A new minimally invasive, nonexcisional, surgical browlift technique with minimal scarring: a protocol for a prospective observational study.

Background: The aim of this study is to prospectively evaluate the new minimal invasive (MINE) browlift technique with possibly superior results and minimal visible scarring. Study design: A prospective observational study will be performed on all available data from patients who will undergo a browlift procedure in the HMC from 1 June 2021 till 31 May 2024. Our goal is to include at least 50 patients. Inclusion criteria are: patients with medical (i.e. brow ptosis and facial paralysis) or cosmetic indication, patients with sufficient understanding of the Dutch or English language and willingness to participate in extra study specific follow-up moments and filling in of questionnaires. Exclusion criteria are: less than 18 years of age and patients with previous brow or eyelid surgery. Patients will be photographed preoperatively and postoperatively using the VECTRA camera. Outcome measurements: Scarring after procedure; functionality of eyebrow movement; amount of correction in brow ptosis, measured in VECTRA; longevity of procedure in months; aesthetic result as assessed by questionnaires and adverse effects of procedure will be measured. Ethics and dissemination: The database management software 'Castor' will be used to store and collect the data from the questionnaire. The Medical Research Ethics Committee found this study not eligible to be submitted to the Dutch Medical Research Involving Human Subjects Acts (WMO). Written consent will be obtained from all patients.

Botulinum toxin treatment of the buccinator muscle facial synkinesis: A systematic review.

BACKGROUND: The purpose of this review is to provide an overview of the available literature assessing the treatment of botulinum toxin injections for the treatment of synkinesis of the buccinator muscle in patients with peripheral facial palsy (PFP). MATERIALS AND METHODS: A multi database search was performed, including the following databases: Pubmed, Medline, Embase, and the Cochrane Library. Each database was searched from its earliest date until 8 June 2023. The following outcome measures were extracted from the articles when available: subjective, somatic, and psychological effects on the patients and objective outcomes such as the House-Brackmann, Sunnybrook and Sydney scores. The methodological quality of the included studies was rated using the Newcastle-Ottawa scale for nonrandomised trials. RESULTS: The primary literature search generated 37 articles. After removing duplicates, 25 articles remained for abstract appraisal, of which 20 underwent full-text appraisal, resulting in 3 studies for analysis. All of these studies showed (significant) improvement in synkinesis either measured using the Synkinesis Assessment Questionnaire or subjectively measured by asking treated patients. CONCLUSION: The available literature supports the finding that botulinum toxin treatment of the buccinator muscle could be a welcome addition to facial synkinesis treatment and could significantly improve patient outcomes. In future studies, the efficacy of EMG-guided buccinator injections, optimal dose, and a validated measuring method could be beneficial in optimising treatment for patients with a PFP and synkinesis.

The surgical anatomy of the deep temporal nerve: A cadaveric study.

BACKGROUND: The aims of this study were to investigate the surgical anatomy of the deep temporal nerve (DTN) and find (fixed/static) anatomical landmarks that could be used during surgery to localise the DTN branches. METHODS: Ten hemifaces of Dutch cadavers were dissected at the Department of Anatomy of the Radboudumc. Landmarks and measurements of interest were number of branches of the DTN, distance from the tragus to the DTN, and distance from the cranial and caudal parts of the posterior root of the zygomatic bone until the DTN. RESULTS: In this cadaveric study, 10 hemifaces were dissected (male, n = 6 [60%]; female, n = 4 [40%]) with an equal left/right side division. The number of deep temporal branches varied from 2 (30%) to 3 (70%) per side. The mean distance to the tragus varied from 40 to 53 mm, with a mean distance of 44.3 ± 4.4 mm. The mean distance from the cranial part of the posterior root of the zygomatic bone to the DTN varied from 29 to 35 mm, with a mean distance of 31.3 ± 2.1 mm. The distance from the caudal part of the posterior root of the zygomatic bone to the DTN varied from 8 to 17 mm, with a mean distance of 13.4 ± 3.4 mm. CONCLUSION: This study investigated the surgical anatomy and landmarks used for identification of the DTN and its branches. It suggested using firm landmarks for nerve identification, such as the posterior root of the cranial and/or the caudal zygomatic bone.

