Reanimation of the long-standing partial facial paralysis

Those unfortunate people who suffer from permanent partial facial paralysis have great difficulty finding surgeons who can offer corrective operations. Improving their function is a most delicate procedure. Great care must be exercised to avoid injuring nerves and muscles which are still operating, although in a greatly diminished state. The pathogenesis must be understood before attempting any corrective procedure. Adequate time must elapse from the moment of injury to surgical intervention, thus allowing for maximal nerve and muscle regeneration. This paper describes techniques that could improve facial movements. The most frequently used procedure is shortening of the levator and/or the zygomatic muscles that are partially atrophied. It must be understood that total reanimation is impossible as of this time.     

Victor von Bruns (1812-1883) and his contributions to plastic and reconstructive surgery

Victor von Bruns was an active surgeon in Germany during the nineteenth century. His work is accompanied by many illustrations, and a selected few are presented in this survey. His original contributions to plastic and reconstructive surgery are notable, mainly in lip and cheek reconstruction. These are still valid today and have been adopted by many plastic surgeons. His books dealt not only with plastic surgery, but with almost every surgical event, such as amputation, larynx surgery, galvanosurgery, and war surgery. His publications and illustrations give an excellent picture of the advances made by him and other plastic surgeons during the second half of the nineteenth century, thus making him an important contributor to the renaissance of plastic surgery.     

Ernst Blasius's contributions to plastic surgery

Blasius was a famous teacher and surgeon. Apart from his own writings on surgery and his new methods for reconstructions, such as the replacement of nose, lips, and eyelids, some theses were also inspired by him. His main work is his three-volume Handbuch der Akiurgie, to which he added an excellent atlas, from which a few illustrations are presented here. His books dealt not only with reconstructive problems, but also with almost every surgical event, e.g., amputations, laparotomy, dental extraction, and so on. Blasius's efforts were concerned with overcoming and preventing the worsening of the shape of newly reconstructed noses, lips, and eyelids due to secondarily healed scars, which was the common practice of the great surgeons of his time, such as von Graefe and Dieffenbach. Therefore, his efforts were toward the primary closure of wounds. In rhinoplasty, Blasius extended the forehead flap into three long points, and then extensions were made by infolding them. Furthermore, he mentioned the first use of a nasolabial flap to reconstruct the lower eyelid. Moreover, Blasius laid down basic principles in flap surgery, such as the V-Y plasty and probably the earliest record of the Z-plasty. His publications and illustrations give an excellent picture of the great advances made by him during the first half of the nineteenth century, thus making him an important contributor to the renaissance of plastic surgery.     

Hypoglossal-facial nerve anastomosis for reinnervation of the paralyzed face.

The hypoglossal-facial nerve crossover is a valuable surgical procedure for the treatment of certain types of facial paralysis. It is most effective when used as an integral part of a primary ablative operation for the treatment of cancer in this region. In the treatment of long-standing facial paralysis, its application requires an intact peripheral facial nerve system and some functioning mimetic muscles with an obliterated proximal facial nerve segment. It is recognized that other procedures are available for repair in patients who meet essentially these same criteria. The disadvantages are minimal intraoral crippling, mass movements of the face and, in some instances, hypertonia of the face. The advantages are improved facial tone, protection of the eye, intentional facial movements controlled by the tongue, and movements associated with physiological functions of the tongue.     

Decompression of the Facial Nerve—A Surgical Emergency

The chance of return of normal function in cases of facial paralysis is enhanced by early surgical decompression and repair of the facial nerve.Modern precision testing is of considerable aid in prognosis as well as diagnosis. Faradic testing and electromyography can offer relatively early information as to the possibility of permanent facial deformity. Now that microscopic surgical techniques have considerably facilitated operations on the facial nerve, early operation is the treatment of choice in such cases.     

