Name: single-stage dynamic reanimation of the smile in irreversible facial paralysis by free functional muscle transfer
Uploaded: 2015-03-01T15:00:00.000+00:00
Duration: 19 min 53 s
Description: Watch this Scientific Journal Video about Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer at JoVE.com

Dr. Eisenhardt is funded by the German Research Foundation (DFG) # EI 866/1-1 and #EI 866/2-1.

<ol>
	<li>Mavrikakis, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Facial+nerve+palsy:+anatomy,+etiology,+evaluation,+and+management.">Facial nerve palsy: anatomy, etiology, evaluation, and management.</a> Orbit. 27 (6), 466-474 (2008).</li><li>Pitanguy, I., Ramos, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+frontal+branch+of+the+facial+nerve:+the+importance+of+its+variations+in+face+lifting.">The frontal branch of the facial nerve: the importance of its variations in face lifting.</a> Plast Reconstr Surg. 38 (4), 352-356 (1966).</li><li>McAllister, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+interventions+for+the+early+management+of+Bell's+palsy.">Surgical interventions for the early management of Bell's palsy.</a> Cochrane Database Syst Rev. 10 (2), (2013).</li><li>Terzis, J. K., Anesti, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Developmental+facial+paralysis:+a+review.">Developmental facial paralysis: a review.</a> J Plast Reconstr Aesthet Surg. 64 (10), 1318-1333 (2011).</li><li>Momeni, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Single-stage+microsurgical+reconstruction+for+facial+palsy+utilising+the+motor+nerve+to+the+masseter.">Single-stage microsurgical reconstruction for facial palsy utilising the motor nerve to the masseter.</a> Handchir Mikrochir Plast Chir. 42 (2), 95-101 (2010).</li><li>Volk, G. F., Pantel, M., Guntinas-Lichius, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modern+concepts+in+facial+nerve+reconstruction.">Modern concepts in facial nerve reconstruction.</a> Head Face Med. 6, 25 (2010).</li><li>Mathes, S. J., Nahai, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Classification+of+the+vascular+anatomy+of+muscles:+experimental+and+clinical+correlation.">Classification of the vascular anatomy of muscles: experimental and clinical correlation.</a> Plast Reconstr Surg. 67 (2), 177-187 (1981).</li><li>Harii, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microneurovascular+free+muscle+transplantation+for+reanimation+of+facial+paralysis.">Microneurovascular free muscle transplantation for reanimation of facial paralysis.</a> Clin Plast Surg. 6 (3), 361-375 (1979).</li><li>Borschel, G. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+motor+nerve+to+the+masseter+muscle:+an+anatomic+and+histomorphometric+study+to+facilitate+its+use+in+facial+reanimation.">The motor nerve to the masseter muscle: an anatomic and histomorphometric study to facilitate its use in facial reanimation.</a> J Plast Reconstr Aesthet Surg. 65 (3), 363-366 (2012).</li><li>Zuker, R. M., Goldberg, C. S., Manktelow, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Facial+animation+in+children+with+Mobius+syndrome+after+segmental+gracilis+muscle+transplant.">Facial animation in children with Mobius syndrome after segmental gracilis muscle transplant.</a> Plast Reconstr Surg. 106 (1), 1-8 (2000).</li><li>Bannasch, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+critical+evaluation+of+the+concomitant+use+of+the+implantable+Doppler+probe+and+the+Vacuum+Assisted+Closure+system+in+free+tissue+transfer.">A critical evaluation of the concomitant use of the implantable Doppler probe and the Vacuum Assisted Closure system in free tissue transfer.</a> Microsurgery. 28 (6), 412-416 (2008).</li><li>Sierra, D. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fibrin+sealant+adhesive+systems:+a+review+of+their+chemistry,+material+properties+and+clinical+applications.">Fibrin sealant adhesive systems: a review of their chemistry, material properties and clinical applications.</a> J Biomater Appl. 7 (4), 309-352 (1993).</li><li>Brien, B. M., Lawlor, D. L., Morrison, W. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microneurovascular+free+muscle+reconstruction+for+long+established+facial+paralysis.">Microneurovascular free muscle reconstruction for long established facial paralysis.</a> Ann Chir Gynaecol. 71 (1), 65-69 (1982).</li><li>Eisenhardt, S. U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+cross+face+nerve+graft+with+masseteric+nerve+as+donor+nerves+for+free+functional+muscle+transfers+in+facial+reanimation+surgery].">Comparison of cross face nerve graft with masseteric nerve as donor nerves for free functional muscle transfers in facial reanimation surgery].</a> Handchir Mikrochir Plast Chir. 45 (4), 223-228 (2013).</li><li>Harrison, D. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+pectoralis+minor+vascularized+muscle+graft+for+the+treatment+of+unilateral+facial+palsy.">The pectoralis minor vascularized muscle graft for the treatment of unilateral facial palsy.</a> Plast Reconstr Surg. 75 (2), 206-216 (1985).</li><li>Frey, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Histomorphometric+studies+in+patients+with+facial+palsy+treated+by+functional+muscle+transplantation:+new+aspects+for+the+surgical+concept.">Histomorphometric studies in patients with facial palsy treated by functional muscle transplantation: new aspects for the surgical concept.</a> Ann Plast Surg. 26 (4), 370-379 (1991).</li><li>Eisenhardt, S. U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Salvage+Procedures+After+Failed+Facial+Reanimation+Surgery+Using+the+Masseteric+Nerve+as+the+Motor+Nerve+for+Free+Functional+Gracilis+Muscle+Transfer.">Salvage Procedures After Failed Facial Reanimation Surgery Using the Masseteric Nerve as the Motor Nerve for Free Functional Gracilis Muscle Transfer.</a> JAMA Facial Plast Surg. , (2014).</li><li>Bae, Y. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comparison+of+commissure+excursion+following+gracilis+muscle+transplantation+for+facial+paralysis+using+a+cross-face+nerve+graft+versus+the+motor+nerve+to+the+masseter+nerve.">A comparison of commissure excursion following gracilis muscle transplantation for facial paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve.</a> Plast Reconstr Surg. 117 (7), 2407-2413 (2006).</li><li>Schaverien, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Activation+of+the+masseter+muscle+during+normal+smile+production+and+the+implications+for+dynamic+reanimation+surgery+for+facial+paralysis.">Activation of the masseter muscle during normal smile production and the implications for dynamic reanimation surgery for facial paralysis.</a> J Plast Reconstr Aesthet Surg. 64 (12), 1585-1588 (2011).</li><li>Manktelow, R. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Smile+reconstruction+in+adults+with+free+muscle+transfer+innervated+by+the+masseter+motor+nerve:+effectiveness+and+cerebral+adaptation.">Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation.</a> Plast Reconstr Surg. 118 (4), 885-899 (2006).</li><li>Eppley, B. L., Zuker, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Salvage+of+facial+reanimation+with+vascularized+adductor+magnus+muscle+flap:+clinical+experience+and+anatomical+studies.">Salvage of facial reanimation with vascularized adductor magnus muscle flap: clinical experience and anatomical studies.</a> Plast Reconstr Surg. 110 (7), 1693-1696 (2002).</li><li>Labbe, D., Huault, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lengthening+temporalis+myoplasty+and+lip+reanimation.">Lengthening temporalis myoplasty and lip reanimation.</a> Plast Reconstr Surg. 105 (4), 1289-1297 (2000).</li><li>Iblher, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+evaluation+tool+for+monitoring+devices+and+its+application+to+evaluate+the+implantable+Doppler+probe.">A new evaluation tool for monitoring devices and its application to evaluate the implantable Doppler probe.</a> J Reconstr Microsurg. 26 (4), 265-270 (2002).</li></ol>

