Triple nerve transfers for the management of early unilateral facial palsy.

BACKGROUND: Early onset facial paralysis is usually managed with cross-face nerve grafts, however the low number of axons that reach the target muscle may result in weakness or failure. Multiple-source innervation, or 'supercharging', seeks to combine the advantages of different donor nerves while minimizing their weaknesses. We propose a combination of cross-face nerve grafts with local extra-facial nerve transfers to achieve earlier facial reanimation in our patients. METHODS: A retrospective cohort including all patients with early unilateral facial palsy (<12 months evolution) who underwent triple nerve transfer between 2019 and 2021 was conducted. We performed single-stage procedure including zygomatic-to-zygomatic and buccal-to-buccal cross-face grafts, a nerve-to-masseter to bucozygomatic trunk transfer, and a mini-hypoglossal to marginal branch transfer. Results were evaluated using the clinician-graded facial function scale (eFACE). RESULTS: Fifteen patients were included (eight females, seven males), mean age at the time of surgery was 48.9 ± 13.3 years. Palsy was right-sided in eight cases. The mean time from palsy onset to surgery was 5.5 ± 2.8 months. Patients showed improvement in static (70.8 ± 21.9 vs. 84.15 ± 6.68, p = 0.002) and dynamic scores (20 ± 16.32 vs. 74.23 ± 7.46, p < 0.001), as well as periocular (57.33 ± 15.23 vs. 74 ± 7.18, p = 0.007), smile (54.73 ± 11.93 vs. 85.62 ± 3.86, p < 0.001), mid-face (46.33 ± 18.04 vs. 95 ± 7.21, p < 0.001) and lower face scores (67.4 ± 1.55 vs. 90.31 ± 7.54, p < 0.001). CONCLUSION: The triple nerve transfer technique using cross-face nerve grafts, the nerve-to-masseter, and the hypoglossal nerve, is an effective and reproducible technique to obtain middle and lower face reanimation in cases of early facial palsy.

Dynamic reanimation of severe blepharoptosis using the neurotized omohyoid muscle graft.

BACKGROUND: Attempts at dynamic reconstruction of the upper eyelid either by neurotization or direct muscle replacement have been scarce. Substitution of the levator palpebrae superioris muscle requires the use of extremely small and pliable structures. As a proof of concept/pilot study, we present a consecutive series of patients who underwent blepharoptosis correction using the neurotized omohyoid muscle graft. METHODS: Retrospective analysis of patients receiving a neurotized omohyoid muscle graft for levator palpebralis substitution between January and December 2019. RESULTS: Five patients were operated (2 male, 3 female); median age was 35.5 years. Median palpebral aperture was 0 mm and levator function was< 1 mm in all cases. Median denervation time for the levator muscle was 9 years. All surgeries were uneventful, and no postoperative complications were seen. Twelve months after the procedure, all patients presented with adequate palpebral aperture on activation of the spinal nerve. Median palpebral aperture was 6.5 mm Postoperative electromyography revealed muscle contraction when stimulation was applied to the spinal nerve. CONCLUSION: This study introduces the concept of severe blepharoptosis correction using the omohyoid muscle. We believe that with time and further technical refinements it could become an invaluable tool in eyelid reconstruction surgery.

Prevalence of Hand Malformations in Patients With Moebius Syndrome and Their Management.

BACKGROUND: Moebius syndrome is a disorder characterized by facial and abducens nerve paralysis. Patients can present a wide range of upper extremity malformations. Literature focused on orthopedic manifestations of Moebius syndrome shows variability in the prevalence and clinical presentation of upper extremity anomalies. The aim of this work is to evaluate the prevalence of upper extremity malformations in patients with Moebius syndrome, clarify its various clinical presentations, and present treatment strategies for their management. METHODS: This is a retrospective, cross-sectional study including patients with Moebius syndrome and upper extremity malformations between 2012 and 2019. Data include demographic characteristics, Moebius syndrome subtype, type of malformation, affected extremity, and surgical procedures underwent. Quantitative data were recorded as mean (standard deviation [SD]), and qualitative data were expressed in terms of totals and percentages. Statistical association between Moebius syndrome subtype and development of upper extremity anomalies was evaluated using binary logistic regression. RESULTS: Twenty-five out of 153 patients (16.3%) presented upper extremity malformations (48% male). Mean age of presentation was 9.08 ± 9.43 years. Sixty-eight percent of the malformations were unilateral. The most common presentations included Poland syndrome and simple syndactyly with 8 cases each (32%), followed by 5 cases of brachysyndactyly (20%), 3 cases of amniotic band syndrome (12%), and 1 case of cleft hand (4%). No statistical association was found between Moebius syndrome subtype and odds ratio for development of upper extremity anomalies. Thirteen patients (52%) underwent reconstructive procedures. CONCLUSION: Poland syndrome and syndactyly are the most common anomalies in patients with Moebius syndrome. Patients may present with a wide range of hand malformations, each patient should be carefully evaluated in order to determine whether surgical treatment is needed and to optimize rehabilitation protocols.

