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Background: Facial nerve (FN) injury during a face lift is a relatively rare but potentially devastating complication. Despite extensive literature discussing FN anatomy and danger zones, few studies describe detailed management, FN exploration intraoperative findings, and outcome after post-face lift facial paralysis (PFFP). The authors reviewed a 20-year experience in managing iatrogenic PFFP., Methods: Patients with PFFP were retrospectively identified between 2002 and 2022. Demographic data, operative details from the face lift procedure, facial function after face lift, medical and surgical management, intraoperative findings, and long-term outcomes were analyzed., Results: A total of 25 patients who experienced PFFP were referred for evaluation over the past 20 years. Eight patients required FN exploration, 6 of whom underwent nerve repair; all recovered to some degree, with 50% achieving essentially normal facial function. Fourteen patients underwent nonsurgical management, including physical therapy, chemodenervation, and filler therapy. Of these nonsurgical patients who were not lost to follow-up, 50% achieved normal facial function and 42% achieved nearly normal facial function. The single patient who had no spontaneous improvement presented outside the reinnervation window and was not an operative candidate., Conclusions: PFFP outcome depends on injury type and location, accurate assessment, and appropriate treatment; however, the overall prognosis is favorable. FN exploration is warranted when nerve transection is suspected. Observation is suitable for patients demonstrating early signs of recovery. Patients presenting beyond a reasonable reinnervation window will need other facial reanimation techniques. When FN exploration is required, outcomes may be superior in a facial nerve center setting. Adjunctive interventions for symmetry improvement while awaiting recovery are available., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Purpose of Review: To present the current literature on management of facial nerve disorder secondary to trauma, with a focus on the utility of electrodiagnostic testing in this setting., Recent Findings: Patients with facial palsy related to temporal bone fractures should be started on high-dose corticosteroids as early as possible. Recent literature on the benefit of surgical intervention in the setting of temporal bone fracture is mixed. Some studies support early surgical decompression whereas others have found no benefit compared with conservative treatment., Summary: The management of facial nerve trauma is based on location and extent of injury. Extratemporal trauma and transected nerve should be treated with surgical exploration and tension-free coaptation ideally within 72 h. There are no guidelines for intratemporal facial nerve trauma. Surgical decompression compared with medical management is debated in the literature without consensus and more large studies are needed., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Iatrogenic facial nerve palsy following otological surgery is a devastating complication that results in adverse aesthetic and functional outcomes. This study aims to review studies that have reported cases of immediate facial nerve palsy to learn why and where injuries occurred and to assess outcomes following management., Databases Reviewed: MEDLINE, Embase, Cochrane CENTRAL, and Pubmed up to June 20, 2023., Methods: Clinical studies of immediate facial nerve palsies following middle ear and cochlear implantation surgery were included. Risk of bias was examined using the Brazzelli risk of bias tool. Due to the inconsistency in reporting of outcomes, we were unable to perform a meta-analysis., Results: Of 234 studies identified, 11 met the inclusion criteria. The most common causes of injury were excessive drilling, use of sharp hooks to remove disease, or disorientation of the surgeon secondary to bleeding or inflammation. Variable usage of preoperative computed tomography (CT) imaging and intraoperative facial nerve monitoring was reported. The tympanic segment was the most common site of injury. A variety of surgical techniques were employed to approach the facial nerve injury including facial nerve decompression, direct closure, and repair using an autologous nerve graft., Conclusions: Otological surgeons should consider utilizing preoperative CT imaging to establish a three-dimensional mental image of key landmarks and anatomical variations before embarking on surgery. Intraoperative FN monitoring enables safe practice. Despite these measures, complex disease processes and hostile intraoperative conditions can present difficulty. Multiple treatment options are available to treat the underlying injury., Competing Interests: Conflict of Interest: Nil., (Copyright © 2024, Otology & Neurotology, Inc.)

The purpose of this study was to assess the effects of protecting the facial nerve with a modified endaural approach with a peripheral dissection of the superficial musculoaponeurotic system to access the temporomandibular joint which allows an excellent operative field of visualization, multiple surgical procedures of the temporomandibular joint, and general care which improves the immediate postoperative period, making this a less morbid surgery. This study included 33 patients (39 sides) who underwent surgical treatment for disorders of the temporomandibular joint from the years 2021 to 2023 at the maxillofacial department of the clinic "Colsanitas" located in Bogota, Colombia. Therapeutic results were evaluated by postoperative facial nerve injury, with the House-Brackman scale; every patient was examined for adequate facial musculature function immediately after surgery. Notably, zero patients presented facial nerve injury. These results imply that the modified endaural approach with a peripheral dissection of the superficial musculoaponeurotic system to access the temporomandibular joint reduces the incidence of facial nerve injuries, improves operative site exposure, and lowers the frequency of complications., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Introduction: Despite the different pathophysiological mechanisms underlying Bell's palsy, in assessing severe traumatic facial paralysis, many surgeons rely on electrophysiological criteria to determine whether facial nerve exploration is warranted. To assess the value of preoperative electroneurography (ENoG) and the time of surgery, we analyzed data from three tertiary medical centers., Materials and Methods: The records of 517 patients with a degenerative ratio (DR) greater than 80% on ENoG were collected, and two groups were defined: group A (90% DR ≤ ENoG) and group B (80% DR ≤ ENoG < 90% DR). The difference in effectiveness of surgery versus conservative treatment was analyzed based on the postoperative outcome determined by the House-Brackmann grading system. The independent-samples t test was used to compare surgery with conservative treatment for each day of surgical exploration., Result: In groups A and B, the average recovery time from facial paralysis was better in patients who had undergone surgical exploration than in those who had been treated conservatively. In group A, the difference was significant only for patients who underwent surgery within 8 days. In group B, a significant difference was found for patients who underwent surgery within 16 days but also for surgery performed 20 and 30 days after the onset of facial paralysis., Discussion: In the surgical treatment of facial paralysis, the criteria for trauma patients should be distinguished from those of patients with Bell's palsy. In traumatic facial paralysis, some axons are more vulnerable to external collapse, and the degree of Wallerian degeneration of the peripheral nervous system will vary depending on the type of injury. The results of this study will help to identify those patients with traumatic facial paralysis who should be treated surgically and when they should be treated., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2022, Otology & Neurotology, Inc.)