The authors have nothing to disclose.

Even though different surgical techniques have been described to regain a dynamic smile in patients with long standing facial paralysis, the two-stage repair with initial cross facial nerve grafting and consecutive free gracilis muscle transfer is seen as the &#8220;criterion standard&#8221;.
Although a two-stage procedure, the technique allows for spontaneity of the smile which is seen as a crucial factor to overcome the social handicap associated with facial palsy13.In cases of bilateral facial paralysis and M&#246;bius syndrome, the concept of muscle transplantation in the absence of the seventh nerve can be applied. Here, the masseter nerve as a branch of the trigeminal (fifth nerve) has increasingly been recommended to power the free muscle flap. As elderly patients or patients with significant morbidity tend to prefer a single-stage procedure, indications of the masseteric coaptation have significantly been expanded during the last years14. 
There are clearly several advantages of masserteric nerve grafting. Apart from secondary thinning of the flap that is necessary in some patients, using the masseteric nerve is a single-stage procedure that preserves the contralateral healthy facial nerve and allows for a greater axonal load that is delivered to the flap. Conversely, incomplete reinnervation and partial muscle atrophy is often seen after facial nerve grafting, as less than 50% of axons cross the nerve graft15,16. Using the masseteric nerve results in a greater excursion of the oral commissure when compared to coaptation of the neural pedicle of the muscle flap to a cross-face nerve graft and consequently might be the method of choice in patients with a strong contralateral smile where cross-face nerve grafting is insufficient to restore symmetry14. Therefore the masseteric nerve can also be used to innervate a gracilis muscle flap in a secondary procedure when a gracilis muscle flap primarily innervated by a CFNG does not show sufficient muscle excursion to achieve a symmetric smile17. As a result of the strong neural input and minimal atrophy of the muscle, thinning out of the flap may become necessary in some patients that then require a minor secondary procedure. 
In some patients, single-stage reanimation of the smile powered by the masseteric nerve does not provide spontaneous activity. The smile movement must be learned as part of a conscious effort. However, spontaneity can be observed in about two thirds of the cases which is also confirmed by our own observations18. To date, the determinants of achieving a spontaneous smile after masseteric reinnervation are unknown, though the parallel innervation of the masseter muscle upon smiling that is seen in about two thirds of the population or alternatively, a degree of cortical plasticity that develops following a program of biofeedback exercises have been proposed19,20. Further research is needed to specify the determinants of achieving a spontaneous smile in the future in order to provide the patient with an individualized treatment plan.We believe that once clear predictions can be made on whether the patient will achieve a spontaneous smile with this single stage procedure we might see a change in paradigm regarding reanimation of the face as in these patients a masseteric nerve coaptation could be preferable to a CFNG coaptation.
Crucial to success is the surgery of the recipient vessels and nerve, as well as the meticulous preparation of the gracilis muscle. Even though most plastic surgeons should be familiar with the raising of the gracilis muscle as a free flap the situation in this context is more demanding. The segmental harvest of the muscle is challenging, as the neural supply has to be maintained. When separating the muscle segment the usefulness of a neural stimulator cannot be emphasized enough. The repetitive control during dissection that the harvested segment still responds by contraction to stimulation of the neural pedicle ensures that no intramuscular branches have been dissected. If unexpectedly the gracilis muscle cannot be harvested or does not seem to be suitable for free flap transfer the adductor magnus muscle can be raised instead as a salvage procedure21.If patients cannot or do not want to undergo microsurgical reconstruction, we usually choose local muscle transfers that can achieve good outcomes but are generally regarded as second choice to free flap transfers22. After microsurgical gracilis muscle transfer, we strongly recommend the use of an implantable doppler probe as this allows for a continuous monitoring of flap perfusion. Though controversy exists in the use implantable dopplers, our own data showed a revision success rate of 75 to 90% that proves that the system is efficient enough in daily use23.
In conclusion dynamic reanimation of the smile remains to be of one of most demanding areas in plastic surgery. Under the multitude of surgical techniques, we here describe pre- and postoperative workup of the single-stage reconstruction utilizing the motor nerve to the masseter and precisely elucidate every single surgical step. We emphasize the importance of a thorough pre-operative patient counseling, as this will significantly affect patient satisfaction. We illustrate the atraumatic preparation of facial vessels and the masseter nerve in a step-by-step fashion. The elevation of the gracilis flap should be a standard procedure to every plastic surgeon. For functional muscle transfer however, there are certain features to be considered in order to gain ideal functional flap dimensions. Finally, we emphasize the importance of flap positioning and application of initial tension for achieving a natural symmetrical smile.

