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Kehrer A, Engelmann S, Knoedler L, Klein SM, Anker AM, Heidekrueger P, Tamm E, Bleys RL, Prantl L, Ruewe M. The masseteric nerve for facial reanimation: Macroscopic and histomorphometric characteristics in 106 human cadavers and comparison of axonal ratio with recipient nerves. J Craniomaxillofac Surg 2024; 52:8-13. [PMID: 38129186 DOI: 10.1016/j.jcms.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 09/05/2023] [Indexed: 12/23/2023] Open
Abstract
Peripheral facial palsy causes severe impairments. Sufficient axonal load is critical for adequate functional outcomes in reanimation procedures. The aim of our study was to attain a better understanding of the anatomy of the masseteric nerve as a donor, in order to optimize neurotization procedures. Biopsies were obtained from 106 hemifaces of fresh frozen human cadavers. Histological cross-sections were fixed, stained with PPD, and digitized. Histomorphometry and a validated software-based axon quantification were conducted. Of the 154 evaluated branches, 74 specimens were of the main trunk (MT), 40 of the anterior branch (AB), and 38 of the descending branch (DB), while two halves of one cadaver featured an additional branch. The MT showed a diameter of 1.4 ± 0.41 mm (n = 74) with 2213 ± 957 axons (n = 55). The AB diameter was 0.9 ± 0.33 mm (n = 40) with 725 ± 714 axons (n = 30). The DB diameter was 1.15 ± 0.34 mm (n = 380) with 1562 ± 926 axons (n = 30). The DB demonstrated a high axonal capacity - valuable for nerve transfers or muscle transplants. Our findings should facilitate a balanced selection of axonal load, and are potentially helpful in achieving more predictable results while preserving masseter muscle function.
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Affiliation(s)
- Andreas Kehrer
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany.
| | - Simon Engelmann
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Leonard Knoedler
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Silvan M Klein
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Alexandra M Anker
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Paul Heidekrueger
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Ernst Tamm
- Department of Human Anatomy and Embryology, University of Regensburg, Regensburg, Germany
| | - Ronald Law Bleys
- Department of Anatomy, University Medical Center (UMC) Utrecht, Utrecht, Netherlands
| | - Lukas Prantl
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Marc Ruewe
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
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Cavalheiro CS, Nakamoto JC, Wei TH, Sorrenti L, Wataya EY. Histological Compatibility in Distal Neurotizations: A Systematic Review. Indian J Plast Surg 2023; 56:405-412. [PMID: 38026776 PMCID: PMC10663082 DOI: 10.1055/s-0043-1774385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Considering the importance of defining the minimum number of axons between recipient and donor branches, that is, the definition of histological compatibility in distal neurotizations for the success of the procedure and the surgeon's freedom to choose individualized strategies for each patient, this systematic review was conducted to find out the most recent studies on the subject. The objective of this systematic review was to determine the importance of the number of axons and the relationship between axon counts in the donor and recipient nerves in the success of nerve transfer. A literature review was performed on five international databases: Web of Science, Scopus, Wiley (Cochrane Database), Embase, and PubMed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed (2020 version), a guide designed to guide the elaboration of systematic literature reviews. One hundred and fifty-seven studies were found, and 23 were selected based on the eligibility criteria. The articles presented were conclusive in determining the importance of the number of axons in the success of nerve transfer. Still, the relationship between the number of axons in the donor and recipient nerves seems more relevant in the success of transfers and is not always explored by the authors. The review of the articles has provided compelling evidence that the number of axons is a critical determinant of the success of nerve transfer procedures. However, the relationship between the number of axons in the donor nerve and that in the recipient nerve appears to be even more crucial for successful transfers, a factor that is not always adequately explored by authors in the existing literature. Level of evidence : Level IV, therapeutic study.
