Review of the Current Medical and Surgical Treatment Options for Microstomia in Patients With Scleroderma.

BACKGROUND: Most patients with scleroderma suffer from microstomia, which can have debilitating consequences on their quality of life. Unfortunately, treatment options remain limited. No specific guidelines exist; hence, microstomia remains a challenge to treat in this patient population. OBJECTIVE: This review aims to evaluate the different medical and surgical treatment modalities currently available for microstomia in patients with scleroderma and make recommendations for future research. MATERIALS AND METHODS: A search of PubMed, Ovid MEDLINE, and Ovid Embase was conducted to identify articles discussing the treatment of microstomia in scleroderma. Twenty articles discussing surgical therapy and one article discussing medical therapy were reviewed. RESULTS: Mostly because of a scarcity of high-level evidence, no individual therapy has documented long-term efficacy. Some treatments demonstrate positive results and warrant further research. CONCLUSION: Given the variability of results, specific recommendations for the treatment of microstomia in patients with scleroderma are difficult to establish. A multifaceted approach that includes surgical and medical therapy is likely the best option to improve oral aperture in this patient population. Surgical treatments such as neurotoxins, autologous fat grafting, and ultraviolet A1 phototherapy may hold the most potential for improvement.

Subcutaneous lateral brow lift, an option with local anesthesia / Levantamiento de cejas lateral con acceso subcutáneo, una opción con anestesia local

The aim of this article is to present a case series of subcutaneous lateral brow lifts withlocal anesthesia. The case series includes 9 subjects operated on between 2014 and 2016, with an averageage of 57 years and with no limitations on ethnic group or gender. The surgery was done bilaterally entirelyunder local anesthesia. After a minimum follow-up of 3 months, no major complications were observed, onlypartial suture dehiscence at two surgical sites that did not require surgical management of the zone. Goodresults were established, being fast, economical and with low morbidity. It is concluded that the subcutaneousbrow lift with local anesthesia can be applied with a low rate of complications and good results.

El objetivo de este articulo es presentar una serie de casos operados para levantamiento lateral de cejas, con disección subcutánea y con uso de anestesia local. Se diseño un estudio de serie de casos, incluyendo 9 sujetos operados entre el año 2014 y 2016, con una edad promedio de 57 años y sin restricción de etnia o sexo. Se realizó la cirugía totalmente bajo anestesia local de forma bilateral. Después de un seguimiento mínimo de 3 meses, no se observaron complicaciones mayores, presentado solo dehiscencia parcial de sutura en dos sitios quirúrgico que no requirieron manejo quirúrgico de la zona; se establecieron buenos resultados, siendo ellos rápidos, de baja morbilidad y de bajo costo. Se concluye que la técnica de levantamiento de cejas con disección subcutánea y anestesia local puede ser aplicado con bajo índice de complicaciones y buenos resultados.

High variability of facial muscle innervation by facial nerve branches: A prospective electrostimulation study.

OBJECTIVES/HYPOTHESIS: To examine by intraoperative electric stimulation which peripheral facial nerve (FN) branches are functionally connected to which facial muscle functions. STUDY DESIGN: Single-center prospective clinical study. METHODS: Seven patients whose peripheral FN branching was exposed during parotidectomy under FN monitoring received a systematic electrostimulation of each branch starting with 0.1 mA and stepwise increase to 2 mA with a frequency of 3 Hz. The electrostimulation and the facial and neck movements were video recorded simultaneously and evaluated independently by two investigators. RESULTS: A uniform functional allocation of specific peripheral FN branches to a specific mimic movement was not possible. Stimulation of the whole spectrum of branches of the temporofacial division could lead to eye closure (orbicularis oculi muscle function). Stimulation of the spectrum of nerve branches of the cervicofacial division could lead to reactions in the midface (nasal and zygomatic muscles) as well as around the mouth (orbicularis oris and depressor anguli oris muscle function). Frontal and eye region were exclusively supplied by the temporofacial division. The region of the mouth and the neck was exclusively supplied by the cervicofacial division. Nose and zygomatic region were mainly supplied by the temporofacial division, but some patients had also nerve branches of the cervicofacial division functionally supplying the nasal and zygomatic region. CONCLUSIONS: FN branches distal to temporofacial and cervicofacial division are not necessarily covered by common facial nerve monitoring. Future bionic devices will need a patient-specific evaluation to stimulate the correct peripheral nerve branches to trigger distinct muscle functions. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:1288-1295, 2017.