Facial paralysis, etiology and surgical treatment in a tertiary care center in plastic and reconstructive surgery in Mexico.

BACKGROUND: Facial paralysis is a frequent disabling entity that causes a negative impact on the cosmetic, functional, social, psychological and economic aspects of the patient. Surgical treatment aims to restore the patient to her previous life with the fewest possible sequelae. OBJECTIVE: Describe the experience of surgical management and propose a treatment algorithm. METHOD: A retrospective study was carried out from 2017 to 2019 of the records of patients with facial nerve involvement. The variables were age, sex, etiology, affected side and procedures performed. RESULTS: 108 patients were obtained. The most frequent cause was development facial paralysis (41,8%), followed by resection of intracranial tumors (29%). A total of 225 procedures were performed, average per patient of 2.7. The most performed dynamic procedure was the gracilis-free flap (59%). The most frequent static procedures were the placement of a gold weight (24%) and the recreation of the nasogenian sulcus (13%). CONCLUSIONS: The surgical treatment algorithm will depend on the evolution time, etiology, donor nerves and state of the facial musculature. The gracilis-free flap continues to be the gold standard procedure in facial paralysis reconstruction. Static procedures are additionally required to achieve a satisfactory aesthetic and functional result.

ANTECEDENTES: La parálisis facial es una afección incapacitante que con frecuencia causa un impacto negativo en los aspectos cosméticos, funcionales, sociales, psicológicos y económicos. El tratamiento quirúrgico tiene como objetivo mejorar la calidad de vida dejando la menor cantidad posible de secuelas. OBJETIVO: Describir la experiencia del manejo quirúrgico y proponer un algoritmo de tratamiento. MÉTODO: Se realizó un estudio retrospectivo, de 2017 a 2019, de los expedientes de pacientes con afección del nervio facial. Las variables consideradas fueron la edad, el sexo, la etiología, el lado afectado y los procedimientos quirúrgicos realizados. RESULTADOS: Se obtuvieron 108 pacientes y la causa más frecuente fue la parálisis facial del desarrollo sindrómica (42%), seguida de la resección de tumores intracraneales (29%). Se realizaron 225 procedimientos, con un promedio de 2.7 por paciente. El procedimiento dinámico más realizado fue el colgajo libre de gracilis (59%). Los procedimientos estáticos más frecuentes fueron la colocación de una pesa de oro (24%) y la recreación del surco nasogeniano (13%). CONCLUSIONES: La secuencia del tratamiento quirúrgico dependerá del tiempo de evolución, la etiología, los nervios disponibles y el estado de la musculatura facial. El colgajo libre de gracilis continúa siendo el procedimiento de elección en la reconstrucción de la parálisis facial. Adicionalmente se requieren procedimientos estáticos para lograr un resultado estético y funcional satisfactorio.

Lower extremity nerve injuries and their management at a referral center in Mexico City.

OBJETIVO: Describir el manejo de las lesiones nerviosas de extremidad inferior atendidas en un centro de referencia en cirugía plástica y reconstructiva en la Ciudad de México. MÉTODO: Estudio descriptivo, transversal y retrospectivo, en el que se evaluaron los expedientes clínicos de pacientes atendidos por lesiones nerviosas de extremidad inferior entre 2010 y 2018. RESULTADOS: Se incluyeron 21 pacientes, 14 hombres (66.6%) y 7 mujeres (33.3%), con una edad promedio de 30.00 ± 8.89 años. Las lesiones en la extremidad derecha fueron más prevalentes (52.3%). El mecanismo de lesión más común fue por herida por proyectil de arma de fuego (28.5%) o por accidente automovilístico (13.6%). Los nervios más afectados fueron el ciático (38.0%) y el peroneo (38.0%), seguidos por el tibial (9.5%), el peroneo y el tibial simultáneamente (9.5%) y el femoral (4.7%). Las medidas de tratamiento más empleadas fueron las transferencias nerviosas (7 casos, 33.3%) y la aplicación de injertos nerviosos para el manejo de brechas (7 casos, 33.3%). CONCLUSIONES: La reparación de las estructuras nerviosas de la extremidad inferior ha recibido poca atención. Sin embargo, nuestro estudio muestra que es posible aplicar diversas estrategias reconstructivas microquirúrgicas, buscando mejorar los desenlaces funcionales de los pacientes. OBJECTIVE: To describe the management of lower extremity nerve injuries at a plastic and reconstructive surgery referral center in Mexico City. METHOD: A descriptive, transversal and retrospective study was performed, evaluating clinical records of patients with lower extremity nerve injuries managed in our center between 2010 and 2018. RESULTS: Twenty-one patients were included, 14 males (66.6%) and 7 females (33.3%); mean age was 30.00 ± 8.89 years. Right-sided injuries were more prevalent (52.3%). The most common etiologies were gunshot injuries (28.5%) and motor vehicle accidents (13.6%). The most frequently affected nerves were the sciatic (38.0%) and the peroneal nerves (38.0%), followed by the tibial (9.5%), simultaneous tibial and peroneal nerve injury (9.5%) and the femoral nerve (4.7%). Nerve transfers (7 cases, 33.3%) and autologous nerve grafts (7 cases, 33.3%) were the preferred surgical techniques for injury management. CONCLUSIONS: Repair of lower extremity nerve injuries has not been popularized, however our study shows that several microsurgical reconstructive strategies are available in order to improve functional outcomes.

