis FFMTs. METHODS Included were adult patients with facial paralysis who underwent either one- (one-stage group) or two-stage (two-stage group) dual-innervated gracilis FFMT with ≥1 year of postoperative follow-up. Facial measurements were obtained from standardized photographs of patients in repose, closed-mouth smile, and open-mouth smile taken preoperatively, 1 year postoperatively, and 3 years postoperatively. Symmetry was calculated from the absolute difference between the paralyzed and healthy hemiface; a lower value indicates greater symmetry. RESULTS Of 553 facial paralysis patients, 14 were included. Five and nine patients were in the one- and two-stage groups, with mean follow-up time, respectively, being 2.5 and 2.6 years. Within-group analysis of both groups, most paralyzed-side and symmetry measurements significantly improved over time with maintained significance at 3 years postoperatively in closed and open-mouth smile (all p ≤ 0.05). However, only the two-stage group had maintained significance in improvements at 3 years postoperatively in paralyzed-side and symmetry measurements in repose with commissure position (median change [interquartile range, IQR], 7.62 [6.00-10.56] mm), commissure angle (median change [IQR], 8.92 [6.18-13.69] degrees), commissure position symmetry (median change [IQR], -5.18 [-10.48 to -1.80] mm), commissure angle symmetry (median change [IQR], -9.78 [-11.73 to -7.32] degrees), and commissure height deviation (median change [IQR], -5.70 [-7.19 to -1.64] mm; all p ≤ 0.05). In the between-group analysis, all measurements were comparable in repose, closed-mouth smile, and open-mouth smile (all p > 0.05). CONCLUSION Long-term outcomes demonstrate that both one- and two-stage dual-innervated gracilis FFMTs significantly improve excursion, but only two-stage reconstruction significantly improves resting tone.
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Affiliation(s)
- Y Edward Wen
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Roshni L Thachil
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Adolfo Zamaro Madrazo
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Cristina V Sanchez
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joan S Reisch
- Department of Population and Data Sciences, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shai M Rozen
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
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Singerman K, Kallenberger E, Humphrey C, Kriet JD, Flynn J. Cross-Facial Nerve Grafting Used Independently in Facial Reanimation: A Narrative Review. Facial Plast Surg Aesthet Med 2024. [PMID: 38946615 DOI: 10.1089/fpsam.2023.0288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Importance: Cross-Facial Nerve Grafting (CFNG) for facial palsy offers potential to restore spontaneous facial expression, but specific indications and associated outcomes are limited. Updates to this technique have aided in its successful employment in select cases. This review aims to explore the context in which CFNG has been successfully utilized as a primary modality. Observations: Literature review was performed auditing all studies investigating CFNG as a primary modality, which reported outcomes. A total of 326 cases reporting outcomes for primary CFNG were included. Eye closure outcomes were 83.3% successful at ages 0-18, 77.3% successful at ages 19-40, and 57.1% successful at ages 41+. Smile outcomes were 73.7% successful at ages 0-18, 81.5% successful at ages 19-40, and 52.8% successful at ages 41+. For synkinesis, 89% of cases were considered successful; 100% successful at ages 0-18, and 78.4% successful in adults. Conclusions and Relevance: CFNG may offer return of spontaneous facial function in select cases. Higher percentages of successful outcomes are observed in younger patients, when performed in two stages, and when performed earlier from the onset of FP in cases of eye closure restoration. In the modern era, CFNG has been more commonly employed as an adjunctive procedure to other reanimation techniques.
