Two-Stage Dual-Nerve Facial Reanimation: Outcomes and Complications in a Series of Pediatric Patients.

BACKGROUND: In facial reanimation via microneurovascular muscle transfer, dual-nerve reinnervation of the muscle capitalizes on the synergistic effects of spontaneous motion from cross facial nerve grafting (CFNG) and increased excursion from masseteric nerve transfer. Two-stage approaches that delay masseteric nerve transfer until the time of the muscle flap increase spontaneity by maximizing muscle reinnervation from the CFNG. While this 2-stage, dual-nerve approach has been described in adults, we present a series of pediatric patients who underwent this reconstructive technique. METHODS: We retrospectively reviewed all pediatric patients who underwent 2-stage, dual-nerve reconstruction with CFNG and ipsilateral masseteric nerve transfers. Procedures were performed between 2004 and 2016 by 2 surgeons at a single centre. Degree of facial paralysis before and after surgical intervention was measured using House-Brackmann scores. RESULTS: Nine patients with a mean age of 8.6 (range: 5-15 years) years at time of surgery underwent 2-stage, dual-nerve reconstruction. Average time between CFNG and transfer of the free gracilis with masseteric nerve transfer was 13.3 (SD 2.4) months. Mean follow-up was 27.3 months (SD 25.7). Patients demonstrated initiation of voluntary movement on paralyzed side by 3.6 months (SD 0.6) on average, with 3 patients demonstrating spontaneous movement at 3 months. CONCLUSION: The 2-stage, dual innervation technique using CFNG and delayed ipsilateral masseteric nerve transfer with a free gracilis is a promising reconstructive option to maximize spontaneous expression in pediatric patients. Validated, objective scoring systems for excursion are needed before meaningful comparisons can be made to other reconstructive strategies.

HISTORIQUE: Lors de la réanimation faciale par transfert du muscle microneurovasculaire, la réinnervation de deux nerfs du muscle tire profit des effets synergétiques du mouvement spontané à partir de la greffe de nerf transfacial (GNTF) et améliore l'excursion du transfert de nerf massétérin. Une intervention en deux étapes qui reporte le transfert du nerf massétérin jusqu'à ce que le lambeau musculaire améliore la spontanéité par une maximisation de la réinnervation musculaire à partir de la GNTF. Cette intervention sur deux nerfs en deux étapes a été décrite chez les adultes, mais les chercheurs présentent les résultats de cette technique chez une série de patients d'âge pédiatrique. MÉTHODOLOGIE: Les chercheurs ont procédé à l'analyse rétrospective de tous les patients pédiatriques qui avaient subi une reconstruction de deux nerfs en deux étapes par transferts de la GNTF et du nerf massétérin ipsilatéral. Deux chirurgiens d'un même centre ont effectué les interventions entre 2004 et 2016. Les chercheurs ont mesuré le degré de paralysie faciale avant et après l'intervention chirurgicale au moyen des scores de House-Brackmann. RÉSULTATS: Neuf patients, d'un âge moyen de 8,6 ans (plage de cinq à 15 ans) au moment de l'opération ont subi une reconstruction de deux nerfs en deux étapes. La période moyenne entre la GNTF et le transfert du muscle gracile libre avec le transfert du nerf massétérin était de 13,3 mois (ÉT 2,4). Le suivi moyen était d'une durée de 27,3 mois (ÉT 25,7). Les patients avaient commencé à faire des mouvements volontaires du côté paralysé au bout d'une moyenne de 3,6 mois (ÉT 0,6), et trois patients faisaient des mouvements spontanés au bout de trois mois. CONCLUSION: La technique d'innervation double en deux étapes à l'aide de la GNTF et du transfert tardif du nerf massétérin ipsilatéral avec le muscle gracile libre est une méthode de reconstruction prometteuse pour maximiser l'expression spontanée chez les patients d'âge pédiatrique. Il faudra établir des systèmes objectifs de scores d'excursion avant de faire des comparaisons significatives avec d'autres stratégies de reconstruction.

Knowledge of neonatal brachial plexus palsy among medical professionals in North America.

PURPOSE: Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP. METHODS: A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge. RESULTS: Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner's syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation. CONCLUSIONS: Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.

Ethical Use of Public Networks and Social Media in Surgical Innovation.

