Cross-face Graft Research Articles

Drop-off in axonal regeneration along the length of a cross-face nerve graft: An experimental study in rats.

The average nerve graft length utilized in cross-face nerve grafting for reconstruction of facial nerve palsy is 20-22 cm. While the graft length is thought to be one of the greatest determinants of muscle strength, the mechanism through which this happens remains unknown. We studied changes in axonal regeneration along the length of a 2 cm cross-face nerve graft in a rat model. The hypothesis was that axon count would decrease along the length of the graft. A 2 cm nerve graft (sciatic nerve) was used as a cross-face nerve graft in 16 adult female, 210-250 g, Sprague Dawley rats. Thirteen weeks later, 5 mm nerve biopsies were taken at four sites: the facial nerve trunk (control), proximal graft, midpoint of graft (1 cm distal to coaptation) and distal graft (2 cm distal to coaptation). Retrograde nerve labeling with FluoroGold was performed at the biopsied nerve site and the facial motor nucleus was taken 1 week later. Microscopic imaging and manual counting of axons and labeled motor nuclei was performed. Retrograde-labeled motor neuron counts were decreased at the midway point of the graft compared to the facial trunk (1517 ± 335 axons, Δ% = 92.5, p = .01) and even further decreased at the distal end of the graft (269 ± 293 axons, Δ% = 175.5, p = .006). Analysis of the nerve biopsies demonstrated no significant differences in myelinated axon count between the nerve trunk and over the length of the nerve graft (range 6207-7179 axons, Δ% = 14.5, p = .07). In a rat model, the number of regenerating motor neurons drops off along the length of the graft and axon count is preserved due to axon sprouting. How this pattern correlates to ultimate muscle strength remains unknown, but this study provides insight into why shorter grafts may afford better outcomes.

Artificial intelligence-based numerical analysis of the quality of facial reanimation: A comparative retrospective cohort study between one-stage dual innervation and single innervation

This study aimed to investigate the difference in facial reanimation surgery using functional gracilis muscle transfer between the masseteric nerve alone and its combined use with cross face nerve graft (CFNG), which has not been explored before. A novel analysis method based on artificial intelligence (AI) was employed to compare the outcomes of the two approaches.Using AI, 3-dimensional facial landmarks were extracted from 2-dimensional photographs, and distance and angular symmetry scores were calculated. The patients were divided into two groups, with Group 1 undergoing one-stage CFNG and masseteric nerve dual innervation, and Group 2 receiving only masseteric nerve. The symmetry scores were obtained before and 1 year after surgery to assess the degree of change.Of the 35 patients, Group 1 included 13 patients, and Group 2 included 22 patients. The analysis revealed that, in the resting state, the change in the symmetry score of the mouth corner showed distance symmetry (2.55 ± 2.94, 0.52 ± 2.75 for Group 1 and Group 2, respectively, p = 0.048) and angle symmetry (1.21 ± 1.43, 0.02 ± 0.22 for Group 1 and Group 2, respectively, p = 0.001), which were significantly improved in Group 1, indicating a more symmetric pattern after surgery. In the smile state, only the angle symmetry was improved more symmetrically in Group 1 (3.20 ± 2.38, 1.49 ± 2.22 for Group 1 and Group 2, respectively, p = 0.041).Within the limitations of the study it seems that this new analysis method enabled a more accurate numerical symmetry score to be obtained, and while the degree of mouth corner excursion was sufficient with only the masseteric nerve, accompanying CFNG led to further improvement in symmetry in the resting state.

