The search for the neurocranial pathways to the fifth nerve nucleus in the reanimation of the paralyzed face

Management of the paralyzed face using temporalis tendon transfer via intraoral and transcutaneous approach: Temporalis tendon transfer

Temporalis tendon transfer is a technique for dynamic facial reanimation. Since its inception, nearly 80 years ago, it has undergone a wealth of innovation to produce the modern operation. Temporalis tendon transfer is a relatively minimally invasive technique for the dynamic reanimation of the paralyzed face. This technique can produce significant and appropriate movement of the lateral oral commissure, more closely mimicking the normal side. The aim of this article is to review the technique of temporalis tendon transfer involving transferring of the coronoid process of the mandible with the insertion of the temporalis tendon via intra-oral and transcutaneous approach.

Masseter-to-facial nerve transfer: is it possible to rehabilitate the function of both the paralyzed eyelid and the oral commissure?

BACKGROUND

This report addresses the efficiency of masseter-to-facial nerve transfer and investigates the patient's ability to perform the functions of eyelid closure and smile movements independently.

METHODS

From November 2010 to January 2012, seven patients underwent the reported procedure and were followed 6 to 12 months postoperatively. The patients' ages varied from 22 to 41 years. The etiology of the injuries was resection of cerebellopontine angle tumors in all the patients. Using Terzis' and Mehta's scale, smile outcomes and synkinetic movements were evaluated pre- and post-operatively. The function of eyelid closure was evaluated by measuring the width of the lagophthalmos. A questionnaire was applied to evaluate ocular problems and donor-site morbidity.

RESULTS

All the patients were able to close their eyelids and smile with biting. Four of the seven patients were able to smile effortlessly without biting. According to Terzis' scale, the postoperative mean score was 4.3 ± 0.8 compared with 1.0 ± 0.0 at the preoperative evaluation. The improvement in the lagophthalmos varied from 2 to 5 mm. The ocular problems all were resolved. All the patients were able to smile easily without eyelid closure and could close their eyes with minimal oral commissure movement. No patients reported weakness of mastication on the affected side, and only minimal atrophy of the masseter muscle at the donor site was noted.

CONCLUSIONS

Masseter-to-facial nerve transfer is a highly efficient technique for reanimating paralyzed muscle. After physical training, both eyelid closure and smiling are restored and discriminated after physical training.

LEVEL OF EVIDENCE IV

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Revisiting orthodromic temporalis transfer in treating long-standing facial paralysis

The treatment of long-standing facial paralysis through temporalis muscle transfer has stood the test of time. Herein, we present a modification in temporalis muscle transfer for lower facial reanimation. Instead of the traditional stripping of the temporalis muscle from its origin, its insertion is stripped from the coronoid process through an intraoral approach. The detached fibers were then sutured to a fascia lata graft, which was passed and secured to the orbicularis oris to reanimate the corner of the mouth. The procedure is less extensive and provides a direct "orthodromic" line of pull with good muscular excursion and power. This simple procedure has been applied to 12 consecutive cases with long-standing complete facial paralysis presenting to the Plastic and Reconstructive Surgery Clinic at the Ain-Shams University Hospital over the past 2 years. In addition to symmetry at rest, this easy procedure allowed for good movement of the corner of the mouth with restoration of a balanced smile.

Double innervation occurs in the facial mimetic muscles after facial-hypoglossal end-to-side neural repair: rat model for neural supercharge concept

BACKGROUND

Double innervation of facial mimetic muscles by both facial and hypoglossal nerves after end-to-side neurorrhaphy has not been proven, although facial -hypoglossal end-to-side neurorrhaphy has been used in persistent incomplete facial palsy recently, and has achieved clinical evidences of recovery with rare synkinesis. We established a rat model to compare synkinesis after end-to-end and end-to-side neurorrhaphy techniques between facial and hypoglossal nerves, and confirmed double innervation using retrograde tracers.

METHODS

Rats were divided into three groups (each consisting of six rats), a facial palsy group (Group A), a facial-hypoglossal end-to-end neurorrhaphy group (Group B), and a facial-hypoglossal end-to-side neurorrhaphy group (Group C). Eight weeks after surgery, synkinesis of the facial mimetic muscles was observed and recorded via video camera. In Group C, post operative, intramuscular injections of retrograde neural tracers (Fast Blue, Diamidino Yellow and DiI) into the facial mimetic muscles were performed to prove double innervation by both the facial and hypoglossal nerves.

RESULTS

In Group B, all rats showed facial palsy. However while eating and drinking, their half of the face showed mass movements (strong contraction of whisker pad muscles, curved nose and eye-closure). In Group C, four rats showed no significant changes however, two rats showed synkinesis of the eyelid while eating and drinking (frequent eye-closure distinguishable from the contralateral normal side). In Group C, retrograde tracers injected in the mimetic muscles were detected in both the facial and hypoglossal motor nuclei in situ of all the rats' brain stem.

CONCLUSION

This study proved that double innervation of mimetic muscles by both facial and hypoglossal nerves occurs after the end-to-side neurorrhaphy. Double-innervated mimetic muscles around the mouth after hypoglossal-facial end-to-side neurorrhaphy showed less synkinesis than the end-to-end neurorrhaphy.

The surgical management of facial nerve injury

Treatment of facial nerve injuries depends upon a detailed understanding of its anatomic course, accurate clinical examination, and timely and appropriate diagnostic studies. Reconstruction depends upon the extent of injury, the availability of the proximal stump. and the time since injury and duration of muscle denervation. Although no alternative is perfect, these techniques, in combination with static and ancillary procedures. can protect the eye, prevent drooling, restore the smile, and improve facial symmetry. New techniques (including single-stage free tissue transfers and bioengineered nerve grafts), further research on the characteristics of the facial musculature, and methods of preserving the neuromuscular junction will undoubtedly manifest themselves as further refinements of established surgical techniques.