Anatomical description of the extratemporal facial nerve under high-definition system: a microsurgical study in rats

Purpose: To describe the microsurgical anatomical aspects of the extratemporal facial nerve of Wistar rats under a high-definition video system. Methods: Ten male Wistar rats (12­15 weeks old), without veterinary diseases, weighing 220­280 g, were used in this study. All animals in this study were submitted to the same protocol and by the same surgeon. A 10-mm incision was made below the bony prominence of the right or left ear, and extended towards the angle of the mandible. The dissection was performed and the main branches of the facial nerve were dissected. Results: The main trunk of the facial nerve has a length of 0.88 ± 0.10 mm and a length of 3.81 ± 1.03 mm, measured from its emergence from the stylomastoid foramen to its bifurcation. Seven branches originating from the facial nerve were identified: posterior auricular, posterior cervical, cervical, mandibular, buccal, temporal, and zygomatic. Conclusions: The anatomy of the facial nerve is comparable to that of humans, with some variations. The most observed anatomical division was the distribution in posterior auricular, posterior cervical, cervical, mandibular, buccal, temporal, and zygomatic branches. There is no statistical difference between the thickness and distance of the structures compared to the contralateral side.

Hypoglossal-Facial Anastomosis for Facial Nerve Reconstruction: Outcomes using the Side-to-End Surgical Technique

Introduction The side-to-end hypoglossal-facial anastomosis (HFA) technique is an excellent alternative technique to the classic end-terminal anastomosis, because itmay decrease the symptoms resulting from hypoglossal-nerve transection. Methods Patients with facial nerve palsy (House-Brackmann [HB] grade VI) requiring facial reconstruction from 2014 to 2017were retrospectively included in the study. Results In total, 12 cases were identified, with a mean follow-up of 3 years. The causes of facial paralysis were due to resection of posterior-fossa tumors and trauma. There was improvement in 91.6% of the patients (11/12) after the HFA. The rate of improvement according to the HB grade was as follows: HB III - 58.3%; HB IV - 16.6%; and HB II - 16.6%. The first signs of improvement were observed in the patients with the shortest time between the paralysis and the anastomosis surgery (3.5months versus 8.5 months; p » 0.011). The patients with HB II and III had a shorter time between the diagnosis and the anastomosis surgery (mean: 5.22 months), while the patients with HB IV and VI had a longer time of paresis (mean: 9.5 months; p » 0.099). We did not observe lingual atrophy or changes in swallowing. Discussion and Conclusion Hypoglossal-facial anastomosis with the terminolateral technique has good results and low morbidity in relation to tongue motility and swallowing problems. The HB grade and recovery appear to be better in patients operated on with a shorter paralysis time.

Masseter nerve-innervated free gracilis muscle transfer for smile reanimation in adults / 中华耳鼻咽喉头颈外科杂志

Objective: To investigate the outcomes of masseter nerve-innervated free gracilis muscle transfer for smile reanimation in adults and to explore surgical indications. Methods: A retrospective chart review of 37 patients (11 males, 26 females, with (40.3±12.7) years old)who underwent masseter nerve-innervated free gracilis muscle transfer for smile reanimation between 2016 and 2017 was performed. Patient-reported quality of life (facial clinimetric evaluation, FaCE), physician-reported facial function (eFACE facial grading scale), and oral commissure excursion were compared preoperatively and postoperatively. SPSS 11.0 software was used to analyze the data. Results: Thirty-seven patients were followed up in one year after surgery. Significant postoperative improvements were demonstrated for commissure excursion with smile (preoperatively: (-1.2±3.1) mm, postoperatively: (6.1±3.5) mm, t=-31.1, P<0.01), ipsilateral FaCE (preoperatively: (29.4±14.1), postoperatively: (57.6±23.4), t=-38.1, P<0.01), eFACE score (Composite score t=-35.8, Static score t=-29.1, Dynamic score t=-41.3,Midface score t=-43.9, all P<0.01), respectively. Conclusion: Masseter nerve-innervated free gracilis muscle transfer is an good option for dynamic smile reanimation in adult patients who have undergone treatment for long-standing facial paralysis.

Reanimação estática do lábio inferior na paralisia facial como complicação de preenchimento / Static lower lip reanimation as a filler complication of facial paralysis

Procedimentos de rejuvenescimento facial substitutos da cirurgia tradicional tornaram-se cada vez mais populares para promover uma aparência jovial com procedimentos minimamente invasivos, como toxina botulínica injetável, preenchimento de tecidos moles e peelings químicos. No entanto, complicações podem ocorrer mesmo na presença de um injetor habilidoso e experiente. Apresentamos o caso de uma paciente submetida a reanimação labial estática usando retalho dermoadiposo para lesão do nervo facial direito após remoção de nódulos como complicação de preenchimento. A "abordagem modificada de bull horn" foi realizada para elevação do lábio superior em torno das asas nasais e columela e ao longo do sulco nasolabial direito. O retalho foi desepitelizado e obtido. Usando a ponta aberta de uma pequena cânula de lipoaspiração, a porção distal do retalho foi encapsulada e fixada diretamente em C-loop e foram utilizados pontos U, transfixando o retalho para o periósteo do arco zigomático. Nos três anos de seguimento não foram observadas complicações significativas e a paciente não relatou nenhuma limitação funcional ou insatisfação com o aspecto das cicatrizes no sulco nasolabial e ao redor das asas nasais e da columela.

