Free vascularized lateral femoral cutaneous nerve graft with anterolateral thigh flap for reconstruction of facial nerve defects

Wide resection of a malignant tumor in the parotid gland often results in loss of a long segment of facial nerve, as well as a soft-tissue defect. With conventional nerve grafts, functional recovery of the facial nerve is poor in cases with risk factors that might inhibit nerve regeneration, such as a history of irradiation and a recipient bed scarred from previous operations. For such cases, a vascularized nerve graft is reported to be more effective than a nonvascularized nerve graft. This paper describes the first successful use of a free vascularized lateral femoral cutaneous nerve graft combined with an anterolateral thigh flap to repair the facial nerve and a soft-tissue defect. This method is technically simple, has minimal donor-site morbidity, and typically results in successful nerve recovery.     

Modern concepts in facial nerve reconstruction

The use of 3D surface imaging technology is becoming increasingly common in craniofacial clinics and research centers. Due to fast capture speeds and ease of use, 3D digital stereophotogrammetry is quickly becoming the preferred facial surface imaging modality. These systems can serve as an unparalleled tool for craniofacial surgeons, proving an objective digital archive of the patient's face without exposure to radiation. Acquiring consistent high-quality 3D facial captures requires planning and knowledge of the limitations of these devices. Currently, there are few resources available to help new users of this technology with the challenges they will inevitably confront. To address this deficit, this report will highlight a number of common issues that can interfere with the 3D capture process and offer practical solutions to optimize image quality.     

The epineural sleeve technique for nerve graft reconstruction enhances nerve recovery

The purpose of the study was evaluation of nerve recovery following epineural sleeve technique for graft reconstruction in rat sciatic nerve. This technique provides the epineural sleeve to cover and separate the site of coaptation. Animals were divided into three groups: CNG-conventional nerve grafting, ESN-epineural sleeve from recipient nerve stumps, ESG-epineural sleeve from graft. Nerve regeneration was evaluated by pin-prick, toe-spread test, walking track analysis and somatosensory-evoked potentials (SEP), gastrocnemius index (GI), and histomorphometric evaluation. Most parameters (SFI, SEPs, and GI) showed significantly better nerve recovery for ESN group when compared to conventional CNG group. Also ESG group revealed better result for SFI. Better functional results for ESN and ESG groups were further confirmed by histomorphometric analysis: higher axon density and diameters as well as thicker myelin sheath. Epineural sleeve graft technique may be promising method with potential application for nerve reconstructive procedures. Better functional nerve recovery can be anticipated.     

End-to-side nerve repair in peripheral nerve injury

In peripheral nerve injury, end-to-side neurorrhaphy has been reported as an alternative in cases that the proximal nerve stump is not accessible. Several hypotheses have been proposed to explain peripheral nerve regeneration after end-to-side neurorrhaphy. Recent evidence suggests that nerve regeneration occurs by collateral sprouting. Although a great number of humoral factors have been identified, molecular mechanism of nerve regeneration after end-to-side neurorrhaphy has not been completely clarified yet. The goal of this technique is to provide satisfactory functional recovery for the recipient nerve, without any deterioration of the donor nerve function. End-to-side technique has been investigated in detail in both experimental and clinical studies. Only a limited number of reported cases in clinical practice, until today, can reveal that end-to-side technique may become a viable means of repairing peripheral nerves in certain clinical situations.     

Results of reconstruction of the facial nerve

The results of surgical treatment for facial paralysis are still difficult to compare as there is no universal scoring method. The purpose of this communication is to review the results of reconstruction of the extratemporal facial nerve with nerve grafts using our own evaluation system. Fifty-nine patients were operated on during the period 1981–1991. They had lacerations or other trauma to the face which resulted in loss of continuity of the facial nerve or branches. Three groups were considered: (a) 12 patients had injuries involving the trunk and extending up to the main branches of the facial nerve; (b) 32 patients had parotid laceration or contusion on the parotid area with resulting nerve defects extending from a main branch up to distal branches; and (c) 15 patients had injuries on the distal branches: frontal, zygomatic, or mandibular. The sural nerve was used as the graft in all instances. The grafting procedure was performed from three weeks to six months after the trauma. The method of evaluation compares the normal with the paralyzed side. A score is given of 0 (no motion), 1 (weak motion), or 2 (strong motion), for each of six voluntary contractions: forehead, closure of eyelids and lips, traction, elevation, and depression of the lips. The assessment of involuntary mimic actions was done while observing blinking, speaking, smiling, and laughing. Mass movements were scored negatively. The numbers were recorded and the ratio between the paralyzed and normal side gave an estimate of the lack of symmetry. Differences between the preoperative and postoperative scores showed that improvement had been achieved by surgery. Nerve grafting provided a significant improvement of function in patients with traumatic injuries to the extratemporal facial nerve. © 1994 Wiley-Liss, Inc.     

