Static and Dynamic Repairs of Facial Nerve Injuries

Measuring Patient-Reported Outcomes After Facial Paralysis Reconstruction Surgery Using the FACE-Q

Background: Patients affected by facial paralysis often experience significant psychosocial impairment, it is, therefore, essential to incorporate their perspective when assessing surgical outcomes. Objective: To study the effect of various patient- and treatment-specific factors on patient satisfaction after facial paralysis reconstruction as measured by FACE-Q. Methods: Seventy-two patients who underwent facial paralysis procedures by our senior author from 2000 to 2020 received the FACE-Q by email. Patient characteristics, duration of paralysis before surgery, type of surgery, complications, and secondary procedures were recorded. Results: Forty-one patients successfully completed the questionnaire. We found that men were significantly more satisfied with the decision to undergo surgery, older patients had significantly lower satisfaction scores with their face and psychosocial well-being, and uninsured patients had higher satisfaction scores with their face and their social and psychosocial well-being, whereas those items were significantly lower in patients with a long-standing facial paralysis. No differences were found between static and dynamic techniques, the presence of complications or the need for secondary procedures. Conclusions: This study found that decreased patient satisfaction was associated with older age, female sex, insured patients, and longer duration of the paralysis before treatment for facial paralysis reconstruction.

Clinical features, evaluation, and management of ophthalmic complications of facial paralysis: A review

The purpose of this review was to study the evaluation, diagnosis, and management of ophthalmic complications associated with facial nerve palsy and to discuss the current and future interventions. The ophthalmic complications of facial paralysis include lagophthalmos, ectropion, exposure keratopathy, ocular synkinesis, and crocodile tears. Evaluation by an ophthalmologist skilled in recognizing and managing complications of facial paralysis shortly after its initial diagnosis can help identify and prevent long-term complications. Several types of grading scales are used to evaluate, measure the severity, and track surgical and patient-reported treatment outcomes. Lagophthalmos or ectropion are managed using temporary measures aimed at lubricating and covering the eye, including scleral lenses; however, these measures can be expensive and challenging to acquire and maintain. Temporary surgical interventions include lateral tarsorrhaphy, weighted eyelid implants, lateral canthoplasty, and other procedures that tighten or lift the eyelid or surrounding tissues. Management of flaccid facial paralysis due to iatrogenic injury or neoplasm requires neurorrhaphy or graft repair. The most common techniques for dynamic reconstruction in chronic facial paralysis are regional and free muscle flap transfer. Future directions for the management of ophthalmic complications aim to induce blinking and eye closure by developing systems that can detect blinking in the normal eye and transmit the signal to the paralyzed eye using mechanisms that would stimulate the muscles to induce eyelid closure. Blink detection technology has been developed, and a study demonstrated that blinking can be stimulated using electrodes on the zygomatic branch of the facial nerve. Further studies are needed to develop a system that will automate blinking and synchronize it with that of the normal eye.

Anatomic Analysis of Masseteric-to-zygomatic Nerve Transfer in Rat and Pig Models

Background

Nerve transfer from the masseteric branch of the trigeminal nerve is a widely performed procedure for facial reanimation. Despite achieving powerful muscle force, clinical and aesthetic results leave room for improvement. Preclinical animal models are invaluable to establishing new therapeutic approaches. This anatomical study aimed to establish a masseteric-to-zygomatic nerve transfer model in rats and pigs.

Methods

The masseteric branch of the trigeminal nerve and the zygomatic branch of the facial nerve were dissected in 30 swine and 40 rat hemifaces. Both nerves were mobilized and approximated to achieve an overlap between the nerve ends. Over the course of dissecting both nerves, their anatomy, length, and branching pattern were documented. At the coaptation point, diameters of both nerves were measured, and samples were taken for neuromorphometric analysis.

Results

Anatomic details and landmarks were described. Tension-free coaptation was possible in all rat and pig dissections. In rats, the masseteric branch had an average diameter of 0.36 mm (±0.06), and the zygomatic branch average diameter was 0.46 mm (±0.13). In pigs, the masseteric branch measured 0.52 (±0.16) mm and the zygomatic branch, 0.59 (±0.16) mm. No significant differences were found between the diameters and axon counts of both nerves in pigs. In rats, however, their diameters, axon counts, and fascicular areas were significantly different.