49. Assessing the Benefit of Adding Cross-facial Nerve Grafts to a Masseteric to Facial Nerve Transfer for Smile and Periorbital Reanimation in Subacute Facial Palsy

PURPOSE: Comparing long-term outcomes of nerve to masseter (NTM) to facial nerve (FN) transfer with and without cross-facial nerve graft (CFNG). METHODS: Patients with subacute facial palsy who received a NTM to FN transfer with or without a CFNG from 2013-2020 were reviewed. One year minimal follow up was required. Outcomes measures based on professional standardized photos of patients in repose, closed, and open smile were analyzed pre-operatively, at 3-months, 1-year, 3-years, and 5-years postoperatively as available. Emotrics software (Massachusetts Eye and Ear Infirmary, Boston, MA) and ImageJ (Rasband, W.S., ImageJ, U.S, National Institutes of Health, Bethesda, MD) were used for all measurements. Between group and within group longitudinal comparisons at each timepoint were analyzed using Wilcoxon Two-Sample Testing. RESULTS: Preoperative midface smile parameters were similar between groups (NTM=7, NTM+CFNG=17). At one-year (NTM=6, NTM+CFNG=17), closed mouth smile modiolus angle in NTM+CFNG was increased (NTM=96.135 degrees, NTM+CFNG=105.953 degrees, p=0.019). At 3-year (NTM=4, NTM+CFNG=16), open mouth modiolus angle in NTM+CFNG was increased (NTM=102.929mm, NTM+CFNG=115.269mm, p=0.0206). Midface smile parameters were similar between the groups at 5-year follow up. Preoperative periorbital symmetry measurements in repose were similar between groups. At one-year, marginal reflex distance 1 in NTM+CFNG was decreased (NTM=1.312mm, NTM+CFNG=0.587mm, p=0.025). At three-year, there were significant differences in marginal reflex distance 1 (NTM=1.728mm, NTM+CFNG=0.417mm, p=0.0264) and marginal reflex distance 2 (NTM=0.603mm, NTM+CFNG=0.632mm, p=0.0071). Symmetry measurements were similar at the 5-year point. CONCLUSION: There was long-term improvement in resting periorbital symmetry with the addition of a CFNG. Midface smile showed no consistent long-term improvement.

Early Simultaneous Cross Facial Nerve Graft and Masseteric Nerve Transfer for Facial Paralysis after Tumor Resection.

Patients undergoing masseter nerve transfer and CFNG for facial paralysis after skull base tumor resection were consented to participate in video interviews. Facial Clinimetric Evaluation (FaCE) Scale (0-100) patient-reported outcome, eFACE, and Facial Grading Scale scores were compared. Nine patients had unilateral facial paralysis from resection of a schwannoma (56%), acoustic neuroma (33%), or vascular malformation (11%). Five underwent early simultaneous CFNG and masseter nerve transfer (mean 3.6 days after resection), whereas four underwent two-stage reanimation including a babysitter procedure (mean 218 days after resection). Postoperative FaCE scale and Facial Grading Scale scores were similar in both groups (P > 0.05). Postoperative mean eFACE scores were similar for both groups for smile (early: 71.5 versus delayed: 75.5; P = 0.08), static (76.3 versus 82.1; P = 0.32), and dynamic scores (59.7 versus 64.9; P = 0.19); however, synkinesis scores were inferior in the early group (76.4 versus 91.1; P = 0.04). Early simultaneous masseter nerve transfer and CFNG provides reanimated movement sooner and in fewer stages than a staged approach in a delayed timeline. The early technique appears to result in similar clinician- and patient-reported outcomes compared with delayed procedures; however, in this preliminary study, the early approach was associated with greater synkinesis, meriting further investigation.

Donor Nerve Selection in Free Gracilis Muscle Transfer; Systematic Review and Meta-Analysis

