Comparison of EMG activity and blood flow during graded exertion in the orbicularis oris muscle of adult subjects with and without lip incompetence: a cross-sectional survey.

Background/Objectives: The peri-oral muscles-including orbicularis oris-are critical in maintaining equilibrium in tooth position. Lip incompetence (LI) can thus be a factor in malocclusion. We therefore aimed to validate a technique to evaluate not only muscle activity via electromyography (EMG) but also muscle endurance and fatigue via blood flow (BF) for LI. Subjects/Methods: Subjects were classified into increased muscle tension/lip incompetent (experimental) and normal muscle tension/lip competent (control) groups. Each subject then exerted force on a custom-made traction plate connected to a tension gauge. Using laser speckle imaging and electromyographic measurements, we characterized muscle activity and corresponding BF rates in these subjects in various states of resting, loading, and recovery. Results: Results showed a significant difference between the experimental and control groups, notably in the rate of change in BF to the inferior orbicularis oris muscle under conditions of increasing load (graded exertion). Furthermore, the data suggested that the muscles in the control group undergo a more prolonged (and therefore presumably more complete) recovery than muscles in the experimental group. These factors of reduced BF and short recovery may combine to accelerate muscle fatigue and produce LI. Limitations: The sample used here was controlled for malocclusion (including open bite) to eliminate this type of confounding effect. Conclusions/Implications: From these findings, we conclude that reduced BF and inadequate recovery in the orbicularis oris muscles may be more significant than EMG activity in the assessment of LI.

Understanding the Perioral Anatomy.

Rejuvenation of the perioral region can be very challenging because of the many factors that affect the appearance of this area, such as repeated muscle movement causing radial lip lines, loss of the maxillary and mandibular bony support, and decrease and descent of the adipose tissue causing the formation of "jowls." Environmental issues must also be addressed, such as smoking, sun damage, and poor dental health. When assessing a client for perioral rejuvenation, it is critical that the provider understands the perioral anatomy so that high-risk areas may be identified and precautions are taken to prevent serious adverse events from occurring.

A novel method for in vivo visualization of the microcirculation of the mandibular periosteum in rats.

OBJECTIVE: The periosteum plays an important role in bone physiology, but observation of its microcirculation is greatly limited by methodological constraints at certain anatomical locations. This study was conducted to develop a microsurgical procedure which provides access to the mandibular periosteum in rats. METHODS: Comparisons of the microcirculatory characteristics with those of the tibial periosteum were performed to confirm the functional integrity of the microvasculature. The mandibular periosteum was reached between the facial muscles and the anterior surface of the superficial masseter muscle at the external surface of the mandibular corpus; the tibial periosteum was prepared by dissecting the covering muscles at the anteromedial surface. Intravital fluorescence microscopy was used to assess the leukocyte-endothelial interactions and the RBCV in the tibial and mandibular periosteum. Both structures were also visualized through OPS and fluorescence CLSM. RESULTS: The microcirculatory variables in the mandibular periosteum proved similar to those in the tibia, indicating that no microcirculatory failure resulted from the exposure technique. CONCLUSION: This novel surgical approach provides simple access to the mandibular periosteum of the rat, offering an excellent opportunity for investigations of microcirculatory manifestations of dentoalveolar and maxillofacial diseases.

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.

The rehabilitation of facial involvement in systemic sclerosis: efficacy of the combination of connective tissue massage, Kabat's technique and kinesitherapy: a randomized controlled trial.

