Da superfície para a profundidade: Curva de aprendizado em lifting facial profundo estendido - meus primeiros 100 casos / From Surface to Depth: Learning Curve in Extended Deep Facelift ­ my First 100 Cases

Introdução: O envelhecimento facial é um processo gradual, complexo e multifatorial. É o resultado de mudanças na qualidade, volume e posicionamento dos tecidos. Cirurgiões plásticos têm modificado sua abordagem na cirurgia do rejuvenescimento facial optando pelo plano subaponeurótico (SMAS). O objetivo deste estudo é analisar 100 casos de pacientes operados pela técnica de SMAS profundo, avaliando sua aplicabilidade e eficácia. Método: Foram avaliados 100 pacientes, submetidos a cirurgia plástica facial pela técnica de SMAS profundo - "Deep Smas", e acompanhados por 6 meses. Observou-se a satisfação dos pacientes, número de complicações, número de reoperações, riscos e vantagens da técnica. Resultados: Foram operados 100 pacientes, num período de 3 anos. A idade variou de 41 a 79 anos, sendo 95% sexo feminino. As complicações foram 8 casos (8%) de lesões de ramos do nervo facial, sendo: 4 casos lesão do zigomático, 3 casos de lesão do mandibular e 1 caso de lesão do bucal; houve 1 caso (1%) de queloide retroauricular; 1 caso (1%) de hematoma. Em relação às revisões cirúrgicas, houve 8 casos (8%) de complementação cirúrgica por insatisfação das pacientes. Houve 15% de lesões nervosas entre a 1ª e a 40ª cirurgia, 5% entre a 41ª e a 80ª, e nenhuma lesão entre o 81º e o 100º paciente. Conclusão: O lifting facial profundo ou subSMAS mostrou ser efetivo, proporcionando bons resultados estéticos. Apresenta baixa taxa de recidiva e baixa taxa de morbidade, porém, necessita de uma longa curva de aprendizagem.

Introduction: Facial aging is a gradual, complex, and multifactorial process. It is the result of changes in the quality, volume, and positioning of tissues. Plastic surgeons have modified their approach to facial rejuvenation surgery, opting for the subaponeurotic plane (SMAS). The objective of this study is to analyze 100 cases of patients operated on using the deep SMAS technique, evaluating its applicability and effectiveness. Method: 100 patients were evaluated, undergoing facial plastic surgery using the deep SMAS technique - "Deep Smas", and followed up for 6 months. Patient satisfaction, number of complications, number of reoperations, risks, and advantages of the technique were observed. Results: 100 patients were operated on over 3 years. Age ranged from 41 to 79 years, with 95% being female. The complications were 8 cases (8%) of injuries to branches of the facial nerve, of which 4 cases of zygomatic injury, 3 cases of mandibular injury, and 1 case of buccal injury; there was 1 case (1%) of post-auricular keloid; 1 case (1%) of hematoma. Regarding surgical revisions, there were 8 cases (8%) of surgical completion due to patient dissatisfaction. There were 15% of nerve injuries between the 1st and 40th surgery, 5% between the 41st and 80th, and no injuries between the 81st and 100th patient. Conclusion: Deep facial lifting or subSMAS has proven to be effective, providing good aesthetic results. It has a low recurrence rate and low morbidity rate; however, it requires a long learning curve.

Desmistificando a técnica de deep plane facelift com dissecção anatômica em cadáveres frescos / Demystifying the deep plane facelift technique with anatomical dissection in fresh cadavers

Introdução: Os estudos de anatomia em cadáveres permitiram um melhor entendimento das estruturas da face e, consequentemente, mais segurança ao explorar os planos profundos da região facial. Uma boa técnica deve ser segura, reprodutível e respeitar os pontos anatômicos. O objetivo deste trabalho é desmistificar a técnica de deep plane facelifting por meio da dissecção de cadáveres e exposição das estruturas faciais. Método: A reprodução da técnica de "deep plane facelifting" foi realizada em 14 hemifaces de 7 peças de cadáveres frescos no Instituto de Treinamento de Cadáver em Curitiba no ano de 2021. A técnica cirúrgica foi realizada conforme nossa prática clínica e reproduzida no cadáver. Após o procedimento, as estruturas anatômicas faciais foram dissecadas para correlacionar seu posicionamento junto aos espaços anatômicos da face. Foram avaliados os posicionamentos dos ligamentos da face, vascularização e os ramos do nervo facial. Resultados: Foram identificados os espaços anatômicos relevantes à técnica de deep plane facelifting, como os espaços massetéricos inferior e superior, espaço pré-zigomático, espaço bucal e espaço cervical. Os ramos do nervo facial foram identificados no plano subSMAS e correlacionados com os espaços e planos anatômicos. Conclusão: A técnica de deep plane facelift pode ser reproduzida com segurança desde que sejam respeitados dois parâmetros. O primeiro é a entrada correta nos espaços a fim de respeitar a anatomia. O segundo é o uso de descoladores rombos para dissecção nos planos profundos da face a fim de evitar lesão nervosa dos ramos do nervo facial.

