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González-Woge OR, Salazar Trujillo BA, Elnecavé Olaiz A, González-Woge MÁ, Aragón Luna V, Loreto FS, González-Navarro M. Electrophysiological Changes in Patients with Postoperative Cross-facial Nerve Graft in a Tertiary Care Center. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5973. [PMID: 39015355 PMCID: PMC11250458 DOI: 10.1097/gox.0000000000005973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/16/2024] [Indexed: 07/18/2024]
Abstract
Background Facial nerve palsy is a multifaceted pathology that causes facial disfigurement, affecting eye closure, speech articulation, oral competence, and emotional expression, with functional, aesthetic, and psychological consequences. Standardized electrophysiological tests, such as electroneurography and electromyography, allow an objective evaluation of the functional state of the nerve. Here, we aimed to compare and correlate clinical findings with electromyography in patients with facial nerve palsy, before and after facial nerve reanimation with cross-facial nerve grafts. Methods Eight patients with traumatic or nontraumatic facial paralysis with complete clinical records who underwent surgical reanimation of facial nerve with cross nerve grafts. Results The median time from diagnosis to treatment was 173 days (interquartile range = 222). Outcomes were evaluated using standard clinical scales (House-Brackmann, Sunnybrook, and eFACE) and electromyography. The median time for postoperative outcome evaluation was 768 days (interquartile range = 1053). A statistically significant difference was found between pre- and postoperative outcomes according to eFACE (Δ median = 13, P = 0.003), House-Brackmann (Δ median = -2, P = 0.008), and electromyography (Δ mean = 855, P = 0.005). A positive correlation between electromyography and clinical evaluation with eFACE was observed (r = 0.751, 95% confidence interval = 0.174-0.944, P = 0.019). Conclusions Our results suggest that cross nerve grafts are associated with clinical and electromyographic improvement of the paralyzed face. Electromyography and eFACE scores validate the reliability of eFACE scale for measuring postoperative outcomes. We suggest postoperative electromyography as an objective measure of postoperative evaluation in patients with a delay in improvement at 6-9 months.
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Affiliation(s)
- Osmar R. González-Woge
- From the Division of Otorhinolaryngology Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Bruno A. Salazar Trujillo
- Division of Plastic Surgery, National Center for Reserch and Care of Burns, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Alejandro Elnecavé Olaiz
- From the Division of Otorhinolaryngology Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | | | - Victoria Aragón Luna
- School of Medicine Instituto Tecnológico de Estudios Superiores de Monterrey, Mexico City, Mexico
| | - Francisca S. Loreto
- Division of Peripheral Nerve Injury Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Mauricio González-Navarro
- From the Division of Otorhinolaryngology Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
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Hadford SP, Genther DJ, Byrne PJ. Pediatric Facial Reanimation. Facial Plast Surg Clin North Am 2024; 32:169-180. [PMID: 37981412 DOI: 10.1016/j.fsc.2023.07.003] [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] [Indexed: 11/21/2023]
Abstract
Pediatric facial palsy is rare but severely debilitating and results in profound functional, developmental, psychosocial, and esthetic consequences. Identifying the specific cause of the palsy is important in directing the treatment course. The most common etiologies of pediatric facial palsy are distinct from those of adults. Facial reanimation interventions are targeted to address the zones of the face, with oral/smile rehabilitation the most common region requiring intervention in pediatric patients. Gracilis microneurovascular free tissue transfer is safe and highly effective in the pediatric population, providing significant functional, psychosocial, and esthetic benefits.
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Affiliation(s)
- Stephen P Hadford
- Department of Otolaryngology - Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, 9500 Euclid Avenue A71, Cleveland, OH 44195, USA
| | - Dane J Genther
- Department of Otolaryngology - Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, 9500 Euclid Avenue A71, Cleveland, OH 44195, USA; Section of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, 9500 Euclid Avenue A71, Cleveland, OH 44195, USA
| | - Patrick J Byrne
- Section of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, 9500 Euclid Avenue A71, Cleveland, OH 44195, USA; Chair, Cleveland Clinic Head and Neck Institute, 9500 Euclid Avenue A71, Cleveland, OH 44195, USA; Chief, Cleveland Clinic Integrated Surgical Institute, Cleveland, OH 44195, USA.
