Perioperative pain management after scapular tip free flap harvesting for head and neck reconstruction using mini-catheters to inject the local anesthetic.

PURPOSE: Although functional and esthetic results after the use of a scapular tip free flap (STFF) in head and neck reconstruction, and the related donor-site morbidity, have been extensively described, data regarding acute postoperative donor-site pain management are lacking. Purpose of this study is to explore the use of mini-catheters to administer local anesthetics for donor-site pain management after reconstruction using STFF. METHODS: Patients who underwent head and neck reconstruction using a STFF were prospectively enrolled and, through a perineural catheter placed in the donor site during the surgical procedure, a bolus of chirochaine was injected before the patient regained consciousness and at 8, 16, and 24 h postoperatively. Before and 40 min after each dose administration, donor-site pain on a numerical rating scale (NRS; 0-10) was evaluated. RESULTS: Study population consisted of 20 patients (40-88 years). At 8 h, the pain scores before and after the injection were 0-10 (mean 3.35) and 0-5 (mean 1.25), respectively. At 16 h, the pain scores before and after the injection were 0-8 (mean 2.55) and 0-4 (mean 0.55), respectively. At 24 h, the pain scores before and after the injection were 0-8 (mean 1.30) and 0-4 (mean 0.30), respectively. CONCLUSION: Statistical analysis confirmed a significant difference between the pain scores before and after administration at 8, 16, and 24 h (p < 0.001, p < 0.001, and p = 0.003, respectively). Mini-catheters for local anesthetic administration represent an effective strategy for pain control after STFF harvesting for head and neck reconstruction.

Delayed Auditory Brainstem Responses (ABR) in children after sight-recovery.

Studies in non-human animal models have revealed that in early development, the onset of visual input gates the critical period closure of some auditory functions. The study of rare individuals whose sight was restored after a period of congenital blindness offers the rare opportunity to assess whether early visual input is a prerequisite for the full development of auditory functions in humans as well. Here, we investigated whether a few months of delayed visual onset would affect the development of Auditory Brainstem Responses (ABRs). ABRs are widely used in the clinical practice to assess both functionality and development of the subcortical auditory pathway and, provide reliable data at the individual level. We collected Auditory Brainstem Responses from two case studies, young children (both having less than 5 years of age) who experienced a transient visual deprivation since birth due to congenital bilateral dense cataracts (BC), and who acquired sight at about two months of age. As controls, we tested 41 children (sighted controls, SC) with typical development, as well as two children who were treated (at about two months of age) for congenital monocular cataracts (MC). The SC group data served to predict, at the individual level, wave latencies of each BC and MC participant. Statistics were performed both at the single subject as well as at the group levels on latencies of main ABR waves (I, III, V and SN10). Results revealed delayed response latencies for both BC children compared with the SC group starting from the wave III. Conversely, no difference emerged between MC children and the SC group. These findings suggest that in case the onset of patterned visual input is delayed, the functional development of the subcortical auditory pathway lags behind typical developmental trajectories. Ultimately results are in favor of the presence of a crossmodal sensitive period in the human subcortical auditory system.

Hypoxic events during non-obstetric abdominal surgery in pregnant women.

OBJECTIVE: Every year 0.5-2% of women undergo non-obstetric surgery in pregnancy. Hypoxic events with short-term and long-term consequences are one of the most frequent complications in surgery. There is only limited data available regarding the impact of these events. This review aims to analyze the current literature on hypoxic events occurring in non-obstetric abdominal surgery in pregnant women, focused on maternal and fetal outcomes. MATERIALS AND METHODS: We performed a non-systematic review of the literature, through a PubMed search using the key words "hypoxemia", "non-obstetric surgery", "surgical procedures", "pregnancy", "pregnant women" and "outcome". RESULTS: There is little data available regarding maternal and fetal outcomes after hypoxic episodes during non-obstetric surgery in pregnancy. In these cases, conservative intrauterine resuscitation maneuvers or immediate delivery should be taken into account. Perimortem cesarean section can be lifesaving for both mother and fetus when maternal collapse is non responsive to resuscitation procedures. Inaccurate information regarding maternal and fetal outcomes is due to the lack of robust data and the heterogeneity of the causes underlying maternal respiratory complications during surgery. CONCLUSIONS: Non-obstetric surgery during pregnancy must be performed when indicated. An expert multidisciplinary team, composed of obstetricians, surgeons, and anesthesiologists need to be included, giving appropriate attention to the physiological changes of respiratory, cardiovascular, and gastrointestinal system that occur during pregnancy. The shortest operative time and peri-operative assistance should be ensured. Complications, such as hypoxic events in pregnant patients need adequate assistance. Multidisciplinary cooperation, continuous training and simulation for anesthesiology and resuscitative procedures can guarantee this.