El nervio facial está implicado en la protección ocular, la articulación, la continencia oral y afecta en gran medida el aspecto estético de la cara. Por lo tanto, Deterioro de este nervio se asocia con una morbilidad significativa y retraimiento social. A pesar de los importantes avances en la terapia, la multitud de problemas asociados con la cara paralizada sólo puede ser dirigido con un amplio espectro de procedimientos adicionales. Común a todas las técnicas quirúrgicas es la necesidad de un conocimiento anatómico exacta. Anatomía del nervio facial El nervio facial consiste en un componente motor branquial para el control voluntario del motor de la musculatura facial y un componente motor visceral para el control parasimpático de lagrimal, submandibular y las glándulas sublinguales. Además, hay dos componentes sensoriales para la inervación del canal auditivo externo y para el sabor en el anterior dos tercio de la lengua. El trayecto del nervio facial puede be subdivide en tres segmentos: intracraneal, intratemporal y extratemporal. En el segmento intracraneal, el grupo superior de las neuronas que inervan el músculo frontal y la región periauricular recibe la entrada cortical bilateral. Las neuronas que inervan los músculos faciales restantes reciben de entrada cortical contralateral exclusivamente. Como consecuencia de ello, la función frontalis se mantiene en las lesiones supranuclear ipsilaterales. El segmento intratemporal puede ser dividida en tres segmentos. En el segmento laberíntico, el nervio petroso mayor deja el tronco para abastecer a la glándula lagrimal con fibras parasimpáticas 1. En el segmento de mastoideo, el nervio delgado estribo corre al músculo corresponsal. Ramas parasimpáticas inervan la submandibular, sublingual y anterior glándulas linguales, mientras que los dos tercios anteriores de la lengua se suministran con fibras gustativas (cuerda del tímpano). El tronco principal del nervio facial sale del canal óseoa través del foramen estilomastoideo. Este es el comienzo del segmento extratemporal, sin embargo arborización no se inicia antes de entrar en la glándula parótida. El nervio se divide primero en 3 a 4 divisiones de motor que forman el plexo intraparotídea y finalmente dan lugar a lo temporal, cigomático, bucal, mandibular y ramas cervicales 2. El diagnóstico diferencial de la parálisis facial Como etiología de la parálisis facial es amplio y difícil de clasificar, la división que se ve afectada debe considerarse en primer lugar. Parálisis facial intracraneal puede ser causada por infartos o tumores de la cavidad intracraneal lacunares. Las infecciones bacterianas y virales, colesteatoma y la parálisis de Bell pueden ser razones de daño nervioso intratemporal. Malignidades neoplásicos y terapia quirúrgica asociada son las causas dominantes para la parálisis facial extratemporal. Aunque la parálisis de Bell representa el diagnóstico más comúnen pacientes con parálisis facial, la mayoría de los pacientes se recuperan completamente sin secuelas y no necesitan cirugía 3. La segunda causa más frecuente de parálisis facial es un trauma. Aquí, fracturas en el hueso temporal son el mecanismo predominante trauma 4. Tipos de tratamiento de la parálisis facial Existen numerosas opciones quirúrgicas para el tratamiento de la parálisis facial y que se pueden clasificar en reinervación, la reconstrucción estática y dinámica de reconstrucción. Típicamente, dos años son considerados como el tiempo desde la lesión en la que la función después de reinervación puede ser recuperado satisfactorio con reinnervating procedimientos 5. Más tarde, la denervación atrofia de los músculos faciales se opone a su utilidad para su posterior reconstrucción. Reinervación se puede obtener la reparación primaria del nervio, injertos de nervios interposicionales, injerto de nervio transversal facial o la transferencia del nervio craneal. Técnicas de reconstrucción estáticas son dirigidos a corregirdiscapacidades funcionales, (protección de la córnea, la mejora del flujo de aire nasal, y la prevención de babeo) y para mejorar la simetría en reposo. Los procedimientos típicos son levantamiento de cejas para ptosis de la ceja, o cantoplastia por menor ectropión tapa. Reconstrucción estática se prefiere en pacientes ancianos con comorbilidades importantes o en los defectos faciales masivas secundarias a traumatismos o la resección del cáncer. Las técnicas quirúrgicas de reconstrucción dinámica se pueden subdividir en transferencia muscular regional y transferencia muscular microneurovascular libre, ya sea con la coaptación de la rama motora masetero o injerto de nervio transversal facial. Este último representa el criterio estándar para la reconstrucción de la sonrisa en la parálisis facial, como ninguna otra opción de tratamiento se consigue de forma fiable una sonrisa espontánea que es crucial para mejorar la desventaja social. Coaptación de la rama motora masetero es la modalidad de tratamiento de elección para pacientes con parálisis bilateral, sin embargo indicaciones tienen extterminaron, ya que los pacientes ancianos o pacientes con comorbilidades significativas por lo general prefieren un procedimiento de una sola etapa 6. Colgajo gracilis Anatomía regional Este músculo es un músculo más superficial de la parte media del muslo, lo que representa el músculo más largo de los músculos aductores. Tiene su origen en la sínfisis inferior y la rama inferior del pubis. Correr distalmente, el músculo se estrecha y se inserta distal a la articulación de la rodilla sobre la tibia que permite no sólo la aducción del muslo sino también la flexión de la rodilla. El músculo gracilis tiene un patrón circulatorio tipo II después de Mathes y Nahai con un aporte arterial de un dominante y algunos pedículos vasculares menores 7. La arteria dominante sale del músculo en el hilio a supuesto lateralmente y generalmente termina en la arteria circunfleja medial. En raras ocasiones, la arteria dominante termina directamente en la arteria femoral profunda. Suministro venosa de la graCilis muscular se consigue normalmente a través de dos venas satélites, que por supuesto la profundidad del músculo aductor largo de seguir la arteria dominante. Inervación del músculo se logra a través de una rama anterior del nervio obturador que entra en el músculo de 1-2 cm por arriba al hilio. El uso clínico El músculo gracilis es una valiosa muscular donante para la microcirugía reconstructiva y se ha convertido en el músculo de elección para muchos cirujanos para transferencia muscular libre funcional. Esto se debe al hecho de que hay poca morbilidad del sitio donante y la solapa muestra proporciones óptimas con respecto a la excursión del músculo y las dimensiones del pedículo vascular respectivamente. Un largo nervio motor inervado solo alivia colgajo funcional 8. Nosotros demostramos aquí el caso de una mujer de 49 años, quien presentó inicialmente con una imagen completa de la parálisis facial periférica izquierda después de la resección de un acústiconeuroma (schwannoma vestibular) 2 años antes. El paciente fue más afectado por la asimetría facial, especialmente cuando sonríe. Otras comorbilidades preexistentes no se documentaron. Tras el examen clínico, el paciente mostró una paresia completa del músculo frontalis, sin embargo una simetría frente satisfactoria en reposo. Cierre de la tapa era insuficiente a la izquierda con un lagoftalmos de 5 mm y el fenómeno de Bell. Los signos de irritación córnea y ectropión estaban ausentes. En reposo, el paciente mostró una asimetría moderada de la esquina de la boca con una distancia trago-modiolo de 11 cm a la derecha y 11,5 cm a la izquierda en reposo. Tras la sonrisa, la distancia trago-modiolo reducido a 9 cm de la derecha y alargada de la izquierda para 12 cm. Después de un extenso asesoramiento, la paciente deseaba una sola etapas de reconstrucción dinámica de la sonrisa con una transferencia gracilis funcional gratis con el masetero como nervio donante. El paciente también se le informó sobre varios techniques de la reconstrucción cierre de la tapa, sin embargo disminuyeron tratamiento quirúrgico en esta etapa. El curso del tratamiento fue sin complicaciones. Los signos de reinervación se observaron tres primeros meses de la cirugía. Cuatro meses después de la cirugía, el paciente presentó con una cicatrización sin complicaciones a lo largo de la antigua línea de incisión cirugía estética modificada. Simetría en reposo y deliberada sonriendo eran excelentes, con una definición satisfactoria del pliegue nasolabial. El paciente también mostró una sonrisa completamente espontánea. Rango pre y postoperatorio de 9 meses de excursión de la comisura de la boca fue documentado por videografía.

