Facial transplantation: the first 9 years.

Since the first facial transplantation in 2005, 28 have been done worldwide with encouraging immunological, functional, psychological, and aesthetic outcomes. Unlike solid organ transplantation, which is potentially life-saving, facial transplantation is life-changing. This difference has generated ethical concerns about the exposure of otherwise young and healthy individuals to the sequelae of lifelong, high-dose, multidrug immunosuppression. Nevertheless, advances in immunomodulatory and immunosuppressive protocols, microsurgical techniques, and computer-aided surgical planning have enabled broader clinical application of this procedure to patients. Although episodes of acute skin rejection continue to pose a serious threat to face transplant recipients, all cases have been controlled with conventional immunosuppressive regimens, and no cases of chronic rejection have been reported.

Difference in triptan effect in patients with migraine and early allodynia.

The aim of this study was to determine whether in migraine patients with and without aura early treatment with various triptans leads to differences in pain reduction after 1 h and in modulating cutaneous allodynia. Thirty-six patients with early manifestation of a clinically recognizable allodynia of the face and non-responders to earlier treatment with sumatriptan 100 mg were included. Patients were randomized to six triptan treatment groups. Significant pain reduction was seen only in the group receiving zolmitriptan nasal spray 5 mg with a mean visual analogue scale (VAS) score of 3.8 (s.d. 1.2) at baseline and 2.4 (s.d. 1.3; P = 0.015) at 1 h after using the triptan and was thus a predictor of a VAS score 3 within 1 h. The study results indicate that migraine headache intensity can be reduced within 1 h by using zolmitriptan 5 mg nasal spray in spite of the presence of early cutaneous allodynia.

New insights into the pathophysiology of primary hemifacial spasm.

Primary hemifacial spasm (pHFS) is due to a benign compression of the facial motor nerve by an offending vessel, leading to increased nerve excitability. Facial nerve hyperexcitability presents two different aspects. First, there is a spontaneous and ectopic generation of action potentials on the incriminated nerve and then this ectopic impulse can propagate and spread "laterally" from one facial nerve branch to another. This results in spontaneous and synkinetic spasms affecting one hemiface. Although the increase in excitability certainly concerns the nucleus of the facial motor nerve in the brainstem, it seems unlikely that the primary origin of this hyperexcitability and the associated phenomenon of lateral spreading strictly originate at the nuclear level. In fact, the mechanisms causing facial nerve hyperexcitability per se remain unknown. The leading implication of a structural nerve lesion, such as segmental demyelination, induced by vessel compression, is also unconvincing. In contrast, a functional mechanical factor increasing nerve excitability is extremely probable, that it is either due to compression or stretch resulting from the neurovascular conflict. Axonal ion channel changes are obviously associated with this mechanism. Then the lateral spreading of nerve fibre hyperexcitability probably results from an ephaptic process, the "cross-talk" between axons being located in the region of the conflict or in the transition zone between central and peripheral myelin, at the end of the facial nerve root exit zone. In any event, pHFS is due to a functional increase in facial nerve excitability triggered by an offending vessel and this clearly explains the remarkable and rapid efficacy of surgical microvascular decompression.

Sphenopalatine endoscopic ganglion block: a revision of a traditional technique for cluster headache.

The diagnosis of chronic cluster headache (CH), the most painful form of headache, is based on typical clinical features characterized by strictly unilateral pain with no side shift and ipsilateral oculofacial autonomic phenomena. The attacks occur several times a day for periods of 1 to 2 months in the episodic form of the disease or less frequently on a daily basis in the chronic form. The pathogenesis of CH involves the activation of parasympathetic nerve structures located within the sphenopalatine ganglion (SPG), which explains many of the associated symptoms, whereas the activation of the ipsilateral hypothalamic gray matter may explain its typical circadian and circannual periodicity. A number of surgical approaches have been tried in cases of chronic CH resistant to pharmacologic therapy, of which SPG blockade has been shown to have certain efficacy. We have adopted a new technique based on endoscopic ganglion blockade that approaches the pterigo-palatine fossa by way of the lateral nasal wall and consists of the injection of a mixture of local anesthetics and corticosteroids, which was performed in 20 selected patients with chronic CH, according to the International Headache Society criteria (18 male, 2 female; mean age 40 yr), who were selected for SPG blockade because they were totally drug resistant. The symptoms improved significantly, but always only temporarily, in 11 cases. These results should be considered rather good because, unlike other frequently used techniques, SPG blockade is not invasive and should therefore always be attempted before submitting patients to more invasive surgical approaches.

The superior auricular artery and retroauricular arterial island flaps.

This paper reports the finding of the superior auricular artery, which is a fairly large arterial branch, about 1 mm in diameter, arising from the superficial temporal artery anterior to the auricular helix. It is covered by skin, the anterior auricular muscle, and the fascia of the parotid gland. It runs together with its concomitant vein posteriorly in the groove between the cartilage of the ear and the temporal bone and anastomoses with the posterior auricular artery. This artery has been used successfully to raise large retroauricular arterial island flaps for one case of total nose reconstruction and seven cases of reconstruction of the severely constricted anophthalmic socket. These operative procedures are described in detail.

[A case of progressive hemifacial atrophy with Pourfour de Petit syndrome which was successfully treated by stellate ganglion block].

We herein report a 31-year-old woman with progressive hemifacial atrophy. The atrophy at her left face began about ten years ago. She had been in a traffic accident one year before the onset of her facial atrophy. Neurological examination revealed anisocoria (right < left) and retraction of the left eyelid, which thus suggested the presence of Pourfour de Petit syndrome. The pupillary reaction to both cocaine and tyramine were reduced bilaterally. Thermography of the face showed slightly lower surface temperature on the left side. A facial thermal sweat test was normal. These findings indicated local hyperactivity of the sympathetic nervous system at the Th 1-Th2 levels on the left side. A left stellate ganglion block effectively induced an accumulation of the subcutaneus tissue of her face on the left side. This is a very rare case in which local sympathetic hyperactivity is present and has caused progressive hemifacial atrophy.

