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.

Il nervo facciale è coinvolta nella protezione oculare, articolazione, la continenza orale e influisce notevolmente l&#39;aspetto estetico del viso. Perdite di valore di questo nervo è quindi associata a significativa morbidità e ritiro sociale. Nonostante i significativi progressi nella terapia, la moltitudine di problemi connessi con la faccia paralizzata può essere mirata solo con un ampio spettro di ulteriori procedure. Comune a tutte le tecniche chirurgiche è la necessità di una conoscenza anatomica esatta. Anatomia del nervo facciale Il nervo facciale è costituito da un componente per il controllo del motore branchial motoria volontaria della muscolatura facciale e un componente motoria viscerale per il controllo del parasimpatico lacrimale, sottomandibolare, e ghiandole sublinguali. Inoltre, ci sono due componenti sensoriali per l&#39;innervazione del canale uditivo esterno e per il gusto nel anterior due terzi della lingua. Il corso del nervo facciale può be suddiviso in tre segmenti: intracranica, intratemporal, e extratemporale. Nel segmento intracranica, il gruppo superiore di neuroni che innervano il muscolo frontale e la regione periauricular riceve l&#39;input corticale bilaterale. I neuroni che innervano i restanti muscoli facciali ricevono input corticale controlaterale esclusivamente. Di conseguenza, la funzione frontalis viene mantenuta nelle lesioni sopranucleare omolaterale. Il segmento intratemporal può essere ulteriormente suddivisa in tre segmenti. Nel segmento labirintico, nervo grande petrosal lascia il tronco di fornire ghiandola lacrimale con fibre parasimpatiche 1. Nel segmento mastoide, il sottile stapedio nervo corre al muscolo corrispondente. Rami parasimpatico innervano la sottomandibolare, sublinguale e anteriore ghiandole linguali, mentre i due terzi anteriori della lingua sono forniti con fibre gustative (corda del timpano). Il fusto principale del nervo facciale esce dal canale osseoattraverso il forame stylomastoid. Questo è l&#39;inizio del segmento extratemporale, tuttavia arborisation non inizia prima di entrare nella ghiandola parotide. Il nervo viene prima diviso in 3 o 4 divisioni motore che formano il plesso intraparotid e, infine, danno origine al temporale, zigomatica, buccale, mandibolare e rami cervicali 2. La diagnosi differenziale di paralisi facciale Come eziologia della paralisi facciale è ampio e difficile da classificare, la divisione che è interessata deve essere considerata prima. Intracranica paralisi facciale può essere causato da infarti lacunari o tumori della cavità endocranica. Infezioni batteriche e virali, colesteatoma e paralisi di Bell possono essere motivi per danni ai nervi intratemporal. Neoplasie neoplastiche e terapia chirurgica associata sono le cause dominanti per extratemporale paralisi facciale. Sebbene paralisi di Bell rappresenta la più comune diagnosiin pazienti con paralisi facciale, la maggior parte dei pazienti guarisce completamente senza conseguenze e non hanno bisogno di un intervento chirurgico 3. La seconda causa più comune di paralisi facciale è un trauma. Qui, fratture dell&#39;osso temporale sono il meccanismo trauma predominante 4. Tipi di trattamento di paralisi facciale Esistono numerose opzioni chirurgiche per il trattamento della paralisi facciale e possono essere classificati in reinnervazione, ricostruzione statica e ricostruzione dinamica. In genere, a due anni sono considerati il tempo da un infortunio in cui la funzione dopo reinnervazione può essere recuperato soddisfacente con reinnervating procedure 5. Più tardi, denervazione atrofia dei muscoli facciali preclude la loro utilità per l&#39;ulteriore ricostruzione. Reinnervazione può essere ottenuto mediante riparazione primaria del nervo, innesti nervosi interposizione, cross-facciale innesto nervo o trasferimento nervo cranico. Tecniche di ricostruzione statiche sono diretti a correggeredisabilità funzionali, (protezione della cornea, il miglioramento del flusso d&#39;aria nasale, e la prevenzione di sbavando) e di migliorare la simmetria a riposo. Procedure tipiche sono browlift per sopracciglio ptosi, o cantoplastica per minori ectropion coperchio. Ricostruzione statica è preferito nei pazienti anziani con comorbidità significative