<table><tbody><tr><td>Nylon Suture, 9-0</td><td>Serag Weissner</td><td>Z0039490</td><td>&amp;deg;</td></tr><tr><td>Polypropylene Suture&amp;nbsp;</td><td>Ethicon</td><td>-</td><td>Multiple thread sizes</td></tr><tr><td>Suprarenin 1mg/ml</td><td>Sanofi</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Cook-Swartz Doppler Probe</td><td>Cook Medical</td><td>G03014</td><td>&amp;deg;</td></tr><tr><td>DP-M350 Blood Flow Monitor</td><td>Cook Medical</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Surgical Microscope OPMI Vario</td><td>Carl Zeiss</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Microsurgical instruments lab set</td><td>S&amp;amp;T</td><td>767</td><td>&amp;deg;</td></tr><tr><td>Biemer vessel clip</td><td>Diener</td><td>64,562</td><td>&amp;deg;</td></tr><tr><td>Applying forceps</td><td>Diener</td><td>64,568</td><td>for Biemer vessel clip</td></tr><tr><td>Cefuroxim 1500mg</td><td>Fresenius</td><td>J01DC02</td><td>&amp;deg;</td></tr><tr><td>Braunoderm</td><td>Braun Melsungen</td><td>3881105</td><td>&amp;deg;</td></tr><tr><td>Octenisept</td><td>Schuelke &amp;amp; Mayr</td><td>5702764</td><td>&amp;deg;</td></tr><tr><td>ISIS Neuromonitoring System</td><td>Inomed</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Tissucol</td><td>Baxter</td><td>1.33052E+12</td><td>Fibrin glue</td></tr><tr><td>Jackson-Pratt Wound Drainage</td><td>Medline</td><td>SU130-1060</td><td></td></tr><tr><td>Myacyne Ointment</td><td>Schur Pharma</td><td>-</td><td></td></tr></tbody></table>