Free proximal gracilis muscle and its skin paddle compound flap transplantation for complex facial paralysis

Gracilis functioning free-muscle transplantation for the correction of pure facial paralysis has been a preferred method used by many reconstructive microsurgeons. However, for complex facial paralysis, the deficits include facial paralysis along with soft-tissue, mucosa, and/or skin defects. No adequate solution has been proposed. Treatment requests in those patients are not only for facial reanimation but also for correction of the defects. Of 161 patients with facial paralysis treated with gracilis functioning free-muscle transplantation from 1986 to 2002, eight patients (5 percent) presented with complex deficits requiring not only facial reanimation but also aesthetic correction of tissue defects. The tissue defects included an intraoral defect created following contracture release (one patient), infra-auricular radiation dermatitis with contour depression (one patient), temporal depression following a temporalis muscle-fascia transfer (one patient), ear deformity (two patients), and infra-auricular atrophic tissue with contour depression (three patients). A compound flap, consisting of a gracilis muscle with its overlying skin paddle separated into two components, was transferred for simultaneous correction of both problems. The blood supply to the gracilis and to the skin paddle originated from the same source vessel and therefore required the anastomosis of only one set of vessels. The versatility of this compound flap allows for a wide arc of rotation of the skin paddle around the muscle. All flaps were transferred successfully without complications. Satisfactory results of facial reanimation were recorded in five patients after all stages were completed. The remaining three patients are undergoing physical therapy and waiting for revision of the skin paddle.     

Dynamic restoration in Möbius and Möbius-like patients

M?bius syndrome is classically characterized by bilateral facial nerve and abducens nerve paralysis in combination with limb defects. In the past 110 years, physicians diagnosed children as having the syndrome on the basis of heterogeneity of symptoms and used the term "M?bius syndrome" or "M?bius-like syndrome" for patients with multiple cranial nerve involvement. The cause and the exact pathogenesis of the syndrome still elude understanding. Genetic work-ups, radiological findings, and data from autopsies differ in their approaches and their findings of the basic causes of M?bius syndrome. In the international literature, about 301 case reports are found scattered through the past century. The appearance of the facial deformity is easy to recognize, because the M?bius patient is impaired in his or her ability to communicate nonverbally. Despite ophthalmologic problems, it is the search for a smile that brings these patients to the reconstructive surgeon. Over the past 100 years, surgical efforts attempted to improve the mask-like appearance by static and dynamic procedures, usually local muscle transpositions. Today, combinations of microsurgical procedures and aesthetic techniques are being used to restore some movement to the expressionless face of these patients by nerve and muscle transplantation. This article discusses the heterogeneity of M?bius syndrome, advocates a new classification system, presents the clinical findings of 42 patients who were seen and examined in consultation, and discusses the surgical management of 20 patients who underwent dynamic restorative microsurgery. Exemplary cases illustrating the preoperative work-up regimen and possible outcomes are reported.     

Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates

Surgeons have constantly sought to achieve the most aesthetic scar. A major factor determining the final cosmetic appearance of a cutaneous scar is the tension acting on the wound edges during the healing phase. Since Theodor Kocher pioneered the alignment of skin incisions with Langer's lines in 1892, surgical techniques that attempt to overcome closing tension have become standard. Yet, no treatment has been available to minimize underlying muscle contractions, which are the major cause of this tension. Botulinum toxin A is a potent drug that produces temporary muscular paralysis when injected locally. It has proven to be safe and effective in the treatment of a variety of disorders, including hyperkinetic facial lines. The objective of this randomized, double-blind, placebo-controlled primate study was to investigate the efficacy of a single injection of botulinum toxin A to improve the cosmetic appearance of cutaneous scars. Symmetric pairs of standardized excisions were performed on either side of the forehead of six primates. The half foreheads were randomized to the botulinum toxin A treatment side versus the placebo injection side. A panel of three blinded facial surgeons assessed the cosmetic appearance of the mature scars 3 months postoperatively. The wounds that had been immobilized with botulinum toxin A were rated as significantly better in appearance than the control wounds (p < 0.01). Histologic examination confirmed that all scars were mature. Blinded, randomized, placebo-controlled human clinical trials are presently under way at the Mayo Clinic.     

Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report.

A clinical operative technique for free muscle transplantation by microneurovascular anastomoses is presented. Two cases of free transfer of the gracilis muscle for dynamic reconstruction of facial paralysis are described, including a follow-up study with electromyography, light microscopy, and electron microscopy. We feel this new technique will have a wide range of application in reconstructive surgery.     

