Filippo Tarabbia

Double innervation in free-flap surgery for long-standing facial paralysis

OBJECTIVE One-stage free-flap facial reanimation may be accomplished by using a gracilis transfer innervated by the masseteric nerve, but this technique does not restore the patients ability to smile spontaneously. By contrast, the transfer of the latissimus dorsi innervated by the contralateral facial nerve provides the correct nerve stimulus but is limited by variation in the quantity of contraction. The authors propose a new one-stage facial reanimation technique using dual innervation; a gracilis muscle flap is innervated by the masseteric nerve, and supplementary nerve input is provided by a cross-face sural nerve graft anastomosed to the contralateral facial nerve branch. METHODS Between October 2009 and March 2010, four patients affected by long-standing unilateral facial paralysis received gracilis muscle transfers innervated by both the masseteric nerve and the contralateral facial nerve. RESULTS All patients recovered voluntary and spontaneous smiling abilities. The recovery time to voluntary flap contraction was 3.8 months, and spontaneous flap contraction was achieved within 7.2 months after surgery. According to Terzis and Noahs five-stage classification of reanimation outcomes, two patients had excellent outcomes and two had good outcomes. CONCLUSIONS In this preliminary study, the devised double-innervation technique allows to achieve a good grade of flap contraction as well as emotional smiling ability. A wider number of operated patients are needed to confirm those initial findings.

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.

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.

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.

Immediate facial reanimation in oncological parotid surgery with neurorrhaphy of the masseteric-thoracodorsal-facial nerve branch

The extracranial facial nerve may be sacrificed together with the parotid gland during a radical parotidectomy, and immediate reconstruction of the facial nerve is essential to maintain at least part of its function. We report five patients who had had radical parotidectomy (two with postoperative radiotherapy) and immediate (n=3) or recent (n=2) reconstructions of the masseteric-thoracodorsal-facial nerve branch. The first mimetic musculature movements started 6.2 (range 4-8.5) months postoperatively. At 24 months postoperatively clinical evaluation (modified House-Brackmann classification) showed grade V (n=3), grade IV (n=1), and grade III (n=1) repairs. This first clinical series of masseteric-thoracodorsal-facial nerve neurorrhaphies has given encouraging results, and the technique should be considered as an option for immediate or recent reconstruction of branches of the facial nerve, particularly when its trunk is not available for proximal neurorrhaphy.

Stereophotogrammetric Evaluation of Labial Symmetry After Surgical Treatment of a Lymphatic Malformation

Abstract Lymphatic malformations (LMs) are rare, nonmalignant masses, frequently involving the head and neck, potentially causing impairment to the surrounding anatomical structures. Major LMs frequently cause facial disfigurement with obvious consequences on self-esteem and social functioning. The attempt to restore symmetry is thus one of the main goals of treatment. In this study, the authors present a not-invasive method to objectively quantify the symmetry of the labial area before and after surgical treatment of a LM, affecting a 16-year-old woman. This was done with sequential three-dimensional stereophotogrammetric imaging and morphometric measurements. The method showed a high reproducibility and supplied quantitative indicators of the local degree of symmetry, helping clinicians in its objective assessment, and facilitating treatment planning and evaluation. A quantitative appraisal of the results can additionally improve patient adherence to a usually multistage therapy.

Photographic technique for the quantitative assessment of lagophthalmos and eyelid position in patients with facial palsy

Functional Anatomy Research Center (FARC), Laboratorio di Anatomia Funzionale dell’Apparato Stomatognatico (LAFAS), Laboratorio di Anatomia unzionale dell’Apparato Locomotore (LAFAL), Dipartimento di Scienze Biomediche per la Salute, Facoltà di Medicina e Chirurgia, Università degli tudi di Milano, via Mangiagalli 31, I-20133 Milano, Italy Surgical Unit of Maxillo-Facial Surgery, San Paolo Hospital, Facoltà di Medicina e Chirurgia, Università degli Studi di Milano, Milano, Italy