Introduction: Anatomy studies on cadavers have allowed a better understanding of the structures of the face and, consequently, greater safety when exploring the deep planes of the facial region. A good technique must be safe, reproducible, and respect anatomical points. The objective of this work is to demystify the deep plane facelifting technique through the dissection of cadavers and exposure of facial structures. Method: The reproduction of the "deep plane facelifting" technique was performed on 14 hemifaces of 7 pieces of fresh cadavers at the Instituto de Treinamento de Cadáver (Cadaver Training Institute) in Curitiba in 2021. The surgical technique was performed according to our clinical practice and reproduced on the cadaver. After the procedure, the facial anatomical structures were dissected to correlate their positioning with the anatomical spaces of the face. The positioning of the facial ligaments, vascularization, and branches of the facial nerve were evaluated. Results: The anatomical spaces relevant to the deep plane facelifting technique were identified, such as the inferior and superior masseteric spaces, prezygomatic space, buccal space, and cervical space. The facial nerve branches were identified in the sub-SMAS plane and correlated with the anatomical spaces and planes. Conclusion: The deep plane facelift technique can be reproduced safely as long as two parameters are respected. The first is the correct entry into spaces to respect the anatomy. The second is the use of blunt detachers for dissection in the deep planes of the face to avoid nerve damage to the branches of the facial nerve.

Electroacupuncture Promotes Functional Recovery after Facial Nerve Injury in Rats by Regulating Autophagy via GDNF and PI3K/mTOR Signaling Pathway / 中国结合医学杂志

OBJECTIVE@#To explore the mechanism of electroacupuncture (EA) in promoting recovery of the facial function with the involvement of autophagy, glial cell line-derived neurotrophic factor (GDNF), and phosphatidylinositol-3-kinase (PI3K)/mammalian target of rapamycin (mTOR) signaling pathway.@*METHODS@#Seventy-two male Sprague-Dawley rats were randomly allocated into the control, sham-operated, facial nerve injury (FNI), EA, EA+3-methyladenine (3-MA), and EA+GDNF antagonist groups using a random number table, with 12 rats in each group. An FNI rat model was established with facial nerve crushing method. EA intervention was conducted at Dicang (ST 4), Jiache (ST 6), Yifeng (SJ 17), and Hegu (LI 4) acupoints for 2 weeks. The Simone's 10-Point Scale was utilized to monitor the recovery of facial function. The histopathological evaluation of facial nerves was performed using hematoxylin-eosin (HE) staining. The levels of Beclin-1, light chain 3 (LC3), and P62 were detected by immunohistochemistry (IHC), immunofluorescence, and reverse transcription-polymerase chain reaction, respectively. Additionally, IHC was also used to detect the levels of GDNF, Rai, PI3K, and mTOR.@*RESULTS@#The facial functional scores were significantly increased in the EA group than the FNI group (P<0.05 or P<0.01). HE staining showed nerve axons and myelin sheaths, which were destroyed immediately after the injury, were recovered with EA treatment. The expressions of Beclin-1 and LC3 were significantly elevated and the expression of P62 was markedly reduced in FNI rats (P<0.01); however, EA treatment reversed these abnormal changes (P<0.01). Meanwhile, EA stimulation significantly increased the levels of GDNF, Rai, PI3K, and mTOR (P<0.01). After exogenous administration with autophagy inhibitor 3-MA or GDNF antagonist, the repair effect of EA on facial function was attenuated (P<0.05 or P<0.01).@*CONCLUSIONS@#EA could promote the recovery of facial function and repair the facial nerve damages in a rat model of FNI. EA may exert this neuroreparative effect through mediating the release of GDNF, activating the PI3K/mTOR signaling pathway, and further regulating the autophagy of facial nerves.

Exploration of correlation between multiple subjective and objective evaluation indicators in early stage with recovery time in combination of acupuncture and medication for treating facial neuritis / 重庆医学