single-stage dynamic reanimation of the smile in irreversible facial paralysis by free functional muscle transfer

Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic facial paralysis (Bell&#8217;s palsy) is the most common diagnosis, patients can also present with a history of physical trauma, infectious disease, tumor, or iatrogenic facial paralysis. Early repair within one year of injury can be achieved by direct nerve repair, cross-face nerve grafting or regional nerve transfer. It is due to muscle atrophy that in long lasting facial paralysis complex reconstructive methods have to be applied. Instead of one single procedure, different surgical approaches have to be considered to alleviate the various components of the paralysis.
The reconstruction of a spontaneous dynamic smile with a symmetric resting tone is a crucial factor to overcome the functional deficits and the social handicap that are associated with facial paralysis. Although numerous surgical techniques have been described, a two-stage approach with an initial cross-facial nerve grafting followed by a free functional muscle transfer is most frequently applied. In selected patients however, a single-stage reconstruction using the motor nerve to the masseter as donor nerve is superior to a two-stage repair. The gracilis muscle is most commonly used for reconstruction, as it presents with a constant anatomy, a simple dissection and minimal donor site morbidity.
Here we demonstrate the pre-operative work-up, the post-operative management, and precisely describe the surgical procedure of single-stage microsurgical reconstruction of the smile by free functional gracilis muscle transfer in a step by step protocol. We further illustrate common pitfalls and provide useful tips which should enable the reader to truly comprehend the procedure. We further discuss indications and limitations of the technique and demonstrate representative results.

<html> El uso del nervio maseterina para la reinervación del injerto muscular se evaluó en 5 pacientes (Tabla 1). Entre ellos, la resección neuroma acústico fue la principal causa de la parálisis facial. 3 candidatos prefieren el procedimiento de una sola etapa en lugar del enfoque de dos etapas &quot;estándar de oro&quot;. En dos pacientes, el procedimiento sirvió como un procedimiento de rescate después de la estimulación insuficiente por el injerto de nervio transversal facial (CFNG). Reinervación del colgajo gracilis después de la reparación de una sola etapa fue detectable en los 3 meses. Excursión Oral comisura fue satisfactoria en todos los pacientes (Figura 1) sin embargo una sonrisa espontánea sólo se podría lograr en un paciente y de vez en cuando en dos pacientes. Adelgazamiento secundaria de la aleta era necesario en tres pacientes. Los resultados representativos se muestran en el video. <img alt="&lt;/ Html">&quot;Figura 1&quot; src = &quot;/ files / ftp_upload / 52386 / 52386fig1.jpg&quot; /&gt; Figura 1: valores de evaluación. Post-operatorio de la distancia entre el trago y la comisura oral (TC) en reposo y bajo excursión máxima de la comisura oral son en% del lado sano en reposo (n = 5). El uso del nervio maseterina para la reinervación del injerto muscular proporciona un fuerte excursión de la comisura oral con un resultado simétrica cuando se compara con el lado sano (ns = no significativo). <img alt="Tabla 1" src="/files/ftp_upload/52386/52386table1.jpg" /> Tabla 1: Datos demográficos del paciente.

Watch this Scientific Journal Video about Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer at JoVE.com

Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer

The use of the masseteric nerve as donor nerve represents a single-stage alternative to the criterion standard two-stage procedure of cross-facial nerve grafting and free muscle transfer in facial paralysis. We provide a detailed description to safely perform this technique with a gracilis muscle transfer and discuss indications and limitations.

De una etapa dinámica Reanimación de la Sonrisa en Irreversible Parálisis facial por Free transferencia muscular funcional

Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic ...

single-stage-dynamic-reanimation-smile-irreversible-facial-paralysis

Universidad San Sebastian

Research

JoVE Journal

Medicine

105.8K vistas.  University of Freiburg Medical Centre. The use of the masseteric nerve as donor nerve represents a single-stage alternative to the criterion standard two-stage procedure of cross-facial nerve grafting and free muscle transfer in facial paralysis. We provide a detailed description to safely perform this technique with a gracilis muscle transfer and discuss indications and limitations.

