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32 Use ofPorcine Urinary Bladder Matrix (UBM-ECM) intheHead andNeck Region
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387
Fig. 32.8 (continued)
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o
B. A. Kraemer and A. G. Rowe
Fig. 32.8 (continued)
32 Use ofPorcine Urinary Bladder Matrix (UBM-ECM) intheHead andNeck Region
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ab
cd
389
Fig. 32.9 A 42-year-old female with an anxiety disorder
who self-injured her face with her ngernails. (a, b) Initial
appearance of the bilateral cheeks being topically treated
for necrotizing cellulitis. (c, d) Cheek wounds after wound
bed preparation. (e, f) UBM-ECM being placed into
cheek wounds—100 mg. MicroMatrix
5 × 5 cm. Cytal
®
Burn Matrix split between the two
®
powder and
wounds. (g, h) One month later. Note the moist salmoncolored granulation tissue typical of UBM-ECM healing.
(i, j) Cheek at 14 months post UBM-ECM treatment
390
gh
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B. A. Kraemer and A. G. Rowe
ef
Fig. 32.9 (continued)
32 Use ofPorcine Urinary Bladder Matrix (UBM-ECM) intheHead andNeck Region
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ij
Fig. 32.9 (continued)
391
392
ab
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B. A. Kraemer and A. G. Rowe
c
d
e
Fig. 32.10 A 91-year-old male with a non-healing left
cheek wound which extends down to the zygomatic
arch—after resection of a squamous cell cancer and radiation therapy. (a) Initial wound. (b) After debridement at
the time of placement of several pieces of a Cytal
®
single
layer wound sheet used to ll the wound cavity. (c) One
week later with small overlying clot. (d) Seven weeks
post-treatment. (e) Final wound 3 months post-treatment.
A polyurethane sheet covering was the only secondary
dressing utilized during the healing process
32 Use ofPorcine Urinary Bladder Matrix (UBM-ECM) intheHead andNeck Region
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393
Acknowledgments Disclosure: Dr. Kraemer has been a
consultant for ACell
and has received monies for presenting his clinical experience on the use of the UBM-ECM wound device. He
began using the UBM-ECM wound devices in 2010.
®
Inc. (Columbia, MD) since 2014
References
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JT. Management of open distal lower extremity
wounds with concomitant fracture using porcine urinary bladder matrix. Wounds. 2016;28(11):387–94.
3. Personal communication with multiple other practitioners using the UBM-ECM wound device
4. Melville JC, Bennetts NA, Tijerina L, Shum JW.The
use of acellular urinary bladder matrix as coverage for
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5. Chalmers RL, Smock E, Geh JLC. Experience of
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technique. Burns. 2012;38:143–4.
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Advances inFacial Nerve Paralysis:
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Surgical Innovation, Tissue
Engineering, andEmerging
Technology
JuliaR.Brennan, MatthewE.Spector,
JenniferC.Kim, andMichaelJ.Brenner
33
33.1 Introduction
The facial nerve is of critical importance to an
individual’s identity and ability to connect and
communicate with others [1]. It takes part both in
day-to-day functions of eating, drinking, and
blinking and also in minute-to-minute expressions of emotion and social interaction [2]. The
involvement of the facial nerve in eye closure
makes it crucial in the prevention of corneal
exposure and keratopathy and ultimately protection of vision [3]. As such, the multifaceted
nature means that injury to the facial nerve can be
very damaging to patients. Facial palsy has a profound impact on activities of daily living, psychosocial well-being, and quality of life measures
and is thus an important focus of a vast array of
both surgical and nonsurgical interventions [4].
In order to select the appropriate approach to
treatment, various considerations must be taken
into account. These include the cause, duration,
and severity of the facial palsy, the integrity of
the underlying neuromusculature, and the general goals of the patient [5]. Due to the nature of
the anatomy, it is challenging to completely
J. R. Brennan · M. E. Spector · J. C. Kim
M. J. Brenner (*)
Department of Otolaryngology—Head and Neck
Surgery, University of Michigan,
Ann Arbor, MI, USA
e-mail: jbren@umich.edu; mespector@umich.edu;
jennkim@umich.edu; mbren@umich.edu
restore the intricacy and cooperation of the facial
mimetic musculature. Current techniques aim to
establish symmetry and movement. Static slings
and nonsurgical approaches can offer improved
resting symmetry to these patients, but they do
not restore muscle tone or allow for voluntary
reanimation [1]. For the purposes of this chapter,
we will be focusing on the dynamic surgical techniques in reanimation and reinnervation which
are currently employed to treat facial paralysis.
Also included is an overview of some areas of
ongoing research in facial nerve repair in which
future techniques are discussed.
Facial nerve repair research has proven to be
an exciting frontier for the elds of tissue engineering, nanotechnology, and bioelectrical interface design. The emerging technologies take
advantage of the ongoing work in basic, clinical,
and translational research that promise to advance
the eld even further in the coming years.