Botulinum toxin A treatment in facial palsy synkinesis: a systematic review and meta-analysis.

BACKGROUND: Synkinesis is defined as involuntary movements accompanying by voluntary movements and can occur during the aftermath of peripheral facial palsy, causing functional, aesthetic and psychological problems in the patient. Botulinum toxin A (BTX-A) is frequently used as a safe and effective treatment; however, there is no standardized guideline for the use of BTX-A in synkinesis. The purpose of this article is to review and summarize studies about the BTX-A treatment of synkinesis in patients with a history of peripheral facial palsy; including given dosages, injection sites and time intervals between injections. MATERIALS AND METHODS: A multi-database systematic literature search was performed in October 2020 using the following databases: Pubmed, Embase, Medline, and The Cochrane Library. Two authors rated the methodological quality of the included studies independently using the 'Newcastle-Ottawa Quality Assessment Scale' for non-randomised studies' (NOS). RESULTS: Four-thousand-five-hundred-and-nineteen articles were found of which 34 studies met the inclusion criteria, in total comprising 1314 patients. Most studies were assessed to be of 'fair' to 'good' methodological quality. The Cohen's kappa (between author FJ and AS) was 0.78. Thirty-one studies investigated the reported dosage injected, 17 studies reported injection location and 17 studies investigated time intervals. A meta-analysis was performed for three studies comprising 106 patients, on the effects of BTX-A treatment on the Synkinesis Assessment Questionnaire (SAQ) scores. The mean difference was 11.599 (range 9.422-13.766), p < 0.01. However, due to inconsistent reporting of data of the included studies, no relationship with the dosage and location could be assessed. CONCLUSIONS: Many treatment strategies for synkinesis exist, consisting of varying BTX-A brands, dosages, time intervals and different injection locations. Moreover, the individual complaints are very specific, which complicates creating a standardized chemodenervation treatment protocol. The BTX-A treatment of long-term synkinesis is very individual and further studies should focus on a patient-tailored treatment instead of trying to standardize treatment.

The Predictive Power of the 14-51 Ng/L High Sensitive Troponin T (hsTnT) Values for Predicting Cardiac Revascularization in a Clinical Setting.

Background: high sensitive Troponin T (hsTnT) values between 14−50 ng/L represent a challenge in diagnosing acute coronary syndrome (ACS) at the Emergency Department (ED). The European Society for Cardiology (ESC) recommends a second hsTnT measurement 3 h later to distinguish between ACS and other causes depending on the Δ hsTnT. Our study aims to evaluate the predictive power this approach in a clinical setting by following patients presenting at the ED with hsTnT values 14−51 ng/L. Materials and methods: patients presenting with chest pain or dyspnea and a hsTnT value between 14 and 50 ng/L at the Erasmus MC ED in 2012−2013 were included and retrospectively monitored for 90 days after initial presentation for the occurrence of a cardiac revascularization. Patient records were reviewed according to the standing protocol, which depended on the Δ hsTnT. The "event-group" consists of patients receiving cardiac revascularization within 90 days after the ED visit, whereas the "no event-group" consisted of patients without revascularization. Results: a total of 889 patients patient records were reviewed. After excluding out-of-hospital-cardia-arrests (60), non-cardiological chest pain (373) and incomplete follow-up (100), 356 patients remained for final analysis. In 207 patients, a second hsTnT was actually performed (58%). From these 207 patients, 68 (33%) had a Δ hsTnT ≥7 ng/L. In these patients, 37 (54%) experienced an event within 90 days. In the 139 patients with a Δ hsTnT < 7 ng/L, 23 (17%) presented with an event within 90 days. Conclusion: our study demonstrated a sensitivity of 62%, a specificity of 79%, a positive predicted value (PPV) of 54% and a negative predictive value (NPV) of 83% for using a 3-h Δ hsTnT ≥7 ng/L cut-off, related to risk of an event in 90 days following ED presentation.

Deep temporal nerve transfer: A systematic review of anatomy, anatomical landmarks and clinical applications.

