Facial Anastomosis Research Articles

Clinical observation of masseter-to-facial nerve anastomosis for treatment of facial paralysis

Objective To evaluate the efficiency and functional improvement of masseter-to-facial nerve transfer for patients who acquired a proximal iniury to the facial nerve and preliminary determine the influence factors for recovery. Methods From January, 2015 to May, 2016, the clinical data of 6 patients with facial paralysis underwent nerve anastomosis were analyzed retrospectively. These patients were required to come back to the hospital for a check every 3 months, in order to evaluate their facial nerve function. House-Brackmann (H-B) grading was used to evaluate the pre-oerative, post-operative and follow-up status. The masseter-to-facial nerve anastomosis was performed in all the 6 patients. Results All patients were followed-up. The mean time of follow-up was 16 months (ranged from 6 to 23 months) . Among 6 cases, the facial nerve function was improved in 5 cases, unchanged in 1 case. The postoperative H-B grades were II in 3 cases, III in 2 cases. The improvement of facial paralysis was most significant for orbicularis muscles, followed by the orbicularis oculi muscles, and the worst was the improvement of frontal muscles. Conclusion Masseter-to-facial nerve transfer anatomosis is a useful treatment for facial paralysis and can improve the facial function. Key words: Facial palsy; Masseter nerve; Nerve end-end anastomosis; Nerve end-side anastomosis

Acute Response of Neurons: An Early Event of Neuronal Cell Death After Facial Nerve Injury.

To research the early acute response events of facial nerve injury. Sixty male Sprague-Dawley rats were randomly divided into 2 groups. Facial nerve anastomosis was performed for rats in study group. Rats in control group underwent the same surgical procedure, but without cutting off the facial nerve. Before nerve anastomosis and at days 1, 3, 7, 14, and 28 after nerve anastomosis, 5 rats of each group were selected and right side brainstem tissue samples containing the facial nerve nucleus were obtained. Hematoxylin and eosin (H&E) staining and TUNEL detection was performed to observe facial neurons changes. Facial neurons mortality and apoptosis were studied. Expression of caspase-3, LC3, and Beclin1 was detected with Western blot assay. In study group on day 7 day after nerve anastomosis, Nissl body dissolution and apoptotic facial neurons were significantly increased, the typical polygonal shape and swollen cells disappeared, the number of facial neurons was significantly lower, and the number of apoptotic facial neurons was significantly higher (P < 0.01). In addition, facial neuron mortality rate was significantly increased at day 7, reaching the peak at day 14. Expression of caspase-3, LC3, and Beclin1 was also significantly up-regulated after nerve anastomosis. Nissl body dissolution, typical polygonal shape disappearing, cell swelling, facial neuron mortality and apoptosis, and up-regulated expression of caspase-3, LC3, and Beclin1 are the early events of cell death after facial nerve injury, which are the important precursors to facial nerve injury.

The effect of tacrolimus on facial nerve injury: Histopathological findings in a rabbit model

HypothesisTacrolimus helps healing of facial nerve injury. BackgroundPositive effects of tacrolimus on axon regeneration and healing of injured peripheral nerves (eg. sciatic nerve) have been reported in the literature. Tacrolimus may be an additional treatment method that could improve the nerve healing after surgical treatment of cut injury of facial nerve. Methods20 New Zealand rabbits were randomly separated into control and study groups of 10. In control group, no medical treatment was given after facial nerve anastomosis, and the animals were followed up for 2months. In the study group rabbits were given 1mg/kg/day tacrolimus subcutaneously for 2months after the facial nerve anastomosis. The histopathologic findings of axon regeneration like axon myelination were analyzed in both groups under electron and light microscopy. The data obtained in the groups were compared. ResultsGreater axon diameters, thicker myelin sheaths, and higher total number of myelinated axons were found in the tacrolimus group, suggesting better regeneration in this group when compared to the control group. There was less vacuolar degeneration in the study group. All these findings suggest that tacrolimus positively affects healing after facial nerve anastomosis. ConclusionThe results of this study indicate that tacrolimus has favorable effects on the healing process of the facial nerve after end-to-end anastomosis. Tacrolimus may be a promising agent in the future for nerve regeneration following traumatic facial paralysis surgery.

