Comparison of Objective Facial Metrics on Both Sides of the Face Among Patients with Severe Bell's Palsy Treated with Mirror Effect Plus Protocol Rehabilitation Versus Controls.

Objective: The extent to which the healthy hemiface dynamically contributes to facial synchronization during facial rehabilitation has been largely unstudied. This study compares the synchronization of both hemifaces in severe Bell's palsy patients who either received facial rehabilitation called "Mirror Effect Plus Protocol" (MEPP) or basic counseling. Methods: Baseline and 1-year postonset data from 39 patients (19 = MEPP and 20 = basic counseling) were retrospectively analyzed using Emotrics+, a software that generates facial metrics with artificial intelligence (AI) algorithms. Paired t-tests were used for intrasubject comparisons of hemifaces, and mixed model analysis were used to compare between groups. Results: For voluntary movements, a significant difference in favor of the MEPP group was only found for smiling (p = 0.025*). However, at 1-year postonset, the control group showed significant variability between hemifaces for most synkinesis measurements [nasolabial fold (p = 0.029*); eye area (p = 0.043*); palpebral fissure (p = 0.011*)]. Conclusion: In this study, a better synchronization of both hemifaces was found in the MEPP group. Interestingly, motor adaptation in movement amplitude of the healthy hemiface seemed to contribute to this synchronization in MEPP patients. Further studies are needed to standardize the procedure of AI measurements and to adapt it for clinical use.

Public and patients' perceptions of facial reanimation using lengthening temporalis myoplasty.

OBJECTIVES: To answer the clinical research questions: "Among facial paralysis patients (FPPs), did lengthening temporalis myoplasty (LTM) improve public's perceptions, patients' perceptions, as well as objective oral measurements of post-operative outcomes?" METHODS: To answer the research questions, we designed and implemented a hybrid cross-sectional and retrospective cohort study enrolling a cohort of laypersons and FPPs treated at a tertiary care center from 2011 to 2020. The primary predictor variables were LTM in FPPs (before/after) and medical background on medical care (FPPs/laypersons). The main outcome variable was post-operative outcomes (from a public's perspective, FPPs' perspective, and with objective measurements). Descriptive and univariate statistics were computed as appropriate, and P ≤ 0.05 was considered statistically significant. RESULTS: The sample consisted of 203 lay volunteers and 15 FPPs. After LTM, public perception voted the significant improvements in disfigured, important to repair, bothersome, severity (DIBS) score, and facial attractiveness. Patients' perspective was also significantly improved for global severity, oral function, and facial movement. Objective measurements of deviation at the oral commissure and the smile angle also significantly improved after LTM. CONCLUSION: Despite no control groups (i.e., other techniques to be compared) in this study, our study results suggest that LTM can be used to improve public's perception, patient's perception, and objective oral measurement of post-operative outcomes in FPPs. Because different questionnaires were used, it is unknown whether public and patient's perceptions are compatible.

Quantification and visualization of aerosols in ear, nose, and throat exam and flexible laryngoscopy.

Objective: To measure and visualize aerosol generation during ear, nose, and throat (ENT) exam and flexible laryngoscopy, as safety recommendations are currently to defer routine and low-priority examinations. Methods: Aerosols generated during ENT examination and flexible laryngoscopy were quantified by laser aerosol spectrometry and visualized live by high-speed imaging during those procedures for three participants who were tested three times for each test. Results: Routine ENT examination and flexible laryngoscopy produce aerosols at levels comparable to normal breathing and speech. Conclusion: During ENT examination and flexible laryngoscopy, the practitioner should wear a surgical mask and potentially contaminated surfaces should be cleaned after the procedure. For flexible laryngoscopy, it is recommended in addition that the patient wear a mask over the mouth in case the procedure induces a sneeze. The time during which the patient is unmasked should be minimized. In these settings, the risk to the practitioner is minimal unless the patient is sneezing or symptomatic. Level of Evidence: 1.

The "Mirror Effect Plus Protocol" for acute Bell's palsy: A randomized controlled trial with 1-year follow-up.

