Fig 4 - uploaded by Andres Rodriguez-Lorenzo
Content may be subject to copyright.
immediate postoperative photograph of the patient showing paralysis of the left lower lip muscle depressors.
Source publication
Background
Injuries of the marginal mandibular nerve (MMN) of the facial nerve result in paralysis of the lower lip muscle depressors and an asymmetrical smile. Nerve reconstruction, when possible, is the method of choice; however, in cases of long nerve gaps or delayed nerve reconstruction, conventional nerve repairs may be difficult to perform or...
Context in source publication
Context 1
... Nerve reconstruction was performed with a nerve transfer of the PMN to the MMN (Fig. 2), and soft tissue recon- struction was performed with a free anterolateral thigh flap anastomosed to the facial vessels (Fig. 3). The postop- erative course was uneventful, and the patient sustained temporary paralysis in the left lower lip muscle depres- sors (Fig. 4). After 3 years, the patient is free of tumor recurrence and has a complete recovery of MMN func- tion (Fig. 5) without the need of central relearning and without functional or aesthetic impairment resulting from denervation of the platysma muscle (Fig. ...
Citations
... The marginal mandibular branches of the facial nerves are extremely special in nature. Once an injury occurs, the complications will be devastating and functions will be lost, which will involve the patient's facial aesthetics [9][10][11], causing great psychological trauma to the patient, and thus affecting tumor treatment [12,13]. Whether it is necessary to dissect the marginal mandibular branches of the facial nerves when removing the submandibular glands during comprehensive cervical lymphadenectomy and whether the dissection can protect the marginal mandibular branches of the facial nerves are a subject worthy of clinical research. ...
Objective
According to the different characteristics of patients and cervical lymph node metastasis of oral and oropharyngeal cancer, the marginal mandibular branches of facial nerves were treated by different surgical procedures, and the safety and protective effects of different surgical procedures were investigated.
Methods
One hundred ninety-seven patients with oral and oropharyngeal cancer satisfying the inclusion criteria were selected. According to the different characteristics of patients and cervical metastatic lymph nodes, three different surgical procedures were used to treat the marginal mandibular branches of the facial nerve: finding and exposing the marginal mandibular branches of the facial nerves at the mandibular angles of the platysma flaps, finding and exposing the marginal mandibular branches of facial nerves at the intersections of the distal ends of facial arteries and veins with the mandible, and not exposing the marginal mandibular branches of the facial nerves. The anatomical position, injury, and complications of the marginal mandibular branches of the facial nerves were observed.
Results
The marginal mandibular branches of the facial nerves were found and exposed at the mandibular angles of the platysma flaps in 102 patients; the marginal mandibular branches of facial nerves were found and exposed at the intersections of the distal ends of the facial arteries and veins with the mandibles in 64 patients; the marginal mandibular branches of facial nerves were not exposed in 31 patients; among them, four patients had permanent injury of the marginal mandibular branches of the facial nerves, and temporary injury occurred in seven patients. There were statistically significant differences in the protection of the mandibular marginal branch of the facial nerve among the three different surgical methods ( P = 0.0184). The best protective effect was to find and expose the mandibular marginal branch of the facial nerve at the mandibular angle of the platysma muscle flap, and the injury rate was only 2.94%.
Conclusion
The three different surgical procedures were all safe and effective in treating the marginal mandibular branches of the facial nerves, the best protective effect was to find and expose the mandibular marginal branch of the facial nerve at the mandibular angle of the platysma muscle flap.
... These attributes potentially confer improved nerve recovery in an irradiated field which, together with a shorter reinnervation time, can be critical in the intended patient demographic (Klein et al., 2019). Potential methods and donor nerves for lower lip reanimation include end-toside hypoglossal transfer (Atlas & Lowinger, 1997;Coyle et al., 2013;Koh et al., 2002;Yetiser & Karapinar, 2007) and intra-facial transfer with the cervical branch of the facial nerve (Rodriguez-Lorenzo et al., 2016). However, in oncological facial nerve resection, the recipient facial nerve branch may not reach the hypoglossal nerve, while the cervical branch may reside within the tumor margin. ...
