Facial Anastomosis Research Articles

Hypoglossal — facial nerve anastomosis: A review of forty cases caused by facial nerve injuries in the posterior fossa

Hypoglossal-facial anastomosis has been our procedure of choice in the repair of the permanently injured facial nerve in the cerebellopontine cistern, when the nerve cannot be primarily repaired. Total failures are few and complications are rare. Most results are good to excellent, if assessment is based upon realistic expectations. These include: 1. normal facial symmetry in repose, 2. good midface voluntary motion, 3. no reflex or emotional facial movement, 4. some synkinesis and donor-injected mass facial movement, and 5. surprisingly little functional loss from hypoglossal paralysis. Our experience indicates better results in younger patients and in those repairs completed shortly after injury. These findings correlate well with the experience gained in peripheral nerve repair in the extremities. There appears to be no absolute time period between injury and repair beyond which this anastomosis is definitely contraindicated. Finally, this procedure does not negate adjunctive plastic surgical procedures. Most of our patients have had tarsorrhaphy or physiologic protection of the eye, but few have had corrective cosmetic surgical procedures until the past few years. We have never used cervical sympathectomy to reduce the size of the palpebral fissure. Better surgical procedures to correct both extracranial and intratemporal facial nerve injuries have significantly reduced the indication for anatomosis procedures. Additionally, over the past two decades, the improved diagnostic and surgical techniques for posterior fossa tumors have considerably reduced the incidence of facial paralysis. As these trends continue, the number of patients requiring nerve anastomosis for facial paralysis will continue to decline and what was once the only surgical procedure to repair the paralyzed face will become a rare operation.

Hypoglossal facial anastomosis; its significance for modern facial surgery. II. Combined approach in extratemporal facial nerve reconstruction

Hypoglossal facial anastomosis; its significance for modern facial surgery. II. Combined approach in extratemporal facial nerve reconstruction

I. Hypoglossal Facial Anastomosis: Its Significance for Modern Facial Surgery II. Combined Approach in Extratemporal Facial Nerve Reconstruction

The difficulties encountered in extratemporial facial nerve reconstruction after extensive trauma or following resection of parotid tumors often lead to unsatisfactory functional and cosmetic results. So far it has been common practice to use as a "regenerative nerve," the original facial nerve. Using this procedure, however, frequently only a portion of the peripheral branches can be reanastomosed. Above all, the "autoparalytic syndrome" develops in this situation owing to undirected outgrowth of axons, and an aberration of the blinking-reflex motoneurons occurs. Experience has shown that the isolated use of a cross-face transplant is not suitable for satisfactory functional regeneration. Depending on the individual anatomic situation, a number of possibilities are therefore recommended for a combined approach using several "regenerative nerves." In this connection, the particular physiologic properties of these nerves have to be taken into account which can help to improve considerably the functional and cosmetic results.

Subtotal evulsion of the facial nerve in hemifacial spasm.

The various surgical procedures performed for hemifacial spasm whereby part of the facial nerve is sectioned, indicate: (1) An intermingled intrafacial arrangement of the various nerve filaments. This arrangement differs from the classical concept that there is a specific regional representation of the peripheral branches and of their tracts in the main trunk. The intermingling of all peripheral filaments in the main trunk explains why even a small portion of the main trunk may represent functionally most of the face. (2) The presence of a wide peripheral anastomosing network connecting the peripheral branches in such a manner that one branch may functionally represent the other branches if they are severed.On the basis of these anatomical observations and because of the frequent recurrence of facial spasm after most prescribed surgical procedures, evulsion of most peripheral twigs is recommended in certain cases. The mandibular branch and one or two superior branches are left. This is considered a compromise surgical procedure, resulting in only slight facial weakness as well as possible recurrence of mild and relatively sparse spasmodic movements.Further theoretical conclusions from the intrafacial fascile arrangements constitute an a priori limitation of surgical results from facial nerve anastomosis and grafting in traumatic cases.

Surgery for acoustic neurinoma.