Facial rejuvenation procedures to circumvent traditional surgery have become increasingly popular to promote a youthful appearance with minimally invasive procedures such as injectable botulinum toxin, soft-tissue fillers, and chemical peels. Nevertheless, complications can occur even with an astute and experienced injector. Here we present the case of a patient who underwent static lip reanimation using a dermoadiposal flap for right facial nerve damage following nodule removal as a filler complication. A "modified bulls horn approach" to the upper lip lift was performed around the nasal wings and columella and along the right nasolabial fold. The flap was de-epithelized and harvested. Using the open tip of a small liposuction cannula, the distal portion of the flap was tunneled and fixed directly in a C-loop fashion using U stitches, transfixing the flap to the periosteum of the zygomatic arch. At 3 years follow-up, no significant complications were observed, and the patient reported no functional limitations or dissatisfaction with the scars in the nasolabial fold or around the nasal wings and columella.

Toxina botulínica para tratamento de síndrome do Choro Assimétrico: relato de caso / Botulinum toxin in the treatment of asymmetric crying face syndrome: a case report

Síndrome do choro assimétrico é uma condição congênita secundária à hipoplasia ou ausência do músculo depressor do ângulo da boca. Trata-se de uma condição não tão incomum que pode cursar com assimetria facial ao chorar e sorrir, além de poder estar associadas a outras malformações congênitas. Crianças com essa deformidade podem sofrer dificuldades psicossociais e introversão. O arsenal terapêutico dessa condição já foi estudado e discutido na literatura com ênfase em abordagens cirúrgicas e invasivas. Relatamos aqui um caso de uma criança de 9 anos com essa síndrome, tratada, de forma menos invasiva, com toxina botulínica, com um bom resultado e satisfação.

Asymmetric crying face syndrome is a congenital condition secondary to hypoplasia or absence of the depressor muscle at the mouth angle. It is a common condition that presents with facial asymmetry while crying and smiling and may be associated with other congenital malformations. Children with this deformity may experience psychosocial difficulties and introversion. The therapeutic arsenal of this condition has already been studied and discussed in the literature with an emphasis on surgical and invasive approaches. We report here a case of a 9-year-old child with this syndrome, treated less invasively with botulinum toxin, with good result and satisfaction.

Comparison between early and delayed facial nerve decompression in traumatic facial nerve paralysis - A retrospective study

ABSTRACT Purpose To study the intraoperative findings in case of early and delayed decompression of facial nerve paralysis and compare their results. Methods Retrospective data analysis of 23 cases of longitudinal temporal bone fracture with House-Brackmann grade V and VI facial nerve paralysis. All cases were thoroughly evaluated and underwent facial nerve decompression through the transmastoid approach. All cases were under regular follow-up till the date of manuscript submission. Results Clinical improvement of the facial nerve function was observed for early vs. delayed facial nerve decompression. In the early decompression group, facial nerve function improved to grade II in eight cases (80%) and grade III in two cases (20%), whereas in the delayed decompression group it improved to grade II in one case (7.70%), grade III in four cases (30.76%), grade IV in seven cases (53.84%), and grade V in one case (7.70%). Conclusions Early decompression of facial nerve provides better results than delayed decompression because it enables early expansion of the nerve.

Outcome of different facial nerve reconstruction techniques / Resultados de diferentes técnicas de reconstrução do nervo facial

Abstract Introduction: There is no technique of facial nerve reconstruction that guarantees facial function recovery up to grade III. Objective: To evaluate the efficacy and safety of different facial nerve reconstruction techniques. Methods: Facial nerve reconstruction was performed in 22 patients (facial nerve interpositional graft in 11 patients and hypoglossal-facial nerve transfer in another 11 patients). All patients had facial function House-Brackmann (HB) grade VI, either caused by trauma or after resection of a tumor. All patients were submitted to a primary nerve reconstruction except 7 patients, where late reconstruction was performed two weeks to four months after the initial surgery. The follow-up period was at least two years. Results: For facial nerve interpositional graft technique, we achieved facial function HB grade III in eight patients and grade IV in three patients. Synkinesis was found in eight patients, and facial contracture with synkinesis was found in two patients. In regards to hypoglossal-facial nerve transfer using different modifications, we achieved facial function HB grade III in nine patients and grade IV in two patients. Facial contracture, synkinesis and tongue atrophy were found in three patients, and synkinesis was found in five patients. However, those who had primary direct facial-hypoglossal end-to-side anastomosis showed the best result without any neurological deficit. Conclusion: Among various reanimation techniques, when indicated, direct end-to-side facial-hypoglossal anastomosis through epineural suturing is the most effective technique with excellent outcomes for facial reanimation and preservation of tongue movement, particularly when performed as a primary technique.

