Surgical approaches to facial nerve deficits

Cerclage sling technique using temporalis muscle fascia to manage paralytic lagophthalmos: A preliminary study

PURPOSE

Despite various existing surgical techniques, treatment of facial nerve palsy remains difficult. The purpose of this report is to present the cerclage sling technique using temporalis fascia to manage paralytic lagophthalmos.

METHODS

A series of six patients underwent a cerclage sling technique using temporalis muscle fascia to treat paralytic lagophthalmos. The technique is presented in detail. Symptoms, palpebral fissures, and lagophthalmos were assessed pre- and postoperatively. Data were submitted for statistical analysis.

RESULTS

After surgery, all patients achieved a reduction in clinical symptoms. The upper eyelids had lowered, and the inferior eyelids had elevated, reducing ocular exposure even if mild residual lagophthalmos was present.

CONCLUSION

Cerclage using the temporalis muscle fascia sling technique is a safe and effective procedure to treat facial nerve paralytic lagophthalmos. A reduction in ocular exposure and lagophthalmos provides improvement in clinical symptoms and eyelid function.

'Precursory symptoms, awareness or progression of facial palsy' are more useful than 'forehead wrinkling ability' in differentiating central facial palsy examined in the emergency department

BACKGROUND

Forehead wrinkling ability has been considered to be the sign of the central facial palsy (CFP).

AIMS/OBJECTIVES

To identify characteristics of peripheral FP (PFP) patients in the emergency room (ER), differentiate PFP from central FP (CFP), and assess the utility of forehead wrinkling for this purpose.

MATERIALS AND METHODS

ER patients with FP were clinically split into PFP (72 patients) and CFP (161 patients) groups. Factors like age, sex, medical history, time from onset to consultation, symptom awareness or progression, precursory symptoms, forehead wrinkling, and imaging history were compared. Multivariate analysis differentiated PFP from CFP, examining misdiagnosis risks based on forehead wrinkling.

RESULTS

Precursory symptoms and symptom awareness or progression had the highest odds ratios. Some PFP patients could wrinkle their foreheads, typically examined within 1 day of symptoms. PFP patients had more same-day imaging than those assessed a day later.

CONCLUSIONS AND SIGNIFICANCE

Forehead wrinkling, a traditional CFP sign, is also common in early-stage PFP, decreasing its diagnostic reliability. Patients with solely CFP unable to wrinkle the forehead are very rare at a single institution. Evaluating precursors symptoms, and FP awareness and progression is crucial for differentiation.

Smile Reanimation with Masseteric-to-Facial Nerve Transfer plus Cross-Face Nerve Grafting in Patients with Segmental Midface Paresis: 3D Retrospective Quantitative Evaluation

Facial paresis involves functional and aesthetic problems with altered and asymmetric movement patterns. Surgical procedures and physical therapy can effectively reanimate the muscles. From our database, 10 patients (18–50 years) suffering from unilateral segmental midface paresis and rehabilitated by a masseteric-to-facial nerve transfer combined with a cross-face facial nerve graft, followed by physical therapy, were retrospectively analyzed. Standardized labial movements were measured using an optoelectronic motion capture system. Maximum teeth clenching, spontaneous smiles, and lip protrusion (kiss movement) were detected before and after surgery (21 ± 13 months). Preoperatively, during the maximum smile, the paretic side moved less than the healthy one (23.2 vs. 28.7 mm; activation ratio 69%, asymmetry index 18%). Postoperatively, no differences in total mobility were found. The activity ratio and the asymmetry index differed significantly (without/with teeth clenching: ratio 65% vs. 92%, p = 0.016; asymmetry index 21% vs. 5%, p = 0.016). Postoperatively, the mobility of the spontaneous smiles significantly reduced (healthy side, 25.1 vs. 17.2 mm, p = 0.043; paretic side 16.8 vs. 12.2 mm, p = 0.043), without modifications of the activity ratio and asymmetry index. Postoperatively, the paretic side kiss movement was significantly reduced (27 vs. 19.9 mm, p = 0.028). Overall, the treatment contributed to balancing the displacements between the two sides of the face with more symmetric movements.

Management of Acute Facial Nerve and Parotid Injuries

Acute soft tissue trauma to the head and neck is a common reason for emergency department presentation and should be appropriately evaluated by a facial plastic surgeon. The evaluation of a patient who has suffered facial trauma should always include a comprehensive facial nerve exam and carry a low threshold of suspicion for parotid duct injury when involving the cheek. Injuries to the facial nerve and parotid duct can result in significant long-term functional, cosmetic, and emotional morbidity, particularly when diagnosis is delayed. In the repair of facial nerve transection, neurorrhaphy technique is primarily based on the ability to obtain tension-free anastomosis and outcomes are in large part related to timing of repair. Parotid duct injuries are generally repaired based on the site of ductal injury. In this article, we present a guide to the relevant anatomy of the facial nerve branches and the parotid duct, the important factors guiding treatment decisions alongside their related risks and benefits, as well as the management of complications of facial nerve neurorrhaphy and parotid duct injuries and repair.

