The Effectiveness of Facial Exercise Therapy in Ophthalmic Complications of Facial Nerve Palsy and the CADS Grading Scale as an Ophthalmic-Specific Grading System.

PURPOSE: The effectiveness of facial exercise therapy in facial nerve palsy is well documented in the literature. However, there is no study examining its effect on ophthalmic manifestations of facial nerve palsy. The study reports its impact on the ophthalmic manifestations of facial nerve palsy using the ophthalmic-specific CADS grading system. METHODS: A retrospective case series of patients aged 18 years or older with facial nerve palsy was performed in a single specialist center between 2013 and 2019. Inclusion criteria were ophthalmic involvement, recorded CADS, and Sunnybrook grading scale pre- and post-treatment. RESULTS: A total of 73 patients were identified. There were 24 patients (M = 11, F = 13) who received facial exercise therapy only (group 1) and 49 patients (M = 17, F = 32) who received combined treatment of facial exercise therapy and eyelid surgery (group 2). The mean ages were 54.8 and 49.7 years, respectively. The groups were further subdivided into early (<3 months), intermediate (3-12 months), and late presenters (>12 months). In group 1, statistically significant improvements were seen in early (static asymmetry and dynamic function), intermediate (cornea), and late groups (cornea, static asymmetry, and dynamic function). The Sunnybrook grading scale was unable to detect changes in the ophthalmic features post-therapy or to report the corneal status. CONCLUSIONS: Facial exercise therapy is likely to improve ophthalmic manifestations of facial nerve palsy, in particular, those with static asymmetry and dynamic function of eye closure. The CADS grading scale is more suitable for the ophthalmic assessment.

A Comprehensive Flap Classification: Beyond the Reconstructive Ladder.

ABSTRACT: Perforator flaps have progressed massively in the last years. The improved vascular imaging techniques and the use of supermicrosurgery have shifted the practice from the traditional predefined angiosomal flaps to the endless variations of custom-made flaps. In this article, we propose a broadened classification of free-style flaps in 3 categories, the angiosomal, including all traditional perforator flaps and their variations, the extra-angiosomal, including flaps that are manufactured to include tissue from a different angiosome, such as turbocharging or supercharging a flap, and neoangiosomal flaps, which are based on the process of neoangiogenesis on autologous or allogenous tissue, such as the venous flow-through flap and integra flap. With this classification, we hope to help unify the classifications and, by doing so, facilitate the exchange of ideas, techniques and knowledge.MeSH terms: surgical flap / classification, terminology as topic.

A Novel Approach to Facial Reanimation and Restoration Following Radical Parotidectomies.

Background: Parotidectomies are indicated for a variety of reasons. Regardless of the indication for surgery, facial reanimation may be required because of facial nerve sacrifice or iatrogenic damage. In these cases, facial restoration performed concurrently with ablative surgery is considered the gold standard, and delayed reanimation is usually not attempted. Methods: A retrospective review of all patients who underwent parotidectomies from 2009 to 2022 in a single institution was performed. Indications, surgical techniques, and outcomes of an algorithmic template were applied to these cases using the Sunnybrook, Terzis scores, and Smile Index. A comparison was made between immediate vs. late repairs. Results: Of a total of 90 patients who underwent parotidectomy, 17 (15.3%) had a radical parotidectomy, and 73 (84.7%) had a total or superficial parotidectomy. Among those who underwent complete removal of the gland and nerve sacrifice, eight patients (47.1%) had facial restoration. There were four patients each in the immediate (n = 4) and late repair (n = 4) groups. Surgical techniques ranged from cable grafts to vascularized cross facial nerve grafts (sural communicating nerve flap as per the Koshima procedure) and vascularized nerve flaps (chimeric vastus lateralis and anterolateral thigh flaps, and superficial circumflex perforator flap with lateral femoral cutaneous nerve). Conclusions: The algorithm between one technique and another should take into consideration age, comorbidities, soft tissue defects, presence of facial nerve branches for reinnervation, and donor site morbidity. While immediate facial nerve repair is ideal, there is still benefit in performing a delayed repair in this algorithm.