Treatment of microstomia caused by burn with a nasolabial flap--an ingenious approach for tugging and fixation of the oral commissure.

The objectives of surgical treatment for microstomia due to cicatricial contracture after burn are to obtain sufficient oral aperture, while maintaining sphincter function of the orbicularis oris muscle, and to secure favorable function for eating and conversation in addition to good oral health.The lips of the mouth have a free border, and the oral aperture, which has been enlarged by the operation, tends to be reduced, because of the actions of the orbicularis oris muscle. When the orbicularis oris muscle is resected, putting a priority on sufficient oral aperture and prevention of redevelopment of contracture, the function of the sphincter is often damaged. With the exception of those cases with deep extensive burn that damages a wide area of orbicularis oris muscle, the muscle should be preserved as expeditiously as is practical. In such cases, however, preventive measures for the redevelopment of microstomia should be established. As a postoperative adjuvant therapy, the usefulness of splint therapy has been suggested in many reports. However, a splint should be used for a long period after the surgery, and in some cases, pain is observed with therapy. When a splint is not used for an appropriate period, microstomia may redevelop. It would be ideal to take preventive measures against the redevelopment of contracture during surgery.We provided treatment with some ingenious attempts for the nasolabial flap to a patient with microstomia caused by cicatricial contracture after burn. We obtained favorable results with no postoperative use of a splint.

Asian upper lid blepharoplasty: an update on indications and technique.

This article (1) briefly reviews the topographical and surgical anatomy of the Asian upper eyelid, (2) provides guidelines for preoperative assessment and postoperative management for upper Asian blepharoplasty, (3) describes the senior author's surgical technique for external incisional approach to upper eyelid crease formation, and (4) discusses potential pitfalls and complications.

Therapeutic strategies in post-facial paralysis synkinesis in pediatric patients.

UNLABELLED: Synkinetic movements comprise abnormal involuntary contractions of one or more facial muscle groups which follow the desired contraction of another facial muscle group. They are frequently encountered in patients with long standing facial paralysis and seriously affect their psychological status due to the impairment of their facial appearance, function and emotional expressivity. PATIENTS AND METHODS: Eleven pediatric patients (2 male and 9 female) presenting with post-facial paralysis synkinesis were included in the study. Mean age was 10.3±4 years and mean denervation time 72.5 months. RESULTS: Patients underwent the following types of treatment: --Cross facial nerve grafting (CFNG) and secondary microcoaptations with botulinum toxin injection which had an improvement of 100% (3 in the 3 grade synkinesis scale) (n=2). --Cross facial nerve grafting (CFNG) and secondary microcoaptations without botulinum toxin injection which had an improvement of 66%(2 in the 3 grade synkinesis scale) (n=5). --CFNG and direct muscle neurotization with (n=2) or without (n=1) botulinum toxin injection where the improvement was 33%. --Contralateral nasalis muscle myectomy was performed in one patient along with CFNG and secondary microcoaptations which resulted in 66% synkinesis improvement. Biofeedback was invariably undertaken by all patients. Postoperative improvement in eye closure and smile was also noted in the respective cases treated for synkinesis ranging from 25 to 50%, with all patients achieving optimum functional return. CONCLUSION: CFNG with secondary microcoaptations and botulinum toxin injections was found to be a very efficient surgical modality addressing post-facial palsy synkinesis with high improvement in facial function and symmetry. Facial neuromuscular re-education contributes considerably in the treatment.

Composite septo-retractor recession; a surgical technique for lower-eyelid retraction and review of the literature.

