Bionic blink improves real-time eye closure in unilateral facial paralysis.

Facial paralysis is the inability to move facial muscles thereby impairing the ability to blink and make facial expressions. Depending on the localization of the nerve malfunction it is subcategorised into central or peripheral and is usually unilateral. This leads to health deficits stemming from corneal dryness and social ostracization.Objective: Electrical stimulation shows promise as a method through which to restore the blink function and as a result improve eye health. However, it is unknown whether a real-time, myoelectrically controlled, neurostimulating device can be used as assistance to this pathological condition.Approach: We developed NEURO-BLINK, a wearable robotic system, that can detect the volitional healthy contralateral blink through electromyography and electrically stimulate the impaired subcutaneous facial nerve and orbicularis oculi muscle to compensate for lost blink function. Alongside the system, we developed a method to evaluate optimal electrode placement through the relationship between blink amplitude and injected charge.Main results: Ten patients with unilateral facial palsy were enrolled in the NEURO-BLINK study, with eight completing testing under two conditions. (1) where the stimulation was cued with an auditory signal (i.e. paced controlled) and (2) synchronized with the natural blink (i.e. myoelectrically controlled). In both scenarios, overall eye closure (distance between eyelids) and cornea coverage measured with high FPS video were found to significantly improve when measured in real-time, while no significant clinical changes were found immediately after use.Significance: This work takes steps towards the development of a portable medical device for blink restoration and facial stimulation which has the potential to improve long-term ocular health.

Future treatment options for facial nerve palsy: a review on electrical stimulation devices for the orbicularis oculi muscle.

Facial nerve palsy can cause diminished eyelid closure (lagophthalmos). This occurs due to functional deficits of the orbicularis oculi muscle, potentially leading to sight-threatening complications due to corneal exposure. Current management options range from frequent lubrication with eye drops, to the use of moisture chambers and surgery. However, achieving functional restoration may not always be possible. Recent efforts have been directed towards the support of orbicularis oculi muscle function through electrical stimulation. Electrical stimulation of the orbicularis oculi muscle has been demonstrated as feasible in human subjects. This article offers a comprehensive review of electrical stimulation parameters necessary to achieve full functionality and a natural-looking eye blink in human subjects. At present, readily available portable electrical stimulation devices remain unavailable. This review lays the foundation for advancing knowledge from laboratory research to clinical practice, with the ultimate objective of developing a portable electrical stimulation device. Further research is essential to enhance our understanding of electrical stimulation, establish safety standards, determine optimal current settings, and investigate potential side effects.

Sutureless transconjunctival insertion of eyelid gold weight.

OBJECTIVE: Surgical intervention for paralytic lagophthalmos has been gold weight implant through supratarsal crease incision for decades. The aim of this study is to propose a modified novel minimally invasive approach that can be described as sutureless and transconjunctival placement of eyelid weights. METHOD: Unilateral eyelid gold weights were implanted in six patients due to paralytic lagophthalmos secondary to peripheral facial nerve palsy. The patients were followed for an average of 6 months. RESULTS: Functional and aesthetically desired results were obtained in all six patients with suture-free transconjunctival placement of the eyelid weight. The patients did not experience any discomfort and avoided the burden of suture removal after the surgery. No complications developed in six patients during the postoperative period. CONCLUSION: Sutureless transconjunctival insertion of eyelid weight without external incision and suturing is practical, relatively easy and fast to perform. It preserves attachment of the levator muscle to the tarsus and presents functional results similar to conventional method. Fixing the implant with sutures to the tarsal plate is not needed. Sutureless of this method avoids external wound care, burden of suture removal for both surgeons and patients, and hence, suture related complications are eliminated.

Development of an implantable bionic for dynamic eye closure in facial nerve paralysis: Evolution of the design.

Facial nerve paralysis (FNP) presents with a constellation of clinical problems but its most concerning consequence is corneal exposure from lack of blinking. Bionic lid implant for natural closure (BLINC) is an implantable solution for dynamic eye closure in FNP. It uses an electromagnetic actuator to mobilise the dysfunctional eyelid by means of an eyelid sling. This study highlights issues relating to device biocompatibility and describes its evolution to overcome some of these issues. The essential components of the device are the actuator, the electronics including energy storage, and an induction link for wireless power transfer. Effective arrangement of these components within the anatomical confines and their integration is achieved through a series of prototypes. The response of each prototype is tested in a synthetic or cadaveric model for eye closure with the final prototype designed for acute and chronic animal trials.

