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Thoracodorsal nerve graft for reconstruction of facial nerve branching
Journal of Cranio-Maxillo-Facial Surgery 42 (2014) e8ee14
Contents lists available at SciVerse ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Thoracodorsal nerve graft for reconstruction of facial nerve branching Federico Biglioli a, *, Valeria Colombo a, Marco Pedrazzoli a, Alice Frigerio b, Filippo Tarabbia a, Luca Autelitano a, Dimitri Rabbiosi a a b
Department of Maxillo-Facial Surgery, San Paolo Hospital, Università degli Studi di Milano, Via A. di Rudinì, 8, 20142 Milano, Italy Institute of Human Physiology, Università degli studi di Milano, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 7 January 2012 Accepted 4 March 2013
Object: Surgical treatment of parotid malignancies may frequently involve facial nerve amputation to achieve oncological radical resection. The entire facial nerve branching from its exit from the stylomastoid foramen to the periphery of the gland is often sacrificed. The first reconstructive strategy is the immediate reconstruction of the facial nerve by directly anastomosing the trunk of the facial nerve to its distal branches by interpositional nerve grafting. The present study was performed to determine the adequacy of thoracodorsal nerve grafting for immediate repair of the facial nerve. The anatomical features of the thoracodorsal nerve make it particularly appropriate to match its trunk to the stump of the facial nerve at its exit from the stylomastoid foramen. Up to seven branches of the thoracodorsal nerve may be distally anastomosed to the severed distal branches of the facial nerve. More complex reconstruction may be addressed simultaneously by contemporary harvesting a de-epithelialized free flap from the same site based on thoracodorsal vessel perforators and preparing a rib graft from the same donor site. Methods: Between October 2003 and August 2010, seven patients affected by parotid tumors (6 with parotid malignancies and 1 with multiple recurrences of pleomorphic adenoma) underwent radical parotidectomy with intentional sacrifice of the facial nerve to obtain oncological radical resection. In all patients, the facial nerve was reconstructed with an interpositional thoracodorsal nerve graft. In four patients, a de-epithelialized free flap based on the latissimus dorsi was transposed to cover soft tissue defects. Moreover, two of these patients also required a rib graft to reconstruct both the condyle and ramus of the mandible. With the exception of one patient affected by recurrent pleomorphic adenoma, all patients underwent radiotherapy after surgical treatment. Results: All patients in our study recovered mimetic facial function. Facial muscles showed clinical signs of recovery within 5e14 (mean: 7.8) months, with varying degrees of mimetic restoration, and almost complete facial symmetry at rest in all patients. The HouseeBrackmann final score was I in two patients, II in two patients, and III in three patients. Conclusions: A thoracodorsal nerve graft to replace extratemporal facial nerve branching is a valid alternative technique to multiple classical nerve grafts, with good matching at both the proximal and distal anastomoses. Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Facial nerve reconstruction Thoracodorsal nerve Radical parotidectomy
1. Introduction While the basic principle of benign parotid surgery is appropriate removal of the parotid tumor(s), preserving all branches of the facial nerve, the deliberate sacrifice of this nerve may also be necessary in oncological surgery of the parotid gland. Conservation of the facial nerve during parotidectomy became the gold standard in the early 20th Century, and the surgical * Corresponding author: Tel.: þ39 0281844707; fax: þ39 0281844704. E-mail address: [email protected] (F. Biglioli).
technique was standardized from the first description of routine identification of the facial nerve main trunk followed by anterograde dissection of its branches (Carwardine, 1907; Janes, 1940). These surgical procedures are still currently used in all cases of benign tumors or intermediate-grade malignant tumors characterized by small-medium size, without clinical evidence of pathological involvement of the facial nerve. However, in cases of aggressive high-grade malignancies and tumors involving the whole parotid gland, due to the impossibility of dissecting the facial nerve trunk and branches and the presence of preoperative facial paralysis, the surgical target becomes
1010-5182/$ e see front matter Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2013.03.001
F. Biglioli et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) e8ee14
oncological radical resection, which often requires the contemporary sacrifice of the facial nerve (Becelli et al., 1999). In such cases, the immediate repair of the severed facial nerve is mandatory to restore facial tone and symmetry at rest, voluntary and spontaneous facial movements, and to minimize the cosmetic and functional sequelae of facial paralysis. When direct anastomosis of the severed facial nerve is not possible, because of the loss of a considerable part of its length, the next best surgical option is immediate reconstruction of the nerve by interpositional nervous grafting between the main trunk and the distal branches. Many sources of nervous tissue have been described for use in facial nerve reconstruction, such as the sural nerve, lateral antebrachial cutaneous nerve, medial antebrachial cutaneous nerve, the nerve to the vastus lateralis, and the great auricular nerve (Haller and Shelton, 1997; Biglioli et al., 2002; Lu et al., 2010). The choice of donor site depends on the length of the nervous segment to be replaced, the diameter of the injured nerve, and the possible need for an adjunctive reconstructive procedure. Here, we present our experience in repairing facial nerve intentional interruptions using a thoracodorsal nerve graft. 1.1. Surgical technique Epinephrine (1:200,000) is injected subcutaneously 5 min before surgery into the parotid region and along the drawn skin incision. This is a facelift-type procedure, beginning at the temporal region, passing hidden behind the tragus, under the earlobe, and extending into the mastoid region. An anteroinferior skin flap is elevated to access the parotid-masseter region. The VII nerve is isolated at its exit from the stylomastoid foramen by a standard extracranial anterograde technique and its main trunk is cut because it is involved in the tumor mass. Meticulous dissection is performed medially to identify the distal, zygomatic, buccal, and marginalis branches of the facial nerve, which are intentionally dissected as well as the main trunk. Radical parotidectomy is performed in accordance with the principle of radical resection of the tumor. At the same time as tumor resection is performed, the main trunk of the thoracodorsal nerve and at least its five main collateral branches are meticulously harvested from the axillary region and the undersurface of the latissimus dorsi muscle. These are subsequently used as an interpositional graft between the facial nerve main trunk and its distal branches isolated previously (Figs. 1 and 2). After freshening the nerve graft and facial nerve stumps ends with a scalpel, both proximal anastomosis (facial nerve main trunk/ thoracodorsal nerve trunk) and distal anastomosis (thoracodorsal distal branches/facial nerve distal branches) are accomplished in a termino-terminal manner with a few epineural 10-0 stitches, surrounded by fibrin glue. In cases in which a major tissue deficit results from the oncological resection, a de-epithelialized free flap, based on the perforators of the thoracodorsal vessels, is harvested from the surgical site, later using the thoracodorsal vessels for the anastomoses with recipient vessels of the neck (primarily the external carotid artery and external jugular vein). In addition, if the mandibular condyle and ramus are included in the resection, a rib is harvested from the same donor site and used as a graft to reconstruct mandibular continuity. 2. Materials and methods Between October 2003 and August 2010, seven patients (3 males, 4 females), six of whom were affected by different