Objective To analyze the correlation between the multiple evaluation indicators in the early stage and the cure time(needed time from treatment to cure)of the patients with facial neuritis treated by ac-upuncture combined with medication,and to optimize the subjective and objective indicators enable predicting the cure time of facial neuritis in early stage.Methods All patients were treated by acupuncture and medica-tion combination.The research subjects were 64 patients with facial neuritis from the outpatient of cupuncture and moxibustion department of this hospital.The correlation between the grade of facial nerve paralysis,sur-face electromyography related data,scores of self-made symptom scoring scale,Sunnybrook Facial Grading System(SFGS)score,Facial Disability Index-Physical(FDIP)score,Facial Disability Index-Social(FDIS)score on 7 d of onset with the cure time was analyzed.Results The cure time was positively correlated with the grade of facial nerve paralysis and FDIS score on 7 d of onset(P＜0.01),amd negatively correlated with the scores of self-made symptom scoring scale,FDIP score,SFGS score and the affected side to healthy ratio of CMAP amplitude of buccal temporal branch of facial nerve(P＜0.01 or P＜0.05);the cure time had no sig-nificant correlation with the ratio of affected side and healthy side of CMAP amplitude in zygomatic branch of facial nerve,the ratio of affected side and healthy side of CMAP latent period of temporal branch,buccal branch and zygomatic branch of facial nerve and F wave output rate(P＞0.05).Conclusion In the early stage subjective indicators of the acupuncture combined with medication for treating facial neuritis,grade of facial nerve paralysis,self-made symptom scoring scale,scores of self-made symptom scoring scale,FDIP and FDIS scores and the ratio of affected side to healthy side of CMAP amplitude of the buccal branch,temporal branch of the facial nerve in sEMG in the objective indicators could be used to predict the cure time,better guide the treatment and have more effective and accurate comunication with the patients.

Autophagy protects neurons against facial nerve injury in rats / 中国组织工程研究

BACKGROUND:After peripheral facial nerve injury,glial cell-derived neurotrophic factor(GDNF)can play a protective role in facial neurons.It has been found that GDNF can regulate the level of autophagy through mammalian target of rapamycin(mTOR),but it is unclear whether it can regulate facial neurons through the adenylate-activated protein kinase/Unc-51-like kinase 1(AMPK/ULK1)signaling pathway after facial nerve injury. OBJECTIVE:To establish a facial nerve injury model in Sprague-Dawley rats and explore the role of autophagy in facial nerve regeneration and the mechanism by which the GDNF/AMPK/ULK1 signaling pathway promotes facial nerve repair after injury. METHODS:Seventy-two Sprague-Dawley rats were randomly divided into sham group,model group and autophagy inhibitor 3-methyladenine(3-MA)group,with 24 rats in each group.Only the main trunk of the facial nerve was exposed in the sham group,while the remaining two groups were modeled for the compression injury of the facial nerve trunk.After successful modeling,the model group was given intraperitoneal injection of normal saline(15 mg/kg),and the 3-MA group was given intraperitoneal injection of 3-MA(15 mg/kg),both once daily for 7 days.The rats in each group were scored on the Simone 10-point behavioral scale at 1,4,7,14,21 and 28 days after surgery.Nissl staining was performed to observe the morphology and number of facial neuron cells at 7,14,21,and 28 days.The expression levels of p-AMPK,p-ULK1,Beclin1 and GDNF in the facial neuron tissues of rats were detected by western blot assay. RESULTS AND CONCLUSION:Behavioral scoring showed that the improvement of facial paralysis symptoms in the 3-MA group was worse and later than that in the model group(P<0.05).Nissl staining showed that the morphology and number of Nissl bodies in facial neurons in the 3-MA group recovered poorly and the number was less than that in the model group(P<0.05).Western blot detection results showed that the expression of p-AMPK and Beclin1 in the model group was higher than that in the 3-MA group and the sham group(P<0.05).The protein expression of p-ULK1 in the model group was lower than that in the 3-MA group and the sham group(P<0.05).To conclude,autophagy inhibitor delays nerve repair after facial nerve injury,which may be related to down-regulation of GDNF expression,inactivation of AMPK,and phosphorylation of ULK1,thereby inhibiting neuronal autophagy levels.

Hearing Performance in Cochlear Implant Users Who Have Facial Nerve Stimulation

Abstract Introduction Facial nerve stimulation (FNS) is a complication in cochlear implant (CI) when the electrical current escapes from the cochlea to the nearby facial nerve. Different management to reduce its effects are available, although changes might result in a less-than-ideal fitting for the CI user, eventually reducing speech perception. Objective To verify the etiologies that cause FNS, to identify strategies in managing FNS, and to evaluate speech recognition in patients who present FNS. Methods Retrospective study approved by the Ethical Board of the Institution. From the files of a CI group, patients who were identified with FNS either during surgery or at any time postoperatively were selected. Data collection included: CI manufacturer, electrode array type, age at implantation, etiology of hearing loss, FNS identification date, number of electrodes that generated FNS, FNS management actions, and speech recognition in quiet and in noise. Results Data were collected from 7 children and 25 adults. Etiologies that cause FNS were cochlear malformation, head trauma, meningitis, and otosclerosis; the main actions included decrease in the stimulation levels followed by the deactivation of electrodes. Average speech recognition in quiet before FNS was 86% and 80% after in patients who were able to accomplish the test. However, there was great variability, ranging from 0% in quiet to 90% of speech recognition in noise. Conclusion Etiologies that cause FNS are related to cochlear morphology alterations. Facial nerve stimulation can be solved using speech processor programming parameters; however, it is not possible to predict outcomes, since results depend on other variables.

