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. 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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.

fasial sinir göz koruma, eklem, sözlü kontinans yer ve büyük ölçüde yüzün estetik görünümünü etkiler. Bu sinirin düşüklüğü dolayısıyla önemli morbidite ve sosyal geri çekilme ile ilişkilidir. Terapisinde önemli gelişmelere rağmen, felç yüzü ile ilişkili sorunların çok sayıda sadece ek prosedürler ile geniş hedeflenebilir. Tüm cerrahi tekniklere ortak tam bir anatomik bilgiye ihtiyaç vardır. Yüz sinir anatomisi fasial sinir yüz kaslarının istemli motor kontrol ve lacrimal, submandibüler parasempatik kontrolü için bir visseral motorlu bileşeni, ve dilaltı bezleri için bir brankial motorlu bileşen oluşur. Ayrıca, dış kulak kanalının innervasyonundan ve dilin ön iki üçte tadı için iki duyusal bileşenler vardır. fasial sinirin seyri olabilir bintrakranial, intratemporal, epilepsiye: e üç segmente bölünmüştür. Intrakranial segmentinde, frontal kas, kulak bölgesini innerve nöronların üst grup ikili kortikal girdi alır. Kalan yüz kasları innerve Nöronlar sadece kontralateral kortikal girdi alırsınız. Bunun bir sonucu olarak, frontal fonksiyon aynı taraf supranükleer lezyonlarında muhafaza edilmektedir. intratemporal segmenti daha üç segmente ayrılabilir. Labirentin segmentinde, daha Petrosal sinir lifleri parasempatik 1 ile lakrimal bezi tedarik gövde bırakır. Mastoid segmentinde, ince stapedius sinir muhabir kas çalışır. Parasempatik dalları submandibuler, dilaltı innerve ve dilin ön üçte ikisi tat liflerden (korda timpani) ile birlikte oysa, dilli bezleri ön. fasial sinirin ana kök kemik kanala çıkarStylomastoid foramenden. Bu ancak arborisation parotis bezi girmeden önce başlamaz, ekstratemporal segmentinin başlangıcı. Sinir ilk intraparotid pleksus oluşturur ve sonuçta zamansal, elmacık, yanak, mandibular ve servikal dalları 2 doğuran 3 ila 4 motorlu kısma bölünmüştür. Fasiyal paralizi ayırıcı tanısı Yüz felci nedenleri sınıflandırmak için geniş ve sert olduğu için, etkilenen bölümü ilk düşünülmelidir. İntrakraniyal yüz felci laküner infarktlar veya intrakranial kavite tümörleri neden olabilir. Bakteriyel ve viral enfeksiyonlar, kolesteatom ve Bell paralizisi intratemporal sinir hasarı nedenleri olabilir. Neoplastik kanserler ve ilişkili cerrahi tedavi ekstratemporal yüz felci için baskın nedenlerdir. Bell paralizisi en yaygın tanı temsil rağmenyüz felci olan hastalarda, hastaların çoğu sekel olmadan tamamen iyileşir ve ameliyat 3 gerekmez. yüz felci ikinci en yaygın nedeni travmadır. Burada, temporal kemik kırıkları için baskın travma mekanizması 4 vardır. Yüz felci tedavisi türleri Sayısız cerrahi seçenekler yüz felci tedavisi için var ve onlar reinnervation, statik ve dinamik yeniden yeniden sınıflandırılabilir. Tipik haliyle, iki yıl innervasyonun sonra işlev prosedürleri 5 reinnervating tatmin edici çıktı edilebildiği yaralanma zaman olarak kabul edilmiştir. Daha sonra, yüz kaslarının denervasyon atrofisi daha rekonstrüksiyon için faydalarını engellemektedir. Reinnervation primer sinir tamiri, interpozisyonel sinir grefti, çapraz-fasial sinir grefti veya kranial sinir transferi ile elde edilebilir. Statik rekonstrüksiyon teknikleri düzeltmek için yönlendirilirFonksiyonel engelli, (korneanın korunması, burun hava akımı iyileştirilmesi ve drooling önlenmesi) ve dinlenme simetriyi iyileştirmek için. Tipik prosedürler alt kapak ektropiyon için kaş pitozis veya canthoplasty için kaş kaldırma edilir. Statik rekonstrüksiyon önemli eşlik eden yaşlı hastalarda veya travma ya da kanser rezeksiyonu sekonder masif yüz kusurları tercih edilir. Dinamik yeniden cerrahi teknikler bölgesel kas transferi ve masseter motoru şube veya çapraz-fasiyal sinir grefti ile coaptation ya ücretsiz microneurovascular kas transferi bölünmüştür olabilir. Başka bir tedavi seçeneği güvenilir sosyal handikap geliştirmek için çok önemlidir kendiliğinden bir gülümseme elde gibi ikinci, yüz felci içinde gülümseme yeniden inşası için kriter standardını temsil eder. Masseter Motor dalına Coaptation göstergeleri ext var ancak ikili paralizisi olan hastalarda tercih edilen tedavi yöntemidirönemli yandaş olan yaşlı hastalar veya hasta genellikle tek-aşamalı prosedür 6 tercih olarak, sona erdi. Gracilis flep Bölgesel anatomi Gracilis kas adduktor kas uzun kas temsil medial uyluk oldukça yüzeysel kas olduğunu. Bu alt simfizisin ve pubis alt ramusun kaynaklanır. Distale Koşu, kas daralır ve sadece uyluk adduksiyon değil, aynı zamanda diz fleksiyona izin veren tibia üzerinde diz eklemine uzak ekler. Gracilis kas baskın ve bazı küçük damar pediküller 7 den arteriyel kaynağı ile Mathes ve Nahai sonra bir tip II dolaşım modeli vardır. baskın arter medial sirkumfleks arterde sona erer genellikle yanal ders hilusta de kas çıkar ve. Nadiren, baskın arter derin femoral arter doğrudan sonlandırır. Gra Venöz kaynağıcilis kas genellikle baskın arter takip o dersi derin adduktor longus kas, iki venae comitantes yoluyla elde edilir. Kas innervasyonu hilusta 1-2 cm superiorda kas girer obturator sinirin anterior dalı ile elde edilir. Klinik kullanımı Gracilis kas rekonstrüktif mikrocerrahi için değerli bir donör kas ve işlevsel ücretsiz kas transferi için birçok cerrah için tercih kas haline gelmiştir. Bu çok az donör sitesi morbidite ve flep kasının gezi ve sırasıyla damar pedikül boyutları açısından optimal oranlarda gösteriyor ki aslında borçlu olduğunu. Uzun tek innervasyonlu motor sinir fonksiyonel flep hasat 8 hafifletir. Biz burada bir akustik rezeksiyonu aşağıdaki başlangıçta sol periferik yüz felci tam bir resim ile sunulan bir 49 yaşındaki kadın, olgu göstermektedir2 yıl önce nöroma (vestibüler schwannoma). Hasta en gülümseyen özellikle fasiyal asimetri, tarafından tutulmuş oldu. Diğer önceden varolan eştanılarının belgelenmiş değil. Klinik muayene sırasında hasta frontal kas tam bir parezi, istirahatte ancak tatmin edici bir alın simetri gösterdi. Kapak kapatma 5 mm ve Bell fenomeni bir Lagoftalmi ile solda yetersiz oldu. Kornea tahriş ve ektropiyonun belirtileri yoktu. Geri kalanı, hasta sağda 11 cm ve dinlenme solda 11.5 cm tragus-modiolus mesafe ile ağız köşesinde bir orta asimetri gösterdi. Gülümseyen üzerine, tragus-modiolus mesafesi sağda 9 cm küçülttüm ve 12 cm soldaki uzatılmış. Kapsamlı danışmanlık sonra, hasta donör sinir olarak masseter kullanarak ücretsiz fonksiyonel grasilis transferi ile gülümseme bir tek aşamalı dinamik yeniden diledi. Hasta ayrıca çeşitli te haberdar edildikapağın kapanma rekonstrüksiyon chniques Ancak bu aşamada cerrahi tedavi azalmıştır. Tedavi süresi komplike oldu. Innervasyonun İşaretler ilk postoperatif üç aylık fark edildi. Dört ay ameliyat sonrası, hastanın eski modifiye facelift kesi hattı boyunca özellik yara izi ile başvurdu. Istirahatte Simetri ve gülümseyerek kasıtlı nazolabial kırışık tatmin edici bir tanımı ile mükemmel. Hasta aynı zamanda, tamamen kendiliğinden gülümseme göstermiştir. Ağız köşesinde gezi öncesi ve 9 aylık postoperatif aralığı videografi tarafından belgelenmiştir.