Background: Reoperative face lift can be technically more demanding than primary face lift because of altered anatomy and scarred tissue plane. This study was carried out to analyze the outcome of reoperative face lift using sub-superficial musculoaponeurotic system (SMAS) techniques, including facial nerve injury., Methods: Seventy reoperative face lifts using sub-SMAS techniques were studied. Data analysis includes the patients' demographic information, the interval between the previous face lift and the reoperative face lift, intraoperative findings of the SMAS-platysma anatomy, complications, and rate of revision. A separate group of 180 primary face lifts using sub-SMAS techniques during the same period was analyzed for the incidence of facial nerve injury only., Results: Intraoperative findings in the reoperative group consist of anatomical changes in the SMAS-platysma in 82.9 percent of the cases, including increased fibrosis, changes in thickness, limited movement, and increased adhesion on the undersurface. Sub-SMAS dissection was completed in 137 hemifaces. Complication consists of seroma (1.4 percent), delayed healing (1.4 percent), and temporary facial nerve injury (7.1 percent), which was not correlated with increased fibrosis or adhesion under the SMAS-platysma. The rate of revision within 18 months was 11.4 percent. There was a 2.2 percent incidence of temporary facial nerve injury in the primary face-lift group., Conclusions: Sub-SMAS techniques, with few exceptions, were successfully used in a series of reoperative face lifts. Temporary facial nerve injury was the most frequent complication. Satisfactory outcome was obtained in all the cases. The incidence of facial nerve injury was higher than in primary face lift using sub-SMAS techniques., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Objective: Facial nerve preservation is critical in vestibular schwannoma (VS) surgery. Direct electrical stimulation (DES) is a widely used method for intraoperative localization of the facial nerve and assessment of nerve integrity. We sought to assess the predictive ability of DES parameters on facial nerve function post-VS surgery., Databases Reviewed: A systematic literature search of English-language studies published from 1946 to 2019 was undertaken using EMBASE, MedLine/PubMed, and the Cochrane Central Register of Controlled Trials., Methods: Included studies involved patients undergoing VS surgery and assessed predictive ability of any DES parameter on postoperative facial function. Two authors independently reviewed studies and extracted data. Meta-analysis of diagnostic accuracy of DES parameters was used to calculate pooled sensitivities and specificities of common cutoffs. For DES parameters reported by less than four studies, outcomes were reported descriptively., Results: A MST cutoff of 0.10 mA had sensitivity of 0.76 (95% CI 0.53-0.90) and specificity 0.68 (95% CI 0.42-0.87) for facial function in the long term, and MST 0.05 mA had sensitivity 0.73 (95% CI 0.58-0.84) and specificity 0.74 (95% CI 0.59-0.85). CMAP amplitude < 500 μV had sensitivity of 0.87 (95% CI 0.78-0.93) for poor short-term facial function., Conclusions: A CMAP amplitude response < 500 μV is sensitive for poor short-term facial function, whereas MST values of 0.05 mA and 0.10 mA are both sensitive and specific in the long term. Other DES parameters may be able to accurately predict both short- and long-term postoperative facial function, but have been less studied., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2020, Otology & Neurotology, Inc.)

Objectives: 1) Describe the effect of tumor size on facial nerve (FN) outcomes after microsurgical resection of vestibular schwannoma (VS).2) Describe the effect of surgical approach, preoperative radiation, and early postoperative facial function on long-term FN outcomes., Study Design: Retrospective analysis., Setting: Tertiary referral center., Patients: Adult (≥18 yr) patients underwent translabyrinthine or retrosigmoid VS resection by a single neurotologist and single neurosurgeon between February 2008 and December 2017., Main Outcome Measures: Long-term FN outcomes (≥12 mo) according to House-Brackmann (HB) grade., Results: During the study period, 350 patients underwent VS resection, of whom 290 met inclusion criteria. Translabyrinthine surgery was performed in 54% (n = 158) and retrosigmoid in 45% (n = 131). One patient underwent a combined approach. Among patients who underwent retrosigmoid approach, none had a tumor more than 30 mm. Gross total resection was achieved in 98% (n = 283). Long-term HB1-2 function was achieved in 90% (n = 261). On univariate analysis, tumor size (per cm increase), history of preoperative radiation, and worse HB score at discharge predicted worse FN function. Multivariate analysis showed that tumor size (per cm increase) and history of radiation were independent predictors of FN function. For patients with tumors less than 30 mm, multivariate analysis of tumor size and surgical approach was performed; tumor size remained predictive of worse FN function (odds ratio [OR] 2.362, p = 0.0035), whereas surgical approach was not significantly predictive (p = 0.7569)., Conclusion: Tumor size and history of radiation predict long-term FN function after VS resection. When accounting for tumor size, the translabyrinthine and retrosigmoid approaches yield equivalent FN results.

The aim of this study was to evaluate the effects of protecting the facial nerve and reducing the scar visibility using a modified tragus edge and transmasseteric anteroparotid approach compared to classic preauricular approach for intracapsular and condylar neck fractures. This retrospective study included 64 patients (78 sides) who underwent surgical treatment for intracapsular or condylar neck fractures from January 2014 to June 2018. Patients were divided into the experimental group (treated via a modified tragus edge and transmasseteric anteroparotid approach), and the control group (treated via the classical preauricular approach). Therapeutic outcome assessment parameters included facial nerve injury, salivary fistulae, wound infection, restricted mouth opening, postoperative occlusion disorders, and scar visibility. In the control group, there were 3 cases of facial nerve injuries and 2 cases of salivary fistulae. One case of temporary facial nerve injury occurred in the experimental group, with complete recovery within 1 month. The scars were less visible in the experimental group than in the control group. These results suggest that a modified tragus edge and transmasseteric anteroparotid approach reduced the incidences of facial nerve injuries, minimized the scar visibility, improved exposure of the operative site and fixation of titanium screws or plates, and did not increase the frequency of other complications.

Purpose of Review: The purpose of this review is to summarize best practices in facial nerve management for patients with head and neck cancer. In addition, we provide a review of recent literature on novel innovations and techniques in facial reanimation surgery., Recent Findings: Although recommended when tumor ablation surgery requires facial nerve sacrifice, facial reanimation procedures are not always performed. Concurrent dynamic facial reanimation with masseteric nerve transfers and cable graft repair can preserve native facial muscle function. Static suspension can provide facial support and immediate resting symmetry for patients. Eyelid weight and eye care should not be delayed, particularly in patients with trigeminal sensory deficits. Choice of neural source to innervate a gracilis-free muscle transfer for smile reanimation remains controversial; however, new techniques, such as dual innervation and multivector muscle transfer, may improve aesthetic and functional outcomes., Summary: Management of the facial nerve in the setting of head and neck cancer presents unique challenges. When possible, simultaneous oncologic resection and facial reanimation is ideal given the open surgical field, newly dissected and electrically stimulatable facial nerve branches, as well as minimizing postoperative healing time to prevent postsurgical treatment delays. A coordinated approach to facial nerve management with a multidisciplinary surgical team may help provide optimal, comprehensive care.

Hypothesis: The risk of electrode migration in cochlear implant (CI) surgery can be reduced by securing the electrode lead in a bone groove in the chorda-facial angle., Background: Electrode migration is an important complication in CI surgery, which affects hearing performance, may induce pain and facial nerve stimulation, and requires surgical revision. A potential method to secure the electrode is to use a bone groove created in the facial recess to fixate the electrode lead. This surgical measure is a standard procedure for lateral wall electrodes (LWE) in our clinic since 2013., Methods: Retrospective analysis of consecutive CI cases of a tertiary referral center from 2006 to 2016 and comparison of incidence rates between group A (without bone groove, years 2006-2012) and group B (with bone groove fixation, years 2013-2016). Clinical cases were reviewed with respect to electrode type, migration length, time interval to migration, and findings during revision surgery., Results: Seventeen cases of electrode migration were found in a total of 1,603 cochlear implantations. Only LWE designs were affected by migration. The cumulative incidence for LWE in group B (0.5%) was significantly lower than in group A (3.7%, p < 0.01). The two migration cases in group B revealed insufficient geometric design of the bone grooves. Only one patient experienced a remigration after revision surgery., Conclusion: The fixation in a bone groove in the chorda-facial angle is an effective measure against migration of LWE. Proper surgical execution is mandatory to ensure a tight and enduring fit.