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Bayezid KC, Joukal M, Karabulut E, Macek J, Moravcová L, Streit L. Donor nerve selection in free gracilis muscle transfer for facial reanimation. A systematic review and meta-analysis of clinical outcomes. J Plast Reconstr Aesthet Surg 2023; 82:31-47. [PMID: 37148809 DOI: 10.1016/j.bjps.2023.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/04/2023] [Accepted: 04/08/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND One of the critical factors in facial reanimation is selecting the donor nerve. The most favored neurotizers are the contralateral facial nerve with a cross-face nerve graft (CFNG) and motor nerve to the masseter (MNM). A relatively new dual innervation (DI) method has shown successful results. This study aimed to compare the clinical outcomes of different neurotization strategies for free gracilis muscle transfer (FGMT). METHODS The Scopus and WoS databases were queried with 21 keywords. Three-stage article selection was performed for the systematic review. Articles presenting quantitative data for commissure excursion and facial symmetry were included in meta-analysis, using random-effects model. ROBINS-I tool and Newcastle-Ottawa scale were used to assess bias and study quality. RESULTS One hundred forty-seven articles containing FGMT were systematically reviewed. Most studies indicated CFNG as the first choice. MNM was primarily indicated in bilateral palsy and in elderly. Clinical outcomes of DI studies were promising. 13 studies including 435 observations (179 CFNG, 182 MNM, 74 DI) were eligible for meta-analysis. The mean change in commissure excursion was 7.15 mm (95% CI: 4.57-9.72) for CFNG, 8.46 mm (95% CI: 6.86-10.06) for MNM, and 5.18 mm (95% CI: 4.01-6.34) for DI. In pairwise comparisons, a significant difference was found between MNM and DI (p = 0.0011), despite the superior outcomes described in DI studies. No statistically significant difference was found in resting and smile symmetry (p = 0.625, p = 0.780). CONCLUSIONS CFNG is the most preferred neurotizer, and MNM is a reliable second option. Outcomes of DI studies are promising, but more comparison studies are needed to draw conclusions. Our meta-analysis was limited by incompatibility of the assessment scales. Consensus on a standardized assessment system would add value to future studies.
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Affiliation(s)
- K Can Bayezid
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marek Joukal
- Department of Anatomy, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Erdem Karabulut
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Jan Macek
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ludmila Moravcová
- Masaryk University Campus Library, Masaryk University, Brno, Czech Republic
| | - Libor Streit
- Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
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Gasteratos K, Azzawi SA, Vlachopoulos N, Lese I, Spyropoulou GA, Grobbelaar AO. Workhorse Free Functional Muscle Transfer Techniques for Smile Reanimation in Children with Congenital Facial Palsy: Case Report and Systematic Review of the Literature. J Plast Reconstr Aesthet Surg 2021; 74:1423-1435. [PMID: 33637466 DOI: 10.1016/j.bjps.2021.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 12/15/2020] [Accepted: 01/23/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pediatric facial palsy represents a rare multifactorial entity. Facial reanimation restores smiling, thus boosting self-confidence and social integration of the affected children. The purpose of this paper is to present a systematic review of microsurgical workhorse free functional muscle transfer procedures with emphasis on the long-term functional, aesthetic, and psychosocial outcomes. MATERIALS AND METHODS We performed a literature search of the PubMed database from 1995 to 2019 using the following search strategy: "facial paralysis"[Title/Abstract] OR "facial palsy"[Title]. We used as limits: full text, English language, age younger than 18 years, and humans. Two independent reviewers performed the online screening process using Covidence. Forty articles met the inclusion criteria. The protocol was aligned with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and was registered at the International Prospective Register of Systematic Reviews (PROSPERO, CRD42019150112) of the National Institute for Health Research. RESULTS Free functional muscle transfer procedures include mainly segmental gracilis, latissimus dorsi, and pectoralis minor muscle transfer. Facial reanimation procedures with the use of the cross-face nerve graft (CFNG) or masseteric nerve result in almost symmetric smiles. The transplanted muscle grows harmoniously along with the craniofacial skeleton. Muscle function and aesthetic outcomes improve over time. All children presented improved self-esteem, oral commissure opening, facial animation, and speech. CONCLUSIONS A two-stage CFNG plus an FFMT may restore a spontaneous emotive smile in pediatric facial palsy patients. Superior results of children FFMT compared to adults FFMT are probably attributed to greater brain plasticity.