End-to-side nerve repair. A review

In recent years, there has been a resurgence of end-to-side peripheral nerve repair. This technique offers a management of a peripheral nerve defect in the absence of a suitable proximal stump. Although numerous animal laboratory investigations demonstrate motor and sensory functional recovery without deleterious effects to the donor nerve, clinical outcomes are yet to be determined.     

Combination of hypoglossal-facial nerve jump graft by end-to-side neurorrhaphy and cross-face nerve graft for the treatment of facial paralysis

The cross-face nerve graft and the interpositional jump graft were performed simultaneously for 13 patients with facial paralysis. The period between the onset of paralysis and surgery ranged from 3 to 32 weeks. In nine patients, surgery was performed within 3 months of the onset of paralysis. The patients in whom reinnervation by both grafts succeeded could smile without closing their eyes by moving the tongue and could close the eye on the affected side without an accompanying oral movement. The expression was natural and included fine muscle movements. Spontaneous recovery of the facial nerve was observed in three patients. Among patients who showed functional recovery without spontaneous recovery, House-Brackman's palsy grade was II in one patient, III in five patients, and IV in one patient. Functional deficits of the tongue were not observed. We recommend that this surgery be performed within 3 months of onset of paralysis.     

Immediate nasal valve reconstruction after facial nerve resection

OBJECTIVES: To highlight the problem of valve collapse after facial paralysis and review the efficacy of performing immediate reconstruction at the time of initial oncologic resection, using a suture technique of suspending the soft tissue of the nasal valve to the inferior orbital rim. METHODS: A review of all patients undergoing immediate nasal valve reconstruction was undertaken. There was a total of 18 patients, 15 men and 3 women, with a median age of 64 years. All patients had undergone facial nerve resection as part of their initial ablative procedure with immediate reconstruction of the nasal valve. A suture technique was used that secured the nasal valve area to the inferior orbital rim periosteum. These patients were compared with a cohort of 10 patients who underwent similar oncologic and reconstructive procedures but had no nasal valve reconstruction. RESULTS: Patients were evaluated with the Nasal Obstruction Septoplasty Evaluation tool. In patients who underwent reconstruction, there was no evidence of valve collapse on clinical examination. Patients who did not undergo reconstruction demonstrated significantly more symptoms of (1) congestion or stuffiness (1.8 vs 0.4; P < .05), (2) nasal blockage or congestion (2.6 vs 0.3; P < .05), (3) trouble breathing through the nose (2.7 vs 0.3; P < .05); (4) trouble sleeping (2.7 vs 0.3; P < .05); and (5) inability to get enough air during exertion (1.2 vs 0.1; P < .05). Follow-up extended to a median of 2 years. In the reconstructed group, cosmesis was acceptable and there were no instances of suture breakage or granuloma. CONCLUSIONS: We propose that the nasal valve should be addressed at the time of initial facial nerve resection if immediate reconstruction is planned. A suture suspension technique is easily used at the time of primary resection and reconstruction.     

Assessment of nerve graft donor sites used for reconstruction of traumatic digital nerve defects

Several donor nerve graft sites commonly are used when repairing segmental defects in sensory nerves distal to the wrist. The cross-sectional area and number of fascicles of donor nerves and specific digital nerve segments were investigated to provide guidelines for selection of nerve graft harvest sites according to defects encountered. Nerve segments were harvested from 10 fresh cadavers (20 upper extremities). Five sites of nerve graft were harvested: lateral and medial antebrachial cutaneous nerves (LABCN, MABCN), posterior and anterior interosseous nerves (PIN, AIN), and sural nerves. Four sites of typical segmental nerve defects were harvested in a zone protocol: common digital nerve (zone 4), proper digital nerve (zone 3), digital nerve distal to main dorsal branch at the metacarpophalangeal joint (zone 2), and digital nerve distal to trifurcation at fingertip (zone 1). Sural nerve is the most anatomically similar nerve graft for defects in zone 4 by cross-sectional area and number of fascicles. Lateral antebrachial cutaneous nerve is most appropriate for zone 2 and 3 injuries by both criteria. Fingertip grafts for zone 1 injuries displayed cross-sectional area similarity to PIN, AIN, and MABCN. With regard to number of fascicles, zone 1 digital nerves are most similar to LABCN donors.     

New one-stage nerve pedicle grafting technique using the great auricular nerve for reconstruction of facial nerve defects

A new one-stage nerve pedicle grafting technique, employing a vascularized great auricular nerve graft, was used to repair a facial nerve defect. The facial nerve of a 39-year-old woman with facial schwannoma was resected, and an island vascularized great auricular nerve graft from the ipsilateral side was transferred to bridge a 4 cm long defect of the buccal branch. Postoperatively, rapid nerve sprouting through the vascularized nerve graft and excellent facial reanimation were obtained within 6 months after surgery. This method in one-stage using a vascularized nerve graft is technically easy, requires a short operating time, has minimal donor-site morbidity, and leads to successful nerve regeneration postoperatively.     

