Da superfície para a profundidade: Curva de aprendizado em lifting facial profundo estendido - meus primeiros 100 casos / From Surface to Depth: Learning Curve in Extended Deep Facelift ­ my First 100 Cases

Introdução: O envelhecimento facial é um processo gradual, complexo e multifatorial. É o resultado de mudanças na qualidade, volume e posicionamento dos tecidos. Cirurgiões plásticos têm modificado sua abordagem na cirurgia do rejuvenescimento facial optando pelo plano subaponeurótico (SMAS). O objetivo deste estudo é analisar 100 casos de pacientes operados pela técnica de SMAS profundo, avaliando sua aplicabilidade e eficácia. Método: Foram avaliados 100 pacientes, submetidos a cirurgia plástica facial pela técnica de SMAS profundo - "Deep Smas", e acompanhados por 6 meses. Observou-se a satisfação dos pacientes, número de complicações, número de reoperações, riscos e vantagens da técnica. Resultados: Foram operados 100 pacientes, num período de 3 anos. A idade variou de 41 a 79 anos, sendo 95% sexo feminino. As complicações foram 8 casos (8%) de lesões de ramos do nervo facial, sendo: 4 casos lesão do zigomático, 3 casos de lesão do mandibular e 1 caso de lesão do bucal; houve 1 caso (1%) de queloide retroauricular; 1 caso (1%) de hematoma. Em relação às revisões cirúrgicas, houve 8 casos (8%) de complementação cirúrgica por insatisfação das pacientes. Houve 15% de lesões nervosas entre a 1ª e a 40ª cirurgia, 5% entre a 41ª e a 80ª, e nenhuma lesão entre o 81º e o 100º paciente. Conclusão: O lifting facial profundo ou subSMAS mostrou ser efetivo, proporcionando bons resultados estéticos. Apresenta baixa taxa de recidiva e baixa taxa de morbidade, porém, necessita de uma longa curva de aprendizagem.

Introduction: Facial aging is a gradual, complex, and multifactorial process. It is the result of changes in the quality, volume, and positioning of tissues. Plastic surgeons have modified their approach to facial rejuvenation surgery, opting for the subaponeurotic plane (SMAS). The objective of this study is to analyze 100 cases of patients operated on using the deep SMAS technique, evaluating its applicability and effectiveness. Method: 100 patients were evaluated, undergoing facial plastic surgery using the deep SMAS technique - "Deep Smas", and followed up for 6 months. Patient satisfaction, number of complications, number of reoperations, risks, and advantages of the technique were observed. Results: 100 patients were operated on over 3 years. Age ranged from 41 to 79 years, with 95% being female. The complications were 8 cases (8%) of injuries to branches of the facial nerve, of which 4 cases of zygomatic injury, 3 cases of mandibular injury, and 1 case of buccal injury; there was 1 case (1%) of post-auricular keloid; 1 case (1%) of hematoma. Regarding surgical revisions, there were 8 cases (8%) of surgical completion due to patient dissatisfaction. There were 15% of nerve injuries between the 1st and 40th surgery, 5% between the 41st and 80th, and no injuries between the 81st and 100th patient. Conclusion: Deep facial lifting or subSMAS has proven to be effective, providing good aesthetic results. It has a low recurrence rate and low morbidity rate; however, it requires a long learning curve.

Post-parotidectomy facial nerve function: comparison between original and modified Sunnybrook Facial Grading Systems / Função do nervo facial pós-parotidectomia: comparação entre os Sistemas Sunnybrook de Graduação Facial original e modificado

Abstract Background: Facial nerve dysfunction is the principal postoperative complication related to parotidectomy. Objective: To test the hypothesis that the modified Sunnybrook Facial Grading System (mS-FGS) is superior to the original S-FGS in the assessment of facial nerve function following parotidectomy. Methods: Prospective, longitudinal study evaluating patients with primary or metastatic parotid neoplasms undergoing parotidectomy with facial nerve-sparing between 2016 and 2020. The subjects were assessed twice, on the first postoperative day and at the first outpatient evaluation, 20-30 days post-surgery. Facial assessments were performed using the original and modified (plus showing the lower teeth) versions of the Sunnybrook System and documented by pictures and video recordings. Intra- and inter-rater agreements regarding the assessment of the new expression were analyzed. Results: 101 patients were enrolled. In both steps, the results from the mS-FGS were significantly lower (p < 0.001). Subjects with a history of previous parotidectomy and those who underwent neck dissection had more severe facial nerve impairment. The mandibular marginal branch was the most frequently injured, affecting 68.3% of the patients on the first postoperative day and 52.5% on the first outpatient evaluation. Twenty patients (19.8%) presented an exclusive marginal mandibular branch lesion. The inter-rater agreement of the new expression assessment ranged from substantial to almost perfect. The intra-rater agreement was almost perfect (wk = 0.951). Conclusion: The adoption of the Modified Sunnybrook System, which includes evaluation of the mandibular marginal branch, increases the accuracy of post-parotidectomy facial nerve dysfunction appraisal.