In Systemic Sclerosis (SSc), face involvement causes functional loss as well as aesthetic changes and loss of the self-image. The aim of the work is to evaluate the efficacy of a rehabilitation program based on the combination of Kabat's technique, connective massage and kinesitherapy specifically conceived for the face of SSc patients. Forty SSc patients were enrolled: 20 patients (interventional group) were treated for 9 weeks (twice a week, 1 h per session) with a combined connective tissue massage, Kabat's technique, kinesitherapy and home exercise program, and 20 patients (control group) were assigned only home exercise program. All patients were assessed at baseline (T0), at the end of the treatment (T1) and after 9 weeks of follow-up (T2). They were evaluated with SF-36, HAQ, modified Rodnan skin score, mouth opening in centimeters and Mouth Handicap in Systemic Sclerosis (MHISS) scale. At T1, both groups improved in mouth opening (P < 0.05), but the improvement was maintained at T2 only in interventional group. In interventional group, facial skin score ameliorated at T1 and maintained at T2 (P < 0.05 vs. T0), while no change was observed in controls. In both groups, SF-36 and HAQ were not affected by the treatment. MHISS scale improved significantly in interventional group at T1 (P < 0.001), while no change was found in controls. The combination of connective tissue massage, Kabat's technique, kinesitherapy and home-based exercises is more effective than a home exercise program alone in the rehabilitative treatment of SSc facial involvement.

Topographic and Neural Anatomy of the Depressor Anguli Oris Muscle and Implications for Treatment of Synkinetic Facial Paralysis.

BACKGROUND: Synkinetic patients often fail to produce a satisfactory smile because of antagonistic action of a hypertonic depressor anguli oris muscle and concomitantly weak depressor labii inferioris muscle. This study investigated their neurovascular anatomy to partially explain this paradoxical depressor anguli oris hypertonicity and depressor labii inferioris hypotonicity and delineated consistent anatomical landmarks to assist in depressor anguli oris muscle injection and myectomy. METHODS: Ten hemifaces from five fresh human cadavers were dissected to delineate the neurovascular supply of the depressor anguli oris and depressor labii inferioris muscles in addition to the depressor anguli oris muscle relation to consistent anatomical landmarks. RESULTS: The depressor anguli oris muscle received innervation from both lower buccal and marginal mandibular facial nerve branches, whereas the depressor labii inferioris muscle was solely innervated by marginal mandibular branches. The mandibular depressor anguli oris origin was on average 39 mm wide, and its medial and lateral borders were located 17 mm from the symphysis and 41 mm from the mandibular angle, respectively. The depressor anguli oris fibers consistently passed anterior to the first mandibular molar toward their insertion into the modiolus, which was located 10 mm lateral and 10 mm caudal to the oral commissure. CONCLUSIONS: Depressor anguli oris muscle dual innervation versus depressor labii inferioris single innervation may explain why depressor anguli oris hypertonicity and depressor labii inferioris weakness are commonly observed concomitantly in synkinetic patients. Based on treatment goals, diagnostic percutaneous injection with lidocaine can be performed on the depressor anguli oris muscle along a cutaneous line from the modiolus to the mandibular first molar border, and an intraoral depressor anguli oris myectomy can be performed along that same transmucosal line.

The research for the function evaluation of facial nerve and the mechanisms of rehabilitation training.

BACKGROUND: Peripheral facial paralysis (PFP) is a common peripheral neural disease. Acupuncture treatment combined with PFP rehabilitation exercises is a routine method of PFP treatment. This article is to provide a new visual and objective evaluation method for exploring the mechanism and efficacy of acupuncture treatment on PFP, and develop an interactive augmented facial nerve function rehabilitation training system with multiple training models. METHODS: This prospective and observational trial will recruit 200 eligible participants for the following study. In the trial, the laser speckle contrast analysis (LASCA) technology will be applied to monitor the microcirculation of facial blood flow during acupuncture, and real-time monitoring algorithms, data sampling, and digital imaging methods will be conducted by machine learning and image segmentation. Then, a database of patient facial expressions will be built, the correlation between surface blood flow perfusion volume and facial structure symmetry will be analyzed, combined with scale assessment and electrophysiological detection. In addition, we will also explore the objectivity and effectiveness of LASCA in the evaluation of facial paralysis (FP), and the changes in blood flow microcirculation before and after acupuncture treatment will be analyzed. RESULTS: The standard image of the facial target area with facial nerve injury will be manually segmented by the convolutional neural network method. The blood flow images of the eyelid, cheek, and mandible of the patients' affected and healthy side will be compared and evaluated. Laser speckle blood flow symmetry Pr and its changes in FP condition evolution and prognosis outcome will be measured, and relevant characteristic signals values will be extracted. Finally, COX regression analysis method is conducted to establish a higher accuracy prediction model of FP with cross-validation based on laser speckle blood flow imaging technology. CONCLUSIONS: We use modern interdisciplinary high-tech technologies to explore the mechanism of acupuncture rehabilitation training in PFP. And we will provide evidence for the feasibility of using the LASCA technique as a typing diagnosis of FP in the acupuncture rehabilitation treatment of PFP. REGISTRATION NUMBER: ChiCTR1800019463.

