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Surgical treatment of synkinesis between smiling and eyelid closure
Accepted Manuscript Surgical treatment of synkinesiss between smiling and eyelid closure Federico Biglioli, Otilija Kutanovaite, Dimitri Rabbiosi, Giacomo Colletti, M.A.S. Mohammed, Alberto M. Saibene, Silvia Cupello, Antonino Privitera, Valeria M.A. Battista, Alessandro Lozza, Fabiana Allevi PII:
S1010-5182(17)30308-6
DOI:
10.1016/j.jcms.2017.09.008
Reference:
YJCMS 2781
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 7 May 2017 Accepted Date: 11 September 2017
Please cite this article as: Biglioli F, Kutanovaite O, Rabbiosi D, Colletti G, Mohammed M, Saibene AM, Cupello S, Privitera A, Battista VMA, Lozza A, Allevi F, Surgical treatment of synkinesiss between smiling and eyelid closure, Journal of Cranio-Maxillofacial Surgery (2017), doi: 10.1016/ j.jcms.2017.09.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Surgical treatment of synkinesis between smiling and eyelid closure
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Federico Biglioli1, Otilija Kutanovaite2, Dimitri Rabbiosi1, Giacomo Colletti1, Mohammed MAS3, Alberto M Saibene4, Silvia Cupello5, Antonino Privitera5, Valeria MA Battista1,
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Alessandro Lozza6, Fabiana Allevi1
Maxillo-Facial Surgery Department, San Paolo Hospital, University of Milan, Milan, Italy
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Maxillo-Facial Surgery Department, Vilnius University Hospital Zalgiris Clinics, Zalgirio,
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1
Vilnius, Lithuania
Plastic Surgery Department, Assiut University, Egypt
4
Otolaryngology Department, San Paolo Hospital, University of Milan, Milan, Italy
5
Rehabilitation Medicine Department, San Paolo Hospital, University of Milan, Milan, Italy
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Service of Neurophysiopathology - National Neurological Institute C. Mondino, Pavia, Italy
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3
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Corresponding Author: Dr. Fabiana Allevi, MD
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Via di Rudinì, 8 20142 Milan, Italy
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Phone: +39 0281844755
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Mail: [email protected]
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Fax: +39 0281844704
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Summary Synkinetic movements are common among patients with incomplete recovery from facial palsy,
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with reported rates ranging from 9.1% to almost 100%. The authors propose the separation of the neural stimulus of the orbicularis oculi from that of the zygomatic muscular complex to treat eyelid closure/smiling synkinesis. This technique,
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associated with an anastomosis between the masseteric nerve and a central branch of the facial nerve, as well as with the use of a cross-facial nerve graft, resolves most of the spasms of the
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midface musculature, leading to a more relaxed tone when the mimic muscle is at rest and enhancing muscle excursion during voluntary and spontaneous smiling. Between 2011 and 2016, 18 patients affected by segmental paresis of the middle of the face underwent surgical treatment at the Maxillofacial Surgery Department of the San Paolo Hospital
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(Milan, Italy). Of these patients, 72.22% of cases with hypertone obtained partial to complete relaxation. Synkinesis was completely resolved in 83.33% of cases, and a significant
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improvement in facial movement was achieved in all patients. Neurorrhaphy of the masseteric nerve and the central branch of the facial nerve appears to
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produce favorable results. These initial data should be confirmed by further studies.
Keywords: Segmental facial palsy, Incomplete facial palsy, Synkinesis, Hypertone
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Introduction Synkinetic movements are common among patients with incomplete recovery from facial palsy,
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with reported rates ranging from 9.1% to almost 100% (Blomstedt et al, 1994; Terzis and Karypidis, 2012a).
The association of involuntary movements with voluntary ones may vary greatly, with the most
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frequent associations relating to the closure of the eyelids while smiling or to involuntary smiling during voluntary eyelid closure. (Terzis and Karypidis, 2012a; Terzis and Karypidis, 2012b; Lee
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et al, 2015)
Synkinesis has a severe negative impact on patients’ facial symmetry and quality of movement, leading to psychological deficits and a worsening quality of life. Although surgical and nonsurgical procedures have both been used to treat patients with facial synkinesis, there is
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currently no consensus on the preferred intervention; therefore, treating this condition remains a challenge (Terzis and Karypidis, 2012a; Terzis and Karypidis, 2012b).
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The majority of physicians prefer to apply non-surgical methods, such as botulinum toxin A (BTX-A) injections, chemical neurectomy, and different types of biofeedback, as the first-choice
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treatment. These are undoubtedly less invasive for patients, but their effects are temporary, with the procedures often failing to satisfy patients due to the frequent need to repeat them and the concomitant level of exercise required (Bennis et al, 2016; Salles et al, 2015; Salles and Ferreira, 2012; Mehta and Hadlock, 2008; Armstrong et al, 1996; Dalla Toffola et al, 2010; Mehdizadeh et al, 2016; Benichou et al, 2015). On the other hand, surgery can lead to more stable results but tends to be underutilized, probably
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because of the available alternative non-surgical techniques and the need for a large degree of confidence on the part of the surgeon when dealing with microsurgery of the tiny facial nerve
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branches (Vakharia and Vakharia, 2016). The aim of this paper is to present a new surgical procedure to treat eyelid closure/smiling
synkinesis; this procedure consists of anastomosing the main facial nerve branch of the great
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zygomatic complex to the masseteric nerve and, in most cases, a cross-facial nerve graft to
Materials and methods Surgical procedure (Fig.1,2)
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enhance synchrony between the healthy and pathological sides of the face.
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For those patients treated with cross-face nerve grafting plus a neurorrhaphy between the masseteric nerve to a selected midface facial nerve branch, a preparatory first surgery is accomplished. On the healthy side of the face, a face lift type of incision accomplished. A skin
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flap is elevated just anterior to the parotid gland to identify a facial nerve branch directed to the zygomatic muscular complex. The branch is also tested with the electrostimulator to verify its
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involvement in smiling. At the same time, a 20–25-cm portion of the suralis nerve is harvested by a second surgical team. The harvested nerve is reversed and placed in a cross-facial manner, joining the contralateral tragus, where it leans subcutaneously. An epineural neurorrhaphy using 11/0 polypropylene stitches is performed to connect the branch of the facial nerve on the healthy side to the suralis nerve in an end-to-end manner. 8 to 13 months later, when a positive Tinel’s sign is detected, second surgery takes place.
