Dr. Eisenhardt is funded by the German Research Foundation (DFG) # EI 866/1-1 and #EI 866/2-1.

<ol>
	<li>Mavrikakis, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Facial+nerve+palsy:+anatomy,+etiology,+evaluation,+and+management.">Facial nerve palsy: anatomy, etiology, evaluation, and management.</a> Orbit. 27 (6), 466-474 (2008).</li><li>Pitanguy, I., Ramos, A. 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F., Pantel, M., Guntinas-Lichius, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modern+concepts+in+facial+nerve+reconstruction.">Modern concepts in facial nerve reconstruction.</a> Head Face Med. 6, 25 (2010).</li><li>Mathes, S. J., Nahai, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Classification+of+the+vascular+anatomy+of+muscles:+experimental+and+clinical+correlation.">Classification of the vascular anatomy of muscles: experimental and clinical correlation.</a> Plast Reconstr Surg. 67 (2), 177-187 (1981).</li><li>Harii, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microneurovascular+free+muscle+transplantation+for+reanimation+of+facial+paralysis.">Microneurovascular free muscle transplantation for reanimation of facial paralysis.</a> Clin Plast Surg. 6 (3), 361-375 (1979).</li><li>Borschel, G. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+motor+nerve+to+the+masseter+muscle:+an+anatomic+and+histomorphometric+study+to+facilitate+its+use+in+facial+reanimation.">The motor nerve to the masseter muscle: an anatomic and histomorphometric study to facilitate its use in facial reanimation.</a> J Plast Reconstr Aesthet Surg. 65 (3), 363-366 (2012).</li><li>Zuker, R. M., Goldberg, C. S., Manktelow, R. 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H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fibrin+sealant+adhesive+systems:+a+review+of+their+chemistry,+material+properties+and+clinical+applications.">Fibrin sealant adhesive systems: a review of their chemistry, material properties and clinical applications.</a> J Biomater Appl. 7 (4), 309-352 (1993).</li><li>Brien, B. M., Lawlor, D. L., Morrison, W. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microneurovascular+free+muscle+reconstruction+for+long+established+facial+paralysis.">Microneurovascular free muscle reconstruction for long established facial paralysis.</a> Ann Chir Gynaecol. 71 (1), 65-69 (1982).</li><li>Eisenhardt, S. U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+cross+face+nerve+graft+with+masseteric+nerve+as+donor+nerves+for+free+functional+muscle+transfers+in+facial+reanimation+surgery].">Comparison of cross face nerve graft with masseteric nerve as donor nerves for free functional muscle transfers in facial reanimation surgery].</a> Handchir Mikrochir Plast Chir. 45 (4), 223-228 (2013).</li><li>Harrison, D. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+pectoralis+minor+vascularized+muscle+graft+for+the+treatment+of+unilateral+facial+palsy.">The pectoralis minor vascularized muscle graft for the treatment of unilateral facial palsy.</a> Plast Reconstr Surg. 75 (2), 206-216 (1985).</li><li>Frey, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Histomorphometric+studies+in+patients+with+facial+palsy+treated+by+functional+muscle+transplantation:+new+aspects+for+the+surgical+concept.">Histomorphometric studies in patients with facial palsy treated by functional muscle transplantation: new aspects for the surgical concept.</a> Ann Plast Surg. 26 (4), 370-379 (1991).</li><li>Eisenhardt, S. U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Salvage+Procedures+After+Failed+Facial+Reanimation+Surgery+Using+the+Masseteric+Nerve+as+the+Motor+Nerve+for+Free+Functional+Gracilis+Muscle+Transfer.">Salvage Procedures After Failed Facial Reanimation Surgery Using the Masseteric Nerve as the Motor Nerve for Free Functional Gracilis Muscle Transfer.</a> JAMA Facial Plast Surg. , (2014).</li><li>Bae, Y. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comparison+of+commissure+excursion+following+gracilis+muscle+transplantation+for+facial+paralysis+using+a+cross-face+nerve+graft+versus+the+motor+nerve+to+the+masseter+nerve.">A comparison of commissure excursion following gracilis muscle transplantation for facial paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve.</a> Plast Reconstr Surg. 117 (7), 2407-2413 (2006).</li><li>Schaverien, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Activation+of+the+masseter+muscle+during+normal+smile+production+and+the+implications+for+dynamic+reanimation+surgery+for+facial+paralysis.">Activation of the masseter muscle during normal smile production and the implications for dynamic reanimation surgery for facial paralysis.</a> J Plast Reconstr Aesthet Surg. 64 (12), 1585-1588 (2011).</li><li>Manktelow, R. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Smile+reconstruction+in+adults+with+free+muscle+transfer+innervated+by+the+masseter+motor+nerve:+effectiveness+and+cerebral+adaptation.">Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation.</a> Plast Reconstr Surg. 118 (4), 885-899 (2006).</li><li>Eppley, B. L., Zuker, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Salvage+of+facial+reanimation+with+vascularized+adductor+magnus+muscle+flap:+clinical+experience+and+anatomical+studies.">Salvage of facial reanimation with vascularized adductor magnus muscle flap: clinical experience and anatomical studies.</a> Plast Reconstr Surg. 110 (7), 1693-1696 (2002).</li><li>Labbe, D., Huault, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lengthening+temporalis+myoplasty+and+lip+reanimation.">Lengthening temporalis myoplasty and lip reanimation.</a> Plast Reconstr Surg. 105 (4), 1289-1297 (2000).</li><li>Iblher, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+evaluation+tool+for+monitoring+devices+and+its+application+to+evaluate+the+implantable+Doppler+probe.">A new evaluation tool for monitoring devices and its application to evaluate the implantable Doppler probe.</a> J Reconstr Microsurg. 26 (4), 265-270 (2002).</li></ol>