Reconstructive breast surgery: referring physician knowledge and learning needs

Despite the positive impact that reconstructive breast surgery can have on a woman's quality of life, the percentage of eligible candidates that have this procedure remains surprisingly low. The authors hypothesized that this may be attributable to inadequate knowledge, inadequate information, and/or misinformation available to physicians caring for these patients. A needs assessment of primary care physicians, general surgeons, oncologists, and plastic surgeons was conducted to determine referring physicians' current level of knowledge of reconstructive breast surgery and to discover potential learning needs. This comprised a survey, focus groups, and individual interviews. Referring physicians rated their own knowledge of reconstructive breast surgery as low. Plastic surgeons rated their referring physicians' knowledge as even lower. Specific learning needs were identified, as large discrepancies between referring physicians' self-reported knowledge of individual breast reconstruction topics and their own opinion of their relevance were revealed. In addition, despite evidence to the contrary, more than one-third of referring physicians indicated a belief that a breast reconstruction delayed the detection of local cancer recurrence and adversely interfered with adjuvant oncologic therapy. This lack of knowledge and misinformation may be negatively affecting patient referrals to plastic surgeons, as more than one-third of referring physicians and 90 percent of plastic surgeons believed that eligible candidates were not being offered referrals because of inadequate referring physician knowledge of this topic. Furthermore, patients older than 49 years were not being referred despite the fact that plastic surgeons would consider these patients as potential surgical candidates. Referring physician gender affected both referral patterns and perceived importance of reconstructive breast surgery. Finally, personal beliefs and past experiences played a role both in physicians' decisions to refer patients and in patients' decisions to have breast reconstructions. These deficiencies in information, knowledge, and learning needs should be addressed by educational interventions during residency training and through continuing education endeavors.     

Primary neoplasms of the facial nerve

A series of 30 primary facial nerve tumors is reviewed. Most of them were benign (n = 26); there were four malignant tumors. Neoplasms originating within the temporal bone were found to have preoperative facial paralysis in 84 percent of cases; the extracranial tumors had a 35 percent incidence of preoperative facial paralysis. All tumors in this series were treated surgically--by means of a middle fossa or transmastoid approach for the intratemporal group of tumors; the extracranial tumors were removed by the technique of parotid tumor surgery with complete facial nerve dissection. All the patients with preoperative facial weakness required facial nerve transection. Facial paralysis was rehabilitated with nerve grafts, hypoglossal crossover, or muscle transfers. Because "normal" facial expression is still not attainable following repair of complete facial nerve transection, an early diagnosis, hopefully prior to total neurotmesis, is essential. All patients with unexplained facial weakness, especially that which is progressive and persistent, should have the entire course of the facial nerve investigated for the possibility of treatable etiology.     

Neurovascular free-muscle transfer to treat facial paralysis associated with hemifacial microsomia

Despite the wide spectrum of hemifacial microsomia manifestations, treatment mainly focuses on mandible and ear abnormalities, rather than on facial paralysis. In fact, the surgical treatment of facial paralysis associated with hemifacial microsomia is quite underdeveloped, because the degree of paralysis is frequently incomplete or partial. Timing and type of surgery are also difficult to determine. Neurovascular free-muscle transfer is now a standard procedure for the dynamic smile reconstruction of longstanding facial paralysis. This type of strategy has considerable potential in the treatment of facial paralysis in patients with hemifacial microsomia. We present here our experience with neurovascular free-muscle transfer for smile reconstruction in eight patients with facial paralysis associated with hemifacial microsomia. The age of the patients at the time of surgery ranged from 7 to 28 years old, (average, 13.9 years). Six were male patients and two were female patients. The two-stage method combining gracilis muscle transfer with cross-face nerve grafting was performed in three patients, whereas the one-stage transfer of the latissimus dorsi muscle was performed in five. To construct a natural or near-natural smile, the muscles were transferred into the paralyzed cheek in all except one patient, in whom the latissimus dorsi muscle was transferred into the sublabial area to reconstruct a paralyzed lower lip. A dermal flap segment vascularized with perforating vessels from the latissimus dorsi muscle was simultaneously inserted into the underdeveloped cheek for soft-tissue augmentation in this patient. Muscle contraction was evident in all patients between 4 and 8 months after muscle transfer. Our present series revealed that neurovascular free-muscle transfer is a good option not only for smile reconstruction but also for restoration of the facial contours of patients with hemifacial microsomia. Compared with the two-stage method combining gracilis muscle transfer with cross-face nerve grafting, the one-stage method using the latissimus dorsi muscle has some advantages, including a one-stage operation, a shorter recovery period, and the absence of sequelae that occur after harvesting a sural nerve.     