Task force of the Brazilian Society of Otology — evaluation and management of peripheral facial palsy

Abstract Objective To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults. Methods Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on peripheral facial palsy were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions. Results The topics were divided into 2 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve. Conclusions Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

Post-parotidectomy facial nerve function: comparison between original and modified Sunnybrook Facial Grading Systems / Função do nervo facial pós-parotidectomia: comparação entre os Sistemas Sunnybrook de Graduação Facial original e modificado

Abstract Background: Facial nerve dysfunction is the principal postoperative complication related to parotidectomy. Objective: To test the hypothesis that the modified Sunnybrook Facial Grading System (mS-FGS) is superior to the original S-FGS in the assessment of facial nerve function following parotidectomy. Methods: Prospective, longitudinal study evaluating patients with primary or metastatic parotid neoplasms undergoing parotidectomy with facial nerve-sparing between 2016 and 2020. The subjects were assessed twice, on the first postoperative day and at the first outpatient evaluation, 20-30 days post-surgery. Facial assessments were performed using the original and modified (plus showing the lower teeth) versions of the Sunnybrook System and documented by pictures and video recordings. Intra- and inter-rater agreements regarding the assessment of the new expression were analyzed. Results: 101 patients were enrolled. In both steps, the results from the mS-FGS were significantly lower (p < 0.001). Subjects with a history of previous parotidectomy and those who underwent neck dissection had more severe facial nerve impairment. The mandibular marginal branch was the most frequently injured, affecting 68.3% of the patients on the first postoperative day and 52.5% on the first outpatient evaluation. Twenty patients (19.8%) presented an exclusive marginal mandibular branch lesion. The inter-rater agreement of the new expression assessment ranged from substantial to almost perfect. The intra-rater agreement was almost perfect (wk = 0.951). Conclusion: The adoption of the Modified Sunnybrook System, which includes evaluation of the mandibular marginal branch, increases the accuracy of post-parotidectomy facial nerve dysfunction appraisal.

Resumo Antecedentes: A disfunção do nervo facial é a principal complicação pós-operatória relacionada à parotidectomia. Objetivo: Testar a hipótese de que o sistema Sunnybrook de graduação facial modificado (mS-FGS) é superior ao S-FGS original na avaliação da função do nervo facial após parotidectomia. Métodos: Estudo longitudinal prospectivo avaliando o pós-operatório de pacientes com neoplasias parotídeas primárias ou metastáticas, submetidos à parotidectomia com preservação do nervo facial, entre 2016 e 2020. Os indivíduos foram avaliados duas vezes, no primeiro dia de pós-operatório e na primeira avaliação ambulatorial, 20-30 dias após a cirurgia. As avaliações faciais foram realizadas usando as versões original e modificada (que incluem mostrar os dentes inferiores) do sistema Sunnybrook e documentadas por fotos e vídeos. Foram adicionalmente analisadas as concordâncias intra e interexaminadoras da avaliação da nova expressão. Resultados: Cento e um pacientes foram incluídos. Em ambas as etapas, os resultados do mS-FGS foram significativamente menores (p < 0,001). Indivíduos com história de parotidectomia prévia e aqueles submetidos ao esvaziamento cervical apresentaram comprometimento mais grave do nervo facial. O ramo marginal mandibular foi o mais afetado, acometendo 68,3% dos pacientes no primeiro dia de pós-operatório e 52,5% na primeira avaliação ambulatorial. Vinte pacientes (19,8%) apresentaram lesão exclusiva do ramo marginal mandibular. A concordância interexaminadores da avaliação da nova expressão variou de substancial a quase perfeita. A concordância intraexaminador foi quase perfeita (wk = 0,951). Conclusão: A adoção do sistema Sunnybrook modificado, que inclui a análise do ramo marginal mandibular, aumenta a precisão da avaliação da disfunção do nervo facial pós-parotidectomia.

Lower Four Cranial Nerves in the Management of Glomus Jugulare: Anatomical Study

Abstract Introduction The surgical management that achieves minimal morbidity and mortality for patients with glomus and non-glomus tumors involving the jugular foramen (JF) region requires a comprehensive understanding of the complex anatomy, anatomic variability, and pathological anatomy of this region. Objective The aim of this study is to propose a rational guideline to expose and preserve the lower cranial nerves (CNs) in the lateral approach of the JF. Methods The technique utilized is the gross and microdissection of 4 fixed cadaveric heads to revise the JF's surgical anatomy and high part of the carotid sheath compared with surgical cases to understand and preserve the integrity of lower CNs. The method involves radical mastoidectomy, microdissection of the JF, facial nerve, and high neck just below the carotid canal and the JF. The CNs IX, X, XI, and XII are microscopically dissected and kept in sight up to the JF. Results This study realized well the surgical and applied anatomy of the lower CNs with relation to the facial nerve and JF. Conclusions The JF anatomy is complicated, and the key to safely operate on it and preserving the lower CNs is to find the posterior belly of the digastric muscle, to skeletonize the facial nerve, to remove the mastoid tip preserving the stylomastoid foramen, to skeletonize the sigmoid sinus and posterior fossa dura not only anterior but also posteroinferior to reach and drill the jugular tubercle.