Resumo Antecedentes: A disfunção do nervo facial é a principal complicação pós-operatória relacionada à parotidectomia. Objetivo: Testar a hipótese de que o sistema Sunnybrook de graduação facial modificado (mS-FGS) é superior ao S-FGS original na avaliação da função do nervo facial após parotidectomia. Métodos: Estudo longitudinal prospectivo avaliando o pós-operatório de pacientes com neoplasias parotídeas primárias ou metastáticas, submetidos à parotidectomia com preservação do nervo facial, entre 2016 e 2020. Os indivíduos foram avaliados duas vezes, no primeiro dia de pós-operatório e na primeira avaliação ambulatorial, 20-30 dias após a cirurgia. As avaliações faciais foram realizadas usando as versões original e modificada (que incluem mostrar os dentes inferiores) do sistema Sunnybrook e documentadas por fotos e vídeos. Foram adicionalmente analisadas as concordâncias intra e interexaminadoras da avaliação da nova expressão. Resultados: Cento e um pacientes foram incluídos. Em ambas as etapas, os resultados do mS-FGS foram significativamente menores (p < 0,001). Indivíduos com história de parotidectomia prévia e aqueles submetidos ao esvaziamento cervical apresentaram comprometimento mais grave do nervo facial. O ramo marginal mandibular foi o mais afetado, acometendo 68,3% dos pacientes no primeiro dia de pós-operatório e 52,5% na primeira avaliação ambulatorial. Vinte pacientes (19,8%) apresentaram lesão exclusiva do ramo marginal mandibular. A concordância interexaminadores da avaliação da nova expressão variou de substancial a quase perfeita. A concordância intraexaminador foi quase perfeita (wk = 0,951). Conclusão: A adoção do sistema Sunnybrook modificado, que inclui a análise do ramo marginal mandibular, aumenta a precisão da avaliação da disfunção do nervo facial pós-parotidectomia.

Lower Four Cranial Nerves in the Management of Glomus Jugulare: Anatomical Study

Abstract Introduction The surgical management that achieves minimal morbidity and mortality for patients with glomus and non-glomus tumors involving the jugular foramen (JF) region requires a comprehensive understanding of the complex anatomy, anatomic variability, and pathological anatomy of this region. Objective The aim of this study is to propose a rational guideline to expose and preserve the lower cranial nerves (CNs) in the lateral approach of the JF. Methods The technique utilized is the gross and microdissection of 4 fixed cadaveric heads to revise the JF's surgical anatomy and high part of the carotid sheath compared with surgical cases to understand and preserve the integrity of lower CNs. The method involves radical mastoidectomy, microdissection of the JF, facial nerve, and high neck just below the carotid canal and the JF. The CNs IX, X, XI, and XII are microscopically dissected and kept in sight up to the JF. Results This study realized well the surgical and applied anatomy of the lower CNs with relation to the facial nerve and JF. Conclusions The JF anatomy is complicated, and the key to safely operate on it and preserving the lower CNs is to find the posterior belly of the digastric muscle, to skeletonize the facial nerve, to remove the mastoid tip preserving the stylomastoid foramen, to skeletonize the sigmoid sinus and posterior fossa dura not only anterior but also posteroinferior to reach and drill the jugular tubercle.

A Clinical and Anatomical Study on the Localization of the Temporal Branch of the Facial Nerve Crossing the Zygomatic Arch / Estudio Clínico y Anatómico sobre la Localización del Ramo Temporal del Nervio Facial que Cruza el Arco Cigomático

SUMMARY: To clarify the path of the temporal branch of facial nerve (TB) crossing the zygomatic arch (ZA). Eighteen fresh adult heads specimens were carefully dissected in the zygomatic region, with the location of TB as well as its number documented. The hierarchical relationship between the temporal branch and the soft tissue in this region was observed on 64 P45 plastinated slices. 1. TB crosses the ZA as type I (21.8 %), type II (50.0 %,), and type III (28.1 %) twigs. 2. At the level of the superior edge of the ZA, the average distance between the anterior trunk of TB and the anterior part of the auricle is 36.36±6.56 mm, for the posterior trunk is 25.59±5.29 mm. At the level of the inferior edge of the ZA, the average distance between the anterior trunk of TB and the anterior part of the auricle is 25.77±6.19 mm, for the posterior trunk is 19.16±4.71 mm. 3. The average length of ZA is 62.06±5.36 mm. TB crosses the inferior edge of the ZA at an average of 14.67±6.45 mm. TB crosses the superior edge of the ZA at an average of 9.08±4.54 mm. 4. At the level of the ZA, TB passes on the surface of the pericranium while below the SMAS. The TB obliquely crosses the middle 1/3 part of the superior margin of the ZA and the junction of the middle 1/3 part and the posterior 1/3 part of the inferior margin of the ZA below the SMAS while beyond the periosteum. It is suggested that this area should be avoided in clinical operation to avoid the injury of TB.