Purpose of Review: Marginal mandibular nerve palsy (MMNP) is often an understated complication after neck dissection. This article reviews literature regarding anatomic landmarks that help define marginal mandibular nerve (MMN) during neck dissection, oncologic safety of surgical maneuvers, implications of MMNP, and reconstructive options., Recent Findings: A thorough knowledge of anatomy of the nerve can aid in its preservation. Course, branching pattern and communications of MMN are extremely variable. The Hayes Martin method classically described to preserve the nerve may not be oncologically safe in patients with prefacial nodal involvement. MMNP significantly affects quality of life after neck dissection. Cause, timing, and degree of neural damage play an important role in determining diagnostic and therapeutic options to correct the deformity resulting from MMNP. Owing to treatment-related factors, functionality of local structures may be compromised, which limits available reconstructive options for the surgeon. This should favor a shift of management option toward more conservative procedures in patients treated for head and neck cancer., Summary: When oncologically safe, the MMN must always be preserved. The patient perceived deformity resulting from MMNP is significantly higher than clinician-detected rate. In select patients who are affected by significant smile asymmetry, multiple dynamic and static corrective procedures can be offered.

Objective: To study the early and late facial nerve (FN) outcomes in different tumor classes in addition to determining the predictive factors for the same., Study Design: A retrospective clinical study., Setting: A quaternary referral otology and skull base center., Patients and Methods: A retrospective study of 1983 cases of vestibular schwannomas (VSs) with preoperative normal FN function, undergoing total excision with anatomical preservation of the nerve by enlarged translabyrinthine approach (ETLA) were included. FN status was recorded postoperatively at day 1, at discharge, and at 1-year follow-up and were analyzed in different tumor sizes., Results: At 1 year, 988 patients with House-Brackmann (H-B) grade I and II FN at day 1 after surgery, 958 (96.9%) maintained their status up-to 1 year. Of the 216 patients with H-B grade III at day 1 after surgery, 113 (52.3%) improved to H-B grade I and II. Similarly, of the 779 patients with H-B grade IV and VI FN function at day 1 after surgery, improvement to H-B III and H-B I and II were noted in 442 (56.7%) and 80 (10.3%) of patients, respectively. Intrameatal and extrameatal tumors upto 2 cm showed better recovery from H-B grade III to H-B I and II and from H-B grade IV and VI to H-B I and III when compared with extrameatal tumors >2 cm (p = 0.001)., Conclusion: Tumors of smaller sizes have good immediate postoperative FN results and recover well at the end of 1 year while more than 3 cm have poor outcomes and recover poorly at the end of 1 year. When the VSs reaches more than 1 cm, the HB I and II outcomes drop significantly.

There exist 2 classic extraoral approaches to the posterior aspect of the mandible, namely the submandibular or Risdon approach, and the retromandibular approach. Despite their widespread use, there still exist concerns of damage to surrounding structures, in particular cranial nerve VII, as well as vascular structures and salivary glands. Evidence of facial nerve palsy has been shown to be as high as 48% in the patient with the Risdon approach, and as high as 30% in the retromandibular approach. The authors wish to propose a more conservative, technically easier, and less time-consuming approach to the posterior mandible, with less risk of damage to the branches of the facial nerve, as well as other structures such as the facial vessels and the parotid gland.

Objective: This study aimed to evaluate the safety of a modified pre-aricular approach in the treatment of orbital zygomatic maxillary complex fractures., Methods: This was a retrospective study of clinical data from 108 adults who were diagnosed with orbital zygomatic maxillary complex fractures and undergo open reduction and internal fixation through a modified pre-auricular approach. Exophthalmometry and limitation of extraocular muscle movement were determined using a Hertel exophthalmometer or synoptophore examination respectively. Primary complications were recorded, and postoperative facial nerve injury was tested by electrophysiologic analysis., Results: All patients received satisfied functional and cosmetic results at least 6 moths postoperatively. There were 2 cases (1.85%) involving complete or incomplete facial nerve injury confirmed by electrophysiologic analysis. The incidence of other postoperative complications including a hematoma rate of 1.85% patients and permanent hypesthesia or paresthesia in 2.78% of patients, and no cases of clinically significant temporal hollowing, alopecia, infection, or unacceptable scars encountered during a mean follow-up period of 2 years., Conclusion: A modified pre-auricular approach with dissection deep to the temporalis fascia offers a safe and reliable surgical technique for accessing the malar arch in orbital zygomatic maxillary complex fractures.

Hypoglossal-facial anastomosis provides excellent motor supply to the mimetic muscles of the face when there is no chance of recovery of the damaged facial nerve. However, to achieve optimal results, the timing of facial nerve surgery based on electrophysiological testing and clinical evaluation requires close follow-up of the patient. Functional results after delayed surgery are not predictable and depend on the number of surviving fibers, type of injury, severity of damage, degree of infiltration of inflammatory cells, and local fibrosis. Facial hypertonia, synkinesis, and involuntary mass movement are the major problems of delayed reanimation of the facial nerve. Surgery in the vicinity of the facial nerve always aims to preserve neural integrity. However, immediate facial nerve grafting is sometimes required. We present our experience with 4 patients having normal facial function prior to surgery. The facial nerve was severed due to tumor infiltration and instantaneously reconstructed with the hypoglossal nerve. Two patients had House-Brackmann grade-II 10 days and 28 months after surgery, respectively, and another 2 patients had House-Brackmann grade-III facial paralysis 2 weeks and 6 months after surgery, respectively.

Objective: This study was conducted to investigate subclinical electrophysiological deleterious effect due to microtrauma to the nerve in response to the dissection of a tumor and parotid tissue from the facial nerve and its branches and surgical traction experienced during the operation., Methods: The study included 34 adult patients who underwent parotidectomy operations under intraoperative facial nerve monitoring. Three measurements were taken from each patient to evaluate facial nerve functions, with 3 stimuli of different intensities applied with different timing. An initial stimulus of 1 mA was applied to confirm the identification of the main trunk of the facial nerve (Group 1: Initial-Normal). Then, a threshold value was found by stimulating the main trunk until muscle fasciculations were observed on facial muscles (Group 2: Basal-Minimal). The same procedure was repeated after the tumor was resected (Group 3: Final-Minimal)., Results: There was no significant difference between the stimulus thresholds of Group 2 (0.31 mA) and Group 3 (0.30 mA). The highest amplitude in all 3 groups was observed at the mental branch, and the lowest at the frontal. The highest latency value was measured at the frontal branch and the lowest at the mental branch. Five (14.7%) of the patients developed postoperative pareses that was completely resolved by the seventh postoperative day visit in these patients., Conclusion: This study demonstrated that the surgical trauma of a meticulously conducted dissection and surgical traction did not cause any deleterious electrophysiological alteration on the facial nerve.