Comparison of Direct Side-to-End and End-to-End Hypoglossal-Facial Anastomosis for Facial Nerve Repair

The hypoglossal facial anastomosis (HFA) is the gold standard for facial reanimation in patients with severe facial nerve palsy. The major drawbacks of the classic HFA technique are lingual morbidities due to hypoglossal nerve transection. The side-to-end HFA is a modification of the classic technique with fewer tongue-related morbidities. In this study we compared the outcome of the classic end-to-end and the direct side-to-end HFA surgeries performed at our center in regards to the facial reanimation success rate and tongue-related morbidities. Twenty-six successive cases of HFA were enrolled. In 9 of them end-to-end anastomoses were performed, and 17 had direct side-to-end anastomoses. The House-Brackmann (HB) and Pitty and Tator (PT) scales were used to document surgical outcome. The hemiglossal atrophy, swallowing, and hypoglossal nerve function were assessed at follow-up. The original pathology was vestibular schwannoma in 15, meningioma in 4, brain stem glioma in 4, and other pathologies in 3. The mean interval between facial palsy and HFA was 18 months (range: 0-60). The median follow-up period was 20 months. The PT grade at follow-up was worse in patients with a longer interval from facial palsy and HFA (P value: 0.041). The lesion type was the only other factor that affected PT grade (the best results in vestibular schwannoma and the worst in the other pathologies group, P value: 0.038). The recovery period for facial tonicity was longer in patients with radiation therapy before HFA (13.5 vs. 8.5 months) and those with a longer than 2-year interval from facial palsy to HFA (13.5 vs. 8.5 months). Although no significant difference between the side-to-end and the end-to-end groups was seen in terms of facial nerve functional recovery, patients from the side-to-end group had a significantly lower rate of lingual morbidities (tongue hemiatrophy: 100% vs. 5.8%, swallowing difficulty: 55% vs. 11.7%, speech disorder 33% vs. 0%). With the side-to-end HFA technique the functional restoration outcome is at least as good as that following the classic end-to-end HFA, but the complications related to the complete hypoglossal nerve transection can be avoided. Best results are achieved if this procedure is performed within the first 2 years after facial nerve injury. Patients with facial palsy of longer duration also have the chance for good functional restoration after HFA.

Oncological and functional results after the surgical treatment of parotid cancer

The objective of this study was to analyze the oncological and functional outcomes after the surgical treatment of parotid cancer. We reviewed 80 primary parotid carcinomas retrospectively. A superficial parotidectomy was performed in 10 patients; 27 patients underwent total parotidectomy and 43 patients underwent radical parotidectomy. A facial–facial nerve anastomosis was chosen for the facial nerve reconstruction in eight patients, while an interpositional graft was selected in 24 patients. The overall N-positive rate of pathology was 21.3%. The rate of occult metastasis was 8.1%. High-grade carcinoma and lymphovascular emboli were independent factors for nodal metastasis. The 5-year disease-free survival and overall survival rates were 79.7% and 78.8%, respectively. Preoperative facial nerve palsy and extraparenchymal invasion were the independent factors associated with poor disease-free survival. Of the 41 patients in the facial nerve preservation group, 13 (31.7%) had transient facial nerve paresis. In the facial nerve sacrifice group of 39 cases, (sub)total recovery (House–Brackmann grade I/II) occurred in 14 (35.9%), partial recovery (House–Brackmann grade III/IV) in 13 (33.3%), and no recovery (House–Brackmann grade V) in 12 (30.8%). Facial nerve palsy upon presentation and extraparenchymal invasion indicate a grave prognosis. Facial nerve function after proper reconstruction is tolerable.

Facial nerve anastomosis for facial paralysis resulting from surgery of cerebellopontine angle tumors

Objective To evaluate the efficiency and functional improvement of the facial nerve anastomosis for facial paralysis after cerebellontine angle (CPA) tumor surgery.Methods The clinical data of seven patients with facial paralysis after CPA tumors surgery underwent nerve anastomosis were analyzed retrospectively.House-Brackmann (H-B) grading was used to evaluate the pre-,post-operative and follow-up status.The end-end anastomosis of facial nerve was performed in one case,and facial-hypoglossal nerve anastomosis in six.Results All patients were followed-up.The mean time of follow-up was 23 months (ranged from 1 to 48 months).Among seven cases,the facial nerve function was improved in five cases,unchanged in one,and could not be evaluated in one because of short-time follow-up.The postoperative HB grades were Ⅱ in one case,Ⅲ in two and Ⅳ in two.Conclusions Facial nerve anatomosis was a useful treatment for facial paralysis after CPA tumors resection and could improve the facial function. Key words: Facial nerve injuries; Facial Palsy; Cerebellopontine angle; Nerve anastomosis