The authors have nothing to disclose.

Even though different surgical techniques have been described to regain a dynamic smile in patients with long standing facial paralysis, the two-stage repair with initial cross facial nerve grafting and consecutive free gracilis muscle transfer is seen as the &#8220;criterion standard&#8221;.
Although a two-stage procedure, the technique allows for spontaneity of the smile which is seen as a crucial factor to overcome the social handicap associated with facial palsy13.In cases of bi...

Der Gesichtsnerv wird in der Augenschutz, Artikulation, orale Kontinenz beteiligt und das ästhetische Erscheinungsbild des Gesichts stark beeinflusst. Wertminderung von diesem Nerv ist daher mit einer erheblichen Morbidität und sozialem Rückzug verbunden. Trotz bedeutender Fortschritte in der Therapie kann die Vielzahl von Problemen mit der gelähmten Gesicht assoziiert nur mit einem breiten Spektrum an zusätzlichen Verfahren ausgerichtet sein. Gemeinsam ist allen Operationstechniken ist die Notwendigkeit einer genauen anatomischen Kenntnisse. Gesichtsnerv Anatomie Der Gesichtsnerv besteht aus einem Kiemenmotorkomponente für Willkürmotorik der Gesichtsmuskulatur und einer viszeralen Motorkomponente für parasympathischen Kontrolle Tränen, submandibularis und sublingualis. Außerdem gibt es zwei sensorische Komponenten für die Innervation des äußeren Gehörgangs und dem Geschmack in den vorderen zwei Drittel der Zunge. Der Verlauf der Gesichtsnerven kann bintrakranielle, im Schädelbein und extratemporal: e in drei Segmente unterteilt. Im Hirn Segment erhält der oberen Gruppe von Neuronen, die die Stirnmuskels und der periauricular Region innervieren bilaterale kortikale Eingang. Neuronen, die die übrigen Gesichtsmuskeln innervieren erhalten kontralateralen kortikalen Eingang exklusiv. Als Folge davon wird frontalis Funktion ipsilateral supranukleärer Läsionen gehalten. Die Schädelbein Segment kann ferner in drei Abschnitte unterteilt werden. Im labyrinthischen Segment verlässt der N. petrosus major den Kofferraum, um die Tränendrüse mit parasympathischen Fasern 1 zu liefern. In dem Mastoid Segment läuft das dünne stapedius Nerv zum Muskel-Korrespondent. Parasympathischen Zweige innervieren die submandibularis, sublingual und vorderen Zungendrüsen, während die vorderen zwei Drittel der Zunge sind mit Geschmacksfasern (Chorda) geliefert. Der Hauptstamm des Gesichtsnervs verlässt den knöchernen Kanaldurch die Foramen stylomastoideum. Dies ist der Beginn des extratemporal Segment jedoch Verästelungen nicht vor Eintritt in die Parotis starten. Der Nerv wird zuerst in 3 bis 4 Motor Divisionen, die intraparotideale Plexus und schließlich führen die zeitliche, Jochbein, bukkale Unterkiefer und zervikale Verzweigungen 2 unterteilt. Differentialdiagnose von Gesichtslähmung Als Ursache der Gesichtslähmung ist breit und schwer zu unterteilen, sollte der Unternehmensbereich, der betroffen ist zunächst zu berücksichtigen. Intrakranielle Gesichtslähmung kann durch lakunäre Infarkte oder Tumoren der Schädelhöhle verursacht werden. Bakteriellen und viralen Infektionen, Cholesteatom und Bell-Lähmung kann Gründe für Schädelbein Nervenschäden sein. Neoplastischen bösartigen Erkrankungen und die damit verbundenen chirurgischen Therapie sind die dominierenden Ursachen für extratemporal Gesichtslähmung. Obwohl Bell-Lähmung ist die häufigste Diagnosebei Patienten mit Gesichtslähmung, erholen sich die meisten Patienten völlig ohne Folgeerscheinungen und nicht Chirurgie 3 benötigen. Die zweithäufigste Ursache von Gesichtslähmung ist Trauma. Hier Frakturen des Schläfenbeins sind die vorherrschende Traumamechanismus 4. Die Behandlung Arten von Gesichtslähmung Zahlreiche chirurgische Optionen gibt es für die Behandlung von Gesichtslähmung, und sie können in Reinnervation, statische und dynamische Rekonstruktion Rekonstruktion klassifiziert werden. Typischerweise werden 2 Jahre als die Zeit von der Verletzung in dem Funktion nach reinnervation kann zufriedenstellend reinnervating Verfahren 5 wiedergewonnen werden können. Später Denervierung Atrophie der Gesichtsmuskeln schließt ihre Nützlichkeit für die weitere Rekonstruktion. Reinnervation können durch primäre Nervenreparatur, interpositional Nerventransplantate, Quergesichtsnerven Pfropfen oder Hirnnervenübertragung erzielt werden. Statische Rekonstruktionstechniken sind darauf gerichtet, zu korrigierenfunktionellen Behinderungen, (Schutz der Hornhaut, die Verbesserung der Nasenatmung und Prävention von