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Thachil R, Wen YE, Madrazo AZ, Sanchez CV, Reisch JS, Rozen SM. Dual versus Single Innervation of Gracilis Free Functional Muscle Transfer in Facial Paralysis: Long-Term Resting and Dynamic Outcomes. Plast Reconstr Surg 2024; 154:633-648. [PMID: 37607261 DOI: 10.1097/prs.0000000000011005] [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: 08/24/2023]
Abstract
BACKGROUND The purpose of this study was to compare long-term tone and excursion in single- versus dual-innervated free functional muscle transfer (FFMT) in patients with longstanding facial paralysis. METHODS Patients with longstanding facial palsy treated with an FFMT innervated either by a nerve-to-masseter graft (single-innervation group) or nerve-to-masseter and cross-facial-nerve grafts (dual-innervation group) were included. One-year minimum follow-up was required. Outcome measures, based on standardized photographs, included excursion, smile angle, teeth exposure, commissure height deviation, and upper lip height deviation in repose and in closed and open-teeth smile preoperatively and at 3 months, 1 year, and 3 years postoperatively. Emotrics software and ImageJ software were used to take measurements. Between-group and within-group longitudinal comparisons were analyzed. RESULTS At 3 years (single, n = 24; dual, n = 13), significance was found between groups in commissure position (single, 26.42 mm versus dual, 31.51 mm; P < 0.0001) and excursion with open-mouth smile (single, 31.32 mm versus dual, 26.59 mm; P < 0.001). Single-innervation FFMT within-group analysis lacked significant improvement in commissure height deviation and upper lip height deviation at 3 years in repose, whereas the dual-innervation group revealed significant improvements (3.67 mm [ P < 0.001], 3.17 mm [ P < 0.001], respectively). Teeth exposure revealed an increase in the dual-innervation group (single, 35.753 mm 2 versus dual, 64.177 mm 2 ), but significance was not observed. CONCLUSION Dual-innervated FFMT revealed improvements in resting tone and teeth exposure with minimal decrease in smile excursion compared with single-innervated FFMT. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
| | | | | | | | - Joan S Reisch
- Population and Data Sciences, University of Texas Southwestern Medical Center
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Souza S, Bhethanabotla RM, Mohan S. Applications of artificial intelligence in facial plastic and reconstructive surgery: a systematic review. Curr Opin Otolaryngol Head Neck Surg 2024; 32:222-233. [PMID: 38695544 DOI: 10.1097/moo.0000000000000975] [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: 05/06/2024]
Abstract
PURPOSE OF REVIEW Arguably one of the most disruptive innovations in medicine of the past decade, artificial intelligence is dramatically changing how healthcare is practiced today. A systematic review of the most recent artificial intelligence advances in facial plastic surgery is presented for surgeons to stay abreast of the latest in our field. RECENT FINDINGS Artificial intelligence applications developed for use in perioperative patient evaluation and management, education, and research in facial plastic surgery are highlighted. Selected themes include automated facial analysis with landmark detection, automated facial palsy grading and emotional assessment, generation of artificial facial profiles for testing and model training, automated postoperative patient communications, and improving ethnicity-sensitive facial morphometry norms. Inherent bias can exist in artificial intelligence models, and care must be taken to utilize algorithms trained with diverse datasets. SUMMARY Artificial intelligence tools are helping clinicians provide more standardized, objective, and efficient care to their patients. Increasing surgeon awareness of available tools, and their widespread implementation into clinical workflows are the next frontier. Ethical considerations must also shape the adoption of any artificial intelligence functionality. As artificial intelligence applications become a fixture in medicine, surgeons must employ them effectively to stay at the vanguard of modern medicine.
