A Patient With Severe Lower Face Degloving Injury.

Avulsions of mandible are among the most devastating lesions observed in cranio-maxillofacial traumas. They present an important health problem because of the high risk of morbidity related to deformities that cause functional limitations and esthetic changes. The avulsions commonly result from high-energy effects, which cause complete or partial separation of the mandibular bone of the face. As a result of the intense aggression, the skin and subcutaneous tissues of the bone are usually removed, affecting muscles, fascia, blood vessels, and the surrounding nerves. This article aimed to present a case of partial avulsion of mandible caused by car accident. Here, we emphasize the importance of correctly performing patient stabilization and maintenance of the airways, damage control, and facial reconstruction. Finally, we proceeded with a literature review to discuss standard protocols and controversies in the treatment of these lesions.

Differences in pharmacodynamic responses to rocuronium in normal or injured orbicularis oris are associated with expression of acetylcholine receptor subunits.

Previous research has indicated that differences in sensitivities to muscle relaxants exist between facial nerve- and somatic nerve-innervated muscles. Here, we report that the 50% inhibitory concentration (IC50) values for rocuronium were significantly larger in the normal orbicularis oris than those in the gastrocnemius. Increased IC50 values and reduced twitch tension were observed after facial nerve injury. The normal orbicularis oris had a smaller muscle fiber cross-sectional area (CSA) and a larger ratio of endplate surface area (ESA) to muscle fiber CSA (ESA/CSA), but no difference was found in the density of nicotinic acetylcholine receptor (nAChR) subunits on endplates between normal orbicularis oris and gastrocnemius. Expression of the nAChR α1, ß1, δ, ε, and γ subunits increased significantly on the postsynaptic membranes of endplates and extra-junctional muscle membranes after facial nerve injury. Our results suggest that facial nerve-innervated muscle was less sensitive than somatic nerve-innervated muscle, and the mechanisms underlying this result may be related to muscle fiber CSA and the ESA/CSA ratio, but not to the density of nAChR subunits on endplates. Facial nerve injury caused the resistance to neuromuscular blockers and reduced twitch tension, which was related to qualitative, quantitative, and locational changes in nAChR subunits.

Enhancement of facial nerve motoneuron regeneration through cross-face nerve grafts by adding end-to-side sensory axons.

BACKGROUND: In unilateral facial palsy, cross-face nerve grafts are used for emotional facial reanimation. Facial nerve regeneration through the grafts takes several months, and the functional results are sometimes inadequate. Chronic denervation of the cross-face nerve graft results in incomplete nerve regeneration. The authors hypothesize that donor axons from regional sensory nerves will enhance facial motoneuron regeneration, improve axon regeneration, and improve the amplitude of facial muscle movement. METHODS: In the rat model, a 30-mm nerve graft (right common peroneal nerve) was used as a cross-face nerve graft. The graft was coapted to the proximal stump of the transected right buccal branch of the facial nerve and the distal stumps of the transected left buccal and marginal mandibular branches. In one group, sensory occipital nerves were coapted end-to-side to the cross-face nerve graft. Regeneration of green fluorescent protein-positive axons was imaged in vivo in transgenic Thy1-green fluorescent protein rats, in which all neurons express green fluorescence. After 16 weeks, retrograde labeling of regenerated neurons and histomorphometric analysis of myelinated axons was performed. Functional outcomes were assessed with video analysis of whisker motion. RESULTS: "Pathway protection" with sensory axons significantly enhanced motoneuron regeneration, as assessed by retrograde labeling, in vivo fluorescence imaging, and histomorphometry, and significantly improved whisker motion during video analysis. CONCLUSION: Sensory pathway protection of cross-face nerve grafts counteracts chronic denervation in nerve grafts and improves regeneration and functional outcomes.

Treatment of microstomia caused by burn with a nasolabial flap--an ingenious approach for tugging and fixation of the oral commissure.