Speichelfluss) und der Symmetrie in Ruhe zu verbessern. Typische Verfahren sind für die Stirn Ptosis oder Kanthoplastik für untere Deckel Ektropium browlift. Statische Rekonstruktion bei älteren Patienten mit signifikanten Begleiterkrankungen oder in massiven Gesichtsdefekten nach Trauma oder Krebs Resektion bevorzugt. Die chirurgischen Techniken der dynamischen Rekonstruktion kann in regionale Muskeltransfer und kostenlose microneurovascular Muskeltransfer entweder Koaptation auf die masseter Motorabzweig oder Quergesichtsnerven Transplantation unterteilen. Letzteres stellt das Kriterium Standard für die Rekonstruktion des Lächelns in Gesichtslähmung, wie keine andere Behandlungsoption zuverlässig ein spontanes Lächeln, das entscheidend für die soziale Behinderung zu verbessern, ist erreicht. Koaptation auf die masseter Motorabzweig ist die Behandlungsmethode der Wahl für Patienten mit beidseitiger Lähmung jedoch Anzeichen haben extendete, wie älteren Patienten oder Patienten mit signifikanten Begleiterkrankungen der Regel lieber ein einstufiges Verfahren 6. Gracilis Klappe Regional Anatomie Der M. gracilis ist eine eher oberflächliche Muskel des medialen Oberschenkel, die die längste Muskel der Adduktoren. Es stammt aus der unteren Symphyse und dem unteren Ast des Schambeins. Lauf distal, wird die Muskel schmalen und fügt distal zu dem Kniegelenk des Schienbeins, die nicht nur die Adduktion des Oberschenkels sondern auch Beugung des Knies ermöglicht. Der M. gracilis hat eine Typ-II-Kreislauf-Muster nach Mathes und Nahai mit einem arterielle Versorgung aus einer dominanten und einige kleinere Gefäßstiele 7. Die dominierende Arterie verlässt den Muskel am Hilus Kurs seitlich und endet in der medialen Kranzarterie in der Regel. In seltenen Fällen endet die dominierende Arterie direkt in der tiefen Oberschenkelarterie. Venöse Versorgung des gracilis Muskel ist in der Regel durch zwei Venae comitantes erreicht, dass natürlich tief in die M. adductor longus, um die dominante Arterie zu folgen. Innervation des Muskels wird durch einen vorderen Ast des Nervus obturatorius, die den Muskel an den Hilus tritt 1-2 cm kranial erreicht. Klinische Anwendung Der M. gracilis ist eine wertvolle Muskel Spender für die rekonstruktive Mikrochirurgie und hat die Muskeln der Wahl für viele Chirurgen für funktionelle freier Muskeltransfer zu werden. Dies wird auf die Tatsache, dass es wenig Spenderstellenmorbidität und die Klappe zeigt optimale Verhältnisse in Bezug auf die Auslenkung des Muskels und Gefäßstiel Abmessungen jeweils verdanken. Eine lange einzigen innervierten motorischen Nerven lindert Funktionsklappe Ernte 8. Wir zeigen hier den Fall einer 49 Jahre alte Frau, die zunächst ein vollständiges Bild von links peripheren Gesichtslähmung präsentiert nach Resektion eines akustischenNeurom (Vestibularisschwannom) 2 Jahre zuvor. Der Patient wurde am stärksten von Gesichtsasymmetrie, besonders beim Lächeln heimgesucht. Andere bereits bestehenden Begleiterkrankungen wurden nicht dokumentiert. Bei der klinischen Untersuchung zeigte der Patient eine komplette Parese des Stirnmuskels jedoch eine zufriedenstellende Stirn Symmetrie in Ruhe. Deckelverschluss nicht ausreichend war auf der linken Seite mit einem Lagophthalmus von 5 mm und Bell-Phänomen. Zeichen der Hornhaut Reizungen und Ektropium fehlten. Im Ruhezustand, zeigte der Patient eine moderate Asymmetrie der Ecke der Mund mit einem Tragus-modiolus Abstand von 11 cm auf der rechten und 11,5 cm auf der linken Seite in Ruhe. Nach Lächeln, Tragus-modiolus Entfernung von 9 cm auf der rechten skaliert und auf der linken Seite von 12 cm gestreckt. Nach umfangreicher Beratung, wünschte der Patient für eine einstufige dynamische Rekonstruktion des Lächelns mit einer freien funktionellen gracilis Übertragung mit dem masseter als Spendernerv. Der Patient wurde auch über verschiedene te informiertchniques der Deckelverschluss Rekonstruktion jedoch sank die chirurgische Behandlung in diesem Stadium. Der Verlauf der Behandlung war unkompliziert. Zeichen der Reinnervation wurden zum ersten Mal bemerkt 3 Monate postoperativ. Vier Monate nach der Operation, der Patient mit unauffälligen Narben entlang der ehemaligen geändert Facelift Schnittführung vorgestellt. Symmetrie in Ruhe und bewusste lächelnd waren mit einem zufriedenstellenden Definition der Nasenlippenfalte ausgezeichnet. Der Patient zeigte auch eine völlig spontane Lächeln. Vor- und 9-Monatspostoperativen Bereich der Auslenkung des Mundwinkel wurde von Videografie dokumentiert.