Masseteric cooptation and crossfacial nerve grafting: Is it still applicable 22 months after the onset of facial palsy?

BACKGROUND: Eighteen months is usually considered the cutoff time within which recovery of the mimic muscle remains possible using facial nerve cooptation. Few reports on the use of cooptation after this interval have appeared. Purpose of this study is to investigate the feasibility of this procedure also after 22 months. METHODS: Six patients treated via crossfacial nerve grafting between healthy and paralyzed middle and middle-upper facial nerve branches and masseteric cooptation of the main trunk of the paralyzed facial nerve between 20 and 24 months after the onset of palsy were analyzed. Population consisted of two males and four females ages 8-42 years (mean 24 years). Facial palsy developed after acoustic neuroma resection in three patients, after the removal of a cerebellopontine angle astrocytoma in one, and as a consequence of Bell's palsy or cerebral hemorrhage in the other two (one each). House-Brackman and Sunnybrook clinical evaluation systems and FDI questionnaire were used to assess results. RESULTS: House-Brackman scores changed from VI before the operation for all patients to II for two patients and III for four patients. Sunnybrook scores were 0-10 before the operation, but 62-84 at the last visit. Mean FDI scores moved from 24 to 38.5 meaning a statistical high significant improvement (P < .01). CONCLUSIONS: Masseteric/crossfacial nerve grafting is feasible for patients with palsies 20-24 months in duration, affording satisfactory functional and esthetic results and a dramatic improvement in quality of life.

Masseteric nerve for gracilis muscle re-innervation in unilateral facial palsy: Impact on quality of life.

BACKGROUND: Unilateral established or congenital facial palsies are usually treated with neuromuscular transplantation to reanimate the impaired side of the face. One of the most debated points is the motor nerve to choose for the reinnervation of the transplant. Contra-lateral healthy facial nerve is usually preferred, but in selected cases motor nerve to masseter is considered a valuable option. However only a few clinical studies focused on quality of life in this subset of patients are available in literature. METHODS: Twenty patients treated for established or congenital unilateral facial palsy reanimated with gracilis muscle transplant reinnervated with masseteric nerve were retrospectively analyzed. The FDI questionnaire on quality of life was administered before and after surgery and statistical analysis of results was conducted to score changes. RESULTS: Overall results of the questionnaire resulted in a statistically significant improvement after surgery, with a p value of 0.05. CONCLUSION: Facial animation with gracilis muscle transplant re-innervated with masseteric nerve is a safe and reliable procedure in selected unilateral facial palsy patients. Results reported here confirm that surgery mainly improves the functional aspects of a patient's daily life quality, while the impact on social interactions and self-perception is less significant. The comparison of these results with those obtained in patients treated with gracilis muscle transplant re-innervated via contralateral facial nerve suggests that spontaneity is probably highly relevant to improve social aspects of QOL in this subset of patients.

T helper type 1-related molecules as well as interleukin-15 are hyperexpressed in the skin lesions of patients with pyoderma gangrenosum.

Pyoderma gangrenosum (PG) is a rare, immune-mediated skin disease classified into the group of neutrophilic dermatoses. Although a number of studies confirmed the central role of innate immunity, only few studies have investigated the possible contributing role of acquired immunity. In particular, no reports concerning T helper type 1 (Th1) and Th2 cells are available as yet. Therefore, 15 patients with PG, five with Sweet's syndrome (SS) and nine skin specimens from healthy controls (HC) were investigated, evaluating the expression of Th1-related markers interleukin (IL)-12, interferon (IFN)-γ, C-X-C motif chemokine receptor 3 (CXCR3) and C-C motif chemokine receptor 5 (CCR5), of the Th2-related molecules IL-4, IL-5, IL-13 and CCR3, of the co-stimulatory axis CD40/CD40 ligand, of IL-15 and the natural killer (NK) cell marker CD56 in skin lesions by immunohistochemistry. Patients with PG and SS showed a higher expression of Th1 markers than HC. Conversely, IL-5- and CCR3-expressing cells were less numerous in PG skin lesions compared to SS (P = 0·0157 and < 0·0001, respectively). Both CD40 and CD40L were expressed more in PG than in SS and HC (P < 0·0001 for both). Finally, the number of IL-15+ and CD56+ cells was higher in the skin of patients with PG than in those of SS and HC (P < 0·0001 for both). Our results suggest that Th2 cells are down-regulated in PG. At the same time, over-expression of the co-stimulatory axis CD40/CD40L amplifies the impairment of the Th1/Th2 balance. Both these findings might explain the most aggressive behaviour of PG in comparison to SS. Moreover, over-expression of IL-15+ and CD56+ cells may suggest a possible role of NK cells in the pathogenesis of the disease.