Refined Concept of Motor Supply to the Medial Periorbital Area Relevant to Periorbital Surgery.

BACKGROUND: Mimetic muscles in the medial periorbital area have been thought to be innervated solely by the angular nerve. Recently, however, the upper medial palpebral branch and lower palpebral branch were reported as additional motor suppliers in this area. This study aimed to define all the motor nerve systems passing through the medial canthal area. METHODS: Motor nerve branches that passed through the medial canthal region were identified and traced thoroughly from the parotid gland to their destinations under a surgical microscopic field in 74 hemifaces. The courses, anatomical positions of, and anatomical relationships between the angular nerve and the upper medial palpebral branch were observed. RESULTS: The upper medial palpebral branch and the angular nerve were found in all samples within a 3-mm to 6-mm area lateral to the intersecting point of the medial orbital rim and medial canthal ligament. The upper medial palpebral branch supplied the upper eyelid, whereas the angular nerve supplied the extraorbicularis muscles in the medial periorbital area. The medial pretarsal area of the upper eyelid was supplied solely by the pretarsal branches of the upper medial palpebral branch, which was formed by uniting three or four minor branches that traveled throughout the anterior cheek. CONCLUSIONS: Two separate motor nerve systems, the upper medial palpebral branch and the angular nerve, exist in the medial canthal area. The upper medial palpebral branch course along the medial orbital rim is considered as a facial nerve danger zone.

An anatomical appraisal of dynamic muscle transfer of the orbicularis oculi muscle.

Facial nerve palsy can cause significant distress for patients. We investigated the innervation of the orbicularis oculi muscle (OOM) and assessed the viability of unipedicle contralateral muscle transfer to restore symmetrical and spontaneous blinking. Cadaveric dissection and measurements were performed on lite fixed cadavers (n = 15). Medial innervation of the OOM was identified prior to raising and transposing a flap to the contralateral eyelid. Measurements were performed in-situ and following transposition. A medial ascending branch of the buccal nerve innervating the OOM was identified bilaterally in all cadavers. The average length of flap raised was 59.85 mm (± 4.69 mm) with no difference between the left and right. Flaps with pedicles not dissected off the bone covered 48% of the ciliary margin length (CM) and 62% of the palpebral length (PL). Flaps dissected off the bone covered 72% of the CM and 92% of the PL. The results demonstrate that a flap can theoretically transpose to >50% of the contralateral eyelid length. Increased coverage of the eyelid was achieved by releasing the pedicle from the underlying bone. Little attention was focused on buccal innervation of the eyelids, and this consistent medial pattern may allow an innervated flap transfer to restore symmetrical blinking, something that eludes modern paralysis surgery in a single-stage procedure.

Transfer of the deep temporal nerve for eyelid reconstruction in Mobius syndrome - an anatomic feasibility study and proposed surgical approach.

Facial paralysis may result in significant functional, esthetic, and psychological morbidity. Mobius syndrome is a form of bilateral congenital facial paralysis that is particularly difficult to treat owing to the lack of readily available donor nerves, particularly in the upper face. In this study, we evaluate the feasibility of using the deep temporal nerves as donors for the innervation of free muscle grafts in the periorbital region. Preserved and fresh cadaver facial halves are dissected, and the course of the deep temporal nerves delineated. We find the middle branch of the deep temporal nerve to be located consistently 4.6 cm from the posterior edge of the tragus along the zygomatic arch, giving an easily identifiable surface landmark for our donor. Finally, we outline a proposed surgical approach for using the middle deep temporal nerve to innervate a free muscle graft to the eyelids through an interpositional nerve graft.

Macaque monkey trigeminal blink reflex circuits targeting levator palpebrae superioris motoneurons.

