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Sequelae after Facial Palsy: Clinical, Anatomical and Electrophysiological Studies
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Plastic Surgery.ORCID iD: 0000-0002-6353-7070
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Sequelae after peripheral facial palsy, which among others include synkinesis, non-functional smile and/or lower lip asymmetry, may be devastating for the patient. Bell’s palsy is the most common form of peripheral facial palsy. 

Aim: The aim was to study a) frequency and potential predictive factors of synkinesis in Bell’s palsy b) new surgical treatment options after facial nerve injury c) coactivation between muscles innervated by the facial nerve and the most common donor nerves in smile reanimation d) anatomical features of the lower lip depressors. 

Methods: I: Frequency, severity and early predictors of synkinesis development were studied in 829 Bell’s palsy patients. II and IV: Anatomical technical feasibility of intra-facial nerve transfers was analyzed. V: Anatomical features of lower lip depressor muscles were studied and a literature review for lower lip depressor myectomies was performed. III: Coactivation of muscles innervated by cranial nerves during voluntary facial movements was measured with electromyography. 

Results: I: In Bell’s palsy, synkinesis frequency was 21.3% at 12-months and Sunnybrook composite score at one month was found to be a good predictor for synkinesis. II and IV: A tension-free oculo-zygomatic and platysma-marginal mandibular nerve transfer was anatomically feasible. Full recovery of the lower lip after platsysma-marginal mandibular nerve transfer was found in a clinical case. III: The masseter muscle had a narrower coactivation pattern compared to the tongue. Bite induced a strong coactivation in the zygomaticus major muscle. V: The width of the depressor labii inferioris was 20 ± 4 mm and the distance from the midline to the lateral muscle border was 32 ± 4 mm. For the depressor anguli oris muscle, the corresponding measurements were 14 ± 3 mm and 54 ± 4 mm. The mean recurrence rate after lower lip myectomy reported in the literature is 21%.  

Conclusion: I: Synkinesis in Bell’s palsy was 21%. Sunnybrook composite score at one month is a good predictor for synkinesis. II: Oculo-zygomatic nerve transfer may be a suitable technique to reduce eye synkinesis and achieve a stronger smile. III: The narrow coactivation pattern in the masseter muscle may be advantageous for spontaneous smile development. IV: The platysma motor nerve transfer is a feasible procedure and can lead to full recovery in lower lip paralysis. V: Knowledge of the width of the depressor muscles is of importance to ensure complete resection in lower lip myectomy.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. , p. 44
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1601
Keywords [en]
Facial palsy, Marginal mandibular paralysis, Smile reconstruction, Synkinesis
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-394136ISBN: 978-91-513-0766-4 (print)OAI: oai:DiVA.org:uu-394136DiVA, id: diva2:1357428
Public defence
2019-11-30, Skoog salen, Ingång 78-79, Akademiska sjukhuset, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2019-11-11 Created: 2019-10-03 Last updated: 2019-11-27
List of papers
1. Platysma Motor Nerve Transfer for Restoring Marginal Mandibular Nerve Function
Open this publication in new window or tab >>Platysma Motor Nerve Transfer for Restoring Marginal Mandibular Nerve Function
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2016 (English)In: Journal of Plastic, Reconstructive & Aesthetic Surgery, ISSN 1748-6815, E-ISSN 1532-1959, Vol. 4, no 12, p. e1164-Article in journal (Refereed) Published
Abstract [en]

Background: Injuries of the marginal mandibular nerve (MMN) of the facial nerve result in paralysis of the lower lip muscle depressors and an asymmetrical smile. Nerve reconstruction, when possible, is the method of choice; however, in cases of long nerve gaps or delayed nerve reconstruction, conventional nerve repairs may be difficult to perform or may provide suboptimal outcomes. Herein, we investigate the anatomical technical feasibility of transfer of the platysma motor nerve (PMN) to the MMN for restoration of lower lip function, and we present a clinical case where this nerve transfer was successfully performed.