Sural communicating nerve for application as a vascularized nerve graft: A microneurovascular anatomic study in cadavers.

INTRODUCTION: Sural nerve harvest causes paraesthesia to the lateral heel of the foot, which can debilitate those with already compromised proprioception. To circumvent this, we investigated an alternative donor nerve, branch of the lateral sural nerve complex called the sural communicating nerve (SCoNe), for its harvest and use as a vascularized nerve graft, in cadaver. METHODS: The SCoNe was visualized by dissection in 15 legs from 8 human cadavers and the relationship of the SCoNe to the overall sural nerve complex was documented. The surface markings, dimensions, and the micro-neurovascular anatomy in the super-microsurgery range (up to 0.30 mm) of the SCoNe was recorded and analyzed. RESULTS: SCoNe graft surface marking was confined within a triangle drawn between the fibular head laterally, the popliteal vertical midline medially and the tip of the lateral malleolus inferiorly. The proximal end of the SCoNe was situated at a mean intersection distance of 5 cm from both the fibular head and popliteal midline respectively. The mean length of the SCoNe was 226 ± 43 mm with a mean proximal diameter of 0.82 mm and mean distal diameter of 0.93 mm. In 53% of the cadavers, an arterial input was present in the proximal third of the SCoNe and veins were predominantly (87%) present in the distal third. In 46% and 20% of the 15 legs respectively, there was a nutrient artery and vein perfusing the SCoNe in its central segment. The external mean diameter of this artery was 0.60 ± 0.30 mm, while the vein was slightly larger with a mean diameter of 0.90 ± 0.50 mm. DISCUSSION: SCoNe graft may preserve lateral heel sensation, compared to sural nerve harvest, pending clinical studies. It may have wide applications as a vascularized nerve graft, including being ideal as a vascularized cross-facial nerve graft because its nerve diameter is similar to the distal facial nerve branches. The accompanying artery is a good anastomotic match to the superior labial artery.

Smile Outcomes When Using Masseteric Nerve-based Nerve Transfers versus Direct Muscle Neurotization in Facial Palsy Patients.

When dealing with a weak smile, nerve transfer is a viable strategy. We evaluated outcomes of masseteric nerve to facial nerve transfers and compared them with direct muscle neurotization (DMN). Methods: In a retrospective cohort study of 20 patients (n = 20), we compared nerve transfer versus DMN over a 6-year period (2016-2021). Outcomes were measured using the validated Sunnybrook score, Ackerman Smile Index, and Terzis scores. Statistical analysis was performed using the Wilcoxon sign rank and Mann-Whitney U tests. Results: Comparing pre- versus postoperative scores after nerve transfers, there was a significant improvement in median overall Sunnybrook score (24 versus 47, P = 0.043), lip elevation (1 versus 2, P = 0.046), open mouth smile (1 versus 3, P = 0.003), and Terzis scores (1 versus 3, P = 0.005), with no difference in resting symmetry (-15 versus -5; P = 0.496). Compared with DMN, there was no difference in median Terzis score improvement from preoperative to postoperative state (2 versus 1, P = 0.838), median smile improvement (2 versus 2, P = 0.838), resting symmetry (10 versus 5, P = 0.144) or overall Sunnybrook score (23 versus 21, P = 1.000). Lip elevation improvement was in favor of nerve transfers (1 versus 0, P = 0.047). Conclusions: This is the first study evaluating nerve transfer neurotization of smile-mimetic muscles and comparing the outcomes with DMN, with masseteric nerve as donor. Nerve transfer leads to improved facial mimetic function, smile excursion and open mouth smiles, as does DMN, with improvement in lip elevation in favor of nerve transfer. Nerve transfer was preferred for more severe smile weakness.