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histological malignancies of the parotid gland, and one with multiple recurrences of pleomorphic adenoma, underwent radical parotidectomy with sacrifice of the facial nerve and its reconstruction using a thoracodorsal nerve graft. Five patients with preoperative histological diagnoses of squamous carcinoma or high-grade mucoepidermoid carcinoma underwent ipsilateral cervical lymphadenectomy in conjunction with parotid tumor resection. The patients ranged in age between 34 and 78 years old (mean: 60.8 years old). Four patients required soft tissue reconstruction with a microvascular latissimus dorsi flap and two underwent mandibular condyle and ramus reconstruction with a rib bone graft. The numbers of distal anastomoses between the thoracodorsal branches and the facial distal branches were three in one case, four in two cases, five in three cases, and seven in one case. The patients’ age, gender, pathology, and type of surgery are shown in Table 1. Facial nerve function prior to surgery was classified according to the HouseeBrackmann scale: none of the patients had normal facial function (grade I). Two patients were classified as grade II, three patients as grade III, and the other two patients were classified as grade IV. All except one patient affected by pleomorphic adenoma underwent full-dose postoperative radiotherapy. All patients received physiotherapy from the time of commencement of postoperative mimetic muscle recovery up to 1 year thereafter. Symmetry of the face at rest and movements of the mimetic musculature were recorded 1 year after the appearance of the first facial muscle contractions. Scoring according to the HouseeBrackmann scale was conducted by a panel of two physicians not involved in the surgery and one physiotherapist (House and Brackmann, 1985). Finally, all patients were recorded on a video camera while watching a funny movie to evaluate the quality and quantity of spontaneous facial activation. In four patients, a de-epithelialized free perforator flap over the latissimus dorsi muscle was harvested and placed in the parotid region to cover soft tissue defects. The tumor mass infiltrated the mandibular bone deep to the parotid gland parenchyma in two cases; thus, the mandibular condyle and ramus were excised en bloc with the tumor and reconstruction was achieved using a rib graft harvested from the same donor site as the free flap and the thoracodorsal nerve graft (Fig. 3aec). 3. Results The average duration of surgery was 6.4 h (range: 4e7.5 h), depending on the type and complexity of reconstruction. Temporal and cervical wound healing and postoperative recovery were normal in all patients. Complete survival of the microvascular flaps and bone grafts were recorded in all cases, clinically and by MRI and CT scan as follow-up control images. All of the patients were available for follow-up and had recovered partial facial mimetic function. Mimetic muscle contraction began at a mean of 7.8 months (range: 5e14 months) after surgery. Facial reanimation results were classified according to Housee Brackmann grading. Over this scale of six grades, based on symmetry at rest, during smiling and eye closure, two patients reached grade I, two reached grade II, and three reached grade III. Individual improvements are shown in Table 2. Representative results are shown in Figs. 3d and Fig. 4. All patients showed consistent recovery of eyelid closure without the need for eye lubricants after facial function recovery. Two patients classified preoperatively as grade IV improved to grade III postoperatively.
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Fig. 1. Drawing of the thoracodorsal nerve grafting: (A) the thoracodorsal nerve is isolated with its main branches; (B) the facial nerve was isolated and cut because involved in the tumor mass; (C) anastomosis between the thoracodorsal nerve graft and the facial nerve stumps are performed.
None of the patients reported significant disability as result of harvesting the thoracodorsal nerve graft and no perioperative complications related to nerve grafting were observed. One patient had a surgical field infection immediately after surgery, which was treated by irrigation with saline solution every 12 h for 1 week and antibiotic therapy. His final score after surgery was grade I. Table 2 presents a summary of the results. Statistical analyzes were applied to the final data to determine whether any original features could be correlated with the clinical results. Table 3 shows statistical analysis of data. ANOVA was use to determine whether gender, age, or the number of anastomoses in each patient were related first to the timing of recovery and then to the postoperative clinical grade. The results of statistical analyzes indicated no relations between these variables and either timing of functional recovery or quality of final recovery (P > 0.05). Our data were too limited to establish a statistically significant correlation between preoperative and postoperative HouseeBrackmann scores.
4. Discussion Previous reports have shown that immediate primary repair or grafting of the facial nerve after intentional or involuntary injury is a suitable method to restore good facial function (Vaughan and Richardson, 1993). The first observations related to poor results of facial nerve neurorrhaphy under tension and the consequent need for interposition nervous grafts were made by Seddon over 50 years ago (Seddon, 1947). Several graft options are available in cases in which the length of the damaged facial nerve is insufficient for direct tensionless repair. The most commonly used graft sources are the great auricular nerve, the sural nerve, the medial and lateral antebrachial cutaneous nerves, the cervical plexus branches, and the superficial radial nerve (Vaughan and Richardson, 1993; Reddy et al., 1999; Meyer, 2001; Humphrey and Kriet, 2008). The sural nerve is one of the most commonly used options, offering greater length (up to 40 cm) and a good number of neural fascicles, with only lateral
F. Biglioli et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) e8ee14
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Fig. 2. Intra-operative images: (A) the main facial nerve distal branches and proximal trunk are isolated; (B) the thoracodorsal nerve graft is harvested; (C) Anastomosis between the thoracodorsal nerve graft and the facial nerve stumps are performed.