History of total nasal reconstruction with particular emphasis on the folded forehead flap technique

The history of plastic surgery is identified throughout the centuries with the history of rhinoplasty. The Indian Koomas first and later the Italian surgeons found valid solutions to the problems caused by partial loss of the nasal pyramid. However, the idea of rebuilding, with a single forehead flap, the tip and columella and providing at the same time a lining of skin for the newly formed nose goes back to the middle of the nineteenth century. The Italian Natale Petrali (1842) and the Germans Johann Friedrich Dieffenbach (1845) and Ernst Blasius (1848) contend for precedence in carrying out this important procedure still used today, which, barring postoperative contracture, represented a great advance in successful total rhinoplasty.     

Selective myectomy for postparetic facial synkinesis

Synkinetic movements are secondary to facial palsy because they appear like a late sequela to spontaneously healing facial nerve injury. They are produced by an involuntary contraction of a muscle group simultaneous with contraction of other homologous muscle groups. The disorderly regeneration of severed axons is responsible for these movements. According to the Lippschitz theory, the regenerating nerve fibers sprout into the wrong peripheral branches. Between 1975 and 1986, 71 patients with facial paralysis were evaluated. Spontaneous recovery from the facial paralysis occurred in 28 of these patients; 14 (50 percent) developed synkinetic movements, and surgical treatment was sought by only 6 patients. In all patients, the lesion of the facial nerve was in the trunk, proximal to the principal ramification. The most frequent clinical finding was simultaneous activation between the orbicularis oculi and the elevators of the corner of the mouth (12 patients) or the elevators of the upper lip (2 patients). In 8 patients, in whom the slight synkinesis was not noticed by the patients, surgical correction was not necessary, but in the other 6 patients with severe aesthetic disturbances, surgical treatment for "disconnection" of the wrong impulses was realized. I obtained this "disconnection" through resection of the involved perioral muscle groups instead of paralysis of the orbicularis oculi. Follow-up of the 6 patients operated with the surgical treatment proposed herein for between 4 and 8 years has shown good aesthetic results without functional or aesthetic sequelae.     

Lengthening temporalis myoplasty and lip reanimation

The authors report a new surgical technique of myoplasty of the temporalis muscle applied to the treatment of permanent peripheral facial paralysis. It consists of a muscle lengthening, using the totality of the temporalis muscle and the transfer of its tendon attached to the coronoid process directly to the lips, therefore modifying the temporal fixed point and respecting the deep temporal pedicles. Ten cadaver dissections were performed for a better understanding of the muscle fiber redistribution during surgery to measure the distance between coronoid process and lip commissure and to measure the width of the temporal tendon. The results in 10 patients have been very encouraging. This technique was performed on ten cases of permanent facial paralysis of various etiologies, by the same surgeon, with a 4-year follow-up.     

The changing role of platysma in face lifting

Since the 1970s, surgical procedures on platysma muscle, aiming to achieve better results in face lifting, became popular and turned out to be an important surgical step for the plastic surgeon. Many plastic surgeons have contributed to the topic throughout these years, as several articles on the subject have been published. Articles dealing with platysma muscle still bring great interest among plastic surgeons. My concern with platysma muscle began in the mid-1970s and since then has grown continuously. I have steadily been studying the importance of the platysma muscle in the surgeries for facial rejuvenation, involving its anatomy, the techniques proposed, the results obtained, the recommendations for the best surgical procedure for each patient, and the complications. My experience and studies regarding platysma muscle, and the contributions I have brought into this field, are thoroughly described and discussed in this article.     