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A facelift-type skin incision is now made on the paralyzed side. An anterior skin flap is then elevated into the deep subcutaneous tissue a few centimeters medial to the anterior margin of the parotid gland. Then, a horizontal incision is made just in front of the gland, 1 centimeter below
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the zygomatic arch. The masseteric nerve is located 1.5–2 cm from the muscle surface and is exposed by gently dissecting the muscle fibers along the axis. A 2.5–3-cm-long nerve trunk segment is released after severing its small collateral branches, if necessary. The nerve is cut at
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this level and turned superficially to accomplish the neurorrhaphy. The middle-third facial nerve branch is identified on the reddish surface of the masseter muscle, running horizontally in the
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direction of the zygomatic muscles. The use of curare for anesthesia is avoided, and an electrostimulator is employed to confirm the correct choice of the appropriate facial nerve branch. Under a high-magnification surgical microscope, an epineural neurorrhaphy is performed between the masseteric nerve and the detached selected facial nerve branch. Selective
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neurectomy of a tiny facial nerve branch to the orbicularis oculi muscle is performed if spasms in this muscle were diagnosed preoperatively.
An epineural window is opened to allow the end-to-side neurorrhaphy of the suralis nerve cross-
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faced during the previous surgery, to the middle branch of the facial nerve, distally to the
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neurorrhaphy with the masseteric nerve.
Patients
Between January 2011 and January 2016, 18 consecutive patients (12 females and 6 males) affected by segmental paresis of the middle of the face underwent surgical treatment at the Maxillofacial Surgery Department of the San Paolo Hospital (Milan, Italy) to correct eyelid
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closure/smiling synkinesis and reduced smiling movement, with or without hypertonia of the zygomatic muscular complex at rest. (Fig.3). The senior author (F.B.) performed surgery in all
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cases.
Fourteen patients (77.78%) reported synkinesis consisting of an elevation of the upper lip while
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closing the eyelids, whereas the opposite (closing the eyelids during smiling) was true for the remaining four patients (22.22%). Hypertonia of the face at rest leading to enhancement of the
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nasolabial sulcus, eyelid rim reduction, and skin crease increase was present in 15 of 18 cases (83.33%). Three patients (16.67%) reported spontaneous facial pain due to mimetic muscle contracture. All patients showed some degree of smile reduction in comparison to the contralateral side. Hyperlacrimation and corneal discomfort were reported by all patients, but
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none had experienced irreversible corneal lesions.
The aetiology of incomplete facial palsy was incomplete recovery of Bell’s palsy in 10 cases (55.55%), facial trauma in 4 cases (22.22%), facial nerve injury during cranial base surgery in 2
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cases (11.11%), developmental anomalies in 1 case (5.55%), and Ramsey–Hunt syndrome in 1
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case (5.55%). The patients ranged in age from 12 to 47 years (average: 32.72 ± 10.49 years). All patients underwent a preoperative clinical and neurophysiological assessment to obtain data relating to muscular trophism and the residual presence of muscle fibrillations. Neurophysiological tests included needle electromyography (EMG), which confirmed the residual presence of motor unit action potential recruitment. The trigeminal motor component was tested by palpating the masseteric region during chewing and by needle EMG of the ipsilateral masseter muscle to verify its availability as a donor motor nerve.
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Three patients (16.67%) had grade IV facial palsy according to the modified House–Brackmann (HB) scale (moderately severe dysfunction with upper eyelid involvement), whereas 15 patients
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(83.33%) had grade III facial palsy (moderate dysfunction) (House and Brackmann, 1985). Among the 18 patients affected by middle-third incomplete facial palsy, six (33.33%) were
treated by severing one or more pathological facial nerve branches for the zygomatic muscular
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complex and forming an end-to-end anastomosis directly with the homolateral masseteric nerve. The aims of surgery were to attain the correct muscle tone at rest (the tone provided by the
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masseteric nerve), to reduce synkinesis by leaving the eyelids innervated by the facial nerve while the zygomatic muscular complex was innervated by the masseteric nerve, and to enhance the ability to smile due to the strong action of the masseteric nerve. After observing a lack of spontaneous activation of the masseteric nerve in response to amusing and happy emotions, two surgeries were planned in 12 cases (66.66%). The first surgery was a preparatory operation in
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which cross-facial nerve grafting was performed with a suralis nerve neurorrhaphied to a facial nerve branch directed to the great zygomatic muscle on the healthy side. The second surgery was performed 8 to 13 months later (mean: 11.3 months) but never prior to identification of a positive
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Tinel’s sign. The intervention consisted of performing an end-to-end neurorrhaphy between the
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masseteric nerve and one or two main branches of the pathological facial nerve directed to the zygomatic muscles as receiving nerves. The distal end of the suralis cross-facial nerve graft was joined end-to-side to the chosen branches of the facial nerve, and distally to the neurorrhaphy with the masseteric nerve.
Among the three patients with grade IV palsy of the upper eyelid, one underwent an upper eyelid lipofilling procedure to improve eyelid weight to enhance eyelid closure, whereas two patients received a cross-facial suralis nerve graft directed to the upper eyelid (direct neurotisation of the
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orbicularis oculi muscle) to improve blinking movements. Five patients (27.77%) required improvement in some detail of their facial symmetry or
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enhancement of their lower eyelid function. These patients underwent the following ancillary procedures: correction of lower eyelid ptosis and lagophthalmos via a fascia lata graft (one patient, 5.55%), middle-third soft tissue and upper lip suspension via fascia lata graft (one
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patient, 5.55%), lateral canthoplasty (two patients, 11.11%), and lipofilling in the mental symphysis (one patient, 5.55%).
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All patients received postoperative physiotherapy and worked directly with our physiotherapist (S.C.) either in the office or via an online video chat service (Skype). In the second case, a physiotherapist located near to the patient’s residence was also contacted and worked in accordance with our physiotherapist’s suggestions.
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Patients were asked to inform the medical team when they recognized the first mimic muscle contraction after surgery. From that moment, the patient was required to begin physiotherapeutic rehabilitation: the physiotherapist proposed physical exercises as intensive as the patient could
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bear, voluntary movements associated with emotion, re-imagining motor imagery, and imitation
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movements of facial expressions (Moran et al, 2011). Patients were taught to reduce the use of the masseteric nerve to obtain the same movement of the cheek, mouth, and eye; they were required to learn to coordinate eye opening and closure with functional requests (looking, gazing, peeking, smiling) and to observe their face by comparing the healthy side to the affected side to control movements and obtain perfect symmetry. During the complete regeneration phase, the voluntary and automatic motility became excellent, and patients were able to control their synkinesis, obtaining clear movement of their lips during
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talking without closing their eyes. High-intensity synkinesis was, however, still present. During the first 3 weeks after the first mimic muscle contraction, rehabilitation was performed three times per week and then reduced to two times per week for the following 3 weeks; from this
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period to 1 year after the first mimic muscle contraction, patients underwent rehabilitation once per week. In addition to the rehabilitation program performed under the supervision of the
physiotherapist, patients were asked to perform their exercises every day at home and monitor
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every small improvement with videos and pictures. The rehabilitation program was usually long and marked by the alternation between improvements and stable periods; thus, patients had to be
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assessed at least once per month to prevent demotivation.