A Clinical and Anatomical Study on the Localization of the Temporal Branch of the Facial Nerve Crossing the Zygomatic Arch / Estudio Clínico y Anatómico sobre la Localización del Ramo Temporal del Nervio Facial que Cruza el Arco Cigomático

SUMMARY: To clarify the path of the temporal branch of facial nerve (TB) crossing the zygomatic arch (ZA). Eighteen fresh adult heads specimens were carefully dissected in the zygomatic region, with the location of TB as well as its number documented. The hierarchical relationship between the temporal branch and the soft tissue in this region was observed on 64 P45 plastinated slices. 1. TB crosses the ZA as type I (21.8 %), type II (50.0 %,), and type III (28.1 %) twigs. 2. At the level of the superior edge of the ZA, the average distance between the anterior trunk of TB and the anterior part of the auricle is 36.36±6.56 mm, for the posterior trunk is 25.59±5.29 mm. At the level of the inferior edge of the ZA, the average distance between the anterior trunk of TB and the anterior part of the auricle is 25.77±6.19 mm, for the posterior trunk is 19.16±4.71 mm. 3. The average length of ZA is 62.06±5.36 mm. TB crosses the inferior edge of the ZA at an average of 14.67±6.45 mm. TB crosses the superior edge of the ZA at an average of 9.08±4.54 mm. 4. At the level of the ZA, TB passes on the surface of the pericranium while below the SMAS. The TB obliquely crosses the middle 1/3 part of the superior margin of the ZA and the junction of the middle 1/3 part and the posterior 1/3 part of the inferior margin of the ZA below the SMAS while beyond the periosteum. It is suggested that this area should be avoided in clinical operation to avoid the injury of TB.

El objetivo de estudio fue esclarecer el trayecto del ramo temporal del nervio facial (RT) que cruza el arco cigomático (AC). Se disecaron la región cigomática de 18 especímenes de cabezas sin fijar de individuos adultas y se documentó la ubicación del RT y su número de ramos. La relación jerárquica entre el ramo temporal y el tejido blando en esta región se observó en 64 cortes plastinados o P45. 1º El RT cruza el AC como tipo I (21,8 %), tipo II (50,0 %) y tipo III (28,1 %). 2º A nivel del margen superior del AC, la distancia promedio entre el tronco anterior de RT y la parte anterior de la aurícula fue de 36,36±6,56 mm, para el tronco posterior fue de 25,59±5,29 mm. A nivel del margen inferior del AC, la distancia promedio entre el tronco anterior del RT y la parte anterior de la aurícula era de 25,77±6,19 mm, para el tronco posterior era de 19,16±4,71 mm. 3º La longitud media de RT fue de 62,06±5,36 mm. EL RT cruzaba el margen inferior del AC a una distancia media de 14,67±6,45 mm. El RT cruzaba el margen superior del AC a una distancia media de 9,08±4,54 mm. 4º Anivel del AC, el RT pasaba por la superficie del pericráneo mientras se encuentra por debajo del SMAS. El RT cruza oblicuamente el tercio medio del margen superior del AC y la unión del tercio medio y el tercio posterior del margen inferior del AC por debajo del SMAS, más allá del periostio. Se sugiere que esta área debe evitarse en la operación clínica para evitar la lesión de la RT.

Parálisis facial alternobárica: a propósito de un caso y revisión de la literatura / Alternobaric facial palsy: case report and literature review

La parálisis o paresia facial alternobárica es una neuropraxia del séptimo nervio cra-neal debido a cambios de presión. Se produce en el contexto de una disfunción de la trompa de Eustaquio, una dehiscencia canal del nervio facial y cambios en la presión atmosférica. Se considera una rara complicación de barotrauma. Su prevalencia es difícil de estimar y, probablemente, se encuentre subreportada. La forma de presentación más habitual incluye paresia facial, plenitud aural, hipoacusia, otalgia, parestesias faciales y linguales. La mayoría de los episodios son transitorios, con una duración entre minutos y algunas horas, con recuperación posterior completa. Entre los diagnósticos diferenciales se encuentran causas periféricas y centrales de paresia facial, las cuales hay que sospechar ante la persistencia de los síntomas en el tiempo o ante la presencia de otros signos o síntomas neurológicos. La evaluación inicial debe incluir un examen otoneurológico completo. La tomografía computarizada de hueso temporal favorece la visualización de posibles dehiscencias del canal del facial. La prevención de nuevos episodios incluye la práctica de ecualización efectiva, la resolución de la disfunción de la trompa de Eustaquio y en algunos casos específicos, métodos alternativos de ventilación del oído medio como la colocación de tubos de ventilación. Una vez instalada la parálisis facial, si no se produce recuperación espontánea, el uso de corticoides es una opción. Se presenta un caso de paresia facial alternobárica recurrente y una revisión de literatura.