33.2 Diagnosis andClinical
Decision-Making
In order to reinstate symmetric facial movement,
there must be a functional nerve that can provide
input to a functional bed of muscle with intact
neuromuscular junctions (Fig.33.1). Options for
neural input include the ipsilateral facial nerve,
the contralateral facial nerve, or coaptation
between an alternative cranial nerve and the
© Springer Nature Switzerland AG 2019
D. Duscher, M. A. Shiffman (eds.), Regenerative Medicine and Plastic Surgery,
https://doi.org/10.1007/978-3-030-19958-6_33
395
396
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Fig. 33.1 Confocal imaging illustrating terminal axons
and motor end plates, adapted from Magill CK, Tong A,
Kawamura D, Hayashi A, Hunter DA, Parsadanian A,
Mackinnon SE, Myckatyn TM.Reinnervation of the tibialis anterior following sciatic nerve crush injury: A confocal microscopic study in transgenic mice. Experimental
Neurology. 2007;207(1)
distal facial nerve segment. The muscle bed can
be that of existing facial muscles or that of a
transfer, either regional or distant [5].
The choice of repair is contingent upon the
duration of denervation and site of the injury.
The time since injury can often indicate the viability of the underlying facial mimetic musculature. Although the exact cutoff is debated, studies
demonstrate functional reinnervation can be
achieved for approximately 12–18months after
injury before there is irreversible muscle atrophy
and degeneration of the neuromuscular junction
[6]. An electromyographic study can help evaluate the viability of the neuromuscular unit.
Together with a comprehensive preoperative
evaluation, these studies can assist in diagnosis
and informed clinical decision-making [7].
Figure 33.2 illustrates an algorithm that can
assist in evaluating a patient with facial palsy.
33.3 Approaches
33.3.1 Reinnervation
There are three available surgical techniques by
which facial nerve reinnervation is achieved. For
J. R. Brennan et al.
nerve transections there are primary suture repair
and tissue adhesives. For any larger nerve defects,
there are nerve grafts and conduits to avoid tension and bridge the gap. For any injury involving
an unavailable proximal or distal nerve segment,
there are nerve transfers [
8].
33.3.2 Primary Suture Repair
Primary end-to-end neurorrhaphy of fresh
nerve endings remains the best option for nerve
transection injuries in the event that tensionfree approximation is possible. A study in a
primate model suggested that, for defects up to
3–4 cm, primary repair under modest tension
results in better axon regeneration than grafting [9]. In the setting of larger nerve gaps,
however, the higher tension on the nerve endings can result in impairments in nerve vascularity, scar tissue formation, and even nerve
rupture [10, 11].
There has historically been a dispute as to the
best technique for microsurgical neural repair.
The advantage of fascicular repair is that it facilitates the best axonal alignment, but this requires
increased operational complexity and has the
potential for disruption of the nerve and the vasa
nervorum. Alternatively, epineural repair is
faster and less disruptive and is often the favored
technique for primary neurorrhaphy [5, 12]. The
epineural sleeve technique has been demonstrated to have better functional nerve recovery
and is thus favored over standard end-to-end
repair. In this technique, the epineural sheath of
the distal nerve ending is rolled back 2mm so as
to create a sleeve over the proximal stump at the
area of coaptation (Fig.33.3). This is thought to
create a chamber within which the repair site is
separated from the surrounding tissues to collect
axoplasmic uid and promotes regeneration
[13]. Alternatively, another technique involves
end-to- end epineural repair with the use of a vein
graft cuff placed over the repair to facilitate a
similar isolation of the neurorrhaphy site. Of
note, this graft is placed on the proximal stump
before the repair and is later transposed over the
repair site.
33 Advances inFacial Nerve Paralysis: Surgical Innovation, Tissue Engineering, andEmerging Technology
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Patient with chronic facial palsy
Diagnostics: Clinical examination, MRI, facial EMG (if applicable)
Determination of severity and consideration of the patient’s desire, age, and life expectancy
397
Early reconstruction of nerve transection
or nerve gap injury
Primary direct nerve suture
or
Interpositional graft
12-24 months later: Standardized evaluation of therapeutic results
Adjuvant surgical procedures: Eyebrow lift, rhinoplasty, rhytidectomy, myectomys, and/or botulinum toxin application
Fig. 33.2 Algorithm for approaches to repair in a patient
with facial nerve palsy. It is the authors’ opinion that combined nerve supply—particularly use of masseteric-tobuccal branch of facial nerve in conjunction with
Early reconstruction with absent proximal
nerve stump
Hypoglossal-facial jump
coaptation
or
Masseteric-facial nerve transfer
or
Cross-facial nerve graft
or
Combined nerve transfer approaches
or
Static sling
metry for patients with an absent proximal stump. Adapted
from Gerd FV, Pantel M, Guntinas-Lichius O. Modern
Concepts in facial nerve reconstruction. Head Face Med
2010;6
Late reconstruction >18 months after
injury or congenital palsy
Free muscle transfer
Temp oralis muscle transfer powered
by CFNG, masseteric, or combination
Static sling
hypoglossal-to-facial—provides the best tone and sym-
or
or
33.3.3 Tissue Adhesive
Fibrin glue and other adhesives also play an
increasing role in nerve repair. Studies in rodents
demonstrated no difference in recovery outcomes
between primary suture and brin adhesive coaptation, yet there was a signicantly reduced operative
time for the latter [14, 15]. Additionally, because
the epineural sutures used in neurorrhaphy are permanent, there is the concern for a chronic foreign
body reaction and increased inammation which
may inhibit axonal regeneration [16].
Historically, a potential disadvantage about
brin glue concerns about its ability to hold the
nerve endings together and maintain an adequate tensile strength at the site of repair.
Multiple studies in animal models have indicated that these adhesives actually have biomechanical performances that are equivalent to
that of primary suture repair, suggesting that
these concerns are unfounded [17, 18]. As such,
brin glue presents as a quicker and easier
modality that may indeed be functionally comparable to primary suture repair.
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