A final assessment was performed at least 12 months after surgery by a team composed of one surgeon and one physiotherapist not involved in the treatment. The team observed the patient and
al, 2009).
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rated the photos and videos according to the HB scale modified by the Bell’s Society (Vrabec et
Using the modified House-Brackman scale as a reference, we performed a statistical analysis to
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assess the statistical significance of the patients’ facial movement improvement. A Wilcoxon signed-rank test for paired groups was used to assess the difference between the pre-operative
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and post-operative House-Brackman scale score. All statistical analyses were performed using the SPSS software (PASW Statistics for Windows, version 21.0; SPSS Inc., Chicago, IL). Values of p<.05 were considered to indicate statistical significance.
Results
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Surgery was uneventful in all 18 cases. Little temporary weakening of the affected facial segment was evident immediately after surgery in 9 of 18 cases (50%). One case (5.55%) had evident weakening of the contralateral facial donor site, but this recovered spontaneously after 2
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months. Overall, facial recovery began within 2 to 6 months (average: 3.8 months).
In 13 (72.22%) cases with hypertone at rest in the middle third of the face, partial-to-complete
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relaxation was obtained immediately after surgery without recurrence of any symptoms.
Synkinesis was completely resolved in 15 patients (83.33%). Three patients (16.67%) continued
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to present synkinesis between closure of the eyelids and smiling, although at a reduced intensity and in response to a more intense stimulus compared to their preoperative clinical status. An improvement in facial movement was achieved in all evaluated patients according to the modified HB scale. (Table 1)
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Using a Wilcoxon signed-rank test to compare the preoperative and postoperative modified House-Brackman score, the improvement was shown as statistically significant (p<0.001). After the postoperative onset of function, all patients were required to clench their teeth while
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smiling for a period of time varying from 2 to 4 months. After this period, they communicated a
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voluntary impulse to the midface muscles during smiling, but clenching was no longer necessary. Subsequently (6 to 10 months after surgery), smiling became automatic without the need to voluntarily contract the middle-third mimetic musculature. Emotional smiling was a completely different matter, as this was seldom detectable among those who did not receive a cross-facial nerve graft (significantly, the masseteric nerve does not activate itself in response to humour). Among 12 patients (66.67%) who received an additional cross-facial nerve graft, 9 patients (50%) smiled using the pathological side while watching a
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funny movie, although the smile was of a lower quantity compared to that produced through voluntary activation and was never completely symmetrical with the contralateral side. The quantity of movement made on the pathological side during voluntary smiling was substantially
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higher than that produced during emotional smiling. However, the “quality”/pleasantness of the emotional smile was completely natural.
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Two patients (11.11%) required a lipofilling procedure to restore symmetry to the masseteric region due to evident atrophy of the masseter muscle that appeared after masseteric-to-facial
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nerve neurorrhaphy. (Fig.4 and Video 1)
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Discussion
Numerous techniques have been proposed for the treatment of facial synkinesis, including biofeedback exercises, BTX-A (Mandrini et al, 2016; Pourmomeny and Asadi, 2014; Pereira et
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al, 2011), chemical neurectomy, selective orbicularis neuromyectomy (Yoshioka, 2015; Guerrissi, 1991; Hohman et al, 2013), cross-facial nerve grafting and secondary microcoaptation
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with or without botulinum toxin injection, direct muscle neurotisation (Terzis and Karypidis, 2012a; Terzis and Karypidis, 2012b), and combinations of different techniques (Biglioli, 2015a; Biglioli, 2015b; Allevi et al, 2015; Biglioli et al, 2014). BTX-A is now a first-line agent for the treatment of facial synkinesis and hyperkinesis (Lee et al, 2015).
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The underlying aim of its use is to reduce synkinesis and spasm of the musculature, phenomena often associated with synkinesis. BTX-A injections are also often utilized on the healthy side to make the face symmetrical to the extent possible. The use of BTX-A has the advantage of
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avoiding surgery and being reversible; in the case of an undesirable result, the patient’s face will return to its previous features in the space of a few months. Although BTX-A injections usually last only 3–5 months, Lee et al. reported that half-mirror biofeedback exercises in combination
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with three BTX-A injections might have a lasting effect on sequelae after facial paralysis over a
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period of 2 years (Lee et al, 2015).
On the other hand, it is difficult to reproduce the exact result achieved during previous infiltrations with BTX-A treatment, the patient needs lifelong treatment, the treatment entails great effort and expense, and a shift from an initially effective treatment to complete nonresponsiveness might occur due to the patient’s immune response and production of toxin-
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neutralising antibodies (Bran and Lohuis, 2014). Moreover, no actual increase in mimetic contraction is possible, although an apparent enhancement of movement might appear because
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the beginning of the contraction proceeds from a more relaxed position. To obtain a permanent result and increase the ability to contract the mimetic muscles, surgical
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treatment is required. Several surgical techniques have been introduced as an effective treatment option for facial synkinesis, although the result usually remains less than optimal (Terzis and Karypidis, 2012a; Terzis and Karypidis, 2012b; Yoshioka, 2015; Zhang et al, 2010; Marre et al, 2013; Hohman et al, 2013). Therefore, the development of a new and effective technique would have a tremendous impact on the treatment of facial synkinesis. Terzis and Karypidis proposed the use of cross-facial nerve grafting with secondary microcoaptations associated with BTX-A injections. The combination of restoring normal, coordinated, symmetric function coupled with
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the function of the unaffected side along with a decrease in undesirable movements using BTXA injections resulted in full restoration. A retrospective review that included 11 pediatric patients reported cross-facial nerve grafting and secondary microcoaptations as a highly effective
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procedure with 66% improvement; 100% improvement was reached only with the additional use of BTX-A (Terzis and Karypidis, 2012a; Terzis and Karypidis, 2012b).
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Selective orbicularis neuromyectomy is simple and effective for patients who exhibit periocular synkinesis, but the main disadvantage is that it results in the complete paralysis of the lower
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orbicularis muscle for several months after the operation (Allevi et al, 2014). Complete recovery from synkinesis is also not possible. There is a reported decrease, of up to 48%, in synkinetic movements (Yoshioka, 2015).