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Affiliation(s)
- Cristina Schmitt Cavalheiro
- Department of Hand, Wrist and Microsurgery, Instituto Vita, São Paulo, SP, Brazil
- Institute of Orthopedic and Traumatology, Faculdade de Medicina, Universidade de Sâo Paulo, São Paulo, SP, Brazil
| | - João Carlos Nakamoto
- Department of Hand, Wrist and Microsurgery, Instituto Vita, São Paulo, SP, Brazil
| | - Teng Hsiang Wei
- Institute of Orthopedic and Traumatology, Faculdade de Medicina, Universidade de Sâo Paulo, São Paulo, SP, Brazil
| | - Luiz Sorrenti
- Department of Hand, Wrist and Microsurgery, Instituto Vita, São Paulo, SP, Brazil
| | - Erick Yoshio Wataya
- Department of Hand, Wrist and Microsurgery, Instituto Vita, São Paulo, SP, Brazil
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Assessing the Efficacy of Anastomosis between Ansa Cervicalis and Facial Nerve for Patients with Concomitant Facial Palsy and Peripheral Neuropathy. J Pers Med 2022; 13:jpm13010076. [PMID: 36675739 PMCID: PMC9863281 DOI: 10.3390/jpm13010076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 11/29/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023] Open
Abstract
Background: For decades, patients with facial asymmetry have experienced social interaction difficulties, leading them to seek treatment in the hope of restoring facial symmetry and quality of life. Researchers evaluated numerous surgical techniques, but achieving results remains a significant hurdle. Specifically, anastomosis between the ansa cervicalis (AC) and facial nerve (FN) can hinder the patient's physical appearance. Objective: Our study goal was to examine the efficiency of anastomosis between AC and FN for facial motor function recovery even in the presence of peripheral neuropathy. Materials and Methods: Four patients diagnosed with facial palsy grade VI on the House & Brackmann Scale (HB) after vestibular schwannoma (VS) resection (Koos grade IV) via the retrosigmoid approach underwent AC and FN anastomosis. Outcomes were related to tumor grade, previous therapy, and the time between postoperative facial palsy and anastomosis. Images and neurophysiological data were evaluated. Results: After vs. resection, all four patients demonstrated HB grade VI facial palsy for an average of 17 months. During the follow-up program, lasting between 6 and 36 months, two patients were evaluated as having HB grade III facial palsy; the other two patients were diagnosed with grade IV HB facial palsy. None of the patients developed tongue atrophy, speech disorder, or masticatordys function. Conclusions: Anastomosis between the AC and FN is a safe and effective treatment for facial paralysis after cerebellopontine tumor resection. Nerve reanimation may be feasible even for patients with peripheral polyneuropathy. This study also offers a new option for patients with a progression-free status.
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Wenzel C, Brix E, Heidekrueger P, Lonic D, Lamby P, Klein SM, Anker A, Taeger C, Prantl L, Kehrer A. A favorable donor site in microsurgery: Nerve and vein graft harvest from the dorsum of the foot. Clin Hemorheol Microcirc 2021; 83:1-10. [PMID: 34719482 DOI: 10.3233/ch-211135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVES In complex hand traumas nerves and vessels are often destructed without the possibility for primary repair. For bridging defects of nerves, veins and arteries grafts are necessary. Commonly nerve and vein grafts from adjacent donor sites as the wrist, forearm or cubital region are harvested. METHODS This study is a retrospective cohort study. Between 2017 and 2019, 10 patients with complex hand injuries were treated. There were 8 males and 2 females, with an average age of 39 years (range 8-63 years). In all cases grafts were used of the dorsum of the foot for reconstructing of the severed digital nerves and arteries. All donor sites could be closed primarily. RESULTS In 100% of cases nerves and veins of the dorsum of the foot showed a good size match as well as adequate length for a sufficient repair. The overall Hand Injury Severity Score (HISS) was determined with a median of 86 (range 57 to 286). In the area of the donor site no relevant complications were seen. CONCLUSIONS In complex hand injuries the dorsum of the foot is a favorable donor site for nerve and vein graft harvest.
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Affiliation(s)
- C Wenzel
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - E Brix
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - P Heidekrueger
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - D Lonic
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - P Lamby
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - S M Klein
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - A Anker
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - C Taeger
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - L Prantl
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - A Kehrer
- Department of Plastic and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany.,Department of Plastic and Reconstructive Surgery, Ingolstadt Hospital Ingolstadt, Ingolstadt, Germany
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Effects of electrostimulation therapy in facial nerve palsy. Arch Plast Surg 2020; 48:278-281. [PMID: 32967408 PMCID: PMC8143947 DOI: 10.5999/aps.2020.01025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/10/2020] [Indexed: 11/08/2022] Open
Abstract
Facial palsy (FP) is a functional disorder of the facial nerve involving paralysis of the mimic muscles. According to the principle “time is muscle,” early surgical treatment is tremendously important for preserving the mimic musculature if there are no signs of nerve function recovery. In a 49-year-old female patient, even 19 months after onset of FP, successful neurotization was still possible by a V-to-VII nerve transfer and cross-face nerve grafting. Our patient suffered from complete FP after vestibular schwannoma surgery. With continuous application of electrostimulation (ES) therapy, the patient was able to bridge the period between the first onset of FP and neurotization surgery. The significance of ES for mimic musculature preservation in FP patients has not yet been fully clarified. More attention should be paid to this form of therapy in order to preserve the facial musculature, and its benefits should be evaluated in further prospective clinical studies.
