Facial composite tissue allograft.

Despite complex facial anatomy, transplantation of soft tissues of the entire face, including the maxilla and mandibular segment anterior to the masseter muscle insertion, can be safely performed based on facial vessels alone. Inclusion of hair-bearing scalp requires dissection of the superficial temporal vessels. Unlike other groups, we advocate for supercharging dissected superficial temporal vessels in the preauricular area avoiding difficult dissections in the depth of external auditory canal that presents significant challenges associated with lengthy dissection and bleeding. Neurorrhaphy at the trunk of the facial nerve leads to less targeted postoperative reinnervation, with potential for synkinesis, and whenever possible, individual peripheral facial nerve branches should be reconnected. Adequate planning for integration of the facial allograft requires both complete sensory and motor nerve connection and should be part of each operation. Bilateral external carotid anastomosis may cause a variety of functional problems including oropharyngeal dysfunction and ocular ischemia and hence is not recommended.

Local neurotoxins for prevention of laryngeal synkinesis after recurrent laryngeal nerve injury.

OBJECTIVES: Persistent vocal fold motion impairment after recurrent laryngeal nerve (RLN) injury is not characteristically due to absent reinnervation, but often results from spontaneous aberrant reinnervation (synkinesis). We administered local neurotoxins to selected laryngeal muscles after RLN injury to determine whether aberrant reinnervation could be selectively inhibited. METHODS: Unilateral RLN transection was performed in 24 male rats. Three weeks later, the denervated laryngeal adductor complex was injected with phenol, high- or low-dose vincristine sulfate (VNC), or saline solution. One month later, rat larynges were evaluated via videolaryngoscopy and laryngeal electromyography (LEMG). Larynges from euthanized animals were analyzed via immunofluorescent staining for the presence of reinnervation. RESULTS: One animal that received phenol and 3 animals that received high-dose VNC died of toxicity-related complications. In the surviving neurotoxin-treated animals, videolaryngoscopy showed increased lateralization of the immobile vocal fold. Only 1 phenol-injected rat had adductor complex motor recruitment (score of 3+) with LEMG. The other neurotoxin-treated animals demonstrated an absence of adductor complex reinnervation, with only insertional activity and fibrillations (no motor units/recruitment). Spontaneous ipsilateral abductor reinnervation was not affected by the adductor injections. CONCLUSIONS: Low-dose VNC injections appear to be relatively safe and effective in selectively inhibiting spontaneous aberrant reinnervation after RLN injury in an animal model.

Efficacy of Tape Feedback Therapy on Synkinesis Following Severe Peripheral Facial Nerve Palsy.

BACKGROUND: Mirror feedback rehabilitation is effective in preventing the development of oro-ocular synkinesis following severe facial palsy. However, we do not have effective maneuvers to prevent the deterioration of oculo-oral synkinesis. We developed a new method of biofeedback rehabilitation using tape for the prevention of oculo-oral synkinesis. OBJECTIVE: The aim of the present study was to investigate the efficacy of taping feedback rehabilitation. METHODS: Twelve consecutive patients with peripheral facial nerve palsy who developed synkinesis were divided into 2 groups. Six patients were treated with the new training method, and the remaining 6 patients were treated with conventional therapy as controls. In the experiment group, tape was placed around the mouth, and the patient was instructed to close the eyes so that no movements of the mouth would be perceived from sensations of the taped skin. After 4 weeks of training, facial movements were recorded and movie images were graded for mouth synkinesis using the revised Sunnybrook facial grading system by examiners blinded to patient grouping. RESULTS: Mouth corner contraction during eye closure was significantly weaker in the experimental group than in the control group. CONCLUSIONS: Our new feedback method could help prevent the deterioration of oculo-oral synkinesis.

Usefulness of BFB/EMG in facial palsy rehabilitation.