The objectives of surgical treatment for microstomia due to cicatricial contracture after burn are to obtain sufficient oral aperture, while maintaining sphincter function of the orbicularis oris muscle, and to secure favorable function for eating and conversation in addition to good oral health.The lips of the mouth have a free border, and the oral aperture, which has been enlarged by the operation, tends to be reduced, because of the actions of the orbicularis oris muscle. When the orbicularis oris muscle is resected, putting a priority on sufficient oral aperture and prevention of redevelopment of contracture, the function of the sphincter is often damaged. With the exception of those cases with deep extensive burn that damages a wide area of orbicularis oris muscle, the muscle should be preserved as expeditiously as is practical. In such cases, however, preventive measures for the redevelopment of microstomia should be established. As a postoperative adjuvant therapy, the usefulness of splint therapy has been suggested in many reports. However, a splint should be used for a long period after the surgery, and in some cases, pain is observed with therapy. When a splint is not used for an appropriate period, microstomia may redevelop. It would be ideal to take preventive measures against the redevelopment of contracture during surgery.We provided treatment with some ingenious attempts for the nasolabial flap to a patient with microstomia caused by cicatricial contracture after burn. We obtained favorable results with no postoperative use of a splint.

An impressive case of complete traumatic maxillofacial degloving.

By definition, degloving is skin and subcutaneous tissue detachment, most often affecting the limbs and extremities and occasionally the scalp. Degloving generally stems from high-energy trauma, but can also be intentional, such as in the case of planned surgical access in the anterior region of the mandible in oral-maxillofacial surgery. This paper describes an extreme case of complete traumatic maxillofacial degloving that caused partial avulsion of the soft tissues and maxilla. This is an extremely rare condition that has not previously been described in the literature, as the patient survived despite the risk of imminent death. This case report addresses the decisions made regarding the prevention of necrosis and infection that guided the emergency care and subsequent elective steps.

Orofacial problems in musicians: a review of the literature.

OBJECTIVE: The objective of our study was to review the different pathologies of the stomatognathic system that can present in musicians as a result of playing their instruments. DESIGN: The National Library of Medicine's PubMed database was searched to identify all peer-reviewed articles in the English literature dealing with orofacial problems in musicians, using both subject headings such as MeSH terms (PubMed) and free text words in combination (oral, musician, violin, wind instruments, vocalists, orthodontic, tooth, temporomandibular disorders [TMD]). The identified studies were assessed independently by two authors. We included any instruments that involved the orofacial area: i.e., wind and brass instruments, vocalists, and violins and violas. RESULTS: Thirty-two articles were selected that were of many different types (clinical reviews, longitudinal and transverse studies of therapeutic procedures, case-control studies). Among orofacial problems, the most common disorders that affect musicians are TMDs, herpes simplex virus infections, orthodontic problems, and problems with perioral musculature. CONCLUSIONS: Musicians may suffer from pathological conditions that are worsened by their occupation due to excessive practice and stress. These conditions can cause permanent injuries that subsequently prevent the musicians from playing. Depending on the characteristics of the musical instrument and the way it is played, professional musicians generally show a propensity for buccodental problems.

Facial necrotizing fasciitis secondary to accidental bite of the upper lip.

We describe a case with facial wounds over the left upper lip that became contaminated with saliva. A facial necrotizing fasciitis developed 2 days after injury. This produced a serious and almost fatal infection.

Lateral rectus muscle injury, orbital fracture, mouth locking, and facial palsy resulting from reduction malarplasty.

I report here on a patient with serious complications (lateral rectus muscle injury, orbital fracture, mouth locking, and facial palsy) that were caused by reduction malarplasty. A 32-year-old woman was referred to our department with complaints of inability to move her right eyeball laterally and inability to open her mouth. She has undergone reduction malarplasty 30 days previously at a local clinic. On examination, her maximal mouth opening was less than 3 mm. Her upper lip deviated to the left side when whistling. The orbit was displaced laterally and inferiorly. The upward and lateral gaze were limited. Computed tomography revealed fracture of the right orbital floor and lateral orbital wall extending to the orbital roof. The right lateral rectus muscle showed disconnection. The osteotomized segments were displaced inferiorly, and they pressed on the masseter muscle and coronoid process on the left side. On the 43rd postoperative day, a revision operation for the zygoma and orbit was carried out. Four days after the revision operation, surgery was performed for the myorrhaphy of the lateral rectus muscle and transposition of the medial rectus muscle. This case suggests the possibility of orbital fracture that can occur as a result of sawing in the wrong direction when using the intraoral approach. Although orbital fracture is extremely rare, it is hoped that this case will heighten the awareness of surgeons for this potential orbital fracture.

