Facial reanimation using the hypoglossal nerve and ansa cervicalis: a short-term retrospective analysis of surgical outcomes

Background: Transferring the hypoglossal nerve to the facial nerve using an end-to-end method is very effective for improving facial motor function. However, this technique may result in hemitongue atrophy. The ansa cervicalis, which arises from the cervical plexus, is also used for facial reanimation. We retrospectively reviewed cases where facial reanimation was performed using the ansa cervicalis to overcome the shortcomings of existing techniques of hypoglossal nerve transfer.Methods: The records of 15 patients who underwent hypoglossal nerve transfer were retrospectively reviewed. Three methods were used: facial reanimation with hypoglossal nerve transfer (group 1), facial nerve reanimation using the ansa cervicalis (group 2), and sural nerve interposition grafting between the hypoglossal nerve and facial nerve (group 3). In group 1, the ansa cervicalis was coapted to neurotize the distal stump of the hypoglossal nerve in a subset of patients. Clinical outcomes were evaluated using the House-Brackmann (H-B) grading system and Emotrics software.Results: All patients in group 1 (n = 4) achieved H-B grade IV facial function and showed improvements in the oral commissure angle at rest (preoperative vs. postoperative difference, 6.48° ± 0.77°) and while smiling (13.88° ± 2.00°). In groups 2 and 3, the oral commissure angle slightly improved at rest (group 2: 0.95° ± 0.53°, group 3: 1.35° ± 1.02°) and while smiling (group 2: 2.06° ± 0.67°, group 3: 1.23° ± 0.56°). In group 1, reduced tongue morbidity was found in patients who underwent ansa cervicalis transfer.Conclusion: Facial reanimation with hypoglossal nerve transfer, in combination with hypoglossal nerve neurotization using the ansa cervicalis for complete facial palsy patients, might enable favorable facial reanimation outcomes and reduce tongue morbidity. Facial reanimation using the ansa cervicalis or sural nerve for incomplete facial palsy patients did not lead to remarkable improvements, but it warrants further investigation.

The Facial Vein on Computed Tomographic Angiography: Implications for Plastic Surgery and Filler Injection

Background The knowledge of the anatomy of the facial vein (FV) is essential for plastic surgery and filler injection. Objectives The purpose of this study was to investigate the variation and three-dimensional course of FV using computed tomographic angiography (CTA). Methods The CTA images of 300 FVs from 150 Asian patients were included in this study. The distance between each anatomical landmark and FV was measured to position the course. The depth of FV beneath the skin and the height of FV above the periosteum were measured at five anatomical planes. Results The facial vein showed a relatively constant course with a frequency of 7.0% variation. The average diameter of FVs was 2.42 ± 0.58 mm. The vertical distance between medial canthus, the midpoint of inferior orbital rim or external canthus and the facial vein was 10.28 ± 2.17 mm, 6.86 ± 2.02 mm, or 48.82 ± 7.26 mm, respectively. The horizontal distance between medial canthus, nasal alar or oral commissure and the facial vein was 6.04 ± 1.44 mm, 22.34 ± 3.79 mm, or 32.21 ± 4.84 mm, respectively. The distance between mandibular angle or oral commissure and the facial vein at the inferior of mandible was 24.99 ± 6.23 mm, or 53.04 ± 6.56 mm. The mean depth of FV beneath the skin at the plane of medial canthus, infraorbital, nasal ala, oral commissure, and mandible was 1.16 ± 0.99 mm, 5.83 ± 1.64 mm, 16.07 ± 4.56 mm, 14.92 ± 2.49 mm, and 9.67 ± 2.88 mm, respectively. The mean height of FV above the periosteum at the plane of medial canthus, infraorbital, nasal ala, and mandible was 1.17 ± 1.32 mm, 3.59 ± 1.48 mm, 3.92 ± 1.95 mm, and 3.50 ± 2.03 mm, respectively. Conclusions This study revealed the three-dimensional course of the facial vein with reference to the anatomical landmarks. The detailed findings of the facial vein will provide a valuable reference for plastic surgery and filler injection.