Based on EMG results showing the normal function of the masseter, the optimal results have
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been achieved in facial reanimation with the masseteric nerve as a donor nerve (Biglioli, 2015a; Biglioli, 2015b; Biglioli et al, 2017; Sforza et al, 2014; Sforza et al, 2015; Pavese et al, 2016; Boahene, 2013; Biglioli et al, 2012a; Zuker, 2015; Bianchi et al, 2014). The authors’ proposal to
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utilize this nerve for the treatment of eyelid closure/smiling synkinesis was based on separating the neural stimulus of the orbicularis oculi from that of the zygomatic muscular complex. Such a
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procedure resolves most of the synkinesis. Additionally, the correct function of the masseteric nerve resolves most of the spasms of the midface musculature, leading to a more relaxed muscle tone at rest. This, together with increased innervation of the zygomatic muscles, enhances muscle movement during smiling. If eyelid spasm is also present, selective neurectomy of a tiny facial nerve branch of the orbicularis oculi muscle is also performed. The addition of an end-to-side neurorrhaphy of a cross-facial nerve graft also appears to guarantee more spontaneous and natural smiling in response to humour.
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Physical therapy, biofeedback, and retraining all have a role in synkinesis treatment, as they increase the patient’s awareness of the intensity, timing, and symmetry of facial muscle
best rehabilitation results. (Biglioli et al, 2017; Biglioli et al, 2016)
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contractions. Surgical treatment should always be associated with physical therapy to obtain the
Different features characterise the physical rehabilitation program: exercises to restore smiling
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and cheek movements through clenching of the teeth, functional exercises to gain excellent coordination between eye and mouth movements to obtain a specific function without the
at home. (Lotter et al, 2012)
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activation of undesired muscles, and patient education to reproduce the aforementioned exercises
The human brain conceives every movement as a series of finalised actions, whereas every
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action requires multisensorial integration. (Denlinger et al, 2008) Patients are required to reproduce finalized movements using the motor imagery technique
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(Vanswearingen, 2008; Lotter et al, 1990): they are asked to visualize the movement and evoke the same somaesthetic sensation they actually feel when reproducing the same action. Facial
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functional rehabilitation after surgical treatment includes sensitive, cognitive, and emotional components to manage synkinesis and obtain the best facial movement. Synkinesis management should, therefore, avoid severe voluntary contractions and electrostimulations. (Targan et al, 2000)
A number of perceptive movements are proposed to understand both the direction and the size of these movements. (Moran et al, 2011; Biglioli et al, 2012b)
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Conclusions
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Neurorrhaphy between the masseteric nerve and the facial nerve branch to the great zygomatic muscular complex appears to produce favorable results in treating eyelid closure/smiling
synkinesis. Moreover, the facial muscle tone at rest is relaxed, and there is an improvement in
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the quantity of smiling. These initial data should be confirmed by follow-up studies.
Acknowledgements: none
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Conflicts of interest: none
The English in this document has been checked by at least two professional editors, both native
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speakers of English. For a certificate, please see:
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Mehdizadeh OB, Diels J, White WM: Botulinum Toxin in the Treatment of Facial
Mehta RP, Hadlock TA: Botulinum Toxin and Quality of Life in Patients with Facial Paralysis. Arch Facial Plast Surg 10:84-87, 2008
Moran A, Guillot A, MacIntyre T, Collet C: Re-Imagining Motor Imagery: Building
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Bridges between Cognitive Neuroscience and Sport Psychology. Br J Psychol 103:224-247,
Pavese C, Cecini M, Lozza A, Biglioli F, Lisi C, Bejor M, Dalla Toffola E:
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Rehabilitation and Functional Recovery after Masseteric-Facial Nerve Anastomosis. Eur J Phys
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Rehabil Med 52:379-388, 2016
Pereira LM, Obara K, Dias JM, Menacho MO, Lavado EL, Cardoso JR: Facial Exercise
Therapy for Facial Palsy: Systematic Review and Meta-Analysis. Clin Rehabil 25:649-658, 2011 Pourmomeny AA, Asadi S: Management of Synkinesis and Asymmetry in Facial Nerve Palsy: A Review Article. Iran J Otorhinolaryngol 26:251-256, 2014 Lotte M, Quinci A: Proposta di condotta terapeutica per la riabilitazione delle paralisi del
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facciale. Riabilitazione e apprendimento 10:259-277, 1990 Salles AG, Ferreira MC: Botulinum Toxin in the Treatment of the Synkinesis Associated
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with Facial Paralysis – Preliminary Report. Plast Reconstr Surg 130:49-50, 2012 Salles AG, da Costa EF, Castro Ferreira M, do Nascimento Remigio AF, Borsoi Moraes L, Gemperli R: Epidemiologic Overview of Synkinesis in 353 Patients with Longstanding Facial
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Paralysis under Treatment with Botulinum Toxin for 11 Years. Plast Reconstr Surg 136:1289-
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1298, 2015
Sforza C, Frigerio A, Mapelli A, Tarabbia F, Annoni I, Colombo V, Latiff M, PimentaFerreira CL, Rabbiosi D, Sidequersky FV, Zago M, Biglioli F: Double-Powered Free Gracilis Muscle Transfer for Smile Reanimation: A Longitudinal Optoelectronic Study. J Plast Reconstr
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Sforza C, Tarabbia F, Mapelli A, Colombo V, Sidequersky FV, Rabbiosi D, Annoni I, Biglioli F: Facial Reanimation with Masseteric to Facial Nerve Transfer: A Three-Dimensional
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Longitudinal Quantitative Evaluation. J Plast Reconstr Aesthet Surg 67:1378-1386, 2014 Targan RS, Alon G, Kay SL: Effect of Long-Term Electrical Stimulation on Motor
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Recovery and Improvement of Clinical Residuals in Patients with Unresolved Facial Nerve Palsy. Otolaryngol Head Neck Surg 122:246-252, 2000 Terzis JK, Karypidis D: Therapeutic Strategies in Post-Facial Paralysis Synkinesis in
Adult Patients. Plast Reconstr Surg 129:925e-939e, 2012a Terzis JK, Karypidis D: Therapeutic Strategies in Post-Facial Paralysis Synkinesis in
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Pediatric Patients. J Plast Reconstr Aesthet Surg 65:1009-1018, 2012b Vakharia K, Vakharia K: Bell’s Palsy. Facial Plast Surg Clin North Am 24:1-10, 2016
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Vanswearingen J: Facial Rehabilitation: A Neuromuscular Reeducation, Patient-Centered Approach. Facial Plast Surg 24:250-259, 2008
Vrabec JT, Backous DD, Djalilian HR, Gidley PW, Leonetti JP, Marzo SJ, Morrison D,
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Facial Nerve Disorders Committee: Facial Nerve Grading System 2.0. Otolaryngol Head Neck Surg 140:445-450, 2009
Yoshioka N: Selective Orbicularis Neuromyectomy for Postparetic Periocular Synkinesis. J Plast Reconstr Aesthet Surg 68:1510-1515, 2015
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Zhang B, Yang C, Wang W, Li W: Repair of Ocular-Oral Synkinesis of Postfacial Paralysis Using Cross-Facial Nerve Grafting. J Reconstr Microsurg 26:375-380, 2010
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Zuker RM: Facial Paralysis and the Role of Free Muscle Transplantation. Ann Chir Plast
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Esthet 60:420-429, 2015
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Captions to illustrations Fig.1: Schematic picture showing a branch of the injured facial nerve (a) sectioned and
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anastomosed to the masseteric nerve (b) and to the cross-face sural nerve graft (c). Fig.2: Intraoperative picture showing anastomosis between the masseteric nerve and a central branch of the facial nerve (big arrow) and the anastomosis between the cross-face sural nerve
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graft and a facial branch for the orbicularis oculi (small arrow).