OBJECTIVE: To analyze and to compare the recovery and the development of synkinesis in patients with idiopathic facial palsy (Bell's palsy) following treatment with two methods of rehabilitation, kinesitherapy (KT) and biofeedback/EMG (BFB/EMG). STUDY DESIGN: Retrospective cases--series review. METHODS: Seventy-four patients with Bell' palsy were clinically evaluated within 1 month from onset of palsy and at 12 months after palsy (House scale and synkinesis evaluation). Electromyography (EMG) and Electroneurography (ENG) were performed about 4 weeks after palsy to better evaluate functional abnormalities due to facial nerve lesion. The patients followed two different protocols for rehabilitation: the first 32 patients were treated with therapeutic exercises performed by therapists (KT group), the latter 42 patients were treated using BFB/EMG methods (BFB group) with inhibition of synkinetic movement as the primary goal. RESULTS: KT and BFB patients were evaluated for clinical and neurophysiological characteristics before rehabilitative treatment. BFB patients showed better clinical recovery and minor synkinesis than KT patients. CONCLUSIONS: BFB/EMG seems to be more useful than KT in Bell's palsy treatment. This could be due to the fact that BFB/EMG gives more accurate information than KT on muscle activation with better modulation in voluntary recruitment of motor unit.

Prevention of synkinesis by biofeedback therapy: a randomized clinical trial.

OBJECTIVE: The aim of present study was to find a better procedure to prevent synkinesis in facial nerve palsy. DESIGN: A randomized clinical trial. SETTING: Clinical rehabilitation faculty and general rehabilitation centers. SUBJECTS: Twenty- nine patients with facial nerve palsy were selected via electrodiagnosis tests. INTERVENTION: The experimental group (n = 16) was treated with biofeedback electromyography, whereas the control group (n = 13) received common physiotherapy. All patients received 1-year treatment. MAIN OUTCOME MEASURES: Evaluation of facial grading scale before and after treatment and severity of synkinesia. RESULTS: At the end of treatment, there was a rise in facial grading system in both groups compared with baseline (p < 0.05, paired t test). There were significant differences in the facial grading system between 2 groups at the end of the study, but the experimental group showed better result than the other one. The number of patients with synkinesis and the severity of their synkinesis in the experimental group were lesser than those of the control group. CONCLUSION: Biofeedback therapy is more efficient than common physiotherapy. By using this approach, controlling and reducing synkinesis is more feasible.

Efficacy of functional training of the facial muscles for treatment of incomplete peripheral facial nerve injury.

OBJECTIVE: To investigate the efficacy of functional training of facial mimic muscles for patients with incomplete peripheral facial nerve injury. METHODS: Ninety-two patients with 241 injured branches of incomplete peripheral facial nerve injury were divided into a treatment group and a control group. The treatment group consisted of 58 cases that received functional training of facial mimic muscles. The rest of the cases served as controls. Assessment parameters included the House-Brackmann grading system, a quantitative facial nerve function estimating system and electroneurography. According to the three assessments, the facial nerve injury was divided into four grades: normal, minor, moderate and severe. The treatment group started training facial mimic muscle activity 2 weeks after facial nerve injury. After follow-ups of 1 to 4 years, the outcomes were statistically analysed. RESULTS: In the minor facial nerve injury group, there was no significant difference in the time needed for initial recovery (Ti, the time needed for significant recovery of the facial nerve function after injury) and final recovery (Tf, the time point after which no further improvement of facial nerve function was obtained) between the two groups (P > 0.05). No adverse effect was found in these cases. In the moderate facial nerve injury group, the Ti and Tf of the treatment group were shorter than those of the control group (P < 0.05). One case had synkinesis. In the patients with severe facial nerve injury, the recovery rate of facial nerve function in the treatment group was higher than that of the control group and the sequelae were less. CONCLUSION: Functional training of facial mimic muscles cannot shorten the time of recovery for the patients with minor facial nerve injury but it can speed up the recovery and reduce the undesirable sequelae such as synkinesis and hemifacial spasm for the patients with moderate and severe facial nerve injury.