Cutaneous vasculitidis: histology and immunofluorescence.

Cutaneous vasculitis comprises a wide spectrum of diseases that involve predominantly the blood vessels and surrounding tissues of the skin. Few vasculitic syndromes have pathognomonic clinical, radiographic and/or laboratory findings; thus, confident and accurate diagnosis of vasculitis requires histological confirmation. Skin biopsy should be done, optimally within 24 to 48 hours after vasculitic lesions appear. Deep excision biopsy must be preferred. Direct immunofluorescence of lesional skin is helpful in the diagnosis of vasculitides in the light of a proper clinico-pathological setting and diagnostic in some peculiarly forms. Cutaneous histological patterns can be used to generate relevant clinical differential diagnoses, and, when coupled with patient's history, clinical and laboratory data, allow more precise and accurate diagnosis of vasculitic syndromes. This review will focus on histopathological and immunologic pattern of the more common cutaneous vasculitis syndromes, based on the 2012 Revised International CHCC.

Upper eyelid platinum chain placement for treating paralytic lagophthalmos.

For the definitive treatment of lagophthalmos and satisfactory rehabilitation of the affected eye, different surgical strategies have been proposed, including static or dynamic procedures. Although some of these can have good results, lid loading is now the most common technique for treating paralytic long-term lagophthalmos. Among the different types of loading, the use of a platinum chain is preferred to the use of a standard gold weight because platinum has a higher density than gold and is also more biocompatible. In this paper authors retrospectively analyzed 43 patients with regards to functional and cosmetic results. Questionnaires were also employed to assess changes and improvements in the patients' quality of life. Analysis of the excellent results achieved confirmed that platinum chain lid loading should be considered as a first-line treatment for paralytic lagophthalmos rehabilitation. It is a simple, reliable, and effective technique that significantly improves the health-related quality of life of patients.

The submental island flap: pedicle elongation and indications in head and neck reconstruction.

BACKGROUND: The submental island flap is an axial pattern skin flap first described by Martin et al. in 1993. When used to reconstruct skin defects it matches the recipient site in terms of colour, texture and thickness. One of the main limitations to its application is the arc of the pedicle allowing coverage of only the lower two thirds of the face. METHODS: A retrospective review was performed of all patients who had had a submental island flap reconstruction at the Operative Unit of Maxillo-Facial Surgery of the University Hospital of Parma, Italy, between 2001 and 2011. The Authors focused on the surgical technique adopted, the clinical indications and the results obtained. They analysed the different ways to elongate the pedicle and discuss their thoughts on the choice of reconstruction. A flowchart was created to help in the decisional process. RESULTS: Between 2001 and 2011 the submental island flap was used to reconstruct head and neck defects in 22 patients. Thirteen patients had defects of the oral cavity; the remaining 9 patients had skin defects involving the pre-auricular region, the temporal area and the peri-nasal cheek skin. No major complications occurred and in one case a partial necrosis of the distal portion of the flap was observed. Five patients underwent surgical revision involving intraoral flap debulking 6-10 months after the primary procedure. DISCUSSION AND CONCLUSIONS: The techniques to elongate the pedicle used and described were: additional dissection of the pedicle, Y-V procedure, reverse flow flap, section of facial vein and microvascular anastomosis. Their choice is mainly conditioned by the site of the defect.

The masseteric nerve: a versatile power source in facial animation techniques.

