The Split Hypoglossal Nerve and Cross-Face Nerve Graft for Dual Innervation of the Functional Muscle Transfer in Facial Reanimation.

Facial paralysis is a disabling deformity. The affected individual is seriously affected both esthetically and functionally. Free functional muscle transfer is currently the corner stone in the management of long-standing facial nerve paralysis. Several nerve options are available to supply the free muscle transfer. These nerves can be used alone or in combination. The aim of this work is to study the possibility and results of dually innervating the free functioning muscle transfer. The dual innervation is done using the split hypoglossal nerve and cross-face nerve graft (CFNG) both sutured in an end-to-end manner to the nerve to gracilis. Twenty-nine patients with unilateral long-standing facial nerve paralysis (more than 1 y) were treated using free gracilis muscle transfer dually supplied by the split hypoglossal nerve and CFNG, both sutured in an end-to-end manner. The gained excursion after the free gracilis transfer was 9 to 29 mm (mean: 17.24 mm). A statistically significant increase ( P -value=0.0001) in the distance from where the midline crosses the lower vermilion border to commissure occurred from preoperative (mean: 16.55 mm) to postoperative setting (mean: 33.79 mm). Spontaneity was achieved in 26 patients (89.6%). In conclusion, dual innervation of the free muscle transfer using both the split hypoglossal nerve and CFNG (both sutured in an end-to-end manner to the nerve to gracilis) is a good possible option to treat long-standing cases of facial nerve paralysis. It yields adequate muscle excursion with acceptable spontaneity.

Amer's classification of territories of facial nerve injury in early cases and strategies for the management of different territories.

Early cases of facial nerve injury are best treated by restoring the neural pathway to the same existing facial muscles. Knowledge of the exact territory of facial nerve injury is required to design a plane for the reconstruction of these injuries and to compare results. The current study aims to design a classification system for territories of facial nerve injury based on the location of nearest healthy fascicles to the site of injury both proximally and distally. Two hundred-one patients with early facial nerve injury were assessed for treatment. According to the results of the exploration, 13 territories of injury were identified. The management strategy was planned according to the territory of injury. The current classification system is a simple, easy and effective method for the classification of territories of facial nerve injury. The classification system accurately describes the nearest possible healthy proximal and distal fascicles and can be employed to easily report cases and implement a management plan. This classification scheme also allows us to more effectively compare results.

The split hypoglossal nerve versus the cross-face nerve graft to supply the free functional muscle transfer for facial reanimation: A comparative study.

Long-standing cases of facial paralysis are currently treated with free functional muscle transfer. Several nerves are mentioned in the literature to supply the free muscle transfer. The aim of this study is to compare the split hypoglossal nerve and the cross-face nerve graft to supply the free functional muscle transfer in facial reanimation. Of 94 patients with long-standing, unilateral facial palsy, 49 were treated using the latissimus dorsi muscle supplied by the split hypoglossal nerve, and 45 patients were treated using the latissmus dorsi muscle supplied by healthy contralateral buccal branch of the facial nerve. The excursion gained by the free muscle transfer supplied by the split hypoglossal nerve (mean 19.20 ± 6.321) was significantly higher (P value 0.001) than that obtained by the contralateral buccal branch of the facial nerve (mean 14.59 ± 6.245). The split hypoglossal nerve appears to be a good possible option to supply the free vascularised muscle transfer in facial reanimation. It yields a stronger excursion in less time than the contralateral cross-face nerve graft.

Low-level versus high-level placement of gold plates in the upper eyelid in patients with facial palsy.

BACKGROUND: Lagophthalmos is a condition that results from facial paralysis causing functional as well as esthetic problems. This condition can be treated by a range of techniques, including tarsorrhaphy, facial slings, and canthopexies. Gold plates provide a solution for temporary or permanent lagophthalmos resulting from facial paralysis. This study discusses the use of gold plates in the treatment of lagophthalmos but with the introduction of gold plates in two different positions in the upper lids. METHODS: Group 1 (38 eyes) had a low level of placement (2 mm from the lid margin) of gold plates, while Group 2 (23 eyes) had a high level of placement (5 mm from the lid margin). RESULTS: Noticeable bulge was seen in 18.4% of Group 1 eyes compared with 13% in Group 2, and migration of the plate occurred in 2.6% and 0% of eyes in Group 1 and Group 2, respectively, as well as ptosis (7.8% and 4.3%) and conjunctival perforation (0% and 4.3%). The degree of improvement of eyelid closure, keratopathy, and visual acuity were the same for both techniques. CONCLUSION: Placement of gold plates at a higher level could avoid some of the drawbacks of lower level placement of these plates, such as upper eyelid bulge and ptosis, especially given the thinning of the eyelids and orbicularis muscles that occurs in facial palsy.

A single hypoglossal nerve for bilateral smile reconstruction in Möbius syndrome.

Möbius syndrome is a rare congenital disorder characterized by a variety of cranial nerve defects. Although there are several variants of Möbius syndrome depending on which cranial nerves are affected, the commonest form involves facial and abducens cranial nerve paralysis. Despite several strategies for bilateral smile reconstruction that have been advocated, the condition still presents a challenge to the plastic surgeon. The most acceptable method nowadays is bilateral free neurovascularized muscle transfer. The author represents a new method of using a single hypoglossal nerve to supply both free flaps in a Möbius patient. The procedure is done on 2 stages using both latissimus dorsi muscles and a single hypoglossal nerve. The patient regained a natural symmetric smile 12 months after the first stage. Despite hemilingual atrophy, no tongue morbidity was observed. The author concludes that despite the limitation of the study, the hypoglossal nerve is a good nerve source to supply both free flaps for smile reconstruction in Möbius syndrome.