Methods: Ten adult fresh cadavers were dissected. Measurements included the number of MMN and PMN branches, the maximal length of dissection of the PMN from the parotid, and the distance from the anterior border of the parotid to the facial artery. The PMN reach for direct coaptation to the MMN at the level of the crossing with the facial artery was assessed. We performed histomorphometric analysis of the MMN and PMN branches.

Results: The anatomy of the MMN and PMN was consistent in all dissections, with an average number of subbranches of 1.5 for the MMN and 1.2 for the PMN. The average maximal length of dissection of the PMN was 46.5 mm, and in every case, tension-free coaptation with the MMN was possible. Histomorphometric analysis demonstrated that the MMN contained an average of 3,866 myelinated fiber counts per millimeter, and the PMN contained 5,025. After a 3-year follow-up of the clinical case, complete recovery of MMN function was observed, without the need of central relearning and without functional or aesthetic impairment resulting from denervation of the platysma muscle.

Conclusions: PMN to MMN transfer is an anatomically feasible procedure for reconstruction of isolated MMN injuries. In our patient, by direct nerve coaptation, a faster and full recovery of lower lip muscle depressors was achieved without the need of central relearning because of the synergistic functions of the PMN and MMN functions and minimal donor-site morbidity.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-315905 (URN)10.1097/GOX.0000000000001164 (DOI)
Available from: 2017-02-22 Created: 2017-02-22 Last updated: 2019-10-03Bibliographically approved
2. Cranial Nerve Coactivation and Implication for Nerve Transfers to the Facial Nerve.
Open this publication in new window or tab >>Cranial Nerve Coactivation and Implication for Nerve Transfers to the Facial Nerve.
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2018 (English)In: Plastic and reconstructive surgery (1963), ISSN 0032-1052, E-ISSN 1529-4242, Vol. 141, no 4, p. 582e-585eArticle in journal (Refereed) Published
Abstract [en]

In reanimation surgery, effortless smile can be achieved by a nonfacial donor nerve. The underlying mechanisms for this smile development, and which is the best nonfacial neurotizer, need further clarification. The aim of the present study was therefore to further explore the natural coactivation between facial mimic muscles and muscles innervated by the most common donor nerves used in smile reanimation. The study was conducted in 10 healthy adults. Correlation between voluntary facial muscle movements and simultaneous electromyographic activity in muscles innervated by the masseter, hypoglossal, and spinal accessory nerves was assessed. The association between voluntary movements in the latter muscles and simultaneous electromyographic activity in facial muscles was also studied. Smile coactivated the masseter and tongue muscles equally. During the seven mimic movements, the masseter muscle had fewer electromyographically measured coactivations compared with the tongue (two of seven versus five of seven). The trapezius muscle demonstrated no coactivation during mimic movements. Movements of the masseter, tongue, and trapezius muscles induced electromyographically recorded coactivation in the facial muscles. Bite resulted in the strongest coactivation of the zygomaticus major muscle. The authors demonstrated coactivation between voluntary smile and the masseter and tongue muscles. During voluntary bite, strong coactivation of the zygomaticus major muscle was noted. The narrower coactivation pattern in the masseter muscle may be advantageous for central relearning and the development of a spontaneous smile. The strong coactivation between the masseter muscle and the zygomaticus major indicates that the masseter nerve may be preferred in smile reanimation.

National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-347468 (URN)10.1097/PRS.0000000000004235 (DOI)000428668900014 ()29595736 (PubMedID)
Available from: 2018-04-03 Created: 2018-04-03 Last updated: 2019-10-03Bibliographically approved
3. Anatomical features in lower lip depressor muscles for optimization of myectomies in marginal mandibular nerve palsy
Open this publication in new window or tab >>Anatomical features in lower lip depressor muscles for optimization of myectomies in marginal mandibular nerve palsy
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(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-394017 (URN)
Available from: 2019-10-01 Created: 2019-10-01 Last updated: 2019-10-03Bibliographically approved
4. Oculo-zygomatic nerve transfer for facial synkinesis: An anatomical feasibility study
Open this publication in new window or tab >>Oculo-zygomatic nerve transfer for facial synkinesis: An anatomical feasibility study
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2019 (English)In: Microsurgery, ISSN 0738-1085, E-ISSN 1098-2752, Vol. 37, no 7, p. 629-633Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Patients with severe oro-ocular synkinesis often present with concomitant inefficient smile excursion on the affected site. In theory, oculo-zygomatic nerve transfer may decrease synkinesis and improve smile by redirecting nerve fibers to their target muscle. The aim of this study was to explore the feasibility of nerve transfer in human cadavers between a caudal branch innervating the orbicularis oculi to a cephalad branch innervating the zygomaticus major muscles.