Table 1 Case series. Patients Gender Age Diagnosis 1
Male
44
2
Female 75
3
Male
4
Female 67
5
Female 34
6
Female 44
7
Male
70
78
Reconstructive surgery
Parotid adenocarcinoma
Thoracodorsal nerve grafting Parotid adenocarcinoma Thoracodorsal nerve grafting with facial nerve De-epithelialized latissimus infiltration dorsi flap Parotid leiomyosarcoma Thoracodorsal nerve grafting De-epithelialized latissimus dorsi flap Parotid mucoepidermoid Thoracodorsal nerve carcinoma grafting De-epithelialized latissimus dorsi flap Rib bone graft Parotid adenoid cystic Thoracodorsal nerve carcinoma grafting Relapsing pleomorphic Thoracodorsal nerve adenoma grafting Parotid adenocarcinoma Thoracodorsal nerve grafting De-epithelialized latissimus dorsi flap Skin graft for reconstruction of external auditory canal
dorsal foot hypoesthesia as a donor site postoperative deficit. Hyodo et al. (2007) described the vascularized sural nerve with a free lateral gastrocnemius muscle flap as a good option for facial nerve reconstruction after radical parotidectomy. Although this flap is not difficult to harvest and presents no significant morbidity of the donor site, surgical time is significantly increased and this technique has not been widely used clinically. The need to rehabilitate several distal branches of the facial nerve requires the use of several grafts of the sural nerve. These are anastomosed proximally to the trunk of the facial nerve and distally to the different severed
branches. Due to the similar caliber of the main trunks of the facial nerve and the sural nerve, it is quite difficult to join a single donor trunk to several receiving grafts. The great auricular nerve graft is another good choice because of its appropriate diameter and length (up to 10 cm). Moreover, it is relatively easy to harvest and is located near the primary operative field, avoiding additional surgical scars. The only disadvantage of the donor site is numbness of the earlobe, an acceptable side effect for most patients. Due to these features, the great auricular nerve is a valid and often-employed source, either in cable grafting or in other techniques for facial reanimation (Biglioli et al., 2002, 2011). In 2004, Koshima et al. first described a new technique for facial nerve grafting using a vascularized great auricular nerve graft to fill the defect of the buccal branch (Koshima et al., 2004). This surgical technique leaves minimal donor site morbidity, but is rarely used in cases of parotid gland malignancy because of possible microscopic involvement of the nervous structure or because of its intentional sacrifice during surgical resection. Moreover, it is impossible to join the trunk of the facial nerve to multiple distal branches with only a single nerve graft. The medial antebrachial cutaneous nerve (MACN) and lateral antebrachial cutaneous nerve (LACN) of the upper arm are other possible donor sites. The MACN has been cited in several reports because it has an excellent diameter match for the facial nerve, provides a length of up to 15e20 cm, and has a branching pattern useful for grafting to multiple facial nerve branches (3e5 peripheral branches) (Haller and Shelton, 1997). Although it may represent a good choice for facial nerve reconstruction after ablative surgery, the risk of injury to the median nerve and to the vessels (brachial artery and basilica vein) must be taken into consideration. In addition to advantages similar to the other techniques cited above, Vaughan reported that the superficial radial nerve can be harvested together with a radial forearm flap to fill soft tissue defects after the parotidectomy (Vaughan and Richardson, 1993). Some reports stated that conventional radiotherapy is a contraindication to nerve grafting because bed scarring from any
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F. Biglioli et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) e8ee14
Fig. 3. a) (A) Preoperative image of a 75-years old woman affected by squamous-cell carcinoma of the parotid gland, conditioning left facial nerve function; (B) Preoperative CT scan showing the tumor mass (arrow); (C) the mandibular condyle and coronoid process excised en bloc with the tumor mass. b) Intra-operative images: (A) Latissimus dorsi flap is harvested for soft tissue reconstruction; (B) the mandibular condyle and ramus is reconstructed by rib bone graft, harvested from the same donor site; (C) then, anastomosis between thoracodorsal nerve graft and facial nerve branches are performed. c) Postoperative X-ray image, showing the mandibular condyle and ramus reconstruction. d) Postoperative images of the patient at rest (A), while smiling (B) and during eye closure (C).
previous operations can block nerve regeneration (Brown et al., 2000). Because of this reason, Iida et al. suggested using a free vascularized lateral femoral cutaneous nerve graft with an anterolateral thigh flap to repair both the facial nerve and the soft tissue gap (Iida et al., 2006; Agostini et al., 2013). However, various reports have asserted that traditional nerve grafts do provide optimal result even in cases with an irradiated surgical recipient
site (Brown et al., 2000). Results of the present study seem to support these data. The thoracodorsal nerve is a favorable alternative to the options described above; it is a motor nerve, which is favorable in terms of the regeneration of the facial motor nerve (Lu et al., 2008; Theeuwes et al., 2011). In contrast, sensory nerves, such as the cervical plexus, great auricular, and sural nerve, are less desirable with regard to reestablishment of motor function. The
F. Biglioli et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) e8ee14 Table 2 Comparison among preoperative and postoperative HouseeBrackmann grading scores for each patient. Patients
Preoperative grading HB
Postoperative grading HB
1 2 3 4 5 6 7 8
IV III IV II III II III I
III II III I II I II I
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harvesting may be associated with the harvesting of a free deepithelialized flap based of perforators of the latissimus dorsi muscle and/or a rib bone graft to simultaneously reconstruct the ramus and condyle of the mandible and overlaying soft tissue after radical parotidectomy (Biglioli et al., 2012; Li BH et al., 2012). Rib is not necessarily the first bone graft option to reconstruct mandibular ramus and condyle, because of its relatively rare bony density. Other options like scapular lateral border, with or without the combination of a latissimus dorsi free flap, may assure less resorption to mandible reconstruction and long-term stability (Schultes et al., 1999; Fairbanks and Hallock, 2002). That is partic-
Fig. 4. Postoperative images of a 44-years old woman affected by relapsing pleomorphic adenoma at rest (A), during eye closure (B) and while smiling (C).