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Fig.3: Preoperative picture showing asymmetry of the face during smiling. Fig.4: Picture showing good ability to smile 12 months after surgery.
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Video1: Smiling and eyelids closure 12 months postoperatively, with no signs of synkinesis.
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Table 1 PREOP POSTOP PREOPERATIVE M.H.B. M.H.B. SYMPTOMS SCALE SCALE hypertone, ascending iatrogenic III grade II grade synkinesis hypertone, descending iatrogenic III grade II grade synkinesis hypertone, ascending facial trauma III grade II grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis hypertone, descending developmental III grade II grade synkinesis hypertone, descending facial trauma IV grade III grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis hypertone, descending Bell's palsy IV grade II grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis Bell's palsy III grade II grade ascending synkinesis hypertone, descending bell's palsy III grade II grade synkinesis Ramsey-Hunt IV grade III grade ascending synkinesis syndrome hypertone, descending facial trauma III grade II grade synkinesis facial trauma III grade II grade descending synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis
A.F. A.V.E. A.M.
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B.P. B.A.
B.F. C.D. C.D. C.A.
F.A: G.M. L.A. P.M. P.M. S.M.
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POSTOPERATIVE SYMPTOMS no more hypertone and synkinesis no more hypertone and synkinesis no more hypertone and synkinesis no more hypertone and synkinesis no more hypertone and synkinesis no more hypertone and synkinesis hypertone still present, synkinesis reduced no more hypertone and synkinesis hypertone still present, synkinesis reduced no more hypertone and synkinesis no more hypertone and synkinesis synkinesis reduced no more hypertone and synkinesis
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PATIENT ETIOLOGY
no more synkinesis no more hypertone and synkinesis no more synkinesis no more hypertone and synkinesis no more hypertone and synkinesis
The table reports preoperative and postoperative data for all patients included in the study. Modified House-Brackmann scale was used to assess preoperative and postoperative grade of facial paresis.
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S1010-5182(17)30308-6
DOI:
10.1016/j.jcms.2017.09.008
Reference:
YJCMS 2781
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 7 May 2017 Accepted Date: 11 September 2017
Please cite this article as: Biglioli F, Kutanovaite O, Rabbiosi D, Colletti G, Mohammed M, Saibene AM, Cupello S, Privitera A, Battista VMA, Lozza A, Allevi F, Surgical treatment of synkinesiss between smiling and eyelid closure, Journal of Cranio-Maxillofacial Surgery (2017), doi: 10.1016/ j.jcms.2017.09.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Surgical treatment of synkinesis between smiling and eyelid closure
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Federico Biglioli1, Otilija Kutanovaite2, Dimitri Rabbiosi1, Giacomo Colletti1, Mohammed MAS3, Alberto M Saibene4, Silvia Cupello5, Antonino Privitera5, Valeria MA Battista1,
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Alessandro Lozza6, Fabiana Allevi1
Maxillo-Facial Surgery Department, San Paolo Hospital, University of Milan, Milan, Italy
2
Maxillo-Facial Surgery Department, Vilnius University Hospital Zalgiris Clinics, Zalgirio,
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1
Vilnius, Lithuania
Plastic Surgery Department, Assiut University, Egypt
4
Otolaryngology Department, San Paolo Hospital, University of Milan, Milan, Italy
5
Rehabilitation Medicine Department, San Paolo Hospital, University of Milan, Milan, Italy
6
Service of Neurophysiopathology - National Neurological Institute C. Mondino, Pavia, Italy
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3
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Corresponding Author: Dr. Fabiana Allevi, MD
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Via di Rudinì, 8 20142 Milan, Italy
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Phone: +39 0281844755
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Mail: [email protected]
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Fax: +39 0281844704
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Summary Synkinetic movements are common among patients with incomplete recovery from facial palsy,
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with reported rates ranging from 9.1% to almost 100%. The authors propose the separation of the neural stimulus of the orbicularis oculi from that of the zygomatic muscular complex to treat eyelid closure/smiling synkinesis. This technique,
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associated with an anastomosis between the masseteric nerve and a central branch of the facial nerve, as well as with the use of a cross-facial nerve graft, resolves most of the spasms of the
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midface musculature, leading to a more relaxed tone when the mimic muscle is at rest and enhancing muscle excursion during voluntary and spontaneous smiling. Between 2011 and 2016, 18 patients affected by segmental paresis of the middle of the face underwent surgical treatment at the Maxillofacial Surgery Department of the San Paolo Hospital
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(Milan, Italy). Of these patients, 72.22% of cases with hypertone obtained partial to complete relaxation. Synkinesis was completely resolved in 83.33% of cases, and a significant
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improvement in facial movement was achieved in all patients. Neurorrhaphy of the masseteric nerve and the central branch of the facial nerve appears to
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produce favorable results. These initial data should be confirmed by further studies.
Keywords: Segmental facial palsy, Incomplete facial palsy, Synkinesis, Hypertone
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Introduction Synkinetic movements are common among patients with incomplete recovery from facial palsy,
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with reported rates ranging from 9.1% to almost 100% (Blomstedt et al, 1994; Terzis and Karypidis, 2012a).
The association of involuntary movements with voluntary ones may vary greatly, with the most
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frequent associations relating to the closure of the eyelids while smiling or to involuntary smiling during voluntary eyelid closure. (Terzis and Karypidis, 2012a; Terzis and Karypidis, 2012b; Lee
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et al, 2015)
Synkinesis has a severe negative impact on patients’ facial symmetry and quality of movement, leading to psychological deficits and a worsening quality of life. Although surgical and nonsurgical procedures have both been used to treat patients with facial synkinesis, there is
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currently no consensus on the preferred intervention; therefore, treating this condition remains a challenge (Terzis and Karypidis, 2012a; Terzis and Karypidis, 2012b).