Facial artery-based islanded myomucosal and bone flaps in head and neck reconstruction.

This article aims to illustrate various applications of facial artery-based islanded myomucosal (iFAMM) and osseous/osteo-myomucosal flaps (iFOMM) in head and neck reconstruction. A retrospective analysis of 75 patients who underwent the reconstruction of various head and neck mucosal defects with iFAMM/iFOMM in a tertiary head and neck cancer department from May 2015 to May 2019 was performed. The patients had surgery for cancer, which involved the oral tongue, floor of mouth, oropharynx, lower alveolus, larynx, hypopharynx, cricopharynx and trachea. iFOMM was used in 3 patients. Functional and esthetic outcomes, short-term and long-term complications were analyzed. The flap was successful in 74 out of 75 patients. Speech was intelligible in almost all patients and majority of patients could take oral feeds without any restrictions. The esthesis of reconstruction was scored high with a mean visual analog scale score of 8.4. The most commonly observed complication was marginal mandibular paresis, which improved with time. Mouth opening was >3 cm in 68/75 patients. Adjuvant radiation was a common factor in patients with <3 cm mouth opening. Flap was sensate by 4 months in majority of patients. The reach, pliability, and esthetics of the flap combined with recoverable morbidity of donor site present in the facial artery-based flap as a good option in the reconstruction of various head and neck subsites. Reduced operative time, lesser complication rates, less financial burden, and simplicity of the procedure make it a cost-effective alternate solution for reconstruction.

Morphological parameters of the periorbital arterial arcades and potential clinical significance based on anatomical identification.

The aim of the study was to investigate the locations, diameters, and connections of the periorbital arterial vessels. The peripheral and marginal arcades of the superior and inferior eyelids were revealed by bilateral meticulous anatomic dissections in 12 adult male and 5 female preserved cadavers. Silicone rubber injection was used to fill the regional arteries. The mean external diameter of the lacrimal (0.4 mm), supraorbital (1.0 mm), supratrochlear (0.9 mm), superior medial palpebral (0.9 mm), inferior medial palpebral (1.0 mm), dorsal nasal (0.8 mm), and infraorbital (2.0 mm) arteries were measured. Contribution of superficial temporal artery to palpebral arcades via frontal, zygomatico-orbital, and transverse facial branches was demonstrated. The purpose of this study was to demonstrate the periorbital arterial supply with contributing anastomosis from facial vasculature and impact on clinical practice.

Three-dimensional primary reconstruction of anterior mouth floor and ventral tongue using the 'trilobed' buccinator myomucosal island flap.