The use of social media among surgeons is increasing in the professional domain as a result of the benefits of rapid communication for advertising, professional development, advocacy, and innovation. Social media allows for collaboration and consultation on cases that may be difficult or uncommon, drawing on collective wisdom but also bypassing traditional privacy protections and other regulatory firewalls. The expanded access that comes with social media produces challenges, including the management of information dissemination and ensuing perceptions, the risk of biased patient/research participant recruitment, the potential for overlap between personal and professional lives, and the precarious nature of self-interest in professional social media use. The ethics of surgical innovation in the context of social media has not been extensively discussed. The nature of social media favors attention grabbing, sensationalized content. Innovation is inherently sensational and demands attention. The alignment of these intrinsic characteristics forms a basis for its appeal and contagion on social media. Despite strict regulatory clinical research environment, many surgical innovations and subsequent evolution in practice arise from a longitudinal surgical culture of trial and error that happens every day. The difficulty in distinguishing innovation from research and the precarious nature of interactions found on social media create a unique ethical dilemma to be addressed for the innovative surgeon. Therefore, the use of social media in surgical innovation thus requires a more robust ethical analysis.

Early biochemical response to parathyroidectomy for primary hyperparathyroidism and its predictive value for recurrent hypercalcemia and recurrent primary hyperparathyroidism.

BACKGROUND: The traditional definition of cure after parathyroidectomy (PTX) for primary hyperparathyroidism is normocalcemia. Our hypothesis was that early postoperative levels of serum calcium and parathyroid hormone after PTX would have predictive value for later recurrence. METHODS: We performed a retrospective study of 1,146 patients with primary hyperparathyroidism who underwent PTX and had long-term biochemical follow-up. The first postoperative serum level of calcium and parathyroid hormone values were used to categorize patients into the following four early biochemical response groups: (1) complete response (normal calcium and normal parathyroid hormone), (2) partial response with hyperparathormonemia (normal calcium and increased parathyroid hormone), (3) partial response with hypercalcemia (increased calcium and normal parathyroid hormone), and (4) non-response (increases in both calcium and parathyroid hormone). Incidences of recurrent hypercalcemia and recurrent primary hyperparathyroidism >6 months after operation were then analyzed. RESULTS: The overall rate of any elevated serum levels of calcium and any increase in serum levels of parathyroid hormone during >6-month follow-up was 9.8% (112 of 1146), with 6.6% (57 of 861) for group 1, 27% (35 of 129) for group 2, and 16% (20 of 127) for group 3 (P < .02). Partial biochemical responses with either increased serum calcium or increased parathyroid hormone levels were the strongest predictors of any episode of increased serum levels of calcium after 6 months and was associated with 2.7× to 4.3× the risk of recurrent primary hyperparathyroidism, respectively. CONCLUSION: This study demonstrates the importance of measuring parathyroid hormone in the early postoperative period to better predict later recurrent primary hyperparathyroidism.

Debunking a Surgical Myth: Do Not Touch the Temporalis.

BACKGROUND: A longstanding dictum exists to avoid surgical manipulation of the temporalis muscle out of concern for an exceedingly high rate of muscle atrophy and recurrent temporal hollowing. The authors challenge this surgical myth, considering such advice to be erroneous. The authors hypothesize that elevation of the temporalis muscle, if performed using standard muscle flap principles, will demonstrate excellent results. METHODS: To assess temporalis response to surgical manipulation, the authors reviewed patients who underwent calvarial vault remodeling by the senior author for craniosynostosis between 1988 and 2011. Nonsyndromic patients with single-suture synostosis and 5 years of follow-up were eligible for inclusion. The medical record was used to measure rates of reoperation, recurrent temporal hollowing, and persistent temporalis overcorrection. RESULTS: Of the cohort reviewed, 196 patients met inclusion criteria. Ten patients (5.1%) exhibited recurrent bitemporal constriction. One patient (0.5%) underwent a revision temporalis turnover flap, and 2 patients (1.0%) underwent soft tissue augmentation. The overall reoperation rate was 1.5%. Temporalis overcorrection, in an attempt to prophylactically rectify the expected atrophy after temporalis manipulation, persisted in 11 patients (5.6%). Three of these patients required treatment with steroid injections, Botox injections, or operative muscle debulking. The overall reoperation rate for temporalis overcorrection was 1.5%. CONCLUSIONS: The authors' low reoperation rates for recurrent deformity, in combination with persistent temporalis overcorrection in 5.6% of patients, should dispel the myth that manipulation of the temporalis invariably results in atrophy. The muscle may be surgically manipulated, as long as plastic surgery principles are followed.