End-to-side choledochoduodenostomy: A widely applicable procedure for biliary reconstruction

End-to-side choledochoduodenostomy was originally used for reconstruction between the duodenum and the biliary tree in iatrogenic bile duct stricture. However, we believe the procedure could be applied for various biliary disorders. We have recently shown the high carcinogenicity of biliary epithelium in patients with pancreaticobiliary maljunction, and consequently we recommend excision of the bile duct, along with appropriate reconstruction of the biliary system to divert the flow of pancreatic juice from bile fluid, to prevent carcinoma in biliary epithelium even in patients without dilatation of the bile duct. The conditions causing primary or recurrent bile duct stones must be removed. We employed this procedure for biliary reconstruction in 42 patients with pancreatico-biliary maljunction and in 30 patients with various benign biliary diseases, such as bile duct stones and benign biliary stenosis. We also used the procedure for palliation in 6 patients with malignant tumors around the head of the pancreas. Among these 78 patients over 20 years, we experienced 5 cases of reflux cholangitis with anastomotic stenosis, for which conservative dilatation was required. This procedure of end-to-side choledochoduodenostomy could be widely applicable for biliary reconstruction in terms of its being simplicity, minimal invasiveness and the establishment of a single physiological route for bile flow into the duodenum.     

End-to-side nerve suture--a technique to repair peripheral nerve injury.

End-to-side nerve suture (ETSNS) has until recently been extensively researched in the laboratory animal (rat and baboon). Lateral sprouting from an intact nerve into an attached nerve does occur, and functional recovery (sensory and motor) has been demonstrated. We have demonstrated conclusively that ETSNS in the human is a viable option in treating peripheral nerve injuries, including injuries to the brachial plexus. Among the many advantages of this new technique are: (i) simple and short operation; (ii) shorter recovery time--suture is done closer to the target organs; (iii) nerve grafts to bridge injured gaps are eliminated, reducing the morbidity of nerve surgery to a minimum; (iv) innervation of paralysed muscles, for which there was previously thought to be no hope of recovery, opens up many new treatment options; and (v) certain aspects of nerve function and regeneration, unknown until recently, open new horizons and understanding. ETSNS has given us new dimensions in the management of peripheral nerve injuries.     

Indication,technique and results of facial nerve reconstruction

Summary 160 patients with various intraor extracranial pathologies were treated by microsurgical facial nerve reconstruction at Nordstadt Neurosurgical Clinic between 1978 and 1993. Facial nerve reconstruction was accomplished along the anatomical course of the facial nerve from its origin at the brainstem, within the mastoid, at the stylomastoid foramen and within the face. Mostly, reconstruction was indicated because of nerve discontinuity (n=61), whereas facial nerve reanimation with a donor nerve such as the contralateral facial nerve or the ipsilateral hypoglossal nerve was indicated in 99 cases of loss of a proximal nerve stump. Depending on the site of the lesion reinnervation started at 5 to 15 months postoperatively lasting for 2 to 3 years with overall satisfactory results. 69% of all the patients regained good symmetry on rest, complete eye closure equivalent to House-Brackmann-Score III: Patients with complete failures either suffered of non-related diseases such as cancer leading to death before the estimated time of recovery or were exposed to radiation or received facial nerve reconstruction after long-standing facial deficit and marked muscular atrophy. The indication of the adequate method depends on the clinical course with or without preexisting facial paresis, on considering the intraoperative state of the facial nerve, the identification and microsurgical preparation of adequate nerve stumps, as well as on the adaptation techniques and the postoperative guidance of the patient. We conclude that facial nerve reconstruction by transplantation at either site of the nerve course or by reanimation with a donor nerve are effective and reliable procedures of treatment leading to satisfactory functional and cosmetic results.     

Cavernous nerve graft reconstruction using an autologous nerve guide to restore potency

OBJECTIVE: To present our experience of cavernous nerve graft reconstruction, using an autologous nerve vein-guide technique, to restore potency. PATIENTS AND METHODS: Prostate cancers frequently require radical resection involving one or both cavernous nerves that usually results in erectile dysfunction; nerve grafting has been used to restore erectile function, but clinical results are unsatisfactory owing to inadequate surgical techniques. In all, eight patients with prostate cancer who required radical resection involving one cavernous nerve had sural nerve grafting, with two or three sutures using the autologous vein-guide technique, in our unit between 2004 and 2005. Because of the difficulty of performing microsurgical manoeuvres deep within the pelvic cavity, the nerve anastomosis might be unsatisfactory. RESULTS: Seven of the eight patients had spontaneous erectile activity after grafting and six of these patients were able to have intercourse. CONCLUSION: Sural nerve grafting using the autologous vein-guide technique is simple, has minimal morbidity, and yields good outcomes.