A Comparison of Outcomes between Finger and Pulp Replantation/Revascularization in a Single Center.

Supermicrosurgery has allowed the replantation/revascularization of the pulp, but how does this currently compare with more proximal digit replantation/revascularization? Methods: In a retrospective case study over a 5-year period at our institute, a total of 21 patients (n = 21) had either finger or pulp replantation-revascularization posttrauma. All pulp replants had a single-vessel anastomosis viz., "artery-to-artery" or "artery-to-vein" only, with venous outflow dependent on the skin-shave technique, while more proximal replants had both arterial and venous anastomoses. Age, sex, ischemic time, handedness, smoker status, and injury-replant interval were compared between the two groups, with all procedures performed by a single surgeon. The outcome parameters studied were length of hospital stay, timeline for wound healing, viability, and functional outcomes. Results: Our patients consisted of 18 men and three women, of which 14.3% were smokers and 85.7% were right-handed. There were 11 finger replantation/revascularizations (n = 11) versus 10 pulp replantation/revascularizations (n = 10). The average age of digit replantation/revascularization patients was 44.8 years compared with 26.4 years in pulp replantation/revascularization patients (Student t test, P = 0.04). Mean ischemia time in digital replants was 67 minutes versus 32.3 minutes in pulp replantation/revascularization (Student t test, P = 0.056). Digital replantation/revascularization was viable in 72% of cases versus a 90% viability in the pulp subcohort. Conclusions: In our patient cohort, pulp replantation/revascularizations produced better postoperative viability. Where supermicrosurgery expertise is available, pulp replantation/revascularization should be considered a worthwhile option when compared with digital replantation/revascularization.

Comment on Kehrer et al. Using High-Resolution Ultrasound to Assess Post-Facial Paralysis Synkinesis-Machine Settings and Technical Aspects for Facial Surgeons. Diagnostics 2022, 12, 1650.

In "Using High-Resolution Ultrasound to Assess Post-Facial Paralysis Synkinesis-Machine Settings and Technical Aspects for Facial Surgeons", Andreas Kehrer et al. present ultrasound (US) device settings for facial muscle examination to be used by facial surgeons to improve their workflow and enhance their image quality [...].

Comparative Study of Multimodal Therapy in Facial Palsy Patients.

Introduction In chronic facial palsy, synkinetic muscle overactivity and shortening causes muscle stiffness resulting in reduced movement and functional activity. This article studies the role of multimodal therapy in improving outcomes. Methods Seventy-five facial palsy patients completed facial rehabilitation before being successfully discharged by the facial therapy team. The cohort was divided into four subgroups depending on the time of initial attendance post-onset. The requirement for facial therapy, chemodenervation, or surgery was assessed with East Grinstead Grade of Stiffness (EGGS). Outcomes were measured using the Facial Grading Scale (FGS), Facial Disability Index, House-Brackmann scores, and the Facial Clinimetric Evaluation scale. Results FGS composite scores significantly improved posttherapy (mean-standard deviation, 60.13 ± 23.24 vs. 79.9 ± 13.01; confidence interval, -24.51 to -14.66, p < 0.0001). Analysis of FGS subsets showed that synkinesis also reduced significantly ( p < 0.0001). Increasingly, late clinical presentations were associated with patients requiring longer durations of chemodenervation treatment ( p < 0.01), more chemodenervation episodes ( p < 0.01), increased doses of botulinum toxin ( p < 0.001), and having higher EGGS score ( p < 0.001). Conclusions This study shows that multimodal facial rehabilitation in the management of facial palsy is effective, even in patients with chronically neglected synkinesis. In terms of the latency periods between facial palsy onset and treatment initiation, patients presenting later than 2 years were still responsive to multimodal treatment albeit to a lesser extent, which we postulate is due to increasing muscle contracture within their facial muscles.