Cephalometric Analysis of the Craniofacial Morphology in Patients With Moebius Syndrome.

BACKGROUND: Patients with Moebius syndrome may present a wide range of associated orofacial malformations, however, their craniofacial morphology has not been established via controlled cephalometric studies. OBJECTIVE: To present our institution's findings in the cephalometric evaluation in patients with Moebius syndrome. METHODS: Retrospective, cross-sectional study that included patients with Moebius syndrome over 9 years of age who had lateral cephalometric radiographs. Cephalometric analysis measurements of Ricketts, Steiner, and McNamara were performed. Quantitative data are expressed as mean and standard deviation, and qualitative data are expressed in totals and percentages. Comparative statistics between classic and incomplete Moebius and between patients older and younger than 16 years of age were performed. RESULTS: Twenty-four patients were included (54.2% females), mean age 17.46 ±â€Š8.85 years. Fifteen patients (62.5%) had classic Moebius syndrome, and nine (37.5%) had incomplete Moebius. Sixty-six percent of the patients presented either micrognathia or retrognathia, 95% showed mandibular hypoplasia, and 75% had a skeletal class II. Maxillary height was increased resulting in a vertical growth pattern. Upper and lower incisors tended towards proclination, and upper and lower lips protruded over cephalometric markings, and a long upper lip was evidenced in 41% of the patients. No significant differences were noted when comparing classic and incomplete Moebius syndrome. Patients younger than 16 years of age had significantly larger sella-nasion-A point and sella-nasion-B point angles, and a higher proportion of skeletal class II cases. CONCLUSIONS: Patients with Moebius syndrome have a vertical maxillary growth, micro or retrognathia, developing a skeletal class II and lip protrusion.

Diagnosis and treatment of speech disorders in children with Moebius syndrome.

BACKGROUND: Moebius syndrome (MS) is characterized by congenital bilateral paralysis of the facial and abducens nerves. Clinical features include feeding problems, dysarthria, dysphagia, sialorrhea, strabismus, and lack of facial expression. Patients with MS frequently present with dysphagia during infancy. Further on during childhood a severe speech disorder is a common feature. However, articulation deficits in patients with MS are scarcely reported in the related scientific literature. OBJECTIVE: The aim of this study is to describe speech deviations, intelligibility and sialorrhea in patients with MS. MATERIAL AND METHODS: Eighty-seven patients with MS were prospectively studied. Age ranged from 4 to 18 years. A complete Speech and Language Pathology (SLP) evaluation was performed in all cases. The evaluation focused on articulation placement, sialorrhea and intelligibility of speech. RESULTS: Sialorrhea was detected in 23% of the patients. Abnormal articulation placement of bilabial phonemes was observed in 68% of the patients. Another 50% of the patients presented with articulation placement errors in other phonemes. Intelligibility was classified as adequate in 18% of the cases. Mildly affected intelligibility was found in 51% of the patients. Speech was considered moderately unintelligible in 20% of the cases. Unintelligible speech was found in 11% of the patients. CONCLUSIONS: From the results of this prospective study it can be concluded that a high percentage of patients with MS are at high risk of presenting with moderate to severe speech disorders. Thus, an early SLP intervention should be provided for this population in order to enhance speech development and reducing the risk of severe oral communication impairments.