Conclusion

Our study demonstrated the feasibility of direct masseteric-to-zygomatic nerve transfer in rats and pigs and provided general anatomic knowledge of both nerves.

Complicated Facial Lacerations: Challenges in the Repair and Management of Complications by a Facial Trauma Team

Study Design: This is a descriptive study where we present our experience in managing complicated facial wounds over a period of 1 year at a level 1 trauma centre by a dedicated facial trauma team consisting of a plastic surgeon, a trauma surgeon and a Maxillofacial surgeon. Objective: Facial deformities have profound impact on the social and psychological aspect of a person's life. Hence, management of facial wounds is very crucial. Most of the facial injuries are usually managed by emergency care physician and emergency surgeon. But certain wounds require specialised knowledge and care due to their complicated nature. The objective of this paper is to highlight those special types of wounds and the challenges they pose. It also aims to enumerate the best possible management according to each situation in a protocol-based manner, which will help in decision making by the attending emergency physician/surgeon. Methods: Facial lacerations were designated as "complicated" according to some pre-defined features and pre, intra and post operative data and photographs were collected by interviewing the concerned surgical team. The data were analysed and presented as different clinical scenarios. Results: The cases were broadly grouped under 6 scenarios according to the unique combination of difficulties faced and their specific management. The challenges faced were enumerated and the steps undertaken were also mentioned against them. Lastly, the scenarios were compared with available literature to find out the best possible management in each situation and to present them in a protocol-based manner. Conclusion: Protocol-based management of injuries to the different parts and specialised structures of the face is extremely helpful. Role of a specialised facial trauma team also should be emphasised in complicated facial injuries.

Utility of an oral competence questionnaire for patients with facial nerve paralysis

OBJECTIVE

To investigate the utility of a patient-reported outcome measure that evaluates oral competence; speech and swallowing functions after facial nerve paralysis (FNP).

METHODS

The Oral Competence Questionnaire (OCQ) covers 16 questions from known, validated patient-reported outcome measures. The OCQ was completed by 40 patients with facial nerve paralysis (FNP) and 40 healthy controls. The sensitivity of the questionnaire was tested against other validated questionnaires for oral function, speech/swallowing functions, and facial nerve-related disability. Normative data were obtained by administering the OCQ to a group of healthy volunteers.

RESULTS

A total of 80 participants completed the OCQ (40 FNP and 40 healthy controls). Strong linear relationships (Spearman correlation coefficients >0.8) were observed between speech intelligibility ratings, objective speech outcomes, and the OCQ. Linear correlations were also noted between OCQ and FDI (Spearman correlation coefficient >0.4). The mean OCQ score for participants with FNP was 28.8 and 0.0 for healthy controls.

CONCLUSIONS

This succinct, 16-item questionnaire demonstrated good sensitivity for testing oral competence and oral function for patients with FNP, and the ability to discriminate between patients with FNP from patients with normal facial nerve function.

Facial Nerve Repair following Acute Nerve Injury

Background  Acute facial nerve iatrogenic or traumatic injury warrants rapid management with the goal of reestablishing nerve continuity within 72 hours. However, reconstructive efforts should be performed up to 12 months from the time of injury since facial musculature may still be viable and thus facial tone and function may be salvaged.

Methods  Data of all patients who underwent facial nerve repair following iatrogenic or traumatic injury were retrospectively collected and assessed. Paralysis etiology, demographics, operative data, postoperative course, and outcome were examined.

Results  Twenty patients underwent facial nerve repair during the years 2004 to 2019. Data were available for 16 of them. Iatrogenic injury was the common category ( n  = 13, 81%) with parotidectomy due to primary parotid gland malignancy being the common surgery ( n  = 7, 44%). Nerve repair was most commonly performed during the first 72 hours of injury ( n  = 12, 75%) and most of the patients underwent nerve graft repair ( n  = 15, 94%). Outcome was available for 12 patients, all of which remained with some degree of facial paresis. Six patients suffered from complete facial paralysis (50%) and three underwent secondary facial reanimation (25%). There were no major operative or postoperative complications.

Conclusion  Iatrogenic and traumatic facial nerve injuries are common etiologies of acquired facial paralysis. In such cases, immediate repair should be performed. For patients presenting with facial paralysis following previous surgery or trauma, nerve repair should be considered up to at least 6 months of injury. Longstanding paralysis is best treated with standard facial reanimation procedures.

