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

Three-dimensional superimposition for patients with facial palsy: an innovative method for assessing the success of facial reanimation procedures

Facial palsy is a severe condition that may be ameliorated by facial reanimation, but there is no consensus about how to judge its success. In this study we aimed to test a new method for assessing facial movements based on 3-dimensional analysis of the facial surfaces. Eleven patients aged between 42 and 77 years who had recently been affected by facial palsy (onset between 6 and 18 months) were treated by an operation based on triple innervation: the masseteric to temporofacial nerve branch, 30% of the hypoglossal fibres to the cervicofacial nerve branch, and the contralateral facial nerve through two cross-face sural nerve grafts. Each patient had five stereophotogrammetric scans: at rest, smiling on the healthy side (facial stimulus), biting (masseteric stimulus), moving the tongue (hypoglossal stimulus), and corner-of-the-mouth smile (Mona Lisa). Each scan was superimposed onto the facial model of the "rest" position, and the point-to-point root mean square (RMS) value was automatically calculated on both the paralysed and the healthy side, together with an index of asymmetry. One-way and two-way ANOVA tests, respectively, were applied to verify the significance of possible differences in the RMS and asymmetry index according to the type of stimulus (p = 0.0329) and side (p < 0.0001). RMS differed significantly according to side between the facial stimulus and the masseteric one on the paralysed side (p = 0.0316). Facial stimulus evoked the most asymmetrical movement, whereas the masseteric produced the most symmetrical expression. The method can be used for assessing facial movements after facial reanimation

Multidisciplinary integration between maxillofacial and vascular surgery

AIM: An increasing growth in medical notions as well as surgical techniques is leading to a deeper sectorialization among specialists in different branches. For this reason, cooperation between head and neck surgeons such as neurosurgeons, maxillofacial, ear, nose and throat surgeons and ophthalmologists is common. On the other hand, this kind of cooperation between maxillofacial and vascular surgeons is rare but nonetheless invaluable for an optimal result. The aim of this paper was to report the experience of the authors in terms of collaboration between maxillofacial and vascular surgery. METHODS: Between January 2001 and July 2009 nine patients were operated by a team composed of maxillofacial and vascular surgeons. In five cases the maxillofacial surgeon performed a mandibular osteotomy to allow the access to the cranial tract of the internal carotid artery, treated by the vascular surgeon. In other three cases the maxillofacial surgeon performed a neck dissection for oral malignancies and the vascular surgeon subsequently performed a carotid tromboendarterectomy. In one case the multidisciplinary surgical team performed a modified radical neck dissection with common and internal carotid resection and reconstruction because of a neck metastasis of an oral squamous cell carcinoma with involvement of the carotid itself. RESULTS: Outcomes were always favorable. In detail, in none of the osteotomy cases delayed bone healing or postoperative malocclusion was detected. None of the patients experienced signs of cerebral ischemia secondary to clamping freeing or reconstruction involving the common or internal carotid artery. CONCLUSION: There are delicate contexts such as common or internal carotid pathologies as well as the need for carotid tromboendarterectomy and contextual neck dissection, which require a multidisciplinary approach. This allows to put in place the different competences which are invaluable in order to reach optimal results in terms of survival rate while minimizing complications and postoperative morpho-functional reliquates

Miniretromandibular access for mandibular condyle biopsies. [Accesso miniretromandibolare per l'esecuzione di biopsie del condilo mandibolare]

Obiettivo. La biopsia del condilo mandibolare è uno strumento diagnostico fondamentale per l’indagine delle diverse lesioni condilari e potrebbe diventare necessaria per stabilire diagnosi corrette e conseguentemente impostare un adeguato trattamento terapeutico della lesioni condilari. Metodi. Il 18 maggio e il 26 giugno 2009, due pazienti (entrambi di sesso maschile) sono stati sottoposti a biopsia del condilo mandibolare mediante l’approccio mini-retromandibolare. Gli autori hanno applicato la stessa tecnica chirurgica ad entrambi i pazienti, considerandola terapeutica nel caso di lesioni condilari benigne e solo diagnostica nel caso di istologia maligna. Risultati. In entrambi i casi, la biopsia del condilo si è rivelata diagnostica e curativa allo stesso tempo, permettendo sia la diagnosi istologica (miofibroma ed osteoma del collo del condilo, rispettivamente) che l’asportazione completa della lesione ossea. Conclusioni. La nuova tecnica è pertanto valida e ideale, poichè coniuga facilità e rapidità d’esecuzione con risultati estetici soddisfacenti.Mandibular condylar biopsy is an important tool in defining various condylar lesions and it could become necessary in establishing a correct diagnosis to plan the adequate treatment of the condylar lesions. METHODS: From May to June 2009, two patients affected by a miofibroma and an osteoma of the condyle underwent an open-field biopsy throught a mini-retromandibular access. The approach was deviced to be curative in case of benign lesion or just diagnostic in case of malignant or doubtfull hystology. RESULTS: In both cases, mandibular condyle biopsies were diagnostic and curative at the same time, allowing both the hystologic diagnosis and the complete removal of the bony lesions. CONCLUSION: The present technique seems to be a valid and ideal technique, because ease and quick while simultaneously leaves little esthetic reliquate

Thoracodorsal nerve graft for reconstruction of facial nerve branching

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 stylo-mastoid 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 stylo-mastoid 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 5e14 (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 anastomose

Facial reanimation with masseteric to facial nerve transfer: a three-dimensional longitudinal quantitative evaluation

Facial paralysis is a severe pathological condition, negatively affecting patients' quality of life. The altered tone and mobility of the mimetic musculature provoke both functional and morphological deficits. In the present study, we longitudinally measured facial movements in 14 patients (21\u201369 years) affected by unilateral facial paralysis not lasting longer than 23 months. The patients were analyzed before and after surgical masseteric to facial nerve neurorrhaphy. Examinations were performed at least 3 months after they had clinically started to regain facial mimicry. The displacement of selected facial landmarks was measured using an optoelectronic three-dimensional motion analyzer during: maximum smile without clenching (pre- and postsurgery), maximum smile by clenching on their posterior teeth (only postsurgery), and spontaneous smile (recorded during the vision of a funny video in both examinations). Before facial surgery, in all smiles facial landmarks moved more in the healthy than in the paretic side; after surgery, the differences decreased for both reduction of the healthy-side motion, and increment of the paretic-side motion (motion ratio before 52%, after 87%, p &lt; 0.05, Students' t-test). The ratio between the paretic and healthy-side total motion (asymmetry) did not modify for maximum and spontaneous smiles, but significantly increased for the maximum smiles made with teeth clenching (asymmetry before 32%, after 11%, p &lt; 0.001). Spontaneous smiles were recorded only in a subset of patients, but their execution was modified by surgery, with more symmetrical movements of the rehabilitated-side landmarks (asymmetry before 33%, after 10%), and reduced motion of the healthy-side ones (motion ratio before 51%, after 83%). In conclusion, the significant asymmetry in the magnitude of facial movements that characterized the analyzed patients before surgery reduced after surgery, at least in those facial areas interested by the masseteric to facial nerve reanimation