Descriptive Study of Facial Motor Cocontractions During Voluntary Facial Movement in a Healthy Population: A New Hypothesis Contributing to Synkinesis.

Background: Motor overflow refers to involuntary movements that accompany voluntary movements in healthy individuals. This may have a role in synkinesis. Objective: To describe the frequency and magnitude of facial motor overflow in a healthy population. Methodology: Healthy participants performed unilateral facial movements: brow elevation, wink, snarl, and closed smile. Two reviewers analyzed the magnitude of each movement and cocontraction. Patterns of movements are described. Univariate analysis was used to assess the relationship between efficacy of unilateral facial control and the frequency and magnitude of cocontractions. Results: Eighty-nine participants completed the videos. Consensual mirror movements occurred in 96% of participants during unilateral eye closure and 86% during brow elevation. The most common associated movement was ipsilateral eye constriction occurring during snarl (90.1%). Improved unilateral facial control was associated with a decrease in frequency and magnitude of associated movements during brow elevation, wink, and snarl. Conclusion: This study showed stereotyped patterns of motor overflow in facial muscles that resemble those in synkinesis and become more evident as unilateral control of the face decreases.

Streamlining the Diagnosis of Atypical Facial Palsies: A 5-year Review of 805 Patients.

BACKGROUND: Currently, there are no definitive guidelines in the investigation and management of atypical facial palsies (AFPs). Our aim was to determine the etiology of AFPs presenting to a tertiary facial palsy center and to review the current spectrum of diagnostic and management approaches to these conditions. METHODS: A retrospective cohort analysis of attendees at the Queen Victoria Hospital multidisciplinary facial palsy clinic over a 5-year period from 2016 to 2020 was conducted. Demographic data were collated from the QVH Research and Governance team. Those presenting with classic Bell's palsy or Ramsay-Hunt syndrome were excluded. Anyone with atypical presentations (including multiple recurrences, focal neurological deficits, polycranial neuropathies, autoimmune conditions, hemifacial spasms, hearing/balance issues, weight loss, segmental facial palsies, and gradual onset presentations) were included under the AFP category. These patients were subjected to standard serological and radiological investigations and their follow-ups were reviewed. RESULTS: A total of 849 patients were identified, and 805 had actual facial palsy presentations. Of these, 172 patients had AFP. The majority of these patients had MRI imaging tests, which were useful, but the remaining serological tests were found to correlate more with symptom clusters and specific questions rather than with random tests for all AFPs. CONCLUSIONS: Although serological and radiological investigations help in the diagnosis of AFP, specific questions and presentations help streamline the diagnosis, without affecting its accuracy whilst reducing unnecessary tests and, thereby, cost and time. We present an algorithm organized by specific questions of presentations in those with AFPs.

Facial Nerve Revascularization Strategies in Facial Restoration.

Facial transplants represent the current exemplar in the reconstruction of severely damaged faces, whereas conventional free flap reconstruction has its limitations in restoring both function and surface cover. METHODS: In a retrospective study over 6 years (2014-2020), 5 cases (n = 5) of vascularized nerve flaps (VNFs) were performed by our team. These involved three acute and two late reconstructions. The mean age was 41 years with a maximum of 6-year follow-up. To objectify the different permutations and combinations, we categorized composite, chimeric, and hybrid VNFs into types I, IIa-c, and III, each with a unique characteristic. Postoperative function was evaluated using the validated Sunnybrook and Terzis scores for facial nerve palsy; masticatory function was assessed using dental impression studies. RESULTS: There was a 100% flap survival rate, with no instances of flap necrosis and only one complication: hematoma at 24 hours postoperative. Sunnybrook and Terzis scores showed a statistically significant improvement postoperatively, indicating both improved repose and facial expressions (paired student t test, P < 0.05). Given that each VNF was specifically customized for a particular patient, each type of VNF in this cohort was unique, thereby illustrating each type succinctly. CONCLUSIONS: VNFs are separate entities from standard free flaps, as they require extensive preoperative planning to allow the deconstructing of composite blocks of tissue into separate vascularized entities and amalgamating them into a new conglomerate. This allows VNFs to fill a niche area in facial reconstructive surgery between face transplants and conventional free tissue transfers, with enormous potential.