PURPOSE: To report the outcomes of a technique for correcting lower-eyelid retraction with composite recession of the inferior retractor and orbital septum complex, release of the lateral horn of the lower-eyelid retractors, and the orbito-malar ligament (OML) followed by skin, orbicularis, and conjunctival advancement. METHODS: We performed a retrospective, noncomparative review of consecutive procedures performed on patients with lower-eyelid retraction undergoing composite septo-retractor recession for lower-eyelid retraction over a 4-year period, performed or supervised by a single surgeon (RM). Outcomes are based on postoperative standard photographs, including central pupil to lower-eyelid distance, inferior scleral show, and subjective improvement in lower-eyelid lateral flare. RESULTS: We reviewed 26 eyes of 16 patients (12 men, 4 women; mean age, 61.0 ± 14.3 years). Causes of lower-eyelid retraction included involutional (n = 6), thyroid orbitopathy (n = 4), previous lower-eyelid surgery (n = 3), mechanical secondary to proptosis (n = 1), Crouzon syndrome (n = 1), and longstanding facial nerve palsy (n = 1). Mean lower-eyelid elevation achieved was 1.4 mm ± 1.3 mm (range, 0.2 to 6.6 mm; p = 0.001). Scleral show improved by 1.0 ± 0.7 mm (range, 0.0 to 2.9; p = <0.001). Preoperatively, all patients had an altered lower-eyelid contour with lateral flare, 89% cases being graded "significant." Lower-eyelid contour improved postoperatively, with only 19% graded "significant" lateral flare (p = <0.0001). No significant complications occurred, although one patient required excision of a secondary lateral canthal cyst. CONCLUSION: Composite recession of the inferior retractor and orbital septum complex combined with release of the inferior retractor lateral horn and the OML significantly improves lower-eyelid height and contour in cases of lower-eyelid retraction and should be considered a useful option for this condition.

[The value of "migraine surgery". Overview of the pathophysiological concept and current evidence]. / Stellenwert der "Migränechirurgie". Ubersicht über das pathophysiologische Konzept und die aktuelle Datenlage.

Often without sufficient scientific evidence, unconventional methods for migraine treatment are being put forward. Recently a trial using "migraine surgery" has been published. Its design is based on a concept of migraine pathogenesis without any scientific background and includes several severe methodological flaws. In spite of the above, the study is frequently cited in the lay press. The surgical procedure as well as the study are critically discussed.

A placebo-controlled surgical trial of the treatment of migraine headaches.

BACKGROUND: Many of the nearly 30 million Americans suffering with migraine headaches are not helped by standard therapies, a proportion of which can harbor undesirable side effects. The present study demonstrates the efficacy of independent surgical deactivation of three common migraine headache trigger sites through a double-blind, sham surgery, controlled clinical trial. METHODS: Seventy-five patients with moderate to severe migraine headache who met International Classification of Headache Disorders II criteria were studied. Trigger sites were identified (frontal, temporal, and occipital), and patients were randomly assigned to receive either actual or sham surgery in their predominant trigger site. Patients completed the Migraine Disability Assessment, Migraine-Specific Quality of Life, and Medical Outcomes Study 36-Item Short Form Health Survey health questionnaires before treatment and at 1-year follow-up. RESULTS: Of the total group of 75 patients, 15 of 26 in the sham surgery group (57.7 percent) and 41 of 49 in the actual surgery group (83.7 percent) experienced at least 50 percent reduction in migraine headache (p < 0.05). Furthermore, 28 of 49 patients in the actual surgery group (57.1 percent) reported complete elimination of migraine headache, compared with only one of 26 patients in the sham surgery group (3.8 percent) (p < 0.001). Compared with the control group, the actual surgery group demonstrated statistically significant improvements in all validated migraine headache measurements at 1 year. These improvements were not dependent on the trigger site. The most common surgical complication was slight hollowing of the temple in the group with temporal migraine headache. CONCLUSION: This study confirms that surgical deactivation of peripheral migraine headache trigger sites is an effective alternative treatment for patients who suffer from frequent moderate to severe migraine headaches that are difficult to manage with standard protocols.

Closed, nonendoscopic, small-incision forehead lift.