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Affiliation(s)
- Kyle Singerman
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas, Kansas City, Kansas, USA
| | - Ethan Kallenberger
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas, Kansas City, Kansas, USA
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Clinton Humphrey
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas, Kansas City, Kansas, USA
| | - J David Kriet
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas, Kansas City, Kansas, USA
| | - John Flynn
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas, Kansas City, Kansas, USA
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Kollar B, Weiss JBW, Kiefer J, Eisenhardt SU. Functional Outcome of Dual Reinnervation with Cross-Facial Nerve Graft and Masseteric Nerve Transfer for Facial Paralysis. Plast Reconstr Surg 2024; 153:1178e-1190e. [PMID: 37384874 DOI: 10.1097/prs.0000000000010888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
BACKGROUND The combination of cross-facial nerve graft (CFNG) and masseteric nerve transfer (MNT) for reinnervation of facial paralysis may provide advantages of both neural sources. However, quantitative functional outcome reports with a larger number of patients are lacking in the literature. Here, the authors describe their 8-year experience with this surgical technique. METHODS Twenty patients who presented with complete facial paralysis (duration, <12 months) received dual reinnervation with CFNG and MNT. The functional outcome of the procedure was evaluated with the physician-graded outcome metric eFACE scale. The objective artificial intelligence-driven software Emotrics and FaceReader were used for oral commissure measurements and emotional expression assessment, respectively. RESULTS The mean follow-up was 31.75 ± 23.32 months. In the eFACE score, the nasolabial fold depth and oral commissure at rest improved significantly ( P < 0.05) toward a more balanced state after surgery. Postoperatively, there was a significant decrease in oral commissure asymmetry while smiling (from 19.22 ± 6.1 mm to 12.19 ± 7.52 mm). For emotional expression, the median intensity score of happiness, as measured by the FaceReader software, increased significantly while smiling (0.28; interquartile range, 0.13 to 0.64). In five patients (25%), a secondary static midface suspension with fascia lata strip had to be performed because of unsatisfactory resting symmetry. Older patients and patients with greater preoperative resting asymmetry were more likely to receive static midface suspension. CONCLUSION The authors' results suggest that the combination of MNT and CFNG for reinnervation of facial paralysis provides good voluntary motion and may lessen the use of static midface suspension in the majority of patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Branislav Kollar
- From the Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg
| | - Jakob B W Weiss
- From the Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg
| | - Jurij Kiefer
- From the Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg
| | - Steffen U Eisenhardt
- From the Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg
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Eytan DF, Kowalski HR, Li ML. Controversies in facial reanimation: An international survey. J Plast Reconstr Aesthet Surg 2024; 93:114-116. [PMID: 38688176 DOI: 10.1016/j.bjps.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 04/05/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Danielle F Eytan
- Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology - Head & Neck Surgery, New York University Grossman School of Medicine, 550 1st Ave, New York, NY 10016, USA.
| | - Haley R Kowalski
- Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology - Head & Neck Surgery, New York University Grossman School of Medicine, 550 1st Ave, New York, NY 10016, USA
| | - Myriam Loyo Li
- Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology - Head & Neck Surgery, Oregon Heath & Science University, 3303 S Bond Ave, Portland, OR 97239, USA
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Kaufman Goldberg T, Trzcinski LO, McGonagle ER, Hadlock TA. Does supercharging with cross-face nerve graft enhance smile in non-flaccid facial paralysis patients undergoing selective neurectomy? Microsurgery 2024; 44:e31118. [PMID: 37772398 DOI: 10.1002/micr.31118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/30/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Cross face nerve grafting (CFNG) is a well-established nerve transfer technique in facial reanimation; however, no study has assessed outcome of supercharging the smile with CFNG in patients with synkinesis. The goal of this study was to examine the smile outcome in non-flaccid facial paralysis (NFFP) patients after supercharging with CFNG during selective neurectomy. METHODS NFFP patients who underwent CFNG with end-to-side coaptation to a smile branch on the paralyzed side during selective neurectomy were retrospectively identified and their charts were reviewed. Pre-operative and post-operative facial function was assessed with the electronic clinician-graded facial function tool (eFACE), and an automated computer-aided facial assessment tool (Emotrics). Smile metrics were compared pre-operatively, in early post-operative time (EPO, <6 months), and late post-operative time (LPO, >9 months) when CFNG contribution would be expected. RESULTS Thirteen cases were performed between June 2019 and December 2021. No objective smile metrics improved following supercharging with CFNG. Oral commissure excursion improved by 1.23 points in eFACE (p = .812), and by 0.84 in Emotrtics (p = .187) from EPO to LPO. EFACE dynamic score was improved by 0.08 points from EPO to LPO (p = .969). CONCLUSIONS Using CFNG for supercharging the smile during selective neurectomy in NFFP patients may not enhance smile. Longer term results following supercharging and long term natural history of selective neurectomy should be assessed.
