Temporal Development of Depression and Anxiety in a Large Facial Palsy Cohort.

INTRODUCTION: Diagnosis with facial palsy (FP) has been linked to increased psychosocial distress and communication disorders, but limited data exists on the temporal development of depression and anxiety after diagnosis. In a large cohort of FP patients, we characterize the rates of depression and anxiety at several time points post-FP diagnosis. METHODS: A de-identified database of all FP patients who presented to a single healthcare system over 22 years was created using Epic SlicerDicer. Demographics and comorbidities were collected and depression and anxiety diagnosis rates at three timepoints (non-inclusive lower bounds) post-FP diagnosis were examined. RESULTS: 3,910 FP patients were identified, with a median age of 59. 56% were female and 51% were white. At 0-6, 6-12-, and 12-36-months post-FP diagnosis, 156 (4%), 58 (1.4%), and 205 (5.2%) individuals were diagnosed with depression, and 171 (4.4%), 84 (2.1%), and 237 (6.1 %) were diagnosed with anxiety. At each time point, the median time between FP and depression diagnosis (2.1, 3.4, and 11.4 months) or anxiety diagnosis (2.5, 4.0, and 11.1 months) was similar. Dual depression and anxiety diagnoses were observed in 52 (1.3%), 32 (0.8%), and 122 (3.1%) patients at each time point. Compared to the overall cohort, more patients with anxiety were female (65% vs. 56%, p < 0.001) and younger (57 vs. 59, p=0.002), and more depressed patients were Black (7.3% vs. 3.3%, p=0.02). CONCLUSIONS: Facial palsy may lead to increased risk of depression and/or anxiety in the first year after diagnosis as demonstrated here in one of the largest FP cohorts to date. We report high rates of depression (5.5%), anxiety (6.5%), and comorbid depression and anxiety (2.1%) occurring within 1 year after FP diagnosis. Of these, the majority occurred within the first 6 months (72%, 67%, 62%, respectively). Anxiety was more common in young female patients and depression more common in Black patients, which can inform targeted mental health resources within the first 6 months post-FP diagnosis.

The Rate of Occult Lesion Diagnosis in a Large Bell's Palsy Cohort.

OBJECTIVES: We characterize occult lesion diagnosis rates after initial Bell's palsy diagnoses. METHODS: A de-identified database of all facial palsy patients who presented to an extensive health care system across 22 years was created using Epic SlicerDicer. Among patients with Bell's palsy diagnoses, we extracted demographic and any subsequent occult lesion diagnosis data across various clinical sites. Descriptive and multivariable regression analyses comparing patients with occult lesion diagnoses made at different time points were included. RESULTS: Among the total 3912 facial palsy patients, 2240 had Bell's palsy diagnoses, of which 217 (9.7%) had subsequent lesion diagnoses at a median (IQR) of 12.3 (4.2, 23.8) months, consisting of cranial nerve neoplasms (62.2%), parotid gland neoplasms (34.1%), and cholesteatomas (3.7%). Although a large proportion of total lesions were diagnosed within the first 3 months (19.8%), 69.5% were diagnosed after 6 months. There were no demographic differences among patients diagnosed with different lesion types, but Asian patients were more likely to be diagnosed with occult lesions after 12 months after Bell's palsy diagnosis compared with white patients (odds ratio = 6.2, p = 0.001). CONCLUSIONS: In one of the largest Bell's palsy cohorts to date, we identified a 9.7% occult lesion diagnosis rate at a median of 12.3 months after Bell's palsy diagnosis. These data underscore the importance of timely workup for occult lesions in cases of facial palsy with no signs of recovery after 3-4 months. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:911-918, 2024.

Freeing the Animal Model: A Modular, Wirelessly Powered, Implantable Electronic Platform.