The masseteric nerve has many advantages including low morbidity, its proximity to the facial nerve, the strong motor impulse, its reliability, and the fast reinnervation that is achievable in most patients. Reinnervation of a neuromuscular transplant is the main indication for its use, but it has been used for the treatment of recent facial palsies with satisfactory results. We have retrospectively evaluated 60 patients who had facial animation procedures using the masseteric nerve during the last 10 years. The patients included those with recent, and established or congenital, unilateral and bilateral palsies. The masseteric nerve was used for coaptation of the facial nerve either alone or in association with crossfacial nerve grafting, or for the reinnervation of gracilis neuromuscular transplants. Reinnervation was successful in all cases, the mean (range) time being 4 (2-5) months for facial nerve coaptation and 4 (3-7) months for neuromuscular transplants. Cosmesis was evaluated (moderate, n=10, good, n=30, and excellent, n=20) as was functional outcome (no case of impairment of masticatory function, all patients able to smile, and achievement of a smile independent from biting). The masseteric nerve has many uses, including in both recent, and established or congenital, cases. In some conditions it is the first line of treatment. The combination of combined techniques gives excellent results in unilateral palsies and should therefore be considered a valid option.

Regulatory T cells in skin lesions and blood of patients with bullous pemphigoid.

BACKGROUND: Although regulatory T cells (Tregs) are affected in several autoimmune skin diseases, only two studies have been performed in patients with bullous pemphigoid (BP) with contrasting results. OBJECTIVE: To characterize Tregs and to determine the serum levels of regulatory cytokines in patients with BP. METHODS: In BP lesional skin, immunohistochemistry and confocal microscopy were performed for CD4(+) , CD25(+) , forkhead/winged helix transcription factor (FOXP3)(+) , transforming growth factor (TGF)-ß(+) and interleukin (IL)-10(+) cells. In addition, the number of CD4(+) CD25(++) FOXP3(+) Tregs in peripheral blood was assessed by flow cytometry, and the levels of TGF-ß and IL-10 were determined in serum samples by enzyme-linked immunosorbent assay before and after steroid therapy. Controls included patients with psoriasis, atopic dermatitis (AD) and healthy donors. RESULTS: The frequency of FOXP3(+) cells was significantly reduced in skin lesions from patients with BP (P < 0.001) compared with psoriasis and AD. Moreover, the number of IL-10(+) cells was lower in BP than in psoriasis (P < 0.001) and AD (P = 0.002), while no differences were observed in the number of TGF-ß(+) cells. CD4(+) CD25(++) FOXP3(+) Treg in the peripheral blood of patients with BP was significantly reduced compared with healthy controls (P < 0.001), and augmented significantly after steroid therapy (P = 0.001). Finally, TGF-ß and IL-10 serum levels were similar in patients with BP compared with healthy controls. However, after therapy, BP patients showed significantly higher IL-10 serum levels than before therapy (P = 0.01). CONCLUSIONS: These data suggest that the depletion of Tregs and of IL-10 in patients with BP may be an important factor in the pathogenesis of the disease.

Selective deep lobe parotidectomy for pleomorphic adenomas.

The authors' experience of the selective deep lobe parotidectomy for the treatment of pleomorphic adenomas of the deep parotid lobe is presented. A retrospective analysis of 11 patients treated between 1997 and 2010 was performed; seven were males and four were females, ranging in age from 35 to 51 years. Parameters evaluated included facial nerve weakness, the occurrence of Frey's syndrome, cosmetic outcome, and recurrence. Follow-up ranged from 18 months to 11 years. No major complications, permanent facial nerve weakness, or Frey's syndrome occurred. Four patients developed temporary facial nerve impairments that lasted between 2 and 6 weeks, and two developed a sialocele that healed in 9 days in one case and 12 days in the other. The overall cosmetic assessment was excellent in eight patients, good in two, and satisfactory in the remaining one. No recurrences occurred. The selective deep lobe parotidectomy can be considered an effective technique for the management of deep parotid lobe pleomorphic adenomas. The major advantages of this procedure include a reduction in complications such as facial nerve impairments and Frey's syndrome, and an improved cosmetic outcome.

Rehabilitation with endosseous implants in fibula free-flap mandibular reconstruction: a case series of up to 10 years.