Background
Donor nerve options for lower lip reanimation are limited in patients undergoing oncological resection of the facial nerve. The ansa cervicalis nerve (ACN) is an advantageously situated donor with great potential but has not been examined in detail. In the current study, the anatomical technical feasibility of selective ACN to marginal mandibular nerve (MMN) transfer for restoration of lower lip tone and symmetry was explored. A clinical case is presented.
Methods
Dissections were conducted in 21 hemifaces in non-embalmed human cadavers. The maximal harvestable length of ACN was measured and transfer to MMN was simulated. A 28-year-old male underwent ACN-MMN transfer after parotidectomy (carcinoma) and was evaluated 12 months post-operatively (modified Terzis' Lower Lip Grading Scale [25 observers] and photogrammetry).
Results
The harvestable length of ACN was 100 ± 12 mm. A clinically significant anatomical variant (“short ansa”) was present in 33% of cases (length: 37 ± 12 mm). Tensionless coaptation was possible in all cases only when using a modification of the surgical technique in “short ansa” cases (using an infrahyoid muscle nerve branch as an extension). The post-operative course of the clinical case was uneventful without complications, with improvement in tone, symmetry, and function at the lower lip at 12-month post-operative follow-up.
Conclusions
Selective ACN-MMN nerve transfer is anatomically feasible in facial paralysis following oncological ablative procedures. It allows direct nerve coaptation without significant donor site morbidity. The clinical case showed good outcomes 12 months post-operatively. A strategy when encountering the “short ansa” anatomical variant in clinical cases is proposed.
... In addition to the commonly used donor nerves mentioned above, the antebrachial cutaneous nerve and motor nerve to the vastus lateralis also have the potential to be used in the repair of the craniofacial nerve, especially for facial nerve repair (Revenaugh et al., 2012;Jandali and Revenaugh, 2019). Rodriguez-Lorenzo et al. observed complete restoration of nerve function after using the platysma motor nerve to repair the segmental defect of the marginal mandibular nerve caused by resection of soft tissue sarcoma of the jaw (Rodriguez-Lorenzo et al., 2016). This approach has been proven to be more effective in recovering laryngeal local function than performing laryngeal reinnervation utilizing the ansa cervicalis, but it has not shown significant advantages compared with the traditional vocal fold medialization laryngoplasty. ...
Neural tissue is an important soft tissue; for instance, craniofacial nerves govern several aspects of human behavior, including the expression of speech, emotion transmission, sensation, and motor function. Therefore, nerve repair to promote functional recovery after craniofacial soft tissue injuries is indispensable. However, the repair and regeneration of craniofacial nerves are challenging due to their intricate anatomical and physiological characteristics. Currently, nerve transplantation is an irreplaceable treatment for segmental nerve defects. With the development of emerging technologies, transplantation donors have become more diverse. The present article reviews the traditional and emerging alternative materials aimed at advancing cutting-edge research on craniofacial nerve repair and facilitating the transition from the laboratory to the clinic. It also provides a reference for donor selection for nerve repair after clinical craniofacial soft tissue injuries. We found that autografts are still widely accepted as the first options for segmental nerve defects. However, allogeneic composite functional units have a strong advantage for nerve transplantation for nerve defects accompanied by several tissue damages or loss. As an alternative to autografts, decellularized tissue has attracted increasing attention because of its low immunogenicity. Nerve conduits have been developed from traditional autologous tissue to composite conduits based on various synthetic materials, with developments in tissue engineering technology. Nerve conduits have great potential to replace traditional donors because their structures are more consistent with the physiological microenvironment and show self-regulation performance with improvements in 3D technology. New materials, such as hydrogels and nanomaterials, have attracted increasing attention in the biomedical field. Their biocompatibility and stimuli-responsiveness have been gradually explored by researchers in the regeneration and regulation of neural networks.
