Composite Sterno-Omohyoid Functional Muscle Transfer for Dual-Vector Smile Reanimation: A Case Series.

Background: Facial reanimation flaps often add bulk and produce single-vector smiles, and multivector flaps frequently require challenging intramuscular dissection. Objective: To evaluate the effectiveness of sterno-omohyoid flap (SOHF) transfer for dual-vector smile reanimation by measuring upper dental show and oral commissure movement. Methods: SOHF transfers from 2017 to 2020 were retrospectively evaluated using eFACE and Emotrics software. Results: Four patients with flaccid and one with nonflaccid facial paralysis were identified (four females and one male, median age: 39 years (range: 38-65); two acoustic neuromas, two congenital, one temporal bone fracture). Median follow-up was 20 months (range: 14-26). All flaps received masseteric nerves and two had additional cross-face grafts. Four developed contraction [median time to contraction: 5.5 months (range: 3-10)]. Mean oral commissure excursion and dental exposure improvements were 7.6 ± 4.0 mm (p = 0.03) and 2.9 ± 1.8 mm (p = 0.05), respectively. Dynamic, smile, and midface-smile eFACE improvements were 20.3 ± 6.8 (p = 0.007), 25.5 ± 14.5 (p = 0.03), and 50.5 ± 12.0 mm (p = 0.004) points, respectively. Mean SOHF mass was 14 ± 1.7 g. Conclusion: The SOHF is a small flap that provides dual-vector smile reanimation in flaccid and nonflaccid facial paralysis.

Sterno-omohyoid Free Flap for Dual-Vector Dynamic Facial Reanimation.

BACKGROUND: Dynamic rehabilitation of longstanding facial palsy with damaged, atrophied, or absent facial muscles requires replacement of neural and muscular components. The ideal reconstruction would include a fast-twitch muscle that is small, a reliable donor vessel and nerve, and the potential to provide a natural, synchronous, dentate smile with minimal donor site morbidity. Many flaps have been successfully used historically, but none has produced ideal rehabilitation. OBJECTIVE: To evaluate the novel sterno-omohyoid, dual-vector flap in rehabilitation of chronic facial paralysis. RESULTS: We performed sterno-omohyoid free tissue transfer for smile reanimation in a 39-year-old male with a history of longstanding right facial palsy following resection of a skull base tumor several years previously. We transferred both muscles with the superior thyroid artery, middle thyroid vein, and ansa cervicalis. The patient developed a dynamic smile by 6 months postoperatively, and he had improved objective facial symmetry. CONCLUSION: Herein, we demonstrate the first use of the sterno-omohyoid flap for successful facial reanimation. Overall, it is a novel flap in facial reanimation with many advantages over traditional flaps, including the potential to produce a more synchronous, dynamic smile while adding minimal bulk to the face. Future series will better elucidate the potential of the sterno-omohyoid flap.

Masseteric-to-Facial Nerve Transfer and Selective Neurectomy for Rehabilitation of the Synkinetic Smile.

IMPORTANCE: Synkinesis is the involuntary movement of 1 area of the face accompanying volitional movement of another; it is commonly encountered in patients affected by facial palsy. Current treatments for synkinesis include biofeedback for muscular retraining and chemodenervation via the injection of botulinum toxin. Chemodenervation is effective in reducing unwanted muscle movement, but it requires a commitment to long-term maintenance injections and may lose effectiveness over time. A permanent solution for synkinesis remains elusive. OBJECTIVE: To evaluate masseteric-to-facial nerve transfer with selective neurectomy in rehabilitation of the synkinetic smile. DESIGN, SETTING, AND PARTICIPANTS: In this case series, 7 patients at a tertiary care teaching hospital underwent masseteric-to-facial nerve transfer with selective neurectomy for synkinesis between September 14, 2015, and April 19, 2018. The medical records of these patients were retrospectively reviewed and demographic characteristics, facial palsy causes, other interventions used, and changes in eFACE scores were identified. INTERVENTION: Masseteric-to-facial nerve transfer. MAIN OUTCOMES AND MEASURES: Changes in eFACE scores (calculated via numeric scoring of many sections of the face, including flaccidity, normal tone, and hypertonicity; higher scores indicate better function and lower scores indicate poorer function) and House-Brackmann Facial Nerve Grading System scores (range, 1-6; a score of 1 indicates normal facial function on the affected side, and a score of 6 indicates absence of any facial function [complete flaccid palsy] on the affected side). RESULTS: Among the 7 patients in the study (6 women and 1 man; median age, 49 years [range, 41-63 years]), there were no postoperative complications; patients were followed up for a mean of 12.8 months after surgery (range, 11.0-24.5 months). Patients experienced a significant improvement in mean (SD) eFACE scores in multiple domains, including smile (preoperative, 65.00 [8.64]; postoperative, 76.43 [7.79]; P = .01), dynamic function (preoperative, 62.57 [15.37]; and postoperative, 75.71 [8.48]; P = .03), synkinesis (preoperative, 52.70 [4.96]; and postoperative, 82.00 [6.93]; P < .001), midface and smile function (preoperative, 60.71 [13.52]; and postoperative, 78.86 [14.70]; P = .02), and lower face and neck function (preoperative, 51.14 [16.39]; and postoperative, 66.43 [20.82]; P = .046). Preoperative House-Brackmann Facial Nerve Grading System scores ranged from 3 to 4, and postoperative scores ranged from 2 to 3; this change was not significant. CONCLUSION AND RELEVANCE: This study describes the application of masseteric-to-facial nerve transfer with selective neurectomy for smile rehabilitation in patients with synkinesis, with statistically significant improvement in smile symmetry and lower facial synkinesis as measured with the eFACE tool. This technique may allow for long-term improvement of synkinesis and smile. This study is only preliminary, and a larger cohort will permit more accurate assessment of this therapeutic modality. LEVEL OF EVIDENCE: 4.

