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

Insights on the Choice and Preparation of the Donor Nerve in Corneal Neurotization for Neurotrophic Keratopathy: A Narrative Review

The article introduces neurotrophic keratopathy (NK), a condition resulting from corneal denervation due to various causes of trigeminal nerve dysfunctions. Surgical techniques for corneal neurotization (CN) have evolved, aiming to restore corneal sensitivity. Initially proposed in 1972, modern approaches offer less invasive options. CN can be performed through a direct approach (DCN) directly suturing a sensitive nerve to the affected cornea or indirectly (ICN) through a nerve auto/allograft. Surgical success relies on meticulous donor nerve selection and preparation, often involving multidisciplinary teams. A PubMed research and review of the relevant literature was conducted regarding the surgical approach, emphasizing surgical techniques and the choice of the donor nerve. The latter considers factors like sensory integrity and proximity to the cornea. The most used are the contralateral or ipsilateral supratrochlear (STN), and the supraorbital (SON) and great auricular (GAN) nerves. Regarding the choice of grafts, the most used in the literature are the sural (SN), the lateral antebrachial cutaneous nerve (LABCN), and the GAN nerves. Another promising option is represented by allografts (acellularized nerves from cadavers). The significance of sensory recovery and factors influencing surgical outcomes, including nerve caliber matching and axonal regeneration, are discussed. Future directions emphasize less invasive techniques and the potential of acellular nerve allografts. In conclusion, CN represents a promising avenue in the treatment of NK, offering tailored approaches based on patient history and surgical expertise, with new emerging techniques warranting further exploration through basic science refinements and clinical trials

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

Virtual Surgical Reduction in Atrophic Edentulous Mandible Fractures: A Novel Approach Based on “in House” Digital Work-Flow

Featured Application: Virtual Surgical Planning in Cranio-Facial Traumatology. Atrophic edentulous mandible fractures are a challenge for maxillo-facial surgeons because of low vascularization, low bone regeneration, and lack of occlusion. Whereas occlusion is the main guide in the reduction of mandibular fractures, the aim of our study is to show the advantages of using virtual surgical planning (VSP) in surgery when the occlusal guide is absent. This work is a prospective study that shows the in-house digital workflow for the management of these fractures in the Maxillo-Facial Surgery Unit of Federico II University Hospital of Naples. Four patients who satisfied the criteria were included in the study. For each patient, the same defined CAD/CAM-based was applied. The workflow followed four steps: (1) bone segmentation and virtual reduction of fracture fragments; (2) three-dimensional printing of virtually reduced mandible and modelling of 2.4 reconstruction plate on printed resin model; (3) surgery aided by the pre-formed plate; (4) digital and clinical outcomes analysis. In the last step, a distance colour map was conducted to compare the virtual planning and postoperative CT outcome. In all cases, the discrepancies values between the two images were lower than 1.5 mm, and good clinical outcomes in terms of facial symmetry, absence of sensory disturbance, and possibility of prosthetic rehabilitation were obtained. In conclusion, the VSP, with our in-house workflow brings benefits in the management of atrophic edentulous mandible fractures in terms of the high accuracy of bone repositioning

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

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