For normal viewing, the eyes are held open by the tonic actions of the levator palpebrae superioris (levator) muscle raising the upper eyelid. This activity is interrupted during blinks, when the eyelid sweeps down to spread the tear film or protect the cornea. We examined the circuit connecting the principal trigeminal nucleus to the levator motoneurons by use of both anterograde and retrograde tracers in macaque monkeys. Injections of anterograde tracer were made into the principal trigeminal nucleus using either a stereotaxic approach or localization following physiological characterization of trigeminal second order neurons. Anterogradely labeled axonal arbors were located both within the caudal central subdivision, which contains levator motoneurons, and in the adjacent supraoculomotor area. Labeled boutons made synaptic contacts on retrogradely labeled levator motoneurons indicating a monosynaptic connection. As the eye is also retracted through the actions of the rectus muscles during a blink, we examined whether these trigeminal injections labeled boutons contacting rectus motoneurons within the oculomotor nucleus. These were not found when the injection sites were confined to the principal trigeminal nucleus region. To identify the source of the projection to the levator motoneurons, we injected retrograde tracer into the oculomotor complex. Retrogradely labeled cells were confined to a narrow, dorsoventrally oriented cell population that lined the rostral edge of the principal trigeminal nucleus. Presumably these cells inhibit levator motoneurons, while other parts of the trigeminal sensory complex are activating orbicularis oculi motoneurons, when a blink is initiated by sensory stimuli contacting the face.

Assessment of eye closure and blink with facial palsy: A systematic literature review.

Facial palsy can cause the impairment of eye closure and affect blink, ocular health, communication, and esthetics. Dynamic surgical procedures can restore eye closure in patients with decreased facial nerve function. There are no standardized measures of voluntary and spontaneous eye closure that are used to evaluate the outcomes of blink restoration procedures. The purpose of this systematic literature review was to identify the measures used to assess normal and abnormal eye closure and blinking in patients with facial palsy. A literature search of the PubMed database using the keyword "facial nerve/surgery" was conducted. Only English language articles that pertain to the use of facial paralysis assessment systems published in the past 20 years, which involve eyelid closure were included. There were 57 articles that used a facial paralysis classification system with an eyelid closure component: House-Brackmann Facial Nerve Grading Scale (n = 43, 67%); Sunnybrook Facial Grading Scale (n = 9); palpebral fissure heights (n = 4), and the electronic clinician-graded facial function tool (n = 3) and three additional measures were reported once. Although the Terzis and Bruno Scoring System, blink ratio, and electronic, clinician-graded facial function scale(eFACE) Clinician-Graded Scoring System were valid measures of eyelid closure, there was no one comprehensive eye assessment that demonstrated all aspects of eye closure in facial palsy, which include closure amplitude, spontaneity, and quality of life. For blink assessment, eFACE is the most comprehensive tool currently available and recommended to be used with a patient-reported quality of life supplement that captures the specific domains related to facial nerve dysfunction.

[Restoration of orbicularis oculi muscle function with totally implanted artificial facial nerve].

Objective: To investigate the effect of the artificial facial nerve on the restoration of orbicularis oculi muscle function for unilateral peripheral facial paralysis in rabbit. Methods: Artificial facial nerve was implanted into the rabbit with unilateral peripheral facial paralysis between January 2018 and May 2019. At different time points after operation, the affected orbicularis oculi muscles' stimulation closure threshold and the synchronism about the motion of the two sides of orbicularis oculi muscles were monitored. T test was used with SPSS 13.0 software. Results: There was no significant difference in the closure threshold of the orbicularis oculi muscle on the 7th and 28th days after artificial facial nerve implantation (P>0.05). The synchronism of the normal side eye closing movement triggered the affected orbicular oculi muscle movement with the artificial facial nerve was up 19/20 to 20/20 at different times. Conclusions: The artificial facial nerve system had the features of stable working condition and high synchronizing effect for stimulating movement. It could restore the closed eye function in animals with peripheral facial paralysis animals and had great clinical application prospects.

Influence of epinephrine contained in local anesthetics on upper eyelid height in transconjunctival blepharoptosis surgery.