El objetivo de estudio fue esclarecer el trayecto del ramo temporal del nervio facial (RT) que cruza el arco cigomático (AC). Se disecaron la región cigomática de 18 especímenes de cabezas sin fijar de individuos adultas y se documentó la ubicación del RT y su número de ramos. La relación jerárquica entre el ramo temporal y el tejido blando en esta región se observó en 64 cortes plastinados o P45. 1º El RT cruza el AC como tipo I (21,8 %), tipo II (50,0 %) y tipo III (28,1 %). 2º A nivel del margen superior del AC, la distancia promedio entre el tronco anterior de RT y la parte anterior de la aurícula fue de 36,36±6,56 mm, para el tronco posterior fue de 25,59±5,29 mm. A nivel del margen inferior del AC, la distancia promedio entre el tronco anterior del RT y la parte anterior de la aurícula era de 25,77±6,19 mm, para el tronco posterior era de 19,16±4,71 mm. 3º La longitud media de RT fue de 62,06±5,36 mm. EL RT cruzaba el margen inferior del AC a una distancia media de 14,67±6,45 mm. El RT cruzaba el margen superior del AC a una distancia media de 9,08±4,54 mm. 4º Anivel del AC, el RT pasaba por la superficie del pericráneo mientras se encuentra por debajo del SMAS. El RT cruza oblicuamente el tercio medio del margen superior del AC y la unión del tercio medio y el tercio posterior del margen inferior del AC por debajo del SMAS, más allá del periostio. Se sugiere que esta área debe evitarse en la operación clínica para evitar la lesión de la RT.

Parálisis facial alternobárica: a propósito de un caso y revisión de la literatura / Alternobaric facial palsy: case report and literature review

La parálisis o paresia facial alternobárica es una neuropraxia del séptimo nervio cra-neal debido a cambios de presión. Se produce en el contexto de una disfunción de la trompa de Eustaquio, una dehiscencia canal del nervio facial y cambios en la presión atmosférica. Se considera una rara complicación de barotrauma. Su prevalencia es difícil de estimar y, probablemente, se encuentre subreportada. La forma de presentación más habitual incluye paresia facial, plenitud aural, hipoacusia, otalgia, parestesias faciales y linguales. La mayoría de los episodios son transitorios, con una duración entre minutos y algunas horas, con recuperación posterior completa. Entre los diagnósticos diferenciales se encuentran causas periféricas y centrales de paresia facial, las cuales hay que sospechar ante la persistencia de los síntomas en el tiempo o ante la presencia de otros signos o síntomas neurológicos. La evaluación inicial debe incluir un examen otoneurológico completo. La tomografía computarizada de hueso temporal favorece la visualización de posibles dehiscencias del canal del facial. La prevención de nuevos episodios incluye la práctica de ecualización efectiva, la resolución de la disfunción de la trompa de Eustaquio y en algunos casos específicos, métodos alternativos de ventilación del oído medio como la colocación de tubos de ventilación. Una vez instalada la parálisis facial, si no se produce recuperación espontánea, el uso de corticoides es una opción. Se presenta un caso de paresia facial alternobárica recurrente y una revisión de literatura.

Alternobaric facial palsy or paralysis is a neuropraxia of the seventh cranial nerve due to pressure changes. It occurs in the context of Eustachian tube dysfunction, facial nerve canal dehiscence, and changes in atmospheric pressure. It is considered a rare complication of barotrauma. Its prevalence is difficult to estimated, and this condition is probably underreported. The most common form of presentation includes facial weakness, ear fullness or pressure, hearing loss, otalgia, facial and lingual paresthesias. Most episodes are transient, lasting from minutes to a few hours, with a subsequent complete recovery. Among the possible differential diagnoses are peripheral and central causes of facial paralysis, which must be suspected due to the persistence of symptoms over time or the presence of other neurological signs or symptoms. The initial evaluation should include a complete otoneurological examination. Computed tomography of the temporal bone is useful for the visualization of facial canal dehiscence. Prevention of further episodes includes practicing effective equalization, Eustachian tube dysfunction treatment, and in certain specific cases, alternative middle ear ventilation methods such as tympanostomy tubes. Once facial paralysis is established, if spontaneous recovery does not occur, the use of corticosteroids is considered an option. A case of recurrent alternobaric facial paresis and a review of the literature are presented.

The potential applicability of facial nerve monitoring as a navigation tool in parotid gland surgery

Abstract Objectives: The aim of this study was to assess the relationship between the stimulation amplitude and the distance to the facial nerve. Methods: This study was designed as a prospective clinical study. A total of 20 patients (12 males, 8 females) were included. Partial superficial parotidectomy was performed in all patients with intraoperative facial monitoring. Measurements were made on the main trunk and major branches. Stimulation was started at 1 mA and incrementally increased to 2 and 3mA's. The shortest distance creating a robust response (>100mV) was recorded. Results: At 1 mA, 2 mA and 3 mA stimulation intensity, the average distance between the tip of the stimulation probe and the main trunk was 2.20±0.76 mm (range 1-3 mm), 3.80±0.95 mm (range 2-5 mm), 4.80±1.05 mm (range 3-7 mm) respectively. The stimulus intensity was inversely proportional in respect to the distance between the nerve and the tip of the stimulus probe (P < .00). The same relation was present in the facial nerve major branch measurements (P < .00). Conclusion: The proportional stimulation amplitude and distance to the facial nerve is thought to be a reliable auxillary method to assist the surgeon by facilitating the estimation of the distance to the facial nerve during extracapsular dissection and minimally invasive cases where the facial nerve isn't routinely dissected. Level of evidence: Level 3.