Video: Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer

In Vivo Canine Muscle Function Assay

We describe a minimally-invasive and reproducible method to measure canine pelvic limb muscle strength and muscle response to repeated eccentric 
contractions. The pelvic limb of an anesthetized dog is immobilized in a stereotactic frame to align the tibia at a right angle to the femur. Adhesive wrap affixes the 
paw to a pedal mounted on the shaft of a servomotor to measure torque. Percutaneous nerve stimulation activates pelvic limb muscles of the paw to either push (extend) or 
pull (flex) against the pedal to generate isometric torque. Percutaneous tibial nerve stimulation activates tibiotarsal extensor muscles. Repeated eccentric (lengthening) 
contractions are induced in the tibiotarsal flexor muscles by percutaneous peroneal nerve stimulation. The eccentric protocol consists of an initial isometric contraction 
followed by a forced stretch imposed by the servomotor. The rotation effectively lengthens the muscle while it contracts, e.g., an eccentric contraction. During 
stimulation flexor muscles are subjected to an 800 msec isometric and 200 msec eccentric contraction. This procedure is repeated every 5 sec. To avoid fatigue, 4 min rest 
follows every 10 contractions with a total of 30 contractions performed.

In Vivo Canine Muscle Function Assay

We describe a minimally-invasive and painless method to measure canine hindlimb muscle strength and muscle response to repeated eccentric contractions.

Ensayo in vivo del canino función muscular

We describe a minimally-invasive and reproducible method to measure canine pelvic limb muscle strength and muscle response to repeated eccentric 
...

Investigación

Medicina

The Use of Primary Human Fibroblasts for Monitoring Mitochondrial Phenotypes in the Field of Parkinson's Disease

Parkinson's disease (PD) is the second most common movement disorder and affects 1% of people over the age of 60 1. Because ageing is the most important risk factor, cases of PD will increase during the next decades 2. Next to pathological protein folding and impaired protein degradation pathways, alterations of mitochondrial function and morphology were pointed out as further hallmark of neurodegeneration in PD 3-11.
After years of research in murine and human cancer cells as in vitro models to dissect molecular pathways of Parkinsonism, the use of human fibroblasts from patients and appropriate controls as ex vivo models has become a valuable research tool, if potential caveats are considered. Other than immortalized, rather artificial cell models, primary fibroblasts from patients carrying disease-associated mutations apparently reflect important pathological features of the human disease.
Here we delineate the procedure of taking skin biopsies, culturing human fibroblasts and using detailed protocols for essential microscopic techniques to define mitochondrial phenotypes. These were used to investigate different features associated with PD that are relevant to mitochondrial function and dynamics. Ex vivo, mitochondria can be analyzed in terms of their function, morphology, colocalization with lysosomes (the organelles degrading dysfunctional mitochondria) and degradation via the lysosomal pathway. These phenotypes are highly relevant for the identification of early signs of PD and may precede clinical motor symptoms in human disease-gene carriers. Hence, the assays presented here can be utilized as valuable tools to identify pathological features of neurodegeneration and help to define new therapeutic strategies in PD.

Fibroblasts from patients carrying mutations in Parkinson's disease-causing genes represent an easily accessible ex vivo model to study disease-associated phenotypes. Live cell imaging gives the opportunity to study morphological and functional parameters in living cells. Here we describe the preparation of human fibroblasts and subsequent monitoring of mitochondrial phenotypes.

El uso de fibroblastos humanos primarios para la Supervisión de fenotipos mitocondriales en el campo de la enfermedad de Parkinson

Parkinson's disease (PD) is the second most  common movement disorder and affects 1% of people over the age of 60 1. Because ageing is  the most important ...

Facial Nerve Surgery in the Rat Model to Study Axonal Inhibition and Regeneration

This protocol describes consistent and reproducible methods to study axonal regeneration and inhibition in a rat facial nerve injury model. The facial nerve can be manipulated along its entire length, from its intracranial segment to its extratemporal course. There are three primary types of nerve injury used for the experimental study of regenerative properties: nerve crush, transection, and nerve gap. The range of possible interventions is vast, including surgical manipulation of the nerve, delivery of neuroactive reagents or cells, and either central or end-organ manipulations. Advantages of this model for studying nerve regeneration include simplicity, reproducibility, interspecies consistency, reliable survival rates of the rat, and an increased anatomic size relative to murine models. Its limitations involve a more limited genetic manipulation versus the mouse model and the superlative regenerative capability of the rat, such that the facial nerve scientist must carefully assess time points for recovery and whether to translate results to higher animals and human studies. The rat model for facial nerve injury allows for functional, electrophysiological, and histomorphometric parameters for the interpretation and comparison of nerve regeneration. It thereby boasts tremendous potential toward furthering the understanding and treatment of the devastating consequences of facial nerve injury in human patients.

This protocol describes a reproducible approach to facial nerve surgery in the rat model, including descriptions of various inducible patterns of injury.

Cirugía de nervios faciales en el modelo de rata para estudiar la inhibición y regeneración axonal

This protocol describes consistent and reproducible methods to study axonal regeneration and inhibition in a rat facial nerve injury model. The facial ...

