Comparison of Objective Outcomes in Dynamic Lower Facial Reanimation With Temporalis Tendon and Gracilis Free Muscle Transfer

Evaluation of the Patient with Facial Palsy: A Multidisciplinary Approach

This article aims to provide an overview of the management of facial palsy within a multidisciplinary team setting and discusses considerations used to develop patient-specific management plans. The national landscape of facial function services is also discussed including suggestions on what may enable a more equitable and sustainable service for the future.

Composite Sterno-Omohyoid Functional Muscle Transfer for Dual-Vector Smile Reanimation: A Case Series

Background: Facial reanimation flaps often add bulk and produce single-vector smiles, and multivector flaps frequently require challenging intramuscular dissection. Objective: To evaluate the effectiveness of sterno-omohyoid flap (SOHF) transfer for dual-vector smile reanimation by measuring upper dental show and oral commissure movement. Methods: SOHF transfers from 2017 to 2020 were retrospectively evaluated using eFACE and Emotrics software. Results: Four patients with flaccid and one with nonflaccid facial paralysis were identified (four females and one male, median age: 39 years (range: 38-65); two acoustic neuromas, two congenital, one temporal bone fracture). Median follow-up was 20 months (range: 14-26). All flaps received masseteric nerves and two had additional cross-face grafts. Four developed contraction [median time to contraction: 5.5 months (range: 3-10)]. Mean oral commissure excursion and dental exposure improvements were 7.6 ± 4.0 mm (p = 0.03) and 2.9 ± 1.8 mm (p = 0.05), respectively. Dynamic, smile, and midface-smile eFACE improvements were 20.3 ± 6.8 (p = 0.007), 25.5 ± 14.5 (p = 0.03), and 50.5 ± 12.0 mm (p = 0.004) points, respectively. Mean SOHF mass was 14 ± 1.7 g. Conclusion: The SOHF is a small flap that provides dual-vector smile reanimation in flaccid and nonflaccid facial paralysis.

Modification of Technique of Temporalis Transfer for Lagophthalmos and Lip Animation

The aim of this case report is to describe a modification of the technique of temporalis transfer for patients with paralysis of the facial neve. Primary fixation of fascia lata strips to the medial canthus, angle of mouth, lips, and ala of nose, and later executing the orthodromic transfer of a relevant segment of the muscle are the modifications to be described. Symmetry of the face, mouth, eye closure, and smooth elevation of angle of mouth were the measured outcomes by the surgeon. Our refinement of the technique is easy to perform with good results.

Releasing the Smile: Depressor Anguli Oris Excision in the Context of Managing Nonflaccid Facial Palsy

BACKGROUND

Nonflaccid facial palsy is a debilitating entity characterized by hypertonicity, synkinesis, and hypomobility. Patients with nonflaccid facial palsy often have smile asymmetry and restriction because of disruption of normal vector forces on the modiolus. Excision of the depressor anguli oris can lead to improved oral commissure excursion, smile angle, dental show, and symmetry.

METHODS

All depressor anguli oris resection cases between January 8, 2018, and December 26, 2019, were reviewed. Patients with postoperative photographs were included in this cohort study. Preoperative and postoperative photographs were analyzed using the Emotrics software program, and changes in oral commissure excursion, smile angle, and dental show were tracked. Clinician-graded facial palsy assessments and patient-reported outcome measures were compared preoperatively and postoperatively using the Electronic Facial Paralysis Assessment and Facial Clinimetric Evaluation Scale, respectively.

RESULTS

Forty-three patients were included in this study; 79 percent of patients underwent isolated depressor anguli oris resection. Depressor anguli oris resection led to a statistically significant increase in oral commissure median excursion, smile angle, and dental show [3.02 mm (p = 0.015), 1.70 degrees (p = 0.002), and 2.36 mm (p < 0.001), respectively]. Median Electronic Facial Paralysis Assessment and Facial Clinimetric Evaluation Scale instrument scores also improved [6.0 (p = 0.001) and 7.5 (p = 0.013), respectively]. Depressor anguli oris resection also led to more symmetric smiles. No correlation was seen between duration of follow-up and change in metrics.