This presentation is concerned with the one-stage translabyrinthine operation of small acoustic neurinomas and a combined translabyrinthine suboccipital staged operation for removal of large acoustic neurinomas. The technique for the translabyrinthine approach to the cerebellopontine angle is described in detail and demonstrated by photographs of the dissection as it progresses. The technique includes both a one-staged translabyrinthine operation for removal of small acoustic neurinomas and preparation of the involved field when the second stage suboccipital operation is necessary. The first 75 consecutive cases are reviewed. Total removal of tumor was accomplished in 43 of these patients by the translabyrinthine route with incidence of 12% permanent facial nerve paralysis. Twenty-seven patients required a second stage suboccipital operation. Total removal was accomplished in 16 of these patients. Only three of the 11 patients with subtotal removal of tumor have required additional surgery. There was an incidence of permanent facial nerve paralysis in eight of these patients. Five of 75 patients underwent a translabyrinthine operation with subtotal removal of tumor. A second stage suboccipital operation was not performed in these patients because of advanced age or refusal. One of these five patients has a permanent facial paralysis and none have required further surgery to date. There was an incidence of 18% permanent facial paralysis among the entire 75 cases. The author prefers the hypoglossal facial nerve anastomosis procedure for rehabilitation for those patients with facial nerve paralysis. There has been no operative mortality in this entire series and 94% of the patients have been able to resume their previous level of work and activity. There was only one transient episode of cerebrospinal fluid otorhinorrhea among the 75 patients.

Protection of facial nerve anastomosis with a vein graft.

AbstractWhen a cut nerve, which has been repaired, does not function properly it is usually due to the regenerating axons failing to cross the site of the anastomosis. The axonal regrowth may be blocked either by the presence of granulation tissue between the cut ends of the nerve, or to poor stabilization of the nerve stumps with resultant movement and torsion.In the past, many substances have been utilized to protect these anastomosis, most with unfavorable results. The most popular material used today for nerve protection is silastic sheeting which appears to offer some protection without having any major undesirable side effects.Gibb in a previous article, suggested that autogenous vein may be an excellent material for the protection of facial nerve anastomosis. It is readily available, easily tailored and completely physiologic. We felt his proposal had merit, but that it first should be evaluated in an animal model before embarking on a clinical trial.Eighteen dog facial nerves were severed. In six animals (control group) the nerve was repaired with three 7/0 silk sutures in neurolemmal sheath. In the second six, after the nerve sheath was repaired, a section of post auricular vein was wrapped around the anastomosis, being held in place with 7/0 silk sutures. In the remaining six animals, prior to repairing the severed nerve, a tube‐like section of post‐auricular vein was slipped around the proximal segment of the nerve, then after the nerve anastomosis was completed, the vein tube was pulled down over the anastomosis and held in place with 7/0 silk suture.Animals in each group were sacrificed at one, two and three months, in addition, three animals in each group were kept until maximum return of facial function occurred.Clinical evaluation revealed that the animals which had their nerve anastomosis protected with the vein tube or vein sheeting, had more complete return of facial function than the control group.Histological sections showed the vein still to be identifiable during the first two postoperative months, after this is became lost in the general fibrous reaction that occurred around the anastomosis. There was no difference between the groups in the amount of granulation tissue or fibroblasts in the area of the anastomosis. It appears that a careful anastomosis of the neurolemmal sheath will prevent granulations from entering the nerve as effectively as the vein tube; however, we felt that the additional stabilizing effect of the vein tube contributed to the improved results in the sheated animals.It appears that autogenous vein is a safe substance for the protection of facial nerve anastomosis, and is suitable for clinical use.

Facial nerve anastomosis for facial paralysis following acoustic neurinoma surgery.

A satisfactory long term result was obtained in 19 out of 25 cases of facial paralysis, consequent upon complete removal of an acoustic neurinoma, by anastomosis of the facial nerve, in 24 cases with the spinal accessory and in 1 case with the hypoglossal nerve. The technique ofBragdon andGray whereby the deep branch of the spinal accessory nerve is spared and only the superficial branch is used for the anastomosis has proved to be of great value.

Surgical treatment of acoustic neuroma with preservation or reconstitution of the facial nerve.