SUMMARY: Fully implantable electronic devices in freely roaming animal models are useful in biomedical research, but their development is prohibitively resource intensive for many laboratories. The advent of miniaturized microcontrollers with onboard wireless data exchange capabilities has enabled cost-efficient development of myriad do-it-yourself electronic devices that are easily customizable with open-source software ( https://www.arduino.cc/ ). Likewise, the global proliferation of mobile devices has led to the development of low-cost miniaturized wireless power technology. The authors present a low-cost, rechargeable, and fully implantable electronic device comprising a commercially available, open-source, wirelessly powered microcontroller that is readily customizable with myriad readily available miniature sensors and actuators. The authors demonstrate the utility of this platform for chronic nerve stimulation in the freely roaming rat with intermittent wireless charging over 4 weeks. Device assembly was achieved within 2 hours and necessitated only basic soldering equipment. Component costs totaled $115 per device. Wireless data transfer and wireless recharging of device batteries was achieved within 30 minutes, and no harmful heat generation occurred during charging or discharging cycles, as measured by external thermography and internal device temperature monitoring. Wireless communication enabled triggered cathodic pulse stimulation of the facial nerve at various user-selected programmed frequencies (1, 5, and 10 Hz) for periods of 4 weeks or longer. This implantable electronic platform could be further miniaturized and expanded to study a vast array of biomedical research questions in live animal models. CLINICAL RELEVANCE STATEMENT: The clinical relevance of electrical stimulation in neural recovery remains controversial, and long-term neural stimulation in small animal models is challenging. We have developed a low-cost, fully implantable, wirelessly powered nerve stimulation device to facilitate further research in nerve stimulation in animal models.

Race and sex demographics in the surgical management of facial nerve palsy.

Objective: Facial palsy affects patients of all backgrounds, yet no existing studies describe differences in its treatment patterns between demographic groups. Methods: We used the National Surgical Quality Improvement Project database to investigate whether race and sex disparities exist in facial reanimation surgery. Patients were identified using CPT codes corresponding to facial-nerve procedures. Results: Seven hundred sixty-one patients met criteria; 681 self-identified as White (89.5%), 51 as Black (6.7%), 43 as Hispanic (5.6%), 23 as Asian (3.0%), and 5 patients as other (0.61%). White patients were more than twice as likely to undergo brow ptosis repair than Non-White patients (OR 2.49, 95% CI 1.16-6.15, p = .03). After controlling for malignancy, men had longer operative times than women (480.2 vs. 413.9 min, p = .04) and higher likelihood of free tissue transfer (OR 4.1, 95% CI 1.9-9.8), fascial free tissue transfer (OR 10.7, 95% CI 2.1-195), and ectropion repair (OR 1.8, 95% CI 1.2-2.8). Conclusion: Most patients undergoing facial reanimation surgery in the United States are White. Men have longer operative times and a higher likelihood of undergoing free fascial grafts and cutaneous and fascial free tissue transfer than women regardless of malignancy status. Level of Evidence: 2c.

Reducing Risk in Facial Reanimation Surgery.

Facial reanimation surgery can greatly improve quality of life, but these procedures are not without risk. Important considerations for risk reduction in facial reanimation surgery include preoperative risk-stratification, protecting patients' clinical media, clearly and thoroughly setting expectations, and intraoperative strategies to maximize technical success and minimize operative time.

Commentary on: "Tri-Vector Gracilis Microneurovascular Free Tissue Transfer with Periocular Component to Achieve a Duchenne Smile in Patients with Facial Paralysis" by Byrne et al.

In this commentary, we review Dr. Byrne and colleagues' article "Tri-vector Gracilis Microneurovascular Free Tissue Transfer with Periocular Component to Achieve a Duchenne Smile in Patients with Facial Paralysis." The authors successfully demonstrate the feasibility of separating the gracilis muscle into three bellies while maintaining neuromuscular input to achieve restoration of lower lid movement during smile, resulting in a more natural appearing or "Duchenne smile." Although the concept of spontaneity remains controversial, beautiful smile outcomes are illustrated in the featured photograph and videos.

The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?

Introduction: During a two-stage free gracilis muscle transfer (FGMT) to restore smile to patients with facial paralysis, some surgeons assess nerve regeneration through the cross-face nerve graft (CFNG) with the Tinel sign and a nerve biopsy. Objective: To test whether ultimate smile reanimation outcomes are correlated with (1) the Tinel sign or (2) myelinated axons of the biopsied CFNG at the time of FGMT. Methods: Retrospective case series was performed at a tertiary care facial nerve center. Dynamic smile outcomes were quantified with Emotrics analysis of pre- and postoperative photographs. Results: Of the 113 FGMT surgeries by CFNG performed since 2002, 92 patients had pre- and postoperative photo-documentation. Most patients (89%, N = 82) had a positive Tinel sign at the time of FGMT; however, 14 patients with positive Tinel signs were deemed failures. Interestingly, 4 patients with a negative Tinel sign went on to have successful dynamic outcomes and 16 patients lacking myelinated axons in their CFNG biopsy ultimately achieved successful smile outcomes. Conclusion: Although the majority of patients had a positive Tinel sign and myelinated axons in the CFNG at the time of FGMT, the presence or absence of either factor did not predict ultimate smile outcome in this series.