... The marginal mandibular branches of the facial nerves are extremely special in nature. Once an injury occurs, the complications will be devastating and functions will be lost, which will involve the patient's facial aesthetics [9][10][11], causing great psychological trauma to the patient, and thus affecting tumor treatment [12,13]. Whether it is necessary to dissect the marginal mandibular branches of the facial nerves when removing the submandibular glands during comprehensive cervical lymphadenectomy, and whether the dissection can protect the marginal mandibular branches of the facial nerves are a subject worthy of clinical research. ...
Background and objective: Tumor treatment has been progressive. Targeted therapy and immunotherapy have contributed in the surgical success of several patients with advanced oral and oropharyngeal cancer. Surgery is the primary treatment for oral and oropharyngeal cancer, and cervical lymphadenectomy is crucial in surgery. Evidence has shown that submandibular glands can be preserved in cervical lymphadenectomy for early stage oral and oropharyngeal cancer; however, the removal of the submandibular glands is inevitable in cervical lymphadenectomy for locally advanced oral and oropharyngeal cancer. Nowadays, with individualized and precise treatment, the anatomy and protection of the marginal mandibular branches of the facial nerves have received increasing attention. In this study, according to the different characteristics of patients and cervical lymph node metastasis of oral and oropharyngeal cancer, the marginal mandibular branches of facial nerves were treated by different surgical procedures, and the safety and protective effects of different surgical procedures were investigated. Methods: From January 2014 to June 2021, 197 patients with oral and oropharyngeal cancer satisfying the inclusion criteria were selected from the Head and Neck Department of Shenzhen Otolaryngology Research Institute/Shenzhen Longgang Otolaryngology Hospital, Head and Neck Department of Gannan Medical University Affiliated Cancer Hospital, Department of Oral and Maxillofacial Surgery of the First Hospital of Qiqihar in Heilongjiang Province, and Department of Otorhinolaryngology-Head and Neck Surgery of First Affiliated Hospital of Gannan Medical University. All patients underwent radical surgery by comprehensive cervical lymphadenectomy or radical surgery plus repair and reconstruction. During the operation, the marginal mandibular branches of the facial nerves were treated and the submandibular glands were removed. According to the different characteristics of patients and cervical metastatic lymph nodes, three different surgical procedures were used to treat the marginal mandibular branches of the facial nerve: finding and exposing the marginal mandibular branches of the facial nerves at the mandibular angles of the platysma flaps, finding and exposing the marginal mandibular branches of facial nerves at the intersections of the distal ends of facial arteries and veins with the mandible, and not exposing the marginal mandibular branches of the facial nerves. The anatomical position, injury, and complications of the marginal mandibular branches of the facial nerves were observed. Results: The marginal mandibular branches of the facial nerves penetrated from the front or lower ends of the parotid glands. They were constantly located between the deep surface of the platysma and the superficial layer of the deep fascia cervicalis, and on the plane of the lower mandible. They crossed the superficial surface of the posterior facial veins, mandibular angles, and anterior facial veins from back to front and entered the deep surface of deltoid muscles at the distal ends of facial arteries and veins. Among the 197 oral and oropharyngeal cancer patients undergoing comprehensive cervical lymphadenectomy with excision of the submandibular glands, the marginal mandibular branches of the facial nerves were found and exposed at the mandibular angles of the platysma flaps in 102 patients (102/197, 51.78%); the marginal mandibular branches of facial nerves were found and exposed at the intersections of the distal ends of the facial arteries and veins with the mandibles in 64 patients (64/197, 32.49%); the marginal mandibular branches of facial nerves were not exposed in 31 patients (31/197, 15.73%); the two methods for finding the marginal mandibular branches of the facial nerves both successfully found the marginal mandibular branches. Among the 197 patients with oral and oropharyngeal cancer, four patients (4/197, 2.03%) had permanent injury of the marginal mandibular branches of the facial nerves. Among them, one patient (1/102,0.98%) had injury of the marginal mandibular branches of the facial nerves found and exposed at the mandibular angles of platysma flaps; one patient (1/64, 1.56%) had injury