Resumo Introdução: Não existe uma técnica de reconstrução do nervo facial que garanta a recuperação da função facial até o grau III. Objetivo: Avaliar a eficácia e segurança de diferentes técnicas de reconstrução do nervo facial. Método: Ao todo, 22 pacientes foram submetidos a reconstrução do nervo facial (enxerto com interposição do nervo facial em 11 pacientes e com transferência do nervo hipoglosso facial em 11 pacientes). Todos os pacientes apresentavam função facial de grau VI (de acordo com a classificação de House-Brackmann - HB) causada por trauma ou pela ressecção de um tumor. A reconstrução do nervo principal foi efetuada, exceto em sete pacientes, nos quais a reconstrução foi realizada entre duas semanas a quatro meses após a cirurgia inicial. O período de acompanhamento foi de, no mínimo, dois anos. Resultados: Para a técnica de enxerto com interposição de nervo facial, o grau de função facial obtido foi HB III em oito pacientes e HB IV em três pacientes. Sincinesia foi observada em oito pacientes e contratura facial com sincinesia em dois pacientes. Em relação à transferência do nervo hipoglosso facial com o uso de diferentes modificações, obtivemos função facial HB grau III em nove pacientes e HB grau IV em dois pacientes. Contratura facial, sincinesia e atrofia lingual foram observadas em três pacientes e sincinesia observada em cinco pacientes. No entanto, aqueles submetidos a anastomose primária direta hipoglosso-facial término-lateral apresentaram o melhor resultado, sem qualquer déficit neurológico. Conclusão: Entre as várias técnicas de reanimação, sempre que possível, a anastomose direta término-lateral hopoglosso-facial por meio de sutura epineural é a técnica mais eficaz, com excelentes resultados para reanimação facial e preservação do movimento da língua, especialmente quando realizada como técnica primária.

Estrategias de reanimación facial: resultados preliminares de un estudio de cohorte / Results of a face reanimation protocol in patients with facial paralysis

Objetivo: El objetivo de este trabajo es presentar el protocolo de reanimación facial y determinar los resultados del tratamiento quirúrgico de la parálisis facial. Materiales y métodos: Se realizó un estudio de cohorte prospectiva con todos los pacientes que ingresaron en el Hospital Clínico de la Universidad de Chile (HCUCH) y se sometieron al protocolo de reanimación facial, desde el año 2008 al 2014. Los resultados quirúrgicos se evaluaron según el protocolo de medición directa publicado por Mantkelow. Se utilizó estadística descriptiva para caracterizar la muestra y analítica para determinar el cambio en la excursión de la comisura labial como indicador de movilidad facial. Resultados: Desde el año 2008 hasta la fecha se han intervenido 21 pacientes, de los cuales 6 han completado su protocolo de tratamiento y período de seguimiento. La edad promedio fue de 35 años, el seguimiento promedio alcanzó los 22 meses. La excursión de la comisura labial postoperatoria promedio alcanzó los 12,8 mm, lo que significa una mejoría significativa, con un promedio de 7 mm respecto al preoperatorio. La excursión postoperatoria promedio del labio superior fue de 5,9 mm, lo que también constituye una mejoría significativa respecto al preoperatorio. Conclusiones: Existe una mejoría significativa en la movilidad facial en los pacientes sometidos al protocolo de reanimación facial. Si bien estos cambios pueden parecer pequeños en magnitud, implican un cambio profundo en la calidad de vida. Con el fin de optimizar resultados resulta esencial una terapia de rehabilitación especializada, con terapias individualizadas.

Background: The deformity caused by facial paralysis has important functional and psychological consequences. Aim:To report a face reanimation protocol and the results of surgical treatment of facial paralysis.Materials and methods: Prospective intervention of 25 patients aged 8 to 79 years (13 males) with facial paralysis, between 2008 and 2014. Surgical results were evaluated using measurements according to Mantkelow protocol. Results: Patients were followed for 22 months. Postoperative excursion of the labial commissure reached 12.8 mm, which was 7 mm better than before surgery. The postoperative excursion of the upper lip was 5.9 cm, which also represented an improvement. Conclusions: There is a significant improvement in facial movements in these patients subjected to the face reanimation protocol. Although changes are of low magnitude, they have an impact in their quality.

Facial reanimation by hypoglossal-facial neurorrhaphy

Objective: Facial palsy may still occur after removal of large vestibular schwannomas. The aim of this paper is to describe the outcome of patients submitted to facial reanimation and make a concise revision about modern techniques available to reanimate a paralyzed face. Methods: A retrospective study of was performed about the surgical results of 12 patients submitted to hypoglossal-facial neurorrhaphy. These patients were submitted to radical removal of large vestibular schwannomas (> 3 cm) before and anatomic preservation of the facial nerve was not possible. Results: In 10 cases (83%) patients had a good outcome with House-Brackmann facial grading III. In two other cases the facial grading was IV and VI. All patients were follow-up for at least one year after the reanimation procedure. Conclusion: Hypoglossal-facial neurorrhaphy is a very useful technique to restore facial symmetry and minimize the sequela of a paralyzed face. Long last palsy seemed to be the main reason of poor outcome in two cases...

