Current Treatments and Future Directions for Facial Paralysis.

Facial palsy is a condition that affects the facial nerve, the seventh of the twelve cranial nerves. Its main function is to control the muscles of facial expression. This involves the ability to express emotion through controlling the position of the mouth, the eyebrow, nostrils, and eye closure. The facial nerve also plays a key role in maintaining the posture of the mouth and as such, people with facial paralysis often have problems with drooling, speech, and dental hygiene. Due to the devastating effects on the quality of life of individuals with facial palsy, there are a multitude of various treatment options for the paralyzed face. This article reviews current management strategies, and points towards promising future directions for research in the field of facial reanimation.

A Scoping Review of Quality-of-Life Assessments Employed in Abdominal Wall Reconstruction.

INTRODUCTION: Surgeons use several quality-of-life instruments to track outcomes following abdominal wall reconstruction (AWR); however, there is no universally agreed upon instrument. We review the instruments used in AWR and report their utilization trends within the literature. METHODS: This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines using the PubMed, Embase, Web of Science, ClinicalTrials.gov, and Cochrane databases. All published articles in the English language that employed a quality-of-life assessment for abdominal wall hernia repair were included. Studies which focused solely on aesthetic abdominoplasty, autologous breast reconstruction, rectus diastasis, pediatric patients, inguinal hernia, or femoral hernias were excluded. RESULTS: Six hernia-specific tools and six generic health tools were identified. The Hernia-Related Quality-of-Life Survey and Carolinas Comfort Scale are the most common hernia-specific tools, while the Short-Form 36 (SF-36) is the most common generic health tool. Notably, the SF-36 is also the most widely used tool for AWR outcomes overall. Each tool captures a unique set of patient outcomes which ranges from abdominal wall functionality to mental health. CONCLUSIONS: The outcomes of AWR have been widely studied with several different assessments proposed and used over the past few decades. These instruments allow for patient assessment of pain, quality of life, functional status, and mental health. Commonly used tools include the Hernia-Related Quality-of-Life Survey, Carolinas Comfort Scale, and SF-36. Due to the large heterogeneity of available instruments, future work may seek to determine or develop a standardized instrument for characterizing AWR outcomes.

Cost minimization in breast conserving surgery: a comparative study of radiofrequency spectroscopy and full cavity shave margins.

BACKGROUND: In an effort to minimize positive margins and subsequent re-excision after breast conserving surgery (BCS), many providers and facilities have implemented either a Full Cavity Shave (FCS) approach or adding the MarginProbe Radiofrequency Spectroscopy System. OBJECTIVE: We sought to create a functioning Pro-Forma for use by facilities and payers to evaluate and compare the cost savings of implementing FCS or MarginProbe based on personalized variable inputs. METHODS: A decision tree demonstrating three possible surgical pathways, BCS, BCS + FCS, and BCS + MarginProbe was developed with clinical inputs for re-excision rate, mastectomy as 2nd surgery, rate of reconstruction, and rate of 3rd surgery derived by a literature review. A surgical pathway cost formula was created using the decision tree and financial inputs derived by utilizing the nation's largest database of privately billed health insurance claims and Medicare claims data (fairhealth.org). Using the surgical pathway formula and financial inputs, a customizable Pro-Forma was created for immediate cost savings analysis of BCS + FCS and BCS + Marginprobe using variable inputs. Costs are from the perspective of third-party payers. RESULTS: Utilizing MarginProbe to reduce re-excisions for positive margins can be associated with better cost-savings than FCS due to the increased pathology processing costs by using an FCS approach. The reduction in re-excision provided by both FCS and MarginProbe offset their increased expense to various degrees with cost savings of each method improving as baseline re-excisions rates increase, until ultimately each may become cost-neutral or cost-prohibitive when compared to BCS alone. Our data suggest that in the privately insured population, MarginProbe provides a cost-savings over BCS alone when baseline re-excision rates are over 20% and that FCS becomes cost-saving when baseline re-excision rates are over 29%. For Medicare patients, MarginProbe provides a cost-savings when baseline re-excision rates exceed 34%, and FCS becomes cost-saving for re-excision rates over 52%. Our Pro-Forma allows an individual provider or institution to evaluate the cost savings of the FCS approach and/or utilization of the MarginProbe device such that the additional cost or cost-savings of utilizing one or both of these methods can be quickly calculated based on their facility's volume and baseline re-excision rate. CONCLUSIONS: Our data suggest that utilizing either an FCS approach or the MarginProbe radiofrequency spectroscopy system may be a cost-saving solution to reducing the rate of re-excisions depending on a facility or practice's surgical volume and baseline re-excision rate. The degree to which each of these interventions provides an added cost or cost-savings to healthcare payers can be evaluated by utilizing the Pro-Forma outlined herein with customizable variable inputs.