Nuevas estrategias terapéuticas para elevar el colesterol unido a lipoproteínas de alta densidad / New therapeutic strategies to increase high-density lipoprotein cholesterol

Los marcados efectos antiaterogénicos y antioxidantes de las partículas de lipoproteínas de alta densidad (HDL) justifican la búsqueda de nuevas estrategias que mejoren no tanto los valores de colesterol unido a HDL (cHDL), sino que también promuevan un transporte reverso de colesterol más eficiente. Este capítulo revisa fármacos que han sido testados en investigación animal y que se han mostrado capaces de aumentar el eflujo de colesterol (agonistas LXR), promover la captación hepática de cHDL (inactivadores parciales de SRB1) o de incrementar la capacidad antioxidante (antiinflamatoria) de las HDL (D4F, miméticos de apo A-I). Sólo este último, junto con la perfusión de apo A-I Milano y la administración de un PPAR-α/γ (aleglitazar) han sido evaluados en humanos, mostrando resultados prometedores, lo que justifica la inversión en nuevos proyectos de investigación en este campo (AU)

The search for new strategies to improve not only HDL-cholesterol levels but also to promote more efficient reverse cholesterol transport is justified by the marked antiatherogenic and antioxidant effects of high-density lipoprotein (HDL) particles. The present article reviews the drugs tested in animal research that have been shown to be capable of increasing cholesterol efflux (LXR agonists), promoting HDL-cholesterol uptake by the liver (partial inactivators of SRB1 ) or increasing the antioxidant (antiinflammatory) capacity of HDL (D4F, apo A-I mimetics). Only the latter, together with apo A-I Milano infusion and administration of a PPARα/γ (aleglitazar) have been evaluated in humans and have shown promising results, thus justifying investment in further research in this field (AU)

Management outline of oral and maxillofacial missile injuries in Iraq: the value of the intermediate phase.

Oral and maxillofacial surgeons in Iraq are practicing in a paradoxical situation where a high number of extensive injuries are accompanied by limited resources. Steps of management should be followed cautiously in attempts to reduce residual deformities that characterize the end results of severe missile injuries. This study elucidate lessons extirpated from surgical experience in the management of diversity of causalities with special emphasis on the intermediate phase of management as well as different modalities of treatment, trying to get best benefit from available resources.

[Orofacial and hearing specific problems among 340 wind instrumentalists in Lebanon]. / Problèmes spécifiques de la sphère oro-maxillo-faciale et de l'ouïe chez 340 musiciens libanais pratiquant les instruments à vent.

INTRODUCTION: The aim of this study is to detect the problems related to wind instruments in order to determine the contributing factors. MATERIAL AND METHOD: This study is a prospective study of a sample of Lebanese wind-instruments musicians. Questionnaire of 17 items about personal data, musical activities in general and specific problems related to wind instruments. RESULTS: 340 response out of 400 (85%). Gender: male 100%. Age: 28.5 +/- 6.5 years (13-50). Practice of any physical activity: 57.5%. Smokers: 40.5% Data about musical practice - Years of practice: 6.5 +/- 5.5. Daily practice: 2.5 +/- 1.5 hours with 3.5 +/- 2 rest periods of 16.5 +/- 15 minutes. Weekly practice: 5 +/- 2 days. Data about medical problems - Hear loss 34%; respiratory difficulties: 19.5%; wound of lips muscles: 5%; gums and tongue lesions: 7.8%; myospasms of the cheeks and lips: 34.5%; dental problems: 30.7%; temporo-mandibular disorders (TMD): 22.5%. There is a high association between risk factors and pathology. Risks related to the instrument's use : hear loss (p = 0.001), traumas to lips muscles (p = 0.065), myospasms (p = 0.064), TMD (p = 0.000). Other factors: physical activity is beneficial; smoking is harmful (breathing difficulties, spasms, headaches). Factors influencing the different problems: age (31 +/- 7 years); years of practice (9 +/- 6); hours of practice per day (2 +/- 1.5); days of practice per week (4.5 +/- 2.5). CONCLUSION: Wind instruments are related to problems of mouth, facial muscles and hearing. This may lead musicians to stop their activities or to irreversible professional disabilities. A medical follow-up during the musicians training is needed to prevent these problems.