Tips and Pearls for Recovering Symmetry after Facial Palsy Using a Tendon Sling: Our 20-Year Experience

Background: In facial palsy reconstruction, static techniques with the use of slings can improve the appearance and functionality of the paralyzed face and may be used in patients who cannot undergo complex surgeries or as an ancillary procedure to a dynamic reconstruction. The objective of this study was to assess the improvement in facial symmetry and quality of life among older patients with flaccid facial palsy with the use of a plantaris tendon sling. Methods: A total of 46 patients who had undergone a static reconstruction with the plantaris tendon sling were studied. The surgical technique is detailed emphasizing the tips and pearls. Results: The displacement of the oral commissure was assessed with the FACIAL CLIMA demonstrating a mean elevation of 1.5 ± 0.4 cm and an improvement of 97 ± 7% in the recovery of oral commissure symmetry 2 years after the surgery, whereas the Sunnybrook Facial Grading System showed an improvement of symmetry at rest (-15 ± 5) at 2 years. The Facial Disability Score indicated an improvement of the physical disability (+73.5 ± 14) as well as the social impairment (+21 ± 7) at 1 year postoperatively. Patients were followed for a median of 2 years (range 2-6 years). Conclusions: The use of tendon slings for static facial paralysis reconstruction is a reliable technique with no functional sequelae and good long-term results.

Hedgehog signaling promotes endoneurial fibroblast migration and Vegf-A expression following facial nerve injury

BACKGROUND

Peripheral nerve injuries are a common clinical problem which may result in permanent loss of motor or sensory function. A better understanding of the signaling pathways that lead to successful nerve regeneration may help in discovering new therapeutic targets. The Hedgehog (Hh) signaling pathway plays significant roles in nerve development and regeneration. In a mouse model of facial nerve injury, Hedgehog-responsive fibroblasts increase in number both at the site of injury and within the distal nerve. However, the role of these cells in facial nerve regeneration is not fully understood. We hypothesize that the Hh pathway plays an angiogenic and pro-migratory role following facial nerve injury.

METHODS

Hedgehog pathway modulators were applied to murine endoneurial fibroblasts isolated from the murine facial nerve. The impact of pathway modulation on endoneurial fibroblast migration and cell proliferation was assessed. Gene expression changes of known Hedgehog target genes and the key angiogenic factor Vegf-A were determined by qPCR. In vivo, mice were treated with pathway agonist (SAG21k) and injured facial nerve specimens were analyzed via immunofluorescence and in situ hybridization.

RESULTS

Hedgehog pathway activation in facial nerve fibroblasts via SAG21k treatment increases Gli1 and Ptch1 expression, the rate of cellular migration, and Vegf-A expression in vitro. In vivo, expression of Gli1 and Vegf-A expression appears to increase after injury, particularly at the site of nerve injury and the distal nerve, as detected by immunofluorescence and in situ hybridization. Additionally, Gli1 transcripts co-localize with Vegf-A following transection injury to the facial nerve.

DISCUSSION

These findings describe an angiogenic and pro-migratory role for the Hedgehog pathway mediated through effects on nerve fibroblasts. Given the critical role of Vegf-A in nerve regeneration, modulation of this pathway may represent a potential therapeutic target to improve facial nerve regeneration following injury.

The impact of misdiagnosing Bell's palsy as acute stroke

Idiopathic Bell's palsy can lead to a serious and, sometimes permanently, disfiguring and emotionally challenging facial palsy. Early diagnosis and treatment with corticosteroids are important, as they significantly improve recovery rates. Bell's palsy is a benign condition that should be diagnosed and managed in primary care. Patients who self-present to the emergency department should be managed and discharged without needing admission. We reviewed all patients referred urgently to our hospital with facial weakness and discharged with a diagnosis of Bell's palsy, to explore whether clinicians were confident in making this diagnosis at initial assessment and, if not, how often they sought a specialist opinion. Furthermore, we assessed the impact of its over-investigation and mistreatment on healthcare resources and the patients.

Efficacy of Laser Photobiomodulation on Morphological and Functional Repair of the Facial Nerve

OBJECTIVE

Evaluate the efficacy of low-level laser therapy (LLLT) on qualitative, quantitative, and functional aspects in the facial nerve regeneration process.