Side-to-End Hypoglossal to Facial Anastomosis With Transposition of the Intratemporal Facial Nerve

To describe results in a large series of patients using a recent variation of hypoglossal-facial nerve anastomosis (HFA) in which the intratemporal facial nerve segment is used, obviating the need for a sensory nerve "jump graft." Retrospective chart review. Tertiary neurotologic referral center. Nineteen patients (12 female/7 male subjects) with facial paralysis because of posterior fossa surgery for tumor (n = 15), Bell's palsy (n = 1), facial neuroma (n = 1), hemangioma (n = 1), and trauma (n = 1) who underwent HFA from 1997 to 2011, with at least 1-year follow-up. Mean age at surgery is 47.4 years (range, 11.2-83 yr). Mean follow-up is 4.0 years. Side-to-end hypoglossal to facial anastomosis with transposition of the intratemporal facial nerve (swingdown HFA). House-Brackmann (H-B) facial nerve grade. Seven patients (36.8%) achieved an H-B Grade III, 9 patients (47.4%) a grade IV, and 3 patients (15.8%) a grade V at last follow-up. No patients complained of dysphagia, dysarthria, or had evidence of oral incompetence. One patient complained of mild tongue weakness. Age at time of HFA (p ≤ 0.049, III younger than V) and time from facial nerve injury to HFA (p ≤ 0.02, III<IV and V) were significant factors for ultimate facial nerve outcome. All patients with an H-B III result had HFA within 6 months of injury. Other factors were not significant. The HFA swingdown technique is a safe and effective method to restore facial nerve function in patients with facial paralysis and obviates the need for an interposition jump graft.

Comparison of 3 Procedures for Hypoglossal–Facial Anastomosis

We aimed to evaluate rehabilitation of complete facial palsy with 3 procedures for hypoglossal-facial anastomosis: end-to-end ("original"), partial end-to-end with interpositional jump grafting ("jump") and the new partial end to end without grafting ("modified"). A medical jury reviewed videos of 36 patients with complete facial palsy who underwent surgery from 1998 to 2008 by original (n = 13), jump (n = 13), and modified (n = 10) procedures. The jury of 5 ear, nose, and throat surgeons who were blinded to the procedure evaluated rehabilitation by 3 facial nerve grading systems-House and Brackman (HB), Sunnybrook, and Freyss scales-and 3 subjective scores for the face at rest and during voluntary and emotional motions. Recovery time was shorter with the modified and original procedures than jump procedure (5, 6, and 8 mo, respectively). All patients achieved at least good results. Scores on the HB scale (I-VI) were mainly III. HB and Sunnybrook scores did not differ by procedure. Freyss score was better for the modified procedure than original and jump procedures. Scores for the face at rest did not differ by procedure, but those during voluntary and emotional movements were worse for the jump procedure than for other procedures. Synkinesis was more severe with the original procedure than other procedures. The 3 procedures give satisfactory results for rehabilitation after surgery for facial palsy. The original procedure should be performed in patients with strong mimic or long-standing facial palsy. The jump procedure is delicate and entails risk of weak reinnervation. The modified procedure is a good compromise in terms of muscle tone and side effects.

Rapid and Accurate Identification of Cut Ends of Facial Nerves Using a Nerve Monitoring System During Surgical Exploration and Anastomosis

Surgical exploration and end-to-end neurorrhaphy is the preferred management for traumatic facial nerve injury. Traditionally, finding the cut ends of facial nerves depends mainly on a surgeon's experience. In this study, a nerve monitoring system to help the surgeon quickly and accurately identify, confirm, and locate the cut ends of facial nerve branches was investigated. Six patients with traumatic facial nerve injury were selected, and the nerve monitoring system was applied during the surgical process of facial nerve exploration and anastomosis. Operation time and surgical outcome were used to evaluate the effect of this method. The surgical procedures required 6 to 15 minutes (mean, 10 minutes) for detecting and dissecting each cut end of a facial nerve branch. All cut ends of injured facial nerve branches were found during surgery in all 6 patients, and no intraoperative complications were encountered. The postoperative function of the facial nerve, evaluated by clinical examination and diagnostic electroneurography, was satisfactory and symmetrical in all 6 patients at 3 months. Using a nerve monitoring system could effectively help surgeons achieve rapid and accurate identification of the cut ends of facial nerves during surgical facial nerve exploration for traumatic facial nerve injury.