Background: Facial paralysis has a debilitating impact on facial function, especially the eyebrow. Static procedures have long been the standard treatment strategy, but in more recent years, dynamic procedures are being developed. To reconstruct the upper branches of the facial nerve (temporal and zygomatic branches), the deep temporal nerve (DTN) and its branches, with its close proximity to the eyebrow, can be used as a possible donor nerve for reinnervation. This systematic review provides an overview of the DTN anatomy and possible surgical treatment strategies. Materials and methods: A PubMed systematic literature search was performed in October 2021. Studies on cadavers and clinical studies providing anatomical or surgical information on the dissection of the DTN as well as surgical treatment strategies using the DTN were included. Results: The literature search produced 311 results, including 36 duplicates. After screening on title and abstract, 11 studies were found possibly relevant and underwent a full-text critical appraisal, resulting in 4 exclusions. In total seven studies were included. The data gathered were used to adequately describe the DTN anatomy, surgical approaches and landmarks used during surgery. Conclusion: The DTN and its branches prove to be a viable donor for the reconstruction of facial nerve branches, since the location and anatomical consistency can be relied upon through a multitude of studies, especially of the middle branch. Our study describes anatomy and nerve characteristics for its use in facial reanimation.

Psychological counselling in patients with a peripheral facial palsy: initial experience from an expert centre.

BACKGROUND: The aims of this pilot study were to evaluate the psychologist's role on the multidisciplinary team during peripheral facial palsy (PFP) patient care and to identify the potential predictors of anxiety and depressive symptoms/disorders in PFP patients. METHODS: Using the prospective non-controlled study design, PFP patients aged 18-75 years who presented to the Radboud Facial Palsy Expert Centre, the Netherlands, were enrolled during a 1-year interval. The main outcome variables were 1) anxiety and depression in relation to PFP using the Hospital Anxiety and Depression Scale (HADS) and 2) the outcome of psychological counselling in patients with a HADS score ≥ 8. RESULTS: A sample comprised 25 patients (68% females, 56% right-side PFP, 16% House-Brackmann scale I-II) with a mean age of 50 ± 14 years were referred to a psychologist. The proportion of patients with a HADS score ≥8, were 16 (64%) and 13 (52%), respectively. Especially, coping (in general or coping with the disease, 48%) and/or help with the choice of possible surgery (8.0%) were important reasons for counselling. In one case, a patient had chronic fatigue syndrome and was therefore referred to a psychological specialist centre. One patient was treated with acceptance and commitment therapy (ACT) with good results. CONCLUSIONS: Despite a small sample size and limited statistical analyses, the results of this study suggest that one-eighth of the PFP patients require psychological evaluation and treatments. This pilot study emphasises the important role of psychological screening and counselling in PFP patient care.

The effects of glucagon like peptide-1 (GLP-1) on cardiac remodeling: exploring the role of medication and physiological modulation after metabolic surgery.

Obesity and associated comorbidities reach epidemic proportions nowadays. Several treatment strategies exist, but bariatric surgery has the only longstanding effects. Since a few years, there is increasing interest in the effects of gastro-intestinal hormones, in particular Glucagon-Like Peptide-1 (GLP-1) on the remission of Type 2 Diabetes (T2DM) and its effects on cardiac cardiovascular morbidity, cardiac remodeling, and mortality. In the past years several high quality multicenter randomized controlled trials were developed to assess the effects of GLP-1 receptor agonist therapy on cardiovascular morbidity and mortality. Most of the trials were designed and powered as non-inferiority trials to demonstrate cardiovascular safety. Most of these trials show a reduction in cardiovascular morbidity in patients with T2DM. Some follow-up studies indicate potential beneficial effects of GLP-1 receptor agonists on cardiovascular function in patients with heart failure, however the results are contradictory, and we need long-term studies to make firm conclusions about the pleiotropic properties of incretin-based therapies. However, it seems that GLP-1 receptor agonists have different effects than the increased GLP-1 production after bariatric surgery on cardiovascular remodeling. One of the hypotheses is that the blood concentrations of GLP-1 receptor agonists are three times higher compared to GLP-1 increase after bariatric and metabolic surgery. The purpose of this narrative review is to summarize the effects of GLP-1 on cardiovascular morbidity, mortality and remodeling due to medication but also due to bariatric and metabolic surgery. The second objective is to explain the possible differences in effects of GLP-1 agonists and bariatric and metabolic surgery.

Association between duration of peripheral facial palsy, severity, and age of the patient, and psychological distress.