Neurociencias

An Implantable System For Chronic In Vivo Electromyography

Electromyography (EMG) measures the muscle response to electrical stimulation or spontaneous activity of motor units and plays an important role in assessing neuromuscular function. Chronic recording of EMG activity reflecting a muscle&#8217;s reinnervation status after nerve injury has been limited, due to the invasive nature of traditional EMG recording techniques. In this regard, an implantable system is designed for long-term, in vivo EMG recording and nerve stimulation. It has been applied and tested in a study on reinnervation of laryngeal muscles. This system consists of 1) two bipolar electrode nerve cuffs and leads for stimulating each of two nerves: the recurrent laryngeal nerve (RLN) and internal branch of the superior laryngeal nerve (SLN); 2) two EMG recording electrodes and leads for each of the two laryngeal muscles: posterior cricoarytenoid (PCA) muscle and thyroarytenoid-lateral cricoarytenoid (TA-LCA) muscle complex; and 3) a skin receptacle interfacing all implanted lead terminals to an external recording preamplifier and stimulator using a connection cable. The wire leads are Teflon-coated, multi-filament, type 316 stainless steel. They are coiled and can stretch during body movement of the awake animal to prevent lead breakage and electrode migration. This system is implanted during an aseptic surgery. Afterwards, baseline EMG recordings are performed before the RLN is transected in the second surgery to study muscle reinnervation. Throughout the study, multiple physiological sessions are conducted in the anesthetized animal to obtain evoked and spontaneous EMG activity that reflects the reinnervation status of laryngeal muscles. The system is compact, free of infection over the course of the study, and highly durable. This implantable system can provide a reliable platform for research in which long-term recording or nerve stimulation is required in an anesthetized or freely moving animal.&#160;

Presented here is a protocol for the manufacturing of an implantable system for in vivo chronological recording of evoked and spontaneous electromyographic potentials. The system is applied to the investigation of reinnervation of laryngeal muscles following nerve injury. &#160;&#160;

Un sistema implantable para la electromiografía crónica in vivo

Electromyography (EMG) measures the muscle response to electrical stimulation or spontaneous activity of motor units and plays an important role in ...

Structured Motor Rehabilitation After Selective Nerve Transfers

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on the successful re-innervation of the targets in the periphery and on the motor re-learning process entailing cortical plasticity. While there is an increasing number of methods to improve rehabilitation, their routine implementation in a clinical setting remains a challenge due to their complexity and long duration. Therefore, recommendations for rehabilitation strategies are presented with the aim of guiding medical doctors and therapists through the long-lasting rehabilitation process and providing step-by-step instructions for supporting motor re-learning.
Directly after nerve transfer surgery, no motor function is present, and therapy should focus on promoting activity in the sensory-motor cortex areas of the paralyzed body part. After about two to six months (depending on the severity and modality of injury, the distance of nerve regeneration and many other factors), the first motor activity can be detected via electromyography (EMG). Within this phase of rehabilitation, multimodal feedback is used to re-learn the motor function. This is especially critical after nerve transfers, as muscle activation patterns change due to the altered neural connection. Finally, muscle strength should be sufficient to overcome gravity/resistance of antagonistic muscles and joint stiffness, and more functional tasks can be implemented in rehabilitation.

Here, we present a protocol for the motor rehabilitation of patients with severe nerve injuries and selective nerve transfer surgery. It aims at restoring the motor function proposing several stages in patient education, early-stage therapy after surgery and interventions for rehabilitation after successful re-innervation of the nerve&#8217;s target.

Rehabilitación del Motor Estructurado Después de Transferencias Selectivas de Nerve

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on ...

<meta charset="utf8"></head><body>Evaluación de biomateriales en lesiones craneofaciales de VML mediante un modelo de rata

Rodent Model of Masseter Volumetric Muscle Loss for Studying Bioengineering Materials

Craniofacial volumetric muscle loss (VML) injuries can occur as a result of severe trauma, surgical excision, inflammation, and congenital or other acquired conditions. Treatment of craniofacial VML involves surgical, functional muscle transfer. However, these procedures are unable to restore normal function, sensation, or expression, and more commonly, these conditions go untreated. Very little research has been conducted on skeletal muscle regeneration in animal models of craniofacial VML. This manuscript describes a rat model for the study of craniofacial VML injury and a protocol for the histological evaluation of biomaterials in the treatment of these injuries. Liquid hydrogel and freeze-dried scaffolds are applied at the time of surgical VML creation, and masseters are excised at terminal time points up to 12 weeks with high retention rates and negligible complications. Hematoxylin and eosin (HE), Masson's Trichrome, and immunohistochemical analysis are used to evaluate parameters of skeletal muscle regeneration as well as biocompatibility and immunomodulation. While we demonstrate the study of a hyaluronic-acid-based hydrogel, this model provides a means for evaluating subsequent iterations of materials in VML injuries.

<meta charset="utf8"></head><body>Modelo de roedores de pérdida muscular volumétrica de masetero para el estudio de materiales de bioingeniería

Here, we describe a protocol for the surgical creation of a volumetric muscle loss (VML) injury in the rat masseter, providing a reproducible and accessible model for the study of craniofacial muscle injuries and their treatment using biomaterials such as the novel hydrogel.