OBJECTIVE: To study the effects of the "Mirror Effect Plus Protocol" (MEPP) on global facial function in acute and severe Bell's Palsy. DESIGN: Single blind and randomized controlled trial to compare the effects of basic counseling (control group) versus MEPP (experimental group) over one year. SETTING: Outpatient clinic following referrals from Emergency or Otorhinolaryngology Departments. SUBJECTS: 40 patients (n = 20 per group) with moderately severe to total palsy who received standard medication were recruited within 14 days of onset. Baseline characteristics were comparable between the groups. INTERVENTIONS: The experimental group received the MEPP program (motor imagery + manipulations + facial mirror therapy) while the control group received basic counseling. Both groups met the clinician monthly until 6 months and at one-year post-onset for assessments. OUTCOME MEASURES: Facial symmetry, synkinesis, and quality of life were measured using standardized scales. Perceived speech intelligibility was rated before and after therapy by naïve judges. RESULTS: Descriptive statistics demonstrated improvements in favor of the MEPP for each measured variable. Significant differences were found for one facial symmetry score (House-Brackmann 2.0 mean (SD) = 7.40 (3.15) for controls versus 5.1 (1.44) for MEPP), for synkinesis measures (p = 0.008) and for quality-of-life ratings (mean (SD) score = 83.17% (17.383) for controls versus 98.36% (3.608) for MEPP (p = 0.002)). No group difference was found for perceived speech intelligibility. CONCLUSION: The MEPP demonstrates promising long-term results when started during the acute phase of moderately severe to total Bell's Palsy.

Development of an open-source and free facial rehabilitation website for severe bell's palsy: a within-subject study on user experience and patient's compliance with the MEPP-website.

PURPOSE: An open source and free website called Mirror Effect Plus Protocol (MEPP)-website was developed with features to diminish cognitive load and support motor learning during facial exercises. Assessing patient's perceptions is crucial when developing rehabilitation tools because patients' willingness to use the tools strongly affect engagement in the rehabilitation process. This study compared clinicians' and patients' user experience with the MEPP-website versus a hobby-designed website. MATERIALS AND METHODS: Ten patients with acute severe Bell's palsy and five clinicians were enrolled in a within-subject and crossover design. User experience was assessed with the Modular evaluation of Components of User Experience questionnaire. Wilcoxon-Signed-Rank test analysed user experience, and descriptive analyses explored the order effect. Therapeutic compliance was verified for the MEPP-website by an integrated feature. Clinicians' descriptive statistics and subjective observations were also reported. RESULTS: Both patients and clinicians demonstrated a preference for the MEPP-website, whether they used it first or second. Despite this preference, compliance with the MEPP-website was reduced, although it tended to be better when used first. CONCLUSIONS: MEPP- website during facial rehabilitation improved user experience. Better user experience likely optimizes how patients perform and facilitate their exercises. Factors affecting compliance with facial rehabilitation remain to be addressed.Implications for rehabilitationRecent data suggests that mirror effect therapy combined with drug therapy supports the recovery of severe Bell's Palsy.The specialized Mirror Effect Plus Protocol (MEPP)- website is a clinical computer-based tool developed to promote patients' motor learning and diminish cognitive load during mirror therapy.The MEPP-website increase clinicians' accessibility to a specialized facial rehabilitation tool for mirror therapy.Clinicians using the MEPP-website can also objectively and easily measure compliance to facial therapy with the MEPP-website.

Reconstruction of medium-size defects of the oral cavity: radial forearm free flap vs facial artery musculo-mucosal flap.

BACKGROUND: The radial forearm free flap (RFFF) is the most commonly used flap for defects of the oral cavity. The facial artery musculomucosal (FAMM) is a safe and effective method to reconstruct medium sized defects of the oral cavity. No comparison exists between the FAMM flap and RFFF. METHODS: 1) Retrospective chart review from 2007 to 2016. 2) Cost difference analysis. RESULTS: Thirteen FAMM flap cases and 18 RFFF met inclusion criteria. The FAMM flap showed a tendency to lower rates of return to the operating room (p = 0.065) as well as lower rates of complications not requiring return to the OR with 1 complication in 1 patient as opposed to 10 patients with 15 complications (p = 0.008). Also, FAMM flap had shorter operative times compared to the RFFF group (7.2HR and 8.9 HR respectively, p = 0.002). The average operative room related costs for a FAMM flap were 6510 CAD vs 10,703 CAD for RFFF (p < 0.0005). Speech and swallowing outcomes were similar (p > 0.05). CONCLUSION: The FAMM flap can be used for reconstruction of medium-size defects of the oral cavity with functional outcomes similar to the RFFF while decreasing the associated costs and morbidity.

Face Transplant: Current Update and First Canadian Experience.