BACKGROUND: Peripheral facial palsy (PFP) (paralysis) can be a devastating condition that has been shown to have associations with increased depression and worse quality of life. The aim of the present study is to better understand the complex association of psychological distress with the duration, severity, and age of patients with PFP. We hypothesize that a shorter duration of PFP is associated with higher levels of psychological distress. METHODS: Fifty-nine patients with PFP that existed longer than 3 months were included in this study. The Hospital Anxiety and Depression Scale (HADS) was used to assess the presence and severity of anxiety and depressions. Spearman's correlation analysis was used to determine correlation between psychological distress, duration, severity of the PFP, and age. RESULTS: Fifty-nine patients were included in this study, of whom 22 were male and 37 were female. The mean age was 55.6 ±â€¯14.6 years and mean duration of PFP from onset ranged from 3 months to 35 years (with a mean duration of 5.39 ±â€¯6.06 years). Twenty-eight patients had left-sided PFP, 30 patients had right-sided PFP, and one patient had bilateral PFP. The majority were caused by Bell's palsy (50.8%). In the group with a duration less than 5 years, there were five (12.8%) patients having a score between 11 and 15 (on HADS) compared to two (10%) patients in the group with a duration of 5 years or more(p = 0.04). CONCLUSION: There seems to be an association between moderate depression and duration of the PFP. Further studies need to substantiate our findings.

Cosmetic appreciation and emotional processing in patients with a peripheral facial palsy: A systematic review.

Background; The goal of this review is 1) to summarize the studies assessing PFP by casual observers, patients themselves and the cosmetic appreciation of the PFP and 2) to summarize the studies assessing whether there is a difference in emotional recognition/processing of facial emotions and/or cognitive tasks in patients with a PFP. Materials and Methods; A multi-database systematic literature search was performed using the following databases: Pubmed, Embase, Medline, and The Cochrane Library from the earliest date of each database up to December 2019. Population of interest consisted of patients with a PFP and studies that investigated cosmetic appreciation and/or emotional recognition and/or emotional processing in these patients. Two authors rated the methodological quality of the included studies independently using the 'Newcastle - Ottawa Quality Assessment Scale' for nonrandomised studies' (NOS). Two authors extracted the outcome data regarding cosmetic appreciation and/or emotional recognition/processing from the included studies. Results; Twelve hundred and thirty-two studies were found of which eleven studies met the inclusion criteria. Most studies were assessed to be of 'fair' to 'good' methodological quality. The Cohen's kappa (between author RL and SP) was 0.68. Two studies investigated emotional processing and/or emotional recognition. Nine studies investigated cosmetic appreciation in both patients and casual observers. Important findings of this systematic review are that there is a correlation between the perceived severity of the PFP of the patients and the ratings by casual observers. Secondly there seems to be a laterality difference in cosmetic appreciation and thirdly there might to be a decreased emotional recognition and processing in patients with a PFP. Conclusion; Emotional recognition and cosmetic appreciation in patients with a PFP is an under investigated area, in which further studies are needed to substantiate the findings in current literature.

Effects of Bariatric Surgery on Heart Rhythm Disorders: a Systematic Review and Meta-Analysis.

The aim of this systematic review is to provide an overview of the literature on the effects of bariatric surgery on obesity-associated electrocardiogram (ECG) abnormalities and cardiac arrhythmias. Fourteen studies were included with a methodological quality ranging from poor to good. Majority of the studies showed a significant decrease of QT interval and related measures after bariatric surgery. Seven studies were included in the meta-analysis on effects of bariatric surgery on QTc interval and a significant decrease in QTc interval of - 33.6 ms, 95%CI [- 49.8 to - 17.4] was seen. Bariatric surgery results in significant decrease in QTc interval and P-wave dispersion, i.e., a normalization of initial pathology. The effects on atrial fibrillation are conflicting and not yet fully understood.

e-Health and telemedicine implementation in facial paralysis: challenges and pitfalls.