Two-point discrimination values vary depending on test site, sex and test modality in the orofacial region: a preliminary study

Abstract The two-point discrimination (TPD) test is one of the most commonly used neurosensory tests to assess mechanoperception in the clinical settings. While there have been numerous studies of functional sensibility of the hand using TPD test, there have been relatively not enough reports on TPD in the orofacial region. Objective The aims of the present study were to determine the normal values of TPD in the six trigeminal sites (the forehead, cheek, mentum, upper lip, lower lip, and the tongue tip) and to investigate the effect of the site, sex, and test modality on the TPD perception. Material and Methods Forty healthy volunteers consisting of age-matched men (20) and women (20) with a mean age of 27.1 years were recruited. One examiner performed the TPD test using a simple hand-operated device, i.e., by drawing compass with a blunt or sharp-pointed tip. The static TPD with a blunt-pointed tip (STPDB), moving TPD with a blunt-pointed tip (MTPDB), and static TPD with a sharp-pointed tip (STPDS) were measured. The predictors were the site, sex, and test modality, and the outcome variable was the TPD value. Three-way ANOVA was used for statistics. Results The analysis showed a significant effect of the site, sex and test modality on the TPD values. Significant differences between the test sites were observed with the descending order from the forehead and cheek>mentum>upper lip and lower lip>tongue tip and index finger. Women showed lower TPD values than those of men. The STPDS measurements were consistently lower than those of the STPDB and MTPDB. Conclusions The normal values of TPD in this study suggest that the cheek and forehead were less sensitive than other regions evaluated and women were more sensitive than men. The STPDS was the most sensitive test modality.

Facial animation in patients with Moebius and Moebius-like syndromes.

Moebius syndrome, a rare congenital disorder of varying severity, involves multiple cranial nerves and is characterised predominantly by bilateral or unilateral paralysis of the facial and abducens nerves. Facial paralysis causes inability to smile and bilabial incompetence with speech difficulties, oral incompetence, problems with eating and drinking, including pocketing of food in the cheek and dribbling, as well as severe drooling. Other relevant clinical findings are incomplete eye closure and convergent strabismus. The authors report on 48 patients with Moebius and Moebius-like syndromes seen from 2003 to September 2007 (23 males and 25 females, mean age 13.9 years). In 20 cases a reinnervated gracilis transplant was performed to re-animate the impaired sides of the face. In this series, all free-muscle transplantations survived the transfer, and no flap was lost. In 19 patients complete reinnervation of the muscle was observed with an excellent or good facial symmetry at rest in all patients and whilst smiling in 87% of cases. In conclusion, according to the literature, the gracilis muscle free transfer can be considered a safe and reliable technique for facial reanimation with good aesthetic and functional results.

Nerve injuries and treatment in facial cosmetic surgery.

Surgical intervention remains a popular choice in patients seeking facial rejuvenation. Although uncommon, temporary or permanent peripheral nerve injury may complicate almost any type of invasive aesthetic procedure of the face, resulting in functional and psychological consequences for patients. Prompt recognition and appropriate intervention are necessary to avoid the long-term sequelae and improve the chances of complete neurologic recovery. Depending on the type of injury, various interventions may range from observation and close follow-up to interposition nerve grafting. This article reviews the pertinent anatomy of nerves at risk in facial cosmetic surgery and discusses various management strategies for inadvertent injury to peripheral nerves of the face.

Probabilidade de erupção dos terceiros molares inferiores a partir da distância Xi-D7 em pacientes na faixa etária de 8-10 anos naturais de Teresina-PI / Cephalometric analysis of the probability of lower third molar eruption in pacients 8 to 10 years of age from Teresina-PI

Os terceiros molares constituem-se em uma das grandes preocupações do Cirurgião-dentista. Tendo em vista a alta prevalência desses dentes impactados ou inclusos, cabe, principalmente aos Ortodontistas, a decisão sobre extrações, enucleações, bem como a idade ideal para tais procedimentos. O propósito deste trabalho foi avaliar a freqüência de cada uma das três situações propostas por Turley, para a previsão da erupção dos terceiros molares inferiores, a partir da distância Xi-Distal dos segundos molares (D7), em pacientes naturais de Teresina, Pi, na faixa etária de 8-10 anos, bem como associar essa probabilidade de erupção ao padrão facial. Foram utilizadas telerradiografias cefalométricas de 113 pacientes, sendo 51 do sexo masculino e 62 do sexo feminino, e os traçados e as mensurações foram obtidos através do método computadorizado Radiocef 1.0. Os resultados mostraram que 95,58% dos pacientes apresentaram a distância Xi-D7 menor que 20mm, indicando a impossibilidade da erupção; 4,42% apresentaram Xi-D7 maior que 20 e menor que 30, o que significa probabilidade parcial de erupção e nenhum paciente mostrou previsão de erupção normal dos terceiros molares (Xi-D7 maior que 30). Observou-se, ainda, a ausência de associação entre os espaços medidos para os terceiros molares e o padrão facial

Manifestaçoes fonoaudiologicas em um grupo de doentes de Hanseniase / Manifestations fonoaudiologicas in a group of patients from leprosy

A Hansenise, doença cronica infecto-contagiosa e de nofificaçao compulsoria, e causada pelo bacilo de Hansen (Mycobacterium leprae), e pode apresentar multiplas lesoes em qualquer local do corpo...