Dimitri Rabbiosi

Masseteric–facial nerve anastomosis for early facial reanimation

OBJECTIVE Early repair of facial nerve paralysis when cortical neural input cannot be provided by the facial nerve nucleus, is generally accomplished anastomozing the extracranial stump of the facial nerve to a motor donor nerve. That is generally the hypoglossus, which carries a variable degree of morbidity. The present work aims to demonstrate the effectiveness of the masseteric nerve as donor for early facial reanimation, with the advantage that harvesting is associated with negligible morbidity. METHODS Between October 2007 and August 2009, 7 patients (2 males, 5 women) with unilateral facial paralysis underwent a masseter-facial nerves anastomosis with an interpositional nerve graft of the great auricular nerve. The interval between the onset of paralysis and surgery ranged from 8 to 48 months (mean 19.2 months). All patients included in the study had signs of facial mimetic muscle fibrillations on electromyography. The degree of preoperative facial nerve dysfunction was grade VI following the House-Brackmann scale for all patients. RESULTS At the time of the study, all the patients with a minimum follow-up time of 12 months after the onset of mimetic function had recovered facial animation. Facial muscles showed signs of recovery within 2-9 months, mean 4.8 months, with the restoration of facial symmetry at rest. Facial movements appeared while the patients activated their chewing musculature. Morbidity related to this intervention is only the loss of sensitivity of earlobe and preauricular region. CONCLUSION The present technique seems to be a valid alternative to classical hypoglossal-facial nerve anastomosis because of similar facial nerve recovery and lower morbidity.

Single-stage facial reanimation in the surgical treatment of unilateral established facial paralysis.

Background: Surgical treatment of unilateral long-standing facial paralysis requires transposition of new musculature to restore the function of the atrophied mimetic musculature. Facial reanimation with free neuromuscular flaps is actually the accepted standard treatment. Two-stage procedures have been used for years, with a total flap recovery time of 18 to 24 months. In 1998, Harii proposed single-stage facial reanimation using the latissimus dorsi flap, showing a faster recovery compared with two-stage procedures. The present study evaluated the results of the authors’ center applying the single-stage facial reanimation. Methods: From April of 1999 to April of 2006, 33 patients with unilateral established facial paralysis underwent single-stage facial reanimation via latissimus dorsi free flap transplantation. Time from the onset of paralysis ranged from 20 months to 64 years (mean, 11.6 years). Patients were followed postoperatively for at least 24 months. Results were studied and compared using Terzis and Noah’s 1997 classification. Results: Among the 33 patients included in the study, there was an average reinnervation time of 8.9 months. According to Terzis and Noah’s classification system, 12 patients (36.3 percent) were considered grade V, 12 (36.3 percent) were grade IV, four (12.2 percent) were grade III, two (6.1 percent) were grade II, and three (9.1 percent) were grade I. Conclusions: Single-stage facial reanimation with a latissimus dorsi flap achieved morphofunctional results similar to those obtained with the classic two-stage technique. In addition, the authors were able to reduce the morbidity associated with treatment and the time required for recovery.

Traumatic and Iatrogenic Retrobulbar Hemorrhage: An 8-Patient Series

Retrobulbar hemorrhage (RBH) is 1 of the 3 main causes of traumatic vision loss; the other 2 are direct penetrating injuries and traumatic optic neuropathy. The underlying causes of RBH are bleeding after trauma or a surgical intervention, although RBH can occur in the absence of orbital trauma, especially after maneuvers that increase blood pressure. The reorted incidence of RBH after blunt or penetrating rauma to the orbit or zygoma ranges from 0.45% to %. RBH can occur after surgery on or near the orbit, such as blepharoplasty (0.0052%), the treatment of facial fractures (0.3%), and endoscopic sinus surgery (ESS; 0.006%). RBH is an emergency that must be recognized and treated quickly. However, according to a recent report, only 17% of emergency senior house officers could identify RBH and perform first-line treatment. This article presents an 8-patient case series of traumatic and iatrogenic RBH.

A systematic review on tracheostomy decannulation: A proposal of a quantitative semiquantitative clinical score