o in enormi difetti del viso secondarie a traumi o la resezione del cancro. Le tecniche chirurgiche di ricostruzione dinamica possono essere suddivisi in trasferimento muscolo regionale e il trasferimento del muscolo microneurovascular gratuito con o coaptazione al ramo del motore massetere o cross-facciale innesto del nervo. Quest&#39;ultimo rappresenta il criterio standard per la ricostruzione del sorriso in paralisi facciale, come nessun altra opzione di trattamento raggiunge in modo affidabile un sorriso spontaneo che è fondamentale migliorare handicap sociale. Coaptazione al ramo del motore massetere è la modalità di trattamento di scelta per i pazienti con paralisi bilaterale, ma le indicazioni sono extchiuso, come i pazienti anziani o pazienti con comorbidità significative di solito preferiscono una procedura in un&#39;unica fase 6. Gracilis lembo Anatomia regionale Il muscolo gracile è un muscolo piuttosto superficiale della coscia mediale, che rappresenta la più lunga muscolare dei muscoli adduttori. Nasce dal sinfisi inferiore e il ramo inferiore del pube. Esecuzione distalmente, il muscolo si restringe e inserisce distale all&#39;articolazione del ginocchio sulla tibia che consente non solo di adduzione della coscia, ma anche la flessione del ginocchio. Il muscolo gracile ha un modello circolatorio di tipo II dopo Mathes e Nahai con una fornitura arteriosa da un dominante e alcuni peduncoli vascolari minori 7. L&#39;arteria dominante esce il muscolo al ilo di corso lateralmente e di solito termina con l&#39;arteria circonflessa mediale. Raramente, l&#39;arteria dominante termina direttamente nel profondo dell&#39;arteria femorale. Fornitura venosa del gracilis muscolare è di solito realizzato attraverso due comitantes vene, che naturalmente profondo al muscolo adduttore lungo a seguire l&#39;arteria dominante. Innervazione del muscolo è ottenuta attraverso un ramo anteriore del nervo otturatore che entra nel muscolo 1-2 cm superiormente alla ilo. Uso clinico Il muscolo gracile è un muscolo donatori prezioso per microchirurgia ricostruttiva ed è diventato il muscolo di scelta per molti chirurghi per il trasferimento funzionale del muscolo gratuito. Questo è dovuto al fatto che c&#39;è poco morbilità del sito donatore e il lembo mostra proporzioni ottimali per quanto riguarda escursione del muscolo e dimensioni peduncolo vascolare rispettivamente. Un lungo nervo unico motore innervata allevia lembo funzionale raccolto 8. Siamo qui dimostriamo il caso di una donna di 49 anni, che inizialmente ha presentato un quadro completo di sinistra paralisi facciale periferica dopo resezione di un acusticaneuroma (schwannoma vestibolare) 2 anni prima. Il paziente è stato più afflitto da asimmetria facciale, in particolare quando sorride. Altri comorbidità preesistenti non sono stati documentati. Dopo esame clinico, il paziente ha mostrato una completa paralisi del muscolo frontale, comunque una simmetria fronte soddisfacente a riposo. Chiusura coperchio era insufficiente a sinistra con un lagoftalmo di 5 mm e fenomeno di Bell. Segni di irritazione della cornea e ectropion erano assenti. A riposo, il paziente ha mostrato una moderata asimmetria di un angolo della bocca con una distanza trago-modiolus di 11 cm a destra e 11,5 centimetri a sinistra a riposo. Su sorridente, distanza trago-modiolus ridotta a 9 cm a destra e allungata a sinistra a 12 cm. Dopo ampia consulenza, il paziente ha voluto per un singolo-messa in scena la ricostruzione dinamica del sorriso, con un trasferimento gracile funzionale gratuitamente utilizzando il massetere come nervo donatore. Il paziente è stato inoltre informato vari terie di ricostruzione chiusura del coperchio, tuttavia diminuite trattamento chirurgico in questa fase. Il corso del trattamento è semplice. Segni di reinnervazione stati notati tre mesi dopo l&#39;intervento. Quattro mesi dopo l&#39;intervento, il paziente ha presentato con cicatrici insignificante lungo l&#39;ex linea lifting incisione modificata. Simmetria a riposo e deliberata sorridente erano eccellenti, con una definizione soddisfacente della piega naso-labiale. Il paziente ha anche mostrato un sorriso del tutto spontaneo. Pre- e 9 mesi gamma postoperatorio di escursione del angolo della bocca è stata documentata da videografia.