Facial Palsy, Radiographic and Other Workup Negative: FROWN.

OBJECTIVES: Slow-onset peripheral facial palsy is far less common than acute-onset peripheral facial palsy and necessitates diagnostic evaluation for benign or malignant tumors or other less common etiologies. In the rare scenario in which no clarifying etiology is discovered following long-term evaluation (no radiographic or hematologic abnormalities and an otherwise unremarkable evaluation), a diagnostic and management dilemma occurs. We present a series of patients with this possible new clinical entity: Facial palsy, Radiographic and Other Workup Negative (FROWN) and propose a management strategy for this diagnosis of exclusion. METHODS: A series of 3,849 patients presenting with facial palsy to a tertiary facial nerve center was retrospectively assessed to identify those with progressive loss of facial function over at least 1 month. Exclusion criteria were history, physical or hematologic findings indicative of known diseases associated with facial palsy, and radiographic studies demonstrating a benign or malignant tumor. RESULTS: Patients with slow-onset facial palsy constituted 5% (190 patients) of the cohort and were ultimately diagnosed with either a benign or malignant neoplasm or other facial nerve pathology. Fourteen patients with slow-onset facial palsy remained without a diagnosis following long-term evaluation and serial imaging. Eleven patients underwent dynamic facial reanimation surgery and facial nerve and muscle biopsy, with no clear histopathologic diagnosis. CONCLUSION: Patients with slow-onset facial palsy with negative radiographic and medical evaluations over several years may be characterized as having FROWN, an idiopathic and as yet poorly understood condition, which appears to be amenable to facial reanimation but requires further investigation as to its pathophysiology.

Advances in facial nerve management in the head and neck cancer patient.

PURPOSE OF REVIEW: The purpose of this review is to summarize best practices in facial nerve management for patients with head and neck cancer. In addition, we provide a review of recent literature on novel innovations and techniques in facial reanimation surgery. RECENT FINDINGS: Although recommended when tumor ablation surgery requires facial nerve sacrifice, facial reanimation procedures are not always performed. Concurrent dynamic facial reanimation with masseteric nerve transfers and cable graft repair can preserve native facial muscle function. Static suspension can provide facial support and immediate resting symmetry for patients. Eyelid weight and eye care should not be delayed, particularly in patients with trigeminal sensory deficits. Choice of neural source to innervate a gracilis-free muscle transfer for smile reanimation remains controversial; however, new techniques, such as dual innervation and multivector muscle transfer, may improve aesthetic and functional outcomes. SUMMARY: Management of the facial nerve in the setting of head and neck cancer presents unique challenges. When possible, simultaneous oncologic resection and facial reanimation is ideal given the open surgical field, newly dissected and electrically stimulatable facial nerve branches, as well as minimizing postoperative healing time to prevent postsurgical treatment delays. A coordinated approach to facial nerve management with a multidisciplinary surgical team may help provide optimal, comprehensive care.

Facial Clinimetric Evaluation Scale and Synkinesis Assessment Questionnaire Translation into Brazilian Portuguese: A Validation Study