Table 3 Statistical analysis of main parameters analyzed in the study.
No. of cases Minimum Maximum Arithmetic mean Standard deviation
Gender
Age
Number anastomosis
Grading pre
Grading post
Timing recovery
7 1.000 2.000 1.571
7 34.000 78.000 58.857
7 3.000 7.000 4.714
7 2.000 4.000 3.000
7 1.000 3.000 2.143
7 5.000 14.000 7.857
0.535
17.686
1.254
0.816
0.900
3.132
ularly suitable for those patients who will be subsequently irradiated. On the other side, rib bone graft assures an easier and better tridimensional positioning and freedom of setting compared to a microvascular compound reconstruction. Moreover, no late infection nor consistent bone graft resorption has been registered in this case series. Whatever all these reconstructive components can be obtained without the need of a new surgical field. Physiotherapy is strongly advocated to obtain the best results.
5. Conclusions thoracodorsal nerve as part of the latissimus dorsi flap has been described in detail in the contemporary literature both for reconstruction after ablative surgery of the head and neck and for reanimation of established facial paralysis (Takushima et al., 2004; Biglioli et al., 2009). The use of thoracodorsal nerve graft to replace a cranial nerve after ablative surgery was first reported by Schultes et al. (1999). The spinal accessory nerve has been reconstructed with a nonvascularized thoracodorsal nerve or with a vascularized long thoracic nerve transfer, looking for the more suitable donor nerve. The Author proved the superior results obtained using the vascularized long thoracic nerve graft, especially in patients who undergone radiotherapy (Schultes et al., 1999). White Matthew et al. (2006) first described use of the thoracodorsal nerve as a graft for facial nerve reconstruction; this technique was used in only one patient in their study, providing little confirmation of its effectiveness. This nerve provides great length and an appropriate branching pattern, being able to reconstruct up to seven distal branches of the facial nerve. Moreover, its
Simultaneous reconstruction of the facial nerve during parotidectomy with a thoracodorsal nerve graft represents a valid alternative technique that can ensure optimal functional results with a likely smaller amount of axonal loss than traditional multiple nerve grafts due to a better nerve branches caliber matching. The same donor site may be used for contemporaneous harvesting of a deepithelialized free flap, based on latissimus dorsi perforators, and/ or a rib graft.
Funding We have no funding and we have not to declare any conflicts of interest nor ethical approval.
Conflict of interest statement The authors have no financial interests or personal relationships with other people or organizations that may have inappropriately influenced the work presented here.
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References Agostini Tommaso, Lazzeri Davide, Spinelli Giuseppe: Anterolateral thigh flap: systematic literature review of specific donor-site complications and their management. J Craniomaxillofac Surg 41(1): 15e21, 2013 Becelli R, Frati R, Renzi G, Iannetti G: Facial nerve functionality after parotid tumors surgery. J Exp Clin Cancer Res 18(4): 469e473, 1999 Biglioli F, D’Orto O, Bozzetti A, Brusati R: Function of the great auricular nerve following surgery for benign parotid disorders. J Craniomaxillofac Surg 30(5): 308e317, 2002 Oct Biglioli F, Frigerio A, Colombo V, Colletti G, Rabbiosi D, Mortini P, et al: Massetericfacial nerve anastomosis for early facial reanimation. J Craniomaxillofac Surg, 2011 Biglioli F, Frigerio A, Rabbiosi D, Brusati R: Single-stage facial reanimation in the surgical treatment of unilateral established facial paralysis. Plast Reconstr Surg 124(1): 124e133, 2009 Biglioli F, Pedrazzoli M, Rabbiosi D, Colletti G, Colombo V, Frigerio A, et al: Reconstruction of complex defects of the parotid region using a lateral thoracic wall donor site. J Craniomaxillofac Surg, Dec 2012 Brown PD, Eshleman JS, Foote RL, Strome SE: An analysis of facial nerve function in irradiated and unirradiated facial nerve grafts. Int J Radiat Oncol Biol Phys 48(3): 737e743, 2000 Carwardine T: Excision of the parotid gland with preservation of the facial nerve. Lancet, 1907 Fairbanks GA, Hallock GG: Facial reconstruction using a combined flap of the subscapular axis simultaneously including separate medial and lateral scapular vascularized bone grafts. Ann Plast Surg 49(1): 104e108, 2002 Haller JR, Shelton C: Medial antebrachial cutaneous nerve: a new donor graft for repair of facial nerve defects at the skull base. Laryngoscope 107(8): 1048e 1052, 1997 House JW, Brackmann DE: Facial nerve grading system. Otolaryngol Head Neck Surg 93: 146e147, 1985 Humphrey CD, Kriet JD: Nerve repair and cable grafting for facial paralysis. Facial Plast Surg 24(2): 170e176, 2008 Hyodo I, Ozawa T, Hasegawa Y, Ogawa T, Terada A, Torii S: Management of a total parotidectomy defect with a gastrocnemius muscle transfer and vascularized sural nerve grafting. Ann Plast Surg 58(6): 677e682, 2007