Caracterización electrofisiológica y análisis con la escala eFACE de la parálisis facial en el espectro óculo aurículo vertebral / Electrophysiological characterization and eFACE evaluation in facial palsy associated to the oculo auriculo vertebral spectrum

INTRODUCCIÓN Y OBJETIVO: El Espectro Óculo Aurículo Vertebral (EOAV) es un conjunto de malformaciones congénitas que incluye malformaciones orbitarias, mandibulares, auriculares, de tejidos blandos, del nervio facial y malformaciones vertebrales. El compromiso de los pares craneales, y más específicamente del nervio facial, se presenta en un 10 a un 45% de los casos. La clasificación de OMENS evalúa la función del nervio facial con parámetros anatómo-clínicos, a diferencia de la escala eFACE que permite determinar la función del nervio facial y la simetría del rostro en reposo y en movimiento. Los estudios electrofisiológicos son los más útiles y objetivos para valorar la función del nervio facial y de sus músculos diana. El objetivo de este estudio es realizar una caracterización electrofisiológica y una evaluación con la escala eFACE de la parálisis facial en el EOAV. Material y MÉTODO: Estudio observacional descriptivo, prolectivo y transversal que incluye todos los pacientes de nuestra institución con compromiso del nervio facial asociado a EOAV excluyendo aquellos expedientes sin estudios electrofisiológicos. RESULTADOS: Evaluamos 32 pacientes que cumplían criterios de inclusión: 12 varones y 20 mujeres, con edad media de 11.46 años, de los que 17 presentaron parálisis facial izquierda, 14 derecha y 1 bilateral. Según la clasificación de OMENS las ramas superiores del nervio facial estaban comprometidas en 6 pacientes, las inferiores en 3 y todas en 23. En la escala de eFACE obtuvimos un puntaje (score) de reposo promedio de 74, dinámico promedio de 56, periocular promedio de 72, de tercio medio facial y de la sonrisa promedio de 68 y de tercio inferior promedio de 79. Los estudios de neuroconducción del nervio facial reportaron axonopatia motora mixta con compromiso de 3 ramas en 23 pacientes, 2 ramas en 5 y 1 rama en 4 casos; 13 pacientes presentaron compromiso en la rama maseterina del nervio trigémino y 4 en el nervio hipogloso. En la electromiografía 5 pacientes tuvieron ausencia de respuesta en tercio superior, 3 en los músculos de la sonrisa y 7 en los depresores del labio inferior. CONCLUSIONES: La evaluación clínica funcional con la escala de eFACE y la caracterización electrofisiológica de los pacientes con parálisis facial del desarrollo asociada al EOAV permiten determinar el compromiso de las distintas ramas del nervio facial, el estado de la musculatura facial y el compromiso de otros pares craneales

BACKGROUND AND OBJECTIVE: The Oculo Auriculo Vertebral Spectre (OAVS) refers to a series of malformations in the orbit, mandible, ear, facial nerve as well as spine/vertebral defects. Facial nerve compromise is present in up to 10-45% of the cases. OMENS classification evaluates facial nerve function according to clinical parameters, whereas the eFACE scale system provides a graphic output, it evaluates 3 categories static, dynamic, and synkinetic. Further, eletrophysiological studies are currently one of the most useful and objective methods to evaluate nerve viability and target muscles. The aim of this investigation is to conduct an electrophysiological characterization and an evaluation with the eFACE scale in patients with facial palsy associated to OAVS. METHODS: All cases of OAVS associated to facial palsy from our institution were included. Each patient was evaluated with the eFACE scale system. We excluded patients without electrophysiological studies. RESULTS: A total of 32 patients were evaluated: 12 male and 20 female, with a mean age of 11.46 years old. Seventeen had a left facial palsy, 14 had right facial palsy and 1 had bilateral involvement. The superior facial nerve branches were affected in 6 patients, 3 had inferior nerve involvement and 23 had involvement of all of the facial nerve branches. According to the eFACE scale, the mean score was 74 (repose) and 56 (dynamic). The peri-ocular score was 72, a mean score of 68 for middle facial third (including smile) and an inferior score of 79. As for the neuroconduction studies, most of them reported a mixed axonopathy, with involvement of 3 branches in 23 patients, 2 branches in 5 and 1 branch in 4 cases. Thirteen patients had involvement of the masseteric nerve branch and 4 in the hypoglossal nerve. As for the electromyography, 5 patients had no activity in the upper third, 3 in the smile muscles and 7 in the depressors. CONCLUSIONS: The eFACE scale and electrophysiological characterization of patients with facial palsy associated to OAVS provides useful information regarding the facial nerve's branches involvement and the current state of muscular function, both of utmost importance when clinical evaluation is performed before any type of surgical procedure is planned in this patients

Changes in Electrical Activity of the Masseter Muscle and Masticatory Force after the Use of the Masseter Nerve as Donor in Facial Reanimation Surgery.