Paralisia facial pode ocorrer após remoção de schwannomas vestibulares volumosos.Neste artigo é descrito o resultado obtido em pacientes submetidos à reanimação facial, bem comoé realizada uma revisão concisa das técnicas modernas disponíveis para reanimação de uma faceparalisada. Métodos: Estudo retrospectivo do resultado cirúrgico de 12 pacientes submetidos àneurorra&a hipoglosso-facial. Todos esses pacientes foram operados anteriormente de schwannomasvestibulares volumosos (> 3 cm) e não foi possível a preservação anatômica ou funcional do nervofacial. Resultados: Em 10 casos (83%), observou-se boa recuperação da paralisia e gradação &nal IIIna escala de House-Brackmann. Em dois outros casos, um paciente evoluiu com grau IV e outro comgrau VI. Todos os pacientes foram seguidos por pelo menos um ano após o procedimento. Conclusão:A neurorra&a hipoglossal-facial é uma técnica útil para restaurar a simetria facial e minimizar as sequelasde uma face paralisada. Paralisia de longa duração foi a causa de insucesso em dois casos nesta série...

Frontoplastia não endoscópica, com mínimas incisões para elevação do supercílio, em portadores de paralisia facial periférica / Nonendoscopic minimal incision Forehead lift for brow suspension in peripheral facial paralysis subjects

Novas técnicas de frontoplastia, assistidas ou não de endoscópio, têm sido utilizadas na tentativa de diminuir as incisões tradicionalmente bi-coronais. Contudo, os resultados das cirurgias realizadas com mínimas incisões, sem endoscópio, ainda não são bem conhecidos, principalmente quando há sequelas de paralisia facial periférica (PFP). Dessa forma, o objetivo do presente estudo prospectivo foi avaliar a eficácia da frontoplastia não endoscópica com mínimas incisões na elevação do supercílio em indivíduos com PFP, 24 meses após a cirurgia. Constituíram variáveis do estudo a posição dos supercílios aferida em milímetros em fotografias digitais, por um software especialmente criado para este fim. Exploratoriamente, as fotos foram também avaliadas após o intervalo de 12 meses, e ainda, entre 36 a 78 meses. A satisfação dos pacientes com o resultado cirúrgico foi questionada verbalmente com a utilização de duas perguntas. A primeira, se o paciente estava satisfeito ou não e; a segunda, como o paciente qualificava sua aparência pós-cirurgia (entre as opções: pior, indiferente, melhor ou muito melhor). A amostra foi composta por 20 pacientes adultos que sofreram PFP há mais de 12 meses, com paralisia residual do ramo temporal e ptose do supercílio. Os pacientes foram submetidos a frontoplastia através de 2 incisões temporais no couro cabeludo, medindo 2,5 cm cada. Quando desejada fixação da parte medial do supercílio, esta foi realizada com agulha de Reverdin e 1 ou 2 incisões frontais acessórias, de 1 cm cada no couro cabeludo. Foi realizado descolamento frontal e temporal pelo plano subgaleal e liberação dos ligamentos do arcus marginalis sem visualização direta, com palpação externa dos reparos anatômicos. Não ocorreram lesões neurais sensitivas ou motoras permanentes em nenhum paciente em decorrência deste procedimento. As medidas pós-operatórias dos supercílios foram maiores do que as préoperatórias (p < 0,05)...

New forehead lift techniques assisted by endoscopic visualization or not, have currently been used to reduce the traditional bi-coronal incision. However, the results of surgeries performed with minimal incisions are unknown, especially when given in cases of sequelae of peripheral facial paralysis (PFP). Therefore, the objective of this prospective study was to assess the efficacy of nonendoscopic forehead lift with minimal incisions in PFP patient brow suspension, 24 months after surgery. Study variables were the position of the eyebrow assessed in millimeters on digital photographs, by software developed for this purpose. Brow position after 12 month and also between 36 and 78 months was exploratory analyzed. Patient's satisfaction and improvement was verbally inquired after surgery "are you satisfied or not" and "are you looking worst, the same, better or much better". The sample was composed of 20 adult patients who suffered PFP over 12 month and remain with paralysis of the temporal branch and eyebrow ptosis. Patients underwent forehead lift performed by two incisions in the lateral hair bearing area measuring 2.5 cm each. When desired medial eyebrow fixation a Reverdin needle was used and an extra incision measuring 1 cm each was placed centrally on hair bearing. Frontal and temporal flap detachment was performed by subgaleal plane and the release of the arcus marginalis was blindly accomplished by external palpation, minding anatomic parameters. No patient exhibited permanent sensitive or motor neural lesion after this procedure. Eyebrow position in the post-operative periods was higher than pre-operative (p < 0,05) confirming brow lift efficacy 24 months after surgery. Al the patients declared satisfied and qualified themselves as looking "better" or "much better"

Enxertos e anastomoses do nervo facial na orelha média: caixa do tímpano e mastoide / Facial nerve grafting and end-to-end anastomosis in the middle ear: tympanic cavity and mastoid

