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Zuo KJ, Heinelt M, Ho ES, Borschel GH, Zuker RM. Evaluation of Long-Term Surgical and Patient-Reported Outcomes after Pediatric Facial Reanimation. Plast Reconstr Surg 2024; 154:618-629. [PMID: 39196867 DOI: 10.1097/prs.0000000000011073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2024]
Abstract
BACKGROUND Outcomes of pediatric facial reanimation beyond 10 years are not known. This cross-sectional study evaluated long-term surgical and patient-reported outcomes of adults who underwent smile reconstruction as children with either a cross-face nerve graft (CFNG) or masseter nerve transfer at least 10 years previously. METHODS Commissure excursion was quantified with FACE-Gram software at 3 time points: preoperatively, early postoperatively within 2 years, and at long-term follow-up. Patient-reported outcomes were evaluated with validated questionnaires (Facial Clinimetric Evaluation Scale, FACE-Q 1.0) and thematic analysis of semistructured interviews. Results are reported as median (interquartile range [IQR]). RESULTS A total of 42 patients were included (26 women and 16 men). Median long-term follow-up was 19.3 years (IQR, 8.8 years) for CFNG and 17.6 years (IQR, 5.8 years) for masseter nerve transfer. For both groups, commissure excursion increased significantly from preoperative to early postoperative time points and remained stable at long-term follow-up (P < 0.0001). Commissure excursion at long-term follow-up between the 2 groups was not significantly different (CFNG, 5.0 mm [IQR, 9.4 mm]; masseter nerve transfer, 8.4 mm [IQR, 4.1 mm]); P > 0.05). For patient-reported outcomes, median Facial Clinimetric Evaluation Scale score was 72 of 100, and 95% of respondents agreed with the statement "I am pleased with the result" on the FACE-Q 1.0. Overall quality of life was rated at 7 of 10 or greater by 97% of participants, and all participants would recommend the surgery to other children. CONCLUSIONS Pediatric facial reanimation with CFNG or masseter nerve transfer reliably improves commissure excursion with longevity beyond 10 years. Adult patients report overall high satisfaction and social functioning.
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Affiliation(s)
- Kevin J Zuo
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children
| | | | - Emily S Ho
- Department of Occupational Science and Occupational Therapy, University of Toronto
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children
| | - Gregory H Borschel
- Division of Plastic Surgery, Riley Children's Hospital, Indiana University School of Medicine
| | - Ronald M Zuker
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children
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López Gutierrez D, Luna López I, Medina Mata BA, Moreno Castro S, García Rangel FY. Physiopathologic Bases of Moebius Syndrome: Combining Genetic, Vascular, and Teratogenic Theories. Pediatr Neurol 2024; 153:1-10. [PMID: 38306744 DOI: 10.1016/j.pediatrneurol.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/16/2023] [Accepted: 01/05/2024] [Indexed: 02/04/2024]
Abstract
Moebius syndrome (MBS) is a congenital cranial dysinnervation disorder (CCDD) characterized by a bilateral palsy of abducens and facial cranial nerves, which may coexist with other cranial nerves palsies, mostly those found in the dorsal pons and medulla oblongata. MBS is considered a "rare" disease, occurring in only 1:50,000 to 1:500,000 live births, with no gender predominance. Three independent theories have been described to define its etiology: the vascular theory, which talks about a transient blood flow disruption; the genetic theory, which takes place due to mutations related to the facial motor nucleus neurodevelopment; and last, the teratogenic theory, associated with the consumption of agents such as misoprostol during the first trimester of pregnancy. Since the literature has suggested the existence of these theories independently, this review proposes establishing a theory by matching the MBS molecular bases. This review aims to associate the three etiopathogenic theories at a molecular level, thus submitting a combined postulation. MBS is most likely an underdiagnosed disease due to its low prevalence and challenging diagnosis. Researching other elements that may play a key role in the pathogenesis is essential. It is common to assume the difficulty that patients with MBS have in leading an everyday social life. Research by means of PubMed and Google Scholar databases was carried out, same in which 94 articles were collected by using keywords with the likes of "Moebius syndrome," "PLXND1 mutations," "REV3L mutations," "vascular disruption AND teratogens," and "congenital facial nerve palsy." No exclusion criteria were applied.