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Affiliation(s)
- Tal Kaufman Goldberg
- Department of Otolaryngology Head & Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Lauren O Trzcinski
- Department of Otolaryngology Head & Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Elizabeth R McGonagle
- Department of Otolaryngology Head & Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Tessa A Hadlock
- Department of Otolaryngology Head & Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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Kollar B, Weiss JBW, Nguyen CT, Zeller J, Kiefer J, Eisenhardt SU. Secondary dynamic midface reanimation with gracilis free muscle transfer after failed reconstruction attempt: A 15-year experience. J Plast Reconstr Aesthet Surg 2023; 87:318-328. [PMID: 37925922 DOI: 10.1016/j.bjps.2023.10.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/18/2023] [Accepted: 10/08/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The quantitative outcome of secondary reanimation after a failed primary reconstruction attempt for facial paralysis is rarely reported in the literature. This study aimed to investigate the feasibility of secondary reanimation with gracilis free muscle transfer (GFMT) and whether this outcome is influenced by the primary reconstruction. METHODS Twelve patients with previously failed static procedures (static group, n = 6), temporal muscle transfer (temporal transfer group, n = 2), and GFMT (GFMT group, n = 4) were all secondarily reanimated with GFMT. The clinical outcome was graded with the eFACE metric. The objective oral commissure excursion was measured with Emotrics, and the artificial intelligence software FaceReader evaluated the intensity score (IS) of emotional expression. RESULTS The mean follow-up was 40 ± 27 months. The eFACE metric showed a statistically significant (p < 0.05) postoperative improvement in the dynamic and smile scores across all groups. In the GFMT group, oral commissure with smile (75.75 ± 20.43 points), oral commissure excursion while smiling with teeth showing (32.7 ± 4.35 mm), and the intensity of happiness emotion while smiling without teeth showing (IS of 0.37 ± 0.23) were significantly lower as compared with the static group postoperatively (98.83 ± 2.86 points, p = 0.038; 41.7 ± 4.35 mm, p = 0.025; IS 0.83 ± 0.16, p = 0.01). CONCLUSIONS Our data suggest that secondary dynamic reconstruction with GFMT is feasible should the primary reconstruction fail. The secondary GFMT appears to improve the outcome of primary GFMT; however, the oral commissure excursion while smiling might be lower than that in patients who had static procedures as primary reconstruction.
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Affiliation(s)
- Branislav Kollar
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Jakob B W Weiss
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Cam Tu Nguyen
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Johannes Zeller
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Jurij Kiefer
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Steffen U Eisenhardt
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany.
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Weiss JBW, Spuerck F, Weber J, Zeller J, Eisenhardt SU. Age-related outcomes of facial reanimation surgery using gracilis free functional muscle transfer innervated by the masseteric nerve: A retrospective cohort study. J Plast Reconstr Aesthet Surg 2023; 85:436-445. [PMID: 37586310 DOI: 10.1016/j.bjps.2023.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/28/2023] [Accepted: 07/22/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The free functional muscle gracilis transfer is an established approach in facial reanimation surgery; however, the significance of its neurotization and the patient's age is still inconclusive. Several donor nerves are available for facial reanimation using the free functional gracilis muscle transfer. OBJECTIVE This retrospective cohort study investigates whether the masseteric nerve is an equally reliable donor nerve in both older and younger patients. METHODS We included 46 patients (13-71 years, male and female) who underwent nerve-to-masseter (NTM)-driven free functional muscle transfer (FFMT) between January 2008 and December 2019. Patients were distributed into three cohorts according to their age at surgery. We assessed the facial symmetry before and after surgery using the pupillo-modiolar angle. Commissure height and excursion deviation were measured with the Emotrics software. Patient-reported outcome measurements were taken using the Facial Clinimetric Examination (FaCE) scale. RESULTS All patients had successful flap innervation, except for one patient in the middle-aged cohort (31-51 years). The postoperative facial symmetry at rest, smiling, and laughing was analyzed with the pupillo-modiolar angle and the Emotrics software and showed similar results between all cohorts. The FaCE scale showed similar scores for the middle-aged (31-51 years) cohort and the senior cohort (52-71 years). The social function score in the senior cohort was higher than in the middle-aged cohort, without statistical significance. One patient in the middle-aged (31-51 years) cohort and the senior cohort (52-71 years), respectively, underwent emergency revision due to impaired flap perfusion and could be salvaged. CONCLUSIONS NTM-driven FFMT for facial reanimation is a safe and reliable procedure across all age groups of patients.