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Affiliation(s)
- Konstantinos Gasteratos
- Plastic and Reconstructive Surgery Department, Papageorgiou General Hospital, Thessaloniki, Greece.
| | - Saif Al Azzawi
- Microsurgery Fellow, Royal Adelaide Hospital, Port Rd, Adelaide SA 5000, Australia; Melbourne Institute of Plastic Surgery, Malvern, Victoria 3144 Australia; Department of Plastic and Reconstructive Surgery, St Thomas' Hospital, Westminster Bridge Road, London SE7 1EH, United Kingdom
| | - Nikolaos Vlachopoulos
- Graduate of the Aristotle University of Thessaloniki, School of Medicine -Hellenic Military Academy of Combat Support Officers, Thessaloniki, Greece
| | - Ioana Lese
- Department of Plastic and Hand Surgery; Inselspital, Bern University Hospital, Bern, Switzerland; Department of Plastic and Reconstructive Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | | | - Adriaan O Grobbelaar
- Department of Plastic and Reconstructive Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom; Department of Plastic and Hand Surgery; Inselspital, Bern University Hospital, Bern, Switzerland; Professor at University College of London, Division of Surgery and Interventional Science, London, United Kingdom
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Abstract
Facial expressions play a fundamental role in interpersonal communication and interaction; consequently, facial palsy has profound effects on the quality of life of patients. Reanimation of lower lip depressors is rarely addressed during facial reanimation but is as important as treating the eye sphincter and the lip levators. Depressors of lower lip are vital for full denture smile and the expression of facial emotions. Static and dynamic techniques are used to reanimate the lower lip depressors. Static techniques provide stationary results either by weakening the contralateral normal side to achieve symmetry using botulinum toxin injection, depressor labi inferioris myectomy and marginal mandibular nerve neurectomy, or by creating static slings and tightening procedures on the affected side. Dynamic techniques provide functional results by reanimating the affected depressor complex using nerve transfers, muscle transfers, and direct muscle neurotization. The purpose of this article is to present an overview of the literature on the applications of these techniques in lower lip reanimation. Furthermore, preoperative evaluation and indications are also discussed.
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Lóderer Z, Vereb T, Paczona R, Janovszky Á, Piffkó J. An anterolateral thigh chimeric flap for dynamic facial and esthetic reconstruction after oncological surgery in the maxillofacial region: a case report. Head Face Med 2018; 14:7. [PMID: 29642922 PMCID: PMC5896052 DOI: 10.1186/s13005-018-0164-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 03/28/2018] [Indexed: 11/10/2022] Open
Abstract
Background The surgical management of malignant tumors in the head and neck region often leads to functional and esthetic defects that impair the quality of life of the patients. Reconstruction can be solved with prostheses in these cases, but various types of microsurgical free flaps can provide a better clinical outcome. Case presentation In this case report, the tumor and parts of the involved facial muscles and nerve were excised surgically from a 42-year-old patient after a third relapse of basal cell carcinoma in the left midface. The tissue defect was reconstructed with an anterolateral thigh chimeric type I fascio-myocutaneous flap, where the facial palsy was restored with a segmental branch of the femoral nerve and the involved mouth corner elevator muscles for the segmented vastus lateralis muscle. The 6-month follow-up revealed a good esthetic outcome, the soft tissue defect reconstruction with good functional activity of the reconstructed facial nerve and with acceptable mimic movements. There has been no subsequent recurrence. Conclusions It is concluded that the chimeric type I anterolateral fascio-myocutaneous free flap can offer a good option for the esthetic and functional reconstruction of an extensive tissue defect in the maxillofacial region.