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Affiliation(s)
| | - Ingrid Luna López
- Facultad Mexicana de Medicina, Universidad La Salle, Mexico City, Mexico
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Fernández-Carrera González I, Gavilanes Plasencia J, Mata Castro N. Gracilis Muscle-Free Flap Objective Improvement of Oral Commissure Excursion in Facial Palsy Reanimation Surgery: Systematic Review and Meta-Analysis. Facial Plast Surg Aesthet Med 2023; 25:396-402. [PMID: 36787475 DOI: 10.1089/fpsam.2022.0283] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Background: Facial palsy patients face significant challenges. Gracilis free flap transfer is a key procedure in facial reanimation. Objective: This study aims to analyze oral commissure excursion improvement after gracilis free flap transfer and the differences regarding donor nerve: cross-facial nerve graft (CFNG), hypoglossal or spinal accessory nerves, motor nerve to masseteric (MNTM), and most recently, double anastomosis using both the MNTM and CFNG. Methods: A systematic review and meta-analysis were conducted of studies reporting oral commissure excursion improvement after free gracilis muscle transfer. Pooled proportions were calculated using a random-effects model. Results: Eighteen studies, 453 patients, and 488 free gracilis flaps were included. The mean change in perioperative oral commissure excursion was 7.0 mm, for CFNG 7.2 mm, for MNTM 7.7, and for double anastomoses 5.5 mm. Conclusions: There is a significant improvement in oral commissure excursion after gracilis muscle-free flap. Unfortunately, we could not make definitive conclusions regarding the optimal choice of donor nerve.
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Affiliation(s)
| | | | - Nieves Mata Castro
- ENT Head and Neck Surgery, Hospital de Torrejón, Torrejon de Ardoz, Spain
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Ferri A, Zito F, Menapace G, Zannoni C, Bergonzani M, Perlangeli G, Bianchi B. Optimizing the results of facial animation surgery: Botulinum toxin injection into free functional gracilis flap transfer. J Plast Reconstr Aesthet Surg 2023; 83:415-422. [PMID: 37307620 DOI: 10.1016/j.bjps.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 03/22/2023] [Accepted: 04/08/2023] [Indexed: 06/14/2023]
Abstract
Although neuromuscular gracilis transplantation is the best choice for facial reanimation in patients with congenital or inveterate palsy, the results are not completely satisfactory. Ancillary procedures developed to achieve better symmetry of the smile and reduce the hypercontractility of the transplanted muscle have been reported. However, the intramuscular injection of botulinum toxin has not been described for this purpose. Patients undergoing gracilis injections of botulinum toxin after facial reanimation surgery between September 1, 2020, and June 1, 2022, were retrospectively enrolled in this study. We collected photographs taken before and 20-30 days after injection and compared the symmetry of the face using software. Nine patients with a mean age of 23.56 years (range, 7-56 years) were enrolled. Reinnervation of the muscle was provided by the contralateral healthy facial nerve via a sural cross-graft (four patients), by the ipsilateral masseteric nerve (three cases), and by the contralateral masseteric and facial nerve (two). Using Emotrics software, we identified differences in the commissure excursion discrepancy of 3.82 mm, the smile angle discrepancy of 0.084°, and the dental show discrepancy of 1.49 mm; the average difference in the commissure height deviation was 2.26 mm (P = 0.02), and those in the upper- and lower-lip height deviation were 1.05 mm and 1.49 mm, respectively. Gracilis injection of botulinum toxin after gracilis transplantation is a safe and feasible procedure that could be applicable to all patients with asymmetric smiles related to excessive transplant contraction. It yields good esthetic results with little to no related morbidity.
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Affiliation(s)
- Andrea Ferri
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Francesca Zito
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy.