BackgroundTracheostomy is one of the most common surgical procedures performed in critical care patient management; more specifically, ventilation through tracheal cannula allows removal of the endotracheal tube (ETT). Available literature about tracheostomy care and decannulation is mainly represented by expert opinions and no certain knowledge arises from it.MethodsIn lack of statistical requirements, a systematic and critical review of literature regarding tracheostomy tube removal was performed in order to assess predictor factors of successful decannulation and to propose a predictive score. We combined 3 terms and a literature search has been performed using the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE via Ovid SP; EMBASE via Ovid SP; EBSCO. Abstracts were independently reviewed: for those studies fitting the inclusion criteria on the basis of the title and abstract, full-text was achieved. We included studies published from January 1, 1995 until March 31, 2014; any sort of review and expert opinion has been excluded by our survey. English language restriction was applied. Ten studies have been considered eligible for inclusion in the review and were analysed further.ResultsCough effectiveness and ability to tolerate tracheostomy tube capping are the most considered parameters in clinical practice; other parameters are taken into different consideration by many authors in order to proceed to decannulation. Among them, we distinguished between objective quantitative parameters and semi-quantitative parameters more dependent from clinician’s opinion. We then built a score (the Quantitative semi Quantitative score: QsQ score) based on selected parameters coming from literature.ConclusionsOn our knowledge, this review provides the first proposal of decannulation score system based on current literature that is hypothetical and requires to be validated in daily practice. The key point of our proposal is to give a higher value to the objective parameters coming from literature compared to less quantifiable clinical ones.

Recovery of emotional smiling function in free-flap facial reanimation.

PURPOSE Long-standing unilateral facial palsy is treated primarily with free-flap surgery using the masseteric or contralateral facial nerve as a motor source. The use of a gracilis muscle flap innervated by the masseteric nerve restores the smiling function, without obtaining spontaneity. Because emotional smiling is an important factor in facial reanimation, the facial nerve must serve as the motor source to achieve this fundamental target. MATERIALS AND METHODS From October 1998 to October 2009, 50 patients affected by long-standing unilateral facial paralysis underwent single-stage free-flap reanimation procedures to recover smiling function. A latissimus dorsi flap innervated by the contralateral facial nerve was transplanted in 40 patients, and a gracilis muscle flap innervated by the masseteric nerve in 10 patients. All patients underwent a clinical examination that analyzed voluntary and spontaneous smiling. RESULTS All patients who received a latissimus dorsi flap innervated by the contralateral facial nerve and recovered muscle function (92.5%) showed voluntary and spontaneous smiling abilities. All patients who received a gracilis free flap innervated by the masseteric nerve recovered function, but only 1 (10%) showed occasional spontaneous flap activation. During those rare activations, much less movement was visible on the operated side than when the patient was asked to smile voluntarily. CONCLUSIONS The masseteric nerve is a powerful motor source that guarantees free voluntary gracilis muscle activation; however, it does not guarantee any spontaneous smiling. Single-stage procedures that use a latissimus dorsi flap innervated by the contralateral facial nerve have a lower success rate and obtain less movement; however, spontaneous smiling is always observed.

Extraoral approach to mandibular condylar fractures: our experience with 100 cases.

INTRODUCTION Mandibular condylar fractures are very common. The current literature contains many indications and methods of treatment. Extraoral approaches are complicated by the need to avoid injury to the facial nerve. On the other hand intraoral approaches can make fracture reduction and/or fixation difficult. The mini-retromandibular approach provides an excellent view of the surgical field, minimises the risk of injury to the facial nerve, and allows rapid and easy management of condylar fractures. We have collected and reviewed our first 100 condylar fractures treated by means of a mini-retromandibular approach. PATIENTS AND METHODS Between June 2006 and June 2012, Eighty-seven patients with extracapsular condylar fractures underwent open reduction and rigid fixation for 100 extracapsular condylar fractures via a mini-retromandibular approach. RESULTS Dental occlusion and anatomic reduction were restored in all 100 condylar fractures. Postoperative infection developed in three patients. There was one sialocele and one case of plate fracture. Four patients experienced transient palsy of the buccal branch of the facial nerve. No permanent deficit of any facial nerve branch was observed. No patient showed condylar head resorption. CONCLUSIONS Our experience with the treatment of the first 100 condylar fractures using the mini-retromandibular approach has demonstrated that this technique has allowed the Authors to safely manage extracapsular condylar fractures at all levels.

Masseteric-facial nerve neurorrhaphy: results of a case series.