Introduction: One of the crucial factors in facial reanimation surgery is the donor nerve selection. There have been several neurotizers to reinnervate the free gracilis muscle flap (FGMT). Currently the cross-face nerve graft (CFNG) and motor nerve to masseter are the most favored options. The “dual innervation” is described as potential way to combine the advantages of individual donor nerves and has shown successful results. Materials and Methods: Two databases were searched for the CFNG, masseteric nerve and dual innervation of FGMT. Defined primary measures were applied to the results to compare the extent of commissure excursion, facial symmetry at rest and smile, spontaneity, time to flap contraction for each neurotizer. Meta-analysis was conducted for studies including quantitative data for commissure excursion and facial symmetry. We included all study types except the animal studies. Only articles written in English language from 2001 were taken into consideration. We followed PRISMA guidelines. ROBINS-I and Newcastle-Ottawa tools were used to assess the risk of bias and quality for each study included in the meta-analysis. Results: 147 articles on FGMT were systematically reviewed and 13 studies were evaluated in the meta-analysis. All studies were high in quality. Heterogeneity was high among the studies, limiting the efficiency of our meta-analysis. Conclusion: CFNG is the most frequently utilized reinnervation technique. Masseteric nerve is very reliable and has the potential to provide more commissural excursion and higher success rate. Dual innervation is an effective alternative leading to effective clinical outcomes. A globalized and quantitative measurement method will contribute to the future of facial reanimation surgery.

Evidence-based Considerations on Donor Nerve Selection and Ideal Muscle Weight in Long-standing Facial Paralysis – The Freiburg Algorithm

Introduction: Free functional muscle transfer (FMT) is the standard for smile reconstruction in long-standing facial paralysis. Using the contralateral NVII for innervation of the transferred muscle frequently produces satisfying results. However, axon counts of facial nerve branches used as donor nerves for cross-face nerve grafts (CFNG) generally decrease with age resulting in insufficient muscle contraction. Also, the volume of the transferred muscle segment necessary for symmetric oral excursion depends on the donor nerve. This study presents our algorithm for donor nerve selection and ideal muscle weight in long-standing facial paralysis. Materials and Methods: In a prospective cohort study, we evaluated facial palsy patients scheduled for dynamic smile reanimation preoperatively via EMG for involuntary masseter muscle activation upon smiling. Six months after noting the first muscle contraction, we assessed smile synchronicity and correlated the results with the EMG results. Furthermore, we correlated oral commissure amplitude with the weight of the muscle segment and the donor nerve used. Results: We recruited 30 patients for the prospective study and included 22 patients in the retrospective analysis. Postoperatively, all patients demonstrated a voluntary smile. The preoperative coactivation of the masseter muscle predicted the outcome regarding synchronicity of the smile with high sensitivity and specificity. Also, we observed a significant increase in oral commissure excursion with increasing muscle weight when using the NV. Conclusion: The lack of masseter coactivation upon smiling predicts the absence of a synchronous, involuntary smile after FMT using the masseteric nerve. The ideal muscle weight depends on the donor nerve and should be smaller for the NV.

Gracilis Muscle-Free Flap Objective Improvement of Oral Commissure Excursion in Facial Palsy Reanimation Surgery: Systematic Review and Meta-Analysis.

Background: Facial palsy patients face significant challenges. Gracilis free flap transfer is a key procedure in facial reanimation. Objective: This study aims to analyze oral commissure excursion improvement after gracilis free flap transfer and the differences regarding donor nerve: cross-facial nerve graft (CFNG), hypoglossal or spinal accessory nerves, motor nerve to masseteric (MNTM), and most recently, double anastomosis using both the MNTM and CFNG. Methods: A systematic review and meta-analysis were conducted of studies reporting oral commissure excursion improvement after free gracilis muscle transfer. Pooled proportions were calculated using a random-effects model. Results: Eighteen studies, 453 patients, and 488 free gracilis flaps were included. The mean change in perioperative oral commissure excursion was 7.0 mm, for CFNG 7.2 mm, for MNTM 7.7, and for double anastomoses 5.5 mm. Conclusions: There is a significant improvement in oral commissure excursion after gracilis muscle-free flap. Unfortunately, we could not make definitive conclusions regarding the optimal choice of donor nerve.