PURPOSE: To evaluate the clinical outcome and the aesthetic and functional results of implant rehabilitation of fibula free-flap reconstructed mandibles. MATERIALS AND METHODS: The charts of patients who underwent mandibular reconstruction with fibula free flap and implant prosthodontic rehabilitation between 1998 and 2008 at the Operative Unit of Maxillofacial Surgery of Parma, Italy, were reviewed. In the study the estimated survival rates of implants placed in reconstructed mandibles we identified the prognostic factors and evaluated the functional outcomes. RESULTS: Fourteen patients with a mean age of 50 years (range 15-63 years), were included in the study. A total of 62 implants were positioned. Complications occurred in 7 cases, an improvement in function and aesthetics was reported by the majority of patients. CONCLUSIONS: A high survival rate for implants placed in fibula free-flap reconstructed mandibles was observed. Although different factors were believed to be associated with a poorer prognosis (radiotherapy, composite defects, etc.) no statistically significance was found, showing no absolute contraindications to implant placement.

Free flaps in elderly patients: outcomes and complications in head and neck reconstruction after oncological resection.

INTRODUCTION: Free flaps represent the first reconstructive option for many head and neck defects. The increasing life expectancy of the population results in increasing numbers of ageing patients facing complex reconstructive surgery. In this study we evaluated our experience with free-flap transfers in older patients, analysing the post-operative reconstructive and systemic complications. MATERIALS AND METHODS: Between 2000 and 2009, 360 patients underwent free flap reconstruction of defects resulting from the treatment of head and neck tumours at the Operative Unit of Maxillofacial Surgery, University - Hospital of Parma, Italy. Fifty-five patients (15.3%) were more than 75 years old at the time of treatment. RESULTS: At the end of the follow-up successful free-flap transfer was achieved in 360 of the 373 flaps harvested (96.5%). The overall reconstructive complication rate was 31.4%, (31.8% in the younger group and 29.1% in the remaining patients). Medical complications were observed in 29.2% of cases (less than 75 years: 28.8%; more than 75 years: 30.9%). The ASA status was associated with a statistically significantly higher incidence of complications within patients less than 75 years old (p < 0.0001). DISCUSSION AND CONCLUSIONS: The results of this study, in agreement with previous studies, provide evidence that free-tissue transfer may be performed in ageing patients with a high degree of technical success. The chronologic age cannot be considered an appropriate criterion in the reconstructive decision. On the contrary, a careful selection of the patients based on comorbidities and general conditions (ASA status) is of primary importance in reducing post-operative complications and to improving the results of surgery.

Orthognathic surgery for the complete rehabilitation of Moebius patients: principles, timing and our experience.

Moebius syndrome is a rare disorder found in approximately 1/100,000 neonates and the treatment of facial palsy is now well established worldwide and consists of free-muscle transplants reinnervated with motor nerves. Dentofacial deformities are often detected in Moebius patients, and different degrees of micrognathia are often present, particularly in patients with complete expressions of Moebius syndrome. However only two published reports have described the surgical treatment of such anomalies in these patients; in both cases, the suggested approach consisted of orthognathic surgery followed by soft-tissue management. In this paper we discuss the indications and correct timing of orthognathic surgery and suggest to perform facial animation at an early age and then to wait for the completion of maxillofacial skeletal growth before performing orthognathic surgery. Finally, facial animation should precede orthognathic surgery in adult patients to prevent lower lip deformities and to ensure more predictable and satisfactory results.

Propagação in vitro de Hypericum cordatum (Vell. ) N. Robson (Clusiaceae) e análise fitoquímica de seus compostos secundários / In vitro propagation of Hypericum cordatum (Vell. Conc. ) N. Robson (Clusiaceae) and phytochemical analysis of its secondary compounds

Hypericum cordatum, planta com possível atividade medicinal foi analisada no presente estudo quanto a sua propagação in vitro e seus principais compostos secundários em comparação com Hypericum perforatum, espécie medicinal utilizada como antidepressivo. Diante das dificuldades que ocorrem na coleta e sua multiplicação por sementes ou via estacas caulinares, iniciou-se a propagação in vitro tendo como resultados: que a indução e o crescimento de brotações foram estimulados pelo regulador 6-benziladenina (2,0 mg L-1), que houve indução de raízes por ácido indol-butírico (0,5 mg L-1), e que as baixas concentrações de auxinas, ácido 2,4-diclorofenoxiacético, ou ácido naftalenoacético (0,01 a 0,4 mg L-1) induziram a formação de calos sendo uma alternativa viável para a multiplicação desta espécie in vitro. Constatou-se com base nas análises bioquímicas e cromatográficas realizadas nesta fase de desenvolvimento das plantas mantidas em culturas in vitro, que as mesmas não contêm hipericina. No entanto, pode-se atribuir o potencial medicinal de H. cordatum às outras substâncias que também possuem importantes atividades biológicas, tais como a xantona e o ácido clorogênico sintetizados nas glândulas foliares de H. cordatum.