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Affiliation(s)
- Jakob B W Weiss
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany.
| | - Felicitas Spuerck
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany
| | - Janick Weber
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany
| | - Johannes Zeller
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany
| | - Steffen U Eisenhardt
- Department of Plastic and Hand Surgery, Medical Faculty of the University of Freiburg, University of Freiburg Medical Center, 79106 Freiburg, Germany
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Kehrer A, Hollmann KS, Klein SM, Anker AM, Tamm ER, Prantl L, Engelmann S, Knoedler S, Knoedler L, Ruewe M. Histomorphometry of the Sural Nerve for Use as a CFNG in Facial Reanimation Procedures. J Clin Med 2023; 12:4627. [PMID: 37510742 PMCID: PMC10380239 DOI: 10.3390/jcm12144627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
Facial palsy (FP) is a debilitating nerve pathology. Cross Face Nerve Grafting (CFNG) describes a surgical technique that uses nerve grafts to reanimate the paralyzed face. The sural nerve has been shown to be a reliable nerve graft with little donor side morbidity. Therefore, we aimed to investigate the microanatomy of the sural nerve. Biopsies were obtained from 15 FP patients who underwent CFNG using sural nerve grafts. Histological cross-sections were fixated, stained with PPD, and digitized. Histomorphometry and a validated software-based axon quantification were conducted. The median age of the operated patients was 37 years (5-62 years). There was a significant difference in axonal capacity decrease towards the periphery when comparing proximal vs. distal biopsies (p = 0.047), while the side of nerve harvest showed no significant differences in nerve caliber (proximal p = 0.253, distal p = 0.506) and axonal capacity for proximal and distal biopsies (proximal p = 0.414, distal p = 0.922). Age did not correlate with axonal capacity (proximal: R = -0.201, p = 0.603; distal: R = 0.317, p = 0.292). These novel insights into the microanatomy of the sural nerve may help refine CFNG techniques and individualize FP patient treatment plans, ultimately improving overall patient outcomes.
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Affiliation(s)
- Andreas Kehrer
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
- Division of Plastic and Facial Palsy Surgery, Hospital Ingolstadt, 85049 Ingolstadt, Germany
| | - Katharina S Hollmann
- Department of Molecular Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Silvan M Klein
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Alexandra M Anker
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Ernst R Tamm
- Department of Human Anatomy and Embryology, University of Regensburg, 93053 Regensburg, Germany
| | - Lukas Prantl
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Simon Engelmann
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Samuel Knoedler
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Leonard Knoedler
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Marc Ruewe
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
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Macielak RJ, Lohse CM, Wallerius KP, Lawlor SK, Neff BA, Celda MP, Van Gompel JJ, Driscoll CLW, Link MJ, Carlson ML. The Effect of Age on Facial Nerve Recovery After Vestibular Schwannoma Resection. Otol Neurotol 2023:00129492-990000000-00334. [PMID: 37400264 DOI: 10.1097/mao.0000000000003937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
OBJECTIVE The objective of this study is to assess the influence of age on facial nerve recovery after microsurgical resection of sporadic vestibular schwannoma. STUDY DESIGN A historical cohort study was performed. SETTING The study was performed at a tertiary referral center. PATIENTS The studied cohort included patients with a House-Brackmann (HB) Grade III or worse in the immediate postoperative period. INTERVENTIONS The studied intervention was microsurgical resection. MAIN OUTCOME MEASURES The main outcome measure was complete recovery of facial nerve function to HB Grade I at least 12 months postoperatively. RESULTS There were six patients with intracanalicular tumors and 100 with cerebellopontine angle (CPA) tumors eligible for study. Given the few patients with intracanalicular tumors, no further analysis was pursued in this subset. For patients with CPA tumors, a multivariable analysis of several patient and tumor characteristics demonstrated age at surgery (odds ratio for 10-year increase of 0.68; 95% confidence interval [CI], 0.47-0.98; p = 0.04) and immediate postoperative HB grade (odds ratio for one-grade increase of 0.27; 95% CI, 0.15-0.50; p < 0.001) to be jointly significantly associated with complete recovery to HB Grade I, indicating that the likelihood of complete facial nerve recovery was higher for younger patients and for those with better immediate postoperative HB grades. For example, the predicted probability of complete facial nerve recovery for a 30-year-old with immediate postoperative HB Grade III was 0.76 (or 76% when expressed as a percentage), whereas the predicted probability for a 50-year-old with immediate postoperative HB Grade V was only 0.10. CONCLUSIONS After considering immediate postoperative HB grade, younger age at surgery was independently significantly associated with complete facial nerve recovery, which can assist in intraoperative decision-making regarding extent of resection and postoperative counseling.