Comparison of static and dynamic symmetry between masseter-innervated and dual-innervated free multivector serratus anterior muscle transfer for complete facial paralysis

In this study, facial symmetry was compared between the masseter-innervated and dual-innervated free multivector serratus anterior muscle transfer (FMSAMT) methods. Eighteen patients with unilateral complete facial paralysis underwent facial reanimation surgery between April 2006 and July 2019. The masseter-innervated FMSAMT group (Group M, n=8) underwent end-to-end coaptation with the ipsilateral masseter nerve in one stage. The dual-innervated FMSAMT group (Group D, n=10) underwent end-to-end coaptation with the masseter nerve and end-to-side coaptation with the contralateral facial nerve via cross-face nerve graft. They were further divided into the one-stage (Group D1, n=5) and two-stage (Group D2, n=5) subgroups. The durations of periods until the first visible muscle contraction with clenching, first spontaneous smile, and the completion of resting tone were evaluated. The possibility of a spontaneous smile and symmetry of the midline and horizontal deviation at rest and during voluntary smiling were compared between each group. Groups M and D differed significantly in the possibility of a spontaneous smile and improvement rate of midline deviation and horizontal deviation at rest (p<0.001, p<0.001, and p=0.001, respectively) but not in the improvement rate of midline and horizontal deviation during voluntary smiling. The duration of the period until the completion of resting tone was significantly shorter in Group D1 than in Group D2 (p=0.048); however, the possibility of a spontaneous smile and the improvement rate of midline and horizontal deviation were not significantly different. Dual-innervated FMSAMT was effective in guaranteeing a symmetrical resting tone, voluntary smiling, and reproducing a spontaneous smile.

Restoration of Upper Eyelid Reanimation with Free Platysma Graft: Final Stage of Facial Reanimation After Gunshot Wound to Face

Objective: Patients with gunshot wound (GSW) to the face will have massive soft tissue and bony damage from projectile and blast injury. They often will need multiple, staged reconstructive surgeries including restoration of the bony framework, facial reanimation with cross-facial nerve grafting, and free muscle flap for re-establishment of facial expression. Injury to or total loss of the facial nerve and branches can result in loss of function of the orbicularis oculi muscle, which leads to the loss of protective mechanisms of eyelid function and blink reflex. The purpose of the current paper with to provide a literature review and discussion of eyelid reanimation after facial paralysis and to discuss our surgical technique to staged blink reconstruction with free platysma muscle grafts of upper and lower eyelid. Methods: The patient is a 45-year-old male with a history of GSW to the right face. He underwent multiple reconstructive surgeries in the past including stabilization with soft tissue reconstruction, right mandibular reconstruction, right sided facial reanimation with cross-facial nerve graft and gracilis flap. In preparation for eyelid reanimation, he underwent cross-facial nerve graft from left temporal branch to right upper eyelid and right lower eyelid Results: At initial postoperative evaluation and removal of the Frost stitch, the patient had the ability to close his right eye with minimal lagophthalmos. Upon continued follow-up and after surgical swelling decreased, he had continued improvement of spontaneous blinking of the right eyelid with 1-2mm of lagophthalmos. At the 3-month follow-up he exhibited stronger blinking reflex and no symptoms of dry eye or further irritation. Conclusion: The presented case demonstrates that a free platysma graft with direct neurotization with cross-facial nerve graft fascicles can be utilized for restoration of spontaneous upper and lower eyelid animation. Furthermore, restoring upper eyelid reanimation with a free platysma graft has several shortcomings. Primarily, there may be failure of neurotization and inability of the spontaneous blink reflex to be present. Despite these limitations, we still recommend the utilization of free platysma graft to provide upper eyelid reanimation through cross-facial nerve grafting. Corresponding Author: Kongkrit Chaiyasate, 3555 W 13 Mile Rd #120, Royal Oak, MI, 48073, [email protected], 248-890-2515

Smile Reanimation with Masseteric-to-Facial Nerve Transfer plus Cross-Face Nerve Grafting in Patients with Segmental Midface Paresis: 3D Retrospective Quantitative Evaluation