Evaluation of peripheral nerve regeneration in Murphy Roths Large mouse strain following transection injury.

Aim: Murphy Roths Large (MRL/MpJ) mice have demonstrated the ability to heal with minimal or no scar formation in several tissue types. In order to identify a novel animal model, this study sought to evaluate whether this attribute applies to peripheral nerve regeneration. Materials & methods: This was a two-phase study. 6-week-old male mice were divided into two interventional groups: nerve repair and nerve graft. The MRL/MpJ was compared with the C57BL/6J strain for evaluation of both functional and histological outcomes. Results: MRL/MpJ strain demonstrated superior axon myelination and less scar formation, however functional outcomes did not show significant difference between strains. Conclusion: Superior histological outcomes did not translate into superior peripheral nerve regeneration in MRL/MpJ strain.

A Systematic Review of the Reported Complications Related to Facial and Upper Extremity Vascularized Composite Allotransplantation.

INTRODUCTION: Twenty three years after the first successful upper extremity transplantation, the role of vascularized composite allotransplantation (VCA) in the world of transplantation remains controversial. Face and upper extremity reconstruction via transplantation have become successful options for highly selected patients with severe tissue and functional deficit when conventional reconstructive options are no longer available. Despite clear benefit in these situations, VCA has a significant potential for complications that are more frequent when compared to visceral organ transplantation. This study intended to perform an updated systematic review on such complications. MATERIALS AND METHODS: MEDLINE database via PubMed, Embase and Cochrane Library were searched. Face and upper extremity VCA performed between 1998 and 2021 were included in the study. Relevant media and press conferences reports were also included. Complications related to face and upper extremity VCA were recorded and reviewed including their clinical characteristics and complications. RESULTS: One hundred fifteen patients underwent facial (43%) or upper extremity (57%) transplantation. Overall, the surgical complication rate was 23%. Acute and chronic rejection was identified in 89% and 11% of patients, respectively. Fifty eight percent of patients experienced opportunistic infection. Impaired glucose metabolism was the most common immunosuppression-related complication other than infection. Nineteen percent of patients ultimately experienced partial or complete allograft loss. CONCLUSIONS: Complications related to VCA are a significant source of morbidity and potential mortality. Incidence of such complications is higher than previously reported and should be strongly emphasized in patient consent process. Strict patient selection criteria, complex preoperative evaluation, consideration of alternatives, and thorough disclosure to patients should be routinely performed prior to VCA indication.

Axonal Regeneration Through Autologous Grafts: Does the Axonal Load Influence Regeneration?

INTRODUCTION: Two-stage free functional muscle transfers for long-standing facial palsy can yield unpredictable results. Earlier studies have demonstrated incomplete regeneration across neurorrhaphies in native nerve and higher donor axonal counts correlating with improved outcomes but axonal count in nerve grafts have not been as thoroughly reviewed. To investigate the impact of varying axonal counts in autologous grafts on functional outcomes of repair. MATERIALS AND METHODS: Animals were allocated into three groups: Direct Nerve Repair (DNR, n = 50), Small Nerve Graft (SNG, n = 50), and Large Nerve Graft (LNG, n = 50). All grafts were inset into the Posterior Auricular Nerve with ear movement recovery (EMR) monitored as functional outcome. At various postoperative weeks (POWs), excised specimens were imaged with electron microscopy. Axonal counts were measured proximal to, distal (DAC) to, and within grafts. Total Success Ratio (TSR) was calculated. RESULTS: In DNR, DAC was significantly lower than proximal axonal counts at all POWs, with maximum TSR of 80%. TSR for LNG and SNG were significantly lower at all POWs when compared to DNR, with maximums of 56% and 38%, respectively. LNG had a significantly larger DAC than SNG at POW12 and beyond. A direct relationship was present between DAC and EMR for all values. CONCLUSIONS: Higher native axonal count of autologous nerve grafts resulted in higher percentage of regeneration across neurorrhaphies.