Introduction The masseter nerve has been used as a donor nerve for facial reanimation procedures due to the multiple advantages it offers; it has been generally considered that sacrifice of the masseter nerve does not alter the masticatory apparatus; however, there are no objective studies to support this claim. Objective To evaluate the impact that the use of the masseter nerve in dynamic facial reconstruction has on the electrical activity of the masseter muscle and on bite force. Materials and Methods An observational and prospective longitudinal study was performed measuring bite force and electrical activity of the masseter muscles before and 3 months after dynamic facial reconstructive surgery using the masseter nerve. An occlusal analyzer and surface electromyography were employed for measurements. Results The study included 15 patients with unilateral facial paralysis, with a mean age of 24.06 ± 23.43. Seven patients were subjected to a masseter-buccal branch nerve transfer, whereas in eight patients, the masseter nerve was used as a donor nerve for gracilis free functional muscle transfer. Electrical activity of the masseter muscle was significantly reduced after surgery in both occlusal positions: from 140.86 ± 65.94 to 109.68 ± 68.04 ( p = 0.01) in maximum intercuspation and from 123.68 ± 75.64 to 82.64 ± 66.56 ( p = 0.01) in the rest position. However, bite force did not show any reduction, changing from 22.07 ± 15.66 to 15.56 ± 7.91 ( p = 0.1) after the procedure. Conclusion Masseter nerve transfer causes a reduction in electromyographic signals of the masseter muscle; however, bite force is preserved and comparable to preoperative status.

Electromyographic evaluation of the facial and motor donor nerves before facial reanimation surgery in Moebius syndrome.

BACKGROUND: Moebius syndrome is a clinical entity characterized by bilateral facial and abducens nerve palsies; other cranial nerver might be affected as well. So far, no studies have reported the electromyographic responses of the facial musculature in this group of patients. OBJECTIVE: The objective of our study is to describe the electromyographic responses of the facial muscle and the main donor nerves for facial reanimation in patients with Moebius syndrome. METHOD: We analyzed electromyographies from the facial, hypoglossal, masseterine (trigeminal) and accessory nerves from patients with Moebius syndrome treated between 2010 and 2016. Results are presented as percentages and central tendency measures. RESULTS: 24 patients were included, mean age 11.79 ± 9.39 years. The facial nerve showed complete unilateral recruitment in 4 patients, partial bilaterally in 11, 7 showed no activity bilaterally and two had unilateral inactivity. The masseterine was normal in 14 patients, had partial recruitment bilaterally in 4 and unilaterally in 4 cases. The accessory nerve was normal in 20 patients, showed partial recruitment bilaterally in 3 and unilaterally in 1 patients. The hypoglossal was normal in 22 patients, and altered in 2 cases. CONCLUSION: Patients with Moebius syndrome show several degrees of alteration in electromyographic evaluation of the facial nerve. Electromyography is a useful tool in evaluating potential motor donor nerves for facial reanimation surgery.

ANTECEDENTES: El síndrome de Moebius es una entidad clínica caracterizada por parálisis bilateral congénita del nervio facial y el abducens. Adicionalmente se pueden encontrar afectados otros pares craneales. Actualmente no existen estudios que reporten la respuesta electromiográfica de la musculatura facial en esta población. OBJETIVO: Describir la respuesta electromiográfica de la musculatura facial y de los principales nervios donadores para reconstrucción facial dinámica en pacientes con síndrome de Moebius. MÉTODO: Se analizaron electromiografías de los nervios facial, hipogloso, maseterino (trigémino) y accesorio en pacientes con síndrome de Moebius atendidos entre 2010 y 2016. Los resultados se presentan en porcentajes y medidas de tendencia central y de dispersión. RESULTADOS: Se incluyeron 24 pacientes, con una edad promedio de 11.79 ± 9.39 años. El nervio facial presentó reclutamiento unilateral completo en 4 pacientes, parcial bilateral en 11 pacientes, en 7 pacientes ausencia de reclutamiento bilateral e inactividad unilateral en 2 pacientes. El maseterino tuvo reclutamiento completo en 14 pacientes, parcial bilateral en 4 pacientes y parcial unilateral en 4 pacientes. El nervio accesorio mostró reclutamiento completo en 20 pacientes, parcial bilateral en 3 pacientes y parcial unilateral en 1 paciente. El hipogloso mostró actividad normal en 22 pacientes, parcial bilateral en 1 paciente y parcial unilateral en 1 paciente. CONCLUSIÓN: Los pacientes con síndrome de Moebius presentan alteraciones en los registros electromiográficos del nervio facial. La electromiografía permite identificar los nervios donadores para realizar la reconstrucción dinámica.

Difficult Airway Identification and Management in Patients With Moebius Syndrome.