The Role of Supermicrosurgery and Arborization Capture in Improving Free-styled Propeller Flap Survival.

BACKGROUND: Propeller flaps have a higher-than-normal incidence of partial flap necrosis. Although venous supercharging has been shown to reduce this risk, its application is limited outside the scope of lower limb propeller flaps. In this article, we look at the ability of arborization capture and supermicrosurgery to allow propeller flaps to capture adjacent perforasomes and significantly improve flap survival. METHODS: In a retrospective case series across two institutions, the outcomes of two groups of patients who had propeller flaps were compared. Group A patients were those who had conventional free-styled propeller flaps (n = 25), whereas Group B (n = 19) patients had propeller flaps algorithmically selected for either (1) arborization capture or (2) venous supercharging, or both. Two-way ANOVA analysis was performed to evaluate inter-group differences. RESULTS: Conventional propeller flaps had a 64% complete survival rate (32% partial necrosis rate and a 4% total necrosis rate) compared with a 94% complete survival rate in modified propeller flaps. Of the 12 cases of arborization capture (perforator complex diameters of 1-2 mm), only one flap sustained partial flap loss, whereas all seven supercharged propeller flaps (selected for perforator diameter <1 mm, with venous supercharging, in addition to arborization capture) survived completely. CONCLUSIONS: The arborization technique should be the mainstay technique for all propeller flaps with perforator complex diameters of less than 2 mm while supercharging further enhances its survival, particularly in perforator complex diameters of less than 1 mm.

The Use of a Neurotized Arterio-venous Flow-through Flap for Concurrent Pulp Revascularization and Reconstruction.

Digital fingertip soft tissue defects requiring both reconstruction and revascularization pose challenges to the reconstructive surgeon. Traditional options, including terminalization, vein graft and cross-finger flap, and free flow-through flaps, maybe unsuitable or unavailable, with potential for significant donor site morbidity. Venous free flaps rely on venous circulation alone, with no sacrifice of an artery. We present a unique case of a self-employed tradesman with Raynaud's disease, with four-finger injury, and three-finger ischemia for whom we performed a neurotized arterialized venous flow-through flap to revascularize and reconstruct a pulp defect (with a concomitant vessel gap of 2 cm). After allowing for a period of intrinsic delay, the neurotized arterialized venous flow-through flap was inset after 10 days. The flap survived and the patient began to return to his activities within a month of the injury.

Overcoming the Patent Gap: A Guide to Patenting for Plastic Surgeons.

BACKGROUND: Patenting protects innovation, fosters academic incentives, promotes competition, and generates new revenue for clinician-inventors and their institutions. Despite these benefits, and despite plastic surgery's history of innovation, plastic surgery-related patent applications are few. The goal of this article was to use unpublished data and formulate a robust discussion. METHODS: The U.S. Patent and Trademark Office's boolean search was investigated between the timeline of 1975 and June 23, 2020, to identify patents related to the key phrases to contrast patent (both, issued and filed) tally in each specialty. Queries for two key phrases related to plastic surgery and a core plastic surgical activity, both with and without the added term "plastic surgery," were performed. RESULTS: Total patents with "cardiology" outnumber those with "plastic surgery" by 22,450 versus 7749 (i.e., almost 3:1). The overwhelming number of patents with "cosmetic" are non-plastic-surgery related: 87,910 total versus 2782 for those with plastic surgery. The corresponding numbers for "wound healing" are 36,359 versus 2703. Reasons for the patent gap between clinical innovations in plastic surgery and number of patents in our field are identified. Clear steps to bridge this gap are delineated that include a step-by-step process for patenting, from idea creation through commercialization. The authors propose "breakthrough to bank," a framework wherein academic medical centers can create an environment of innovative freedom, establish the infrastructure for technological transfer of intellectual property, and generate a pipeline toward commercial applications. CONCLUSIONS: Innovation and inventions are important hallmarks for the progress of plastic surgery. Using a stepwise process, it may be possible to convert ideas into patents.