Facial nerve has great functional and aesthetic importance to the face, and damage to its structure can lead to major complications. This article reports a clinical case of neuroanastomosis of the facial nerve after facial trauma, describing surgical procedure and postoperative follow-up. A trauma patient with extensive injury cut in right mandibular body causing neurotmesis of the VIIth cranial nerve and mandibular angle fracture right side was treated. During surgical exploration, the nerve segments were identified and a neuroanastomosis was performed using nylon 10-0, after reduction and internal fixation of the mandibular fracture. Postoperatively, an 8-month follow-up showed good evolution and preservation of motor function of the muscles of facial mime, highlighting the success of the surgical treatment. Nerve damage because of facial trauma can be a surgical treatment challenge, but when properly conducted can functionally restore the damaged nerve.

Objectives: Controversy exists regarding the role of surgery for patients with skull base trauma and facial paralysis. Our goal is to report the long-term outcomes of early facial nerve decompression and repair via the middle fossa (MF) approach for patients with traumatic paralysis., Study Design: Retrospective case series., Setting: Academic medical center., Patients: There were 18 patients who met surgical criteria: immediate complete paralysis, greater than 90% degeneration on electroneurography (ENoG), and no voluntary electromyography (EMG) potentials within 14 days after trauma and 1 year minimum follow-up., Intervention: MF approach for traumatic facial paralysis and for irreversible injuries nerve grafting was performed., Main Outcome Measure: Long-term facial function, hearing results, and surgical complications., Results: At MF decompression, 11 patients had an anatomically intact facial nerve. Of these patients with intact nerves, 72.7% obtained normal to near normal facial function (HB I or II) at 1 year: 27.3% to HB I, 45.5% to HB II, and 27.3% to HB III. At surgery, seven patients were found to have injuries that required nerve grafting and 100% improved to HB III. For all patients, facial nerve function significantly improved after surgery (p < 0.01). The average difference in pure tone average and word recognition after surgery was +2.9 dB and +3.3%, respectively (p = 0.44; p = 0.74). Minor, transient complications occurred in three patients and an abscess required drainage in one patient, but no other major complications., Conclusion: In our series, all patients with traumatic complete paralysis and poor facial prognosis achieved a long-term outcome of HB III or better after MF approach for decompression and repair of the facial nerve.

This study aimed to evaluate the prevalence of facial nerve canal dehiscence in tympanoplasty patients and its influence on the need for revision surgery and on hearing results and anatomical outcomes. Patients who underwent tympanoplasty with/without mastoidectomy at Ankara University Otolaryngology Department from 2006 through 2013 with a minimum follow-up period of 6 months were reviewed retrospectively in this original study. Patients were divided into those with and without cholesteatoma. Numbers and frequencies of dehiscence were recorded according to disease type, the need for revision surgery, and hearing results and anatomical outcomes. Study subjects included 206 patients, of whom 15 (7.3%) had dehiscence. The prevalence of dehiscence was significantly high in the patients with cholesteatoma (13/50 patients) compared with those without (2/156 patients). The dehiscence frequency was significantly high in cholesteatoma (42.8%), as well as overall (14.7%), revision-surgery patients. Hearing results (P < 0.05) and anatomical outcomes were better in patients without dehiscence. Dehiscence is more common in patients with than without cholesteatoma and negatively affects tympanoplasty outcomes, including hearing results, anatomical outcomes, and the need for revision surgery.

Patients suffering different intervals of facial nerve injury were investigated by functional magnetic resonance imaging to study changes in activation within cortex.Forty-five patients were divided into 3 groups based on intervals of facial nerve injury. Another 16 age and sex-matched healthy participants were included as a control group. Patients and healthy participants underwent task functional magnetic resonance imaging (eye blinking and lip pursing) examination.Functional reorganization after facial nerve injury is dynamic and time-dependent. Correlation between activation in sensorimotor area and intervals of facial nerve injury was significant, with a Pearson correlation coefficient of -0.951 (P < 0.001) in the left sensorimotor area and a Pearson correlation coefficient of 0.333 (P = 0.025) in the right sensorimotor area.Increased activation in integration areas, such as supramarginal gyrus and precunes lobe, could be detected in the early-middle stage of facial dysfunction compared with normal individuals. Decreased activation in sensorimotor area contralateral to facial nerve injury could be found in late stage of facial dysfunction compared with normal individuals. Dysfunction in the facial nerve has devastating effects on the activity of sensorimotor areas, whereas enhanced intensity in the sensorimotor area ipsilateral to the facial nerve injury in middle stage of facial dysfunction suggests the possible involvement of interhemispheric reorganization. Behavioral or brain stimulation technique treatment in this stage could be applied to alter reorganization within sensorimotor area in the rehabilitation of facial function, monitoring of therapeutic efficacy, and improvement in therapeutic intervention along the course of recovery.

Injury to the facial nerve during a face lift is a relatively rare but serious complication. A large body of literature has been dedicated toward bettering the understanding of the anatomical course of the facial nerve and the relative danger zones. Most of these prior reports, however, have focused on identifying the location of facial nerve branches based on their trajectory mostly in two dimensions and rarely in three dimensions. Unfortunately, the exact location of the facial nerve relative to palpable or visible facial landmarks is quite variable. Although the precise location of facial nerve branches is variable, its relationship to soft-tissue planes is relatively constant. The focus of this report is to improve understanding of facial soft-tissue anatomy so that safe planes of dissection during surgical undermining may be identified for each branch of the facial nerve. Certain anatomical locations more prone to injury and high-risk patient parameters are further emphasized to help minimize the risk of facial nerve injury during rhytidectomy.

Iatrogenic facial nerve injury is one of the most severe complications of cochlear implantation (CI) surgery. Intraoperative facial nerve monitoring (IFNM) is used as an adjunctive modality in a variety of neurotologic surgeries. The purpose of this retrospective study was to assess whether the use of IFNM is associated with postoperative facial nerve injury during CI surgery. The medical charts of 645 patients who underwent CI from 1999 to 2014 were reviewed to identify postoperative facial nerve palsy between those who did and did not receive IFNM. Four patients (3 children and 1 adult) were found to have delayed onset facial nerve weakness. IFNM was used in 273 patients, of whom 2 had postoperative facial nerve weakness (incidence of 0.73%). The incidence of facial nerve weakness was 0.54% (2/372) in the patients who did not receive IFNM. IFNM had no significant effect on postoperative delayed facial palsy (P = 1.000). All patients completely recovered within 3 months after surgery. Interestingly, all 4 cases of facial palsy received right CI, which may be because all of the surgeons in this study used their right hand to hold the drill. When right CI surgery is performed by a right-handed surgeon, the shaft of the drill is closer to the inferior angle of the facial recess, and it is easier to place the drilling shaft against the medial boundary (facial nerve) when the facial recess is small. The facial nerve sheaths of another 3 patients were unexpectedly dissected by a diamond burr during the surgery, and the monitor sounded an alarm. None of these 3 patients developed facial palsy postoperatively. This suggests that IFNM could be used as an alarm system for mechanical compression even without current stimulation. Although there appeared to be no relationship between the use of monitoring and delayed facial nerve palsy, IFNM is of great value in the early identification of a dehiscent facial nerve and assisting in the maintenance of its integrity. IFNM can still be used as an additional technique to optimize surgical success.