<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> kas greft innervasyonun için masseterik sinir kullanımı 5 hastada (Tablo 1) değerlendirildi. Bunlar arasında, akustik nöroma rezeksiyonu yüz felci için ana nedeni oldu. 3 aday, tek aşamalı prosedür yerine &quot;altın standart&quot; iki aşamalı bir yaklaşım tercih. İki hastada, prosedür çapraz-fasiyal sinir grefti (CFNG) tarafından yetersiz uyarılması sonra kurtarma prosedürü olarak görev yaptı. Tek aşamalı onarımı sonrası gracilis flep reinnervation 3 ay içinde saptanabilir. Sözlü komissür gezi tüm hastalarda (Şekil 1) ancak spontan bir gülümseme yalnızca bir hastada elde edilebilir ve bazen iki hastada tatmin edici oldu. Flep İkincil incelme üç hastada gerekli oldu. Temsilcisi sonuçları video içinde gösterilmiştir. <img alt="&lt;/ Html">&quot;Şekil 1&quot; src = &quot;/ files / ftp_upload / 52.386 / 52386fig1.jpg&quot; /&gt; Şekil 1:. Tragus ve istirahat ve sözlü komissürün maksimum gezi kapsamında sözlü komissür (TC) arasındaki mesafenin Post-operatif değerlendirme Değerler geri kalanı sağlıklı tarafının% (n = 5) vardır. Sağlıklı tarafı (ns = anlamlı) göre kas greft reinnervation için masseterik sinir kullanımı simetrik sonuç oral komissür güçlü bir gezi sağlar. <img alt="Tablo 1" src="/files/ftp_upload/52386/52386table1.jpg" /> Tablo 1: Hastaların demografik.