An analysis of petrous bone cholesteatomas treated with translabyrinthine transotic petrosectomy

Conclusion: In cases of petrous apex cholesteatoma, radical removal should be prioritized over an unreasonable sparing of hearing or facial symmetry. Restoration of facial nerve function is achievable by reanimation procedures. Objectives: To analyze clinical manifestations, surgical findings, and postoperative functional results of petrous apex cholesteatoma. Methods: From 1995 to 2012, 34 cases of petrous apex cholesteatoma underwent operations. Clinical and surgical findings and postoperative functional outcomes were analyzed retrospectively. Results: Hearing loss was the most common symptom in 95% of patients, followed by otorrhea in 64% and facial palsy in 59%. Four patients had recurrent facial palsy. In eight (24%) patients petrous apex cholesteatomas were recurrent or iatrogenic in origin. The supralabyrinthine and massive type of petrous bone cholesteatoma were the most common types, followed by, infralabyrinthine-apical, infralabyrinthine, and apical. Among 18 cases with facial nerve paralysis, 8 underwent hypoglossal–facial nerve anastomosis, 4 underwent rerouting and end to end anastomosis, 3 of them did not undergo any treatment because of the duration of facial palsy (> 3 years), and another 3 patients for whom we had recommended facial–hypoglossal anastomosis did not accept the operation. There were no major complications. Recurrence was observed in two (5%) cases.

Delayed repair of facial nerve trauma: an experimental study in guinea pigs

Conclusion: The curative effect in the group where facial–facial anastomosis (FFA) was delayed for 7 days was similar to that in the immediate FFA group and had a better repair within 60 days. Objective: Due to the uncertainty about optimal timing of delayed facial nerve repair, we designed an experimental study in guinea pigs to find out the cut-off duration for delayed nerve repair. Methods: In this study, 64 male guinea pigs were randomly divided into 8 groups: normal, immediate FFA, and delayed FFA for 7, 14, 21, 30, 60, and 90 days (n = 6). Two months after suture of the nerves, the passing rate of myelinated fibers growing from the proximal to the distal stumps was calculated. Results: The passing rates of myelinated fibers in the groups with immediate FFA and FFA delayed for 7 days were significantly higher than those in other delayed FFA groups and the difference was statistically significant (p < 0.05), whereas the passing rates of the groups where FFA was delayed for 60 and 90 days were apparently lower than those of the immediate FFA and other delayed FFA groups. Under the electron microscope, regenerated fibers of the groups with immediate FFA and FFA delayed for 7 days were very similar to the normal myelinated fibers.

Amniotic membrane covering for facial nerve repair.

Amniotic membranes have been widely used in ophthalmology and skin injury repair because of their anti-inflammatory properties. In this study, we measured therapeutic efficacy and determined if amniotic membranes could be used for facial nerve repair. The facial nerves of eight rats were dissected and end-to-end anastomosis was performed. Amniotic membranes were covered on the anastomosis sites in four rats. Electromyography results showed that, at the end of the 3rd and 8th weeks after amniotic membrane covering, the latency values of the facial nerves covered by amniotic membranes were significantly shortened and the amplitude values were significantly increased. Compared with simple facial nerve anastomosis, after histopathological examination, facial nerve anastomosed with amniotic membrane showed better continuity, milder inflammatory reactions, and more satisfactory nerve conduction. These findings suggest that amniotic membrane covering has great potential in facial nerve repair.

Detailed Analysis of Neurological Status and Functional Outcome after Spinal Accessory Nerve-Facial Nerve Anastomosis: Comparison versus Other Reinnervation Procedures in Reported Series

Introduction: Few long-term studies of spinal accessory nerve–facial nerve anastomosis (AFA) for facial nerve (FN) palsy exist.