Purpose: The purpose of the present study was to describe a surgical technique for treatment of condylar fractures through the modified submandibular access, by means of a small incision in the mandibular angle that promotes a dissection between the parotideomasseteric and the transmasseteric fascia in a quick way and with low morbidity. Fixation may be made with plates and screws according to the technique prescribed by the surgeon., Methods: Owing to the high incidence and importance of condylar fractures, various therapeutic methods have been described and may be divided into conservative and surgical methods. Various open surgical techniques are recommended in the treatment of mandibular condylar fractures, and the methods of internal rigid fixation and surgical accesses vary. The techniques that offer an adequate treatment of these fractures with shorter surgical time very often remain matters of controversy among surgeons. The procedure must guarantee maximum safety for the facial nerve and must provide a good cosmetic outcome, besides providing a suitable surgical field., Results: A modified submandibular access is a safe and reproducible procedure providing excellent functional results. This procedure has been routinely performed in our department.

Objective: To review the postoperative surgical outcomes of cystic vestibular schwannomas (CVSs), especially facial nerve outcomes, and compare these results with those from matched solid vestibular schwannomas (SVS) resected during the same period at a tertiary referral center., Study Design: Retrospective case series., Methods: One hundred thirty-one surgically managed patients with cystic vestibular schwannomas (CVSs) were age, sex, and tumor size matched to 131 surgically managed patients with solid vestibular schwannomas (SVSs). Demographics, tumor morphology, surgical approach, extent of resection, facial and nonfacial complications, and recurrence rates were compared between the 2 groups. Subtotal removal was defined as removal of at least 95% of the tumor., Results: The mean maximal tumor diameter was 2.8 cm for both groups. For CVS, gross total tumor resection (GTR) was achieved in 92 patients (70.2%), and subtotal tumor resection (STR) was achieved in 39 patients (29.8%). Postoperative facial nerve outcomes at 1-year follow-up were good (HB Grade I-III) in 116 (88.5%) of 131 CVS patients. Twenty-three patients developed nonfacial nerve-related complications (17.6%). For SVS, GTR was achieved in 102 patients (77.9%), and STR was achieved in 29 patients (22.1%). Postoperative facial nerve outcomes at 1-year follow-up were good (HB Grade I-III) in 118 (90.1%) of 131 SVS patients. Nonfacial nerve related complications occurred in 14 patients (10.7%). None of the differences in outcome between the 2 groups were statistically significant., Conclusion: The difference in surgical outcomes is minimal between patients with CVS and those with SVS, not reaching statistical significance. We think, with judicious surgical management, similar outcomes can be achieved in cystic tumors and solid tumors.

Objective: To find the etiology, frequency, and prognosis of delayed facial nerve weakness (DFW) in our department after intact canal wall tympanomastoidectomy for a tubotympanic (TT) type of chronic suppurative otitis media (CSOM) without cholesteatoma., Study Design: Retrospective case review., Setting: Tertiary care center., Subjects and Methods: A total of 315 patients who underwent intact canal wall tympanomastoidectomy for TT type of CSOM without cholesteatoma in our department for the past 3 years were selected. Patients with facial nerve weakness after 72 hours of surgery were noted and assessed for a history of herpes zoster virus infection. There were 6 patients who developed DFW; of these, blood samples of 4 patients for serum antibody titers to varicella zoster virus and herpes simplex type 1 were sent on the 3rd day of developing DFW. Blood samples of each of the remaining 2 patients were sent on the 13th day and 1st day of developing DFW. All 6 patients were treated with prednisolone and acyclovir, and their prognosis was assessed., Main Outcome Measure: House-Brackmann facial nerve grading system and serum antibody titers for varicella zoster virus and herpes simplex type 1., Results: Six patients (1.9%) developed DFW in this study. All patients had a history of herpes zoster virus infection. Serology results of 4 patients showed positive immunoglobulins M and G for varicella zoster virus and had significantly elevated titers of serum immunoglobulin G for varicella zoster virus, thus confirming the etiology., Conclusion: The incidence of DFW after tympanomastoidectomy is low and is due to viral reactivation, that is, varicella zoster. The overall prognosis seems impressive because all of the patients' facial nerve function improved by the end of 6 weeks. This study also illustrates the medicolegal importance of informing the patients with a history of herpes zoster virus infection the chance of developing DFW after undergoing tympanomastoidectomy.

Objective: To determine whether partial tumor removal in large vestibular schwannoma improves facial nerve outcomes while maintaining a low risk of tumor regrowth/recurrence., Study Design: Retrospective chart review and prospective database., Setting: Tertiary neurotologic referral center., Patients: Four hundred patients with a vestibular schwannoma of 2.5 cm or greater in maximum diameter undergoing translabyrinthine microsurgical resection from 2001 to 2011. There were 325 gross total resections (GTR), 44 near total resections (NTR), and 31 subtotal resections (STR), with an overall mean tumor size of 3.2 cm (standard deviation, 0.7)., Intervention(s): Translabyrinthine surgical tumor resection., Main Outcome Measures: House-Brackmann (H-B) facial nerve grade postoperatively and at 1 year, tumor regrowth/recurrence (≥2 mm), additional treatment, and complications., Results: Higher rates of H-B facial nerve Grades I and II were achieved at both the postoperative and 1-year follow-ups in the NTR (78%, 97%) and STR (71%, 96%) groups compared with GTR (53%, 77%) (p ≤ 0.001). Eye treatment, medical or surgical, was required more often in GTR (28.0%) than NTR and STR (8% and 21%, respectively, p ≤ 0.04), with no other differences in complications. The NTR and STR groups had a significantly higher rate of regrowth than GTR resection (21% and 22% versus 3%) (p ≤ 0.001) at average follow-up times of 3.7, 3.7, and 5.1 years, respectively, and need for further treatment occurred at a higher rate, although infrequently, in NTR and STR (2% and 10% versus 0%) (p ≤ 0.001)., Conclusion: Near total and subtotal removal in large tumors are viable treatment options to maintain facial nerve function. During the follow-up period examined in this study, there was a low risk of need for further treatment. Longer-term follow-up is needed to better assess the need for retreatment in patients treated with NTR and STR.

Objective: To demonstrate and quantify the learning curve for microsurgical excision of vestibular schwannoma in a newly formed neurootologic team by using the cumulative summation test for learning curve (LC-CUSUM). To secondarily identify the factors influencing postoperative facial nerve outcome., Study Design: Retrospective review., Setting: Tertiary referral center., Patients: Between 1999 and 2011, 153 consecutive cases of vestibular schwannoma excision., Intervention: One-hundred and fifty-three patients underwent excision of vestibular schwannoma., Main Outcome Measures: Facial nerve outcomes were assessed using the House-Brackmann (HB) facial nerve grading system. Postoperative facial nerve outcomes at 12 months were analyzed using the LC-CUSUM method with HB Grades I to III being defined as successful outcomes. The factors that influence postoperative facial nerve outcome were analyzed., Results: The constructed learning curve shows a gradual improvement in facial nerve outcomes. The learning curve crossed the derived LC-CUSUM barrier at the 56th procedure, indicating that sufficient evidence had accumulated to demonstrate that the surgeon had achieved optimal outcomes at this point. Tumor size (p = 0.008) and surgical approach (p = 0.005) were 2 additional significant factors influencing postoperative facial nerve outcome., Conclusion: The learning curve is evident in this series of microsurgical excisions of vestibular schwannoma. A newly formed team needs to perform at least 56 cases to gain sufficient experience to accomplish optimal results. Position along the learning curve, tumor size, and familiarity with a preferred surgical approach are the factors, which dominated facial nerve outcome. We recommend the use of LC-CUSUM test for learning curve analysis.