BACKGROUND: Airway management in patients with Moebius syndrome can be difficult due to the presence of orofacial malformations. This paper aims to present our institution's experience in the evaluation and management of the upper airway in patients with Moebius syndrome METHODOLOGY:: The authors performed a retrospective study including every patient with Moebius syndrome submitted to surgery between 2012 and 2017. Difficult airway was defined as one requiring more than 2 attempts to achieve endotracheal tube placement, a Mallampati score equal or above III, a Cormack score equal or above III, or need of a fiberscope during intubation. RESULTS: Fifty-one patients were included, (39.3% males) requiring 172 procedures. Each patient required an average of 3.37 ±â€Š1.94 anesthetic events. Average Body Mass Index (BMI) was 20.07 ±â€Š6.06, 45.1% were overweight or obese. Four patients (7%) were considered as having a potentially difficult airway. Endotracheal intubation was achieved in all patients; 38 patients were intubated in a single attempt, while the rest were successfully intubated on a second try. Fiberscope was not necessary. Univariate analysis showed that overweight/obese patients were more likely to be considered as having a difficult airway (P = 0.03). CONCLUSION: Intubation can be difficult in patients with Moebius syndrome, but failure is rare. Overweight or obese patients are at risk of presenting a difficult airway. An extensive preoperative evaluation and adequate communication between the members of the multidisciplinary team in charge of these patients is paramount.

Bite force and electromyographic activity of the masseter muscle in children with hemifacial microsomia.

Hemifacial microsomia (HFM) is a malformation characterized by asymmetric facial growth with mandibular and muscular involvement. There are no reports focused on the functional status of the masticatory system of patients with HFM. The objective of this work evaluate bite force and electrical activity of masseter muscle in children with HFM, and compare them to healthy controls. A cross-sectional study was performed to compare bite force and electrical activity of masseter muscle between subjects with HFM and healthy children. Mean bite force (MBF) and surface electromyography (EMG) on maximum intercuspation (MIC) and rest position (RP) from both sides of the face were recorded. Comparative statistics between HFM patients and controls were performed using the Mann-Whitney test, Wilcoxon's signed rank test was used to compare the microsomic and healthy hemifaces. Twenty children with HFM and 10 controls were included, average age was 7.2 years (range 3-14). MBF did not show statistical significance between both groups. Surface EMG signal at MIC was significantly diminished when compared to the healthy side (p = .003) and to the control group (p = .016), this significance was also present at RP when comparing the affected and non-affected sides of the face (p < .01) but not against the controls (p = .08). This study showed that patients with HFM had diminished EMG values of the masseter muscle on the affected side, compared to healthy individuals, but bite force did not show significant alterations.

An International Collaborative Standardizing Patient-Centered Outcome Measures in Pediatric Facial Palsy.

IMPORTANCE: Standardization of outcome measurement using a patient-centered approach in pediatric facial palsy may help aid the advancement of clinical care in this population. OBJECTIVE: To develop a standardized outcome measurement set for pediatric patients with facial palsy through an international multidisciplinary group of health care professionals, researchers, and patients and patient representatives. DESIGN, SETTING, AND PARTICIPANTS: A working group of health care experts and patient representatives (n = 21), along with external reviewers, participated in the study. Seven teleconferences were conducted over a 9-month period between December 3, 2016, and September 23, 2017, under the guidance of the International Consortium for Health Outcomes Measurement, each followed with a 2-round Delphi process to develop consensus. This process defined the scope, outcome domains, measurement tools, time points for measurements, and case-mix variables deemed essential to a standardized outcome measurement set. Each teleconference was informed by a comprehensive review of literature and through communication with patient advisory groups. Literature review of PubMed was conducted for research published between January 1, 1981, and November 30, 2016. MAIN OUTCOMES AND MEASURES: The study aim was to develop the outcomes and measures relevant to children with facial palsy as opposed to studying the effect of a particular intervention. RESULTS: The 21 members of the working group included pediatric facial palsy experts from 9 countries. The literature review identified 1628 papers, of which 395 (24.3%) were screened and 83 (5.1%) were included for qualitative evaluation. A standard set of outcome measurements was designed by the working group to allow the recording of outcomes after all forms of surgical and nonsurgical facial palsy treatments among pediatric patients of all ages. Unilateral or bilateral, congenital or acquired, permanent or temporary, and single-territory or multiterritory facial palsy can be evaluated using this standard set. Functional, appearance, psychosocial, and administrative outcomes were selected for inclusion. Clinimetric and psychometric outcome measurement tools (clinician-, patient-, and patient proxy-reported) and time points for measuring patient outcomes were established. Eighty-six independent reviews of the standard set were completed, and 34 (85%) of the 40 patients and patient representatives and 44 (96%) of the 46 health care professionals who participated in the reviews agreed that the standard set would capture the outcomes that matter most to children with facial palsy. CONCLUSIONS AND RELEVANCE: This international collaborative study produced a free standardized set of outcome measures for evaluating the quality of care provided to pediatric patients with facial palsy, allowing benchmarking of clinicians, comparison of treatment pathways, and introduction of value-based reimbursement strategies in the field of pediatric facial palsy. LEVEL OF EVIDENCE: NA.