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Affiliation(s)
- Spenser Souza
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Rohith M Bhethanabotla
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Suresh Mohan
- Division of Otolaryngology, Yale School of Medicine, New Haven, Connecticut, USA
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Zumbusch F, Schlattmann P, Guntinas-Lichius O. Facial nerve reconstruction for flaccid facial paralysis: a systematic review and meta-analysis. Front Surg 2024; 11:1440953. [PMID: 39104714 PMCID: PMC11298393 DOI: 10.3389/fsurg.2024.1440953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 07/08/2024] [Indexed: 08/07/2024] Open
Abstract
Objectives To determine the functional outcome after facial nerve reconstruction surgery in patients with flaccid facial paralysis. Methods A systematic review and meta-analysis was performed on studies reporting outcomes after direct facial nerve suture (DFS), facial nerve interpositional graft suture (FIGS), hypoglossal-facial nerve suture (HFS), masseteric-facial nerve suture (MFS), and cross-face nerve suture (CFS). These studies were identified from PubMed/MEDLINE, Embase, and Web of Science databases. Two independent reviewers performed two-stage screening and data extraction. A favorable result was defined as a final House-Brackmann grade I-III and is presented as a ratio of all patients in percentage. Pooled proportions were calculated using random-effects models. Results From 4,932 screened records, 54 studies with 1,358 patients were included. A favorable result was achieved after DFS in 42.67% of the patients [confidence interval (CI): 26.05%-61.12%], after FIGS in 66.43% (CI: 55.99%-75.47%), after HFS in 63.89% (95% CI: 54.83%-72.05%), after MFS in 63.11% (CI: 38.53%-82.37%), and after CFS in 46.67% (CI: 24.09%-70.70%). There was no statistically significant difference between the techniques (Q = 6.56, degrees of freedom = 4, p = 0.1611). Conclusions The established facial nerve reconstruction techniques including the single nerve cross-transfer techniques produce satisfactory results in most of the patients with permanent flaccid facial paralysis. An international consensus on standardized outcome measures would improve the comparability of facial reanimation techniques.
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Affiliation(s)
| | - Peter Schlattmann
- Department of Medical Statistics, Computer Sciences and Data Sciences, Jena University Hospital, Jena, Germany
| | - Orlando Guntinas-Lichius
- Department of Otorhinolaryngology, Jena University Hospital, Jena, Germany
- Facial-Nerve-Center, Jena University Hospital, Jena, Germany
- Center for Rare Diseases, Jena University Hospital, Jena, Germany
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Kollar B, Weiss JBW, Kiefer J, Eisenhardt SU. Functional Outcome of Dual Reinnervation with Cross-Facial Nerve Graft and Masseteric Nerve Transfer for Facial Paralysis. Plast Reconstr Surg 2024; 153:1178e-1190e. [PMID: 37384874 DOI: 10.1097/prs.0000000000010888] [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: 07/01/2023]
Abstract
BACKGROUND The combination of cross-facial nerve graft (CFNG) and masseteric nerve transfer (MNT) for reinnervation of facial paralysis may provide advantages of both neural sources. However, quantitative functional outcome reports with a larger number of patients are lacking in the literature. Here, the authors describe their 8-year experience with this surgical technique. METHODS Twenty patients who presented with complete facial paralysis (duration, <12 months) received dual reinnervation with CFNG and MNT. The functional outcome of the procedure was evaluated with the physician-graded outcome metric eFACE scale. The objective artificial intelligence-driven software Emotrics and FaceReader were used for oral commissure measurements and emotional expression assessment, respectively. RESULTS The mean follow-up was 31.75 ± 23.32 months. In the eFACE score, the nasolabial fold depth and oral commissure at rest improved significantly ( P < 0.05) toward a more balanced state after surgery. Postoperatively, there was a significant decrease in oral commissure asymmetry while smiling (from 19.22 ± 6.1 mm to 12.19 ± 7.52 mm). For emotional expression, the median intensity score of happiness, as measured by the FaceReader software, increased significantly while smiling (0.28; interquartile range, 0.13 to 0.64). In five patients (25%), a secondary static midface suspension with fascia lata strip had to be performed because of unsatisfactory resting symmetry. Older patients and patients with greater preoperative resting asymmetry were more likely to receive static midface suspension. CONCLUSION The authors' results suggest that the combination of MNT and CFNG for reinnervation of facial paralysis provides good voluntary motion and may lessen the use of static midface suspension in the majority of patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Branislav Kollar