Advances in the Reconstruction of Orbital Fractures.

Orbital reconstruction is one of the most challenging tasks for surgeons who treat craniofacial trauma. Suboptimal outcomes carry a high level of morbidity, with functional, emotional, and aesthetic implications. However, advances in reconstruction techniques, including the use of orbital endoscopy, computer-guided navigation, and mirror image overlay techniques, have been shown to provide significant improvements in outcomes. This article provides practical advice for applying these techniques to orbital reconstruction following trauma.

Unfavorable Results After Free Tissue Transfer to Head and Neck: Lessons Learned at the University of Washington.

This article discusses the lessons learned from nearly 2700 free tissue transfer procedures to reconstruct defects of the head and neck at the University of Washington. It discusses the authors' perioperative management practices regarding perioperative tracheotomy tube placement, their method of postoperative flap monitoring, and their current protocol for use of postoperative antibiotics. It reports on the reconstructive preferences for 2 difficult defects that frequently result in unfavorable outcomes: the total glossectomy defect and the pharyngolaryngectomy defect. Key points for harvesting and insetting flaps, to maximize reconstructive outcomes, are provided.

Otolaryngology clinic of North America: evidence-based practice: management of hoarseness/dysphonia.

This article reviews the evidence for the evaluation and management for patients with dysphonia. The evidence behind laryngoscopy, laryngostroboscopy, laryngeal imaging, laryngeal electromyography, and disease-specific questionnaires are reviewed. The evidence for management of some of the common conditions leading to dysphonia is also reviewed. This article reviews the evidence for voice therapy for various voice pathologies; medical management of dysphonia, including antibiotics, steroids, and antireflux therapy; and surgical management of glottic insufficiency and some benign laryngeal masses.

Endoscopic resection of juvenile nasopharyngeal angiofibroma.

Juvenile nasopharyngeal angiofibromas remain rare tumors representing approximately 0.05% of head and neck tumors. The typical presentation is a male teenager with recurrent epistaxis and nasal obstruction. These tumors were traditionally approached via external and/or intraoral incisions, but many are amenable to endoscopic removal. Preoperative embolization of major feeding vessels to these tumors by interventional radiology has resulted in significantly less blood loss and facilitated endoscopic resection. The following chapter discusses endoscopic resection of juvenile nasopharyngeal angiofibromas and outlines pertinent anatomy while covering important surgical techniques. Appropriate patient selection, anesthesia considerations, surgical preparation and techniques, and postoperative care are discussed. A case presentation is included with preoperative imaging and an accompanying video to demonstrate these surgical techniques.

Double-reversing z-plasty (Furlow palatoplasty).

Dr. Leonard Furlow first described the double-reversing z-plasty technique for cleft soft palate repair in 1978. This approach allows for repair of an overt or submucous cleft palate, but just as an importantly, provides additional length to the palate and also realigns the palatal musculature. The Furlow palatoplasty (the name by which the procedure is commonly referred) has therefore been instrumental in the treatment of velopharyngeal insufficiency. The primary aims of this chapter are to provide the clinician with the indications for when to consider utilizing the Furlow palatoplasty and to give a stepwise description of how to perform the procedure.

Effect of visual error size on saccade adaptation in monkey.

Saccades that consistently over- or undershoot their targets gradually become smaller or larger, respectively. The signal that elicits adaptation of saccade size is a difference between eye and target positions appearing repeatedly at the ends of saccades. Here we describe how visual error size affects the size of saccade adaptation. At the end of each saccade, we imposed a constant-sized error by moving the target to a specified point relative to eye position. We tested a variety of error sizes imposed after saccades to target movements of 6, 12, and 18 degrees. We found that the size of the gain change elicited in a particular experiment depended on both the size of the imposed postsaccade error and on the size of the preceding target movement. For example, imposed errors of 4-5 degrees reduce saccades tracking 6, 12, and 18 degrees target movements by an average of 18, 35, and 45%, respectively. The most effective errors were those that were 15-45% of the size of the initial target eccentricity. Negative errors, which reduce saccade size, were more effective in changing saccade gain than were positive errors, which increased saccade size. For example, for 12 degrees target movements, negative and positive errors of 2-6 degrees changed saccade gain an average of 35 and 8%, respectively. This description of the relationship between error size and adaptation size improves our ability to adapt saccades in the laboratory and characterizes the error sizes that will best drive neurons carrying the adaptation-related visual error signal.