Perception about Importance of Buccal Corridor and its Width in Smile Esthetics

Aim: To assess the perception of dental students and house officers regarding role of buccal corridor in smile esthetics and to determine the most esthetically pleasing buccal corridor width. Methods: A photograph of the patient’s face, smiling with the teeth visible up to the first molar was modified digitally to create smiles with no buccal corridor, increasing buccal corridors widths of 5%, 10%, 15%, 20 % and 25% respectively compared with the width of inner oral commissure. A total of 376 dental students and HOs participated in the study and data was collected in questionnaires. Results: Buccal corridor is considered to affect the smile esthetics of an individual by 72.4% of house officers, 67.6% of second year students, 48.7% of 3rd year students and 52.4% of fourth year students(P value: 0.002). Visibility of around 5-10% of buccal corridor was considered most esthetically pleasing, however, the result was not significant. Conclusion: Buccal corridor is an important component in smile esthetics considered by students and house officers of dental colleges. Buccal corridor width of 5-10 % was considered most esthetically pleasing among participants. Keywords: Buccal corridor, Esthetics, perception

A giant cutaneous horn of oral commissure: a case report

Cutaneous horn is a conical, circumscribed, dense hyperkeratotic protrusion from skin with epithelial cornification. It is also known by the Latin name ‘Cornu cutaneum’. This rare medical entity resembles animal horn but histological disparity is present between both. They are more commonly present in sun exposed sites or areas that are prone for actinic radiation, burns and hence frequently seen in forearm and upper part of face. Only few cases have been reported with cutaneous horns in unusual sites. Cutaneous horns occurring in oral cavity or perioral regions are extremely rare. The significance of knowing about this dead keratinous cutaneous horn is that it may occur as a part of or in association with a wide range of underlying pathologies, either malignant, premalignant or benign. Majority are due to benign pathologies. We report an unusual presentation of cutaneous horn in left oral commissure of a 45-year-old gentleman which is an extremely rare perioral location for such an ailment.

Forehead flap: a reconstructive option in selected complex defects following resection of oral cancers staged T4

<p class="abstract"><strong>Background:</strong> Head and neck squamous carcinoma constitutes 30% of malignancies in our region, oral carcinoma being most common among them. Most of these tumours involve lower gingivobuccal sulcus and buccal mucosa. 80% patients present with locally advanced disease. Following resection of these tumours, reconstruction of composite defects is challenging. Though microvascular free flaps are ideal in such cases, it is not always feasible due to malnutrition, peripheral vascular disease, sometimes non–availability of microvascular surgeon and financial constraints. Pectoralis major myocutaneous flap, the workhorse of reconstruction is bulky, non-pliable and cannot be advanced over intact mandible. Forehead flap in complex defects is pliable, versatile, has excellent vascularity and colour matching, easy to harvest and suitable in selected cases and as salvage flap when other flaps fail. The aim of the study was to document outcome of folded forehead flap reconstruction of complex defects following resection of T4 staged oral carcinoma.</p><p class="abstract"><strong>Methods:</strong> This retrospective study in a tertiary rural hospital included 31 patients with oral carcinoma staged T4. The patients underwent folded forehead flap reconstruction for full thickness cheek defects with some extending into oral commissure and lower lip, along with segmental or alveolar resection of mandible or maxilla.</p><p class="abstract"><strong>Results: </strong>27 patients had uneventful healing, 2 had wound dehiscence and 2 had necrosis of distal part of flap. Patients with externally rotated flap had mild trismus and patients in whom forehead flap was used to reconstruct the oral commissure had oral incompetence.</p><p class="abstract"><strong>Conclusions: </strong>Folded forehead flap is good reconstructive option in complex full thickness defects of cheek and as salvage reconstruction.</p>