<table><tbody><tr><td>Nylon Suture, 9-0</td><td>Serag Weissner</td><td>Z0039490</td><td>&amp;deg;</td></tr><tr><td>Polypropylene Suture&amp;nbsp;</td><td>Ethicon</td><td>-</td><td>Multiple thread sizes</td></tr><tr><td>Suprarenin 1mg/ml</td><td>Sanofi</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Cook-Swartz Doppler Probe</td><td>Cook Medical</td><td>G03014</td><td>&amp;deg;</td></tr><tr><td>DP-M350 Blood Flow Monitor</td><td>Cook Medical</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Surgical Microscope OPMI Vario</td><td>Carl Zeiss</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Microsurgical instruments lab set</td><td>S&amp;amp;T</td><td>767</td><td>&amp;deg;</td></tr><tr><td>Biemer vessel clip</td><td>Diener</td><td>64,562</td><td>&amp;deg;</td></tr><tr><td>Applying forceps</td><td>Diener</td><td>64,568</td><td>for Biemer vessel clip</td></tr><tr><td>Cefuroxim 1500mg</td><td>Fresenius</td><td>J01DC02</td><td>&amp;deg;</td></tr><tr><td>Braunoderm</td><td>Braun Melsungen</td><td>3881105</td><td>&amp;deg;</td></tr><tr><td>Octenisept</td><td>Schuelke &amp;amp; Mayr</td><td>5702764</td><td>&amp;deg;</td></tr><tr><td>ISIS Neuromonitoring System</td><td>Inomed</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Tissucol</td><td>Baxter</td><td>1.33052E+12</td><td>Fibrin glue</td></tr><tr><td>Jackson-Pratt Wound Drainage</td><td>Medline</td><td>SU130-1060</td><td></td></tr><tr><td>Myacyne Ointment</td><td>Schur Pharma</td><td>-</td><td></td></tr></tbody></table>

single-stage dynamic reanimation of the smile in irreversible facial paralysis by free functional muscle transfer

Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic facial paralysis (Bell&#8217;s palsy) is the most common diagnosis, patients can also present with a history of physical trauma, infectious disease, tumor, or iatrogenic facial paralysis. Early repair within one year of injury can be achieved by direct nerve repair, cross-face nerve grafting or regional nerve transfer. It is due to muscle atrophy that in long lasting facial paralysis complex reconstructive methods have to be applied. Instead of one single procedure, different surgical approaches have to be considered to alleviate the various components of the paralysis.
The reconstruction of a spontaneous dynamic smile with a symmetric resting tone is a crucial factor to overcome the functional deficits and the social handicap that are associated with facial paralysis. Although numerous surgical techniques have been described, a two-stage approach with an initial cross-facial nerve grafting followed by a free functional muscle transfer is most frequently applied. In selected patients however, a single-stage reconstruction using the motor nerve to the masseter as donor nerve is superior to a two-stage repair. The gracilis muscle is most commonly used for reconstruction, as it presents with a constant anatomy, a simple dissection and minimal donor site morbidity.
Here we demonstrate the pre-operative work-up, the post-operative management, and precisely describe the surgical procedure of single-stage microsurgical reconstruction of the smile by free functional gracilis muscle transfer in a step by step protocol. We further illustrate common pitfalls and provide useful tips which should enable the reader to truly comprehend the procedure. We further discuss indications and limitations of the technique and demonstrate representative results.

<html> Die Verwendung des massetericus Nerv reinnervation des Muskels Transplantat wurde bei 5 Patienten (Tabelle 1) bewertet. Unter ihnen Akustikusneurinom Resektion war die Hauptursache für die Gesichtslähmung. 3 Kandidaten bevorzugt, die einstufiges Verfahren anstatt der &quot;Goldstandard&quot; zweistufigen Ansatz. Bei zwei Patienten war die Prozedur als Rettungsverfahren nach unzureichende Stimulation durch den Quergesichtsnerventransplantat (CFNG). Reinnervation des g...

Watch this Scientific Journal Video about Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer at JoVE.com

Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer

The use of the masseteric nerve as donor nerve represents a single-stage alternative to the criterion standard two-stage procedure of cross-facial nerve grafting and free muscle transfer in facial paralysis. We provide a detailed description to safely perform this technique with a gracilis muscle transfer and discuss indications and limitations.

Einstufige Dynamische Reanimation des Lächelns in Irreversible Fazialisparese von Free Funktionsmuskelüber

Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic ...

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JoVE Journal

Medicine

105.8K Aufrufe.  University of Freiburg Medical Centre. The use of the masseteric nerve as donor nerve represents a single-stage alternative to the criterion standard two-stage procedure of cross-facial nerve grafting and free muscle transfer in facial paralysis. We provide a detailed description to safely perform this technique with a gracilis muscle transfer and discuss indications and limitations.

Serie: Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer

Microvascular Decompression: Salient Surgical Principles and Technical Nuances

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure&#x2014;with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation.
In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed.

There are many available options for management of the patient with trigeminal neuralgia. Microvascular decompression, while the most invasive of all options, is also the most effective at achieving long term remission of symptoms. Video instruction on how to maximize efficacy and minimize complications with this procedure is described.

Mikrovaskulären Dekompression: Salient Chirurgische Prinzipien und technischen Feinheiten

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports ...

Forschung

Medizin

Breathing-controlled Electrical Stimulation (BreEStim) for Management of Neuropathic Pain and Spasticity

Electrical stimulation (EStim) refers to the application of electrical current to muscles or nerves in order to achieve functional and therapeutic goals. It has been extensively used in various clinical settings. Based upon recent discoveries related to the systemic effects of voluntary breathing and intrinsic physiological interactions among systems during voluntary breathing, a new EStim protocol, Breathing-controlled Electrical Stimulation (BreEStim), has been developed to augment the effects of electrical stimulation. In BreEStim, a single-pulse electrical stimulus is triggered and delivered to the target area when the airflow rate of an isolated voluntary inspiration reaches the threshold. BreEStim integrates intrinsic physiological interactions that are activated during voluntary breathing and has demonstrated excellent clinical efficacy. Two representative applications of BreEStim are reported with detailed protocols: management of post-stroke finger flexor spasticity and neuropathic pain in spinal cord injury.