Functional assessments of the rodent facial nerve: a synkinesis model.

OBJECTIVES/HYPOTHESIS: Rodent whisker movement has been used as a tool, after facial nerve manipulation, to quantify functional recovery. We have recently established a method to study functional correlates of aberrant regeneration of the facial nerve. Our objective was to establish normative parameters for both spontaneous and induced whisking and blinking behavior in a large group of normal rats. STUDY DESIGN: Prospective animal study. METHODS: Eighty animals underwent quantitative facial movement testing to measure simultaneous vibrissal movement and ocular closure for each side independently. Right and left C-1 whisker positions were continuously recorded for 5-minute sessions, and changes in infrared detection corresponding to eye closure were continuously recorded. Whisking and blinking were elicited by delivery of olfactory stimuli (10 s scented airflows) and corneal air puffs. Whisks were counted and analyzed, and eye closures were counted. RESULTS: Whisking amplitude, velocity, and acceleration were consistent with literature values. Air puff delivery elicited an ipsilateral blink 99% of the time, a contralateral blink 18% of the time, and changes in or initiation of bilateral whisking 70% of the time. Olfactory stimulus delivery prompted a change in whisking behavior 83% of the time, and eye closure 20% of the time. CONCLUSIONS: This study establishes normative data for assessing cranial nerve VII-controlled facial movement in four separate facial regions. We demonstrate the capability and tendency of animals to move their orbicularis oculi muscles independently of and simultaneously with their midfacial muscles. This model provides an excellent tool for the study of aberrant regeneration after facial nerve injury in the rodent.

Peribulbar anesthesia for blepharoplasty.

BACKGROUND: Peribulbar anesthesia for inferior blepharoplasty was used successfully in 788 selected cases over the past 9 years. This technique is largely accepted for ophthalmologic procedures, but is not yet specifically used for blepharoplasty. METHODS: In the past 9 years, 788 patients ages 36 to 77 years were submitted to inferior peribulbar anesthesia for blepharoplasty procedures. Of these patients, 623 (79%) were women and 165 (21%) were men. The anesthetic procedure is performed using a needle introduced at the junction of the medial two-thirds and the lateral third of the inferior orbital rim (point A). With the patient staring forward, the needle is introduced through the lid at point A. It enters the orbital cavity just above the orbital floor periosteum until the globe equator is minimally trespassed (depth, approximately 31 mm). There, 3 ml of the local anesthetic solution (2% lidocaine + 0.5% bupivacaine) is slowly injected. RESULTS: None of our treated patients reported pain or discomfort during or after the surgical procedure. Immediately after inferior peribulbar anesthesia, chemosis was observed in 17 cases (2.2%) and orbital hematoma in 3 cases (0.4%). Diplopia, or a slight imaging distortion lasting a few hours may occur after inferior peribulbar anesthesia. CONCLUSION: Inferior peribulbar anesthesia for blepharoplasty offers surprising results. The surgical procedures are performed pain free, leaving the patients completely relaxed and allowing an easier surgical procedure. This technique should be performed only by highly skilled anesthesiologists or surgeons with a perfect knowledge of the complex orbital anatomy.

The white-eyed medial blowout fracture.

