Polyetheretherketone Implant Cranioplasty for Large Cranial Defects: A Seven-Year Follow-Up.

BACKGROUND: Goals of a cranioplasty include protection of the brain, restoration of normal appearance, and neurological function improvement. Although choice of materials for cranial remodeling has changed through the years, computer-designed polyetheretherketone (PEEK) implant has gained traction as a preferred material used for cranioplasty. However, long-term outcomes and complications of PEEK implants remain limited. The goal of this study was to report long-term clinical outcomes after PEEK implant cranioplasty. METHODS: A retrospective chart review was performed on patients undergoing PEEK cranioplasty between January 2007 and February 2023. Preoperative, intraoperative, and postoperative data were collected and analyzed. RESULTS: Twenty-two patients were included in this study. Mean postoperative follow-up time was 83.45 months (range: 35.47-173.87). Before PEEK implant cranioplasty, patients with multiple cranial procedures had undergone a mean of 2.95 procedures. PEEK implant cranioplasty indications were prior implant infection (14) and secondary reconstruction of cranial defect (8). The mean implant size was 180.43 cm2 (range: 68.00-333.06). Four patients received a 2-piece implant. Postoperative complications included: perioperative subgaleal self-resolving fluid collection in 1 patient, hematoma in another, and 3 infections resulting in explantations with successful reinsertion in 2 patients. Four of 5 patients with preoperative history of seizures reported improved seizures and all 4 patients with preoperative syndrome of the trephined reported improved symptoms and neurological function. CONCLUSION: At a mean follow-up of 7 years, most PEEK implants continued to provide protection to the brain and consistent symptom relief in patients suffering from prior postcraniectomy/craniotomy sequelae of seizures and syndrome of the trephined.

Post-Paretic Synkinesis: Objective & Subjective Comparisons of Depressor Anguli Oris (DAO) Myectomies vs DAO & Buccinator Myectomies.

BACKGROUND: Muscles affected by post-paretic synkinesis have imbalanced tonicity that limit peri-oral mimetic movement and inhibit the ability to smile. The depressor anguli oris (DAO) muscle has been a common myectomy target for the treatment of peri-oral synkinesis. While addition of buccinator myectomies to DAO myectomies has risen, no studies have analyzed the effects of buccinator myectomies. The goal of this study was to evaluate and compare the effects of a DAO myectomy with and without concomitant buccinator myectomy through objective facial metrics and subjective patient reported outcomes. METHODS: This study is a retrospective review of patients with post-paretic synkinesis who underwent DAO myectomy (DAO myectomy group) or DAO myectomy with buccinator myectomy (DAO+Buccinator myectomies group). Outcomes included post-operative differences in objective smile measures (smile angle, excursion, and dental show) using validated software, and patient reported outcomes using the Facial Disability Index (FDI) questionnaire and a myectomy-specific questionnaire. RESULTS: After chart review, 18 patients were included in the DAO myectomy group and 19 in the DAO+Buccinator myectomies group. There were no significant post-operative differences between the groups in 1. smile excursion, angle, or dental show at resting, closed smile, or open smile (p>.05), 2. FDI physical and social scores, p=.198 and p=.932, respectively, or 3. myectomy-specific questionnaire responses (p>.05). CONCLUSION: The addition of a buccinator myectomy to a DAO myectomy does not provide significant clinical benefit when compared with an isolated DAO myectomy, based on objective measures and subjective patient reported outcomes.

Effect of Lower Extremity Nerve Decompression in Patients With Painful Diabetic Peripheral Neuropathy: The Diabetic Neuropathy Nerve Decompression Randomized, Observation Group and Placebo Surgery-Controlled Clinical Trial.

OBJECTIVE: To evaluate the effect of nerve decompression on pain in patients with lower extremity painful diabetic peripheral neuropathy (DPN). BACKGROUND: Currently, no treatment provides lasting relief for patients with DPN. The benefits of nerve decompression remain inconclusive. METHODS: This double-blinded, observation and same-patient sham surgery-controlled randomized trial enrolled patients aged 18 to 80 years with lower extremity painful DPN who failed 1 year of medical treatment. Patients were randomized to nerve decompression or observation group (2:1). Decompression-group patients were further randomized and blinded to nerve decompression in either the right or left leg and sham surgery in the opposite leg. Pain (11-point Likert score) was compared between decompression and observation groups and between decompressed versus sham legs at 12 and 56 months. RESULTS: Of 2987 screened patients, 78 were randomized. At 12 months, compared with controls (n=37), both the right-decompression group (n=22) and left-decompression group (n=18) reported lower pain (mean difference for both: -4.46; 95% CI: -6.34 to -2.58 and -6.48 to -2.45, respectively; P < 0.0001). Decompressed and sham legs equally improved. At 56 months, compared with controls (n=m 14), pain was lower in both the right-decompression group (n=20; mean difference: -7.65; 95% CI: -9.87 to -5.44; P < 0.0001) and left-decompression group (n=16; mean difference: -7.26; 95% CI: -9.60 to -4.91; P < 0.0001). The mean pain score was lower in decompressed versus sham legs (mean difference: 1.57 95% CI: 0.46 to 2.67; P =0.0002). CONCLUSIONS: Although nerve decompression was associated with reduced pain, the benefit of surgical decompression needs further investigation as a placebo effect may be responsible for part or all of these effects.

The synkinetic mentalis muscle and its negative effect on the smile: pathomechanism and treatment with mentalis targeted selective neurectomies.