of the marginal mandibular branches of the facial nerves found and exposed at the intersections of the distal ends of the facial arteries and veins with the mandible; the marginal mandibular branches of the facial nerves were not found and exposed in two patients (2/31, 6.45%), and the differences were not statistically significant (P>0.05). Temporary injury occurred in seven patients (7/197, 3.55%). Among them, two patients (2/102, 1.96%) had injury of the marginal mandibular branches of the facial nerves found and exposed at the mandibular angles of platysma flaps; two patients (2/64, 3.13%) had injury of the marginal mandibular branches of the facial nerves found and exposed at the intersections of the distal ends of facial arteries and veins with the mandible; and the marginal mandibular branches of facial nerves were not found and exposed in three patients (3/31, 9.68%). The differences were not statistically significant (P>0.05). The patients were followed up for 6 to 90 months after surgery, and the functions were restored in all patients with temporary injury of the marginal mandibular branches of the facial nerves. Conclusion: The three different surgical procedures were all safe and effective in treating the marginal mandibular branches of the facial nerves. Finding and exposing the marginal mandibular branches of the facial nerves at the mandibular angles of the platysma flaps was suitable for those with larger and more lymph nodes in region Ib. Finding and exposing the marginal mandibular branches of the facial nerves at the intersections of the distal ends of facial arteries and veins with the mandible was suitable for those with larger and more lymph nodes in region IIa. Not exposing the marginal mandibular branches of the facial nerves was suitable for those without obvious lymph nodes in region Ib or region IIa. Intraoperatively, we should choose an appropriate method in dealing with the marginal mandibular branches of the facial nerves according to the different characteristics of patients and cervical metastatic lymph nodes as well as the proficiency of surgeons.
... Over 90% of marginal nerve injuries recover over several months without treatment. In severe cases, a platsymal motor nerve transfer can restore nerve palsy [57]. ...
In this chapter, the authors will review the complications associated with liposuction and laser liposuction procedures, using published reports as the guide to document these complications and deformities to the readers. In addition, the authors will also report on the use of tumescent anesthesia and the published documentation regarding safety concerns that have been presented via the use of tumescence versus general anesthesia when performing liposuction or laser liposuction. Real-world discussions also will take place in which the authors describe best treatment practices as solutions to those complications described. Liposuction and laser liposuction are wonderful procedures that have been performed for many years. Understanding and being able to identify and treat any untoward complications is extremely important to make everyone a better surgeon and a better physician.
... Use of the platysmal branch as a donor source for MMN reinnervation has also been described. 52 Terzis described a twostage "babysitter" procedure, 53 wherein motor neural input to the depressor muscles is quickly re-established by sideto-end transfer of ipsilateral hypoglossal axons, with reestablishment of coordinated lip depression through crossfacial nerve grafting of marginal mandibular branches. 54 Hypoglossal nerve transfer to the lower lip may be achieved by mobilization of the lower division of the facial nerve to the ipsilateral hypoglossal nerve with side-to-end coaptation, 55 or in end-to-end fashion by partial transection of the hypoglossal nerve (typically comprising ∼30% of its caliber). ...
The lower lip serves pivotal functional and aesthetic roles in the face. Palsy of lower lip musculature may result in oral incompetence, articulation difficulties, and impairment of facial expression. Loss of lower lip sensation may result in unrecognized trauma, sialorrhea, and social embarrassment. Herein, we review therapeutic approaches to lower lip reanimation and sensory neurotization.
... As to that, upper buccal or cervical branches of the facial nerve are sacrificed in order to restore zygomatic or marginal mandibular branches, thus lowering the risk for corneal exposure, drooling, and asymmetrical smile. 27,28 For lack of intra-branch connections of the MMN with other facial nerve branches, spontaneous recovery of its innervated muscles is less likely in case of its damage. 29 As the cervical branch (platysma motor nerve [PMN]) of the facial nerve arises from the lower division of the facial nerve coursing more posterior and deeper than the MMN, it is less prone to injury. ...