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Engelmann S, Ruewe M, Geis S, Taeger CD, Kehrer M, Tamm ER, Bleys RLAW, Zeman F, Prantl L, Kehrer A. Rapid and Precise Semi-Automatic Axon Quantification in Human Peripheral Nerves. Sci Rep 2020; 10:1935. [PMID: 32029860 PMCID: PMC7005293 DOI: 10.1038/s41598-020-58917-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 01/20/2020] [Indexed: 11/09/2022] Open
Abstract
We developed a time-efficient semi-automated axon quantification method using freeware in human cranial nerve sections stained with paraphenylenediamine (PPD). It was used to analyze a total of 1238 facial and masseteric nerve biopsies. The technique was validated by comparing manual and semi-automated quantification of 129 (10.4%) randomly selected biopsies. The software-based method demonstrated a sensitivity of 94% and a specificity of 87%. Semi-automatic axon counting was significantly faster (p < 0.001) than manual counting. It took 1 hour and 47 minutes for all 129 biopsies (averaging 50 sec per biopsy, 0.04 seconds per axon). The counting process is automatic and does not need to be supervised. Manual counting took 21 hours and 6 minutes in total (average 9 minutes and 49 seconds per biopsy, 0.52 seconds per axon). Our method showed a linear correlation to the manual counts (R = 0.944 Spearman rho). Attempts have been made by several research groups to automate axonal load quantification. These methods often require specific hard- and software and are therefore only accessible to a few specialized laboratories. Our semi-automated axon quantification is precise, reliable and time-sparing using publicly available software and should be useful for an effective axon quantification in various human peripheral nerves.
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Affiliation(s)
- S Engelmann
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Ruewe
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - S Geis
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - C D Taeger
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Kehrer
- Department of Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - E R Tamm
- Institute of Human Anatomy, University of Regensburg, Regensburg, Germany
| | - R L A W Bleys
- Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - L Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - A Kehrer
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany.
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Significance of the Marginal Mandibular Branch in Relation to Facial Palsy Reconstruction: Assessment of Microanatomy and Macroanatomy Including Axonal Load in 96 Facial Halves. Ann Plast Surg 2019; 83:e43-e49. [PMID: 31567417 DOI: 10.1097/sap.0000000000002038] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The marginal mandibular branch (MMB) of the facial nerve provides lower lip symmetry apparent during human smile or crying and is mandatory for vocal phonation. In treating facial palsy patients, so far, little attention is directed at the MMB in facial reanimation surgery. However, isolated paralysis may occur congenital, in Bell's palsy or iatrogenic during surgery, prone to its anatomical course. A variety of therapies address symmetry with either weakening of the functional side or reconstruction of the paralyzed side. To further clarify the histoanatomic basis of facial reanimation procedures using nerve transfers, we conducted a human cadaver study examining macroanatomical and microanatomical features of the MMB including its axonal capacity. METHODS Nerve biopsies of the MMB were available from 96 facial halves. Histological processing, digitalization, nerve morphometry investigation, and semiautomated axonal quantification were performed. Statistical analysis was conducted with P < 0.05 as level of significance. RESULTS The main branch of 96 specimens contained an average of 3.72 fascicles 1 to 12, and the axonal capacity was 1603 ± 849 (398-5110, n = 85). Differences were found for sex (P = 0.018), not for facial sides (P = 0.687). Diameters were measured with 1130 ± 327 μm (643-2139, n = 79). A significant difference was noted between sexes (P = 0.029), not for facial sides (P = 0.512.) One millimeter in diameter corresponded to 1480 ± 630 axons (n = 71). A number of 900 axons was correlated with 0.97 mm (specificity, 90%; sensitivity, 72%). CONCLUSIONS Our morphometric results for the MMB provide basic information for further investigations, among dealing with functional reconstructive procedures such as nerve transfers, nerve grafting for direct neurotization or babysitter procedures, and neurectomies to provide ideal power and authenticity.
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Kehrer A, Engelmann S, Ruewe M, Geis S, Taeger C, Kehrer M, Prantl L, Tamm E, Bleys RR, Mandlik V. Anatomical study of the zygomatic and buccal branches of the facial nerve: Application to facial reanimation procedures. Clin Anat 2019; 32:480-488. [DOI: 10.1002/ca.23332] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 12/16/2018] [Accepted: 01/05/2019] [Indexed: 01/23/2023]
Affiliation(s)
- Andreas Kehrer
- Department of Plastic, Reconstructive, and Hand SurgeryUniversity Hospital Regensburg Regensburg Germany
| | - Simon Engelmann
- Department of Plastic, Reconstructive, and Hand SurgeryUniversity Hospital Regensburg Regensburg Germany
| | - Marc Ruewe
- Department of Plastic, Reconstructive, and Hand SurgeryUniversity Hospital Regensburg Regensburg Germany
| | - Sebastian Geis
- Department of Plastic, Reconstructive, and Hand SurgeryUniversity Hospital Regensburg Regensburg Germany
| | - Christian Taeger
- Department of Plastic, Reconstructive, and Hand SurgeryUniversity Hospital Regensburg Regensburg Germany
| | - Michael Kehrer
- Department of Trauma SurgeryUniversity Hospital Bonn Bonn Germany
| | - Lukas Prantl
- Department of Plastic, Reconstructive, and Hand SurgeryUniversity Hospital Regensburg Regensburg Germany
| | - Ernst Tamm
- Institute of Human AnatomyUniversity of Regensburg Regensburg Germany
| | | | - Veronika Mandlik
- Department of Plastic, Reconstructive, and Hand SurgeryUniversity Hospital Regensburg Regensburg Germany
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