Comentario al artículo "Evaluación de la perfusión de colgajos mediante indocianina verde" / No disponible

No disponible

[Implementation of intraoperative neurophysiologic monitoring in children and adults in secondary and tertiary health care facilities]. / Implementación del monitoreo neurofisiológico intraoperatorio en niños y adultos en el segundo y tercer nivel de atención.

INTRODUCTION: Intraoperative neurophysiological monitoring (IONM) is a procedure that uses neurophysiological techniques in order to evaluate the motor and sensitive systems during surgeries that endanger the nervous system. METHOD: The approach, scope, target population, and clinical questions to be answered were defined. A systematic search of the evidence was conducted step by step; during the first stage, clinical practice guidelines were collected, during the second stage systematic reviews were obtained, and during the third stage, clinical trials and observational studies were procured. The MeSH nomenclature and free related terminology were used, with no language restrictions and a 5-10 years frame. The quality of the evidence was graded using the CEPD and SIGN scales. RESULTS: Obtained using the search algorrhythms of 892 documents. Fifty-eight were chosen to be included in the qualitative synthesis. A meta-analysis was not possible due to the heterogeneity of the studies. CONCLUSIONS: Eighteen recommendations were issued and will support the adequate use of the IONM.

INTRODUCCIÓN: El monitoreo neurofisiológico intraoperatorio (MNIO) es un procedimiento que emplea técnicas neurofisiológicas con la finalidad de evaluar los sistemas motor y sensitivo durante cirugías que ponen en riesgo al sistema nervioso. MÉTODO: Se definieron el enfoque, los alcances, la población diana y las preguntas clínicas por resolver. Se realizó una búsqueda sistematizada de la evidencia por etapas. En la primera, se buscaron guías de práctica clínica; en la segunda, revisiones sistemáticas; y en la tercera, ensayos clínicos y estudios observacionales. Se utilizaron los términos MeSH y libres correspondientes, sin restricciones de lenguaje y con una temporalidad de 5 a 10 años. Se graduó la calidad de la evidencia utilizando las escalas CEPD y SIGN. RESULTADOS: Mediante los algoritmos de búsqueda se obtuvieron 892 documentos, y se seleccionaron 58 para la inclusión de la síntesis cualitativa. Debido a la heterogeneidad entre los estudios, no fue posible realizar metaanálisis. CONCLUSIONES: Se emitieron 18 recomendaciones, las cuales servirán como apoyo para la adecuada utilización del MNIO.

Facial Reanimation in the Seventh and Eighth Decades of Life.

BACKGROUND: Treatment of facial paralysis in the older population is often relegated to static rather than dynamic reanimation for fear of poor outcomes. This pervasive approach lacks physiologic foundation and is not evidence based. Thus, the authors present an extensive literature review demonstrating weak evidence supporting this misguided concept, followed by detailed outcomes from three centers of the largest reported series to date of patients older than 60 years after reanimation performed using three techniques-lengthening temporalis myoplasty, free functional muscle, and nerve transfers. METHODS: A PubMed search spanning over 40 years identified all reports on reanimation in patients older than 60 years. In addition, detailed demographics, surgical techniques, and outcomes of 30 patients older than 60 years were analyzed. RESULTS: Of 629 articles, only 45 patients were identified, described in case reports or small series, lacking details or consistent long-term follow-up. In the clinical series, average age, preoperative House-Brackmann score, and comorbidities were similar among the groups. Highest excursion was observed in the free functional muscle group, followed by nerve transfer and temporalis myoplasty, averaging 10.4, 6.8, and 3.1 mm, respectively. The most notable philtral deviation correction was in the lengthening temporalis myoplasty group, followed by the free muscle and nerve transfer groups, averaging 5.6, 2.2, and 1.13 mm, respectively. Complication rates were highest in the free functional muscle group. CONCLUSIONS: Facial palsy patients should not be denied dynamic restoration based on age alone. Although surgical technique may vary based on duration of palsy, surgeon experience, and preference, with each presenting advantages and disadvantages, dynamic restoration is feasible regardless of age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Surgical Resection of Vascular Lesions Involving the Buccal Fat Pad.

Vascular abnormalities are localized structural irregularities, which are performed during vasculogenesis, angiogenesis, and lymphangiogenesis. The involvement of soft tissue in such vascular malformations is frequent; however, the compromising of the buccal fat pads (Bichat bags) is uncommon, even in specialized centers, such as the plastic clinic of our institution, in which very few patients have been reported in the literature. The purpose of this article is to present a series of 2 patients in which vascular malformations involving the buccal fat pads, which were extracted by intraoral approach.