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The majority of physicians prefer to apply non-surgical methods, such as botulinum toxin A (BTX-A) injections, chemical neurectomy, and different types of biofeedback, as the first-choice
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treatment. These are undoubtedly less invasive for patients, but their effects are temporary, with the procedures often failing to satisfy patients due to the frequent need to repeat them and the concomitant level of exercise required (Bennis et al, 2016; Salles et al, 2015; Salles and Ferreira, 2012; Mehta and Hadlock, 2008; Armstrong et al, 1996; Dalla Toffola et al, 2010; Mehdizadeh et al, 2016; Benichou et al, 2015). On the other hand, surgery can lead to more stable results but tends to be underutilized, probably
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because of the available alternative non-surgical techniques and the need for a large degree of confidence on the part of the surgeon when dealing with microsurgery of the tiny facial nerve
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branches (Vakharia and Vakharia, 2016). The aim of this paper is to present a new surgical procedure to treat eyelid closure/smiling
synkinesis; this procedure consists of anastomosing the main facial nerve branch of the great
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zygomatic complex to the masseteric nerve and, in most cases, a cross-facial nerve graft to
Materials and methods Surgical procedure (Fig.1,2)
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enhance synchrony between the healthy and pathological sides of the face.
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For those patients treated with cross-face nerve grafting plus a neurorrhaphy between the masseteric nerve to a selected midface facial nerve branch, a preparatory first surgery is accomplished. On the healthy side of the face, a face lift type of incision accomplished. A skin
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flap is elevated just anterior to the parotid gland to identify a facial nerve branch directed to the zygomatic muscular complex. The branch is also tested with the electrostimulator to verify its
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involvement in smiling. At the same time, a 20–25-cm portion of the suralis nerve is harvested by a second surgical team. The harvested nerve is reversed and placed in a cross-facial manner, joining the contralateral tragus, where it leans subcutaneously. An epineural neurorrhaphy using 11/0 polypropylene stitches is performed to connect the branch of the facial nerve on the healthy side to the suralis nerve in an end-to-end manner. 8 to 13 months later, when a positive Tinel’s sign is detected, second surgery takes place.
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A facelift-type skin incision is now made on the paralyzed side. An anterior skin flap is then elevated into the deep subcutaneous tissue a few centimeters medial to the anterior margin of the parotid gland. Then, a horizontal incision is made just in front of the gland, 1 centimeter below
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the zygomatic arch. The masseteric nerve is located 1.5–2 cm from the muscle surface and is exposed by gently dissecting the muscle fibers along the axis. A 2.5–3-cm-long nerve trunk segment is released after severing its small collateral branches, if necessary. The nerve is cut at
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this level and turned superficially to accomplish the neurorrhaphy. The middle-third facial nerve branch is identified on the reddish surface of the masseter muscle, running horizontally in the
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direction of the zygomatic muscles. The use of curare for anesthesia is avoided, and an electrostimulator is employed to confirm the correct choice of the appropriate facial nerve branch. Under a high-magnification surgical microscope, an epineural neurorrhaphy is performed between the masseteric nerve and the detached selected facial nerve branch. Selective
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neurectomy of a tiny facial nerve branch to the orbicularis oculi muscle is performed if spasms in this muscle were diagnosed preoperatively.
An epineural window is opened to allow the end-to-side neurorrhaphy of the suralis nerve cross-
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faced during the previous surgery, to the middle branch of the facial nerve, distally to the
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neurorrhaphy with the masseteric nerve.
Patients
Between January 2011 and January 2016, 18 consecutive patients (12 females and 6 males) affected by segmental paresis of the middle of the face underwent surgical treatment at the Maxillofacial Surgery Department of the San Paolo Hospital (Milan, Italy) to correct eyelid
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closure/smiling synkinesis and reduced smiling movement, with or without hypertonia of the zygomatic muscular complex at rest. (Fig.3). The senior author (F.B.) performed surgery in all
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cases.
Fourteen patients (77.78%) reported synkinesis consisting of an elevation of the upper lip while
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closing the eyelids, whereas the opposite (closing the eyelids during smiling) was true for the remaining four patients (22.22%). Hypertonia of the face at rest leading to enhancement of the
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nasolabial sulcus, eyelid rim reduction, and skin crease increase was present in 15 of 18 cases (83.33%). Three patients (16.67%) reported spontaneous facial pain due to mimetic muscle contracture. All patients showed some degree of smile reduction in comparison to the contralateral side. Hyperlacrimation and corneal discomfort were reported by all patients, but
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none had experienced irreversible corneal lesions.
The aetiology of incomplete facial palsy was incomplete recovery of Bell’s palsy in 10 cases (55.55%), facial trauma in 4 cases (22.22%), facial nerve injury during cranial base surgery in 2
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cases (11.11%), developmental anomalies in 1 case (5.55%), and Ramsey–Hunt syndrome in 1
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case (5.55%). The patients ranged in age from 12 to 47 years (average: 32.72 ± 10.49 years). All patients underwent a preoperative clinical and neurophysiological assessment to obtain data relating to muscular trophism and the residual presence of muscle fibrillations. Neurophysiological tests included needle electromyography (EMG), which confirmed the residual presence of motor unit action potential recruitment. The trigeminal motor component was tested by palpating the masseteric region during chewing and by needle EMG of the ipsilateral masseter muscle to verify its availability as a donor motor nerve.
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Three patients (16.67%) had grade IV facial palsy according to the modified House–Brackmann (HB) scale (moderately severe dysfunction with upper eyelid involvement), whereas 15 patients
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(83.33%) had grade III facial palsy (moderate dysfunction) (House and Brackmann, 1985). Among the 18 patients affected by middle-third incomplete facial palsy, six (33.33%) were
treated by severing one or more pathological facial nerve branches for the zygomatic muscular
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complex and forming an end-to-end anastomosis directly with the homolateral masseteric nerve. The aims of surgery were to attain the correct muscle tone at rest (the tone provided by the
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masseteric nerve), to reduce synkinesis by leaving the eyelids innervated by the facial nerve while the zygomatic muscular complex was innervated by the masseteric nerve, and to enhance the ability to smile due to the strong action of the masseteric nerve. After observing a lack of spontaneous activation of the masseteric nerve in response to amusing and happy emotions, two surgeries were planned in 12 cases (66.66%). The first surgery was a preparatory operation in
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which cross-facial nerve grafting was performed with a suralis nerve neurorrhaphied to a facial nerve branch directed to the great zygomatic muscle on the healthy side. The second surgery was performed 8 to 13 months later (mean: 11.3 months) but never prior to identification of a positive
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Tinel’s sign. The intervention consisted of performing an end-to-end neurorrhaphy between the
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masseteric nerve and one or two main branches of the pathological facial nerve directed to the zygomatic muscles as receiving nerves. The distal end of the suralis cross-facial nerve graft was joined end-to-side to the chosen branches of the facial nerve, and distally to the neurorrhaphy with the masseteric nerve.