During the current Covid-19 pandemic, a lot of changes had to be made in the care of patients with facial nerve paralysis (FNP). FNP is a life-changing condition with effects on both physical (both esthetic and functional) and psychological aspects of the patient's life. Telemedicine could be a suitable alternative in the therapy for these patients, since it is often not possible to travel to outpatient clinics or to have normal face-to-face appointments with treating physicians because of pandemic restrictions. This review provides an overview of the current literature in the treatment of FNP during the pandemic and the role of telemedicine/e-Health. Secondly, we will discuss the challenges and pitfalls of implementing e-Health and telemedicine applications in clinical practice. Level of evidence: Not ratable.

A closer look at the paralyzed face; a narrative review of the neurobiological basis for functional and aesthetic appreciation between patients with a left and a right peripheral facial palsy.

BACKGROUND: The facial nerve or n. facialis (NVII) is the seventh cranial nerve and it is responsible for the innervation of the mimic muscles, the gustatory organ, and the secretomotor function to the salivary, lacrimal, nasal and palatine glands. Clinical presentation of Facial Palsy (FP) is characterized by unilateral facial asymmetry and may present with a change in taste, decreased saliva production, and dysarthria. A facial palsy has a notable effect on the facial appreciation by both the patient and the environment and also affects quality of life and emotional processing. There appear to be differences in the appreciation of people with a left and right facial palsy. PURPOSE OF THIS REVIEW: The purpose of the review is to give an overview of the anatomy of the facial nerve, neuro-anatomy of face processing, and hemispheric specialization and lateralization. Further,an overview is given of the clinical studies that translated the neuro-anatomical and neurobiological basis of these concepts into clinical studies. What this review adds: This review emphasizes the neurobiological evidence of differences in face processing between the left and right cerebral hemisphere, wherein it seems that the right hemisphere is superior in emotional processing. Several theories are proposed; 1) a familiarity hypothesis and 2) a left-right hemispheric specialization hypothesis. In clinical studies, promising evidence might indicate that, in patients with FP, there is indeed a difference in how left and right FP are perceived. This might give differences in decreased quality of life and finally in occurrence of depression. Further research must aim to substantiate these findings and determine the need for altering the standard therapeutic advice given to patients.

Development and psychometric evaluation of a Dutch-translated shorter Breast Cancer Treatment Outcome Scale (Dutch BCTOS-13).

PURPOSE: To create a Dutch translated short version of the Breast Cancer Treatment Outcome Scale (BCTOS) and validate it in patients who have completed both breast conserving surgery and adjuvant radiotherapy. METHODS: The BCTOS consists of items comparing the treated with the untreated breast. After forward and backward translation, we tested the BCTOS-12 plus 5 additional items. Two-hundred breast cancer patients treated with breast conserving therapy (BCT) between January 2016 and December 2017, were asked to complete the BCTOS items twice with a 2 week interval. The EORTC QLQ-BR23 breast and arm symptoms subscales were completed once in parallel. Feasibility was assessed by missing or non-unique answer rates and content validity with floor and ceiling effect analysis. Construct validity was evaluated with 1) principal component analysis (PCA) 2) convergent validity and 3) known groups comparison (clinical validity differentiating between patients with and without locoregional side effects). From all potential items with good feasibility, content and construct validity, items were selected for the Dutch BCTOS based on clinical validity. The relation to the EORTC QLQ-BR23 subscales and reliability was tested for the new Dutch BCTOS. RESULTS: Hundred and one of 200 (50.5%) approached patients participated in this study, with follow-up after surgery ranging from 5 to 29 months. Feasibility was high (1.5% missing answers). Content validity testing showed a floor effect > 20% in all 17 items. PCA showed that all items loaded well (> 0.4) into the assigned subscale and revealed two distinct subscales: cosmesis and function. Based on clinical validity, item "breast shape" was replaced by "breast elevation/position" and "overall skin appearance". Very good clinical validity (Cohen's d = 1.38) was found for the new Dutch BCTOS-13. Correlation to the EORTC QLQ-BR23 subscales was high (ICC = 0.65-0.85) for both subscales. Test-retest reliability (Cohen's d = 0.105) and internal consistency (Cronbach's α =0.90) were excellent. CONCLUSIONS: Psychometric evaluation of a newly developed Dutch BCTOS-13 questionnaire in BCT patients showed excellent results, that were slightly better than the original BCTOS-22 and the shortened BCTOS-12. The good clinical validity makes the BCTOS-13 a useful tool to identify patients with unfavourable cosmetic and functional outcomes, requiring specific attention.