Comparative Outcome Analysis of Surgical Procedures Performed in Acute and Intermediate Facial Paralysis

Objective: The purpose of this study was to analyze outcomes after different surgical procedures for facial nerve (FN) restoration and facial muscles reanimation. Reviewed procedures included: free nerve graft, FN decompression in temporal bone, and spinal accessory nerve–facial nerve anastomosis (AFA).

Effectiveness of Fibrin Adhesive in Facial Nerve Anastomosis in Dogs Compared With Standard Microsuturing Technique

Epineural suturing is the most common technique used for peripheral nerve anastomosis. In addition to the foreign body reaction to the suture material, the surgical duration and difficulty of suturing in confined anatomic locations are major problems. We evaluated the effectiveness of fibrin glue as an acceptable alternative for nerve anastomosis in dogs. Eight adult female dogs weighing 18 to 24 kg were used in the present study. The facial nerve was transected bilaterally. On the right side, the facial nerve was subjected to epineural suturing; and on the left side, the nerve was anastomosed using fibrin adhesive. After 16 weeks, the nerve conduction velocity and proportion of the nerve fibers that crossed the anastomosis site were evaluated and compared for the epineural suture (right side) and fibrin glue (left side). The data were analyzed using the paired t test and univariate analysis of variance. The mean postoperative nerve conduction velocity was 29.87 ± 7.65 m/s and 26.75 ± 3.97 m/s on the right and left side, respectively. No statistically significant difference was found in the postoperative nerve conduction velocity between the 2 techniques (P = .444). The proportion of nerve fibers that crossed the anastomotic site was 71.25% ± 7.59% and 72.25% ± 8.31% on the right and left side, respectively. The histologic evaluation showed no statistically significant difference in the proportion of the nerve fibers that crossed the anastomotic site between the 2 techniques (P = .598). The results suggest that the efficacies of epineural suturing and fibrin gluing in peripheral nerve anastomosis are similar.

Facial Reanimation After Facial Nerve Injury Using Hypoglossal to Facial Nerve Anastomosis: The Gruppo Otologico Experience

To evaluate the results of facial nerve reanimation after facial nerve injury by means of hypoglossal to facial nerve anastomosis. Retrospective case review. Private neuro-otologic and cranial base quaternary referral center. Sixty patients underwent hypoglossal to facial nerve anastomosis for facial nerve reanimation between April 1987 and December 2010. Only forty patients completed a minimal follow up of 24months at the time of evaluation and were included in the study population. Facial nerve paralysis was present for a mean duration of 11.3months (range 2-42months) and all the patients had a HB grade VI prior their surgery. Final facial nerve motor function. The most common cause of facial paralysis was vestibular Schwannoma surgery. All the patients achieved a postoperative HB grade III or IV after a mean follow-up time of 20months. The facial movements were detected after a period that ranged from ranged from 5 to 9months. Only 4 patients suffered from difficulties during eating and drinking and three of them had associated lower cranial nerve deficit. Despite the various techniques in facial reanimation following total facial nerve paralysis, the end to end of hypoglossal to facial nerve anastomosis remains one of the best treatments in cases of viable distal facial stump and nonatrophic musculature.

Bell′s palsy and partial hypoglossal to facial nerve transfer: Case presentation and literature review

Background:Idiopathic facial nerve palsy (Bell's palsy) is a very common condition that affects active population. Despite its generally benign course, a minority of patients can remain with permanent and severe sequelae, including facial palsy or dyskinesia. Hypoglossal to facial nerve anastomosis is rarely used to reinnervate the mimic muscle in these patients. In this paper, we present a case where a direct partial hypoglossal to facial nerve transfer was used to reinnervate the upper and lower face. We also discuss the indications of this procedure.Case Description:A 53-year-old woman presenting a spontaneous complete (House and Brackmann grade 6) facial palsy on her left side showed no improvement after 13 months of conservative treatment. Electromyography (EMG) showed complete denervation of the mimic muscles. A direct partial hypoglossal to facial nerve anastomosis was performed, including dissection of the facial nerve at the fallopian canal. One year after the procedure, the patient showed House and Brackmann grade 3 function in her affected face.Conclusions:Partial hypoglossal–facial anastomosis with intratemporal drilling of the facial nerve is a viable technique in the rare cases in which severe Bell's palsy does not recover spontaneously. Only carefully selected patients can really benefit from this technique.