CONCLUSION

Depressor anguli oris resection is a minimal-risk procedure that frequently results in improved smile dynamics, smile symmetry, and quality of life in patients with nonflaccid facial palsy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Dynamic Facial Reanimation in an Overweight Patient and with Significant Comorbidities: An Objective Analysis of Labbè Technique

Gracilis free muscle transfer is considered the gold standard technique for facial reanimation in cases of facial palsy. However, it is limited by its long operative and recovery times, the need for a second surgical site, and its outcomes that can sometimes show midfacial bulk and oral commissure malposition. Facial reanimation with lengthening temporalis myoplasty (LTM)-Labbé technique- carries the advantage of having a shorter surgical time, a faster recovery, and being a less invasive surgery. Almost all patients included in studies of LTM were evaluated by subjective methods, and very little quantifiable data was available. A 64-year-old woman presented with long-standing incomplete right facial palsy secondary to acoustic neuroma surgery. Since she was overweight (body mass index [BMI]: 43.9) and had several cardiovascular comorbidities (hypertension, dyslipidemia), she was not a good candidate for gracilis free muscle transfer. She was submitted to facial reanimation with LTM. Fourteen months after surgery, she presented excellent facial symmetry, both at rest and in contraction, while smiling. She was evaluated with the Facegram-3D, a technology that we have developed for dynamic evaluation of facial muscle contraction. The analysis showed symmetry at rest and contraction, according to Terzis and Noah. Regarding vertical and horizontal displacement, the postoperative movement was synchronized and with less fluctuations when compared with the preoperative period. Notably, the anatomical pair's trajectories were smoother. Similar velocity profiles were found between anatomical pairs, with less abrupt changes in velocity values, further supporting improved movement control. Comparing the symmetry index, which takes a theoretical maximum of 1.0 for perfect 3D symmetry, its value was 0.56 for the commissures and 0.5 for the midpoints in the preoperative period, having improved to 0.91 and 0.82, respectively, 3 months postoperatively. Good aesthetic and functional results were achieved using the Labbè technique. LTM is a good option in cases of long-standing facial paralysis, if the patient desires a single-stage procedure with almost immediate dynamic function. Moreover, this technique assumes extreme importance in facial reanimation of patients of advanced age, overweight, or those who have several comorbidities.

Temporalis Tendon Transfer Versus Gracilis Free Muscle Transfer: When and Why?

Temporalis tendon transfer (T3) and gracilis free muscle transfer (GFMT) are popular techniques in lower facial rehabilitation when reinnervation techniques are unavailable. T3 involves a single-stage outpatient procedure resulting in immediate improvement in resting symmetry and a volitional smile. GFMT allows a spontaneous smile, customized vectors, and increased excursion but requires longer surgical time, a delay before movement, and specialized equipment. Ultimately, shared decision making between the clinician and patient should focus on the patient's goals and unique medical condition.

Evaluating Quality of Life After Facial Reanimation Using the Facial Clinimetric Evaluation Scale in a Series of Pediatric Patients

BACKGROUND

Facial palsy can have significant functional and psychological impact. Dynamic facial reanimation methods have provided means of restoration of smile. There remains a dearth of quality of life data in children. The authors aim to assess patient reported outcomes in this underreported population.

METHODS

A retrospective review was performed of pediatric patients with facial palsy who had dynamic facial reanimation from 2009 to 2017 at a single institution. Patients were sent a digital Facial Clinimetric Evaluation (FaCE) questionnaire, a validated tool to assess patient quality of life. FaCE statements are grouped into 6 categories: facial movement, facial comfort, oral function, eye comfort, lacrimal control, and social control.