O nervo facial, quando seccionado, pode ser reparado em seu tronco por enxerto ou anastomose. OBJETIVO: Discutir as técnicas em questão e mostrar o que podemos esperar das mesmas. MÉTODO: Foram operados sete pacientes com secção do nervo facial. As cirurgias foram quatro enxertos e três anastomoses. Cinco paralisias foram iatrogênicas e duas por projéteis de arma de fogo. A avaliação da recuperação motora foi feita pela tabela de Janssen. RESULTADOS: Obtivemos 72,5% em média de recuperação motora nos casos de enxerto e 73,3% nos casos de anastomose. CONCLUSÃO: 1. Enxertos e anastomoses são soluções adequadas para reparar o nervo facial seccionado, mas nunca permitem uma recuperação facial completa, podendo ocorrer sincinesias. 2. Em princípio, o nosso objetivo é fazer a anastomose, mas quando existe tração mínima nos cotos do facial, preferimos os enxertos. 3. Em ambas as técnicas, conseguimos acima de 70% de recuperação motora em média (72,5% nos enxertos e 73,3% nas anastomoses).

Sectioned facial nerves can be repaired with grafting or end-to-end anastomosis. OBJECTIVE: To discuss these repair procedures and what can be expected of them. METHOD: Seven patients with sectioned facial nerves were included in the study. Four underwent grafting and three were offered end-to-end anastomosis. Facial nerve palsy was iatrogenic in five patients and was caused by bullet wounds in two. Assessment of motor function recovery was based on Janssen's scale. RESULTS: Mean motor recovery was rated at 72.5% for subjects offered grafting and 73.3% for patients submitted to anastomosis. CONCLUSION: 1. Grafting and anastomosis are proper solutions to repair sectioned facial nerves; complete recovery is never attained; synkinesis may occur. 2. In principle anastomosis is the procedure of choice, but when there is minimal traction in the facial nerve stump grafting is preferred. 3. Both procedures yielded mean motor recovery rates above 70% (72.5% for grafting and 73.3% for anastomosis).

Perdas auditivas em paralisia facial periférica após cirurgia de descompressão / Hearing loss in peripheral facial palsy after decompression surgery

A paralisia facial pode resultar de uma variedade de etiologias, sendo a mais comum a idiopática. A avaliação e o tratamento são particularmente complexos. O tratamento da paralisia facial aguda pode envolver cirurgia de descompressão do nervo facial. Qualquer estrutura perto do trajeto do nervo facial está em risco durante a cirurgia de descompressão via transmastoidea. OBJETIVO: Estudo retrospectivo que irá avaliar a perda auditiva após descompressão via transmastoidea e a evolução do grau de paralisia nos casos idiopáticos dos últimos 15 anos. MATERIAL E MÉTODO: Foram selecionados prontuários de 33 pacientes submetidos à descompressão do nervo facial via transmastoidea nos últimos 15 anos e avaliou-se a perda auditiva e a paralisia facial. RESULTADOS: Observou-se alta porcentagem (61%) dos pacientes com algum grau de perda auditiva após o procedimento e, em todos os casos, houve melhora da paralisia. CONCLUSÃO: O procedimento cirúrgico não é isento de riscos. Indicações, riscos e benefícios devem ser esclarecidos aos pacientes por meio de consentimento informado.

Facial paralysis can result from a variety of etiologies; the most common is the idiopathic type. Evaluation and treatment are particularly complex. The treatment of acute facial paralysis may require facial nerve decompression surgery. Any structure near the path of the facial nerve is at risk during transmastoid decompression surgery. AIM: This is a retrospective study, carried out in order to evaluate hearing loss after transmastoid decompression and how idiopathic cases evolved in terms of their degree of paralysis in the last 15 years. MATERIALS AND METHODS: We selected the charts from 33 patients submitted to transmastoid facial nerve decompression in the past 15 years and we assessed their hearing loss and facial paralysis. RESULTS: There was a high percentage (61%) of patients with some degree of hearing loss after the procedure and in all cases there was improvement in the paralysis. DISCUSSION: The values obtained are similar to those reported in the literature. One possible explanation for this hearing loss is the vibration transmission by drilling near the ossicular chain. CONCLUSION: The surgical procedure is not risk free; indications, risks and benefits should be explained to patients through an informed consent form.

Double muscle innervation using end-to-side neurorrhaphy in rats / Dupla inervação muscular com neurorrafia término-lateral em ratos

CONTEXT AND OBJECTIVE: One of the techniques used for treating facial paralysis is double muscle innervation using end-to-end neurorrhaphy with sectioning of healthy nerves. The aim of this study was to evaluate whether double muscle innervation by means of end-to-side neurorrhaphy could occur, with maintenance of muscle innervation. DESIGN AND SETTING: Experimental study developed at the Experimental Research Center, Faculdade de Medicina de Botucatu, Unesp. METHODS: One hundred rats were allocated to five groups as follows: G1, control group; G2, the peroneal nerve was sectioned; G3, the tibial nerve was transected and the proximal stump was end-to-side sutured to the intact peroneal nerve; G4, 120 days after the G3 surgery, the peroneal nerve was sectioned proximally to the neurorrhaphy; G5, 120 days after the G3 surgery, the peroneal and tibial nerves were sectioned proximally to the neurorrhaphy. RESULTS: One hundred and fifty days after the surgery, G3 did not show any change in tibial muscle weight or muscle fiber diameter, but the axonal fiber diameter in the peroneal nerve distal to the neurorrhaphy had decreased. Although G4 showed atrophy of the cranial tibial muscle 30 days after sectioning the peroneal nerve, the electrophysiological test results and axonal diameter measurement confirmed that muscle reinnervation had occurred. CONCLUSION: These findings suggest that double muscle innervation did not occur through end-to-side neurorrhaphy; the tibial nerve was not able to maintain muscle innervation after the peroneal nerve had been sectioned, although muscle reinnervation was found to have occurred, 30 days after the peroneal nerve had been sectioned.