PURPOSE: To examine the influence of epinephrine contained in local anesthetic on upper eyelid height in transconjunctival aponeurotic repair for aponeurotic blepharoptosis. METHODS: This retrospective study included 164 eyelids from 94 patients with aponeurotic blepharoptosis. Patients were divided according to the use of local anesthetic with (group A, n = 108) or without 1:100000 epinephrine (group B, n = 56). Margin reflex distance-1 (MRD-1) was measured before and after local anesthesia, and before, during, and 3 months after surgery. Change in MRD-1a (∆MRD-1a) was calculated by subtracting the postanesthetic MRD-1 value from the preanesthetic value, and we defined ∆MRD-1b by subtracting the postoperative 3-month MRD-1 value from the intraoperative value. RESULTS: ∆MRD-1a was positive in group A (0.57 ± 0.63 mm) and negative in group B (- 0.50 ± 0.45 mm; p < 0.001). Postoperative MRD-1 decreased significantly from intraoperative MRD-1 in group A (P < 0.001), although there was no significant difference between intraoperative and postoperative MRD-1 in group B (p = 0.255). The magnitude of ∆MRD-1b in group A (- 0.86 ± 0.63) was larger than that in group B (- 0.23 ± 0.26; p < 0.001). CONCLUSIONS: Epinephrine stimulates Müller's muscle during surgery, which leads to postoperative upper eyelid droop after the disappearance of the epinephrine effect. Using local anesthetics without epinephrine may allow more accurate estimation of postoperative eyelid height in transconjunctival aponeurotic repair.

Anatomical variations of the levator palpebrae superioris, including observations on its innervation and intramuscular nerves' distribution pattern.

BACKGROUND: The levator palpebrae superioris muscle (LPS) acts as the upper eyelid's major elevator and retractor and is innervated by the oculomotor nerve. The muscle's paralysis is manifested by ptosis. MATERIAL AND METHODS: 70 orbits were dissected. After removing the orbital roof, the LPS' shape and anatomical variations (i.e., the presence of accessory muscular bands or atypical formation of the muscle) were assessed. To visualize the distribution of the oculomotor nerve's intramuscular sub-branches, the isolated levator palpebrae superioris muscles were stained using Sihler's staining technique. RESULTS: Several LPS anatomical variations were observed in the specimens examined, in seven of which (7/70; 10%) additional delicate muscular slips arose from the LPS' lateral border and reached the lacrimal gland. Histological examination confirmed the presence of striated skeletal muscle fibers in all those cases. In three other specimens (3/70; 4.28%), supernumerary muscular bands ("tensor trochleae") were found that linked the levator with the superior oblique muscle's trochlea. In the next case, the LPS' origin was double and the muscle was bipartite on its proximal half. In most cases (55/70; 78.6%), muscular branches formed a single bundle that wrapped around the superior rectus muscle's medial border to reach the levator's inferior surface. Intramuscular sub-branches were distributed largely within the proximal two-thirds of the LPS and formed an irregular, tree-like pattern. However, thin sub-branches and small retrograde sub-branches extended as far as the muscle's insertion. CONCLUSIONS: Plastic surgeons and ophthalmologists should be aware of the levator palpebrae superioris muscle's anatomic variations both in planning and conducting surgeries on the upper eyelid.

Neurotized Platysma Graft: A New Technique for Functional Reanimation of the Eye Sphincter in Longstanding Facial Paralysis.

BACKGROUND: In 1984, Terzis reported on the potential use of a free platysma muscle transfer to reanimate the orbicularis oculi in longstanding paralysis of this unit. However, the vascularized platysma flap proved difficult to transfer, and this technique is not widely used today. In the present study, the authors have described the technique involving grafting of the platysma muscle to restore eyelid function and retrospectively discussed its clinical outcomes. METHODS: This retrospective analysis included patients with longstanding facial paralysis who underwent orbicularis oculi reconstruction with neurotized platysma grafts. The authors have described the surgical technique and its retrospective clinical outcomes. RESULTS: Between 1992 and 2015, 38 consecutive patients underwent this procedure; of them, 34 [16 men (47 percent) and 18 women (53 percent)] completed the follow-up. The time between the first and second surgical stages was a mean 8.6 months (range, 6 to 22 months). The surgical results were good in 18 patients (53 percent) and the recovery was satisfactory in 13 (38 percent). CONCLUSIONS: This study confirmed the feasibility and effectiveness of grafted muscle functional recovery and the efficiency of neuromuscular neurotization. The presented surgical technique is safe and effective for treating longstanding facial palsy of the orbicularis oculi muscle. This is the only technique that is easy and reproducible, leads to facial nerve recovery, and places a similar muscle at the original site of the paralyzed muscle for functional recovery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A hybrid technique to address exposure keratopathy secondary to facial nerve paresis: A combination of a lateral tarsorrhaphy and lateral wedge resection.