Alternobaric facial palsy or paralysis is a neuropraxia of the seventh cranial nerve due to pressure changes. It occurs in the context of Eustachian tube dysfunction, facial nerve canal dehiscence, and changes in atmospheric pressure. It is considered a rare complication of barotrauma. Its prevalence is difficult to estimated, and this condition is probably underreported. The most common form of presentation includes facial weakness, ear fullness or pressure, hearing loss, otalgia, facial and lingual paresthesias. Most episodes are transient, lasting from minutes to a few hours, with a subsequent complete recovery. Among the possible differential diagnoses are peripheral and central causes of facial paralysis, which must be suspected due to the persistence of symptoms over time or the presence of other neurological signs or symptoms. The initial evaluation should include a complete otoneurological examination. Computed tomography of the temporal bone is useful for the visualization of facial canal dehiscence. Prevention of further episodes includes practicing effective equalization, Eustachian tube dysfunction treatment, and in certain specific cases, alternative middle ear ventilation methods such as tympanostomy tubes. Once facial paralysis is established, if spontaneous recovery does not occur, the use of corticosteroids is considered an option. A case of recurrent alternobaric facial paresis and a review of the literature are presented.

The potential applicability of facial nerve monitoring as a navigation tool in parotid gland surgery

Abstract Objectives: The aim of this study was to assess the relationship between the stimulation amplitude and the distance to the facial nerve. Methods: This study was designed as a prospective clinical study. A total of 20 patients (12 males, 8 females) were included. Partial superficial parotidectomy was performed in all patients with intraoperative facial monitoring. Measurements were made on the main trunk and major branches. Stimulation was started at 1 mA and incrementally increased to 2 and 3mA's. The shortest distance creating a robust response (>100mV) was recorded. Results: At 1 mA, 2 mA and 3 mA stimulation intensity, the average distance between the tip of the stimulation probe and the main trunk was 2.20±0.76 mm (range 1-3 mm), 3.80±0.95 mm (range 2-5 mm), 4.80±1.05 mm (range 3-7 mm) respectively. The stimulus intensity was inversely proportional in respect to the distance between the nerve and the tip of the stimulus probe (P < .00). The same relation was present in the facial nerve major branch measurements (P < .00). Conclusion: The proportional stimulation amplitude and distance to the facial nerve is thought to be a reliable auxillary method to assist the surgeon by facilitating the estimation of the distance to the facial nerve during extracapsular dissection and minimally invasive cases where the facial nerve isn't routinely dissected. Level of evidence: Level 3.

Morphofunctional regeneration by mesenchymal stem cell and IGF-1 inoculation in a model of facial nerve crush injury in rats

Abstract Objective: To analyze the morphofunctional regeneration process of facial nerve injury in the presence of insulin-like growth factor-1 and mesenchymal stem cells. Methods: Fourteen Wistar rats suffered unilateral facial nerve crushing and were randomly divided into two groups. All received insulin-like growth factor-1 inoculation, but only half of the animals received an additional inoculation of mesenchymal stem cells. The animals were followed for 90 days and facial nerve regeneration was analyzed via spontaneous facial motor function tests and immunohistochemistry in the nerve motor nucleus. Results: The group that received the growth factor and stem cells showed a statistically superior mean in vibrissae movements (p<0.01), touch reflex (p = 0.05) and eye closure (p<0.01), in addition to better immunohistochemistry reactivity. There was a statistically significant difference in the mean number of cells in the facial nerve nucleus between the experimental groups (p = 0.025), with the group that received the growth factor and stem cells showing the highest mean. Conclusion: The association between growth factor and stem cells potentiates the morphofunctional regeneration of the facial nerve, occurring faster and more effectively. Level of Evidence: 4, degree of recommendation C.