Iida T, Nakagawa M, Asano T, Fukushima C, Tachi K: Free vascularized lateral femoral cutaneous nerve graft with anterolateral thigh flap for reconstruction of facial nerve defects. J Reconstr Microsurg 22(5): 343e348, 2006 Janes RM: The treatment of tumors of the salivary glands by radical excision. Can Med Assoc J 43: 554e559, 1940 Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S: New one-stage nerve pedicle grafting technique using the great auricular nerve for reconstruction of facial nerve defects. J Reconstr Microsurg 20(5): 357e361, 2004 Li BH, Jung HJ, Choi SW, Kim SM, Kim MJ, Lee JH: Latissimus dorsi (LD) free flap and reconstruction plate used for extensive maxillo-mandibular reconstruction after tumour ablation. J Craniomaxillofac Surg 39(8): e293ee300, 2012 Lu L, Ding Y, Lin Y, Xu Z, Li Z, Qu J, et al: Greater auricular nerve graft for repair of facial nerve defects. J Clin Otorhinolaryngol Head Neck Surg 24(7): 293e297, 2010 Lu W, Xu JG, Wang DP, Gu YD: Microanatomical study on the functional origin and direction of the thoracodorsal nerve from the trunks of brachial plexus. Clin Anat 21: 509e513, 2008 Meyer RA: Nerve harvesting procedures. Atlas Oral Maxillofac Surg Clin North Am 9(2): 77e91, 2001 Reddy PG, Arden RL, Mathog RH: Facial nerve rehabilitation after radical parotidectomy. Laryngoscope 109(6): 894e899, 1999 Schultes G, Gaggl A, Kärcher H: Reconstruction of accessory nerve defects with vascularized long thoracic vs. non-vascularized thoracodorsal nerve. J Reconstr Microsurg 15(4): 265e270, 1999 Seddon HJ: The use of autogenous grafts for the repair of large gaps in peripheral nerves. Br J Surg 35: 151e167, 1947 Takushima A, Harii K, Asato H, Ueda K, Yamada A: Neurovascular free-muscle transfer for the treatment of established facial paralysis following ablative surgery in the parotid region. Plast Reconstr Surg 113(6): 1563e1572, 2004 Theeuwes HP, Gosselink MP, Bruynzeel H, Kleinrensink GJ, Walbeehm ET: An anatomical study of the length of the neural pedicle after the bifurcation of the thoracodorsal nerve: implications for innervated free partial latissimus dorsi flaps. Plast Reconstr Surg 127(1): 210e214, 2011 Vaughan ED, Richardson D: Facial nerve reconstruction following ablative parotid surgery. Br J Oral Maxillofac Surg 31: 274e280, 1993 White Matthew W, McKenna MJ, Deschler DG: Use of the thoracodorsal nerve for facial nerve grafting in the setting of pedicle latissimus dorsi reconstruction. Otolaryngol Head Neck Surg 135: 962e964, 2006
Contents lists available at SciVerse ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Thoracodorsal nerve graft for reconstruction of facial nerve branching Federico Biglioli a, *, Valeria Colombo a, Marco Pedrazzoli a, Alice Frigerio b, Filippo Tarabbia a, Luca Autelitano a, Dimitri Rabbiosi a a b
Department of Maxillo-Facial Surgery, San Paolo Hospital, Università degli Studi di Milano, Via A. di Rudinì, 8, 20142 Milano, Italy Institute of Human Physiology, Università degli studi di Milano, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 7 January 2012 Accepted 4 March 2013
Object: Surgical treatment of parotid malignancies may frequently involve facial nerve amputation to achieve oncological radical resection. The entire facial nerve branching from its exit from the stylomastoid foramen to the periphery of the gland is often sacrificed. The first reconstructive strategy is the immediate reconstruction of the facial nerve by directly anastomosing the trunk of the facial nerve to its distal branches by interpositional nerve grafting. The present study was performed to determine the adequacy of thoracodorsal nerve grafting for immediate repair of the facial nerve. The anatomical features of the thoracodorsal nerve make it particularly appropriate to match its trunk to the stump of the facial nerve at its exit from the stylomastoid foramen. Up to seven branches of the thoracodorsal nerve may be distally anastomosed to the severed distal branches of the facial nerve. More complex reconstruction may be addressed simultaneously by contemporary harvesting a de-epithelialized free flap from the same site based on thoracodorsal vessel perforators and preparing a rib graft from the same donor site. Methods: Between October 2003 and August 2010, seven patients affected by parotid tumors (6 with parotid malignancies and 1 with multiple recurrences of pleomorphic adenoma) underwent radical parotidectomy with intentional sacrifice of the facial nerve to obtain oncological radical resection. In all patients, the facial nerve was reconstructed with an interpositional thoracodorsal nerve graft. In four patients, a de-epithelialized free flap based on the latissimus dorsi was transposed to cover soft tissue defects. Moreover, two of these patients also required a rib graft to reconstruct both the condyle and ramus of the mandible. With the exception of one patient affected by recurrent pleomorphic adenoma, all patients underwent radiotherapy after surgical treatment. Results: All patients in our study recovered mimetic facial function. Facial muscles showed clinical signs of recovery within 5e14 (mean: 7.8) months, with varying degrees of mimetic restoration, and almost complete facial symmetry at rest in all patients. The HouseeBrackmann final score was I in two patients, II in two patients, and III in three patients. Conclusions: A thoracodorsal nerve graft to replace extratemporal facial nerve branching is a valid alternative technique to multiple classical nerve grafts, with good matching at both the proximal and distal anastomoses. Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Facial nerve reconstruction Thoracodorsal nerve Radical parotidectomy
1. Introduction While the basic principle of benign parotid surgery is appropriate removal of the parotid tumor(s), preserving all branches of the facial nerve, the deliberate sacrifice of this nerve may also be necessary in oncological surgery of the parotid gland. Conservation of the facial nerve during parotidectomy became the gold standard in the early 20th Century, and the surgical * Corresponding author: Tel.: þ39 0281844707; fax: þ39 0281844704. E-mail address: [email protected] (F. Biglioli).