Facial paresis involves functional and aesthetic problems with altered and asymmetric movement patterns. Surgical procedures and physical therapy can effectively reanimate the muscles. From our database, 10 patients (18–50 years) suffering from unilateral segmental midface paresis and rehabilitated by a masseteric-to-facial nerve transfer combined with a cross-face facial nerve graft, followed by physical therapy, were retrospectively analyzed. Standardized labial movements were measured using an optoelectronic motion capture system. Maximum teeth clenching, spontaneous smiles, and lip protrusion (kiss movement) were detected before and after surgery (21 ± 13 months). Preoperatively, during the maximum smile, the paretic side moved less than the healthy one (23.2 vs. 28.7 mm; activation ratio 69%, asymmetry index 18%). Postoperatively, no differences in total mobility were found. The activity ratio and the asymmetry index differed significantly (without/with teeth clenching: ratio 65% vs. 92%, p = 0.016; asymmetry index 21% vs. 5%, p = 0.016). Postoperatively, the mobility of the spontaneous smiles significantly reduced (healthy side, 25.1 vs. 17.2 mm, p = 0.043; paretic side 16.8 vs. 12.2 mm, p = 0.043), without modifications of the activity ratio and asymmetry index. Postoperatively, the paretic side kiss movement was significantly reduced (27 vs. 19.9 mm, p = 0.028). Overall, the treatment contributed to balancing the displacements between the two sides of the face with more symmetric movements.

‘Are dynamic procedures superior to static in treating the paralytic eyelid in facial paralysis?’

Facial nerve weakness can cause deficient eye closure with reduced corneal protection. Surgical remedies can be static to oppose the levator muscle (lid loading) or dynamic procedures, which act to increase the strength of closure. This retrospective cohort study compares these groups. The hypothesis is that dynamic reconstruction has advantages over static techniques in terms of eye closure, symptomatic improvement, blink restoration, and complication rate. Two cohorts were compared: those treated with a gold weight insertion into the upper eyelid and those who had received dynamic reconstruction. These included temporalis transfer; cross face nerve grafting alone (CFNG) and CFNG followed by free tissue transfer. Assessments included standard photography and video; measurement of eyelid excursion including residual gap and if full eye closure was possible. The presence of the blink reflex and symptoms of dry eye was assessed. Overall improvement in eye closure was similar with the gold weight compared to dynamic procedures (5.1mm vs 5.3mm). Dynamic procedures however gave improved results in terms of symptom relief and restoration of blink. They also had fewer complications and revision rates overall. The study confirms the hypothesis that dynamic reconstructions of the paralysed eyelid confer advantages compared to simple lid loading techniques. Improvements in lid excursion are similar, but symptom improvement and blink restoration are significantly better. A decision regarding eyelid reanimation should be made early in the patient's journey of facial reanimation to allow for accurate planning and placement of nerve grafts at an early stage.

Dual-Innervated Free Gracilis Muscle Transfer for Facial Reanimation in Children.

Facial palsy may have deleterious effects for pediatric patients. The most common reconstruction is 2-stage free gracilis muscle transfer (FGMT) after cross-face nerve graft (CFNG). This requires a prolonged period from time of surgery to smile. New techniques using both a CFNG and motor nerve to masseter (MNM) as dual power sources in a single-stage surgery have been described in adults. Here, we examine our experience with this technique in children. A retrospective study was performed examining patients who underwent dual-innervated single-stage FGMT at 2 pediatric hospitals from 2016 to 2019. Demographics, etiology, perioperative characteristics, time to mandibular and emotional smile, and Sunnybrook scores were recorded. Five patients met inclusion criteria with a mean age of 11.8 (range, 8-20). Two patients had congenital facial palsy while 3 had acquired facial palsy. Four patients (80%) received dual end-to-end neural coaptations of the CFNG and MNM to the obturator nerve. One (20%) had end-to-side coaptation of the CFNG to the obturator nerve and end-to-end of the MNM to the obturator nerve. The average time to mandibular smile was 103 ± 15.4 days. The average time to emotional smile was 245 ± 48.1 days. The preoperative Sunnybrook scale was 32 ± 7.5 and improved to 55.3 ± 20.6 at 8 months postoperatively. Dual-innervated FGMT is effective for facial reanimation in children with unilateral facial palsy. Patients can harness a stronger motor source (MNM) and the component of an emotional stimulus (CFNG). This approach may be the new criterion standard pediatric facial reanimation.