Abstract Introduction Facial nerve palsy results in both functional disability and psychological morbidity. There are several well-established grading scales to quantify the quality of life of these patients. Objective Translate and validate the Facial Clinimetric Evaluation (FaCE) scale and Synkinesis Assessment Questionnaire (SAQ) to Brazilian Portuguese. Methods This study adopted a forward-backward translation method and performed cross-cultural adaptation. A pilot study was conducted to correct any confusing language and to evaluate content validity. A validation study was then performed. Internal consistency of the Brazilian Portuguese version of the FaCE and SAQ items was evaluated by Cronbach's alpha coefficient. Construct validity was assessed by Spear- man's Rank Correlation Coefficient between FaCE and SAQ scores to eFACE, House- Brackmann, Short Form 12 (SF-12) and Facial Disability Index (FDI) (sub)scores. Results A total of 90 patients were included. Cronbach's alpha for total domain scored 0.881 for FaCE and 0.809 for SAQ. FaCE total score correlation to eFACE total and House- Brackmann showed Spearman's r value of 0.537 and -0.538, respectively (p < 0.001). SAQ correlation to eFACE synkinesis subdomain was -0.449 (p < 0.001). No correlation was found between SAQ and HB score. FaCE total score correlations were of 0.301 and 0.547 for SF-12 PCS and MCS, respectively (p < 0.001). Correlation between FaCE total and FDI Physical and Social/well-being functions were 0.498 and 0.567 (p < 0.001). Conclusion Brazilian Portuguese FaCE scale and SAQ versions achieved high validity and reliability in the present study. These translated instruments demonstrated good psychometric properties, being proper to use in clinical practice in Brazil and with Brazilian Portuguese speakers.

Facial Clinimetric Evaluation Scale and Synkinesis Assessment Questionnaire Translation into Brazilian Portuguese: A Validation Study.

Introduction Facial nerve palsy results in both functional disability and psychological morbidity. There are several well-established grading scales to quantify the quality of life of these patients. Objective Translate and validate the Facial Clinimetric Evaluation (FaCE) scale and Synkinesis Assessment Questionnaire (SAQ) to Brazilian Portuguese. Methods This study adopted a forward-backward translation method and performed cross-cultural adaptation. A pilot study was conducted to correct any confusing language and to evaluate content validity. A validation study was then performed. Internal consistency of the Brazilian Portuguese version of the FaCE and SAQ items was evaluated by Cronbach's alpha coefficient. Construct validity was assessed by Spearman's Rank Correlation Coefficient between FaCE and SAQ scores to eFACE, House-Brackmann, Short Form 12 (SF-12) and Facial Disability Index (FDI) (sub)scores. Results A total of 90 patients were included. Cronbach's alpha for total domain scored 0.881 for FaCE and 0.809 for SAQ. FaCE total score correlation to eFACE total and House-Brackmann showed Spearman's r value of 0.537 and -0.538, respectively ( p < 0.001). SAQ correlation to eFACE synkinesis subdomain was -0.449 ( p < 0.001). No correlation was found between SAQ and HB score. FaCE total score correlations were of 0.301 and 0.547 for SF-12 PCS and MCS, respectively ( p < 0.001). Correlation between FaCE total and FDI Physical and Social/well-being functions were 0.498 and 0.567 ( p < 0.001). Conclusion Brazilian Portuguese FaCE scale and SAQ versions achieved high validity and reliability in the present study. These translated instruments demonstrated good psychometric properties, being proper to use in clinical practice in Brazil and with Brazilian Portuguese speakers.

Polytetrafluoroethylene granuloma-associated facial palsy following microvascular decompression.

OBJECTIVE: Microvascular decompression (MVD) may be employed in the management of hemifacial spasm (HFS), wherein a pledget of polytetrafluoroethylene (i.e., Teflon, Chemours, Wilmington DE) is sometimes introduced to separate an offending vessel from the cisternal segment of facial nerve. Rarely, Teflon may cause a granulomatous reaction resulting in nerve palsy. We here present the first case series of facial palsy thought to be secondary to Teflon granuloma following MVD for HFS. METHODS: A data repository of 1,312 patients with facial palsy was reviewed to identify individuals who had previously undergone MVD for HFS. Data collected include age at time of MVD, age at onset of facial weakness and at presentation, House-Brackmann scores, clinician-graded facial function using the Electronic Facial Paralysis Assessment scale, imaging findings, and therapeutic interventions and outcomes. RESULTS: Six patients meeting criteria were identified. Average time between MVD with Teflon placement and onset of facial weakness was 16.1 (±4.9) years (range 9.3-23.3 years). Initial House-Brackmann scores were as follows: four patients with V/VI and one each with III/VI and IV/VI. Interventions included eyelid weight placement (n = 3), chemodenervation (n = 2), static suspension with tensor fascia latae (n = 2), dynamic reanimation with cranial nerves V to VII transfer (n = 1), and temporalis muscle transfer (n = 1). CONCLUSION: Teflon granuloma should be considered in the differential diagnosis for patients presenting with new onset facial weakness with a previous history of MVD for HFS. It remains unknown whether early granuloma extirpation is effective. Prompt diagnosis allows consideration of time-sensitive nerve transfer procedures to reanimate facial function. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1422-1427, 2020.