PURPOSE: To present the results of treating combined lower eyelid laxity, retraction and midface descent secondary to facial nerve weakness with a hybrid surgical procedure. MATERIALS AND METHODS: A retrospective analysis of patients from January 2015 to January 2017 who underwent a hybrid surgical technique for the treatment of corneal exposure secondary to facial nerve paresis with a single surgeon was performed. Age, gender, and presence of exposure symptoms were recorded pre-operatively. Outcomes assessed included improvement of lower eyelid laxity and position, operative complications, and post-operative symptomatic relief. RESULTS: A total of 11 patients underwent unilateral eyelid surgery. All patients had symptomatic relief and good functional outcomes defined as improvement in eyelid laxity, lower eyelid position, and objective corneal exposure. No cases required reoperation during an average follow up of 174.5 days. CONCLUSIONS: Combining portions of a tarsorrhaphy and lateral wedge resection technique is a simple and effective procedure to improve lower eyelid position and limit corneal exposure secondary to facial nerve paresis.

Microanatomy of Sensory Nerves in the Upper Eyelid: A Cadaveric Anatomical Study.

BACKGROUND: Plastic surgery requires detailed knowledge of upper eyelid anatomy, but few authors have sufficiently described the specifics of upper eyelid nerve anatomy. This study aimed to provide a thorough description of sensory nerve anatomy in the upper eyelid and to propose considerations for upper eyelid surgery. METHODS: Sixteen orbits were dissected from 16 fixed, adult human cadavers. Microscopically, the authors identified the main trunks of the infratrochlear, supratrochlear, and supraorbital nerves and all branches that projected toward the upper eyelid. The number, size, and distribution of nerve branches were recorded. RESULTS: The branches of the infratrochlear, supratrochlear, and supraorbital nerves covered a wide range in the upper eyelid. The mean numbers of branches per nerve were 1.6 ± 1.2, 3.2 ± 1.5, and 2.6 ± 1.4, respectively. The branches of the infratrochlear nerve were distributed throughout the medial area of the upper eyelid. Those of the supratrochlear nerve were distributed throughout the medial and central areas, and the palpebral branches of the supraorbital nerve were distributed throughout the central and lateral areas of the upper eyelid. The lateral branches of the supraorbital nerve and the cutaneous branches of the lacrimal nerve were distributed in the lateral region of the orbit. CONCLUSIONS: The authors show that upper eyelid sensation is transmitted mainly by the supratrochlear and supraorbital nerves, and the authors provide a map of the distribution of upper eyelid sensory nerves. This precise anatomical knowledge about upper eyelid sensory nerves will facilitate pain control and help minimize nerve injuries during surgery.

Sensory Innervation of the Upper Eyelid.

The aim of this study was to elucidate the sensory territory of the trigeminal nerve on the upper eyelid.Eight hemifaces from Korean cadavers were dissected. The frontal nerve (FN), supraorbital nerve (SON), supratrochlear nerve (STN), infratrochlear nerve (ITN), and lacrimal nerve (LN) were traced.The terminal branches to the eyelid margin of FN were distributed between 1/6 and 2/5 of the palpebral fissure width lateral to the medial canthus and 1/6 of the eyebrow height from eyelid margin. The SON was distributed between 2/5 and 9/10 of the eye width lateral to the medial canthus, at 1/3 of the eyebrow height. The STN was distributed between -1/4 and -1/5 of the eye width medial to the medial canthus, at 1/5 of the eyebrow height. The ITN was distributed at -1/4 and 1/10 of the eye width medial to the medial canthus, and at 1/5 of the eyebrow height. The LN was distributed between approximately 3/5 and 13/10 of the eye width lateral to the medial canthus, and at 1/4 of the eyebrow height. The main branches of FN and SON ran deep to the orbicularis from the supraorbital notch to the upper border of the tarsal plate. In the pretarsal area, they were between the orbicularis and tarsal plate. The STN and ITN were between the orbicularis and the skin. The LN was observed between the orbicularis and the tarsal plate.Upper eyelid was mainly supplied by SON and FN. The medial extremity was supplied by STN and ITN, and the lateral extremity by LN.

Location of the Septoaponeurosis Junction Relative to the Tarsal Plate in Upper Eyelids.