OBJECTIVE Facial palsy is a well-known functional and esthetic problem that bothers most patients and affects their social relationships. When the time between the onset of paralysis and patient presentation is less than 18 months and the proximal stump of the injured facial nerve is not available, another nerve must be anastomosed to the facial nerve to reactivate its function. The masseteric nerve has recently gained popularity over the classic hypoglossus nerve as a new motor source because of its lower associated morbidity rate and the relative ease with which the patient can activate it. The aim of this work was to evaluate the effectiveness of masseteric-facial nerve neurorrhaphy for early facial reanimation. METHODS Thirty-four consecutive patients (21 females, 13 males) with early unilateral facial paralysis underwent masseteric-facial nerve neurorrhaphy in which an interpositional nerve graft of the great auricular or sural nerve was placed. The time between the onset of paralysis and surgery ranged from 2 to 18 months (mean 13.3 months). Electromyography revealed mimetic muscle fibrillations in all the patients. Before surgery, all patients had House-Brackmann Grade VI facial nerve dysfunction. Twelve months after the onset of postoperative facial nerve reactivation, each patient underwent a clinical examination using the modified House-Brackmann grading scale as a guide. RESULTS Overall, 91.2% of the patients experienced facial nerve function reactivation. Facial recovery began within 2-12 months (mean 6.3 months) with the restoration of facial symmetry at rest. According to the modified House-Brackmann grading scale, 5.9% of the patients had Grade I function, 61.8% Grade II, 20.6% Grade III, 2.9% Grade V, and 8.8% Grade VI. The morbidity rate was low; none of the patients could feel the loss of masseteric nerve function. There were only a few complications, including 1 case of postoperative bleeding (2.9%) and 2 local infections (5.9%), and a few patients complained about partial loss of sensitivity of the earlobe or a small area of the ankle and foot, depending on whether great auricular or sural nerves were harvested. CONCLUSIONS The surgical technique described here seems to be efficient for the early treatment of facial paralysis and results in very little morbidity.

Deep-planes lift associated with free flap surgery for facial reanimation

Between April 1999 and April 2008, 37 patients with long-standing facial paralysis underwent a one-stage facial reanimation with neuromuscular free flaps: 28 patients (group A) underwent flap transposition only; 9 patients (group B) underwent a deep-planes lift (DPL) composed of the superficial muscoloaponeurotic system + parotid fascia at the time of facial reanimation. The postoperative and final results were compared between groups A and B, following the classification of Terzis and Noah (1997). Before the onset of contraction, only group B patients (100%) showed good or moderate symmetry at rest, while none of the patients of group A had a symmetric face. The respective final results for patients in groups A and B who already showed the onset of flap contraction were excellent in 28.6% and 44.5%, good in 42.9% and 33.3%, moderate in 10.7% and 22.2%, and fair or poor and fair in 17.8% and 0% of patients, respectively. The DPL allows immediate symmetry of the face at rest and contributes to upgrading the final static and dynamic results in facial reanimation with free muscular flaps.

Thoracodorsal nerve graft for reconstruction of facial nerve branching

OBJECT Surgical treatment of parotid malignancies may frequently involve facial nerve amputation to achieve oncological radical resection. The entire facial nerve branching from its exit from the stylomastoid foramen to the periphery of the gland is often sacrificed. The first reconstructive strategy is the immediate reconstruction of the facial nerve by directly anastomosing the trunk of the facial nerve to its distal branches by interpositional nerve grafting. The present study was performed to determine the adequacy of thoracodorsal nerve grafting for immediate repair of the facial nerve. The anatomical features of the thoracodorsal nerve make it particularly appropriate to match its trunk to the stump of the facial nerve at its exit from the stylomastoid foramen. Up to seven branches of the thoracodorsal nerve may be distally anastomosed to the severed distal branches of the facial nerve. More complex reconstruction may be addressed simultaneously by contemporary harvesting a de-epithelialized free flap from the same site based on thoracodorsal vessel perforators and preparing a rib graft from the same donor site. METHODS Between October 2003 and August 2010, seven patients affected by parotid tumors (6 with parotid malignancies and 1 with multiple recurrences of pleomorphic adenoma) underwent radical parotidectomy with intentional sacrifice of the facial nerve to obtain oncological radical resection. In all patients, the facial nerve was reconstructed with an interpositional thoracodorsal nerve graft. In four patients, a de-epithelialized free flap based on the latissimus dorsi was transposed to cover soft tissue defects. Moreover, two of these patients also required a rib graft to reconstruct both the condyle and ramus of the mandible. With the exception of one patient affected by recurrent pleomorphic adenoma, all patients underwent radiotherapy after surgical treatment. RESULTS All patients in our study recovered mimetic facial function. Facial muscles showed clinical signs of recovery within 5-14 (mean: 7.8) months, with varying degrees of mimetic restoration, and almost complete facial symmetry at rest in all patients. The House-Brackmann final score was I in two patients, II in two patients, and III in three patients. CONCLUSIONS A thoracodorsal nerve graft to replace extratemporal facial nerve branching is a valid alternative technique to multiple classical nerve grafts, with good matching at both the proximal and distal anastomoses.

Vertical excess of the premaxilla in bilateral cleft lip and palate patients: a protocol for treatment.

Bilateral cleft lip and palate patients may present a vertical excess of the premaxilla, which is a severe aesthetic and functional problem. Early surgical correction may lead to secondary growth impairment. We present a suggested protocol based on the severity of the vertical excess and on the age of the patient, which includes orthopedic, orthodontic, and surgical corrections. Patients are presented to elucidate each different approach.