| | - Giorgia Menapace
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Cecilia Zannoni
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Michela Bergonzani
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Giuseppe Perlangeli
- Operative Unite of Maxillo-facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Bernardo Bianchi
- Operative Unite of Maxillo-facial Surgery, Hospital of Genova, Parma, Italy
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Efficacy of retrograde innervation through the distal stump of the thoracodorsal nerve in single-stage neurovascular latissimus dorsi transfer for facial reanimation: A retrospective analysis of 30 cases. J Craniomaxillofac Surg 2022; 50:732-737. [DOI: 10.1016/j.jcms.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 07/03/2022] [Accepted: 07/12/2022] [Indexed: 11/19/2022] Open
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De Stefani E, Barbot A, Zannoni C, Belluardo M, Bertolini C, Cosoli R, Bianchi B, Ferri A, Zito F, Bergonzani M, Schiano Lomoriello A, Sessa P, Ferrari PF. Post-surgery Rehabilitative Intervention Based on Imitation Therapy and Mouth-Hand Motor Synergies Provides Better Outcomes in Smile Production in Children and Adults With Long Term Facial Paralysis. Front Neurol 2022; 13:757523. [PMID: 35665048 PMCID: PMC9156860 DOI: 10.3389/fneur.2022.757523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Rehabilitation after free gracilis muscle transfer (smile surgery, SS) is crucial for a functional recovery of the smiling skill, mitigating social and psychological problems resulting from facial paralysis. We compared two post-SS rehabilitation treatments: the traditional based on teeth clenching exercises and the FIT-SAT (facial imitation and synergistic activity treatment). FIT-SAT, based on observation/imitation therapy and on hand-mouth motor synergies would facilitate neuronal activity in the facial motor cortex avoiding unwanted contractions of the jaw, implementing muscle control. We measured the smile symmetry on 30 patients, half of whom after SS underwent traditional treatment (control group, CG meanage = 20 ± 9) while the other half FIT-SAT (experimental group, EG meanage= 21 ± 14). We compared pictures of participants while holding two postures: maximum and gentle smile. The former corresponds to the maximal muscle contraction, whereas the latter is strongly linked to the control of muscle strength during voluntary movements. No differences were observed between the two groups in the maximum smile, whereas in the gentle smile the EG obtained a better symmetry than the CG. These results support the efficacy of FIT-SAT in modulating the smile allowing patients to adapt their smile to the various social contexts, aspect which is crucial during reciprocal interactions.
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Affiliation(s)
- Elisa De Stefani
- Unit of Neuroscience, Department of Medicine and Surgery, University of Parma, Parma, Italy
- Child and Adolescent Neuropsychiatry–NPIA District of Scandiano, AUSL of Reggio Emilia, Reggio Emilia, Italy
- *Correspondence: Elisa De Stefani
| | - Anna Barbot
- Operative Unit of Maxillo-Facial Surgery, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Cecilia Zannoni
- Operative Unit of Maxillo-Facial Surgery, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Mauro Belluardo
- Unit of Neuroscience, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Chiara Bertolini
- Operative Unit of Maxillo-Facial Surgery, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Rita Cosoli
- Unit of Neuroscience, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Bernardo Bianchi
- Operative Unit of Maxillo-Facial Surgery, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Andrea Ferri
- Operative Unit of Maxillo-Facial Surgery, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Francesca Zito
- Operative Unit of Maxillo-Facial Surgery, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | - Michela Bergonzani
- Operative Unit of Maxillo-Facial Surgery, Head and Neck Department, University Hospital of Parma, Parma, Italy
| | | | - Paola Sessa
- Department of Developmental and Social Psychology, University of Padova, Padova, Italy
- Padova Neuroscience Center (PNC), University of Padova, Padova, Italy
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A New Neurorehabilitative Postsurgery Intervention for Facial Palsy Based on Smile Observation and Hand-Mouth Motor Synergies. Neural Plast 2021; 2021:8890541. [PMID: 33833792 PMCID: PMC8016575 DOI: 10.1155/2021/8890541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To perform a preliminary test of a new rehabilitation treatment (FIT-SAT), based on mirror mechanisms, for gracile muscles after smile surgery. Method A pre- and postsurgery longitudinal design was adopted to study the efficacy of FIT-SAT. Four patients with bilateral facial nerve paralysis (Moebius syndrome) were included. They underwent two surgeries with free muscle transfers, one year apart from each other. The side of the face first operated on was rehabilitated with the traditional treatment, while the second side was rehabilitated with FIT-SAT. The FIT-SAT treatment includes video clips of an actor performing a unilateral or a bilateral smile to be imitated (FIT condition). In addition to this, while smiling, the participants close their hand in order to exploit the overlapped cortical motor representation of the hand and the mouth, which may facilitate the synergistic activity of the two effectors during the early phases of recruitment of the transplanted muscles (SAT). The treatment was also aimed at avoiding undesired movements such as teeth grinding. Discussion. Results support FIT-SAT as a viable alternative for smile rehabilitation after free muscle transfer. We propose that the treatment potentiates the effect of smile observation by activating the same neural structures responsible for the execution of the smile and therefore by facilitating its production. Closing of the hand induces cortical recruitment of hand motor neurons, recruiting the transplanted muscles, and reducing the risk of associating other unwanted movements such as teeth clenching to the smile movements.
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