<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> L&#39;utilizzo del nervo masseterino per reinnervazione dell&#39;innesto muscolare è stata valutata in 5 pazienti (Tabella 1). Tra questi, la resezione neurinoma era la causa principale di paralisi facciale. 3 candidati preferito la procedura in un&#39;unica fase, piuttosto che l&#39;approccio in due fasi &quot;gold standard&quot;. In due pazienti, la procedura servito da una procedura di soccorso dopo la stimolazione insufficiente l&#39;innesto del nervo cross-facciale (CFNG). Reinnervazione del lembo gracile dopo la riparazione singolo stadio era rilevabile entro 3 mesi. Escursione commissura orale era soddisfacente in tutti i pazienti (Figura 1) tuttavia un sorriso spontanea potrebbe essere raggiunto solo in un paziente e, occasionalmente, in due pazienti. Assottigliamento secondario del lembo era necessario in tre pazienti. Risultati rappresentativi sono mostrati nel video. <img alt="&lt;/ Html">&quot;Figura 1&quot; src = &quot;/ files / ftp_upload / 52.386 / 52386fig1.jpg&quot; /&gt; Figura 1:. Valutazione postoperatoria della distanza tra il trago e commissura orale (TC) a riposo e sotto escursione massima della commissura orale valori sono in% del lato sano a riposo (n = 5). L&#39;utilizzo del nervo masseterino per reinnervazione dell&#39;innesto muscolare fornisce una forte escursione della commissura orale con un risultato simmetrica rispetto al lato sano (ns = non significativo). <img alt="Tabella 1" src="/files/ftp_upload/52386/52386table1.jpg" /> Tabella 1: dati demografici dei pazienti.

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.

Single-stage dinamico Rianimazione del Sorriso in Irreversible paralisi facciale da Free Transfer Muscle funzionale

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 Views.  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.

In Vivo saggio canina funzione muscolare

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

Ricerca

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.

L&#39;uso di fibroblasti umani primari per il monitoraggio fenotipi mitocondriali nel campo della malattia di 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.

Chirurgia del nervo facciale nel modello di ratto per studiare l'inibizione assonale e la rigenerazione

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

Neuroscienze

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 impiantabile per l'elettromiografia cronica 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.

Riabilitazione motoria strutturata dopo trasferimenti nervosi selettivi

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>Valutazione dei biomateriali nella lesione VML craniofacciale utilizzando un modello di ratto

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>Modello di roditore della perdita muscolare volumetrica del massetere per lo studio dei materiali di bioingegneria

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.

Modello di roditore della perdita muscolare volumetrica del massetere per lo studio dei materiali di bioingegneria

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

Bioingegneria

<meta charset="utf8"></head><body>Valutazione della forza del muscolo massetere di ratto dopo lesione VML

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.

<meta charset="utf8"></head><body>Valutazione funzionale in vivo del muscolo massetere del ratto dopo la creazione chirurgica di una lesione da perdita muscolare volumetrica (VML)

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.

Single-stage dinamico Rianimazione del Sorriso in Irreversible paralisi facciale da Free Transfer Muscle funzionale

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Esplora Altri Video

Capitoli in questo video

In Vivo saggio canina funzione muscolare

L'uso di fibroblasti umani primari per il monitoraggio fenotipi mitocondriali nel campo della malattia di Parkinson

Chirurgia del nervo facciale nel modello di ratto per studiare l'inibizione assonale e la rigenerazione

Un sistema impiantabile per l'elettromiografia cronica in vivo

Riabilitazione motoria strutturata dopo trasferimenti nervosi selettivi

Modello di roditore della perdita muscolare volumetrica del massetere per lo studio dei materiali di bioingegneria

Modello di roditore della perdita muscolare volumetrica del massetere per lo studio dei materiali di bioingegneria

Modello di roditore della perdita muscolare volumetrica del massetere per lo studio dei materiali di bioingegneria

Valutazione funzionale in vivo del muscolo massetere del ratto dopo la creazione chirurgica di una lesione da perdita muscolare volumetrica (VML)

Valutazione funzionale in vivo del muscolo massetere del ratto dopo la creazione chirurgica di una lesione da perdita muscolare volumetrica (VML)