HE treatment of the innocent acoustic neuroma has, in a sense, been the inost challenging of all intracranial tumors during the recent history of neurological surgery. Although readily accessible by a posterior fossa approach, its intimate involvement with the brain stein, cerebellum, cranial nerves, and the vessels irrigating these structures has taxed the ingenuity of the finest surgeons. History The early surgical treatment was done primarily on very ill patients who had faradvanced large tumors and consisted of an intracapsular removal of the bulk of the tumor, as described by Cushing? Subsequently, encouraged by the reports of Dandy, 3 Olivecrona '2 and McKenzie 19 concentrated on and developed the modern technique for safe complete extirpation of the tumor. The extent of the problem was indicated by an over-all mortality of ~5% in 800 cases in the hands of Olivecrona who pioneered efforts to save the facial nerve. MeKenzie's concentration on the difficulties posed by this tumor resulted in a mortality of 1~.5% in 14~ patients. In these advanced cases, much of the neurological dysfunction due to the nmss of the tumor was irreversible. Hemorrhagic softening of the brain stem was the chief cause of operative mortality and morbidity, and resulted from injury to the anterior inferior cerebellar artery. This vessel usually is intimately related to the tunmr which it supplies with blood; it also has a wide field of irrigation in the adjacent brain stem. 1 The facial nerve was sacrificed more often than not in the interest of safe tumor removal, and the clinical results of facial nerve anastomosis to the hypoglossal, accessory, or phrenic nerves were barely acceptable. Partial removal was practiced in older pa

Surgical Treatment of Seventh Nerve Paralysis

Summary Surgical treatment of facial palsy depends upon the ˦tiology. With recent cases, end-to-end anastomosis, nerve grafting, facial nerve anastomosis with contiguous motor nerves or decompression of the nerve may be of value. With long-standing facial palsy a palliative operation is best with use of muscle, or fascial sling or combination of both. The author's method is to use a portion of the palmaris longus tendon with its paratenon and a flap of the temporalis muscle detached from the coronoid process. Through a tunnel in the cheek the tendon of the palmaris longus is then inserted and sutured on the orbicularis oris muscle and to the detached part of the temporalis muscle. This method has the advantage that the tendon moves freely because it does not attach itself to the surrounding tissue, and the angle of the mouth is drawn in the normal direction because the tendon is fastened to the temporalis muscle. The temporalis muscle, including the separated part, contracts. One gets a mobile and not a fixed smile. Two cases with long-standing facial palsy are described where this method was applied. The second patient had also lost a large part of the posterior part of the mandible, including the condyle. The defect was repaired with a vitallium alloy prosthesis and a bone graft.

Surgical treatment of seventh nerve paralysis

Summary Surgical treatment of facial palsy depends upon the ˦tiology. With recent cases, end-to-end anastomosis, nerve grafting, facial nerve anastomosis with contiguous motor nerves or decompression of the nerve may be of value. With long-standing facial palsy a palliative operation is best with use of muscle, or fascial sling or combination of both. The author's method is to use a portion of the palmaris longus tendon with its paratenon and a flap of the temporalis muscle detached from the coronoid process. Through a tunnel in the cheek the tendon of the palmaris longus is then inserted and sutured on the orbicularis oris muscle and to the detached part of the temporalis muscle. This method has the advantage that the tendon moves freely because it does not attach itself to the surrounding tissue, and the angle of the mouth is drawn in the normal direction because the tendon is fastened to the temporalis muscle. The temporalis muscle, including the separated part, contracts. One gets a mobile and not a fixed smile. Two cases with long-standing facial palsy are described where this method was applied. The second patient had also lost a large part of the posterior part of the mandible, including the condyle. The defect was repaired with a vitallium alloy prosthesis and a bone graft.

Spinal Accessory Facial Anastomosis for Facial Palsy during Acute Destruction of Labyrinth

Spinal Accessory Facial Anastomosis for Facial Palsy during Acute Destruction of Labyrinth

Kinematograph Film illustrating Anastomosis of Facial Nerve in Cases of Facial Palsy

Kinematograph Film illustrating Anastomosis of Facial Nerve in Cases of Facial Palsy