Among the three patients with grade IV palsy of the upper eyelid, one underwent an upper eyelid lipofilling procedure to improve eyelid weight to enhance eyelid closure, whereas two patients received a cross-facial suralis nerve graft directed to the upper eyelid (direct neurotisation of the
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orbicularis oculi muscle) to improve blinking movements. Five patients (27.77%) required improvement in some detail of their facial symmetry or
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enhancement of their lower eyelid function. These patients underwent the following ancillary procedures: correction of lower eyelid ptosis and lagophthalmos via a fascia lata graft (one patient, 5.55%), middle-third soft tissue and upper lip suspension via fascia lata graft (one
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patient, 5.55%), lateral canthoplasty (two patients, 11.11%), and lipofilling in the mental symphysis (one patient, 5.55%).
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All patients received postoperative physiotherapy and worked directly with our physiotherapist (S.C.) either in the office or via an online video chat service (Skype). In the second case, a physiotherapist located near to the patient’s residence was also contacted and worked in accordance with our physiotherapist’s suggestions.
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Patients were asked to inform the medical team when they recognized the first mimic muscle contraction after surgery. From that moment, the patient was required to begin physiotherapeutic rehabilitation: the physiotherapist proposed physical exercises as intensive as the patient could
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bear, voluntary movements associated with emotion, re-imagining motor imagery, and imitation
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movements of facial expressions (Moran et al, 2011). Patients were taught to reduce the use of the masseteric nerve to obtain the same movement of the cheek, mouth, and eye; they were required to learn to coordinate eye opening and closure with functional requests (looking, gazing, peeking, smiling) and to observe their face by comparing the healthy side to the affected side to control movements and obtain perfect symmetry. During the complete regeneration phase, the voluntary and automatic motility became excellent, and patients were able to control their synkinesis, obtaining clear movement of their lips during
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talking without closing their eyes. High-intensity synkinesis was, however, still present. During the first 3 weeks after the first mimic muscle contraction, rehabilitation was performed three times per week and then reduced to two times per week for the following 3 weeks; from this
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period to 1 year after the first mimic muscle contraction, patients underwent rehabilitation once per week. In addition to the rehabilitation program performed under the supervision of the
physiotherapist, patients were asked to perform their exercises every day at home and monitor
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every small improvement with videos and pictures. The rehabilitation program was usually long and marked by the alternation between improvements and stable periods; thus, patients had to be
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assessed at least once per month to prevent demotivation.
A final assessment was performed at least 12 months after surgery by a team composed of one surgeon and one physiotherapist not involved in the treatment. The team observed the patient and
al, 2009).
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rated the photos and videos according to the HB scale modified by the Bell’s Society (Vrabec et
Using the modified House-Brackman scale as a reference, we performed a statistical analysis to
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assess the statistical significance of the patients’ facial movement improvement. A Wilcoxon signed-rank test for paired groups was used to assess the difference between the pre-operative
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and post-operative House-Brackman scale score. All statistical analyses were performed using the SPSS software (PASW Statistics for Windows, version 21.0; SPSS Inc., Chicago, IL). Values of p<.05 were considered to indicate statistical significance.
Results
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Surgery was uneventful in all 18 cases. Little temporary weakening of the affected facial segment was evident immediately after surgery in 9 of 18 cases (50%). One case (5.55%) had evident weakening of the contralateral facial donor site, but this recovered spontaneously after 2
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months. Overall, facial recovery began within 2 to 6 months (average: 3.8 months).
In 13 (72.22%) cases with hypertone at rest in the middle third of the face, partial-to-complete
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relaxation was obtained immediately after surgery without recurrence of any symptoms.
Synkinesis was completely resolved in 15 patients (83.33%). Three patients (16.67%) continued
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to present synkinesis between closure of the eyelids and smiling, although at a reduced intensity and in response to a more intense stimulus compared to their preoperative clinical status. An improvement in facial movement was achieved in all evaluated patients according to the modified HB scale. (Table 1)
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Using a Wilcoxon signed-rank test to compare the preoperative and postoperative modified House-Brackman score, the improvement was shown as statistically significant (p<0.001). After the postoperative onset of function, all patients were required to clench their teeth while
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smiling for a period of time varying from 2 to 4 months. After this period, they communicated a
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voluntary impulse to the midface muscles during smiling, but clenching was no longer necessary. Subsequently (6 to 10 months after surgery), smiling became automatic without the need to voluntarily contract the middle-third mimetic musculature. Emotional smiling was a completely different matter, as this was seldom detectable among those who did not receive a cross-facial nerve graft (significantly, the masseteric nerve does not activate itself in response to humour). Among 12 patients (66.67%) who received an additional cross-facial nerve graft, 9 patients (50%) smiled using the pathological side while watching a
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funny movie, although the smile was of a lower quantity compared to that produced through voluntary activation and was never completely symmetrical with the contralateral side. The quantity of movement made on the pathological side during voluntary smiling was substantially
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higher than that produced during emotional smiling. However, the “quality”/pleasantness of the emotional smile was completely natural.
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Two patients (11.11%) required a lipofilling procedure to restore symmetry to the masseteric region due to evident atrophy of the masseter muscle that appeared after masseteric-to-facial
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nerve neurorrhaphy. (Fig.4 and Video 1)
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Discussion
Numerous techniques have been proposed for the treatment of facial synkinesis, including biofeedback exercises, BTX-A (Mandrini et al, 2016; Pourmomeny and Asadi, 2014; Pereira et
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al, 2011), chemical neurectomy, selective orbicularis neuromyectomy (Yoshioka, 2015; Guerrissi, 1991; Hohman et al, 2013), cross-facial nerve grafting and secondary microcoaptation
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with or without botulinum toxin injection, direct muscle neurotisation (Terzis and Karypidis, 2012a; Terzis and Karypidis, 2012b), and combinations of different techniques (Biglioli, 2015a; Biglioli, 2015b; Allevi et al, 2015; Biglioli et al, 2014). BTX-A is now a first-line agent for the treatment of facial synkinesis and hyperkinesis (Lee et al, 2015).
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The underlying aim of its use is to reduce synkinesis and spasm of the musculature, phenomena often associated with synkinesis. BTX-A injections are also often utilized on the healthy side to make the face symmetrical to the extent possible. The use of BTX-A has the advantage of
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avoiding surgery and being reversible; in the case of an undesirable result, the patient’s face will return to its previous features in the space of a few months. Although BTX-A injections usually last only 3–5 months, Lee et al. reported that half-mirror biofeedback exercises in combination
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with three BTX-A injections might have a lasting effect on sequelae after facial paralysis over a
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period of 2 years (Lee et al, 2015).