BACKGROUND: The pediatric white-eyed blowout fracture with entrapment of the inferior rectus muscle is well recognized as an easily missed injury with significant morbidity if left untreated. A series of five isolated medial orbital blowout fractures with medial rectus muscle entrapment is described. The purpose of this study was to define this injury pattern and its clinical outcome. METHODS: A retrospective review of the presentation, management, and clinical outcomes of identified cases was conducted. RESULTS: Early exploration and release of the entrapped muscle combined with implant reconstruction of the medial orbital wall within 2 weeks resulted in complete resolution of diplopia and full recovery of extraocular movements. Delayed treatment and release of the soft tissues without orbital wall reconstruction were associated with restricted gaze and diplopia. Similar outcomes were confirmed on analysis of other reported cases. CONCLUSIONS: Orbital floor blowout fractures in the pediatric population have a high incidence of muscle entrapment that must be recognized and treated early to avoid muscle necrosis and permanent ocular restriction from fibrosis. Medial orbital wall fractures with entrapment are rare, but early recognition and operative release of the entrapped muscles result in better outcomes.

Laser burn wound healing in naso-labial region of fetal and neonatal mice.

OBJECTIVE: To investigate the characteristics of wound healing in the mouse naso-labial region in both the fetal and neonatal stages, histological and immunohistochemical analyses were performed using a newly established laser burn wound healing system. MATERIALS AND METHODS: Fetal mice at embryonic day 14 (E 14) were wounded as a model of fetal wound healing. To compare it, neonatal mice at day 5 after birth (d 5) were adopted as a model of neonatal wound healing. The healing process was examined by van Gieson staining and immunohistochemistry for fibronectin and tenascin. RESULTS: Relatively large damage remained after wound healing even in fetal mice. In both types of wound healing, rapid regeneration of muscle tissues were observed. Fibronectin and tenascin immunostaining was detected not only in wound healing region, but also in the endomysium of regenerating muscle tissues. Especially, tenascin showed a restricted expression pattern. CONCLUSIONS: Rapid regeneration of muscle tissues in the naso-labial region in both the fetal and neonatal mice seemed to leave relatively large damage even in the fetal wound healing. Contracted force exerted by muscle tissues may be a reason for this phenomenon. Fibronectin and tenascin were closely related to the wound healing process including muscle regeneration in this region.

Impalement injuries of the oral cavity in children: a case report and survey of the literature.

BACKGROUND: Impalement injuries of the soft palate and oropharynx are common in children, especially those of preschool age. These injuries are particularly common in toddlers, given their propensity to fall easily while carrying objects in their mouths. Although most of these injuries do not have lasting sequelae, some can have devastating neurological complications, and consequently, careful assessment of the patient during the early stages of trauma is imperative. Close follow-up for up to 72 h, and parental counselling and instruction should be considered as part of their immediate care. CASE REPORT: A case of toothbrush impalement in a 4-year-old child is presented. The foreign body was noted to be lodged in the cheek. After careful triaging, history taking and appropriate imaging, surgical removal of this brush was carried out uneventfully under general anaesthesia. No further complications were noted postoperatively, and because of the type of injury, the patient was discharged within 24 h and reviewed as an outpatient. CONCLUSION: A survey of the literature confirms that most injuries of this kind can be treated conservatively, and in many cases, without surgical intervention. However, careful assessment by an experienced clinician is necessary to rule out other complications. The present paper discusses the prevalence, management and complications associated with impalement injuries of the oral cavity in children.

[Reconstruction of facial defects with the forehead flap: five case reports].

The authors present several cases of facial defects reconstruction with the forehead flap. They consist of three cases of nasal reconstruction after trauma, one cases of rhinectomy and orbital exenteration for spinocellular cancer of the nasolabial fold, and a case of orbital reconstruction after exenteration for malignant melanoma of the lower eyelid with an island flap. In one of the cases we used a preexpanded forehead flap and in one other a prefabricated flap with a split-thickness skin graft. In four of the cases no complications were observed and the flaps healed uneventfully with with satisfactory results according to the patients. In the case with the island flap we observed a partial flap necrosis. The authors discuss the advantages, disadvantages and results obtained after the facial defect reconstruction with the forehead flap.