technique was standardized from the first description of routine identification of the facial nerve main trunk followed by anterograde dissection of its branches (Carwardine, 1907; Janes, 1940). These surgical procedures are still currently used in all cases of benign tumors or intermediate-grade malignant tumors characterized by small-medium size, without clinical evidence of pathological involvement of the facial nerve. However, in cases of aggressive high-grade malignancies and tumors involving the whole parotid gland, due to the impossibility of dissecting the facial nerve trunk and branches and the presence of preoperative facial paralysis, the surgical target becomes
1010-5182/$ e see front matter Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2013.03.001
F. Biglioli et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) e8ee14
oncological radical resection, which often requires the contemporary sacrifice of the facial nerve (Becelli et al., 1999). In such cases, the immediate repair of the severed facial nerve is mandatory to restore facial tone and symmetry at rest, voluntary and spontaneous facial movements, and to minimize the cosmetic and functional sequelae of facial paralysis. When direct anastomosis of the severed facial nerve is not possible, because of the loss of a considerable part of its length, the next best surgical option is immediate reconstruction of the nerve by interpositional nervous grafting between the main trunk and the distal branches. Many sources of nervous tissue have been described for use in facial nerve reconstruction, such as the sural nerve, lateral antebrachial cutaneous nerve, medial antebrachial cutaneous nerve, the nerve to the vastus lateralis, and the great auricular nerve (Haller and Shelton, 1997; Biglioli et al., 2002; Lu et al., 2010). The choice of donor site depends on the length of the nervous segment to be replaced, the diameter of the injured nerve, and the possible need for an adjunctive reconstructive procedure. Here, we present our experience in repairing facial nerve intentional interruptions using a thoracodorsal nerve graft. 1.1. Surgical technique Epinephrine (1:200,000) is injected subcutaneously 5 min before surgery into the parotid region and along the drawn skin incision. This is a facelift-type procedure, beginning at the temporal region, passing hidden behind the tragus, under the earlobe, and extending into the mastoid region. An anteroinferior skin flap is elevated to access the parotid-masseter region. The VII nerve is isolated at its exit from the stylomastoid foramen by a standard extracranial anterograde technique and its main trunk is cut because it is involved in the tumor mass. Meticulous dissection is performed medially to identify the distal, zygomatic, buccal, and marginalis branches of the facial nerve, which are intentionally dissected as well as the main trunk. Radical parotidectomy is performed in accordance with the principle of radical resection of the tumor. At the same time as tumor resection is performed, the main trunk of the thoracodorsal nerve and at least its five main collateral branches are meticulously harvested from the axillary region and the undersurface of the latissimus dorsi muscle. These are subsequently used as an interpositional graft between the facial nerve main trunk and its distal branches isolated previously (Figs. 1 and 2). After freshening the nerve graft and facial nerve stumps ends with a scalpel, both proximal anastomosis (facial nerve main trunk/ thoracodorsal nerve trunk) and distal anastomosis (thoracodorsal distal branches/facial nerve distal branches) are accomplished in a termino-terminal manner with a few epineural 10-0 stitches, surrounded by fibrin glue. In cases in which a major tissue deficit results from the oncological resection, a de-epithelialized free flap, based on the perforators of the thoracodorsal vessels, is harvested from the surgical site, later using the thoracodorsal vessels for the anastomoses with recipient vessels of the neck (primarily the external carotid artery and external jugular vein). In addition, if the mandibular condyle and ramus are included in the resection, a rib is harvested from the same donor site and used as a graft to reconstruct mandibular continuity. 2. Materials and methods Between October 2003 and August 2010, seven patients (3 males, 4 females), six of whom were affected by different
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histological malignancies of the parotid gland, and one with multiple recurrences of pleomorphic adenoma, underwent radical parotidectomy with sacrifice of the facial nerve and its reconstruction using a thoracodorsal nerve graft. Five patients with preoperative histological diagnoses of squamous carcinoma or high-grade mucoepidermoid carcinoma underwent ipsilateral cervical lymphadenectomy in conjunction with parotid tumor resection. The patients ranged in age between 34 and 78 years old (mean: 60.8 years old). Four patients required soft tissue reconstruction with a microvascular latissimus dorsi flap and two underwent mandibular condyle and ramus reconstruction with a rib bone graft. The numbers of distal anastomoses between the thoracodorsal branches and the facial distal branches were three in one case, four in two cases, five in three cases, and seven in one case. The patients’ age, gender, pathology, and type of surgery are shown in Table 1. Facial nerve function prior to surgery was classified according to the HouseeBrackmann scale: none of the patients had normal facial function (grade I). Two patients were classified as grade II, three patients as grade III, and the other two patients were classified as grade IV. All except one patient affected by pleomorphic adenoma underwent full-dose postoperative radiotherapy. All patients received physiotherapy from the time of commencement of postoperative mimetic muscle recovery up to 1 year thereafter. Symmetry of the face at rest and movements of the mimetic musculature were recorded 1 year after the appearance of the first facial muscle contractions. Scoring according to the HouseeBrackmann scale was conducted by a panel of two physicians not involved in the surgery and one physiotherapist (House and Brackmann, 1985). Finally, all patients were recorded on a video camera while watching a funny movie to evaluate the quality and quantity of spontaneous facial activation. In four patients, a de-epithelialized free perforator flap over the latissimus dorsi muscle was harvested and placed in the parotid region to cover soft tissue defects. The tumor mass infiltrated the mandibular bone deep to the parotid gland parenchyma in two cases; thus, the mandibular condyle and ramus were excised en bloc with the tumor and reconstruction was achieved using a rib graft harvested from the same donor site as the free flap and the thoracodorsal nerve graft (Fig. 3aec). 3. Results The average duration of surgery was 6.4 h (range: 4e7.5 h), depending on the type and complexity of reconstruction. Temporal and cervical wound healing and postoperative recovery were normal in all patients. Complete survival of the microvascular flaps and bone grafts were recorded in all cases, clinically and by MRI and CT scan as follow-up control images. All of the patients were available for follow-up and had recovered partial facial mimetic function. Mimetic muscle contraction began at a mean of 7.8 months (range: 5e14 months) after surgery. Facial reanimation results were classified according to Housee Brackmann grading. Over this scale of six grades, based on symmetry at rest, during smiling and eye closure, two patients reached grade I, two reached grade II, and three reached grade III. Individual improvements are shown in Table 2. Representative results are shown in Figs. 3d and Fig. 4. All patients showed consistent recovery of eyelid closure without the need for eye lubricants after facial function recovery. Two patients classified preoperatively as grade IV improved to grade III postoperatively.