New Onset Facial Nerve Palsy : A Part of Post COVID Mucormycosis Disease Spectrum — A Descriptive Observational Study

Introduction : COVID Associated Mucor (CAM) is a well known entity with defined symptomatology. Cranial Nerve Palsy involving II, III, IV, V, VI th Nerve is common. Facial Nerve involvement is an out of tract presentation. The study was aimed to find the incidence of Facial Nerve involvement in CAM and document their route of involvement. Material and Method : Descriptive observational study was done in an Apex Centre for CAM in West Bengal between April, 2021 to January, 2022. CAM having Rhino-orbital-cerebral Mucormycosis (ROCM) and new onset Facial Palsy were considered. Participants were included following stipulated inclusion and exclusion criteria. Collected data was analysed. Observations : Total 11 patients of new onset Facial Palsy in COVID-19-Associated ROCM were included. 81.8% had coexisting other Cranial Nerve involvement. Facial Palsy was one of the primary presentations in the patients of ROCM. Discussion : CAM is angioinvasive and can cause concomitant hypoxic neural damage due to involvement of the vasa nervorum. Skull base involvement can be hypothesized to be the predominant route of Facial Nerve involvement. Facial palsy can be an important initial presentation of CAM. Conclusion : Facial Nerve Palsy may be a part of the spectrum of disease presentation in CAM.

Basic and Clinical Research Review of the Effects of Acupuncture and Moxibustion on Peripheral Facial Nerve Paralysis / 全日本鍼灸学会雑誌

There is little common understanding among acupuncturists regarding the poor prognosis for peripheral facial paralysis, evaluation methods, precautions during treatment, including acupuncture and moxibustion treatment. Cooperation among relevant occupations is also a major issue. Currently, the treatment of paralysis is focused on how to minimize sequelae during the recovery process of paralysis in cases with poor prognosis. The goal is to prevent sequelae and improve patient quality of life (QOL). For that purpose, it is important to understand the guidelines for medical treatment of paralysis, and like other medical staff, the acupuncturist should provide appropriate medical examination, treatment, self-care guidance, etc., and cooperate with other medical specialists. We hope that this seminar will provide a common understanding of the pathophysiology and evaluation methods of paralysis, precautions for acupuncture and moxibustion treatment, and a consensus of clinical research and the future possibility of using acupuncture and moxibustion in the treatment of paralysis.

Modified tragus edge incision and transmasseteric anteroparotid approach to condyle reconstruction / 华西口腔医学杂志

OBJECTIVES@#This study aimed to analyze the application value of a modified tragus edge incision and transmasseteric anteroparotid approach to condyle reconstruction.@*METHODS@#Condyle reconstruction was performed in 16 patients (9 females and 7 males) with modified tragus edge incision and transmasseteric anteroparotid approach. After regular follow-up, the function of condyle reconstruction was evaluated by clinical indicators, such as parotid salivary fistula, facial nerve function, mouth opening, occlusal relationship, and facial scar. The morphology of rib graft rib cartilage was evaluated by imaging indicators, such as panoramic radiography, CT, and three-dimensional CT image reconstruction.@*RESULTS@#At 6-36 months postoperative follow-up, all patients had good recovery of facial appearance, concealed incisional scar, no parotid salivary fistula, good mouth opening, and occlusion. One case had temporary facial paralysis and recovered after treatment. Radiographic evaluation further showed that costochondral graft survived in normal anatomic locations.@*CONCLUSIONS@#The modified tragus edge incision and transmasseteric anteroparotid approach can effectively reduce parotid salivary fistula and facial nerve injury in condylar reconstruction. The surgical field was clearly exposed, and the incision scar was concealed without increasing the incidence of other complications. Thus, this approach is worthy of clinical promotion.

Multimodal image three-dimensional reconstruction combined with facial nerve tracking in acoustic neuroma surgery / 中华神经医学杂志

Objective:To investigate the application value of multimodal image three-dimensional reconstruction combined with facial nerve tracking in acoustic neuroma surgery.Methods:Forty-five patients with single acoustic neuroma accepted primary surgical treatment at Department of Neurosurgery, Yibin Hospital, West China Hospital, Sichuan University from November 2018 to June 2022 were chosen. The head, skull, brain tissues, arteriovenous system, tumor and facial nerves were reconstructed preoperatively by multimodal three-dimensional image reconstruction combined with facial nerve tracking. Preoperative planning was carried out according to the relationship between tumor and surrounding structures. The accuracy of facial nerve tracking was evaluated by intraoperative microscopic observation and nerve electrophysiological monitoring. House-Brackmann (H-B) criteria was used to evaluate facial nerve functions 2 weeks after surgery. Three months after surgery, all patients underwent enhanced MRI scanning, and combined with intraoperative findings, the degrees of acoustic neuroma resection were determined.Results:The facial nerves and their relations with acoustic neuroma were successfully tracked in all 45 patients; as confirmed by intraoperative microscopy and nerve electrophysiological monitoring, the results of facial nerves and their relations with acoustic neuroma were consistent in 42 patients and inconsistent in 3 patients. Using intraoperative nerve electrophysiological monitoring as gold standard, the accuracy of multimodal image three-dimensional reconstruction of the facial nerves was 93.3%. Preoperative facial nerve tracking results were highly consistent with intraoperative nerve electrophysiological monitoring results (Kappa=0.903, P<0.001). The facial nerves were intraoperatively preserved in 91.1% patients (41/45), and the facial nerve function was good in 86.7% patients (39/45) at 2 weeks after surgery. The total/subtotal resection rate of acoustic neuroma was 88.9% (40/45). No death, cerebrospinal fluid leakage, hematoma, or cerebral infarction were noted during the perioperative period. Conclusion:Multimodal image three-dimensional reconstruction combined with facial nerve tracking can help to protect blood vessels and nerves, improve total resection rate and facial nerve function retention rate in surgery of acoustic neuroma.

