Álvaro Cabello

Facial reanimation with gracilis muscle transfer neurotized to cross-facial nerve graft versus masseteric nerve: a comparative study using the FACIAL CLIMA evaluating system.

Background: Longstanding unilateral facial paralysis is best addressed with microneurovascular muscle transplantation. Neurotization can be obtained from the cross-facial or the masseter nerve. The authors present a quantitative comparison of both procedures using the FACIAL CLIMA system. Methods: Forty-seven patients with complete unilateral facial paralysis underwent reanimation with a free gracilis transplant neurotized to either a cross-facial nerve graft (group I, n = 20) or to the ipsilateral masseteric nerve (group II, n = 27). Commissural displacement and commissural contraction velocity were measured using the FACIAL CLIMA system. Postoperative intragroup commissural displacement and commissural contraction velocity means of the reanimated versus the normal side were first compared using the independent samples t test. Mean percentage of recovery of both parameters were compared between the groups using the independent samples t test. Results: Significant differences of mean commissural displacement and commissural contraction velocity between the reanimated side and the normal side were observed in group I (p = 0.001 and p = 0.014, respectively) but not in group II. Intergroup comparisons showed that both commissural displacement and commissural contraction velocity were higher in group II, with significant differences for commissural displacement (p = 0.048). Mean percentage of recovery of both parameters was higher in group II, with significant differences for commissural displacement (p = 0.042). Conclusions: Free gracilis muscle transfer neurotized by the masseteric nerve is a reliable technique for reanimation of longstanding facial paralysis. Compared with cross-facial nerve graft neurotization, this technique provides better symmetry and a higher degree of recovery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Masseteric nerve for reanimation of the smile in short-term facial paralysis.

Our aim was to describe our experience with the masseteric nerve in the reanimation of short term facial paralysis. We present our outcomes using a quantitative measurement system and discuss its advantages and disadvantages. Between 2000 and 2012, 23 patients had their facial paralysis reanimated by masseteric-facial coaptation. All patients are presented with complete unilateral paralysis. Their background, the aetiology of the paralysis, and the surgical details were recorded. A retrospective study of movement analysis was made using an automatic optical system (Facial Clima). Commissural excursion and commissural contraction velocity were also recorded. The mean age at reanimation was 43(8) years. The aetiology of the facial paralysis included acoustic neurinoma, fracture of the skull base, schwannoma of the facial nerve, resection of a cholesteatoma, and varicella zoster infection. The mean time duration of facial paralysis was 16(5) months. Follow-up was more than 2 years in all patients except 1 in whom it was 12 months. The mean duration to recovery of tone (as reported by the patient) was 67(11) days. Postoperative commissural excursion was 8(4)mm for the reanimated side and 8(3)mm for the healthy side (p=0.4). Likewise, commissural contraction velocity was 38(10)mm/s for the reanimated side and 43(12)mm/s for the healthy side (p=0.23). Mean percentage of recovery was 92(5)mm for commissural excursion and 79(15)mm/s for commissural contraction velocity. Masseteric nerve transposition is a reliable and reproducible option for the reanimation of short term facial paralysis with reduced donor site morbidity and good symmetry with the opposite healthy side.

Spontaneity of smile after facial paralysis rehabilitation when using a non-facial donor nerve.

INTRODUCTION The current focus in dynamic reanimation of facial paralysis lies not only in restoring movement but also regaining smile spontaneity. It has been argued that a spontaneous smile can only be achieved using the contralateral facial nerve as donor via cross-face nerve grafting. Techniques based on the motor nerve to the masseter, however, have shown good rates of spontaneity as well. PATIENTS AND METHODS Patients with complete facial paralysis reanimated using free gracilis to masseteric nerve or masseteric-to-facial nerve transfer were included. Patients were grouped according to gender comparing the rates of spontaneous smile. RESULTS Thirty-six patients (17 women and 19 men) underwent gracilis innervated by the masseteric nerve whereas masseteric-to-facial nerve transfer was performed in 30 cases (14 women and 16 men). For both techniques, women showed significantly higher rates of spontaneity. Additionally, women recovered spontaneity earlier than men. CONCLUSIONS Along with providing a strong and reliable commissural pull, the motor nerve to the masseter is able to restore spontaneity as well. Women seem more prone to achieving it. Brain plasticity and the close relationship between the cortical areas of the masseteric and facial nerves are most likely the mechanisms underlying smile spontaneity.

Cross-face nerve grafting for reanimation of incomplete facial paralysis: quantitative outcomes using the FACIAL CLIMA system and patient satisfaction.

Although in most cases Bell palsy resolves spontaneously, approximately one-third of patients will present sequela including facial synkinesis and paresis. Currently, the techniques available for reanimation of these patients include hypoglossal nerve transposition, free muscle transfer, and cross-face nerve grafting (CFNG). Between December 2008 and March 2012, eight patients with incomplete unilateral facial paralysis were reanimated with two-stage CFNG. Gender, age at surgery, etiology of paralysis denervation time, donor and recipient nerves, presence of facial synkinesis, and follow-up were registered. Commissural excursion and velocity and patient satisfaction were evaluated with the FACIAL CLIMA and a questionnaire, respectively. Mean age at surgery was 33.8 ± 11.5 years; mean time of denervation was 96.6 ± 109.8 months. No complications requiring surgery were registered. Follow-up period ranged from 7 to 33 months with a mean of 19 ± 9.7 months. FACIAL CLIMA showed improvement of both commissural excursion and velocity greater than 75% in 4 patients, greater than 50% in 2 patients, and less than 50% in the remaining two patients. Qualitative evaluation revealed a high grade of satisfaction in six patients (75%). Two-stage CFNG is a reliable technique for reanimation of incomplete facial paralysis with a high grade of patient satisfaction.