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Fig. 1. Drawing of the thoracodorsal nerve grafting: (A) the thoracodorsal nerve is isolated with its main branches; (B) the facial nerve was isolated and cut because involved in the tumor mass; (C) anastomosis between the thoracodorsal nerve graft and the facial nerve stumps are performed.
None of the patients reported significant disability as result of harvesting the thoracodorsal nerve graft and no perioperative complications related to nerve grafting were observed. One patient had a surgical field infection immediately after surgery, which was treated by irrigation with saline solution every 12 h for 1 week and antibiotic therapy. His final score after surgery was grade I. Table 2 presents a summary of the results. Statistical analyzes were applied to the final data to determine whether any original features could be correlated with the clinical results. Table 3 shows statistical analysis of data. ANOVA was use to determine whether gender, age, or the number of anastomoses in each patient were related first to the timing of recovery and then to the postoperative clinical grade. The results of statistical analyzes indicated no relations between these variables and either timing of functional recovery or quality of final recovery (P > 0.05). Our data were too limited to establish a statistically significant correlation between preoperative and postoperative HouseeBrackmann scores.
4. Discussion Previous reports have shown that immediate primary repair or grafting of the facial nerve after intentional or involuntary injury is a suitable method to restore good facial function (Vaughan and Richardson, 1993). The first observations related to poor results of facial nerve neurorrhaphy under tension and the consequent need for interposition nervous grafts were made by Seddon over 50 years ago (Seddon, 1947). Several graft options are available in cases in which the length of the damaged facial nerve is insufficient for direct tensionless repair. The most commonly used graft sources are the great auricular nerve, the sural nerve, the medial and lateral antebrachial cutaneous nerves, the cervical plexus branches, and the superficial radial nerve (Vaughan and Richardson, 1993; Reddy et al., 1999; Meyer, 2001; Humphrey and Kriet, 2008). The sural nerve is one of the most commonly used options, offering greater length (up to 40 cm) and a good number of neural fascicles, with only lateral
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Fig. 2. Intra-operative images: (A) the main facial nerve distal branches and proximal trunk are isolated; (B) the thoracodorsal nerve graft is harvested; (C) Anastomosis between the thoracodorsal nerve graft and the facial nerve stumps are performed.
Table 1 Case series. Patients Gender Age Diagnosis 1
Male
44
2
Female 75
3
Male
4
Female 67
5
Female 34
6
Female 44
7
Male
70
78
Reconstructive surgery
Parotid adenocarcinoma
Thoracodorsal nerve grafting Parotid adenocarcinoma Thoracodorsal nerve grafting with facial nerve De-epithelialized latissimus infiltration dorsi flap Parotid leiomyosarcoma Thoracodorsal nerve grafting De-epithelialized latissimus dorsi flap Parotid mucoepidermoid Thoracodorsal nerve carcinoma grafting De-epithelialized latissimus dorsi flap Rib bone graft Parotid adenoid cystic Thoracodorsal nerve carcinoma grafting Relapsing pleomorphic Thoracodorsal nerve adenoma grafting Parotid adenocarcinoma Thoracodorsal nerve grafting De-epithelialized latissimus dorsi flap Skin graft for reconstruction of external auditory canal
dorsal foot hypoesthesia as a donor site postoperative deficit. Hyodo et al. (2007) described the vascularized sural nerve with a free lateral gastrocnemius muscle flap as a good option for facial nerve reconstruction after radical parotidectomy. Although this flap is not difficult to harvest and presents no significant morbidity of the donor site, surgical time is significantly increased and this technique has not been widely used clinically. The need to rehabilitate several distal branches of the facial nerve requires the use of several grafts of the sural nerve. These are anastomosed proximally to the trunk of the facial nerve and distally to the different severed
branches. Due to the similar caliber of the main trunks of the facial nerve and the sural nerve, it is quite difficult to join a single donor trunk to several receiving grafts. The great auricular nerve graft is another good choice because of its appropriate diameter and length (up to 10 cm). Moreover, it is relatively easy to harvest and is located near the primary operative field, avoiding additional surgical scars. The only disadvantage of the donor site is numbness of the earlobe, an acceptable side effect for most patients. Due to these features, the great auricular nerve is a valid and often-employed source, either in cable grafting or in other techniques for facial reanimation (Biglioli et al., 2002, 2011). In 2004, Koshima et al. first described a new technique for facial nerve grafting using a vascularized great auricular nerve graft to fill the defect of the buccal branch (Koshima et al., 2004). This surgical technique leaves minimal donor site morbidity, but is rarely used in cases of parotid gland malignancy because of possible microscopic involvement of the nervous structure or because of its intentional sacrifice during surgical resection. Moreover, it is impossible to join the trunk of the facial nerve to multiple distal branches with only a single nerve graft. The medial antebrachial cutaneous nerve (MACN) and lateral antebrachial cutaneous nerve (LACN) of the upper arm are other possible donor sites. The MACN has been cited in several reports because it has an excellent diameter match for the facial nerve, provides a length of up to 15e20 cm, and has a branching pattern useful for grafting to multiple facial nerve branches (3e5 peripheral branches) (Haller and Shelton, 1997). Although it may represent a good choice for facial nerve reconstruction after ablative surgery, the risk of injury to the median nerve and to the vessels (brachial artery and basilica vein) must be taken into consideration. In addition to advantages similar to the other techniques cited above, Vaughan reported that the superficial radial nerve can be harvested together with a radial forearm flap to fill soft tissue defects after the parotidectomy (Vaughan and Richardson, 1993). Some reports stated that conventional radiotherapy is a contraindication to nerve grafting because bed scarring from any
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Fig. 3. a) (A) Preoperative image of a 75-years old woman affected by squamous-cell carcinoma of the parotid gland, conditioning left facial nerve function; (B) Preoperative CT scan showing the tumor mass (arrow); (C) the mandibular condyle and coronoid process excised en bloc with the tumor mass. b) Intra-operative images: (A) Latissimus dorsi flap is harvested for soft tissue reconstruction; (B) the mandibular condyle and ramus is reconstructed by rib bone graft, harvested from the same donor site; (C) then, anastomosis between thoracodorsal nerve graft and facial nerve branches are performed. c) Postoperative X-ray image, showing the mandibular condyle and ramus reconstruction. d) Postoperative images of the patient at rest (A), while smiling (B) and during eye closure (C).