Breathing-controlled Electrical Stimulation BreEStim for Management of Neuropathic Pain and Spasticity

The purpose is to present a new method, breathing-control electrical stimulation (BreEStim) for management of neuropathic pain and spasticity.

Breathing-gesteuerte elektrische Stimulation (BreEStim) für die Verwaltung von neuropathischen Schmerzen und Spastik

Electrical stimulation (EStim) refers to the application of electrical current to muscles or nerves in order to achieve functional and therapeutic goals. ...

Facial Nerve Axotomy in Mice: A Model to Study Motoneuron Response to Injury

The goal of this surgical protocol is to expose the facial nerve, which innervates the facial musculature, at its exit from the stylomastoid foramen and either cut or crush it to induce peripheral nerve injury. Advantages of this surgery are its simplicity, high reproducibility, and the lack of effect on vital functions or mobility from the subsequent facial paralysis, thus resulting in a relatively mild surgical outcome compared to other nerve injury models. A major advantage of using a cranial nerve injury model is that the motoneurons reside in a relatively homogenous population in the facial motor nucleus in the pons, simplifying the study of the motoneuron cell bodies. Because of the symmetrical nature of facial nerve innervation and the lack of crosstalk between the facial motor nuclei, the operation can be performed unilaterally with the unaxotomized side serving as a paired internal control. A variety of analyses can be performed postoperatively to assess the physiologic response, details of which are beyond the scope of this article. For example, recovery of muscle function can serve as a behavioral marker for reinnervation, or the motoneurons can be quantified to measure cell survival. Additionally, the motoneurons can be accurately captured using laser microdissection for molecular analysis. Because the facial nerve axotomy is minimally invasive and well tolerated, it can be utilized on a wide variety of genetically modified mice. Also, this surgery model can be used to analyze the effectiveness of peripheral nerve injury treatments. Facial nerve injury provides a means for investigating not only motoneurons, but also the responses of the central and peripheral glial microenvironment, immune system, and target musculature. The facial nerve injury model is a widely accepted peripheral nerve injury model that serves as a powerful tool for studying nerve injury and regeneration.

We present a surgical protocol detailing how to perform a cut or crush axotomy on the facial nerve in the mouse. The facial nerve axotomy can be employed to study the physiological response to nerve injury and test therapeutic techniques.

Facial Nerve Axotomie bei Mäusen: Ein Modell zur Motoneuron Reaktion auf eine Verletzung Studieren

The goal of this surgical protocol is to expose the facial nerve, which innervates the facial musculature, at its exit from the stylomastoid foramen and ...

Facial Nerve Surgery in the Rat Model to Study Axonal Inhibition and Regeneration

This protocol describes consistent and reproducible methods to study axonal regeneration and inhibition in a rat facial nerve injury model. The facial nerve can be manipulated along its entire length, from its intracranial segment to its extratemporal course. There are three primary types of nerve injury used for the experimental study of regenerative properties: nerve crush, transection, and nerve gap. The range of possible interventions is vast, including surgical manipulation of the nerve, delivery of neuroactive reagents or cells, and either central or end-organ manipulations. Advantages of this model for studying nerve regeneration include simplicity, reproducibility, interspecies consistency, reliable survival rates of the rat, and an increased anatomic size relative to murine models. Its limitations involve a more limited genetic manipulation versus the mouse model and the superlative regenerative capability of the rat, such that the facial nerve scientist must carefully assess time points for recovery and whether to translate results to higher animals and human studies. The rat model for facial nerve injury allows for functional, electrophysiological, and histomorphometric parameters for the interpretation and comparison of nerve regeneration. It thereby boasts tremendous potential toward furthering the understanding and treatment of the devastating consequences of facial nerve injury in human patients.

This protocol describes a reproducible approach to facial nerve surgery in the rat model, including descriptions of various inducible patterns of injury.