CONTEXTO E OBJETIVO: Uma das técnicas utilizadas para tratamento da paralisia facial é a dupla inervação muscular com neurorrafia término-terminal, seccionando-se nervos sadios. O objetivo deste trabalho foi avaliar a ocorrência de dupla inervação muscular através de neurorrafia término-lateral e a manutenção da inervação. TIPO DE ESTUDO E LOCAL: Estudo experimental desenvolvido no Centro de Pesquisa Experimental da Faculdade de Medicina de Botucatu, Unesp. MÉTODOS: Cem ratos foram distribuídos em cinco grupos: G1, controle; G2, secção do nervo fibular; G3, o nervo tibial foi seccionado e o coto proximal suturado na lateral do nervo fibular íntegro; G4, 120 dias após a cirurgia do G3, o nervo fibular foi seccionado proximal à neurorrafia; G5, 120 dias após a cirurgia do G3, os nervos fibular e tibial foram seccionados proximal à neurorrafia. RESULTADOS: Após 150 dias da cirurgia, não foi observada variação na massa do músculo tibial ou no diâmetro das fibras musculares no G3, porém, houve redução do diâmetro da fibra axonal do nervo fibular distal à neurorrafia. Embora, no G4, tenha ocorrido atrofia do músculo tibial cranial 30 dias após a secção do nervo fibular, os resultados do teste eletrofisiológico e da medida do diâmetro axonal confirmaram a ocorrência de reinervação muscular. CONCLUSÃO: Estes resultados sugerem que a dupla inervação muscular não ocorreu através da neurorrafia término-lateral; o nervo tibial não foi capaz de manter a inervação muscular após a secção do nervo fibular; contudo, ocorreu reinervação muscular 30 dias após a secção do nervo fibular.

Facial nerve palsy: providing eye comfort and cosmesis

Development of facial nerve palsy [FNP] may lead to dramatic change in the patients's facial function, expression, and emotions. The ophthalmologist may play an important role in the initial evaluation, and the long-term management of patients with new-onset of FNP. In patients with expected temporary facial weakness, no efforts should be wasted to ensure proper corneal protection. Patients with permanent functional deficit may require combination of surgical procedures tailored to the patient's clinical findings that may require good eye comfort and cosmesis

Estudo anatômico do pedículo vásculo-nervoso do retalho do ventre anterior do músculo digástrico / Anatomic study of the anterior belly of the digastric muscle flap neurovascular pedicle

Introdução: A paralisia facial é uma síndrome com implicações estéticas e funcionais importantes.A reanimação do segmento facial afetado pode ser realizada por diversas técnicas. Atransposição de músculos regionais inervados por outro nervo craniano não afetado é um dosmétodos utilizados com frequência. O ventre anterior do músculo digástrico, inervado pelonervo miloioideo, ramo do nervo trigêmio, é um retalho bastante usado para a reanimação dadepressão do lábio inferior. Uma maior mobilidade deste retalho poderia permitir a transposiçãodo músculo para outros segmentos da face, ampliando sua utilização na prática clínica.Método: Estudamos o pedículo vásculo-nervoso do ventre anterior do músculo digástricoem 10 cadáveres, a fim de determinar o arco de rotação do seu retalho mantendo intacto oseu nervo aferente, e estudamos os diâmetros da artéria submentoniana, responsável pelo seusuprimento sanguíneo, com o objetivo de determinar a viabilidade de eventual reanastomosemicrocirúrgica. Resultados: Encontramos um arco de rotação médio de 3,71 cm a partirda borda inferior da mandíbula. O diâmetro externo da artéria submentoniana mediu emmédia 1,05 mm, o que permitiria a anastomose microcirúrgica a outro tronco arterial daface, dando uma maior liberdade para a mobilização do retalho. Conclusão: O retalho assimmobilizado tem, portanto, potencial renovado para uso na reanimação da paralisia facial.

Introduction: Fascial palsy is a syndrome with important esthetical and functional implications.The reanimation of the affected segment of the face can be obtained with severaltechniques. The transposition of local muscles, innervated by other cranial nerves, is frequentlyused. The anterior belly of the digastric muscle flap, innervated by the milohyoidnerve, a branch of the trigeminal nerve, is commonly used to treat the denervation of theinferior lip depressor muscle. A greater mobilization of this flap could allow its transpositionto other fascial segments. Methods: We have studied the vascular and nervous pedicle ofthe anterior belly of the digastric muscle in 10 unfixed cadavers, to determine the rotationarch of the flap, keeping its nerve intact. We have also studied the diameters of the submentonianartery, responsible for the blood suply to the flap, in order to evaluate the possibilityof microsurgical anastomosis to other vascular branches. Results: We have found a medianarch of rotation of 3.71 cm from the inferior border of the mandibule. The median externaldiameter of the artery was 1.05 mm, allowing its revascularization with microsurgicaltechnique. Conclusion: This mobilization of the anterior belly of the digastric muscle flapshows a potential for further use in the reanimation of fascial palsy.