Pre-treatment Neutrophil-to-Lymphocyte Ratio as a predictor for occult cervical metastasis in early stage (T1-T2 cN0) squamous cell carcinoma of the oral tongue

BACKGROUND Optimum management of clinically negative neck (cN0) remains controversial in early stage (T1-T2) squamous cell cancer of the oral tongue (OTSCC). The purpose of this study was to investigate the value of pre-treatment Neutrophil-to lymphocyte ratio (NLR) in predicting occult cervical metastasis in stage I and II OTSCC. METHODS We carried out a retrospective chart review on 110 patients suffering from early stage OTSCC who were surgically treated with tumour excision and elective neck dissection (END). Our cohort was divided in pN+ and pN0 groups basing on histopathological examination after elective neck dissection. For each patient pre-treatment NLR was calculated. RESULTS A statistically significant relationship between high levels of pre-treatment NLR and probability rate for neck occult metastases (0.000496 p-value) has been found. On our model the cut-off value was set for NLR >2.93. Above this level the probability to finding metastasis in a clinically negative neck increases exponentially. CONCLUSION These preliminary results offer clinicians an easily obtainable tool to stratify patients based on risks of metastatic node in whom END could be indicated.

Use of the masseteric nerve to treat segmental midface paresis

Segmental midface paresis with or without synkinesis reflects incomplete recovery from Bells palsy, operations on the cranial base or parotid, or trauma, in 25%-30% of cases. To correct the deficit, the masseteric nerve was used to deliver a powerful stimulus to the zygomatic muscle complex, with the addition of a cross-face sural nerve graft to ensure more spontaneous smiling. By doing this, the orbicularis oculi muscle continues to have an appropriate stimulus from the facial nerve, and the zygomatic muscle complex is separately innervated, which considerably reduces synkinesis between the two muscle compartments. For those patients with muscular contractures of the midface, the new healthy neural stimulus relaxes muscles at rest. From January 2011 to March 2017, 20 patients presented with segmental facial paresis of the midface and were operated on using this new technique. All patients were evaluated before and after operation using Clinician-Graded Electronic Facial Paralysis Assessment (eFACE), and they showed considerable postoperative improvements in static, dynamic, and synkinetic variables. Our proposed use of the masseteric nerve to treat segmental facial paresis produces favourable results, but our initial data require confirmation by further studies.

Stereophotogrammetric assessment of the smiling capability after facial reanimation surgery

Facial palsy causes functional and aesthetic problems; among those, the reduction of facial mimicry and smiling difficulties, require surgical treatment and rehabilitative procedures [1]. To quantitatively evaluate the recovery of the smiling capabilities after reanimation surgery (double cross-face, masseteric-facial nerve neurorraphy, hypoglossus-facial nerve neurorraphy), 11 patients (4 females, 7 males, mean age 59.6, SD 10.4 years) affected by acute unilateral facial palsy were acquired with a 3D stereophotogrammetric instrument. Each patient was acquired in neutral facial position and performing 4 different types of smile, executed taking advantage of the aforementioned surgical stimuli, both separately and together. The smiling facial images were divided in two hemifaces, successively registered on the corresponding neutral one. Root Mean Square (RMS) distances between neutral face and smiling hemifaces were automatically calculated by the software of the stereophotogrametric system. Inter and intra-operator repeatability in performing this procedure were assessed. A two-way ANOVA for repeated measurements was performed in order to verify the differences among the smiles and the facial sides. Results showed good intra and inter operator repeatability of the procedures (R2 0.6 and 0.9, respectively). Statistical significant differences were found among the different smiles and the facial sides (p < 0.01 in both cases) and for the side x smile interaction (p < 0.05). For the affected facial side, post hoc tests revealed statistical significant differences (p < 0.05) between the smiles performed using the double cross-face (mean RMS 0.5 ± 0.2 mm) and masseteric-facial nerve neurorraphy, with this last being more powerful (RMS 0.9 ± 0.5 mm). The results offer the possibility to objectively quantify the recovery of the smiling capability, usually qualitatively evaluated, through subjective grading systems.