BACKGROUND: The treatment of post-paretic facial synkinesis is based on a combination of nonsurgical and surgical strategies. Even if improvements towards the restoration of a natural smile have been obtained with selective neurectomies (SN) and depressor anguli oris (DAO) myectomy, the lower lip frequently remains asymmetric and cranially displaced. The aim of this study was to evaluate the effect of the mentalis muscle on the position and symmetry of the lower lip in patients with synkinesis and to assess the added benefit of neurectomies of nerves innervating the mentalis muscle in improving the lower lip configuration and mandibular teeth show. METHODS: A retrospective cohort study on all patients affected by post-paretic synkinesis at our Institution was performed. A Non-mentalis Neurectomy Group including twelve patients treated with SN without targeting the branches to mentalis muscle was compared to a Mentalis Neurectomy Group, including sixteen patients who underwent additional specific mentalis branches neurectomies. All patients underwent DAO myectomy. Analyses of standardized images were performed with ImageJ software. RESULTS: Post-operative comparisons between the two groups showed superior and significant improvements in the Mentalis Neurectomy Group across all measures, including lower and upper border deviation (p=0.035 and p=.004, respectively), inclination of the lower lip (p=.019), and lower quadrant dental show (p=.004). CONCLUSIONS: The addition of targeted selective neurectomies to the branches innervating mentalis muscle significantly improved dental show and caudal position and symmetry of the lower lip during open mouth smile.

Dual-Innervated Gracilis Free Functional Muscle Transfers in Facial Palsy Patients: Comparing Long-Term Outcomes between One- versus Two-Stage Procedures.

BACKGROUND: In facial reanimation, dual-innervated gracilis free functional muscle transfers (FFMTs) may have amalgamated increases in tone, excursion, synchroneity, and potentially spontaneity when compared with single innervation. The ideal staging of dual-innervated gracilis FFMTs has not been investigated. We aim to compare objective long-term outcomes following one- and two-stage dual-innervated gracilis FFMTs. METHODS: Included were adult patients with facial paralysis who underwent either one- (one-stage group) or two-stage (two-stage group) dual-innervated gracilis FFMT with ≥1 year of postoperative follow-up. Facial measurements were obtained from standardized photographs of patients in repose, closed-mouth smile, and open-mouth smile taken preoperatively, 1 year postoperatively, and 3 years postoperatively. Symmetry was calculated from the absolute difference between the paralyzed and healthy hemiface; a lower value indicates greater symmetry. RESULTS: Of 553 facial paralysis patients, 14 were included. Five and nine patients were in the one- and two-stage groups, with mean follow-up time, respectively, being 2.5 and 2.6 years. Within-group analysis of both groups, most paralyzed-side and symmetry measurements significantly improved over time with maintained significance at 3 years postoperatively in closed and open-mouth smile (all p ≤ 0.05). However, only the two-stage group had maintained significance in improvements at 3 years postoperatively in paralyzed-side and symmetry measurements in repose with commissure position (median change [interquartile range, IQR], 7.62 [6.00-10.56] mm), commissure angle (median change [IQR], 8.92 [6.18-13.69] degrees), commissure position symmetry (median change [IQR], -5.18 [-10.48 to -1.80] mm), commissure angle symmetry (median change [IQR], -9.78 [-11.73 to -7.32] degrees), and commissure height deviation (median change [IQR], -5.70 [-7.19 to -1.64] mm; all p ≤ 0.05). In the between-group analysis, all measurements were comparable in repose, closed-mouth smile, and open-mouth smile (all p > 0.05). CONCLUSION: Long-term outcomes demonstrate that both one- and two-stage dual-innervated gracilis FFMTs significantly improve excursion, but only two-stage reconstruction significantly improves resting tone.

Selective Myectomies Alone vs Selective Myectomies Combined with Selective Neurectomies in Patients with Post-paretic Synkinesis - Comparing Outcomes.

BACKGROUND: In post-paretic synkinesis, muscle tone imbalance between upper and lower lip depressors and elevators, results in the inability to produce an effective smile. Surgical treatments to improve smile, focus on restoring tonicity balance between peri-oral muscles by weakening hyper-toned muscles through selective myectomies or selective neurectomies. The goal of this study was to compare objective outcomes between selective myectomies alone with those of selective myectomies combined with selective neurectomies. METHODS: Retrospective cohort study performed on post-paretic synkinesis patients who underwent depressor anguli oris (DAO) myectomies or DAO and platysma myectomies with selective neurectomies. Objective outcomes included pre- and post-operative analyses of smile measures (excursion, angle, and dental show) and Botox administration (periorbital and platysmal). RESULTS: Thirty-seven pa tients underwent DAO myectomies only (myectomy group) and eighteen patients underwent DAO and platysma myectomies with selective neurectomies (myectomy-neurectomy group). Within group analyses showed significant angle improvement in both groups (p<.05) and improved smile excursion in the myectomy-neurectomy group (p<.05). Between group comparisons showed significant closed mouth smile excursion improvement (difference in means: -1.14 millimeters; 95% CI -2.19 to -0.09; p=.034) and significant decrease in platysmal Botox administration (difference in means: 27.36 Botox units ; 95% CI 18.72 to 36.00; p<.001) in the myectomy-neurectomy group compared to the myectomy group. CONCLUSIONS: This study suggests that selective myectomies and selective myectomies with selective neurectomies provide overlapping and differing benefits to peri-oral synkinesis. Selective neurectomies and platysma myectomy provided slightly improved excursion and significantly decreased botulinum injections to the platysma.