Reanimación facial en Síndrome de Möbius completo mediante transferencia en un solo tiempo de gracilis libre bilateral / One-stage facial reanimation with bilateral free gracilis muscle transfer in complete Möbius Syndrome

Introducción y Objetivo. El síndrome de Möbius es un trastorno congénito Que afecta al nervio facial y al abducens, provocando parálisis facial uni o bilateral y estrabismo. Su tratamiento consiste en lograr la reanimación facial con la transferencia de un músculo funcional libre. Típicamente, se ha realizado en dos o más etapas, siendo controvertido el tiempo entre las cirugías, así como el nervio donador ideal para el colgajo (rama maseterina del trigémino o espinal accesorio). Describimos nuestra cirugía de reanimación facial en Síndrome de Möbius completo mediante transferencia en un solo tiempo de gracilis libre bilateral, usando como nervio donador la rama maseterina del trigémino o el nervio espinal accesorio. Evaluamos resultados y determinamos si es un procedimiento efectivo y seguro. Material y Método. Entre marzo de 2014 y octubre de 2016, sometimos a transferencia en un solo tiempo de gracilis libre bilateral a 4 pacientes con Síndrome de Möbius. Realizamos exploración física y neurológica detallada para determinar los nervios donadores. Tradicionalmente nuestra primera elección es el trigémino, sin embargo estaba afectado en 2 pacientes, por lo que en ellos utilizamos el nervio espinal accesorio. El seguimiento promedio fue de 17 meses Hicimos la evaluación postoperatoria utilizando la escala de valoración estética y funcional de Terzis, la escala de excursión de la sonrisa de Chuang, y una escala de satisfacción postoperatoria. Resultados. De los 4 pacientes operados 2 eran varones y 2 mujeres. Realizamos 8 transferencias musculares libres en 4 tiempos quirúrgicos. Utilizamos los vasos faciales como receptores en todos los casos. Empleamos el nervio trigémino como donador en 2 pacientes y en los otros 2 el nervio espinal accesorio. No hubo complicaciones ni pérdidas de colgajos. Todos los pacientes lograron un mínimo de III en la escala de valoración estética y funcional de Terzis, y de IV en los que usamos el espinal accesorio como donador. El resultado mínimo utilizando la escala de excursión de la sonrisa de Chuang fue de 2, pero mejorando a 3 en los que usamos el espinal accesorio. El promedio en la escala de satisfacción postoperatoria fue de 3, pero en el paciente con mayor tiempo de seguimiento fue de 4. Conclusiones. La cirugía de reanimación facial en pacientes con síndrome de Möbius completo mediante transferencia en un solo tiempo quirúrgico de gracilis libre bilateral es un procedimiento seguro y efectivo. La selección cuidadosa de los pacientes, una exploración física completa cuidadosa, la selección de nervios motores donadores, la realización impecable de la cirugía y un programa de rehabilitación postoperatoria correcto, son indispensables para tener éxito

Background and Objective.Möbius syndrome is a congenital disorder that affects facial and abducens cranial nerves, resulting in uni or bilateral facial palsy and strabismus. The treatment is facial reanimation with free functional muscle transfer. Typically, facial reanimation has been realized in 2 or more stages with controversial issues, such as the amount of time between the stages and the ideal donor nerve (masseter or spinal accessory). We describe our one-stage facial reanimation surgery for complete Möbius Syndrome using 2 free gracilis muscle flaps, and bilateral trigeminal or spinal nerves as a donor. We evaluate our outcomes and determine if this is an effective and safe procedure. Methods. Between March 2014 and October 2016, 4 patients with complete Möbius Syndrome were operated using bilateral gracilis free muscle transfers in one surgical time. Detailed physical and neurologic examinations were performed with special emphasis on which cranial nerves were involved. Traditionally our first choice of nerve donor has been the trigeminal nerve, but it was involved in 2 patients, so in theme we used the spinal nerve as a donor to innervate 2 free gracilis flaps for smile reconstruction. The mean postoperative follow-up time was 17 months. Outcomes were assessed using the Terzis functional and aesthetic grading system, Chuang’s smile excursion score, and a questionnaire to evaluate patient satisfaction. Results. A total of 4 patients were included: 2 male and 2 female. We performed 8 free gracilis muscle transfers in 4 surgical times. We used the facial vessels in every flap, and the trigeminal nerve as a donor in 2 patients and in the 2 remaining, the spinal nerve. We have no complications nor flap failures. All patients achieved at least score of III using the Terzis functional and aesthetic grading system, and IV in those with spinal nerve as a donor. Likewise, the minimum score using Chuang’s smile excursion score was 2, but in those with spinal nerve as a donor we got a score of 3. Finally the mean satisfaction score was 3, but the patient with the longest follow-up time gave a 4. Conclusions. One-stage facial reanimation surgery for complete Möbius Syndrome using 2 free gracilis muscle flaps is an effective and safe procedure. Careful patient selection, adequate physical evaluation, motor nerve donor selection, flawless surgery performance, and adequate postoperative rehabilitation program, are mandatory in order to obtain success