Reanimação da face paralisada: o ponto de vista neurocirúrgico / Reanimation of the paralyzed face: the neurosurgical point of view

Objetivo: Revisão e discussão de técnicas consagradas na reanimação da face paralisada e das inovações sobre o tema. Método: Pesquisa bibliográfica abrangendo o banco de dados eletrônico Medline e pesquisa manual em jornais e revistas médicas, compreendendo o período de 1980 a 2008; facial nerve palsy, facial paralysis, reanimation e reconstruction foram utilizadas como palavras-chave. Conclusão: A despeito dos avanços nas técnicas de monitorização intraoperatória, a lesão do nervofacial permanece sendo uma complicação frequente nos pacientes submetidos à cirurgia de base decrânio. A paralisia facial acarreta alterações funcionais, cosméticas e psicológicas, representando um grande desafio à cirurgia reconstrutiva. Atualmente, uma miríade de técnicas encontra-se disponível para reanimação da face paralisada. A escolha da abordagem adequada leva em consideração a idade do paciente, o tempo de lesão facial, assim como a topografia da lesão do nervo facial, entre outros.

Objective: To review and discuss emphasizing the common surgical techniques and the state-of-the-art techniques for paralyzed face. Method: Bibliographic search in Medline and manual review of related publications from 1280 to 2008; the searching words were: facial nerve palsy, facial paralysis, reanimation e reconstruction. Conclusion: Despite recent advances in intraoperative monitoring, facial nerve lesion still is a complication of major concern in patients undergoing skull base surgeries. Facial nerve palsy has functional, cosmetic and psychological impact on patients representing a challenge to reconstructive surgery. Currently a myriad of surgical techniques is available for reanimation of the paralyzed face. The surgical management for reanimation considers not solely the patient´s age, but also duration of facial palsy and topography of facial nerve injury, among others.

Parálisis facial periférica / Peripheral facial palsy

La parálisis facial periférica (PFP) es una patología frecuente que habitualmente es unilateral, que genera deformidad estética facial y alteraciones funcionales. Se describe la anatomía del nervio facial (NF) en sus segmentos supranuclear, nuclear e infranuclear; describiendo con mejor definición surelación en el hueso temporal. Se hace una breve mención de la fisiopatología de PFP y de los grados de lesión: neuropraxia, axonotmesis y neurotmesis. Especial énfasis se da al diagnóstico en la PFP. Se mencionan las pruebas de topodiagnóstico: Test de Shirmer, Test del Reflejo Estapedial y Test de Blatt con Gustometría que brindan la posibilidad de ubicar topográficamente el lugar de la lesión en el NF Asimismo, se describen las pruebas electrodiagnósticas: Prueba de Excitabilidad del Nervio; - Prueba de Excitabilidad Máxima; - Electroneuronografía y - Electromiografía, todas pruebas que brindan un pronóstico en la evolución de la PFP Se hace mención de las principales causas de PFP vinculándolo a los diferentes segmentos del NF Por último, se plantean las opciones terapéuticas en la PFP, tanto el tratamiento médico donde tiene importante presencia la cortico terapia y el tratamiento quirúrgico, que sobre todo en las causales traumáticas tiene su indicación.

Peripheral facial palsy (PFP) is a common disease, that usually presents as an unilateral form, with facial esthetic deformity, and functional changes. The article describes the anatomy of the facial nerve ( FN), the intranuclear, nuclear and supranuclearsegments, and its relation with the temporal bone. A brief mention of the pathophysiology lesions of the PFP and the type od neurological damage : neuropraxya, axonotmesys and neurotmesys. A special emphasize in the diagnosis of PFP is made and the topodiagnosis tests : Shirmer tests, Estapedial Reflex tests, and Blatt tests with tastemeter, that makes possible to locate topographically the injury zone in the facial nerve. A description is made of the electrodiagnosis tests: Nerve excitabillity test - Maximum excitabillity test - Electroneuronography and eletromiography. All these tests can provide a prognostic information of the PFP. Is mention the underlying explanation of the PFP, associated with the different facial nerve segments. At last, is represented the therapeutic options of the PFP, medical treatment where the corticotherapy is important, and the surgical treatment, specially at the traumatic causes is indicated.

Anatomy of the facial nerve and its implication in the surgical procedures / Anatomía del nervio facial y sus implicancias en los procedimientos quirúrgicos

Facial palsy, parotid diseases and others are a relatively common clinical condition with a variety of causes. Irrespective of its etiology, facial palsy always represents a very serious problem for the patient. Parotid gland diseases also are very common occurrence. In this particular case, the knowledge of surgical anatomy of the facial nerve and its correlations with the parotid gland is very important for an adequate preservation in the cases of surgery of benign and malignant diseases of the parotid gland. Although the surgical anatomy of the facial nerve has been well documented, the concept of surgical treatment for parotid tumors, facial palsy (neurorraphy techniques) and submandibular surgical approach are rarely challenged now.