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Affiliation(s)
- Zoltán Lóderer
- Department of Oral and Maxillofacial Surgery, University of Szeged, Kálvária 57, Szeged, H-6725, Hungary
| | - Tamás Vereb
- Department of Oral and Maxillofacial Surgery, University of Szeged, Kálvária 57, Szeged, H-6725, Hungary
| | - Róbert Paczona
- Department of Oral and Maxillofacial Surgery, University of Szeged, Kálvária 57, Szeged, H-6725, Hungary
| | - Ágnes Janovszky
- Department of Oral and Maxillofacial Surgery, University of Szeged, Kálvária 57, Szeged, H-6725, Hungary.
| | - József Piffkó
- Department of Oral and Maxillofacial Surgery, University of Szeged, Kálvária 57, Szeged, H-6725, Hungary
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Angspatt A, Pannanusorn C. The masseteric nerve: An anatomical study in Thai population with an emphasis on its use in facial reanimation. Asian J Surg 2017; 41:486-489. [PMID: 28918071 DOI: 10.1016/j.asjsur.2017.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 07/20/2017] [Accepted: 08/07/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND The use of the masseteric nerve has been escalated as a donor nerve for facial reanimation in facial palsy patient (Wang et al., 2014; Manktelow et al., 2006; Klebuc, 2011; Bianchi et al., 2012; Zuker et al., 2000; Bae et al., 2006; Terzis, Konofaos, 2013; Terzis, Olivares, 2009; Bianchi et al., 2014). Previous studies had been done in Euro-Caucasian cadavers (Kaya et al., 2014). However, difference in anatomical details does exist between Asian and Euro-Caucasian population (Tzou et al., 2005; Farkas et al., 2005). In this study, we have conducted a detailed anatomical study of masseteric nerve in adult Thai cadavers which might elaborate better details of masseteric nerve anatomy in Asian population. METHODS Twenty eight hemifaces from 14 adult Thai non-formaldehyde preserved soft cadavers were used in this study. The anatomical pathway of the masseteric nerve was defined relating to four surgical landmarks which are auricular tragus, zygomatic arch, posterior border of the temporomandibular joint, and alar base. RESULTS The suitable starting area for the masseteric nerve dissection is 3.7 ± 0.4 cm anterior to the auricular tragus at the level of 0.8 ± 0.2 cm inferior to the zygomatic arch. The nerve was found 1.1 ± 0.2 cm deep to the superficial surface of the masseteric fascia and 1.7 ± 0.2 cm anterior to the posterior border of the temporomandibular joint. The point where the nerve giving off its first branch as it courses distally is 7.3 ± 0.7 cm from the ipsilateral alar base. The mean diameter of this nerve is 1.59 ± 0.42 mm. CONCLUSION The anatomy of the masseteric nerve during its course in the muscle is consistent. In our study, the details of its anatomy is slightly different from the previous works which were performed in the Euro-Caucasian cadavers.
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Affiliation(s)
- Apichai Angspatt
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Chirayu Pannanusorn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Abstract
Facial nerve paralysis, although uncommon in the pediatric population, occurs from several causes, including congenital deformities, infection, trauma, and neoplasms. Similar to the adult population, management of facial nerve disorders in children includes treatment for eye exposure, nasal obstruction/deviation, smile asymmetry, drooling, lack of labial function, and synkinesis. Free tissue transfer dynamic restoration is the preferred method for smile restoration in this population, with outcomes exceeding those of similar procedures in adults.