Mechanism of facial nerve nucleus excitability in patients with hemifacial spasm based on blink reflexes / 中华神经医学杂志

Objective:To further elucidate the pathogenesis of hemifacial spasm by analyzing blinking reflex characteristics.Methods:A total of 63 patients with hemifacial spasm (hemifacial spasm group) who underwent neuroelectrophysiological evaluation in Department of Neurological Electrophysiology, Guizhou Provincial People's Hospital from January 2021 to December 2022 were included as study subjects. Additionally, 58 patients with primary trigeminal neuralgia (trigeminal neuralgia group), 8 patients with post-facial paralysis associated exercise (post-facial paralysis associated exercise group), and 20 healthy volunteers (normal group) were selected as controls. Differences in facial nerve motor conduction velocity, complex muscle action potential latency, and blinking reflex characteristics including R1 latency, R1 amplitude, R2 initiation latency, R2 amplitude, R2 terminal latency, R2' initiation latency recorded on the affected side, R2' amplitude recorded on the affected side, and R2' terminal latency recorded on the affected side were collected and compared. Severity of hemifacial spasm was graded from grade 1 to grade 4 according to Samsung Medical Center scoring system; based on microvascular decompression findings regarding responsible blood vessels contacted with the facial nerve, patients were divided into one responsible blood vessel group and two or more responsible blood vessels group; trends or differences in incidences of increased/prolonged blink reflex indexes among all groups were analyzed.Results:No significant difference in facial nerve motor conduction velocity or complex muscle action potential latency was noted among the 4 groups ( P>0.05); the hemifacial spasm group had significantly higher R1 amplitude than the trigeminal neuralgia group and post-facial paralysis associated exercise group; additionally, the hemifacial spasm group had significantly higher R2 amplitude, R2' amplitude recorded on the affected side, R2 terminal latency, and R2' terminal latency recorded on the affected side compared with the other 3 groups ( P<0.05). Among patients with varying degrees of hemifacial spasm, increased incidences of increased R1 amplitude and prolonged R2 terminal latency were noted with increased spasm degrees, enjoying significant differences ( P<0.05). No significant differences in incidences of increased R1 amplitude, increased R2 amplitude, prolonged R2 terminal latency, increased R2' amplitude recorded on the affected side or prolonged R2' terminal latency recorded on the affected side were noted between one responsible blood vessel group and two or more responsible blood vessels group ( P>0.05). Conclusion:Increased R1 amplitude and prolonged R2 latency in patients with hemifacial spasm further substantiate the pathogenesis of hyperexcitability within facial nerve nucleus.

Expert Consensus on Facial Reanimation with Masseteric-to-facial Nerve Transposition (2023) / 中华显微外科杂志

Facial paralysis causes both physical pain and psychological distress to patients. It is difficult for a patient with facial paralysis to engage with a normal social life and at work. Progresses have been made in recent years in the treatment of facial paralysis. More attentions have been caught by masseteric to facial nerve transposition, which has advantages of adjacency in location, abundancy in nerve supply and reliability in the outcome and now has deemed an important option of facial reanimation. It has not been long since the application of the technique of masseteric to facial nerve transposition in China, therefore it still lacks a universal guidance on practice. In order to achieve the aim of better quality control and popularisation of the technique, hereby a consensus with suggestions on facial reanimation with masseteric to facial nerve transposition is proposed as the reference for surgeons specialised in facial reanimation. This consensus is proposed, discussed and drafted by experts from plastic and reconstructive surgery, oral and maxillofacial surgery, head and neck surgery and neurosurgery.

Professor LI De-hua's experience in treating facial nerve injury after total parotidectomy with blade needle based on jingjin theory / 中国针灸

The paper summarizes the academic thought and clinical experience of professor LI De-hua in treatment of facial nerve injury after total parotidectomy with blade needle based on jingjin (muscle region of meridian, sinew/fascia) theory. This disease is located at muscle regions of hand-/foot-three yang meridians; and the sinew/fascia adhesion is its basic pathogenesis, manifested by "transversely-distributed collaterals" and "knotted tendons". In treatment, the knotted tendons are taken as the points. Using the relaxation technique of blade needle, the lesions of sinews/fascia are dissected and removed to release the stimulation or compression to the nerves and vessels so that the normal function of sinews/fascia can be restored.