Modelo de roedores de pérdida muscular volumétrica de masetero para el estudio de materiales de bioingeniería

Craniofacial volumetric muscle loss (VML) injuries can occur as a result of severe trauma, surgical excision, inflammation, and congenital or other ...

Bioingeniería

Force Assessment of Rat Masseter Muscle After VML Injury

In Vivo Functional Assessment of Rat Masseter Muscle Following Surgical Creation of a Volumetric Muscle Loss (VML) Injury

Volumetric Muscle Loss (VML) is prevalent in civilian and military populations and represents a debilitating skeletal muscle injury surpassing the body&#39;s natural regenerative capacity. These injuries disrupt not only muscle fibers but also nerves, blood vessels, and the extracellular matrix, overwhelming the regenerative capacity of skeletal muscle and leading to severe fibrosis and permanent deficiencies in muscle structure and function. Current clinical management has many limitations, and thus, research is ongoing to develop more effective therapeutic approaches. Notably, however, much of the preclinical emphasis on VML injuries has focused on limb and trunk muscles, with limited investigation into craniofacial muscles. Differences in developmental biology and regenerative capacity between craniofacial and limb/trunk muscles may provide crucial insights that drive more injury-specific VML treatment options. Moreover, evaluation of functional recovery is critical to establishing therapeutic efficacy. In this regard, in vivo testing of muscle contraction with percutaneous nerve stimulation is a minimally invasive method that allows for repeated functional assessment over the course of a study - in the same animal. In light of these considerations, this paper describes a method for the in vivo assessment of muscle function in the rat masseter muscle before and after a VML injury. This protocol is the first published instance to detail the creation and functional evaluation of a biologically relevant craniofacial VML injury in the rat.

Volumetric muscle loss (VML) injuries exceed endogenous regenerative ability, resulting in permanent functional deficits. Current VML research primarily focuses on limb and trunk muscles. To extend mechanistic studies of VML to craniofacial muscles, this article describes an in vivo method for longitudinal assessment of masseter muscle function pre- and post-VML injury.

Volumetric Muscle Loss (VML) is prevalent in civilian and military populations and represents a debilitating skeletal muscle injury surpassing the ...

<meta charset="utf8"></head><body>Electroporación y lesión nerviosa en el músculo elevador del auris largo del ratón

Combined In Vivo Electroporation and Short&#45;Term Reinnervation of the Cranial Levator Auris Longus Skeletal Muscle

The neuromuscular junction (NMJ) is the peripheral synapse controlling the contraction of skeletal muscle fibers to allow the coordinated movement of many organisms. At the NMJ, a presynaptic motor axon terminal contacts a muscle postsynaptic domain and is covered by terminal Schwann cells. The integrity and function of the NMJ is compromised under several conditions, including aging, neuromuscular diseases, and traumatic injuries. To analyze the potential contribution of muscle-derived proteins to NMJ maintenance and regeneration, an in vivo gene transfer strategy has been combined with the denervation of the cranial levator auris longus (LAL) muscle after mechanical nerve injury. Previous findings showed that the forced expression of control fluorescent proteins does not alter NMJ organization or neurotransmission. This procedure aims to describe a detailed method of in vivo electroporation of the LAL muscle followed by transection or crushing of the specific branch of the facial nerve innervating cranial muscles, leading to NMJ denervation and reinnervation, respectively. The combination of these experimental strategies in the convenient LAL muscle constitutes an efficient method to study the potential contribution of muscle protein overexpression or silencing in the context of short-term NMJ reinnervation.

<meta charset="utf8"></head><body>Autor destacado: Roles regenerativos de las proteínas musculares en la unión neuromuscular después de una lesión nerviosa

Here, we present a protocol that combines in vivo electroporation and denervation of the cranial levator auris longus (LAL) muscle. This procedure enables the study of the potential role of muscle-derived proteins in the regeneration of the neuromuscular synapse.

Electroporación in vivo combinada y reinervación a corto plazo del músculo esquelético elevador del auris largo craneal

The neuromuscular junction (NMJ) is the peripheral synapse controlling the contraction of skeletal muscle fibers to allow the coordinated movement of many ...

De una etapa dinámica Reanimación de la Sonrisa en Irreversible Parálisis facial por Free transferencia muscular funcional

Resumen

Explorar más videos

Capítulos en este video

Ensayo in vivo del canino función muscular

El uso de fibroblastos humanos primarios para la Supervisión de fenotipos mitocondriales en el campo de la enfermedad de Parkinson

Cirugía de nervios faciales en el modelo de rata para estudiar la inhibición y regeneración axonal

Un sistema implantable para la electromiografía crónica in vivo

Rehabilitación del Motor Estructurado Después de Transferencias Selectivas de Nerve

Modelo de roedores de pérdida muscular volumétrica de masetero para el estudio de materiales de bioingeniería

Modelo de roedores de pérdida muscular volumétrica de masetero para el estudio de materiales de bioingeniería

Modelo de roedores de pérdida muscular volumétrica de masetero para el estudio de materiales de bioingeniería

In Vivo Functional Assessment of Rat Masseter Muscle Following Surgical Creation of a Volumetric Muscle Loss (VML) Injury

Electroporación in vivo combinada y reinervación a corto plazo del músculo esquelético elevador del auris largo craneal