The effect of late infection and antibiotic treatment on capsular contracture in silicone breast implants: A rat model

BACKGROUND The effect of late infection on capsular contracture has yet to be established, leaving a gap in clinical guidelines for the treatment patients with breast implants. This trial is the first to assess if the treatment of these infections can reverse this effect in an in vivo rat model and whether late distant infections increase the incidence of capsular contracture. MATERIALS AND METHODS Three groups of female Wistar rats (n = 42) received two silicone implants in separate dorsal, subcutaneous pockets. All groups except control underwent injection of a human strain of methicillin-sensitive Staphylococcus aureus (MSSA) at least 30 days after implantation, allowing for physiologic capsule formation. The infection group received a peritoneal injection, inducing a transient bacteremia, the treated group received a course of antibiotics following bacterial inoculation, and a final group received no intervention and served as control. RESULTS Implants were removed 4 months after insertion, and capsules measured for thickness and sent for bacterial quantification. Compared to both the control and treated groups, capsule thickness in the infection group was statistically greater (p < 0.05), a difference not observed between treated and control groups. In addition, a statistically significant positive correlation was found between capsule thickness and bacterial count (R = 0.614, p < 0.01). CONCLUSIONS The difference in thickness between the control capsules and those from the infection group is an indication that bacterial contamination of a capsule from a remote late infection may increase the incidence of capsular contracture suggesting that treating late infections could in fact prevent capsular contracture.

A Predictable Approach for Osteotomy in Rhinoplasty: A New Concept of Open External Osteotomy

Summary: Nasal osteotomies are a cornerstone step for closing an open roof deformity after dorsal hump surgery. Notwithstanding, the optimal method of nasal osteotomy remains controversial, as evidenced by the variety of approaches with no consensus between authors. Moreover, the election of the technique responds to surgeon’s preference. We proposed a new way to perform both medial and lateral osteotomies under direct vision. Direct vision of nasal osteotomies provides more predictable control and precision than blind procedures, making this procedure more reliable and easier for both novel and experienced surgeons. Other advantages include conservation of nasal muscle, angular vasculature, and periosteum, which allow less postoperative ecchymosis and edema and less risk of synechia and lacrimal sac injury.

Cross-Face Neurotized Platysmal Muscular Graft for Upper Eyelid Reanimation: An Anatomic Feasibility Study

BackgroundUpper eyelid reanimation is one of the most important aspects of facial paralysis. The ideal method would be one that provided dynamic restoration of voluntary eye closure, involuntary blinking, and corneal reflex. Innervation to the platysma has shown to be relatively consistent, which would allow its use as a muscle graft neurotized by the contralateral healthy facial nerve for eyelid reanimation. MethodsSix fresh cadavers, 12 sides, were studied by dissecting the main trunk of the facial nerve and its cervicofacial division. Special attention was paid at the emergence of cervical branches to the platysma and its distribution on the undersurface of the muscle as well as its relationships with regional anatomic references. ResultsOne major branch with 1 or 2 accessory branches was found to emerge from the cervicofacial division, 1.5 cm distal to its origin in the facial nerve trunk. The major branch showed an oblique course, starting approximately 1 cm below the angle of the mandible and coursing toward the inferomedial border of the muscle. Harvest of a 3 × 2 muscle piece with a 10-cm–long neural pedicle was possible in all specimens. When presented over the superior eyelid, the nerve branch was found to reach the contralateral frontal branch of the facial nerve. ConclusionsInnervation to the platysma muscle is relatively constant and consists of 1 major branch accompanied by 1 or 2 accessory branches. Harvest of a muscle flap with a neural pedicle long enough to reach the contralateral healthy side is anatomically feasible.

Wrapping a facial nerve graft in a superficial temporofascial flap to optimise vascularisation: technical note

b t i k n he outcome of grafting the facial nerve can be jeopardised hen extensive bone drilling is required for adequate expoure and space for coaptation. Though nerve grafts placed irectly over bone (without periosteum) sometimes work, the dds are reduced. To overcome this, the addition of wellascularised tissue to the bed of the graft can be helpful. A 34-year-old man with a history of cystic adenocarcioma of the right parotid gland had a total parotidectomy with ransection of the facial nerve at the level of the stylomasoid foramen, ipsilateral neck dissection, and postoperative xternal beam radiotherapy. Ten months later he consulted us bout reanimation of a complete right-sided facial paralysis. Fig. 1). Reanimation with nerve grafts was planned. During operation the ENT surgeon drilled the mastoid to xpose the proximal stump of the facial nerve at the level of ts second portion. Examination of biopsy specimens taken uring the operation confirmed the absence of tumour. The ap between the proximal stump and the three distal branches as bridged with a sural nerve graft, which lay directly over completely avascular and scarred, irradiated bed within a neumatised cavity that did not allow for vascularisation from ither its superficial or its deep aspect. We therefore harvested superficial temporofascial flap to wrap around the nerve