Diego Marre

LYMPHATICOVENULAR ANASTOMOSES FOR LYMPHEDEMA TREATMENT: 18 MONTHS POSTOPERATIVE OUTCOMES

The purpose of this work was to report our initial experience with lymphaticovenular anastomoses (LVA), a controversial technique for lymphedema treatment. Although LVA technique was described many years ago, the procedure is not as widespread as it was supposed to be, taking into account the high impact that lymphedema has in the quality of life of patients. Thus, 12 patients, 5 with lower limb and 7 with upper limb lymphedema, underwent LVA surgery under local anesthesia. Two patients were excluded from the study due to the lack of follow‐up. At 18 months, 8 out 10 patients showed a variable objective reduction of the perimeter of the limbs and 9 patients presented a subjective clinical improvement. These results joined to the outcomes of the most experienced surgeons in this field are encouraging, although there are still many issues that need to be addressed with research to optimize the efficacy of this technique.

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.

CD137 on inflamed lymphatic endothelial cells enhances CCL21-guided migration of dendritic cells

CD137/TNFR9/41BB was originally described as a surface molecule present on activated T and NK cells. However, its expression is broader among leukocytes, and it is also detected on hypoxic endothelial cells and inflamed blood vessels, as well as in atherosclerotic lesions. Here, we demonstrate that lymphatic endothelial cells (LECs) up‐regulate CD137 expression from undetectable baseline levels on stimulation with TNF‐α, LPS, and IL‐1β. CD137 cross‐linking with an agonistic mAb results in NF‐κB nuclear translocation, followed by up‐regulation of VCAM and a 3‐fold increase in the production of the chemokine CCL21. Accordingly, there is a 50% increase in CCR7‐dependent migration toward conditioned medium from activated LECs on CD137 cross‐linking with the agonistic mAb or the natural ligand (CD137L). Such an enhancement of cell migration is also observed with monocyte‐derived dendritic cells transmigrating across CD137‐activated LEC monolayers. Using explanted human dermal tissue, we found that inflamed skin contains abundant CD137+ lymphatic vessels and that ex vivo incubation of explanted human dermis with TNF‐α induces CD137 expression in lymphatic capillaries. More interestingly, treatment with CD137 agonistic antibody induces CCL21 expression and DC accumulation close to lymphatic vessels. Collectively, our results demonstrate that the inflammatory function of lymphatic vessels can be regulated by CD137.—Teijeira, A., Palazón, A., Garasa, S., Marré, D., Aubá, C., Rogel, A., Murillo, O., Martínez‐Forero, I., Lang, F., Melero, I., Rouzaut, A. CD137 on inflamed lymphatic endothelial cells enhances CCL21‐guided migration of dendritic cells. FASEB J. 26, 3380–3392 (2012). www.fasebj.org

Comparison of hemihypoglossal nerve versus masseteric nerve transpositions in the rehabilitation of short-term facial paralysis using the Facial Clima evaluating system.

Background: Masseteric and hypoglossal nerve transfers are reliable alternatives for reanimating short-term facial paralysis. To date, few studies exist in the literature comparing these techniques. This work presents a quantitative comparison of masseter-facial transposition versus hemihypoglossal facial transposition with a nerve graft using the Facial Clima system. Methods: Forty-six patients with complete unilateral facial paralysis underwent reanimation with either hemihypoglossal transposition with a nerve graft (group I, n = 25) or direct masseteric-facial coaptation (group II, n = 21). 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 a paired sample t test. Then, mean percentages of recovery of both parameters were compared between the groups using an independent sample t test. Onset of movement was also compared between the groups. Results: Significant differences of mean commissural displacement and commissural contraction velocity between the reanimated side and the normal side were observed in group I but not in group II. Mean percentage of recovery of both parameters did not differ between the groups. Patients in group II showed a significantly faster onset of movement compared with those in group I (62 ± 4.6 days versus 136 ± 7.4 days, p = 0.013). Conclusions: Reanimation of short-term facial paralysis can be satisfactorily addressed by means of either hemihypoglossal transposition with a nerve graft or direct masseteric-facial coaptation. However, with the latter, better symmetry and a faster onset of movement are observed. In addition, masseteric nerve transfer avoids morbidity from nerve graft harvesting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Lymphatic endothelium forms integrin-engaging 3D structures during DC transit across inflamed lymphatic vessels.

Dendritic cell (DC) transmigration across the lymphatic endothelium is critical for the initiation and sustenance of immune responses. Under noninflammatory conditions, DC transit across the lymphatic endothelial cell (LEC) has been shown to be integrin independent. In contrast, there is increasing evidence for the participation of integrins and their ligands in DC transit across lymphatic endothelium under inflammation. In this sense, we describe the formation of ICAM-1 (CD54)-enriched three-dimensional structures on LEC/DC contacts, as these DCs adhere to inflamed skin lymphatic vessels and transmigrate into them. In vitro imaging revealed that under inflammation ICAM-1 accumulated on microvilli projections surrounding 60% of adhered DCs. In contrast, these structures were scarcely formed in noninflammatory conditions. Furthermore, ICAM-1-enriched microvilli were important in promoting DC transendothelial migration and DC crawling over the LEC surface. Microvilli formation was dependent on the presence of β-integrins on the DC side and on integrin conformational affinity to ligand. Finally, we observed that LEC microvilli structures appeared in close vicinity of CCL21 depots and that their assembly was partially inhibited by CCL21-neutralizing antibodies. Therefore, under inflammatory conditions, integrin ligands form three-dimensional membrane projections around DCs. These structures offer docking sites for DC transit from the tissue toward the lymphatic vessel lumen.

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.

Brain plasticity in Möbius syndrome after unilateral muscle transfer: case report and review of the literature.

Background:Möbius syndrome is mainly characterized by bilateral facial palsy. Facial reanimation of these children is achieved by microsurgical techniques, namely free-gracilis muscle innervated by the masseteric nerve. Notorious commissure excursion and speech improvement are reported with such procedure. Several studies have demonstrated the presence of cortical reorganization after injury and repair of different segments of the body. Intensive training of a behaviorally relevant task is key in this process. Case Report:A 4-year-old patient with complete bilateral facial palsy secondary to Möbius syndrome was operated with left hemiface free-gracilis muscle transplant innervated by the masseteric nerve and submitted for postoperative physiotherapy. Eight months later, bilateral movement was noted. Conclusions:Brain plasticity is likely to play an important role in smile restoration in patients with bilateral facial palsy. Intensive physiotherapy and psychosocial relevance of facial expression might be key in such phenomenon.

Effect of postoperative brachytherapy and external beam radiotherapy on functional outcomes of immediate facial nerve repair after radical parotidectomy

There is much controversy regarding the effect of radiotherapy on facial nerve regeneration. However, the effect of brachytherapy has not been studied.

Differences between sexes in dissociation and spontaneity of smile in facial paralysis reanimation with the masseteric nerve

A patients sex is likely to play an important role in facial paralysis reanimation, with women being superior in terms of development of brain plasticity after reanimation. The purpose of this study was to compare the rate of movement dissociation and spontaneity of men versus women reanimated with gracilis transfer neurotized to the masseteric nerve.

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.