Hypericum cordatum, a plant with possible medicinal activity, was analyzed in this study for its in vitro propagation and main secondary compounds, compared to Hypericum perforatum, a medicinal species used as antidepressant. Considering the difficulties that occur in its collection and multiplication through seeds or stem cuttings, in vitro propagation was started and showed the following results: the induction and the growth of sprouts were stimulated by the plant regulator 6-benzyladenine (2.0 mg L-1), there was root induction by indolebutyric acid (0.5 mg L-1) and the low concentrations of auxins, 2,4-dichlorophenoxyacetic acid or naphthaleneacetic acid (0.01 to 0.4 mg L-1) induced callus formation, constituting a viable alternative for the in vitro multiplication of this species. Biochemical and chromatographic analyses carried out at this developmental stage of plants kept in in vitro cultures indicated that they do not contain hypericin. However, the medicinal role of H. cordatum can be attributed to other substances that also have important biological activities, such as xanthone and chlorogenic acid, both synthesized in the leaf glands of H. cordatum.

What kind of surgery for cervical carcinoma?

The incidence and mortality of cervical cancer have changed over the past 50 years in developed countries, but this kind of tumor still remains a significant clinical problem because it is the second most common cause of morbidity and mortality from cancer among women. After histological confirmation of invasive cervical cancer, the extent of disease was determined using clinical criteria to assign a stage. This assessment is important because, while for the other gynecologic cancers clinical information obtained by surgery and histopathological examination is implemented and concurs to define the staging of the disease, the cervical cancer tumor stage is given after the primary diagnosis. In this review we discuss how the surgical approach to cervical cancer has been evolved, in order to modulate the radicality of the intervention itself and thus to preserve the pelvic innervation. This step has been achieved by deepening knowledge of functional pelvic anatomy and modulating the radicality of hysterectomy according to well defined surgical landmarks.

Terapia biológica em artrite reumatoide: novas perspectivas no controle e remissão / Biological therapy in rheumatoide arthritis: new perspectives in control and remission

O tratamento das doenças autoimunes sofreu grande avanço nos últimos anos. A artrite reumatoide, de etiologia desconhecida, porém com uma desregulação do sistema imunológico relacionada à sua eclosão e evolução, é hoje passível de tratamento, visando à remissão tanto clínica quanto das lesões estruturais. Além dos anti-inflamatórios e analgésicos utilizados para alívio dos sintomas, várias outras drogas, rotuladas de modificadoras do curso da doença (DMCDs), que visam controlar este distúrbio imunológico expresso pela atividade de diversos mediadores inflamatórios, estão contribuindo para a melhoria da qualidade de vida e do prognóstico dos pacientes.

Autoimmune diseases, as rheumatoid arthritis (RA) had a strong development in their treatment last years. Over the past years, the knowledge about the pathophysiological mechanism of RA has advanced dramatically, with the development of new classes of drugs and the implementation of different strategies of treatment and follow-up. Beside this new drugs, the associated use of the anti-inflammatory drugs, corticoids, sintetic or traditionals disease-modifying antirheumatic drugs allow control or suppress the disease activity giving a better quality of life and prognosis to the patients.

Successful salvage surgery after treatment failures with cross graft and free muscle transplant in facial reanimation.

BACKGROUND: The microneurovascular transfer of a free-muscle transplant is the procedure of choice for facial animation, It is characterized by low morbidity in both adult and paediatric patients. In spite of the improvements in microsurgical techniques, failures due to absent revascularization or reinnervation of the transplanted muscle or infections causing flap necrosis are observed. We propose a second surgical procedure based on the gracilis muscle transplant reinnervated by the masseteric nerve as a solution for these cases. METHODS: We analyzed and report on two patients treated in our department after the failure of a previous cross-facial nerve graft and free muscle transplant. They were treated with a new facial reanimation using the contralateral gracilis muscle and the masseteric nerve as the donor nerve. RESULTS AND DISCUSSION: We did not observe any postoperative complications, and all of the flaps survived. Reinnervation and contraction of the muscle appeared 3-4 months postoperatively, with good functional and aesthetic results. CONCLUSIONS: This technique is a one-step procedure characterized by reliable flap harvesting, low donor site morbidity and good activity of the masseteric nerve. We consider it as a good option for treatment of facial animation failures.