Facial movement before and after masseteric-facial nerves anastomosis: A three-dimensional optoelectronic pilot study

To quantify the effects of facial palsy reanimation, 14 patients aged 17–66years were analysed. All patients had unilateral facial paralysis, and were candidates for surgical masseteric to facial nerve anastomosis. Two patient groups were measured: seven patients were waiting for surgery, the other seven patients had already been submitted to surgery, and had regained facial mimicry. Each patient performed three facial animations: brow raise; free smile; lip purse. These were recorded using an optoelectronic motion analyser.The three-dimensional coordinates of facial landmarks were obtained, their movements were computed, and asymmetry indices calculated (differential movements between the two hemi-faces: healthy and paretic/rehabilitated). Before surgery, mobility was larger in the healthy than in the paretic side; after surgery, the differences were reduced (brow raise and lip purse), or even reversed (smile). Before surgery, lip purse was performed with significant labial asymmetry (p=0.042; larger healthy side movement). After surgery, asymmetry indices reduced. Total labial asymmetry during smiling was significantly different from 0 before surgery (p=0.018, larger healthy side movement). After surgery, all asymmetry indices became non-significant. Before surgery the lateral displacements of all labial landmarks were towards the healthy side, while they normalized after surgery.

Evaluation of the effect of methylprednisolone and N-acetylcystein on anastomotic degeneration and regeneraton of the facial nerve

This study was aimed to determine the effects of methylprednisolone and N-acetylcystein on nerve healing in facial nerve anastomosis. Thirty rabbits were randomly divided into 3 groups: Group I: control group received no medication; Group II: 50mg/kg/day N-acetylcystein administered group; Group III, 1mg/kg/day Methylprednisolone administered group. All rabbits underwent the same standard surgical procedure. A 1mm segment was resected from the facial nerve and the free ends were anastomosed. The drugs were administered for two months twice a day. At the end of the second month, the anastomosed regions were dissected and examined under electron and light microscopy. Best nerve regeneration was observed in the N-acetylcystein and the control groups, respectively, whereas the weakest regeneration was determined in the methylprednisolone group. In the N-acetylcystein group, due to Schwann cell and glial cell proliferation, the increased regeneration rate was significantly higher compared to that of the methylprednisolone group. In the methylprednisolone group, no significant regeneration was observed despite the presence of degenerative signs of significant axonal withdrawal and an increase in the number of myelin debris. In the present study, we demonstrated that methylprednisolone had no beneficial effect in nerve regeneration after facial nerve anastomosis. It further caused increased degeneration. On the contrary, N-acetylcystein administration significantly increased the extent of regeneration, whereas it decreased the extent of degeneration compared to the control and the methylprednisolone groups.

Masseteric–facial nerve anastomosis for early facial reanimation

Objective Early repair of facial nerve paralysis when cortical neural input cannot be provided by the facial nerve nucleus, is generally accomplished anastomozing the extracranial stump of the facial nerve to a motor donor nerve. That is generally the hypoglossus, which carries a variable degree of morbidity. The present work aims to demonstrate the effectiveness of the masseteric nerve as donor for early facial reanimation, with the advantage that harvesting is associated with negligible morbidity. Methods Between October 2007 and August 2009, 7 patients (2 males, 5 women) with unilateral facial paralysis underwent a masseter–facial nerves anastomosis with an interpositional nerve graft of the great auricular nerve. The interval between the onset of paralysis and surgery ranged from 8 to 48 months (mean 19.2 months). All patients included in the study had signs of facial mimetic muscle fibrillations on electromyography. The degree of preoperative facial nerve dysfunction was grade VI following the House-Brackmann scale for all patients. Results At the time of the study, all the patients with a minimum follow-up time of 12 months after the onset of mimetic function had recovered facial animation. Facial muscles showed signs of recovery within 2–9 months, mean 4.8 months, with the restoration of facial symmetry at rest. Facial movements appeared while the patients activated their chewing musculature. Morbidity related to this intervention is only the loss of sensitivity of earlobe and preauricular region. Conclusion The present technique seems to be a valid alternative to classical hypoglossal–facial nerve anastomosis because of similar facial nerve recovery and lower morbidity.