Morphofunctional regeneration by mesenchymal stem cell and IGF-1 inoculation in a model of facial nerve crush injury in rats

Abstract Objective: To analyze the morphofunctional regeneration process of facial nerve injury in the presence of insulin-like growth factor-1 and mesenchymal stem cells. Methods: Fourteen Wistar rats suffered unilateral facial nerve crushing and were randomly divided into two groups. All received insulin-like growth factor-1 inoculation, but only half of the animals received an additional inoculation of mesenchymal stem cells. The animals were followed for 90 days and facial nerve regeneration was analyzed via spontaneous facial motor function tests and immunohistochemistry in the nerve motor nucleus. Results: The group that received the growth factor and stem cells showed a statistically superior mean in vibrissae movements (p<0.01), touch reflex (p = 0.05) and eye closure (p<0.01), in addition to better immunohistochemistry reactivity. There was a statistically significant difference in the mean number of cells in the facial nerve nucleus between the experimental groups (p = 0.025), with the group that received the growth factor and stem cells showing the highest mean. Conclusion: The association between growth factor and stem cells potentiates the morphofunctional regeneration of the facial nerve, occurring faster and more effectively. Level of Evidence: 4, degree of recommendation C.

New Onset Facial Nerve Palsy : A Part of Post COVID Mucormycosis Disease Spectrum — A Descriptive Observational Study

Introduction : COVID Associated Mucor (CAM) is a well known entity with defined symptomatology. Cranial Nerve Palsy involving II, III, IV, V, VI th Nerve is common. Facial Nerve involvement is an out of tract presentation. The study was aimed to find the incidence of Facial Nerve involvement in CAM and document their route of involvement. Material and Method : Descriptive observational study was done in an Apex Centre for CAM in West Bengal between April, 2021 to January, 2022. CAM having Rhino-orbital-cerebral Mucormycosis (ROCM) and new onset Facial Palsy were considered. Participants were included following stipulated inclusion and exclusion criteria. Collected data was analysed. Observations : Total 11 patients of new onset Facial Palsy in COVID-19-Associated ROCM were included. 81.8% had coexisting other Cranial Nerve involvement. Facial Palsy was one of the primary presentations in the patients of ROCM. Discussion : CAM is angioinvasive and can cause concomitant hypoxic neural damage due to involvement of the vasa nervorum. Skull base involvement can be hypothesized to be the predominant route of Facial Nerve involvement. Facial palsy can be an important initial presentation of CAM. Conclusion : Facial Nerve Palsy may be a part of the spectrum of disease presentation in CAM.

Basic and Clinical Research Review of the Effects of Acupuncture and Moxibustion on Peripheral Facial Nerve Paralysis / 全日本鍼灸学会雑誌

There is little common understanding among acupuncturists regarding the poor prognosis for peripheral facial paralysis, evaluation methods, precautions during treatment, including acupuncture and moxibustion treatment. Cooperation among relevant occupations is also a major issue. Currently, the treatment of paralysis is focused on how to minimize sequelae during the recovery process of paralysis in cases with poor prognosis. The goal is to prevent sequelae and improve patient quality of life (QOL). For that purpose, it is important to understand the guidelines for medical treatment of paralysis, and like other medical staff, the acupuncturist should provide appropriate medical examination, treatment, self-care guidance, etc., and cooperate with other medical specialists. We hope that this seminar will provide a common understanding of the pathophysiology and evaluation methods of paralysis, precautions for acupuncture and moxibustion treatment, and a consensus of clinical research and the future possibility of using acupuncture and moxibustion in the treatment of paralysis.

Modified tragus edge incision and transmasseteric anteroparotid approach to condyle reconstruction / 华西口腔医学杂志

OBJECTIVES@#This study aimed to analyze the application value of a modified tragus edge incision and transmasseteric anteroparotid approach to condyle reconstruction.@*METHODS@#Condyle reconstruction was performed in 16 patients (9 females and 7 males) with modified tragus edge incision and transmasseteric anteroparotid approach. After regular follow-up, the function of condyle reconstruction was evaluated by clinical indicators, such as parotid salivary fistula, facial nerve function, mouth opening, occlusal relationship, and facial scar. The morphology of rib graft rib cartilage was evaluated by imaging indicators, such as panoramic radiography, CT, and three-dimensional CT image reconstruction.@*RESULTS@#At 6-36 months postoperative follow-up, all patients had good recovery of facial appearance, concealed incisional scar, no parotid salivary fistula, good mouth opening, and occlusion. One case had temporary facial paralysis and recovered after treatment. Radiographic evaluation further showed that costochondral graft survived in normal anatomic locations.@*CONCLUSIONS@#The modified tragus edge incision and transmasseteric anteroparotid approach can effectively reduce parotid salivary fistula and facial nerve injury in condylar reconstruction. The surgical field was clearly exposed, and the incision scar was concealed without increasing the incidence of other complications. Thus, this approach is worthy of clinical promotion.

Síndrome de Moebius y ortotropía en posición primaria: ¿es infrecuente esta asociación? (Colombia) / Moebius syndrome and orthotropia in primary position: is this association uncommon? (Colombia) / Síndrome de Moebius e ortotropia em posição primária: é uma associação incomum? (Colômbia)

El síndrome de Moebius es una enfermedad congénita poco común que se caracteriza por el compromiso unilateral o bilateral del VI y VII par craneal, lo que compromete los músculos que controlan la oculomotricidad, produciendo una parálisis en la abducción del globo ocular y los músculos involucrados en la expresión facial. Su presentación clínica y grados de severidad son variables, puede presentar compromiso simétrico o asimétrico. Adicionalmente, gran parte de los casos se relacionan con trastornos del lenguaje, anomalías musculoesqueléticas y orofaciales. En el presente artículo se presenta el caso de una paciente femenina de 3 años producto de un embarazo trigemelar con diagnóstico clínico de síndrome de Moebius al nacer, confirmado por neuroimagen en la que se evidencia la ausencia bilateral del nervio facial en ángulos pontocerebelosos, adicionalmente con un defecto completo en los movimientos oculares de abducción y aducción lo que impide el estrabismo convergente común en estos pacientes.