Sural Nerve Vertical Cross-Face Graft for Lacrimal Gland Neurotization to Improve Tear Secretion in Neurodeprivative Dry Eye.

No specific interventions have been reported for the treatment of severe neurodeprivative dry eye disease owing to facial nerve palsy. We describe herein the feasibility of a novel surgical procedure to reinnervate the lacrimal gland and report the preliminary outcomes of the first series of patients who were treated accordingly. Prospective interventional case series including consecutive patients affected by facial palsy with absolute deficiency of tear secretion who underwent lacrimal gland neurotization. A sural nerve vertical cross-face graft was used to connect the lacrimal gland with the parasympathetic branch of the lingual nerve directed to the contralateral submandibular gland. Lacrimal neurotization was performed uneventfully in 10 patients (4 M, 6 F; mean age 47.1 ± 17.1 years). In all cases, the procedure was combined with facial reanimation, while corneal neurotization was performed in 4 cases. One year postoperatively, mean values of a Schirmer test increased significantly compared with baseline values (7.56 ± 7.84 vs. 0 ± 0 mm/5 min; P = 0.02), while the mean daily number of instillation of tear substitutes decreased significantly (21.8 ± 4.5 vs. 7.1 ± 2.2; P = 0.009). Overall, all patients were satisfied with surgery (very satisfied: n = 7 and satisfied: n = 2). No major postoperative complications occurred. Vertical cross-face using a sural nerve graft to connect the lacrimal gland with the contralateral submandibular gland is a novel technique for treating patients with facial nerve palsy and severe neurodeprivative dry eye disease. This surgery both performed alone and combined with corneal neurotization is able to improve tear secretion and decrease the need for frequent instillations of tear substitutes.

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 1y) 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 29mm (mean: 17.24mm). 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: 16.55mm) to postoperative setting (mean: 33.79mm). 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.

Super-resolved fluorescence imaging of peripheral nerve

Traditional histopathologic evaluation of peripheral nerve employs brightfield microscopy with diffraction limited resolution of ~ 250 nm. Though electron microscopy yields nanoscale resolution of the nervous system, sample preparation is costly and the technique is incompatible with living samples. Super-resolution microscopy (SRM) comprises a set of imaging techniques that permit nanoscale resolution of fluorescent objects using visible light. The advent of SRM has transformed biomedical science in establishing non-toxic means for investigation of nanoscale cellular structures. Herein, sciatic nerve sections from GFP-variant expressing mice, and regenerating human nerve from cross-facial autografts labelled with a myelin-specific fluorescent dye were imaged by super-resolution radial fluctuation microscopy, stimulated emission depletion microscopy, and structured illumination microscopy. Super-resolution imaging of axial cryosections of murine sciatic nerves yielded robust visualization myelinated and unmyelinated axons. Super-resolution imaging of axial cryosections of human cross-facial nerve grafts demonstrated enhanced resolution of small-caliber thinly-myelinated regenerating motor axons. Resolution and contrast enhancement afforded by super-resolution imaging techniques enables visualization of unmyelinated axons, regenerating axons, cytoskeleton ultrastructure, and neuronal appendages of mammalian peripheral nerves using light microscopes.

105. Long Term Surgical and Patient Reported Outcomes After Cross Face Nerve Graft Reconstruction in Pediatric Facial Paralysis