Objective: To analyze malpractice litigation trends to better understand the causes and outcomes of suits involving otologic surgeries to prevent future litigation and improve physician awareness., Methods: Court records of legal trials from 1983 to 2012 were obtained from 2 major computerized databases-WESTLAW and LexisNexis. Data were compiled on the demographics of the defendant, plaintiff, use of otolaryngologists/otologists as expert witnesses, nature of injury, type of surgery, legal allegations, verdicts, and judgments., Results: Fifty-eight unique cases met inclusion criteria and were selected for review. The most common surgeries that went to trial were mastoidectomy (48%), ossiculoplasty (21%), and tympanoplasty (16%). Eleven (19%) of the cases were resolved through a settlement before a verdict was reached. Verdicts in favor of the plaintiffs (31%) were awarded an average of $1,131,189. The most common alleged injuries were hearing loss (45%) and facial nerve injury (38%). Of the cases found in favor of the plaintiff, the most common reasons cited were improper performance of the surgery (50%), failure to properly diagnose and treat (33%), and inadequate informed consent and delay in diagnosis (22% each). Case outcomes involving pediatric patients were not significantly different than those of adults (p = 0.34); however, adults received higher financial awards on average ($1 million versus $232,000; p < 0.0003)., Conclusion: Obtaining an appropriate diagnosis, thoroughly discussing all options and potential risks, presenting realistic expectations, and executing the surgery correctly are crucial to patient care. Understanding the reasons surgeons go to trial may assist in mitigating risk for potential lawsuits.

Mandibular distraction using an implantable device has become a widely accepted and utilized procedure for the treatment of retrognathia. Although excellent results have been reported and observed with distraction osteogenesis, complications such as facial nerve injury have been previously reported. Often, this injury is usually temporary and corrects over the course of time. Frey syndrome has been classically described as an injury or severance of the auricotemporal branch of the trigeminal nerve. It is commonly seen as a complication of parotid surgery and has never been reported in association with mandibular distraction. The authors report a unique case of both facial nerve paralysis and Frey syndrome in a patient following the removal of an internal mandibular distraction device. A review of the literature along with diagnosis and management are discussed.

Introduction: The aim of this study was to report the efficacy of the deep subfascial approach for the treatment of temporomandibular joint pathologies. The procedure set out below satisfies a wide-access approach for the prevention of facial nerve injury., Materials and Methods: The preauricular approach with the additional deep subfascial approach was applied to 18 patients who had various problems from ankylosis to internal derangement. All patients were assessed at the following postoperative times. Facial nerve functions were evaluated after surgery and 24 hours after surgery by the House-Brackmann facial nerve grading system., Results: Temporary facial nerve palsy was seen in a patient who had a residual keratocyst in the condylar neck region. Other patients tolerated the procedure well, and there were no other complications., Discussion: This procedure significantly decreased the risk of facial nerve injury. However, soft tissue traction at the condylar neck region or zygomatic arch where the facial nerve passes close by may increase the risk of nerve damage.

Objective: To compare the long-term outcome of hearing and tumor control of small vestibular schwannomas treated with conservative management or radiation therapy., Data Sources: A thorough search for English-language publications and "in-process" articles dating from 1948 to January 2011 was performed using Ovid MEDLINE., Study Selection: The principal criteria were patients with no microsurgical intervention before their treatment, a follow-up of at least 5 years, and a useful hearing level at diagnosis., Data Extraction: Fourteen studies met our criteria. Hearing preservation outcome (worse, unchanged, and better) and tumor size outcome (growth, unchanged, and regression) data were collected from the articles, as well as all other significant observations. No studies using fractionated stereotactic radiotherapy met our criteria. Stereotactic radiation was the only radiation therapy analyzed., Data Synthesis: The data were analyzed using the Pearson χ2 test., Conclusion: Current data on conservative management and stereotactic radiation do not provide enough evidence to make a clear conclusion on the outcome of useful hearing preservation in a long-term manner. In this study, however, stereotactic radiation is shown to have better tumor control rates than conservative management. Additional studies reporting long-term follow-ups of patients are required so as to provide the medical field with a better understanding of vestibular schwannoma treatment therapies.

Objective: The objective was to study the clinical application and effects of minimal incisions for treating zygomatic complex (ZMC) fractures., Methods: A retrospective study was conducted on the 155 patients who underwent reduction of surgical injury by minimal incision for treating ZMC fractures., Results: The outcomes after treatment were satisfactory functionally and aesthetically in most patients. The clinical results were good in 150 patients. No obvious scars were noticed in all the patients. After a follow-up of average 18 months, zygomatic asymmetry was present in 2 cases, numbness in the infraorbital area in 2 cases, and limitation of mouth opening in 1 patient. Plate removal was conducted in 3 patients., Conclusions: Repositioning of ZMC fractures via minimal incisions can get satisfactory results. With this kind of approach, the surgical injury can be reduced, and clear field of operation, convenient manipulation, less bleeding, high accuracy of reduction, and inconspicuous scar can be achieved as well. It is an ideal method and deserves to be recommended in clinical procedures.

Free transplant of gracilis muscle is the criterion-standard technique in dynamic rehabilitation of long-standing facial paralysis in which the facial musculature is atrophied. When the facial nerve is not available because of a bilateral lesion, other sources are the masseteric, hypoglossal, or accessory nerves. Although the use of hypoglossal nerve has been relegated to the background because of the morbidity caused by its loss, there are special situations in which the hypoglossal nerve should be considered the first option as donor motor nerve. The present article discusses the case of a patient with dynamic reanimation of bilateral facial paralysis with free-muscle transfer neurotized to the hypoglossal nerve. End-to-side coaptation of gracilis motor nerve and hypoglossal motor nerve allows neurotization of the transplanted muscle with minimum repercussion in speech or swallowing and can provide an adequate spontaneous smile with time.

Objective: Our objective was to evaluate whether there was a subclinical change in the functions of the facial nerve after parotidectomy., Methods: Facial nerve functions of 21 patients who had parotidectomy between January 1999 and December 2003 were assessed using electromyography (EMG) at least 5 years after the surgery., Results: There was no significant difference between both sides of the face in the EMG amplitudes (P > 0.05) except for the amplitudes obtained from the site of nasolabial sulcus (P < 0.05). In the patients who underwent total parotidectomy, the EMG amplitudes were significantly different for both sides of the face (P < 0.05). No significant difference was found in the comparison of other measurements performed by EMG., Conclusions: Tumor histopathologic type (benign or malignant) and type of parotidectomy (superficial or total) do not cause a subclinical dysfunction of the facial nerve after parotidectomy in the patients who also have clinically normal facial functions. The only exception to this contention is the subclinical dysfunction in nasal branches of the facial nerve in total parotidectomy cases.