METHODS: Eighteen hemi-faces were dissected. Reach for direct coaptation of a caudal nerve branch innervating the orbicularis oculi muscle to a cephalad nerve branch innervating the zygomaticus major muscle was assessed. Measurements included total number of nerve branches as well as maximum dissection length. Nerve samples were taken from both branches at the site of coaptation and histomorphometric analysis for axonal count was performed.

RESULTS: The number of sub-branches to the orbicularis oculi muscle was 3.1 ± 1.0 and to the zygomaticus major muscle 4.7 ± 1.2. The maximal length of dissection of the caudal nerve branch to the orbicularis oculi muscle was 28.3 ± 7.3 mm and for the cranial nerve branch to the zygomaticus major muscle 23.8 ± 6.5 mm. Transection and tension-free coaptation was possible in all cases but one. The average myelinated fiber counts per mm2 was of 5,173 ± 2,293 for the caudal orbicularis oculi branch and 5,256 ± 1,774 for the cephalad zygomaticus major branch.

CONCLUSION: Oculo-zygomatic nerve transfer is an anatomically feasible procedure. The clinical value of this procedure, however, remains to be proven.

National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-394138 (URN)10.1002/micr.30457 (DOI)000490018500007 ()30957287 (PubMedID)
Available from: 2019-10-03 Created: 2019-10-03 Last updated: 2019-11-06Bibliographically approved
5. Synkinesis in Bell's palsy in a randomised controlled trial
Open this publication in new window or tab >>Synkinesis in Bell's palsy in a randomised controlled trial
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2017 (English)In: Clinical Otolaryngology, ISSN 1749-4478, E-ISSN 1365-2273, Vol. 42, no 3, p. 673-680Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To study the development of synkinesis in Bell's palsy. Frequency, severity, gender aspects and predictors were analysed.

DESIGN: Data from the randomised controlled Scandinavian Bell's palsy trial including 829 patients.

MAIN OUTCOME MEASURES: Frequency and severity of synkinesis at 12 months were the main outcome measures. Mean Sunnybrook synkinesis scores, voluntary movement scores and composite scores between 6 and 12 months were compared.

RESULTS: In 743 patients with a 12-month follow-up, synkinesis frequency was 21.3%. There was no gender difference. Synkinesis was moderate to severe in 6.6% of patients. Those with synkinesis at 6 months had a synkinesis score of 4.1 (±2.8 sd), which increased to 4.7 (±3.2) (P = 0.047) at 12 months (n = 93). Sunnybrook composite score at 1 month was the best predictor for synkinesis development with receiver operating characteristics and area under the curve (AUC) 0.87. Risk for synkinesis increased with a lower Sunnybrook composite score. Furthermore, at 1 month, symmetry of voluntary movement had higher predictive value for synkinesis than resting symmetry with AUC 0.87 and 0.77, respectively. Gentle eye closure and open-mouth smile were the only independent significant predictive items (AUC 0.86).

CONCLUSIONS: Moderate-to-severe synkinesis was present in 6.6% of patients. The mean synkinesis score increased between 6 and 12 months, and outcome should therefore be evaluated after at least 12 months. Sunnybrook composite score and symmetry of voluntary movement at 1 month were good predictors for synkinesis.

National Category
Otorhinolaryngology
Identifiers
urn:nbn:se:uu:diva-315889 (URN)10.1111/coa.12799 (DOI)000399941300024 ()27882653 (PubMedID)
Available from: 2017-02-22 Created: 2017-02-22 Last updated: 2019-10-03Bibliographically approved

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