RESULTS

Twenty patients met inclusion criteria. Fourteen successfully completed the survey. With normal function being 100, our cohort scored: facial movement 38.7 ± 14.3; facial comfort 67.3 ± 23, oral function 75 ± 22.7, eye comfort 68.75 ± 18.2, lacrimal control 53.6 ± 32.5, social function 64.3 ± 25.6. The overall FaCE score was 61.07 ± 10.85. The facial movement subscores were lower for brow raise 16.1 ± 33.4 relative to smiling 53.6 ± 29.2 and lip pucker, 46.4 ± 23.7. No correlation was found between facial movement scores and total scores (R2 < 0.01). There was a strong negative correlation between total scores and time since procedure (Spearman's rho R =  -0.45).

CONCLUSION

Our pediatric facial reanimation cohort demonstrated excellent social function, in contrast to a relatively lower facial movement score. The low facial movement score was mediated by low score for brow raise and was not correlated to overall FaCE score. Interestingly, overall FaCE score tended to decrease with time from procedure.

Evaluating Functional Outcomes in Reanimation Surgery for Chronic Facial Paralysis: A Systematic Review

Background:

Chronic facial paralysis can lead to significant functional and psychosocial impairment. Treatment often involves free muscle flap-based facial reanimation surgery. Although surgical techniques have advanced considerably over the years, consensus has yet to be reached for postoperative outcome evaluation. To facilitate outcome comparison between the various techniques for free muscle-flap-based reanimation, a standardized, widely accepted functional outcomes assessment tool must be adopted.

Methods:

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review of the PubMed, Cochrane, and Embase databases to identify the reported functional outcome measurement tools used in the free muscle flap-based reanimation literature.

Results:

The search yielded 219 articles, 43 of which met our inclusion and exclusion criteria. We noted an increase in publications reporting the utilization of objective measures over time, particularly software-based tools, as well as increased utilization of patient reported outcomes measures.

Conclusions:

Based on the trends identified in the literature, we suggest standardization of outcome measures following facial reanimation surgery with free muscle-flap using a combination of the Facial Assessment by Computer Evaluation (FACEgram) software and the Facial Clinimetric Evaluation (FaCE) Scale.

Free Functional Gracilis Flaps for Facial Reanimation in Elderly Patients

Importance: The free functional gracilis flap (FFGF) is a versatile procedure in reanimating the paralyzed face, yet its application in seniors is limited by perceptions of morbidity and inefficacy. Objective: The study objective was to compare the morbidity and effectiveness of FFGF reanimation among senior and younger patients. Design, Setting, and Participants: A retrospective chart review was performed on 20 consecutive patients aged 60 years and above (seniors) and 35 patients aged 40 years and below (juniors) who underwent FFGF for facial reanimation. Among this group, 16 senior and 22 junior patients with available long-term follow-up data were analyzed for functional outcomes. Main Outcomes and Measures: The length of postoperative stay and postoperative complications were compared with assess immediate results. A second analysis for functional outcomes was assessed by resting and smile facial asymmetry index (FAI), as well as maxillary dental display to compare facial tone and lip excursion. Results: The average age of seniors was 67 ± 5 years and that of juniors was 27 ± 10 years. Mean lengths of postoperative stay were 4 ± 2 versus 3 ± 1 days in seniors versus Juniors, respectively (p = 0.16). There were no intraoperative complications and postoperative complications in one (5%) senior and four (11%) juniors (p = 0.64). There was functional muscle recovery in all cases, with more pronounced correction of both resting (Δ3.0 mm vs. Δ2.4 mm, p = 0.66) and dynamic (Δ5.2 mm vs. Δ4.2 mm, p = 0.37) FAI in seniors than in juniors. Among patients who underwent a multivector FGFF, there was an additional three versus one visualized maxillary teeth (p = 0.03) in seniors versus juniors, respectively. Conclusions and Relevance: The FFGF is effective for facial reanimation among seniors and can be performed with minimal morbidity. Age alone should not preclude the application of the FFGF in seniors with a preference for more dynamic options.