Objective: To evaluate the predictive value of electromyographic recordings for the immediate facial nerve outcome after solitary vestibular schwannoma (VS) removal., Study Design: Prospective cohort study., Setting: Tertiary referral center., Patients and Methods: From November 2005 to July 2007, 120 operated solitary VSs monitored by NIM Response 2.0 (Medtronic, Xomed, Jacksonville, FL, USA) were included. Intraoperative direct facial nerve stimulation at the brainstem (proximal pre site) before resection and at the brainstem (proximal post and distal sites, respectively) and internal acoustic meatus after resection were performed. Intraoperative recordings were performed on 4 muscles: Frontalis, Orbicularis oculi, Orbicularis oris, and chin muscles (CM). Postoperative facial function (House-Brackmann classification) was evaluated at postoperative Days (D) 2, 8, and 30. Grades 1 or 2 were considered as a good result., Results: A good postoperative facial function was obtained in 71, 63, and 77% at postoperative D2, D8, and D30, respectively. Maximal conduction block was found at Day 8. Poor facial nerve outcomes were observed for large tumor with a facial nerve superior to the tumor with a strong adhesion to the nerve. With a stimulation threshold at proximal site after proximal site tumor resection at less than or equal to 0.04 mA, a good facial function was observed in 77% at Day 8. Using these criteria together with CM responses greater than 800 muV to supramaximal stimulation at (proximal post site) and a proximal/distal post ratio at CM response greater than 0.6, 93% of patients presented with a good facial function at Day 8., Conclusion: Using CM recording stimulation and supramaximal stimulation of the facial nerve in combination with thresholds seem to increase the predictive value of the monitoring for the immediate facial nerve function for VS surgery.

Objective: To describe and discuss the midterm complications and pitfalls reported in patients with otosclerosis who received a cochlear implant., Study Design: Prospective cohort study., Setting: Tertiary referral center., Patients: Fifteen patients who received a cochlear implant for otosclerosis, followed up for a minimum of 6 years. Onset of hearing loss occurred at a mean age (+/-standard deviation [SD]) of 32.6 +/- 8.6 years. Mean duration (+/-SD) of hearing loss was 26.8 +/- 7.9 years, and mean age (+/-SD) at implant surgery was 58.7 +/- 9.5 years., Interventions: Before cochlear implantation, hearing thresholds were tested, and temporal bone anatomy and otosclerotic lesions were documented by high-resolution computed tomography and magnetic resonance imaging. All patients were implanted with a Med-El Combi 40 + device and a Standard Electrode Array., Main Outcome Measures: The number of inserted electrodes was checked by x-ray. After cochlear implantation, hearing skills were tested, fitting parameters were recorded, and complications were noted., Results: As the disease progressed, the number of electrodes decreased, and the electrical thresholds, maximum comfort levels, and electric charge increased; these changes were more evident in the middle electrodes. Although facial nerve stimulation rate was lower than previously reported (13.3%), it increased during follow-up. Two patients (13.3%) had untreatable tinnitus. Nevertheless, all speech discrimination parameters improved significantly in all patients., Conclusion: Despite the need for special fitting strategies and the appearance of complications, facial nerve stimulation, and tinnitus, improvements in speech discrimination tests support the use of cochlear implantation for patients with otosclerosis.

Objective: An alternative transcanal surgical technique named "exclusive transcanal approach" for Vibrant Soundbridge (VSB) implantation is presented. The surgical steps and our experience in a series of 12 patients are reported., Study Design: Retrospective study., Setting: : Tertiary referral center. University hospital., Patients: Twelve patients, 8 women and 4 men, mean age 50 years (range, 41-71 yr), were implanted with the VSB through the exclusive transcanal approach. In 7 patients with moderate sensorineural hearing loss, the floating mass transducer (FMT) was placed on the incus, whereas in 5 patients with a mixed hearing loss for chronic otitis media and/or previous middle ear surgeries, the FMT was placed on the round window., Intervention(s): Hearing rehabilitation., Main Outcome Measure(s): Postoperative surgical and anatomic results., Results: Anatomic results and functional results in patients operated with the FMT on the round window., Conclusion: The exclusive transcanal approach proved to be faster, simpler, and safer in comparison to the classic surgical technique through the facial recess, reducing the risk of chorda tympani and facial nerve lesions. All the patients and, in particular, those operated placing the FMT on the round window achieved improvements in hearing thresholds and speech perception tests from the use of the VSB. Moreover, after a mean 21-month follow-up (range, 15-32 mo), we did not observe any complication such as tympanic membrane perforations, external ear canal skin lesions, or extrusion of the coil in the external ear canal.

Objective: To investigate the relation between hospital volume and preservation ratios of facial function in surgery for vestibular schwannoma., Data Sources: A meta-analysis was conducted on current literature concerning preservation ratios of facial function after surgical resection of vestibular schwannoma. Studies reported by the House-Brackmann grading system for facial function were searched; all studies were published in English in peer-reviewed journals between 1992 and 2007., Study Selection: Articles had to report 1) patients who had surgery for vestibular schwannoma, 2) House-Brackmann grades for facial function, and 3) calendar time and number of procedures., Data Extraction: Standard methods for meta-analysis were adapted., Data Synthesis: Data were pooled by weighing studies according to their accuracy. Results were sorted for low-, moderate-, and high-volume hospitals. Linear relations were quantified by metaregression analysis (n = 5,560)., Conclusion: Findings of this meta-analysis suggest that there is a linear relation between hospital volume and preservation ratio of facial function. The concentration of surgical treatment might be a consideration to optimize clinical outcome. Prospective and nationwide registration of surgical results might contribute to more definitive conclusions regarding outcome of vestibular schwannoma surgery.

Background: For the past 30 years, microsurgical free tissue transfer has enabled the reconstruction of pediatric cranial base lesions formerly believed to be refractory to surgical therapy. Due to the relative rarity of these oncologic processes and the highly specialized requirements for their treatment, few large-scale reviews of microsurgical reconstruction of pediatric cranial base lesions have been published to date., Methods: A review of all free tissue transfer reconstructive procedures undertaken by a single microsurgeon for pediatric cranial base defects was performed for operations occurring between 1977 and 2007. All procedures were performed at a single institution on patients ranging from infancy to 16 years of age. Data were culled from a combination of patient charts, hospital records, radiographic studies, and clinical photographs., Results: Thirty patient charts were analyzed from the defined 30-year period. The average patient age at the time of diagnosis was 5.3 years (SD = 4.9 years). The most common primary diagnosis was rhabdomyosarcoma (n = 10; 33%). Most patients received chemotherapy (n = 26; 87%) or radiotherapy (n = 16; 53%). Most patients required extirpative hemimaxillectomy or hemimandiblectomy, necessitating reconstruction of intraoral structures in 16 children (53%). Forty free tissue transfers were performed; the most commonly used donor site was the rectus abdominis muscle (n = 19; 48%), followed by the fibula (n = 13; 30%), scapula (n = 5; 13%), latissimus dorsi muscle (n = 2; 5%), and radial forearm (n = 1; 3%). Reconstructive adjuncts included nonvascularized bone grafts (n = 13; 43%) and sural nerve grafts (n = 6; 20%). Short-term perioperative complications were relatively minor; no flap losses were recorded. The most common anticipated long-term complications included growth disturbances (n = 10; 33%), resorption of nonvascularized bone grafts (n = 8; 27%), and soft tissue atrophy/contracture (n = 8; 27%). Most patients studied were noted to be surviving (n = 22; 73%), with an average age of 19.2 years (SD, 10.1 years); among those patients who had died (n = 8; 27%), the average age at death was 14.6 years (SD, 6.2 years). The preponderance of patients who had died received their initial surgery and reconstruction during the first 15 years of this study period (n = 7; 88% of subgroup), with death most often due to complications related to extension of the original malignancy through the cranial base., Conclusions: As advances in oncologic therapy continue to improve survival among pediatric patients experiencing malignancies involving the cranial base, microsurgery simultaneously continues to enable robust options for postextirpative reconstruction and therefore provides a major benefit to the ongoing care of these individuals.