SUMMARY: Facial vascularized composite allotransplantation has emerged as a groundbreaking reconstructive solution for patients with severely disfiguring facial injuries. The authors report on the first Canadian face transplant. A 64-year-old man sustained a gunshot wound, which resulted in extensive midface bony and soft-tissue damage involving the lower two-thirds of the face. In May of 2018, he underwent a face transplant consisting of Le Fort III and bilateral sagittal split osteotomies in addition to skin from the lower two-thirds of the face and neck. Virtual surgical planning was used to fabricate osteotomy guides and stereolithographic models. Microsurgical anastomoses of the facial (three branches) and infraorbital nerves were performed bilaterally. At 18-month follow-up, the aesthetic outcome was excellent. Partial restoration of light touch sensation had been observed over the majority of the allograft. Although significantly affected, animation, speech, mastication, and deglutition were continuously improving with intensive therapy. Nevertheless, the patient was now tracheostomy and gastrostomy free. Despite these limitations, he reported a high degree of satisfaction with the procedure and had reintegrated into the community. Four grade I episodes of acute rejection with evidence of endotheliitis were successfully treated. Postoperative complications were mainly infectious, including mucormycosis of the left thigh, treated with surgical resection and antifungal therapy. Undoubtedly, immunosuppression represents the greatest obstacle in the field and limits the indications for facial vascularized composite allotransplantation. Continuous long-term follow-up is mandatory for surveillance of immunosuppression-related complications and functional assessment of the graft.

French Translation and Validation of the Synkinesis Assessment Questionnaire.

Synkinesis is a distressing sequela of peripheral facial palsy (PFP). This study aimed to translate and validate the Synkinesis Assessment Questionnaire (SAQ), a reliable patient-reported outcome evaluation tool for synkinesis, in French. The SAQ was translated following a standard forward-backward translation procedure. After a cognitive debriefing with 10 PFP patients, the SAQ-F was assessed amongst 50 patients for internal consistency, known-group validity, construct validity, criterion validity, and test-retest reliability. Results demonstrated that the SAQ-F was valid, reliable, and had a unidimensional structure. The SAQ-F should be accompanied by clinician-based scales, to provide valuable additional information on the severity of synkinesis.

The Mirror Effect Plus Protocol for acute Bell's palsy: a randomised and longitudinal study on facial rehabilitation.

BACKGROUND: Small but interesting evidences suggest that facial rehabilitation for acute Bell Palsy (BP) could improve facial outcomes in patients who benefited from optimal medication, but whose symptoms are still severe two weeks after BP's onset. AIMS: This study aimed to provide preliminary evidence of the long-term effects of a new facial retraining based on motor imagery and mirror therapy, the Mirror Effect Plus Protocol (MEPP). MATERIAL AND METHODS: Twenty BP patients received the standard medication for acute BP and were then randomly allocated to the treatment (MEPP) or control group, if their palsy was still at least moderate-to-severe at 14 days post onset. Three blind independent assessors graded the patients' evolution until 6 months after onset. RESULTS: Significant differences between the groups were not found for any measured variable; however, a trend toward better recovery was found in the treatment group for every measured variable. This trend grew bigger for patients with severe or total BP. CONCLUSIONS: This study suggests a promising effect of the MEPP on acute severe to total BP but requires further investigation with a larger number of participants. SIGNIFICANCE: Facial rehabilitation should be considered as an adjunct to medication for acute and most severe degrees of BP.

Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review.

OBJECTIVE: The present review focuses on comparative studies of reconstruction with free flaps (FF) versus pedicled flaps (PF) after oncologic resection. METHOD: A systematic review was developed in compliance with PRISMA guidelines and performed using the Pubmed, Medline, EMBASE, Amed and Biosis databases. RESULTS: A total of 30 articles were included. FF are associated with a longer operative time, a higher cost and a higher incidence of postoperative revisions compared to PF. FF are associated with a longer stay at the intensive care unit than the supraclavicular artery island flap (SCAIF) and with a more extended hospital stay compared to the submental island flap (SMIF). FF are associated with fewer infections and necrosis compared to the pectoralis major myocutaneous flap (PMMF). CONCLUSION: The comparison of both type of flaps is limited by the inherent design of the studies included. In sum, FF seem superior to the PMMF for several outcomes. SMIF and SCAIF compare favorably to FF for some specific indications achieving similar outcomes at a lower cost.

Decreasing Revision Surgery in FAMM Flap Reconstruction of the Oral Cavity: Traditional Versus Modified Harvesting Technique.