Vaccum drainage system application in the management of operation-related non-regional epidural hematoma

Inadequate tissue perfusion is a key contributor to early complications following reconstructive procedures. Accurate and reliable intraoperative evaluation of tissue perfusion is critical to reduce complications and improve clinical outcomes. Clinical judgment is the most commonly used method for evaluating blood supply, but when used alone, is not always completely reliable. A variety of other methodologies have been evaluated, including Doppler devices, tissue oximetry, and fluorescein, among others. However, none have achieved widespread acceptance. Recently, intraoperative laser angiography using indocyanine green was introduced to reconstructive surgery. This vascular imaging technology provides real-time assessment of tissue perfusion that correlates with clinical outcomes and can be used to guide surgical decision making. Although this technology has been used for decades in other areas, surgeons may not be aware of its utility for perfusion assessment in reconstructive surgery. A group of experts with extensive experience with intraoperative laser angiography convened to identify key issues in perfusion assessment, review available methodologies, and produce initial recommendations for the use of this technology in reconstructive procedures.     

An algorithm for abdominal wall reconstruction

Acquired abdominal wall defects result from trauma, previous surgery, infection, and tumor resection. The correction of complex defects is a challenge to both plastic and reconstructive and general surgeons. The anatomy of the abdominal wall, as well as considerations in patient assessment and surgical planning, are discussed. A simple classification of abdominal wall defects based on size, depth, and location is provided. Publications regarding the various abdominal reconstruction techniques are reviewed and summarized to familiarize the reader with the treatment options for each particular defect. Finally, an algorithm is presented to guide the surgeon in selecting the optimal reconstructive technique.     

家兔迟发性面瘫模型建立及药物干预研究

目的:优化迟发性面瘫的建模方法,并对药物的神经保护作用进行观察。方法:家兔48只共96侧面神经,分A、B、C、D 4个实验组,以一侧面神经进行实验处理,另一侧为自身对照。A组:直视下钳夹损伤桥池段面神经;B组:直视下向桥小脑角注射动脉血,以诱导血管痉挛;C组:处理因素=A组+B组;D组:在C组基础上,应用药物(强的松+丹参+维生素B1+维生素B12)干预。观察家兔面瘫,并做面神经病理切片,比较各组间迟发性面瘫发生率、面瘫持续时间及预后。结果:面瘫发生情况:A组6只家兔(6/11,54.5%)出现迟发性面瘫;平均面瘫持续时间为13.2天。B组有2只(2/12,16.7%)出现迟发性面瘫,平均持续8天。C组6只(6/12,50%)家兔出现迟发性面瘫,平均持续14.3天。D组4只(4/12,33.33%)出现迟发性面瘫,平均持续6天。所有自身对照侧均无面瘫发生。病理:各组均见神经纤维水肿;A、C两组呈高度水肿改变,神经束周围结构紊乱;B组见神经内血管细小,而水肿较A、C两组轻微;D组呈轻度水肿改变。结论:C组出现迟发性面瘫几率高,是较好的模型;联合应用强的松、丹参、维生素B1、维生素B12虽不能防止迟发性面瘫发生,但可使迟发性面瘫病程明显缩短。     

The integral role of the plastic surgeon at a level I trauma center

The role of plastic surgery in urban level I trauma centers in the United States has been largely undefined, despite the undeniable historical involvement of plastic surgery in reconstruction of posttraumatic defects. To explore and define this role, case data were prospectively collected during a 29-month period following initiation of a full-time plastic surgery position at an established urban level I trauma center. Referring and/or interacting surgical service, anatomical area of interest, and procedure data were tabulated. A total of 1009 operative reports comprising 1104 procedures were recorded. The most common interacting surgical services were orthopedics and general/trauma surgery; however, interaction occurred with a total of 10 surgical specialties. The upper extremity was the most common anatomical area operated on followed by head and neck, lower extremity, trunk, urogenital, and breast. A wide variety of procedures were performed in each anatomical area, demonstrating the broad scope of reconstructive surgery practiced in a trauma setting. Three hundred and twenty-four procedures involved expertise in microsurgery, flaps, and burn or frostbite care. Additional procedures commonly performed demonstrated considerable overlap with other fields of surgical specialization. This overlap in skills proved advantageous in distribution of facial trauma call and hand surgery coverage. Data presented in this study reinforce the idea that plastic surgery is a specialty defined by concept rather than anatomical area, and also demonstrate a significant role for plastic surgeons in a level I trauma center.