Triple nerve transfers for the management of early unilateral facial palsy.

BACKGROUND: Early onset facial paralysis is usually managed with cross-face nerve grafts, however the low number of axons that reach the target muscle may result in weakness or failure. Multiple-source innervation, or 'supercharging', seeks to combine the advantages of different donor nerves while minimizing their weaknesses. We propose a combination of cross-face nerve grafts with local extra-facial nerve transfers to achieve earlier facial reanimation in our patients. METHODS: A retrospective cohort including all patients with early unilateral facial palsy (<12 months evolution) who underwent triple nerve transfer between 2019 and 2021 was conducted. We performed single-stage procedure including zygomatic-to-zygomatic and buccal-to-buccal cross-face grafts, a nerve-to-masseter to bucozygomatic trunk transfer, and a mini-hypoglossal to marginal branch transfer. Results were evaluated using the clinician-graded facial function scale (eFACE). RESULTS: Fifteen patients were included (eight females, seven males), mean age at the time of surgery was 48.9 ± 13.3 years. Palsy was right-sided in eight cases. The mean time from palsy onset to surgery was 5.5 ± 2.8 months. Patients showed improvement in static (70.8 ± 21.9 vs. 84.15 ± 6.68, p = 0.002) and dynamic scores (20 ± 16.32 vs. 74.23 ± 7.46, p < 0.001), as well as periocular (57.33 ± 15.23 vs. 74 ± 7.18, p = 0.007), smile (54.73 ± 11.93 vs. 85.62 ± 3.86, p < 0.001), mid-face (46.33 ± 18.04 vs. 95 ± 7.21, p < 0.001) and lower face scores (67.4 ± 1.55 vs. 90.31 ± 7.54, p < 0.001). CONCLUSION: The triple nerve transfer technique using cross-face nerve grafts, the nerve-to-masseter, and the hypoglossal nerve, is an effective and reproducible technique to obtain middle and lower face reanimation in cases of early facial palsy.

Prevalence of Hand Malformations in Patients With Moebius Syndrome and Their Management.

BACKGROUND: Moebius syndrome is a disorder characterized by facial and abducens nerve paralysis. Patients can present a wide range of upper extremity malformations. Literature focused on orthopedic manifestations of Moebius syndrome shows variability in the prevalence and clinical presentation of upper extremity anomalies. The aim of this work is to evaluate the prevalence of upper extremity malformations in patients with Moebius syndrome, clarify its various clinical presentations, and present treatment strategies for their management. METHODS: This is a retrospective, cross-sectional study including patients with Moebius syndrome and upper extremity malformations between 2012 and 2019. Data include demographic characteristics, Moebius syndrome subtype, type of malformation, affected extremity, and surgical procedures underwent. Quantitative data were recorded as mean (standard deviation [SD]), and qualitative data were expressed in terms of totals and percentages. Statistical association between Moebius syndrome subtype and development of upper extremity anomalies was evaluated using binary logistic regression. RESULTS: Twenty-five out of 153 patients (16.3%) presented upper extremity malformations (48% male). Mean age of presentation was 9.08 ± 9.43 years. Sixty-eight percent of the malformations were unilateral. The most common presentations included Poland syndrome and simple syndactyly with 8 cases each (32%), followed by 5 cases of brachysyndactyly (20%), 3 cases of amniotic band syndrome (12%), and 1 case of cleft hand (4%). No statistical association was found between Moebius syndrome subtype and odds ratio for development of upper extremity anomalies. Thirteen patients (52%) underwent reconstructive procedures. CONCLUSION: Poland syndrome and syndactyly are the most common anomalies in patients with Moebius syndrome. Patients may present with a wide range of hand malformations, each patient should be carefully evaluated in order to determine whether surgical treatment is needed and to optimize rehabilitation protocols.

Carpometacarpal Joint Dislocations: Management and Long-Term Outcomes at a Specialized Hand Surgery Center in Latin America.

Carpometacarpal joint dislocations are uncommon hand injuries. These dislocations are usually misdiagnosed due to their non-specific clinical signs and tend to be difficult to identify in simple X-rays. We report our experience in the management of carpometacarpal bone dislocations at a specialized hand surgery center. Patients with carpometacarpal dislocations seen at the emergency department between 2013 and 2017 were included. All patients were treated with either closed reduction and percutaneous pinning (CRPP) or open reduction and internal fixation (ORIF). Postoperative functional assessment was performed at 6 and 18 months using the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Eleven patients were included, 8 (72%) were managed with CRPP and the rest required ORIF (28%). For the functional outcome, we found an average DASH score of 27.9 at the 6 months threshold and of 1.5 at the 18 months threshold. Carpometacarpal dislocations are uncommon and easy to misdiagnose; the hand surgeon should have a high clinical suspicion in patients who sustained high-energy trauma, and imaging studies should be thoroughly evaluated. Closed reduction and percutaneous pinning is a safe and effective treatment option, with long-term good functional results.

Les dislocations des articulations carpométacarpiennes sont des blessures peu courantes de la main. Elles sont généralement mal diagnostiquées en raison de leurs signes cliniques non spécifiques et ont tendance à être difficiles à dépister au moyen d'une simple radiographie. Les auteurs rendent compte de leur expérience dans la prise en charge des dislocations des os carpométacarpiens dans un centre spécialisé de chirurgie de la main. Les patients atteints d'une dislocation carpométacarpienne vus à l'urgence entre 2013 et 2017 étaient inclus dans l'étude. Tous les patients ont subi une réduction fermée et un embrochage percutané (RFEP) ou une réduction ouverte et une fixation interne (ROFI). L'évaluation fonctionnelle postopératoire a eu lieu au bout de six et 18 mois au moyen du score d'incapacité du bras, de l'épaule et de la main (DASH). Onze patients ont participé : huit (72 %) ont subi une RFEP et les autres ont dû subir une ROFI (28 %). Le score DASH moyen du résultat fonctionnel s'établissait à 27,9 au seuil de six mois et à 1,5 à celui de 18 mois. Puisque les dislocations carpométacarpiennes sont rares et faciles à mal diagnostiquer, le chirurgien de la main devrait en présumer la possibilité chez les patients victimes d'un traumatisme de forte énergie, et les études d'imagerie devraient faire l'objet d'une évaluation approfondie. La RFEP est une possibilité de traitement sécuritaire et efficace qui donne de bons résultats fonctionnels à long terme.

Surgical Resection of a Parotid Gland Hemangioma in Teenager Managed with External Carotid Artery Ligation.

Parotid gland hemangiomas represent <0.6% of the total tumors of the gland and there are <50 tumors reported during adult age, so there is no standard treatment. A 18-year-old female presents with a mass in the right parotid gland of 18 months of a slow progressive asymptomatic growth; on physical examination, only the mass was detected. An angiography was performed, and it reported a possible hemangioma that depends on the right internal maxillary artery and right facial artery and was not suitable for embolization. Total parotidectomy was performed with prior ligation of the right external carotid artery, complete resection was achieved and preservation of the facial nerve and all branches with minimal loss of blood (150 cc). External carotid artery ligation is a safe technique that can be considered in carefully selected patients with vascular tumors that affect the head and neck to achieve a clean and safe surgery with minimal sequels.