Three-dimensional reconstruction of the anterior mouth floor and ventral tongue after ablative surgery can be achieved using several techniques. The ideal reconstruction should be accomplished with the same or similar type of tissue, and cheek axial myomucosal flaps based on the branches of facial or internal maxillary arteries seem ideal for this purpose. From March 2005 to May 2007, 23 patients underwent cheek axial myomucosal flap reconstruction after oral cancer surgical ablation. Thanks to their thinness and pliability, these flaps were frequently shaped to obtain an accurate reconstruction. According to Whetzel's hypothesis, an intraoral flap designed to include the axial vessel of one area can safely carry the mucosa of a neighbouring vascular area. The authors describe a large buccinator myomucosal island flap based on the branches of the facial artery and formed in a trilobed shape in order to capture the adjacent buccal mucosal angiosome from the internal maxillary artery. The flap provided the correct anatomical oral reconstruction for the anterior mouth floor and ventral tongue. The function of the tongue, oral intake and mastication were not impaired. The trilobed buccinator myomucosal island flap is a suitable option for the three-dimensional reconstruction of the anterior mouth floor and ventral tongue.

Arterial Vascularization of the Mandibular Condyle and Fractures of the Condyle.

BACKGROUND: Despite substantial displacements, fractures of the mandibular condyle rarely lead to necrosis. This illustrates the negligible role of the inferior alveolar artery in intraosseous supply to the condyle, and led to this systematization of its arterial vascularization. METHODS: Forty-two temporomandibular joints from nonembalmed cadaveric specimens were studied following injection of latex (n = 32) or India ink (n = 10). RESULTS: The intraosseous branches of the inferior alveolar artery that lead to the condyle were inconstant and often rudimentary. In this study, the arteries that consistently led to the condyle were the superficial temporal artery, the deep posterior temporal artery, and arterial branches leading to the lateral pterygoid muscle emanating directly from the maxillary artery. These arteries, along with the transverse facial artery and the masseteric artery (when they participated in condoyle vascularization), formed a quadrangle around the mandibular condyle. After India ink injection, the pterygoid muscle was the most strongly colored muscle, thus indicating substantial vascularization. CONCLUSIONS: Although there is a lack of consensus in the literature regarding the constancy and proportions of the arteries participating in vascularization of the condyle, the superficial temporal artery, the maxillary arterial branches leading to the lateral pterygoid muscle, and the deep posterior temporal artery were constant in this study. This study shows the important role of the lateral pterygoid in the vascularization of the condyle. In case of a fracture with substantial displacement, the vascularization emanating from the superficial temporal artery and the lower alveolar artery is ruptured or compromised.

Islanded facial artery musculomucosal flap for tongue reconstruction.

Reconstruction of the tongue can be achieved by means of various local, regional, and microvascular free flaps. Local flaps commonly used for tongue reconstruction include the nasolabial flap, submental flap, infrahyoid flap, and pedicled facial artery musculomucosal (FAMM) flap. The purpose of this article is to propose a technical modification to the FAMM flap for the reconstruction of small to medium-sized tongue defects post tumour excision: islanding the flap and tunnelling it from the lingual aspect of the mandible in a single-stage procedure. Islanding of the FAMM flap was found to be an extremely useful modification, giving excellent range of movement for the flap and eliminating the need for revision in a second stage procedure.

Versatility of the facial artery myomucosal island flap in neopharyngeal reconstruction.

BACKGROUND: The facial artery myomucosal (FAMM) island flap is a cheek flap, pedicled on the facial artery and suitable for small to medium-sized reconstructions of the oral cavity and neighboring areas. A novel transposition of the flap to the hypopharynx after laryngectomy is presented in this report. METHODS: A 58-year-old man, previously irradiated, was laryngopharyngectomized because of a new supraglottic carcinoma. An unexpected need for a flap was solved by tunneling a FAMM island flap lateral to the mandible. The reach and size of the flap were sufficient to close the defect. RESULTS: Vitality of the flap was ascertained by fiber endoscopy. No donor-site morbidity was seen. Postoperatively, the patient had a minor stomal fistula with spontaneous healing. CONCLUSION: The pedicled FAMM island flap may be considered for smaller reconstructions of the upper hypopharynx. Accessibility, low donor-site morbidity, and recipient tissue similarity count among the advantages. © 2016 Wiley Periodicals, Inc. Head Neck 39: E29-E33, 2017.

Oncologic safety of facial artery myomucosal flaps in oral cavity reconstruction.