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.

Ücretsiz Fonksiyonel kas transferi ile geri dönüşümsüz Yüz felci içinde Smile Tek aşamalı Dinamik Reanimasyon

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 Görüntüleme.  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.

Vivo Köpek Kas Fonksiyon Testi

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

Tıp

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.

Parkinson Hastalığı Alanında Mitokondriyal Fenotiplerinin İzleme İlköğretim İnsan Fibroblast Kullanımı

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.

Aksonal İnhibisyon ve Rejenerasyon Çalışması için Sıçan Modelinde Yüz Sinir Cerrahisi

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

Nörobilim

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;

Vivo Elektromiyografide Kronik İçin İmplante Edilebilir Bir Sistem

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.

Selektif Sinir Transferleri Sonrası Yapılandırılmış Motor Rehabilitasyon

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>Kraniyofasiyal VML Yaralanmasında Biyomalzemelerin Sıçan Modeli Kullanılarak Değerlendirilmesi

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>Biyomühendislik Materyallerini İncelemek İçin Masseter Hacimsel Kas Kaybının Kemirgen Modeli

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.

Biyomühendislik Materyallerini İncelemek İçin Masseter Hacimsel Kas Kaybının Kemirgen Modeli

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

Biyomühendislik

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>Fare Levator Auris Longus Kasında Elektroporasyon ve Sinir Hasarı

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>Yazar Spotlight: Sinir Yaralanması Sonrası Nöromüsküler Kavşakta Kas Proteinlerinin Rejeneratif Rolleri

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.

Kranial Levator Auris Longus İskelet Kasının Kombine İn Vivo Elektroporasyonu ve Kısa Süreli Reinnervasyonu

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

Ücretsiz Fonksiyonel kas transferi ile geri dönüşümsüz Yüz felci içinde Smile Tek aşamalı Dinamik Reanimasyon

Özet

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Vivo Köpek Kas Fonksiyon Testi

Parkinson Hastalığı Alanında Mitokondriyal Fenotiplerinin İzleme İlköğretim İnsan Fibroblast Kullanımı

Aksonal İnhibisyon ve Rejenerasyon Çalışması için Sıçan Modelinde Yüz Sinir Cerrahisi

Vivo Elektromiyografide Kronik İçin İmplante Edilebilir Bir Sistem

Selektif Sinir Transferleri Sonrası Yapılandırılmış Motor Rehabilitasyon

Biyomühendislik Materyallerini İncelemek İçin Masseter Hacimsel Kas Kaybının Kemirgen Modeli

Biyomühendislik Materyallerini İncelemek İçin Masseter Hacimsel Kas Kaybının Kemirgen Modeli

Biyomühendislik Materyallerini İncelemek İçin Masseter Hacimsel Kas Kaybının Kemirgen Modeli

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

Kranial Levator Auris Longus İskelet Kasının Kombine İn Vivo Elektroporasyonu ve Kısa Süreli Reinnervasyonu