La parálisis facial, enfermedades de la parótida y otras patologías son una condición clínica relativamente común con una variedad de causas. Independientemente de su etiología, la parálisis facial siempre representa un problema muy serio para el paciente. Las enfermedades de la glándula parótida son también de una ocurrencia común. En este caso particular, el conocimiento de la anatomía quirúrgica del nervio facial y su correlación con la glándula parótida es de mucha importancia para una adecuada preservación de la misma, en casos de cirugía como tratamiento de enfermedades benignas o malignas. Aunque la anatomía quirúrgica del nervio facial es bien documentada, el concepto de tratamiento quirúrgico para los tumores parotídeos, parálisis facial (técnicas de neurorrafia) y acercamiento quirúrgico submandibular son raramente impugnados hoy en día.

Reconstrucción de la parálisis facial con colgajo del músculo temporal / Reconstruction of facial paralysis with temporalis muscle flap

INTRODUCCIÓN. La transposición de un sistema muscular vital y dinámico en una cara paralizada presenta ventajas biológicas sobre otras técnicas de suspensión que emplean trasplantes musculares de diferentes sitios anatómicos. El objetivo del presente estudio fue describir los resultados, las complicaciones encontradas y la satisfacción de los pacientes tratados mediante transposición del músculo temporal. MÉTODOS. Se realizó una investigación descriptiva y prospectiva con 7 pacientes atendidos entre septiembre de 1997 y julio de 1999. A estos pacientes se les practicó una incisión preauricular que se prolongó hasta la región temporal, en forma de T; se les separó el músculo temporal en toda su extensión y se confeccionaron dos segmentos que a su vez se seccionaron en 4 pequeños colgajos. Se labraron túneles subcutáneos en ambos párpados y labios, donde se introdujeron los colgajos y luego se fijaron al ligamento del canto interno y al tejido celular subcutáneo mediante suturas no absorbibles. El defecto de la fosa temporal fue rellenado con hidroxiapatita en granulado. RESULTADOS. Se obtuvo mejoría en la elevación de la comisura labial en el 100 por ciento de los pacientes operados, pero solo en un paciente (14,3 por ciento) se observó un cierre parcial del ojo. El 87,5 por ciento de los pacientes estuvieron satisfechos con los resultados funcionales obtenidos. Se observaron complicaciones en tres pacientes, las más frecuentes de las cuales fueron la dehiscencia de las suturas musculares, el rechazo al material de relleno y la sepsis local. CONCLUSIONES. Se pudo concluir que esta técnica está indicada en pacientes con secuelas funcionales graves, con atrofia muscular evidente y desviación de la comisura labial(AU)

INTRODUCTION. The transposition of vital and dynamic muscle system in a paralyzed face presents biological advantages over other suspension techniques using muscle transplants from different anatomical sites. The objective of the present study was to describe the results, the complications found and the satisfaction of the patients treated by temporalis muscle transposition. METHODS. A descriptive and prospective research was conducted in 7 patients treated between September 1997 and July 1999. A T-shaped preauricular incision that was prolonged to the temporal region was made. The temporalis muscle was separated in all its extension, the two segments obtained were sectioned into 4 small flaps. Subcutaneous tunnels were made in both eyelids and lips, where the flaps were introduced and fixed then to the ligament of the inner edge and to the subcutaneous cellular tissue by non-absorbable sutures. The defect of the temporal fossa was filled with granulated hydroxyapatite. RESULTS. An improvement of the elevation of the lip commissure was attained in 100 percent of the patients that were operated on, A partial closure of the eye was observed in only one patient (14.3 percent). 87.5 percent of the patients were satisfied with the functional results. Complications were reported in 3 patients. The most frequent were dehiscence of the muscle sutures, the rejection to the filling material and local sepsis. CONCLUSIONS. It was concluded that this technique is indicated in patients with severe functional sequelae, with muscle atrophy and deviation of the lip commissure(AU)

Hypoglossal-facial anastomosis, tricks and trade

Total removal of difficult tumours at the skull base left behind a traumatized facial nerve previously aggressed by the tumour. Reanimation of the nerve was mandatory in order to recover functional and cosmetic results. Despite an additional XII[th] cranial nerve morbidity, hypoglossal-facial nerve anastomosis was still a gold standard to reach this goal. The authors present their experience in managing 11 cases of facial nerve reanimation after skull base tumour resection by using the descending branch of the hypoglossal nerve as axon donator for direct facial anastomosis. Outcome of facial reanimation according to House-Brackmann classification was good [grade I, II and III] in 5 cases, mild [grade IV] in 3 cases and bad [grade IV and V] in 3 cases. Hemi tongue atrophy occurred in none of our patients. Hypoglossal-facial nerve anastomosis using the descending branch of the XII[th] cranial nerve is an effective procedure to reanimate the facial nerve without additional morbidity. Early reanimation of the facial nerve is the key to offer resumption of normal life for these patients who had already undergone a major neurosurgical procedure