The spectrum of facial palsy: The MEEI facial palsy photo and video standard set.

OBJECTIVES: Facial palsy causes variable facial disfigurement ranging from subtle asymmetry to crippling deformity. There is no existing standard database to serve as a resource for facial palsy education and research. We present a standardized set of facial photographs and videos representing the entire spectrum of flaccid and nonflaccid (aberrantly regenerated or synkinetic) facial palsy. To demonstrate the utility of the dataset, we describe the relationship between level of facial function and perceived emotion expression as determined by an automated emotion detection, machine learning-based algorithm. METHODS: Photographs and videos of patients with both flaccid and nonflaccid facial palsy were prospectively gathered. The degree of facial palsy was quantified using eFACE, House-Brackmann, and Sunnybrook scales. Perceived emotion during a standard video of facial movements was determined using an automated, machine learning algorithm. RESULTS: Sixty participants were enrolled and categorized by eFACE score across the range of facial function. Patients with complete flaccid facial palsy (eFACE <60) had a significant loss of perceived joy compared to the nonflaccid and normal groups. Additionally, patients with only moderate flaccid and nonflaccid facial palsy had a significant increase in perceived negative emotion (contempt) when compared to the normal group. CONCLUSION: We provide this open-source database to assist in comparing current and future scales of facial function as well as facilitate comprehensive investigation of the entire spectrum of facial palsy. The automated machine learning-based algorithm detected negative emotions at moderate levels of facial palsy and suggested a threshold severity of flaccid facial palsy beyond which joy was not perceived. LEVEL OF EVIDENCE: NA Laryngoscope, 130:32-37, 2020.

Clinician and Automated Assessments of Facial Function Following Eyelid Weight Placement.

IMPORTANCE: Quantitative assessment of facial function is difficult, and historic grading scales such as House-Brackmann have well-recognized limitations. The electronic, clinician-graded facial function scale (eFACE) allows rapid regional analysis of static, dynamic, and synkinetic facial function in patients with unilateral facial palsy within the course of a clinical encounter, but it relies on clinician assessment. A newly developed, machine-learning algorithm (Emotrics) provides automated, objective facial measurements but lacks clinical input (ie, recognizing laterality of facial palsy or synkinesis). OBJECTIVES: To compare the sensitivity of a clinician-based tool (eFACE) to a well-established intervention for facial palsy (eyelid weight placement) with an automated facial-measurement algorithm (Emotrics). DESIGN, SETTING, AND PARTICIPANTS: A retrospective review was conducted of the most recent 53 patients with unilateral facial palsy who received an eyelid weight at the Massachusetts Eye and Ear Infirmary Facial Nerve Center from 2014 to 2017. Preoperative and postoperative photographs were deidentified and randomized. The entire cohort was analyzed by 3 clinicians, as well as by the Emotrics program. MAIN OUTCOMES AND MEASURES: eFACE scores of the palpebral fissure at rest (0, wide; 100, balanced; 200, narrow), with gentle eyelid closure (0, incomplete; 100, complete), and with forceful eyelid closure (0, incomplete; 100, complete) before and after eyelid weight placement were compared with palpebral fissure measurements by Emotrics. RESULTS: Of the 53 participants, 33 were women, and mean (SD) age was 44.7 (18) years. The mean (SD) eFACE scores and Emotrics measurements (in millimeters) before vs after eyelid weight placement of the palpebral fissure at rest (eFACE, 84.3 [15.9] vs 109.7 [21.4]; Emotrics, 10.3 [2.2] vs 9.1 [1.8]), with gentle eyelid closure (eFACE, 65.9 [28.0] vs 92.1 [15.4]; Emotrics, 4.4 [2.7] vs 1.3 [2.0]), and with forceful eyelid closure (eFACE, 75.1 [28.6] vs 97.0 [10.7]; Emotrics, 3.0 [3.1] vs 0.5 [1.3]) all significantly improved. Subgroup analysis of patients with expected recovery (eg, Bell palsy) (n = 40) demonstrated significant development of ocular synkinesis on eFACE (83.9 [22.7] vs 98.9 [4.4]) after weight placement, which could also explain the improvement in eyelid function. The scores of patients with no expected recovery (n = 13) improved in both eFACE and Emotrics analysis following eyelid weight placement, though results did not reach significance, likely limited by the small subgroup size. CONCLUSIONS AND RELEVANCE: The eFACE tool agrees well with automated, objective facial measurements using a machine-learning based algorithm such as Emotrics. The eFACE tool is sensitive to spontaneous recovery and surgical intervention, and may be used for rapid regional facial function assessment from a clinician's perspective following recovery and/or surgical intervention. LEVEL OF EVIDENCE: 4.