Learning Objectives: After studying this article, the participant should be able to: 1. Understand and describe preoperative medical conditions pertinent to patient selection in facial rejuvenation. 2. Understand and describe anatomical and aesthetic changes that occur with facial aging and how they affect surgical treatment planning. 3. Understand and describe operative approaches to the aging face. 4. Understand and describe the avoidance and treatment of complications following face lifting., Summary: Surgical rejuvenation of the aging face has evolved into one of the most frequently performed cosmetic surgery procedures. Although there are many techniques that are used in facial rejuvenation, the key to consistent results is not technique but rather the surgeon's ability to individualize the treatment plan according to the aesthetic needs of the patient. To ensure safety, preoperative medical conditions need to be both well defined and stabilized preoperatively, and procedures are best performed with anesthesia supervision. Consistency in postoperative result is obtainable through a thorough understanding of facial soft-tissue anatomy, the anatomical changes that occur with aging, and an appreciation of the technical nuances required to reposition descended soft tissues toward the anatomical position of youth. Recognition of potential complications and an appreciation of how to both limit and manage them when they occur are imperative in delivering a satisfying outcome for both patient and physician.

Background: Paralysis of the marginal mandibular branch of the facial nerve is frequently seen in patients with oromandibular reconstructions or facial palsy. However, deformities caused by overpulling of the depressor muscles of the contralateral lower lip without being antagonized by the diseased counterpart is often quite conspicuous. Depressor myectomy of the contralateral lower lip therefore provides a method for correcting the dynamic deformity., Methods: Seventy-six patients with paralysis of the marginal mandibular branch of the facial nerve were treated with either surgical depressor myectomy of the lower lip (25 patients), depressor myectomy with subsequent botulinum toxin injection (eight patients), or only chemical depressor myectomy with botulinum toxin injections (43 patients)., Results: Good to fair results were always achieved, with near balance of the lower lip during mouth opening and in facial expressions. Surgical myectomy may still result in recurrence in eight patients (24 percent), which will necessitate further treatment with botulinum toxin injections., Conclusions: Using myectomy for paralysis of the marginal mandibular branch of the facial nerve can be an effective treatment for this significant deformity. Chemical myectomy with botulinum toxin injection is a safe and convenient mode of treatment; however, the disadvantage is that it needs repeated injections and costs more.

Distraction osteogenesis is a useful technique in temporomandibular joint reconstruction after gap arthroplasty for ankylosis. We report a case of unilateral facial nerve paralysis during the distraction phase of treatment in a patient with temporomandibular joint ankylosis who was treated with gap arthroplasty and distraction osteogenesis. The clinical course is described and discussed.

Bilateral sagittal split osteotomy is the most commonly used osteotomy of the mandible in orthognathic surgery. The authors describe their experience in evaluating the orthognathic patient with a mandibular deformity. The bilateral sagittal split osteotomy surgical technique used by the authors is reviewed along with postoperative management.

Purpose of Review: In this review article different relevant applications of botulinum toxin type A are demonstrated in patients with head and neck cancer., Recent Findings: Patients with head and neck cancers of different etiologies often suffer from disorders concerning their musculature (for example, synkinesis in mimic muscles) or gland secretion in the head and neck region. This leads to many problems and reduces their quality of life. The application of botulinum toxin type A can improve movement disorders like synkinesis following reconstructive surgery in patients with cancers of the parotid gland, spasms of the pharyngo-esophageal musculature following laryngectomies and disorders of the autonomous nerve system like hypersalivation, hyperlacrimation and pathological sweating., Summary: The application of botulinum toxin type A is a helpful and minimally invasive treatment option in different functional disorders improving the quality of life in patients with head and neck cancers of different etiologies. Side effects are rare.

CD4+ (T helper) lymphocytes appear to play important roles in neuron survival and regeneration after injury, although their functions in regulating gene expression in injured neurons are unknown. Mice with targeted mutations in the STAT4 and STAT6 genes are deficient in T helper (Th)1 and Th2 responses, respectively, and have been used to determine the relative importance of T helper subsets in a variety of inflammatory processes. As pituitary adenylyl cyclase-activating peptide mRNA is normally strongly induced in facial motor neurons after axotomy, we examined this induction in Th1 and Th2 lymphocyte-deficient and control Balb/C wild-type mice. As previously reported, pituitary adenylyl cyclase-activating peptide gene expression was strongly induced in ipsilateral but not contralateral motor neurons in the facial motor nucleus of wild-type mice. The mean number of hybridizing motor neurons in STAT4-deficient mice did not differ from that in wild-type mice, whereas the number in STAT6 mice was reduced by more than 50%. The results indicate that STAT6 plays a key role in the upregulation of pituitary adenylyl cyclase-activating peptide gene expression in facial motor neurons after injury, possibly through its role in regulating T helper cell differentiation to the type 2 phenotype.

Facial nerve injuries are rare complications after orthognathic surgery. A literature review shows that such damages can develop with various mechanisms and are usually transient. Two cases of delayed facial paralysis after mandibular osteotomy with spontaneous recovery are reported.

Objective: This paper presents our experience with gunshot wounds to the temporal bone and discusses facial nerve lesions, surgical indication, surgical timing, and other findings., Study Design: We performed a retrospective review of patients treated for facial nerve lesion after gunshot injury to the temporal bone., Setting: The study was performed in the Otolaryngology Department of the University of Sao Paulo Medical School, Sao Paulo, Brazil., Patients: Ninety-eight patients treated between 1988 and 1999 were analyzed., Intervention: Facial nerve lesions, bullet locations, and surgical techniques were analyzed. Patients were monitored for 2 years., Results: Gunshot trauma to the temporal bone presented considerable tissue loss resulting from the abrasion effect and severity of the impact. The third segment of the facial nerve was most affected, and the bullet was typically found lodged in the mastoid tip. Postoperative infection was common. Such cases required revision surgery, resulting in worse cosmetic outcomes than in cases of closed trauma., Conclusions: Surgical exploration of the facial nerve should be performed as soon as possible, since long delays increase the chance of traumatic neuroma and more pronounced scarring around the facial nerve. Open mastoidectomy with meatoplasty is the surgical technique recommended for repairing the mastoid and the facial nerve. In the majority of cases, a cable graft is necessary. Since nerve lesion in proximity to the stylomastoid foramen and extratemporal facial nerve is common, these areas must be explored carefully.