143
Letters to the Editor
The limitation may be due to the fact that experience in clinical medicine has not been officially incorporated as a necessary requirement for a properly trained anaesthetist. If this was the case, then it would be mandatory to devise practical schemes to bring this about. Professor Strunin states that 'All that is required is an altered emphasis of the FFARCS examination.'. Alteration of the emphasis may be a good step, but it would not by itself make a hard pressed anaesthetic registrar working in a peripheral hospital knowledgeable in clinical medicine. Experience gained by one of us (KKM) at the North London Postgraduate Medical Centre in teaching clinical medicine to candidates for the final FFARCS examination, clearly suggests the need for some direct clinical medical experience. Yours faithfully K KYEI-MENSAH S SOMANATHAN
13 November 1976 Cross-face Nerve Transplantation in Facial Palsy From Dr Hans Anderl Universitatsklinik fur Plastische und Wiederherstellungschirurgie, Jnnsbruck, Austria Dear Sir, I am glad to clarify the points raised by Mr David Matthews in his letter to you (December Proceedings, p 949). Table 1 gives details of the cases I reported (October, p 781). It is not easy to determine the optimal time for attempting surgery to achieve reinnervation in facial palsy. On the one hand, one must not interfere with the spontaneous regeneration of
nerve fibres; and on the other hand, the muscles must still be in a condition to react to reinnervation. However, we are prepared to carry out the first stage of our procedure after 6 months if there is no sign of regeneration from EMG studies. There is argument over whether to carry out the whole procedure in a single stage. The sprouting axons will grow through the distal nerve graft anastomosis as easily as they pass the proximal anastomosis. But in a few cases it is necessary to reoperate to reexpose this distal anastomosis of the nerve graft. This is easy in a limb but very difficult or impossible in the face. A second advantage of a two-stage procedure is the inevitable delay (some 4-5 months) before performing the second stage. Occasionally unexpected regeneration of the facial nerve occurs in this period and the main branches of the facial nerve are still intact to permit this. The first stage will have been unnecessary, but has not impaired function in any way. One cannot give precise dates for the second stage. We know that axons grow at about 1-3 mm a day; the nerve axons will thus have reached the end of free nerve grafts, 13-18 cm long, in about 4 months and have formed a neuroma. This axon growth in the grafts can sometimes be demonstrated by EMG studies. Since we have to be certain that axon growth has been complete we allow ourselves a few weeks extra latitude. Further experience may enable us to determine the completion of growth more accurately and hence permit earlier performance of the second stage. Yours sincerely H ANDERL
27 October 1976
Table I Diagnosis Cerebellar tumour
Craniobasal fracture and decompression Bell's Palsy
Malignant parotid tumour + radiation Radical operation of the ear
Age (years) 34 6 50 47 35 35 4 21 34 19 32 50 48
Sex F F F F M F M M M F M M M
Treatment interval (1+II)A (months) 13 (8 + 5) 18 (12+6) 16 (6+10) 16 (10+6) (3 + 8) I1 480 12 (7+5) 15 (10+5 16 (8+8) 8 14 (10+4) 11 years16 (10+6)
53 18
M F
24 15 years
ResultVery satisfactory Satisfactory Very satisfactory Very satisfactory Still under treatment Good Good Good Good Convalescing Good
Follow up (years) i 34 44 2 I I 3
14
44
Convalescing Not very satisfactory
14
Poor Poor
5 44
* Masseteric transplant+CFNT * Good; symmetry, active lifting of the angle of the mouth and cheek, lid closure almost perfect Satisfactory; fair symmetry, cheek tone and slight lifting, lid closure 2/3 Poor; little or no symmetry, little muscle action, poor lid closure * Stage I and II
Letters to the Editor
The limitation may be due to the fact that experience in clinical medicine has not been officially incorporated as a necessary requirement for a properly trained anaesthetist. If this was the case, then it would be mandatory to devise practical schemes to bring this about. Professor Strunin states that 'All that is required is an altered emphasis of the FFARCS examination.'. Alteration of the emphasis may be a good step, but it would not by itself make a hard pressed anaesthetic registrar working in a peripheral hospital knowledgeable in clinical medicine. Experience gained by one of us (KKM) at the North London Postgraduate Medical Centre in teaching clinical medicine to candidates for the final FFARCS examination, clearly suggests the need for some direct clinical medical experience. Yours faithfully K KYEI-MENSAH S SOMANATHAN
13 November 1976 Cross-face Nerve Transplantation in Facial Palsy From Dr Hans Anderl Universitatsklinik fur Plastische und Wiederherstellungschirurgie, Jnnsbruck, Austria Dear Sir, I am glad to clarify the points raised by Mr David Matthews in his letter to you (December Proceedings, p 949). Table 1 gives details of the cases I reported (October, p 781). It is not easy to determine the optimal time for attempting surgery to achieve reinnervation in facial palsy. On the one hand, one must not interfere with the spontaneous regeneration of
nerve fibres; and on the other hand, the muscles must still be in a condition to react to reinnervation. However, we are prepared to carry out the first stage of our procedure after 6 months if there is no sign of regeneration from EMG studies. There is argument over whether to carry out the whole procedure in a single stage. The sprouting axons will grow through the distal nerve graft anastomosis as easily as they pass the proximal anastomosis. But in a few cases it is necessary to reoperate to reexpose this distal anastomosis of the nerve graft. This is easy in a limb but very difficult or impossible in the face. A second advantage of a two-stage procedure is the inevitable delay (some 4-5 months) before performing the second stage. Occasionally unexpected regeneration of the facial nerve occurs in this period and the main branches of the facial nerve are still intact to permit this. The first stage will have been unnecessary, but has not impaired function in any way. One cannot give precise dates for the second stage. We know that axons grow at about 1-3 mm a day; the nerve axons will thus have reached the end of free nerve grafts, 13-18 cm long, in about 4 months and have formed a neuroma. This axon growth in the grafts can sometimes be demonstrated by EMG studies. Since we have to be certain that axon growth has been complete we allow ourselves a few weeks extra latitude. Further experience may enable us to determine the completion of growth more accurately and hence permit earlier performance of the second stage. Yours sincerely H ANDERL
27 October 1976
Table I Diagnosis Cerebellar tumour
Craniobasal fracture and decompression Bell's Palsy
Malignant parotid tumour + radiation Radical operation of the ear
Age (years) 34 6 50 47 35 35 4 21 34 19 32 50 48
Sex F F F F M F M M M F M M M
Treatment interval (1+II)A (months) 13 (8 + 5) 18 (12+6) 16 (6+10) 16 (10+6) (3 + 8) I1 480 12 (7+5) 15 (10+5 16 (8+8) 8 14 (10+4) 11 years16 (10+6)
53 18
M F
24 15 years
ResultVery satisfactory Satisfactory Very satisfactory Very satisfactory Still under treatment Good Good Good Good Convalescing Good
Follow up (years) i 34 44 2 I I 3
14
44
Convalescing Not very satisfactory
14
Poor Poor
5 44
* Masseteric transplant+CFNT * Good; symmetry, active lifting of the angle of the mouth and cheek, lid closure almost perfect Satisfactory; fair symmetry, cheek tone and slight lifting, lid closure 2/3 Poor; little or no symmetry, little muscle action, poor lid closure * Stage I and II