Targeted chemodenervation of the posterior belly of the digastric muscle for the management of jaw discomfort in facial synkinesis.

BACKGROUND: Botulinum toxin (BT-A) chemodenervation has been proved to significantly improve the physical and psychological well-being of patients suffering from facial synkinesis. Despite this, a cohort of patients has persistent tightness and discomfort around the angle of the jaw, which may be caused by synkinesis within the posterior belly of digastric (PBD) muscle. This study was designed to evaluate the benefits of ultrasound-guided BT-A injections into the PBD. METHODS: Thirty-three patients with recalcitrant tightness and discomfort around the angle of the jaw, despite maximal facial therapy and platysmal chemodenervation were selected for inclusion. Patients underwent ultrasound-guided BT-A injection into the ipsilateral PBD muscle (skin puncture site 1 cm inferior and posterior to the angle of mandible). Outcomes consisted of the Facial Disability Index (FDI), Synkinesis Assessment Questionnaire (SAQ), and a visual analogue scale (VAS) designed to assess tightness and pain around the PBD when moving the jaw, swallowing, and masticating. Questionnaires were completed two weeks before and postinjection. Statistical analysis was performed using a paired t-test. RESULTS: Nineteen patients completed the post-treatment outcome questionnaire. A statistically significant improvement was noted in the physical and social function aspects of the FDI and all aspects of the patient-reported VAS scores apart from tightness and pain on jaw retrusion and swallowing. There was no significant difference in the SAQ. CONCLUSION: This study has demonstrated the patient-perceived benefit of ultrasound-targeted BT-A chemodenervation of PBD. This represents a low-risk treatment option that can be easily added to the repertoire of treatments offered to patients with post paralysis facial synkinesis.

Functional and Structural Changes Following Corneal Neurotisation in the Management of Neurotrophic Keratopathy: UK Single Centre Series.

OBJECTIVE: To report the functional and anatomical outcomes including structural changes in corneal nerve density and morphology using in vivo confocal microscopy (IVCM) after corneal neurotisation in patients with neurotrophic keratopathy (NK), using a sural nerve graft. PATIENTS AND METHODS: Prospective study of patients undergoing corneal neurotisation for NK. Functional outcomes were measured through visual acuity, slit-lamp examination of corneal and conjunctival staining, tear production (Schirmer's 1 test), tear film break-up time, tear film meniscus height, quality and osmolarity, central corneal thickness and corneal sensation using Cochet-Bonnet esthesiometry. Structural outcomes were assessed from changes in corneal nerve density and morphology with IVCM. Subjective outcomes were assessed using VFQ-25 and latest telephonic consultation. RESULTS: Between February 2016 and April 2018, 11 corneal neurotisations were performed on 11 patients (3 males, 8 females). Median age was 43 (range 25-62) years. Mean follow-up was 14.5 (range, 4-36) months. Snellen visual acuity improved in 6 patients, corneal and conjunctival staining decreased in 10, tear film breakup time increased in 9, tear meniscus height increased in 7, Schirmers test readings increased in 4, tear film osmolarity reduced in 8 and central corneal thickness increased in 10 patients. Corneal sensation improved in nine patients. Complete IVCM data were available in five cases and demonstrated an improvement of corneal nerve density and length at 12 months. CONCLUSION: This series confirms the fact that the outcomes of this technique are reproducible and that corneal neurotisation surgery helps restore trophic nerve function more consistently than touch-related sensation.