Chemodenervation Algorithm: Functional and Aesthetic Considerations for Facial Harmony in Patients with Post-Facial Paralysis Synkinesis.

Management of post-facial paralysis synkinesis has evolved for the past decade with diversification of neuromuscular retraining, chemodenervation, and advanced surgical reanimation techniques. Chemodenervation with botulinum toxin-A is a commonly used treatment modality for synkinesis patients. Treatment has shifted from solely weakening the unaffected contralateral facial musculature for rote symmetry to selective reduction of undesired or overactive synkinetic muscles, allowing for a more organized motion of the recovered musculature. Facial neuromuscular retraining should be considered a crucial component of treating patients with synkinesis along with soft tissue mobilization, but specifics of these are beyond the scope of this article. Our goal was to create a descriptive platform for our method of chemodenervation treatment in the evolving field of post-facial paralysis synkinesis. A multi-institutional and multidisciplinary comparison of techniques was performed with photograph and video creation, review, and discussion over an electronic platform with all authors. Anatomic specifics of each region of the face and individual muscles were considered. A muscle by muscle algorithm for synkinesis therapy was created to include chemodenervation with botulinum toxin that should be considered for patients suffering from post-facial paralysis synkinesis.

Success of multiple, sequential, free tissue transfers to the head and neck.

INTRODUCTION: Free tissue transfer has become the primary reconstructive modality for significant ablative defects in the head and neck. The overall success rate is high, approaching 95% in most centers. The success rate of multiple sequential free flaps has been thought to be lower, based on the absence of optimal vessel availability and the presence of significant scar tissue in the previously operated patient. We evaluated a series of patients who underwent multiple free flaps at different time points to determine the overall success rate and to identify pitfalls encountered in this population. METHODS: Retrospective review, tertiary care medical center. RESULTS: From 1995 to 2002, 377 free flaps were performed by our reconstructive service. Of this group, 36 underwent multiple free flaps at different time points. Thirty-two had two flaps, and four had three flaps. Reasons for performing sequential free flap procedures were as follows: recurrent disease/new primary (18), need for further augmentation (10), failed previous flap (6), delayed mandibular reconstruction after plate fracture (2), mandibular osteoradionecrosis (3), and delayed pharyngoesophageal stenosis (1). The overall failure rate on the second and third flap was 2 of 32 and 0 of 4, respectively, with an overall success rate of 94%. CONCLUSION: Multiple, sequential, free tissue transfer for reconstruction of head and neck defects is a safe and reliable procedure with success rates equal to that in patients undergoing initial free flap reconstruction. Careful preoperative planning can result in optimal outcomes even in this difficult patient population.