OBJECTIVE: To compare the surgical and functional outcomes between two harvesting techniques for the inferiorly based facial artery musculomucosal (FAMM) flap for oral cavity and oropharynx reconstructions. METHODS: Multicenter retrospective chart review. RESULTS: We reviewed 55 cases of FAMM flap, including 29 traditional cases and 26 performed using the modified harvesting method. The overall rate of surgical re-intervention in the traditional group was 31% (n = 9 of 29) and 15% (n = 4 of 26) in the modified group (P = 0.196). The specific re-intervention rate for pedicle sectioning was 27% (n = 8 of 29) in the traditional group versus 0% (n = 0 of 26) in the modified group. The overall rate of complications was 21%. Nine out of 10 dentate patients in the traditional group and four out of five in the modified group needed tooth extraction. There was no difference between the two groups in terms of tracheostomy duration (P = 0.338) and time to first oral intake (P = 0.629). Speech and feeding outcomes were similar among groups (P = 0.922; P = 0.700, respectively). Dental rehabilitation was achieved in 67% and 78% of patients in the traditional and modified groups, respectively. CONCLUSION: The FAMM flap offers a low morbidity approach to reconstruct the oral cavity. The modified approach to harvesting the flap is a safe and effective technique, with similar functional results and equally low morbidity profile as the traditional technique. It has the added advantage of lower rates of secondary surgical interventions. LEVEL OF EVIDENCE: 4. Laryngoscope, 1802-1805, 2018.

Superiorly based facial artery musculomucosal flap: A versatile pedicled flap.

BACKGROUND: The superiorly based facial artery musculomucosal (FAMM) flap is pedicled on the angular artery. This flap offers a well-vascularized mucosal surface allowing closure of medium size defects, most frequently within the oral cavity and intranasal region. METHODS: We describe a superiorly based harvest of the FAMM flap, which may be used for closure of multiple head and neck surgical defects. An operative technique video is provided, which can be viewed online. RESULTS: Our results demonstrate a fast and relatively straightforward harvest technique of the FAMM flap. This intraoral flap is a useful reconstructive tool, which also has the advantage to leave no visible external scars. CONCLUSION: The superiorly pedicled FAMM flap is a versatile and effective technique that may be integrated in the algorithm for reconstruction of head and neck defects.

Video-Assisted Septoplasty: The Future in Teaching Septal Surgery-A Technical Note.

Teaching and learning septoplasty is challenging due to the limited and intermittent visualization of the surgical site by the resident and the mentor. Our objective was to develop and test the surgical tools required to achieve optimal visualization of the surgical field during septal surgery without having to modify the way conventional septoplasty is performed. A flexible high-definition endoscope is mounted on a modified 50-mm nasal speculum. This allows real-time visualization of all steps of the surgery on the video monitor. The residents can follow all intranasal surgical steps on the monitor while the surgeon is operating. In the same way, the mentor can guide the resident through the surgery and provide more appropriate feedback. All steps of the septal surgery can be recorded for later educational use. Video-assisted septoplasty will help surgeons teach septal surgery more efficiently.

Lengthening temporalis myoplasty for facial paralysis reanimation: an objective analysis of each surgical step.

IMPORTANCE: Lengthening temporalis myoplasty is a dynamic procedure used to reanimate the middle third of the paralyzed face. Since its original description, it has been progressively modified over the years, with a reduction in the number of surgical steps. However, these modifications can decrease lengthening needed for the tendon to reach the oral commissure and upper lip without tension or overcorrection. OBJECTIVES: To evaluate the maximal lengthening of the temporalis tendon that is possible with this technique and to assess the contribution of each surgical step to total lengthening. DESIGN, SETTING, AND PARTICIPANTS: Cadaveric dissection study from September 16 to 23, 2013, at a tertiary referral center using 10 cadaveric hemifaces. MAIN OUTCOMES AND MEASURES: Surgical exposure was obtained using coronal and melolabial incisions. The original surgical technique was broken down into 7 steps. Measurement of temporalis tendon lengthening relative to a fixed point was performed by a single surgeon after each surgical step using a millimeter ruler. RESULTS: Each surgical step resulted in progressive temporalis tendon lengthening for a median maximal total lengthening of 43.5 mm. The steps that contributed most to this lengthening were coronoidotomy and intraoral temporalis tendon dissection (median, 12.0 mm), incision of temporalis fascia insertion over the orbital rim (median, 6.5 mm), and zygomatic osteotomy with dissection of masseteric fibers (median, 11.5 mm), which represent the first and last 2 steps of the procedure, respectively. CONCLUSIONS AND RELEVANCE: Modifications of lengthening temporalis myoplasty must be considered with caution because the maximal lengthening potential can be obtained only when performing all 7 surgical steps. These modifications must be chosen appropriately based on the lengthening required for the temporalis tendon to reach the oral commissure and upper lip without tension or overcorrection. LEVEL OF EVIDENCE: NA.