MATERIALS AND METHODS

Forty-two male Wistar rats were used, randomly divided into a control group (CG; n = 10), in which the facial nerve without lesion was collected, and four experimental groups: (1) suture experimental group (SEG) and (2) fibrin experimental group (FEG), consisting of 16 animals in which the buccal branch of the facial nerve was sectioned on both sides of the face; an end-to-end epineural suture was performed on the right side, and a fibrin sealant was used on the left side for coaptation of the stumps; and (3) laser suture experimental group (LSEG) and (4) laser fibrin experimental group (LFEG), consisting of 16 animals that underwent the same surgical procedures as SEG and FEG with the addition of laser application at three different points along the surgical site (pulsed laser of 830 nm wavelength, optical output power of 30 mW, power density of 0.2586 W/cm², energy density of 6.2 J/cm², beam area of 0.116 cm², exposure time of 24 sec per point, total energy per session of 2.16 J, and cumulative dose of 34.56 J). The animals were submitted to functional analysis (subjective observation of whisker movement) and the data obtained were compared using Fisher's exact test. Euthanasia was performed at 5 and 10 weeks postoperative. The total number and density of regenerated axons were analyzed using the unpaired t-test (p < 0.05).

RESULTS

Laser therapy resulted in a significant increase in the number and density of regenerated axons. The LSEG and LFEG presented better scores in functional analysis in comparison with the SEG and FEG.

CONCLUSIONS

LLLT enhanced axonal regeneration and accelerated functional recovery of the whiskers, and both repair techniques allowed the growth of axons.

Frontal branch of the superficial temporal artery: anatomical study and clinical implications regarding injectable treatments

BACKGROUND

The frontal branch of the superficial temporal artery (Fbr) is vulnerable to damage triggered by iatrogenic manipulation by both dermal filler and BoNT-A injection. The purpose of this study was to elucidate the branching pattern of Fbr and to determine its location and course on the lateral border of the frontal belly of the occipitofrontalis muscle (FB).

METHODS

Sixty-four hemifaces from 38 Korean cadavers (26 males and 12 females; mean age 71.9 years) were dissected, and the location and course of the Fbr were identified with reference to the lateral border of the FB.

RESULTS

The ramification of the frontal branch from the superficial temporal artery (STA) occurred 36.9 ± 14.24 mm (mean ± SD) superior and 17.2 ± 8.2 mm anterior to the posterior-most point of the tragus [i.e., tragion (Tg)]. The Fbr was observed as a single branch in 96.9% of cases and reached its destination at a single point in 71.9%. It reached the Fbr 14.8 ± 7.7 mm superior to the uppermost point of the eyebrow and 15.8 ± 9.1 mm from the lateral epicanthus. The Fbr bifurcated into superior and inferior branches before reaching the FB in 25.0% of cases. In two cases (3%), the Fbr ramified from the STA within 1 mm of the Tg. The diameter of the superior division of Fbr was 1.6 ± 0.5 mm at the lateral border of the FB and 1.8 ± 0.6 mm at other locations.

CONCLUSION

Physicians performing injection treatments such as botulinum toxin type A and dermal filler injection to the posterior frontal area should be aware of the various distributions of the Fbr.

Craniofacial microsomia

Craniofacial microsomia (CFM) is one of the most common congenital conditions treated in craniofacial centers worldwide. This condition is variably associated with anomalies of the jaws, ears, facial soft tissue, orbits, and facial nerve function and can be associated with extracranial anomalies. The cause of this condition is unknown, though CFM has been associated withprenatalexposures and genetic abnormalities. Diagnosis, treatment, and outcome assessment in CFM is challenging due to the wide phenotypic spectrum observed in this condition. Surgical treatment requires a coordinated team approach involving multiple specialties, which can include plastic surgery, craniofacial surgery, orthognathic surgery, and microsurgery. A wide variety of surgical options exist, and individual treatment plans should be based on the patient's needs. Although CFM can be challenging to treat, successful outcomes are rewarding. We provide a review of the common craniofacial surgical treatments for individuals with CFM.

Cranial nerves XIII and XIV: nerves in the shadows

It has been known for over a century that these cranial nerves exist, and that they are not typographical errors nor a sensational event reported in the medical literature. A number of scientific articles on anatomy highlight how textbooks on descriptive anatomy do not always consider variables such as differences related to the geographical areas where people live, and these differences do exist. This is an important concept not only for surgeons, but also for all medical professionals who use manual techniques when treating their patients, ie, osteopaths, chiropractors, physiotherapists, and other manual therapists. This paper highlights the latest developments regarding these cranial nerves, offering at the same time some ideas for further reflection when looking at clinical scenarios that appear to bear little relationship to each other. Inclusion of these concepts in everyday anamnesis is encouraged.