Moebius syndrome is a rare congenital disease characterized by unilateral or bilateral involvement of the VI and VII cranial nerves, which compromises the muscles that control ocular motricity with paralysis in the abduction of the eyeball and the muscles involved in the facial expression. Its clinical presentation and degrees of severity are variable, and it can be symmetric or asymmetric. Additionally, most of the cases are related to language disorders, musculoskeletal and orofacial anomalies. This paper presents the case of a 3-year-old female patient, product of a trigemellar pregnancy with a clinical diagnosis of Moebius syndrome at birth, confirmed by neuroimaging, which shows the bilateral absence of the facial nerve in point-lateral angles. Additionally she has a complete defect in abduction and adduction eye movements, which prevents the common convergent strabismus in these patients.

A síndrome de Moebius é uma doença congênita rara caracterizada pelo envolvimento unilateral ou bilateral dos nervos cranianos VI e VII, que compromete os músculos que controlam a oculomotricidade com paralisia na abdução do globo ocular e dos músculos envolvidos na expressão facial. Sua apresentação clínica e graus de gravidade são variáveis, podendo ser um comprometimento simétrico ou assimétrico. Além disso, a maioria dos casos está relacionada a distúrbios de linguagem, anomalias musculoesqueléticas e orofaciais. Este paper apresenta o caso de uma paciente de 3 anos de idade, fruto de uma gravidez trigêmea com diagnóstico clínico de Síndrome de Moebius ao nascimento, confirmado por neuroimagem em que é evidente a ausência bilateral do nervo facial nos ângulos ponto-cerebelares. Além disso, ela tem um defeito completo nos movimentos oculares de abdução e adução, o que impede o estrabismo convergente comum nesses pacientes.

Estudo topográfico dos giros e sulcos e do nervo facial em cadáveres de fetos humanos / Topographic study of gyri, sulci and facial nerve in human fetus corps / Estudio topográfico de giros, surcos y nervios faciales en cadáveres de fetos humanos

Introdução: Durante o desenvolvimento do encéfalo há formação de sulcos e giros que podem sofrer alterações morfológicas similarmente ao nervo facial (NC VII) que possui funções sensitivas e motoras e sua lesão pode gerar prejuízos clínicos e estéticos. Na literatura há informações sobre essas estruturas em adultos, porém pouco definidas em fetos. Objetivo: Descrever os giros e sulcos e o trajeto do NC VII em cadáveres de fetos humanos. Métodos: Selecionou-se sete fetos humanos, de ambos os sexos, do acervo do Laboratório de Anatomia da UFMS CPTL. Realizou-se três etapas: avaliação da idade fetal, dissecação e descrição anatômica. O estudo foi aprovado pelo Comitê de Ética em Pesquisa, CAEE: 75069617.5.0000.5386 2022. Resultados: observou-se na face dorsolateral sulcos frontal superior e médio e pós-central, temporal superior e inferior, circular da ínsula e central da ínsula. Há giro pré-central, pós-central, temporais, superior inferior e médio. Na face medial há sulco do cíngulo duplo, paracentral, parieto occipital e giro frontal superior. Em todos os fetos, há o tronco do NC VII e seus ramos perfurando o parênquima da glândula parótida na região infratemporal antes da divisão em ramos pela face Conclusão: A topografia dos giros e sulcos dos fetos é fundamental para identificar precocemente malformações corticais. Somado a isso, o estudo morfológico do NC VII poderá fomentar estudos futuros, haja vista que são poucos os registros a respeito das características deste nervo em fetos.

Introduction: In the development of the brain there are grooves and gyri that undergo morphological changes, similarly the facial nerve (CN VII) has sensory and motor functions and its injury generates clinical and aesthetic damage. In the literature there is information about these structures in adults, but little defined in fetuses. Objective: To describe the gyri and sulci and the course of CN VII in fetal cadavers. Methods: Seven human fetuses of both sexes were selected from the collection of the Anatomy Laboratory of the UFMS CPTL. Three steps were performed: assessment of fetal age, dissection and anatomical description. The study was approved by the Research Ethics Committee, CAEE 75069617.5.0000.5386. Results: in the studied brains, superior and medium frontal and postcentral, superior and inferior temporal, insula circular and insula central grooves were observed on the dorsolateral surface. There are precentral, postcentral, temporal, superior, inferior, and middle gyrus. On the medial surface there is the double cingulate sulcus, paracentral, parieto occipital and superior frontal gyrus. In all fetuses, there is the trunk of CN VII and its branches piercing the parotid gland parenchyma in the infratemporal region before dividing into branches across the face. Conclusion: The topography of the gyri and sulcus of fetuses is essential for early identification of cortical malformations. Added to this, the morphological study of CN VII may encourage future studies, given that there are few records regarding the characteristics of this nerve in fetuses.