Purpose: Free functioning muscle transfer is the gold standard for pediatric facial paralysis reconstruction and using the contralateral facial nerve for neurotization via a cross face nerve graft enables spontaneous smile restoration. Outcomes of pediatric facial reanimation beyond 10 years are not known, including how smiles change with aging and how adult patients report their facial function and quality of life. This study evaluated long term surgical and patient-reported outcomes for adults who underwent facial reanimation as children. Methods: This cross-sectional study enrolled patients who underwent facial reanimation with a staged cross face nerve graft and free gracilis muscle transfer as children at least 10 years ago. FACE-Gram software was used to quantify commissure excursion on frontal photographs in repose and maximal smile at three time points: preoperative, early postoperative within 2 years, and current (long term follow up). Patient-reported outcomes were evaluated quantitatively using the FaCE Scale and FACE-Q instruments for patient satisfaction, and qualitatively with semi-structured interviews. Results are reported as mean ± SD and parametric statistical analysis was performed with alpha of 0.05. Results: Eighteen patients who underwent facial reanimation as children more than 10 years ago were included (14 females, 5 males; 10 congenital, 8 acquired; age at stage 1 surgery 7.4 ± 3.6 years). Commissure excursion was measured as -1.3 ± 3.5 mm preoperatively, 5.9 ± 2.3 mm postoperatively within 2 years, and 7.6 ± 3.5 mm at long term follow up (mean 20.5 ± 6.9 years). Commissure excursion increased 7.2 ± 4.9 mm from preoperative to early postoperative time points (p<0.0001) and did not significantly increase or decrease at long term follow up (p>0.05). For patient reported outcomes, mean FaCE scale score for facial movement was 44/100 when including eyebrow function and 79/100 when excluding eyebrow function. Mean FaCE scale scores were 63/100 for eye comfort and 81/100 for social function. On the FACE-Q Satisfaction with Outcome scale, 17/18 respondents somewhat agreed or definitely agreed with the statement, “I am pleased with the result.” On the FACE-Q Social Function scale, 16/18 respondents somewhat agreed or definitely agreed with the statement, “I feel confident when I meet a new person.” Conclusions: Pediatric facial reanimation with cross face nerve grafting improves commissure excursion and this is maintained with aging. Adult patients report overall high satisfaction and social functioning. Ongoing ocular issues remains a problem for many patients, underscoring the importance of refining techniques for reanimation of the eye.

71. Evaluation of Axonal Regeneration Across a Long Cross-face Nerve Graft in Rats

Purpose: Cross-face nerve grafting is a preferred technique in facial reanimation due to its capability in providing spontaneous action and symmetry to a patient following regeneration. The length of graft used is thought to be involved in differing functional outcomes. The present study evaluates changes in axonal regeneration at different lengths along a cross-face nerve graft. Methods: The sciatic nerve of sixteen adult Sprague Dawley rats was harvested as a 2-cm graft and coapted end-to-end to the proximal main trunk of the facial nerve. Thirteen weeks later, the graft site was re-exposed for sectioning. 5mm segments were taken from the native facial nerve trunk (Group 1), in the nerve graft, just distal to coaptation (Group 2), midway (Group 3), and just proximal to the distal end of the graft (Group 4). The nerve segments were preserved and embedded in paraffin, cut in 1um cross-sections, and stained with 1% toluidine blue for axon counting. After segmentation, the nerve stump was immersed in 4% Fluoro-Gold (FG) for one hour, returned to the head for retrograde labeling over one week. The brains were preserved in 4% PFA/30% sucrose, frozen in OCT, and sectioned in 40um cross-sections. Every third section was taken to avoid double-counting cells, and counter-stained with Fluoroshield PI (PI). Images were taken with a fluorescent microscope using a combined filter, and cells with double-positive stain were counted as regenerated motoneurons. Statistical analysis was performed using unpaired t-tests in GraphPad Prism7. Results: Analysis of the retrograde-labeled regenerated motoneuron counts showed no significant difference between the proximal portion of the graft (3,538 ± 1,969) and the facial trunk (4,128 ± 731) (p=0.67). However, the motoneuron count at the midway point of the graft (1,517 ± 335) and at the distal end (269 ± 293) were significantly lower than in the facial trunk (p=0.01 and 0.006, respectively). Analysis of the nerve biopsies along the length of the graft demonstrated no significant differences in myelinated axon count across the graft with a mean count of 6,207 ± 310 at the nerve trunk, and 6,606 ± 2399 (p=0.76), 6,405 ±2340 (p=0.88), and 7,179 ± 744 (p=0.07) moving farther down the graft segment.