BACKGROUND: Buccinator myomucosal flaps are routinely used for oral cavity reconstruction and are indicated mainly in patients classified as having stage N0 cancer. This purpose of this study was to investigate whether preservation of the vascular pedicle of the flap (facial artery and vein) during stadiative neck dissection alters the oncologic safety in these patients. METHODS: Fifty patients underwent resection of T1 to 3, N0 squamous cell carcinoma of the tongue or floor of the mouth, stadiative neck dissection, and reconstruction with a facial artery musculomucosal (FAMM) flap were retrospectively analyzed concerning rate of occult neck metastasis and recurrences. RESULTS: Occult metastasis was detected in 10 patients. Mean follow-up was 41 months. The overall survival rate was 88%, and the disease-specific survival rate was 92%. CONCLUSION: Neck dissection with preservation of the facial artery and vein does not alter the rate of regional recurrences, confirming the oncologic safety of myomucosal flaps in oral cavity reconstruction. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1200-E1202, 2016.

The appearance of foramen in the internal aspect of the mental region of mandible from Japanese cadavers and dry skulls under macroscopic observation and three-dimensional CT images.

The lingual canal with foramen displays different appearances on the internal surfaces of mandible as confirmed by macroscopic observation and computerized tomography (CT). The lingual canal was observed in the inside of mental region run to the outside of lingual foramen, which is extend internally from mandibular canal in right and left sides of the mandible in cadavers (13 sides out of 88 sides) and in dry skulls (43 out of 94 sides) examined. The spinal foramen connected with mental canal occurred at the midline of mandible in 6 cases (6 out of 47 cases) in dry skulls. In this small foramen, the inferior alveolar artery give some branches to the inside of mental region at the anterior mandible and which may be run pass through the lingual canal to the lingual foramen, where they emerge to enter the mylohyoid or anterior belly of digastric muscles. The observations of these are important considerations for surgical placement of dental implants in the region in the mandible.

Manson's point: A facial landmark to identify the facial artery.

INTRODUCTION: The anatomy of the facial artery, its tortuosity, and branch patterns are well documented. To date, a reliable method of identifying the facial artery, based on surface landmarks, has not been described. The purpose of this study is to characterize the relationship of the facial artery with several facial topographic landmarks, and to identify a location where the facial artery could predictably be identified. METHODS: Following institutional review board approval, 20 hemifacial dissections on 10 cadaveric heads were performed. Distances from the facial artery to the oral commissure, mandibular angle, lateral canthus, and Manson's point were measured. Distances were measured and confirmed clinically using Doppler examination in 20 hemifaces of 10 healthy volunteers. RESULTS: Manson's point identifies the facial artery with 100% accuracy and precision, within a 3 mm radius in both cadaveric specimens and living human subjects. Cadaveric measurements demonstrated that the facial artery is located 19 mm ± 5.5 from the oral commissure, 31 mm ± 6.8 from the mandibular angle, 92 mm ± 8.0 from the lateral canthus. Doppler examination on healthy volunteers (5 male, 5 female) demonstrated measurements of 18 mm ± 4.0, 50 mm ± 6.4, and 79 mm ± 8.2, respectively. CONCLUSIONS: The identification of the facial artery is critical for the craniofacial surgeon in order to avoid inadvertent injury, plan for local flaps, and in preparation of a recipient vessel for free tissue microvascular reconstruction. Manson's point can aid the surgeon in consistently indentifying the facial artery.

Facial artery musculomucosal flap in head and neck reconstruction: A systematic review.

BACKGROUND: The facial artery musculomucosal (FAMM) flap has emerged as a popular option in head and neck reconstruction in the last decade. The purpose of this study was to conduct a literature review of the FAMM flap. METHODS: We have conducted a search on PubMed using specific key words to identify all articles related to the FAMM flap. We reviewed the modifications of the FAMM flap, its indications, contraindications, complications, and outcomes. RESULTS: Thirty-eight articles published from 1992 to 2013 were included for review. A total of 441 FAMM flaps were reported in the literature and the most commonly reconstructed site was the floor of the mouth. Functional and aesthetic outcomes were judged to be excellent. CONCLUSION: The FAMM flap is a versatile reconstructive option for small and medium size defects in the head and neck. Recent studies have explored new applications for this flap, such as in skull base reconstruction.