[Economic factors in microsurgery - Report of the consensus workshop of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels - (DAM)]

In addition to outcome assessments, cost effectiveness of surgical treatments becomes increasingly important. Both, insurance companies and hospital administrations aim for short and efficient procedures to reduce costs.Microsurgical procedures are often surpassing traditional treatment options in terms of function and aesthetics. However, they are more expensive as they require a high level of surgical expertise, more theatre capacity and longer inpatient treatment. Adequate reimbursement is mandatory, if we want to continuously perform these procedures with the best possible quality and outcome. To cover the case-related expenses of each specialty, multidisciplinary procedures require appropriate distribution of reimbursements to each department.The main diagnosis as well as all complications and relevant comorbidities should be documented to obtain the correct DRG. The additional financial benefit of a microsurgical procedure in a multidisciplinary case can be calculated by specifying the procedural increment in pay. Therefore, a fair distribution of revenues to each participating department should be performed. Different models exist, which lead to a benefit in compensation for all departments. Unfortunately, distribution of resources is still insufficiently managed in many hospitals, which hampers high quality multidisciplinary microsurgical procedures. Still, picking the best possible procedure for our patients, independently of financial incentives, is of utmost importance.

Advances in facial nerve management in the head and neck cancer patient

PURPOSE OF REVIEW

The purpose of this review is to summarize best practices in facial nerve management for patients with head and neck cancer. In addition, we provide a review of recent literature on novel innovations and techniques in facial reanimation surgery.

RECENT FINDINGS

Although recommended when tumor ablation surgery requires facial nerve sacrifice, facial reanimation procedures are not always performed. Concurrent dynamic facial reanimation with masseteric nerve transfers and cable graft repair can preserve native facial muscle function. Static suspension can provide facial support and immediate resting symmetry for patients. Eyelid weight and eye care should not be delayed, particularly in patients with trigeminal sensory deficits. Choice of neural source to innervate a gracilis-free muscle transfer for smile reanimation remains controversial; however, new techniques, such as dual innervation and multivector muscle transfer, may improve aesthetic and functional outcomes.

SUMMARY

Management of the facial nerve in the setting of head and neck cancer presents unique challenges. When possible, simultaneous oncologic resection and facial reanimation is ideal given the open surgical field, newly dissected and electrically stimulatable facial nerve branches, as well as minimizing postoperative healing time to prevent postsurgical treatment delays. A coordinated approach to facial nerve management with a multidisciplinary surgical team may help provide optimal, comprehensive care.

The mini-temporalis turnover flap for midface reanimation: Photogrammetric and patient-rated outcomes

BACKGROUND

Mini-temporalis transposition (MTT) flaps, modified from Gillies' technique, have become less popular than temporalis tendon transfers for midface reanimation. MTT involves raising the middle third of the temporalis, transposition over the zygomatic arch and lengthening with deep temporalis fascia which is sutured to the orbicularis oris.

AIM

This retrospective study assessed subjective and objective outcomes following MTTs by a single surgeon from 2009 to 2019.

METHODS

Operative and surgical details were recorded. Four blinded consultants rated pre- and postoperative videos according to Terzis' scale. Pre- and postoperative resting, Mona Lisa and canine smile photographs were analysed using Emotrics, the software that automatically computes differences in inter-landmark distances. Patients also completed the Glasgow Benefit Inventory (GBI) patient-rated outcome measure.

RESULTS

Forty-one patients (mean age 65.8 ± 15.5) underwent MTT, median 3 (0.4-57) years post-paralysis and were followed up for median of 2.2 (0.4-8.8) years. Higher mean postoperative Terzis score demonstrates symmetric and aesthetic improvements (3 ± 1.3 vs. 2 ± 1; p<0.05). Emotrics analysis showed postoperative improvements in resting and dynamic symmetry of all indices, with the majority statistically significant (p<0.003). The mean GBI was 35.19 with 17 (94.4%) patients reporting improvement, whereas one (5.6%) patient reported detriment after surgery. Two (5.4%) patients suffered complications: one haematoma and one infection. Four patients (9.8%) required revisional flap tightening. No patients requested revisional surgery for temporal hollowing or zygomatic fullness.