Long-Term Outcomes of Free Gracilis Muscle Transfer for Smile Reanimation in Children.

OBJECTIVE: To evaluate long-term outcomes of free gracilis muscle transfer (FGMT) for smile reanimation on smile excursion, facial symmetry, and quality of life in a cohort of children with facial palsy. STUDY DESIGN: A retrospective analysis of 40 pediatric patients who underwent FGMT for facial palsy at the Massachusetts Eye and Ear Infirmary Facial Nerve Center was performed. Preoperative and postoperative photography and videography were used to quantify smile excursion and facial symmetry. Preoperative and postoperative quality of life was assessed with the Facial Clinimetric Evaluation (FaCE) survey, a validated, patient-based instrument for evaluating facial impairment and disability. RESULTS: Of the 40 patients who underwent FGMT for facial palsy, 38 patients had complete data including preoperative and postoperative photography and videography from 3 months to 10 years following surgery; 13 cases had >5 years of follow-up. FGMT resulted in significant improvements in smile excursion within several months, with continued improvements in smile excursion and symmetry demonstrated more than 5 years later. Fifteen patients completed preoperative and postoperative FaCE surveys, which demonstrated significant improvement in quality of life scores following FGMT. CONCLUSIONS: FGMT significantly improves smile, facial asymmetry, and quality of life for years after this surgery for facial palsy.

Surgical Refinement Following Free Gracilis Transfer for Smile Reanimation.

IMPORTANCE: Gracilis free muscle transfer is widely regarded as the gold standard functional smile reanimation in long-standing facial palsy. Although most patients achieve meaningful oral commissure movement, a subset has suboptimal aesthetic outcomes due to midfacial bulk or oral commissure malposition. Safe refinements that do not compromise excursion would be a welcome addition to the surgical armamentarium for this population. OBJECTIVES: The goal of this study was to describe surgical approaches to the 3 most common postoperative sequelae that detract from the final result after gracilis facial reanimation and to examine how these surgical refinements affect aesthetic outcome, smile excursion, and quality of life. DESIGN: This was a retrospective case series. SETTING: Tertiary care center (Massachusetts Eye and Ear Infirmary Facial Nerve Center). PARTICIPANTS: Of 260 gracilis transfers performed since 2003, meaningful excursion (>3 mm) but poor aesthetic outcome requiring additional surgery was noted in 21 patients and was related either to excess muscle bulk (9), resting inferior malposition of the oral commissure (9), or resting superior/lateral malposition of the oral commissure (3). INTERVENTION: Specific surgical interventions to address each of these negative sequelae were developed and refined, to preserve muscle functionality but eliminate the unsightly feature. MAIN OUTCOME: Aesthetic status, determined by midfacial symmetry; quantitative smile excursion; and quality of life (using the FaCE instrument) were measured before and after revision. RESULTS: Patients who underwent gracilis refinement directed at either muscle debulking, or gracilis tightening or loosening experienced significantly improved aesthetics/midfacial symmetry and improved quality of life with no significant decrease in smile excursion. CONCLUSIONS: Improved aesthetics and quality of life can be achieved through targeted revision of the gracilis free tissue transfer, without significant loss of smile excursion.

Electrophysiological assessment of a peptide amphiphile nanofiber nerve graft for facial nerve repair.

