Open in a separate window Surgical technique the hypoglossal-facial anastomosis was performed under general anaesthesia in the supine position with the head tilted to the contralateral side. Through an extended Lahey incision, the elevation of the anterior subplatysmal flap was done, the sternocleidomastoid muscle was retracted posteriorly and separated from the parotid gland; the facial nerve was identified at its exit from the stylomastoid foramen using the posterior belly of the digastric muscle and the tragal pointer as landmarks. The nerve was dissected of the parotid gland until the level of the pes anserinus. Then the hypoglossal nerve was identified deep to the posterior belly of the digastric muscle and lateral to the internal carotid artery just above the carotid bifurcation, it was identified by following up the ansa hypoglossi up until it emerges from the hypoglossal nerve. The nerve was cut as far distally as possible and mobilised after the transaction of the ansa hypoglossi.
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Three years after the anastomosis, Time to reinnervation was associated with the final House-Brackmann grade. Our study demonstrates that patients undergoing XII-VII anastomosis and a long-term rehabilitation program display a significant recovery of facial symmetry and movement.
The recovery continues for at least three years after the anastomosis, meaning that prolonged follow-up of these patients is advisable. Keywords: facial nerve, facial palsy, hypoglossal-facial nerve anastomosis, mirror feedback, rehabilitation Introduction Hypoglossal-facial nerve XII-VII anastomosis is a surgical procedure that has long been used to restore movement to the facial muscles in cases of paralysis of the seventh cranial nerve Ozsoy et al.
Many surgical techniques have been reported for this procedure, but clinical series in the literature seem to demonstrate comparable functional recovery for the different approaches Lin et al.
After surgery, the facial muscles are reinnervated by the twelfth cranial nerve, therefore patients have to learn how to control facial motility through the use of voluntary tongue movements Rinn, This use of the new motor circuit is accompanied by a reorganization of brain activation patterns: hypoglossal motor cortex activation is observed when patients perform facial movements Bitter et al. In a meta-analysis, Yetiser and Karapinar reported a median improvement of two levels on the House-Brackmann HB grading system in patients who underwent surgery alone.
Following XII-VII anastomosis, patients frequently undergo a rehabilitation program to learn how to use the new motor circuit and how to prevent or control synkinesis Magliulo et al. Preliminary studies suggest a favorable effect of electromyographic biofeedback rehabilitation Brudny et al. The aim of this study was to assess the grade and timing of recovery in patients with complete facial palsy treated with XII-VII anastomosis followed by a home rehabilitation program involving mirror visual feedback.
Patients who met the following inclusion criteria were included in the present study: - first rehabilitation assessment at our unit within 12 months of surgery. The study was approved by the institutional ethics committee and the patients gave their written consent to participate in the research study.
Clinical assessment The HB grading system House and Brackmann, was used to evaluate the severity of paralysis before the anastomosis, at the first rehabilitation assessment and at follow-up sessions 12, 18 and 36 months after surgery. The HB system grades facial function on a six-point scale of increasing severity from I normal function to VI complete paralysis House and Brackmann, Rehabilitation treatment The objectives of rehabilitation are i for the patient to become aware of being able to perform new movements, ii for the patient then to learn the tongue movements that produce facial muscle contractions, and iii to render the newly acquired movements automatic Dalla Toffola and Petrucci, ; Ross et al.
At each clinical assessment patients were taught to perform specific exercises, according to their clinical status, and were then instructed to repeat them daily at home. For the first four to five months after surgery, before the first signs of reinnervation appear, patients who have undergone this procedure have complete facial paralysis.
In order to reduce muscle atrophy and to improve musculocutaneous vascularization during this phase, they are trained to carefully massage their face. In addition, patients are taught compensatory techniques to help them in their activities of daily living and esthetic camouflage in an attempt to both reduce their disability and improve their social participation Coulter and May, ; Dalla Toffola et al.
During the next phase, at the first signs of reinnervation, patients, using mirror feedback, need to learn which tongue positions thrust against teeth or palate produce the desired facial expressions. At first, they need to use a strong tongue thrust to achieve static and dynamic facial symmetry. To help them memorize the correct position and strength of tongue thrust, they are told to repeat the movement several times a day. As reinnervation improves, the tongue thrust does not have to be so strong in order to achieve symmetry.
At this point the patients are taught to use mirror visual feedback to dose the strength of tongue thrust necessary to achieve symmetry of muscle contraction between the reinnervated and the healthy side and to prevent the onset of synkinesis. Once patients have mastered static symmetry, they need to improve dynamic symmetry.
To do this they must learn how to produce a voluntary smile; again they need to use a mirror, dosing the strength of their tongue thrust and repeating the movement several times a day. The same process is then used to learn other voluntary movements such as snarling and lip puckering.
If eye-mouth synkinesis occurs, patients are told to reduce the strength of their tongue thrust. Through repetition of these exercises the movements become automatic, i. The median HB score at different time points was compared using the Friedman test. For post-hoc comparisons, the exact McNemar test was used, as well as a test for linear trend of the log-relative risk to exploit the ordinal nature of the score.
Finally, the Spearman test was used to identify variables associated with the HB grade at 36 months. Results Thirty patients were included in the study. Reinnervation occurred in 29 patients, on average at 5. Only one patient, whose palsy was caused by a brain hemorrhage, did not show signs of reinnervation after the surgery. The first rehabilitation assessment took place on average 5. Eighteen patients had hypoacusis, due to the removal of a neuroma of the eighth cranial nerve in 16 patients, and to an expansive lesion in two.
To prevent eye complications related to incomplete eyelid closure, eight patients had gold weight implants and six patients had undergone tarsorrhaphy.
Four patients had dysphagia, 11 complained of lachrymation disorders, and nine had ataxia. During the rehabilitation period, 29 patients showed clinical improvement as revealed by the HB grading system.
FACIAL HYPOGLOSSAL ANASTOMOSIS PDF
Enhancing facial appearance with cosmetic camouflage. End-to-side intrapetrous hypoglossal—facial anastomosis for reanimation of the face Both the jump graft technique and the intratemporal hemihypoglossal—facial attachment described by other authors Table 2 entail the interruption of approximately one half of the hypoglossal nerve to attach the recipient facial nerve. Fourteen patients developed mild synkinesis involving contraction of the orbicularis oculi muscle on activation of the orbicularis oris, zigomaticus major and risorius muscles; two such cases were treated with botulinum toxin injections Dalla Toffola et al. Efficacy of feedback training in long-standing facial nerve paresis. Noticeable, however, is the fact that the orbicularis oculi muscle is also reinnervated. If eye-mouth synkinesis occurs, patients are told to reduce the strength of their tongue thrust. Ensuring accuracy of this maneuver is of paramount importance to avoid tension at the level of the suture.