Introducción: En el desarrollo del cerebro existen surcos y circunvoluciones que sufren cambios morfológicos, de igual manera el nervio facial (NC VII) tiene funciones sensoriales y motoras y su lesión genera daño clínico y estético. En la literatura existe información sobre estas estructuras en adultos, pero poco definidas en fetos. Objetivo: Describir las circunvoluciones y surcos y el curso del NC VII en cadáveres fetales. Métodos: Siete fetos humanos, de ambos sexos, fueron seleccionados de la colección del Laboratorio de Anatomía de la UFMS CPTL. Se realizaron tres pasos: evaluación de la edad fetal, disección y descripción anatómica. El estudio fue aprobado por el Comité de Ética en Investigación, CAEE 75069617.5.0000.5386. Resultados: en los cerebros estudiados, se observaron surcos en la superficie dorsolateral frontal superior y medio y poscentral, temporal superior e inferior, insular circular e insular central. Hay circunvolución precentral, poscentral, temporal, superior, inferior y media. En la superficie medial se encuentra el doble surco cingulado, paracentral, parieto occipital y giro frontal superior. En todos los fetos, el tronco del NC VII y sus ramas perforan el parénquima de la glándula parótida en la región infratemporal antes de dividirse en ramas a lo largo de la cara. Conclusión: La topografía de las circunvoluciones y surcos de los fetos es fundamental para la identificación temprana de malformaciones corticales. Sumado a esto, el estudio morfológico del NC VII puede alentar futuros estudios, dado que existen pocos registros sobre las características de este nervio en fetos.

Transmastoid exposure of the labyrinthine segment of the facial nerve: an anatomical study,

Abstract Introduction: Compression of the labyrinthine segment of the facial nerve by edema has been considered as an important pathology in the majority of the cases of idiopathic facial nerve paralysis. Hence, it is suggested that total decompression of the facial nerve should also include the labyrinthine segment by a middle fossa approach. However, the middle fossa approach requires craniotomy and temporal lobe retraction, which increases the morbidity. The labyrinthine segment of the facial nerve can also be reached through mastoidectomy. However, many ear surgeons are not familiar with this approach due to the lack of anatomical data on this surgical area. Objective: To study the anatomical limitations of decompression of the labyrinthine segment via transmastoid approach. Methods: Complete mastoidectomy was performed in six adult cadavers heads. Dissection was extended in the zygomatic root and posterior bony wall of the external auditory canal to visualize the incudomallear joint completely. The bone between tympanic segment, lateral and superior semicircular canal's ampullas and middle fossa dural plate was removed. Fine dissection was carried out over tympanic segment of the facial nerve in an anterosuperomedial direction the labyrinthine segment was reached. Results: All the mastoids were well pneumatized. Distances between the labyrinthine segment and middle fossa dura, and between the labyrinthine segment and superior semicircular canal, were 2.5 and 4.5mm on average, respectively. In addition, distances between the middle fossa dura and dome of the lateral semicircular canal, and between the middle fossa dura and tympanic segment were 4.6 mm and 4.3 mm on average, respectively. Conclusion: It is possible to expose the labyrinthine segment of the facial nerve through mastoidectomy by dissecting the bone in the area between the tympanic segment of the facial nerve, middle fossa dural plate and ampullary ends of the lateral and superior semicircular canals.

The efficacy of corticosteroid after facial nerve neurorrhaphy: a systematic review and meta-analysis of randomized controlled trial

Abstract Objectives: The benefit of corticosteroids following facial nerve neurorrhaphy in the setting of complete transection is questionable. This systematic review and meta-analysis aimed to evaluate corticosteroid efficacy on facial nerve regeneration and functional recovery after complete disruption and neurorrhaphy. Methods: Randomized controlled trials on both human and animal models from Ovid MEDLINE and Ovid EMBASE studying corticosteroid efficacy in complete facial nerve disruption followed by neurorrhaphy were included. Data were extracted and pooled for meta-analysis. The outcomes were evaluated from electrophysiology, histology, and functional recovery. However, no randomized controlled trial in human was performed. Possibly, performing human trials with histopathology may not be feasible in clinical setting. Results: Six animal studies (248 participants) met inclusion criteria. Electrophysiologic outcomes revealed no differences in latency (Standardized Mean Difference (SMD) = −1.97, 95% CI −7.38 to 3.44, p = 0.47) and amplitude (SMD = 0.37, 95% CI −0.44 to 1.18, p = 0.37) between systemic corticosteroids and controls. When analysis compared topical corticosteroid and control, the results provided no differences in latency (Mean Difference (MD)=0.10, 95% CI −0.04 to 0.24, p = 0.16) and amplitude (SMD = 0.01, 95% CI −0.08 to 0.10, p = 0.81). In histologic outcomes, the results showed no differences in axon diameter (MD = 0.13, 95% CI −0.15 to 0.41, p = 0.37) between systemic corticosteroid and control; however, the result in myelin thickness (MD = 0.06, 95% CI 0.04 to 0.08, p < 0.05) favored control group. When comparing systemic corticosteroid with control in eye blinking, the results favored control (MD= 1.33, 95% CI 0.60 to 2.06, p = 0.0004). Conclusions: This evidence did not show potential benefits of systemic or topical corticosteroid deliveries after facial nerve neurorrhaphy in complete transection when evaluating electrophysiologic, histologic, and functional recovery outcomes in animal models.

