Background: The choice of neurotization source for gracilis neuromuscular transplant is a key point in the treatment of unilateral long-standing paralysis. To combine the advantages of different donor nerves and overcome their disadvantages, mixed neurotization sources have been described with encouraging results. The authors present a preliminary report of a novel technique, the "supercharged" cross-graft, a two-step technique consisting of a double powered cross nerve graft provided by a zygomatic branch of the healthy facial nerve and the masseter nerve of the healthy side.Patients and methods: From January 2015 to December 2019 eight patients, aged between 19 and 61 years old (mean age at surgery 33.62) suffering unilateral established paralysis (congenital or acquired, >24 months) underwent gracilis reinnervation with the supercharged cross grafting technique. Subjects underwent a two-step surgical rehabilitation: in the first operation sural nerve was harvested and used as cross-graft cooptated by healthy side facial nerve branch and masseteric nerve. During second procedure gracilis neuromuscular transplant was performed reinnervarting the muscle with the cross-graft. Patients were evaluated using Emotrics software, which allowed for automated facial measurements on postoperative pictures taken at the last follow-up. The results of the different poses were compared to assess the contribution to smile excursion by the masseter and facial nerve, together and separately. Finally, we analyzed spontaneous smile to assess whether masseteric contribution is used in daily life.Results: No major or minor complications occurred. Follow-up time ranged from 12 to 41 months, with a mean of 22.75 months. A good commissure excursion (mean 33.84 mm) was obtained during smile with no teeth clenching (without masseter activation), as well as during teeth clenching without smiling (activation of gracilis onlymean 32.55). When smiling and biting simultaneously the excursion was greater than the single two components (mean 35.91). In spontaneous smile, commissure excursion was higher (mean 34.23) than that provided by only the facial nerve (smile only) in most patients.
No abstract
In this article we describe a new evisceration technique with the use of Ellman radiofrequency (RF) with the Goisis elevator [Patented 4-MHz dual radiosurgical unit, Ellman, NY], a new tool for orbital surgery with whom is possible to cut, coagulate, and dissect with greater precision, lower temperature, and reduced alteration of the tissue. With the Goisis RF Elevator we perform a conjunctiva peritomy, then, with the same device, is possible to get inside the chamber and excise the cornea and, after that, eliminate the globe content. The next step is to isolate and hook the superior and medial rectus muscles so that we can perform a full-thickness quadrant sclerotomy from the limbal incision to the optic nerve. The procedure is repeated in the superolateral, inferolateral, and inferomedial quadrants. In the end we can position a large implant between four scleral flaps previously shaped. This new technique makes the procedure to place a large orbital implant easier and faster. The advantages are both for the operator and the patient: enhanced speed, reduced pain, prompt healing, and lesser swelling.
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