The aim of this study was to measure the location of the septoaponeurosis junction relative to the tarsal plate in the upper eyelids of Koreans through a histologic study.Thirty-four upper eyelids from 34 Korean adult cadavers (mean age, 77.8 years) were used. Sagittal sections on the midpupillary line were made, and 10-µm-thick sections were prepared and stained with hematoxylin-eosin and Masson trichrome. Under a magnifying loupe with a scale, the height of the tarsal plate (HTP), thickness of the tarsal plate (TTP), distance from the lid margin to the septoaponeurosis junction (MJD), and distance from the upper border of the tarsal plate to the septoaponeurosis junction (TJD) were measured.The mean HTP was 8.09 ±â€Š1.68 mm (range: 4.0-0.8 mm). The mean TTP was 1.52 ±â€Š1.56 mm (range: 0.8-3.0 mm). The mean MJD was 9.18 ±â€Š2.69 mm (range: 2.5-13.0 mm). The mean TJD was 1.1 ±â€Š2.6 mm (range: -5.5-7.0 mm). In 25 (73.5%) of the 34 eyelids, the SAJ (1.1 ±â€Š2.6 mm) was above the upper border of the tarsal plate (UTP); however, in 9 (26.5%) of the 34 eyelids, below the UTP. The greater the HTP, the greater the MJD was (y=0.620x+4.166, P = 0.024 [linear regression analysis]). However, there was no significant correlation between the HTP and TJD (P = 0.155 [correlation analysis]).The results of this study provide a useful guide for performing operations involving the orbital septum and levator aponeurosis.

Reanimation of the paralyzed lids by cross-face nerve graft and platysma transfer.

Alterations of facial muscles may critically humper patients' quality of life. One of the worst conditions is the reduction or abolition of eye blinking. To prevent these adverse effects, surgical rehabilitation of eyelid function is the current treatment choice. In the present paper, we present a modification of the technique devised by Nassif to recover lids from long-standing paralysis. In our modification, the upper lid is rehabilitated by a platisma graft innervated by the contralateral facial nerve branches using a cross-face sural nerve graft. The lower lid is pulled upward by a fascia lata string suspension. Fourteen patients with unilateral facial paralysis were operated on consecutively. For each patient, two sets of frontal photographs with open and closed eyes were available, before and after the surgical rehabilitation. On average, eyelid lumen with closed eyes decreased by 2.6 mm (SD 2.4) after surgical rehabilitation (37% of the initial value). With open eyes, the decrement was 1.5 mm (SD 1.6, 15%). The modifications were highly significant (p < 0.01), with very large effect sizes. Reanimation of the paralyzed eye by mean of cross-face nerve graft followed by platisma neurotization can restore natural eyelid closure and blink reflex.

Eyelid reanimation using crossface nerve graft: Relationship between surgical outcome and preoperative paralysis duration.

BACKGROUND: To reanimate the mimetic muscles, crossface nerve graft (CFNG) is an effective surgical option. However, muscle atrophy after facial paralysis may influence the surgical result. We analyzed the relationship between surgical result and preoperative paralysis duration. METHODS: We performed CFNG on 15 patients. The sural nerve was transferred between the affected and nonaffected sides of the zygomatic branch. Eyelid function and eyelid lid were evaluated using the modified House-Brackmann scale. The effects of age, sex, cause of facial paralysis, graft nerve length, and preoperative paralysis duration were evaluated. RESULTS: The mean follow up period was 9.3 ± 3.3 (range 4-14) years. Eyelid closure was excellent in four patients, good in six, fair in one, and poor in four. Statistically, no significant difference was observed between those patients with excellent or good outcomes and fair or poor outcomes regarding age (40.9 ± 11.0 years vs. 22.6 ± 20.8; P = .067), sex (male/female = 2/8 vs. 3/2; P = .250), cause (tumor/trauma = 10/0 vs. 3/2; P = .095), and length of nerve graft (14.4 ± 0.8 cm vs. 13.8 ± 1.6 cm; P = .375). The average preoperative paralysis duration in the excellent/good patients was significantly shorter than that in the fair/poor patients (P = .005). All eight cases with preoperative paralysis of less than 6 months showed a marked excellent/good result. Two of the seven patients with preoperative paralysis was 6 months or longer marked fair/poor result. (P = .007). CONCLUSIONS: To achieve successful results with CFNG, surgery should be performed within 6 months of the onset of paralysis.