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Affiliation(s)
- Lisa E Ishii
- Facial Plastic & Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, 601 North Caroline Street, Suite 6231, Baltimore, MD 21287, USA.
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Intracranial Facial Nerve Grafting in the Setting of Skull Base Tumors: Global and Regional Facial Function Analysis and Possible Implications for Facial Reanimation Surgery. Plast Reconstr Surg 2016; 137:267-278. [PMID: 26710031 DOI: 10.1097/prs.0000000000001881] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reconstructive surgeons may encounter patients presenting after intracranial facial nerve resection and grafting in the setting of skull base tumors, who inquire regarding progression, final facial function, and need for future operations. Study goals were to analyze global and regional facial function using established grading systems and videography, while examine variables possibly affecting outcomes. METHODS Between 1997 and 2012, 28 patients underwent intracranial nerve grafting. Fifteen were prospectively evaluated by three facial nerve physical therapists with the Facial Nerve Grading System 2.0 and the Sunnybrook Facial Grading Score for function and the Facial Disability Index for quality of life. Still photographs and videography were used to assess quality of motion and tone, while demographic and medical variables were analyzed regarding their effect on end results. RESULTS Average patient age was 41.9 years (range, 22 to 66 years), and there were 10 women and five men. Average time interval between nerve grafting and evaluations was 42.9 months (range, 12 to 146 months). Both grading scores demonstrated best outcomes in the periorbita and worst outcomes in the brow. Buccinator muscle tone also improved. The average total Facial Disability Index was 67.5 percent. Although not statistically significant, the data suggest that nerve gap length affected total resting symmetry and voluntary movement, whereas preoperative palsy and age may affect total resting symmetry. Perioperative radiation therapy, tumor type, donor nerve, and coaptation technique were not found to affect outcomes. CONCLUSIONS Intracranial facial nerve grafting largely provides better resting tone and facial symmetry, potentially improving end results of future intervention; however, overall voluntary facial motion is poor. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Glass GE, Mosahebi A, Shakib K. Cross-specialty developments: a summary of the mutually relevant recent literature from the journal of plastic, reconstructive and aesthetic surgery. Br J Oral Maxillofac Surg 2015; 54:13-21. [PMID: 26628201 DOI: 10.1016/j.bjoms.2015.08.272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 08/26/2015] [Indexed: 12/18/2022]
Abstract
Keeping abreast of current developments is increasingly challenging when the volume of specialty articles being published is rising exponentially, and it is most acute when surgical specialties overlap, as in the case of head, neck, and facial reconstructive surgery. Here, the potential for missing key developments presents a compelling case for a summary article that highlights articles likely to be of mutual relevance. We evaluated 129 original studies and 6 reviews published in the Journal of Plastic, Reconstructive, and Aesthetic Surgery between September 2012 and August 2014, and summarised the main papers of interest and merit under the subheadings of head and neck reconstruction, cleft lip and palate, craniomaxillofacial surgery, facial palsy, facial trauma, and aesthetic surgery. Most of the evidence presented (86%) is level 4.
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Affiliation(s)
- Graeme E Glass
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Kennedy Institute of Rheumatology, Roosevelt Drive, Oxford, OX 3 7FY.
| | - Ash Mosahebi
- Royal Free Hospital NHS Foundation trust, Pond Street, Hampstead, London, NW3 2QG
| | - Kaveh Shakib
- Royal Free Hospital NHS Foundation trust, Pond Street, Hampstead, London, NW3 2QG
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Abstract
Facial paralysis is a rare but severe condition in the pediatric population. Impaired facial movement has multiple causes and varied presentations, therefore individualized treatment plans are essential for optimal results. Advances in facial reanimation over the past 4 decades have given rise to new treatments designed to restore balance and function in pediatric patients with facial paralysis. This article provides a comprehensive review of pediatric facial rehabilitation and describes a zone-based approach to assessment and treatment of impaired facial movement.
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