Gesichtsnervenchirurgie im Rattenmodell zur Untersuchung der axonalen Hemmung und Regeneration

This protocol describes consistent and reproducible methods to study axonal regeneration and inhibition in a rat facial nerve injury model. The facial ...

Neurowissenschaften

An Implantable System For Chronic In Vivo Electromyography

Electromyography (EMG) measures the muscle response to electrical stimulation or spontaneous activity of motor units and plays an important role in assessing neuromuscular function. Chronic recording of EMG activity reflecting a muscle&#8217;s reinnervation status after nerve injury has been limited, due to the invasive nature of traditional EMG recording techniques. In this regard, an implantable system is designed for long-term, in vivo EMG recording and nerve stimulation. It has been applied and tested in a study on reinnervation of laryngeal muscles. This system consists of 1) two bipolar electrode nerve cuffs and leads for stimulating each of two nerves: the recurrent laryngeal nerve (RLN) and internal branch of the superior laryngeal nerve (SLN); 2) two EMG recording electrodes and leads for each of the two laryngeal muscles: posterior cricoarytenoid (PCA) muscle and thyroarytenoid-lateral cricoarytenoid (TA-LCA) muscle complex; and 3) a skin receptacle interfacing all implanted lead terminals to an external recording preamplifier and stimulator using a connection cable. The wire leads are Teflon-coated, multi-filament, type 316 stainless steel. They are coiled and can stretch during body movement of the awake animal to prevent lead breakage and electrode migration. This system is implanted during an aseptic surgery. Afterwards, baseline EMG recordings are performed before the RLN is transected in the second surgery to study muscle reinnervation. Throughout the study, multiple physiological sessions are conducted in the anesthetized animal to obtain evoked and spontaneous EMG activity that reflects the reinnervation status of laryngeal muscles. The system is compact, free of infection over the course of the study, and highly durable. This implantable system can provide a reliable platform for research in which long-term recording or nerve stimulation is required in an anesthetized or freely moving animal.&#160;

Presented here is a protocol for the manufacturing of an implantable system for in vivo chronological recording of evoked and spontaneous electromyographic potentials. The system is applied to the investigation of reinnervation of laryngeal muscles following nerve injury. &#160;&#160;

Ein implantierbares System für die chronische In-Vivo-Elektromyographie

Electromyography (EMG) measures the muscle response to electrical stimulation or spontaneous activity of motor units and plays an important role in ...

Structured Motor Rehabilitation After Selective Nerve Transfers

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on the successful re-innervation of the targets in the periphery and on the motor re-learning process entailing cortical plasticity. While there is an increasing number of methods to improve rehabilitation, their routine implementation in a clinical setting remains a challenge due to their complexity and long duration. Therefore, recommendations for rehabilitation strategies are presented with the aim of guiding medical doctors and therapists through the long-lasting rehabilitation process and providing step-by-step instructions for supporting motor re-learning.
Directly after nerve transfer surgery, no motor function is present, and therapy should focus on promoting activity in the sensory-motor cortex areas of the paralyzed body part. After about two to six months (depending on the severity and modality of injury, the distance of nerve regeneration and many other factors), the first motor activity can be detected via electromyography (EMG). Within this phase of rehabilitation, multimodal feedback is used to re-learn the motor function. This is especially critical after nerve transfers, as muscle activation patterns change due to the altered neural connection. Finally, muscle strength should be sufficient to overcome gravity/resistance of antagonistic muscles and joint stiffness, and more functional tasks can be implemented in rehabilitation.

Here, we present a protocol for the motor rehabilitation of patients with severe nerve injuries and selective nerve transfer surgery. It aims at restoring the motor function proposing several stages in patient education, early-stage therapy after surgery and interventions for rehabilitation after successful re-innervation of the nerve&#8217;s target.

Strukturierte Motorrehabilitation nach selektiven Nerventransfers

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on ...