On the other hand, it is difficult to reproduce the exact result achieved during previous infiltrations with BTX-A treatment, the patient needs lifelong treatment, the treatment entails great effort and expense, and a shift from an initially effective treatment to complete nonresponsiveness might occur due to the patient’s immune response and production of toxin-
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neutralising antibodies (Bran and Lohuis, 2014). Moreover, no actual increase in mimetic contraction is possible, although an apparent enhancement of movement might appear because
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the beginning of the contraction proceeds from a more relaxed position. To obtain a permanent result and increase the ability to contract the mimetic muscles, surgical
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treatment is required. Several surgical techniques have been introduced as an effective treatment option for facial synkinesis, although the result usually remains less than optimal (Terzis and Karypidis, 2012a; Terzis and Karypidis, 2012b; Yoshioka, 2015; Zhang et al, 2010; Marre et al, 2013; Hohman et al, 2013). Therefore, the development of a new and effective technique would have a tremendous impact on the treatment of facial synkinesis. Terzis and Karypidis proposed the use of cross-facial nerve grafting with secondary microcoaptations associated with BTX-A injections. The combination of restoring normal, coordinated, symmetric function coupled with
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the function of the unaffected side along with a decrease in undesirable movements using BTXA injections resulted in full restoration. A retrospective review that included 11 pediatric patients reported cross-facial nerve grafting and secondary microcoaptations as a highly effective
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procedure with 66% improvement; 100% improvement was reached only with the additional use of BTX-A (Terzis and Karypidis, 2012a; Terzis and Karypidis, 2012b).
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Selective orbicularis neuromyectomy is simple and effective for patients who exhibit periocular synkinesis, but the main disadvantage is that it results in the complete paralysis of the lower
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orbicularis muscle for several months after the operation (Allevi et al, 2014). Complete recovery from synkinesis is also not possible. There is a reported decrease, of up to 48%, in synkinetic movements (Yoshioka, 2015).
Based on EMG results showing the normal function of the masseter, the optimal results have
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been achieved in facial reanimation with the masseteric nerve as a donor nerve (Biglioli, 2015a; Biglioli, 2015b; Biglioli et al, 2017; Sforza et al, 2014; Sforza et al, 2015; Pavese et al, 2016; Boahene, 2013; Biglioli et al, 2012a; Zuker, 2015; Bianchi et al, 2014). The authors’ proposal to
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utilize this nerve for the treatment of eyelid closure/smiling synkinesis was based on separating the neural stimulus of the orbicularis oculi from that of the zygomatic muscular complex. Such a
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procedure resolves most of the synkinesis. Additionally, the correct function of the masseteric nerve resolves most of the spasms of the midface musculature, leading to a more relaxed muscle tone at rest. This, together with increased innervation of the zygomatic muscles, enhances muscle movement during smiling. If eyelid spasm is also present, selective neurectomy of a tiny facial nerve branch of the orbicularis oculi muscle is also performed. The addition of an end-to-side neurorrhaphy of a cross-facial nerve graft also appears to guarantee more spontaneous and natural smiling in response to humour.
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Physical therapy, biofeedback, and retraining all have a role in synkinesis treatment, as they increase the patient’s awareness of the intensity, timing, and symmetry of facial muscle
best rehabilitation results. (Biglioli et al, 2017; Biglioli et al, 2016)
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contractions. Surgical treatment should always be associated with physical therapy to obtain the
Different features characterise the physical rehabilitation program: exercises to restore smiling
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and cheek movements through clenching of the teeth, functional exercises to gain excellent coordination between eye and mouth movements to obtain a specific function without the
at home. (Lotter et al, 2012)
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activation of undesired muscles, and patient education to reproduce the aforementioned exercises
The human brain conceives every movement as a series of finalised actions, whereas every
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action requires multisensorial integration. (Denlinger et al, 2008) Patients are required to reproduce finalized movements using the motor imagery technique
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(Vanswearingen, 2008; Lotter et al, 1990): they are asked to visualize the movement and evoke the same somaesthetic sensation they actually feel when reproducing the same action. Facial
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functional rehabilitation after surgical treatment includes sensitive, cognitive, and emotional components to manage synkinesis and obtain the best facial movement. Synkinesis management should, therefore, avoid severe voluntary contractions and electrostimulations. (Targan et al, 2000)
A number of perceptive movements are proposed to understand both the direction and the size of these movements. (Moran et al, 2011; Biglioli et al, 2012b)
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Conclusions
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Neurorrhaphy between the masseteric nerve and the facial nerve branch to the great zygomatic muscular complex appears to produce favorable results in treating eyelid closure/smiling
synkinesis. Moreover, the facial muscle tone at rest is relaxed, and there is an improvement in
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the quantity of smiling. These initial data should be confirmed by follow-up studies.
Acknowledgements: none
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Conflicts of interest: none
The English in this document has been checked by at least two professional editors, both native
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speakers of English. For a certificate, please see:
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http://www.textcheck.com/certificate/bsRhym
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Captions to illustrations Fig.1: Schematic picture showing a branch of the injured facial nerve (a) sectioned and
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anastomosed to the masseteric nerve (b) and to the cross-face sural nerve graft (c). Fig.2: Intraoperative picture showing anastomosis between the masseteric nerve and a central branch of the facial nerve (big arrow) and the anastomosis between the cross-face sural nerve
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graft and a facial branch for the orbicularis oculi (small arrow).
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Fig.3: Preoperative picture showing asymmetry of the face during smiling. Fig.4: Picture showing good ability to smile 12 months after surgery.
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Video1: Smiling and eyelids closure 12 months postoperatively, with no signs of synkinesis.
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Table 1 PREOP POSTOP PREOPERATIVE M.H.B. M.H.B. SYMPTOMS SCALE SCALE hypertone, ascending iatrogenic III grade II grade synkinesis hypertone, descending iatrogenic III grade II grade synkinesis hypertone, ascending facial trauma III grade II grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis hypertone, descending developmental III grade II grade synkinesis hypertone, descending facial trauma IV grade III grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis hypertone, descending Bell's palsy IV grade II grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis Bell's palsy III grade II grade ascending synkinesis hypertone, descending bell's palsy III grade II grade synkinesis Ramsey-Hunt IV grade III grade ascending synkinesis syndrome hypertone, descending facial trauma III grade II grade synkinesis facial trauma III grade II grade descending synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis hypertone, descending Bell's palsy III grade II grade synkinesis
A.F. A.V.E. A.M.
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B.F. C.D. C.D. C.A.
F.A: G.M. L.A. P.M. P.M. S.M.
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POSTOPERATIVE SYMPTOMS no more hypertone and synkinesis no more hypertone and synkinesis no more hypertone and synkinesis no more hypertone and synkinesis no more hypertone and synkinesis no more hypertone and synkinesis hypertone still present, synkinesis reduced no more hypertone and synkinesis hypertone still present, synkinesis reduced no more hypertone and synkinesis no more hypertone and synkinesis synkinesis reduced no more hypertone and synkinesis
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PATIENT ETIOLOGY
no more synkinesis no more hypertone and synkinesis no more synkinesis no more hypertone and synkinesis no more hypertone and synkinesis
The table reports preoperative and postoperative data for all patients included in the study. Modified House-Brackmann scale was used to assess preoperative and postoperative grade of facial paresis.
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