previous operations can block nerve regeneration (Brown et al., 2000). Because of this reason, Iida et al. suggested using a free vascularized lateral femoral cutaneous nerve graft with an anterolateral thigh flap to repair both the facial nerve and the soft tissue gap (Iida et al., 2006; Agostini et al., 2013). However, various reports have asserted that traditional nerve grafts do provide optimal result even in cases with an irradiated surgical recipient
site (Brown et al., 2000). Results of the present study seem to support these data. The thoracodorsal nerve is a favorable alternative to the options described above; it is a motor nerve, which is favorable in terms of the regeneration of the facial motor nerve (Lu et al., 2008; Theeuwes et al., 2011). In contrast, sensory nerves, such as the cervical plexus, great auricular, and sural nerve, are less desirable with regard to reestablishment of motor function. The
F. Biglioli et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) e8ee14 Table 2 Comparison among preoperative and postoperative HouseeBrackmann grading scores for each patient. Patients
Preoperative grading HB
Postoperative grading HB
1 2 3 4 5 6 7 8
IV III IV II III II III I
III II III I II I II I
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harvesting may be associated with the harvesting of a free deepithelialized flap based of perforators of the latissimus dorsi muscle and/or a rib bone graft to simultaneously reconstruct the ramus and condyle of the mandible and overlaying soft tissue after radical parotidectomy (Biglioli et al., 2012; Li BH et al., 2012). Rib is not necessarily the first bone graft option to reconstruct mandibular ramus and condyle, because of its relatively rare bony density. Other options like scapular lateral border, with or without the combination of a latissimus dorsi free flap, may assure less resorption to mandible reconstruction and long-term stability (Schultes et al., 1999; Fairbanks and Hallock, 2002). That is partic-
Fig. 4. Postoperative images of a 44-years old woman affected by relapsing pleomorphic adenoma at rest (A), during eye closure (B) and while smiling (C).
Table 3 Statistical analysis of main parameters analyzed in the study.
No. of cases Minimum Maximum Arithmetic mean Standard deviation
Gender
Age
Number anastomosis
Grading pre
Grading post
Timing recovery
7 1.000 2.000 1.571
7 34.000 78.000 58.857
7 3.000 7.000 4.714
7 2.000 4.000 3.000
7 1.000 3.000 2.143
7 5.000 14.000 7.857
0.535
17.686
1.254
0.816
0.900
3.132
ularly suitable for those patients who will be subsequently irradiated. On the other side, rib bone graft assures an easier and better tridimensional positioning and freedom of setting compared to a microvascular compound reconstruction. Moreover, no late infection nor consistent bone graft resorption has been registered in this case series. Whatever all these reconstructive components can be obtained without the need of a new surgical field. Physiotherapy is strongly advocated to obtain the best results.
5. Conclusions thoracodorsal nerve as part of the latissimus dorsi flap has been described in detail in the contemporary literature both for reconstruction after ablative surgery of the head and neck and for reanimation of established facial paralysis (Takushima et al., 2004; Biglioli et al., 2009). The use of thoracodorsal nerve graft to replace a cranial nerve after ablative surgery was first reported by Schultes et al. (1999). The spinal accessory nerve has been reconstructed with a nonvascularized thoracodorsal nerve or with a vascularized long thoracic nerve transfer, looking for the more suitable donor nerve. The Author proved the superior results obtained using the vascularized long thoracic nerve graft, especially in patients who undergone radiotherapy (Schultes et al., 1999). White Matthew et al. (2006) first described use of the thoracodorsal nerve as a graft for facial nerve reconstruction; this technique was used in only one patient in their study, providing little confirmation of its effectiveness. This nerve provides great length and an appropriate branching pattern, being able to reconstruct up to seven distal branches of the facial nerve. Moreover, its
Simultaneous reconstruction of the facial nerve during parotidectomy with a thoracodorsal nerve graft represents a valid alternative technique that can ensure optimal functional results with a likely smaller amount of axonal loss than traditional multiple nerve grafts due to a better nerve branches caliber matching. The same donor site may be used for contemporaneous harvesting of a deepithelialized free flap, based on latissimus dorsi perforators, and/ or a rib graft.
Funding We have no funding and we have not to declare any conflicts of interest nor ethical approval.
Conflict of interest statement The authors have no financial interests or personal relationships with other people or organizations that may have inappropriately influenced the work presented here.
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