Nasal osteotomies: a cadaveric study of fracture lines.

IMPORTANCE: The different nasal osteotomy patterns used to perform rhinoplasty are poorly described in the literature, and there is a continuous debate between surgeons on the ideal sequence and technique to obtain desired results. OBJECTIVES: (1) To evaluate the necessity of a paramedian osteotomy when performing a high-low-high (HLH) osteotomy, (2) to study the fracture pattern of a high-low-low (HLL) osteotomy when combined with a paramedian osteotomy in the presence and in the absence of a transverse osteotomy, and (3) to evaluate the mobility of the central segment (located between the paramedian osteotomies) after digital pressure and the ideal osteotomy to mobilize it if needed. DESIGN AND SETTING: This was a prospective cadaveric study performed in the dissection laboratory in our tertiary referral center. EXPOSURE: Twenty cadavers were divided in 2 groups of 10. Group A had a paramedian osteotomy combined with an HLH osteotomy on 1 side and an HLH osteotomy alone on the other side. Group B had a paramedian combined with a transverse osteotomy followed by HLL osteotomy on 1 side. On the other side, we performed a paramedian combined with an HLL osteotomy. Finally, we evaluated the mobility of the central segment in group B, first with digital manipulation and then with a transverse osteotomy. MAIN OUTCOME AND MEASURE: The 3 authors evaluated individually the different fracture patterns. A result was considered successful when (1) the fracture followed the desired pattern, (2) a continuous line was obtained, and (3) a complete mobilization of the nasal segment was visualized. RESULTS: In group A, the side without a paramedian osteotomy had more unstable and greenstick fractures than the other side (P < .001). In group B, the side with a transverse osteotomy had more reliable and stable fractures than the other side (P < .05). Digital manipulation alone was not enough to mobilize the central segment in 8 of the 10 cadavers studied. CONCLUSIONS AND RELEVANCE: Following this study we make the following suggestions: (1) to perform a paramedian osteotomy when an HLH osteotomy is needed, (2) to perform a transverse osteotomy before an HLL osteotomy when combined with paramedian osteotomy, and (3) to manipulate the central segment with a transverse osteotomy in order to mobilize it in a safe and predictable manner. LEVEL OF EVIDENCE: NA.

The submental island flap for soft-tissue head and neck reconstruction: step-by-step video description and long-term results.

UNLABELLED: A clinical case of a man undergoing radical parotidectomy with skin resection for an intraparotid recurrence of squamous cell carcinoma is presented. A step-by-step video description of the regional submental island flap, based on the right submental vessels, is presented and discussed. Long-term results at 1 year in terms of color match at the recipient and donor sites are excellent, along with no functional consequence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

The lion's mane sign: surgical results using the bilateral fronto-orbito-nasal approach in large and giant anterior skull base meningiomas.

OBJECT: Concerns about extreme peritumoral edema and its ensuing surgical and perioperative complications led the authors to use the bilateral fronto-orbito-nasal approach to remove midline anterior skull base meningiomas that were larger than 4 cm. The authors hypothesize that extreme vasogenic edema exemplified by finger-like hyperintensities extending into the bifrontal white matter and external capsule and/or the extreme capsule, coined the lion's mane sign (LMS), would help identify patients with a challenging postoperative course. They hypothesize that the LMS would better predict symptomatic postoperative cerebral edema than the edema index (EI). METHODS: This is an observational case series of 9 patients. The authors noted the grade, pathology, tumor volume, EI, and the presence or absence of the LMS in all tumors. They used the intensive unit care (ICU) length of stay as a nonspecific measure reflecting postoperative symptomatic cerebral edema. Comparisons of edema-related postoperative complications and the EI were made between patients with and without an LMS. RESULTS: Bifrontal hyperintensities, extending into at least three-eighths of the length of the external capsules on T2-weighted MRI, seen in 4 of 9 patients, portended a longer postoperative ICU stay. The presence of an LMS better predicted postoperative complications related to cerebral edema than tumor grade, pathology, volume, or EI. CONCLUSIONS: The LMS predicts an increased duration of stay in the ICU after a bilateral fronto-orbito-nasal approach for resection of large and giant anterior skull base meningiomas. Furthermore, the LMS better predicted increased length of stay in the ICU than did the EI.