Management of Traumatic Trigeminal and Facial Nerve Injuries

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.

An anterolateral thigh chimeric flap for dynamic facial and esthetic reconstruction after oncological surgery in the maxillofacial region: a case report

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.

Facial Nerve Laceration and its Repair

Introduction

Facial paralysis is a devastating condition with profound functional, aesthetic and psychosocial consequences. Tumors within or outside the skull, Bell’s palsy and trauma are the most common causes of facial paralysis in adults.

Case Presentation

Our patient was a 35-year-old man with deep laceration wounds. The patient was taken to the operating room and the nerves were repaired. We observed gradual improvement of muscle performance except branches of the frontal nerve.

Conclusions

Complete rupture of the facial nerve is challenging and the treatment is surgery, which requires careful planning.

Lower facial reanimation techniques following cancer resection and free flap reconstruction

OBJECTIVES/HYPOTHESIS

Evaluate outcomes of the standard static sling and orthodromic temporalis tendon transfer reanimation for facial nerve paralysis.

STUDY DESIGN

Retrospective case series at a tertiary care hospital of head and neck cancer patients with facial nerve palsy secondary to malignancy or resection.

METHODS

From 2004 to 2014, patients undergoing resection of malignancy that involved facial nerve palsy requiring facial reanimation were identified. All procedures were performed by the senior author (e.l.r.). Demographics, methods, revision rates, combination with other procedures, and complications were evaluated.

RESULTS

A total of 77 patients underwent 92 procedures, with two patients requiring more than one revision, for a total of 20 revisions. Average time to revision was 9 months. Age, sex, race, side of repair, paralysis prior to procedure, sling type or method, timing of procedure, and radiation therapy were not significantly different between those requiring revision and those who did not. There was no difference in complications between patients who received radiation and those who did not (P = .5), nor between static versus orthodromic temporalis muscle transfer (P = .5). Complication rate was low at 5.4%.

CONCLUSIONS

Sling procedures can be successfully performed in patients with facial nerve palsy secondary to cancer resection with radiation therapy, with a low revision rate and few complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:1990-1994, 2016.

Effect of FK506 on apoptosis of facial motor neurons in rats and its possible mechanism

To investigate the effect of FK506 on apoptosis of facial motor neurons in rats and its possible mechanism. A total of 48 Wistar rats were randomly divided into experimental group and control group. Facial nerve injury model was established by transection of facial nerve at stylomastoid foramen. Rats in experimental group and control group were provided with FK506 and normal saline by intraperitoneal injection, respectively. The morphology of facial neurons was observed under light microscope at different time points after injury. Apoptotic facial motor neurons were detected by TdT-mediated dUTP-biotin nick and labeling (TUNEL) staining, and expression of bcl-2 and bax was evaluated by immunohistochemistry. After facial nerve transection, the apoptotic cells in experimental group significantly decreased compared to control group (P < 0.05), with higher expression of bcl-2 and lower expression of bax in experimental group. FK506 could inhibit apoptosis of facial motor neurons after facial nerve transection, possibly via up-regulation of bcl-2 expression and down-regulation of bax expression.

Collagen scaffolds modified with CNTF and bFGF promote facial nerve regeneration in minipigs

Most experiments of peripheral nerve repair after injury have been conducted in the rodent model but the translation of findings from rodent studies to clinical practice is needed partly because the nerve regeneration must occur over much longer distances in humans than in rodents. The reconstruction of long distance nerve injuries still represents a great challenge to surgeons who is engaged in peripheral nerve surgery. Here we used the functional nerve conduit (collagen scaffolds incorporated with neurocytokines CNTF and bFGF) to bridge a 35 mm long facial nerve gap in minipig models. At 6 months after surgery, electrophysiology assessment and histological examination were conducted to evaluate the regeneration of peripheral facial nerves. Based on functional and histological observations, the results indicated that the functional collagen scaffolds promoted nerve reconstruction. The number and arrangement of regenerated nerve fibers, myelination, and nerve function reconstruction was better in the CNTF + bFGF conduit group than the single factor CNTF or bFGF conduit group. The functional composite conduit, which exhibited favorable mechanical properties, may promote facial nerve regeneration in minipigs effectively.