Cross Facial Nerve Grafting for Smile Restoration: Thoughts on Improving Graft Inset.

Summary:Cross facial nerve grafts (CFNGs) are one of the most ubiquitous and time-honored surgical tools used in facial reanimation. They may be used for targeting different mimetic muscles in the subacute setting as well as to innervate newly placed muscle flaps in varied facial subunits. In our experience, when used specifically for smile reanimation in two-stage strategies with either traditional “babysitting” approaches in nerve transfers or free functional muscle transfers, the second stage may present some challenges in CFNG identification as well as injury to the previously banked nerve graft. We present some technical modifications in the first-stage CFNG inset that can make the second stage easier and safer. These modifications include: (1) marking the course of the nerve graft with surgical metal clips and inserting loose circumferential sutures throughout the distal course of the nerve in the recipient area to avoid displacement; (2) transferring the nerve graft through the nasal sills rather than lips, protecting it from damage during insertion of free functional muscle transfer; and (3) routing the nerve from the lateral nose to the preauricular area over the zygomatic arch, allowing easier dissection and banking of adequate graft length to provide tension-free coaptation with the flexibility of nerve coaptation in variable positions.

Commentary on: "The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?" by Greene et al.

Facial Plastic Surgery & Aesthetic MedicineVol. 24, No. 4 Invited CommentaryCommentary on: “The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?” by Greene et alBabak Azizzadeh and Adrian E. HouseBabak Azizzadeh*Address correspondence to: Babak Azizzadeh, MD, Center for Advanced Facial Plastic Surgery, 9401 Wilshire Boulevard, Suite #650, Beverly Hills, CA 90212, USA. E-mail Address: drazizzadeh@gmail.comhttps://orcid.org/0000-0002-5607-1022Center for Advanced Facial Plastic Surgery, Beverly Hills, California, USA.Search for more papers by this author and Adrian E. HouseCenter for Advanced Facial Plastic Surgery, Beverly Hills, California, USA.Search for more papers by this authorPublished Online:29 Jul 2022https://doi.org/10.1089/fpsam.2022.0027AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Commentary on: “The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?” by Greene et al." Facial Plastic Surgery & Aesthetic Medicine, 24(4), pp. 260–261FiguresReferencesRelatedDetails Volume 24Issue 4Aug 2022 Information© 2022, American Academy of Facial Plastic and Reconstructive Surgery, Inc.To cite this article:Babak Azizzadeh and Adrian E. House.Commentary on: “The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?” by Greene et al.Facial Plastic Surgery & Aesthetic Medicine.Aug 2022.260-261.http://doi.org/10.1089/fpsam.2022.0027Published in Volume: 24 Issue 4: July 29, 2022Online Ahead of Print:June 3, 2022PDF download

The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?

Introduction: During a two-stage free gracilis muscle transfer (FGMT) to restore smile to patients with facial paralysis, some surgeons assess nerve regeneration through the cross-face nerve graft (CFNG) with the Tinel sign and a nerve biopsy. Objective: To test whether ultimate smile reanimation outcomes are correlated with (1) the Tinel sign or (2) myelinated axons of the biopsied CFNG at the time of FGMT. Methods: Retrospective case series was performed at a tertiary care facial nerve center. Dynamic smile outcomes were quantified with Emotrics analysis of pre- and postoperative photographs. Results: Of the 113 FGMT surgeries by CFNG performed since 2002, 92 patients had pre- and postoperative photo-documentation. Most patients (89%, N = 82) had a positive Tinel sign at the time of FGMT; however, 14 patients with positive Tinel signs were deemed failures. Interestingly, 4 patients with a negative Tinel sign went on to have successful dynamic outcomes and 16 patients lacking myelinated axons in their CFNG biopsy ultimately achieved successful smile outcomes. Conclusion: Although the majority of patients had a positive Tinel sign and myelinated axons in the CFNG at the time of FGMT, the presence or absence of either factor did not predict ultimate smile outcome in this series.