Comparison of arterial and venous implantable Doppler postoperative monitoring of free flaps: Systematic review and meta-analysis of diagnostic test accuracy.

BACKGROUND: Early detection of vascular compromise following free flap microsurgical reconstruction is essential. This can lead to timely reoperations and flap salvage. Both arteries and veins are monitored postoperatively with implantable ultrasound Dopplers based on surgeon preference with no consensus as to which method is best. This systematic review and meta-analysis compared arterial to venous implantable Dopplers for postoperative monitoring of microsurgical free flap reconstruction. METHODS: Five databases (MEDLINE via PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus) were systematically and independently searched. PRISMA and Cochrane guidelines were strictly followed. Clinical characteristics, donor and recipient sites, specific arterial or venous vessels, diagnostic data, outcomes, and complications were recorded. RESULTS: The seven studies included in the meta-analysis were published from 1994 to 2018, with results from 38 of the possible 64 outcomes and complications queried. A total of 763 flaps with implantable Doppler probes on 527 arteries and 388 veins were included in the study. Compared to patients monitored with venous implantable Dopplers, arterial monitoring was associated with a risk of false-positives reduced by 74% (RR:0.26, 95% CI:0.12, 0.55, I2 = 40%, p = .0004) and risk of signal loss reduced by 63% (RR:0.37, 95% CI:0.24, 0.59, I2 = 26%, p < .0001). Patients being monitored with a venous implantable Doppler did not show significantly different sensitivities, specificities, true-positives, false-negatives, true-negatives, positive predictive values, negative predictive values, time to signal loss, take-backs, salvage rates, flap failures, flap failure rates, arterial, venous, vascular, and hematoma compromise compared to an arterial implantable Doppler. CONCLUSION: These findings suggest arteries may be the best vessels to monitor when using an implantable Doppler following free flap microsurgical reconstruction. Caution is advised when interpreting these findings for clinical significance due to no significant differences in take-backs, SR, flap failures, and FFR.

Post-prandial endothelial dysfunction is ameliorated following weight loss in obese premenopausal women.

BACKGROUND: Endothelial dysfunction and postprandial hyperglycemia represent independent risk factors for cardiovascular diseases. Obesity is connected with endothelial impairments; however, it is unclear whether weight loss can modify endothelial function during the postprandial period. The aim of this study was to evaluate endothelial response (post-ischemic forearm blood flow, PIFBF) in a fasted state and following ingestion of 75 g glucose before and after very low caloric diet (VLCD). MATERIAL/METHODS: 40 obese premenopausal women (age 39.6 ± 7.8 years, BMI 34.3 ± 3.2 kg/m2) participated in 4-week very low caloric diet (VLCD, 800 kcal/day). Before and after VLCD, the baseline blood flow and PIFBF were measured using a mercury strain gauge plethysmography in fasting state as well as 1 hour after ingestion of 75 g glucose. RESULTS: Dietary intervention resulted in a 7% weight loss (p<0.05) and a decrease in insulin resistance index HOMA-IR (2.44 ± 1.25 vs. 1.66 ± 0.81, p<0.05). Before VLCD intervention, PIFBF following oral glucose challenge decreased by 8.2 ± 9.1 ml/min/100 g tissue, while after weight loss identical stimulus increased PIFBF by 4.2 ± 8.9 ml/min/100 g tissue (p<0.05). Plasma ICAM-1 and VCAM-1 decreased by 8% and 10%, respectively, throughout the study. CONCLUSIONS: Postprandial endothelial dysfunction is ameliorated following weight loss in obese women. This finding demonstrates the beneficial effects of weight reduction on atherosclerosis risk.