CONCLUSIONS

MTT effectively improves both subjective and objective resting and dynamic midface symmetry in a single stage. These results suggest this technique is a good alternative to temporalis tendon transfer techniques.

Powering the Gracilis for Facial Reanimation: A Systematic Review and Meta-analysis of Outcomes Based on Donor Nerve

Importance

Free gracilis transfer for dynamic reanimation in chronic facial paralysis is the gold standard, but there remains a need to better understand outcomes with respect to the donor nerve.

Objective

To characterize outcomes in adults undergoing primary gracilis transfer for facial paralysis stratified by donor nerve used for neurotization.

Data Sources

Search strategies were used in Ovid MEDLINE (1946-2019), Embase (1947-2019), Scopus (1823-2019), Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov (1997-2019).

Study Selection

Inclusion and exclusion criteria were designed to capture studies in adults with unilateral chronic facial paralysis undergoing single-paddle free gracilis transfer. All study types were included except case reports. Abstracts and full texts were reviewed in duplicate. Of 130 unique citations, 10 studies including 295 patients were included after applying inclusion and exclusion criteria. Data were analyzed between November 2018 and December 2019.

Data Extraction and Synthesis

PRISMA guidelines were followed. The Newcastle-Ottawa scale was used to assess study quality, and the Cochrane Risk of Bias tool was used to assess risk of bias. Independent extraction by 2 authors (P.M.V. and J.J.C.) was performed. Data were pooled using a random-effects model.

Main Outcomes and Measures

Owing to heterogeneity in reporting of facial reanimation outcomes, we first performed a systematic review, and then compiled available outcomes for meta-analysis. Outcomes studied for meta-analysis were oral commissure excursion and facial symmetry.

Results

Meta-analysis of masseteric nerve (MN) (n = 56) vs cross-facial nerve graft (CFNG) (n = 52) in 3 retrospective studies showed no statistical heterogeneity between these studies (I2 = 0%), and the standardized mean difference (SMD) was greater for MN (0.55; 95% CI, 0.17 to 0.94). Meta-analysis of angles of symmetry in 2 retrospective studies comparing MN (n = 51) to CFNG (n = 47) both at rest (-0.22; 95% CI, -0.63 to 0.18) and with smiling (-0.14; 95% CI, -0.73 to 0.46) were better with MN, though the difference was not statistically significant.

Conclusions and Relevance

Owing to heterogeneity in reported outcomes from facial reanimation, we were unable to make definitive conclusions regarding the optimal donor nerve. Establishing a reporting standard at peer-reviewed journals to improve results reporting is one method to allow for improved collaboration in the future. Standardizing follow-up times, assessing spontaneity in an objective and reproducible fashion, and use of consistent outcome measures would allow for future meta-analyses and better understanding of options for facial reanimation.

Cryopreserved fascia lata allograft use in surgical facial reanimation: a retrospective study of seven cases

Background

Facial palsy treatment comprises static and dynamic techniques. Among dynamic techniques, local temporalis transposition represents a reliable solution to achieve facial reanimation. The present study describes a modification of the temporalis tendon transfer using a cryopreserved fascia allograft.

Case presentation

Between March 2015 and September 2018, seven patients with facial palsy underwent facial reanimation with temporalis tendon transfer and fascia lata allograft. Patients with long-term palsy were considered, and both physical and social functions were evaluated. The mean follow-up time was 21.5 months. No immediate complications were observed. Patients reported improvement in facial symmetry both in static and dynamic. Improvement was noticed also in articulation, eating, drinking, and saliva control. The Facial Disability Index revealed an improvement both in physical function subscale and in the social/well-being function subscale.

Conclusions

This modified orthodromic technique allows to reduce the operative time and the risk of complications connected to the use of autologous tissues. The use of the cryopreserved fascia allografts from cadaveric donors seems to provide promising and long-standing results in the treatment of facial palsy.