... 29 As the cervical branch (platysma motor nerve [PMN]) of the facial nerve arises from the lower division of the facial nerve coursing more posterior and deeper than the MMN, it is less prone to injury. 27 MMN and PMN have synergistic functions both innervating muscles expressing unhappy mimic looks, as the lower lip muscle depressors, as well as the platysma, are activated vertically from cranial to caudal. Recent anatomical findings demonstrated comfortable identification and dissection of the PMN as it runs under the platysma from the anterior-inferior part of the parotid gland. ...
... Recent clinical findings demonstrated good to excellent outcomes of both methods described, which some authors explain by the fact of replacing ''same with same.'' 27 In that way, facial motor nerve branches not only replace the injured motor nerve branches but also function as direct vascularized nerve grafts, which advantages have been discussed before. Figure 3 shows an isolated partial resection of the MMN which is restored by intrafacial transfer of the PMN. ...
Transection of the facial nerve and its branches during extensive ablative procedures in the oncologic patient causes loss of control of facial mimetic muscles with severe functional and aesthetic sequelae. In such patients with advanced tumorous disease, copious comorbidities, and poor prognosis, rehabilitation of the facial nerve has long been considered of secondary priority. However, recent advances in primary facial nerve reconstruction after extensive resection demonstrated encouraging results focusing on rapid and reliable restoration of facial functions. The authors summarize 3 innovative approaches of primary dynamic facial nerve reconstruction by using vascularized nerve grafts, dual innervation concepts, and intra-facial nerve transfers.
Early facial nerve reconstruction should be offered in every patient with oncological resections of the facial nerve due to the debilitating functional and psychosocial consequences of facial nerve palsy. Oncologic pathology or oncologic resection accounts for the second most common cause of facial nerve palsy. In the case of these acute injuries, selecting an adequate method for reconstruction to optimize functional and psychosocial well-being is paramount. Authors advocate consideration of the level of injury as a framework for approaching the viable options of reconstruction systematically. Authors break down oncologic injuries to the facial nerve in three levels in relation to their nerve reconstruction methods and strategies: Level I (intracranial to intratemporal), Level II (intratemporal to extratemporal and intraparotid), and Level III (extratemporal and extraparotid). Clinical features, common clinical scenarios, donor nerves available, recipient nerve, and reconstruction priorities will be present at each level. Additionally, examples of clinical cases will be shared to illustrate the utility of framing acute facial nerve injuries within injury levels. Selecting donor nerves is critical in successful facial nerve reconstruction in oncological patients. Usually, a combination of facial and non-facial donor nerves (Hybrid) is necessary to achieve maximal reinnervation of the mimetic muscles. Our proposed classification of three levels of facial nerve injuries provides a selection guide, which prioritizes methods for function nerve reconstruction in relation of the injury level in oncologic patients while prioritizing functional outcomes.
The Marginal Mandibular Nerve, a branch of the seventh cranial nerve (facial nerve), exhibits notable variability in its branching and course. Incorrect identification of the nerve and its branches poses a risk of injury during head and neck surgeries. The muscles supplied by the Marginal Mandibular Nerve are essential for maintaining facial symmetry. Preserving the functional integrity of the MMN is challenging during head and neck surgeries, and inadvertent injury to it can have significant consequences. Such an injury has the potential to distort facial expressions, underscoring the importance of careful consideration and preservation of the nerve during surgery. Therefore, meticulous attention to the anatomy of the Marginal Mandibular Nerve is crucial to minimize the potential for harm during surgical procedures in the head and neck region
Background
This study aims to propose surgical approaches intended to localize and preserve the marginal mandibular nerve (MMN) during routinely performed head and neck surgical procedures.
Main body of abstract
Preservation of the functional integrity of the MMN is a critical measure in the success of orofacial surgeries involving the submandibular triangle. This study systematically reviews the anatomical description of the nerve including origin, course relative to fascial planes, relation to the parotid gland and facial pedicle, branching pattern and anastomosis of nerve and consolidate the findings of several significant studies to determine the “surgically safe” approaches to avoid iatrogenic injury to MMN.
Short conclusion
The systematic approaches described in this study have helped the authors precisely determine which particular MMN preserving approach to be adopted for each aspect of head and neck surgery. This has definitely enhanced the quality of surgery performed and the postoperative satisfaction of the patients.