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12
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Lee ZH, Ismail T, Shuck JW, Chang EI. Innovative Strategies in Microvascular Head and Neck Reconstruction. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1194. [PMID: 37512006 PMCID: PMC10384542 DOI: 10.3390/medicina59071194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/13/2023] [Accepted: 06/13/2023] [Indexed: 07/30/2023]
Abstract
The field of reconstructive microsurgery has witnessed considerable advancements over the years, driven by improvements in technology, imaging, surgical instruments, increased understanding of perforator anatomy, and experience with microsurgery. However, within the subset of microvascular head and neck reconstruction, novel strategies are needed to improve and optimize both patient aesthetics and post-operative function. Given the disfiguring defects that are encountered following trauma or oncologic resections, the reconstructive microsurgeon must always aim to innovate new approaches, reject historic premises, and challenge established paradigms to further achieve improvement in both aesthetic and functional outcomes. The authors aim to provide an up-to-date review of innovations in head and neck reconstruction for oncologic defects.
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Affiliation(s)
- Z-Hye Lee
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Tarek Ismail
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, 4031 Basel, Switzerland
| | - John W Shuck
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Edward I Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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13
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Ferri A, Zito F, Menapace G, Zannoni C, Bergonzani M, Perlangeli G, Bianchi B. Optimizing the results of facial animation surgery: Botulinum toxin injection into free functional gracilis flap transfer. J Plast Reconstr Aesthet Surg 2023; 83:415-422. [PMID: 37307620 DOI: 10.1016/j.bjps.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 03/22/2023] [Accepted: 04/08/2023] [Indexed: 06/14/2023]
Abstract
Although neuromuscular gracilis transplantation is the best choice for facial reanimation in patients with congenital or inveterate palsy, the results are not completely satisfactory. Ancillary procedures developed to achieve better symmetry of the smile and reduce the hypercontractility of the transplanted muscle have been reported. However, the intramuscular injection of botulinum toxin has not been described for this purpose. Patients undergoing gracilis injections of botulinum toxin after facial reanimation surgery between September 1, 2020, and June 1, 2022, were retrospectively enrolled in this study. We collected photographs taken before and 20-30 days after injection and compared the symmetry of the face using software. Nine patients with a mean age of 23.56 years (range, 7-56 years) were enrolled. Reinnervation of the muscle was provided by the contralateral healthy facial nerve via a sural cross-graft (four patients), by the ipsilateral masseteric nerve (three cases), and by the contralateral masseteric and facial nerve (two). Using Emotrics software, we identified differences in the commissure excursion discrepancy of 3.82 mm, the smile angle discrepancy of 0.084°, and the dental show discrepancy of 1.49 mm; the average difference in the commissure height deviation was 2.26 mm (P = 0.02), and those in the upper- and lower-lip height deviation were 1.05 mm and 1.49 mm, respectively. Gracilis injection of botulinum toxin after gracilis transplantation is a safe and feasible procedure that could be applicable to all patients with asymmetric smiles related to excessive transplant contraction. It yields good esthetic results with little to no related morbidity.
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Affiliation(s)
- Andrea Ferri
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Francesca Zito
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy.
| | - Giorgia Menapace
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Cecilia Zannoni
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Michela Bergonzani
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Giuseppe Perlangeli
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Bernardo Bianchi
- Operative Unite of Maxillo-facial Surgery, Hospital of Genova, Parma, Italy
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14
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Pham TB, Greene JJ. Reducing Risk in Facial Reanimation Surgery. Facial Plast Surg Clin North Am 2023; 31:297-305. [PMID: 37001932 DOI: 10.1016/j.fsc.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Facial reanimation surgery can greatly improve quality of life, but these procedures are not without risk. Important considerations for risk reduction in facial reanimation surgery include preoperative risk-stratification, protecting patients' clinical media, clearly and thoroughly setting expectations, and intraoperative strategies to maximize technical success and minimize operative time.
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Affiliation(s)
- Tammy B Pham
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego Health, 9350 Campus Point Drive, La Jolla, CA 92037, USA
| | - Jacqueline J Greene
- Department of Otolaryngology-Head and Neck Surgery, University of California San Diego Health, 9350 Campus Point Drive, La Jolla, CA 92037, USA.
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