Facial nerve injury can cause severe long-term physical and psychological morbidity. There are limited repair options for an acutely transected facial nerve not amenable to primary neurorrhaphy. We hypothesize that a peptide amphiphile nanofiber neurograft may provide the nanostructure necessary to guide organized neural regeneration. Five experimental groups were compared, animals with (1) an intact nerve, (2) following resection of a nerve segment, and following resection and immediate repair with either a (3) autograft (using the resected nerve segment), (4) neurograft, or (5) empty conduit. The buccal branch of the rat facial nerve was directly stimulated with charge balanced biphasic electrical current pulses at different current amplitudes whereas nerve compound action potentials (nCAPs) and electromygraphic responses were recorded. After 8 weeks, the proximal buccal branch was surgically reexposed and electrically evoked nCAPs were recorded for groups 1-5. As expected, the intact nerves required significantly lower current amplitudes to evoke an nCAP than those repaired with the neurograft and autograft nerves. For other electrophysiologic parameters such as latency and maximum nCAP, there was no significant difference between the intact, autograft, and neurograft groups. The resected group had variable responses to electrical stimulation, and the empty tube group was electrically silent. Immunohistochemical analysis and transmission electron microscopy confirmed myelinated neural regeneration. This study demonstrates that the neuroregenerative capability of peptide amphiphile nanofiber neurografts is similar to the current clinical gold standard method of repair and holds potential as an off-the-shelf solution for facial reanimation and potentially peripheral nerve repair.

The Protean Neuropsychiatric and Vestibuloauditory Manifestations of Neurosarcoidosis.

BACKGROUND: A rare subset of sarcoidosis, neurosarcoidosis, is reported to occur in 5-7% of sarcoid patients and can manifest in a variety of ways. The most common are facial paralysis and optic neuritis, less commonly causing cochleovestibulopathy, blindness, anosmia, and other cranial nerve (CN) palsies. The sensory deficit may be severe and psychiatric symptoms may result from the effects of the disease or steroid treatment. Although MRI-compatible cochlear implants are now available, concerns about the feasibility of recoverable hearing with cochlear implantation in these patients as well as the practical difficulty of disease monitoring due to implant artifact must be considered. RESULTS: We present 3 recent cases from different institutions. The first is a 39-year-old man with a history of progressively worsening hearing loss, followed by visual loss, delusions, agitation, ataxia, and musical auditory hallucinations, diffuse leptomeningeal enhancement on MRI with a normal serum angiotensin-converting enzyme (ACE) level but elevated cerebrospinal fluid (CSF) ACE levels, suggesting neurosarcoidosis, was treated with corticosteroids, and underwent successful cochlear implantation. The second is a 36-year-old woman with rapid-onset horizontal diplopia, left mixed severe sensorineural hearing loss (SNHL) and tinnitus, diffuse leptomeningeal enhancement on MRI, and progressive palsy of the left CNs IV, VI, VII, IX, X and XI, with altered mental status requiring admission following high-dose intravenous corticosteroids. The third is a 15-year-old boy who presented with sudden, bilateral, profound SNHL, recurrent headaches, and left facial weakness refractory to antivirals, ultimately diagnosed with neurosarcoidosis following an aborted cochlear implantation where diffuse inflammation was found, and histopathology revealed Schaumann bodies; he was treated with methotrexate and later underwent successful cochlear implantation. CONCLUSIONS: Neurosarcoidosis is an elusive diagnosis and can cause hearing loss and psychiatric symptoms. Cochlear implantation for patients with severe hearing loss should be considered once the diagnosis is confirmed, as it is possible to achieve a successful level of hearing. Psychiatric symptoms can manifest with the onset of neurosarcoidosis, result from CN deficits, or develop as a side effect from long-term, high-dose corticosteroids, and should be monitored carefully in patients with neurosarcoidosis.

The Hyaluronic Acid Fillers: Current Understanding of the Tissue Device Interface.

The article is a detailed update regarding cosmetic injectable fillers, specifically focusing on hyaluronic acid fillers. Hyaluronic acid-injectable fillers are used extensively for soft tissue volumizing and contouring. Many different hyaluronic acid-injectable fillers are available on the market and differ in terms of hyaluronic acid concentration, particle size, cross-linking density, requisite needle size, duration, stiffness, hydration, presence of lidocaine, type of cross-linking technology, and cost. Hyaluronic acid is a natural component of many soft tissues, is identical across species minimizing immunogenicity has been linked to wound healing and skin regeneration, and is currently actively being studied for tissue engineering purposes. The biomechanical and biochemical effects of HA on the local microenvironment of the injected site are key to its success as a soft tissue filler. Knowledge of the tissue-device interface will help guide the facial practitioner and lead to optimal outcomes for patients.