Reconstruction of oral cavity defects with FAMM (facial artery musculomucosal) flaps. Our experience.

INTRODUCTION AND OBJECTIVES: The facial artery musculomucosal (FAMM) flap is a good option for covering small and medium-sized defects in the oral cavity because of its similar tissue characteristics and easy implementation. METHODS: We reviewed our results using this flap between 2006 and 2014. A total of 20 patients were included and 25 FAMM flaps were performed, 16 right (64%) and 9 left (36%) flaps. Five patients had simultaneous bilateral reconstructions. The indications for flap surgery were reconstruction after resection of tumours in the floor of the mouth (8 cases, 40%), tumours in other sites of the oral cavity (4 cases, 20%), mandibular osteoradionecrosis (4 cases, 20%), oroantral fistula (3 cases, 15%) and postoperative ankyloglossia (one case, 5%). RESULTS: Reconstruction was successful in 92% of cases (n=23). Total flap necrosis occurred in one case and dehiscence with exposure of bone in another. Oral function and ingestion were satisfactory in all patients. CONCLUSIONS: The facial artery musculomucosal flap is reliable and versatile for reconstruction of small and medium-sized intraoral defects. It allows functional reconstruction of the oral cavity with a low risk of complications.

Abnormal muscle response (lateral spread) and F-wave in patients with hemifacial spasm.

In patients with hemifacial spasm (HFS) the spasm is due to cross compression of the facial nerve by a blood vessel and microvascular decompression (MVD) has proved to be a successful treatment. Abnormal muscle response (AMR), which can be elicited by one facial nerve branch stimulation in muscles innervated by other branches of the facial nerve, is specific for patients with HFS, and the AMR consists of a constant response occurring about 10 ms after stimulus and an afterdischarge with long duration (variable response, autoexcitation). The F-wave in facial muscles is a small recurrent discharge that antidromically propagates to the facial motonucleus and returns orthodromically down the same axon. We measured the AMRs and F-waves of facial muscles in HFS patients in order to investigate the relationship of both potentials and the origin of the AMRs. We obtained facial nerve evoked electromyograms from 10 HFS patients. The afterdischarges of the AMRs and the enhanced F-waves were always elicited at the same time by marginal mandibular branch stimulation of the facial nerve. There was a linear correlation between the duration of these two potentials in each case. Between the duration of the afterdischarge of the AMRs elicited in the mentalis muscles by the zygomatic branch stimulation of the facial nerve and that of the F-waves in the mentalis muscles, there was also a linear correlation in 10 cases. These results suggest that the F-wave and the afterdischarge have the same origin and that the AMR is an exaggerated F-wave.

Microvascular approach to function and appearance of large orbital maxillary defects.

Forty-three patients with major three-dimensional orbitomaxillary defects underwent 48 free-tissue transfers for defects arising from resection of a neoplasm or trauma. Defects were complex, involving the malar skin, mandible, lateral nasal wall, orbit, palate, and brain. A three-dimensional approach attempting to recreate the midface by folding the flaps was the usual method, with subsequent revisions if necessary. Ten patients had simultaneous free bone grafts and 6 had vascularized bone grafts. There were three flap failures and four perioperative deaths. Excluding the 4 deaths, the results were assessed as excellent in 25 patients, good in 12, and poor in 2. Free-tissue transfer is a reliable method of providing enough tissue at one initial operation to satisfy complex three-dimensional defects of the orbitomaxillary region. Followed by minor revision, it provides a means of restoring function and appearance without multiple staged procedures with a high risk of failure.