As endoscopic techniques made inroads into surgery, one of the first procedures they were adapted to by plastic surgeons was the forehead lift. The "closed" forehead lift procedure has since achieved wide acceptance and exists as a viable alternative to open procedures for many patients. Experience has shown, however, that it is not necessary to use an endoscope to mobilize and release the forehead and modify the corrugator supercilii muscles in "closed" procedures if the anatomy is understood, the operation is appropriately planned, and the corrugator muscles are modified using a transpalpebral approach. In addition, transpalpebral corrugator myectomy, when used in conjunction with closed mobilization and resuspension of the forehead, provides not only a scheme for the performance of closed foreheadplasty without the need for an endoscope, but a method by which medial brow elevation can be minimized or avoided. This may, indeed, be one the procedure's most important advantages over the endoscopic technique.

Reanimation of the paralyzed face with new gold weight implants and Goretex soft-tissue patches.

Although dynamic reconstruction procedures are preferred for treating patients with complete facial paralyses, static procedures are useful for various conditions. One such technique involves the implantation of gold weights into the upper eyelid. We have reported our experiences with 58 patients who underwent gold weight implantation for rehabilitation of eyelid closure with satisfactory results. To obtain better cosmetic results we developed newly shaped thinner weights. Four instead of three perforations in each weight enable better fixation to soft tissue. Since 40% of all cases also required additional surgery to rehabilitate other portion of the face, polytetrafluoroethylene (Goretex) soft-tissue patches were used for suspension to help correct midfacial and perioral asymmetry. From 1990 to 1996, 22 patients underwent this technique under local or general anesthesia. Except for 2 patients, no complications were observed. Overall, both gold implants and Goretex patches were found to provide good results in patients selected for facial reanimation.

Bell's palsy: management of sequelae using EMG rehabilitation, botulinum toxin, and surgery.

Fifteen percent of patients who have had an acute episode of Bell's palsy will be left with debilitating facial dysfunction. This chapter describes our approach to managing a variety of hypo- and hyperkinetic disorders caused by injury and faulty regeneration of the facial nerve, using electromyographic rehabilitation (EMGR) (13 patients), Oculinum toxin injection (14 patients), or surgical reanimation (72 patients). Improvement was noted after EMGR in 12 of 13 patients (92%), all 14 patients treated with Oculinum experienced temporary improvement, and improvement was noted in 66 of 72 patients who underwent surgery (92%). The indications, techniques, and results of these three rehabilitative methods are discussed.

[Dehiscence and disinsertion of the aponeurotic bundle of the upper eyelid levator in acquired ptosis]. / Déhiscence et désinsertion du faisceau aponévrotique du releveur de la paupière supérieure au cours des ptosis acquis.

Aponeurotic defects and disinsertion of the levator aponeurosis are responsible for many cases of acquired ptosis. The typical clinical findings in aponeurotic defects are: history of prior orbital swelling, injury, ocular surgery, blepharochalasis; good to excellent levator function, thinning of the eyelid above the tarsus, high to absent lid crease, and normal Müller's muscle function. The purpose of the treatment is to repair a defect or advance the aponeurosis onto the tarsus. Levator aponeurosis surgery was used to treat 18 upper eyelids with acquired ptosis. Local anesthesia and surgery from an anterior approach were used in all cases. The advantages of this technique are: The lid height is determined by asking the patient to look in various fields of gaze. A blepharoplasty can be performed when necessary. The lid crease is formed. The exposition of the levator aponeurosis disinsertion is easier to recognize.

Contralaterally elicited electrical stimulation of paralyzed facial muscles.

Functional electrical stimulation is being explored in the extremities. A major obstacle is found in programming the firing sequence. In 1976, David Zealear proposed using the activity on the normal side in axial muscle pairs that normally function symmetrically to act as a template to control the stimulator. This method was demonstrated in laryngeal muscles in dogs, and is now demonstrated in the face with future applications being proposed. The facial nerve on one side was sectioned in a series of rabbits. Implanted electrodes received electrical potentials from selected muscles on the normal side. Bursts of electrical activity on the normal side during a blink or a twitch were used to trigger a muscle stimulator, which was routed to matching muscles on the paralyzed side. This technique restored symmetric function to the hemiparalyzed side. This technique restored symmetric function to the hemiparalyzed face.