Parálisis facial periférica bilateral postraumática / Bilateral post-traumatic facial palsy

La parálisis del VII par craneal o nervio facial, es una de las neuropatías más frecuentes. Sin embargo, la bilateral ocurre solo en el 0,3 a 2% de los casos. Se describe el caso de un paciente con parálisis facial periférica bilateral progresiva, secundaria a traumatismo craneoencefálico con fractura de ambos temporales, a quien se le realizó tratamiento médico con esteroides y fisioterapia con mejoría, por lo que se decidió expectar la conducta quirúrgica del nervio facial

Facial nerve palsy is one of the most common neuropathies. However, bilateral occurs only in 0.3 to 2% of cases. The case of a patient with progressive bilateral facial nerve palsy, secondary to cranioencephalic trauma with fracture of both temporal was treated with steroids and physiotherapy with subsequent resolution of symptoms, so it was decided dedicated wait for surgery

Effects of titanium prepared platelet rich fibrin on facial nerve regeneration: an experimental study / Efeitos da fibrina rica em plaquetas preparada com titânio na regeneração do nervo facial: um estudo experimental

Abstract Introduction: Facial nerve damage is a condition that causes functional, psychological, and cosmetic problems; and treatment methods need to be improved. Objective: We investigated the efficacy of titanium-prepared platelet-rich fibrin as a healing enhancer at the region of transection of the facial nerve. Methods: Twenty-seven New Zealand male rabbits were used in this study, divided into three experimental groups. Group 1, the sham group (n=7); Group 2, the suture group (n = 10); and Group 3, the suture + T-PRF group (n = 10). In Group 1, the facial nerve trunk was dissected, and no additional surgical intervention was performed. For Group 2, a transection was made to the facial nerve trunk and the nerve endings were sutured together. In Group 3, nerve endings were sutured after transection, and a titanium-prepared platelet-rich fibrin membrane was wrapped in a tube around the damaged area. All animals were followed up weekly for the presence of corneal reflex, whisker movement and low ears. Bilateral facial electromyography was performed both preoperatively and postoperatively at the 1st, 3rd, 5th, 7th, 10th weeks. Tissue samples obtained at the 10th week were histopathologically examined, and intra-group and inter-group comparisons were performed. Results: Subjects in Group showed improvement in whisker movement and ear drop one week earlier than Group 2. In Group 3, the nerve stimulation threshold required to trigger the compound muscle action potential had returned to values similar to the preoperative control values (11.31 ±2.16V) by 5 weeks postoperatively (12.51 ±3.97V), (p = 0.249). Conclusion: Titanium-prepared platelet-rich fibrin administration contributed to partial nerve healing both on a functional and an electrophysiological level.

Resumo Introdução: A lesão do nervo facial é uma condição que causa problemas funcionais, psicológicos e cosméticos e os métodos de tratamento precisam ser melhorados. Objetivo: Investigamos a eficácia da fibrina rica em plaquetas preparada com titânio como um intensificador de cura na transecção do nervo facial. Método: Vinte e sete coelhos machos da raça New Zealand foram usados neste estudo, divididos em três grupos experimentais. Grupo 1, o grupo simulado (n = 7); Grupo 2, o grupo de sutura (n = 10); e Grupo 3, o grupo sutura + fibrina rica em plaquetas preparada com titânio (n = 10). No Grupo 1, o tronco do nervo facial foi dissecado e nenhuma intervenção cirúrgica adicional foi feita. No Grupo 2, uma secção transversal foi feita no tronco do nervo facial e as terminações nervosas foram suturadas. No Grupo 3, as terminações nervosas foram suturadas após a transecção e uma membrana de fibrina rica em plaquetas preparada com titânio foi envolvida em um tubo ao redor da área danificada. Todos os animais foram acompanhados semanalmente quanto à presença do reflexo corneal, movimento dos bigodes e orelhas baixas. A eletromiografia facial bilateral foi feita no pré e pós-operatório na 1ª, 3ª, 5ª, 7ª e 10ª semanas. Amostras de tecido obtidas na 10- semana foram examinadas histopatologicamente e comparações intra- e intergrupos foram feitas. Resultados: Os animais do Grupo 1 apresentaram melhoria no movimento dos bigodes e orelhas baixas uma semana antes do Grupo 2. No Grupo 3, o limiar de estimulação do nervo necessário para acionar o potencial de ação muscular composta retornou a valores semelhantes aos valores de controle pré-operatório (11,31 ± 2,16 volts) em 5 semanas de pós-operatório (12,51 ± 3,97 volts), (p = 0,249). Conclusão: A administração de fibrina rica em plaquetas preparada com titânio contribuiu para a cicatrização parcial do nervo ao nível funcional e eletrofisiológico.