<meta charset="utf8"></head><body>Bewertung von Biomaterialien bei kraniofazialen VML-Verletzungen anhand eines Rattenmodells

Rodent Model of Masseter Volumetric Muscle Loss for Studying Bioengineering Materials

Craniofacial volumetric muscle loss (VML) injuries can occur as a result of severe trauma, surgical excision, inflammation, and congenital or other acquired conditions. Treatment of craniofacial VML involves surgical, functional muscle transfer. However, these procedures are unable to restore normal function, sensation, or expression, and more commonly, these conditions go untreated. Very little research has been conducted on skeletal muscle regeneration in animal models of craniofacial VML. This manuscript describes a rat model for the study of craniofacial VML injury and a protocol for the histological evaluation of biomaterials in the treatment of these injuries. Liquid hydrogel and freeze-dried scaffolds are applied at the time of surgical VML creation, and masseters are excised at terminal time points up to 12 weeks with high retention rates and negligible complications. Hematoxylin and eosin (HE), Masson's Trichrome, and immunohistochemical analysis are used to evaluate parameters of skeletal muscle regeneration as well as biocompatibility and immunomodulation. While we demonstrate the study of a hyaluronic-acid-based hydrogel, this model provides a means for evaluating subsequent iterations of materials in VML injuries.

<meta charset="utf8"></head><body>Nagetiermodell des volumetrischen Muskelverlusts von Masseter zur Untersuchung von Bioengineering-Materialien

Here, we describe a protocol for the surgical creation of a volumetric muscle loss (VML) injury in the rat masseter, providing a reproducible and accessible model for the study of craniofacial muscle injuries and their treatment using biomaterials such as the novel hydrogel.

Nagetiermodell des volumetrischen Muskelverlusts von Masseter zur Untersuchung von Bioengineering-Materialien

Craniofacial volumetric muscle loss (VML) injuries can occur as a result of severe trauma, surgical excision, inflammation, and congenital or other ...

Biotechnik

Force Assessment of Rat Masseter Muscle After VML Injury

In Vivo Functional Assessment of Rat Masseter Muscle Following Surgical Creation of a Volumetric Muscle Loss (VML) Injury

Volumetric Muscle Loss (VML) is prevalent in civilian and military populations and represents a debilitating skeletal muscle injury surpassing the body&#39;s natural regenerative capacity. These injuries disrupt not only muscle fibers but also nerves, blood vessels, and the extracellular matrix, overwhelming the regenerative capacity of skeletal muscle and leading to severe fibrosis and permanent deficiencies in muscle structure and function. Current clinical management has many limitations, and thus, research is ongoing to develop more effective therapeutic approaches. Notably, however, much of the preclinical emphasis on VML injuries has focused on limb and trunk muscles, with limited investigation into craniofacial muscles. Differences in developmental biology and regenerative capacity between craniofacial and limb/trunk muscles may provide crucial insights that drive more injury-specific VML treatment options. Moreover, evaluation of functional recovery is critical to establishing therapeutic efficacy. In this regard, in vivo testing of muscle contraction with percutaneous nerve stimulation is a minimally invasive method that allows for repeated functional assessment over the course of a study - in the same animal. In light of these considerations, this paper describes a method for the in vivo assessment of muscle function in the rat masseter muscle before and after a VML injury. This protocol is the first published instance to detail the creation and functional evaluation of a biologically relevant craniofacial VML injury in the rat.

Volumetric muscle loss (VML) injuries exceed endogenous regenerative ability, resulting in permanent functional deficits. Current VML research primarily focuses on limb and trunk muscles. To extend mechanistic studies of VML to craniofacial muscles, this article describes an in vivo method for longitudinal assessment of masseter muscle function pre- and post-VML injury.

Einstufige Dynamische Reanimation des Lächelns in Irreversible Fazialisparese von Free Funktionsmuskelüber

Zusammenfassung

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Mikrovaskulären Dekompression: Salient Chirurgische Prinzipien und technischen Feinheiten

Breathing-gesteuerte elektrische Stimulation (BreEStim) für die Verwaltung von neuropathischen Schmerzen und Spastik

Facial Nerve Axotomie bei Mäusen: Ein Modell zur Motoneuron Reaktion auf eine Verletzung Studieren

Gesichtsnervenchirurgie im Rattenmodell zur Untersuchung der axonalen Hemmung und Regeneration

Ein implantierbares System für die chronische In-Vivo-Elektromyographie

Strukturierte Motorrehabilitation nach selektiven Nerventransfers

Nagetiermodell des volumetrischen Muskelverlusts von Masseter zur Untersuchung von Bioengineering-Materialien

Nagetiermodell des volumetrischen Muskelverlusts von Masseter zur Untersuchung von Bioengineering-Materialien

Nagetiermodell des volumetrischen Muskelverlusts von Masseter zur Untersuchung von Bioengineering-Materialien

In Vivo Functional Assessment of Rat Masseter Muscle Following Surgical Creation of a Volumetric Muscle Loss (VML) Injury