Bilateral Facial Nerve Palsy after Sars-Cov2 Infection in Pediatric Patient

COVID-19 infection has been associated with several neurologic manifestations including anosmia, acute ischemic stroke, Guillain-Barré syndrome, encephalopathy and cranial nerve involvement. Though multiple cases of unilateral facial nerve palsy have been reported but bilateral facial palsy is very rare. Our case was 12 years old female patient who presented with difficulty in closing mouth, drooling of saliva and change in voice. On examination, there was loss of bilateral nasolabial folds, nasal twang of speech and incomplete eye closure bilaterally. Laboratory reports suggested raised CRP and amylase along with positive Immunoglobulin IgG covid-19 antibodies. Magnetic Resonance Imaging of brain and neck showed no abnormality. The child was managed conservatively with supportive care, subsequent to which she gradually improved over next 4-6 weeks. To the best of our knowledge, this is the first pediatric case where SARS-COV2 infection was found to be associated with bilateral facial nerve palsy as a post covid complication. Therefore, bilateral facial palsy should be considered as one of the associations of COVID especially in the present era. A detailed history and examination should be done as it often gets missed due to bilateral involvement. All differential diagnosis should be ruled out by relevant laboratory & radiological tests. Most children are likely to recover well with supportive treatment.

Activación de la microglía en el hipocampo asociada con lesión del nervio facial / Facial nerve injury-associated hippocampal microglíal activation

Introducción. Las lesiones del nervio facial afectan la plasticidad a largo plazo en el hipocampo, así como la memoria de reconocimiento de objetos y la memoria espacial, dos procesos dependientes de esta estructura. Si bien se ha descrito una activación de la microglía en la corteza motora primaria asociada con esta lesión, no se conoce si ocurre algo similar en el hipocampo. Objetivo. Caracterizar en ratas el efecto de la lesión unilateral del nervio facial sobre la activación de células de la microglía en el hipocampo contralateral. Materiales y métodos. Se hicieron experimentos de inmunohistoquímica para detectar células de la microglía en el hipocampo de ratas sometidas a lesión irreversible del nervio facial. Los animales se sacrificaron en distintos momentos después de la lesión, para evaluar la evolución de la proliferación (densidad de células) y la activación (área celular) de la microglía en el tejido del hipocampo. Los tejidos cerebrales de los animales de control se compararon con los de animales lesionados sacrificados en los días 1,3, 7, 21 y 35 después de la lesión. Resultados. Las células de la microglía en el hipocampo de animales con lesión del nervio facial mostraron signos de proliferación y activación a los 3, 7 y 21 días después de la lesión. Sin embargo, al cabo de cinco semanas, estas modificaciones se revirtieron, a pesar de que no hubo recuperación funcional de la parálisis facial. Conclusiones. La lesión irreversible del nervio facial produce proliferación y activación temprana y transitoria de las células de la microglía en el hipocampo. Estos cambios podrían estar asociados con las modificaciones electrofisiológicas y las alteraciones comportamentales dependientes del hipocampo descritas recientemente.

Introduction: Facial nerve injury induces changes in hippocampal long-term synaptic plasticity and affects both object recognition memory and spatial memory consolidation (i.e., hippocampus-dependent tasks). Although facial nerve injury-associated microglíal activation has been described regarding the primary motor cortex, it has not been ascertained whether something similar occurs in the hippocampus. Peripheral nerve injury- associated microglíal changes in hippocampal tissue could explain neuronal changes in the contralateral hippocampus. Objective: To characterize the effect of unilateral facial nerve injury on microglíal proliferation and activation in the contralateral hippocampus. Materials and methods: Immunohistochemical experiments detected microglíal cells in the hippocampal tissue of rats that had undergone facial nerve injury. The animals were sacrificed at specific times after injury to evaluate hippocampal microglíal cell proliferation (cell density) and activation (cell area); sham-operated animals were compared to lesioned animals sacrificed 1,3, 7, 21, or 35 days after injury. Results: Facial nerve-injured rats' hippocampal microglíal cells proliferated and adopted an activated phenotype 3- to 21-days post-lesion. Such modifications were transient since the microglíal cells returned to their resting state five weeks after injury, despite the injury's irreversible nature. Conclusions: Facial nerve injury causes the transient proliferation and activation of microglíal cells in the hippocampus. This finding might partly explain the morphological and electrophysiological changes described for CA1 pyramidal neurons and the impairment of spatial memory consolidation which has previously been observed in facial nerve-injured rats.

Evaluation of Clinical Outcome in Traumatic Facial Nerve Paralysis

Abstract Introduction The facial nerve is the most commonly paralyzed nerve in the human body, resulting in far-reaching functional, aesthetic and emotional concerns to the patient. Objective Evaluation of the clinical outcome of 47 patients with traumatic facial nerve paralyses, with respect to clinical recovery and audiological sequelae. Methods A descriptive longitudinal study was conducted over 24 months between January 2017 and December 2018 at a tertiary center with detailed clinical, topodiagnostic, audiometric and radiological evaluation and regular follow-up after discharge. Results Road traffic accidents constituted 82.98% of the trauma cases, out of which 76.60% were found to be under the influence of alcohol. Delayed facial paralysis was observed in 76.60% cases. Temporal bone fracture was reported in 89.36%, with otic capsule (OC) sparing fractures forming 91.49% of the cases. Topologically, the injury was mostly at the suprachordal region around the second genu. The majority of the patients (65%) attained full recovery of facial nerve function with conservative medical management. Audiometrically, 77.27% of the patients had hearing loss at the time of presentation, of which 64.71% were conductive in nature; 51.22% attained normal hearing at follow-up visits. Conclusion Early initiation of steroid therapy, concurrent eye care and physiotherapy are the cornerstones in the management of traumatic facial nerve paralysis.