- From the Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg
| | - Jakob B W Weiss
- From the Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg
| | - Jurij Kiefer
- From the Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg
| | - Steffen U Eisenhardt
- From the Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg
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Bayezid KC, Morkuzu S, Karabulut E, Bajus A, Streit L. Restoring the spontaneous smile through free functional muscle transfer. A systematic review and meta-analysis of the last twenty years' experience. J Plast Reconstr Aesthet Surg 2024; 88:196-207. [PMID: 37988971 DOI: 10.1016/j.bjps.2023.10.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/04/2023] [Accepted: 10/23/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND The recovery of the spontaneous smile has become a primary focus in facial reanimation surgery and its major determinant is the selected neurotizer. We aimed to compare the spontaneity outcomes of the most preferred neurotization methods in free functional muscle transfer for long-standing facial paralysis. METHODS The Embase, Ovid Medline, and PubMed databases were queried with 21 keywords. All clinical studies from the last 20 years reporting the postoperative spontaneity rate for specified neurotization strategies [cross-face nerve graft (CFNG), contralateral facial nerve (CLFN), motor nerve to the masseter (MNM), and dual innervation (DI)] were included. A meta-analysis of prevalence was performed using Freeman-Tukey double arcsine transformation, I2 statistic, and generic inverse variance with a random-effects model. Risk Of Bias In Non-randomized Studies of Interventions and Newcastle-Ottawa scale were used to assess bias and study quality. RESULTS The literature search produced 2613 results and 473 unique citations for facial reanimation. Twenty-nine studies including 2046 patients were included in the systematic review. A meta-analysis of eligible data (1952 observations from 23 studies) showed statistically significant differences between the groups (CFNG: 0.94; 95% confidence interval [CI], 0.76-1.00, CLFN: 0.91; 95% CI, 0.49-1.00, MNM: 0.26; 95% CI, 0.05-0.54, DI: 0.98; 95% CI, 0.90-1.00, P < 0.001). In pairwise comparisons, statistically significant differences were found between MNM and other neurotization strategies (P < 0.001 in CFNG compared with MNM, P = 0.013 for CLFN compared with MNM, P < 0.001 for DI compared with MNM). CONCLUSIONS DI- and CLFN-driven strategies achieved the most promising outcomes, whereas MNM showed the potential to elicit spontaneous smile at a lower extent. Our meta-analysis was limited primarily by incongruency between spontaneity assessment systems. Consensus on a standardized tool would enable more effective comparisons of the outcomes.
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Affiliation(s)
- K Can Bayezid
- Department of Burns and Plastic Surgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Plastic and Aesthetic Surgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Suat Morkuzu
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell School of Medicine, Houston, TX, United States
| | - Erdem Karabulut
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Adam Bajus
- Department of Plastic and Aesthetic Surgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Libor Streit
- Department of Burns and Plastic Surgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Plastic and Aesthetic Surgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
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Fuzi J, Meller C, Ch'ng S, Dusseldorp J. The Emerging Role of Artificial Intelligence Tools for Outcome Measurement in Facial Reanimation Surgery: A Review. Facial Plast Surg Aesthet Med 2023; 25:556-561. [PMID: 37782135 DOI: 10.1089/fpsam.2022.0424] [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: 10/03/2023] Open
Abstract
Importance: Surgeons treating facial paralysis with reanimation surgery measure the outcomes of surgery and adjust treatment to each patient's needs. Our objective is to review the current subjective facial paralysis assessment tools and the emerging computer-based objective analysis, which may involve artificial intelligence. Observations: In recent years, many new automated approaches to outcome measurement in facial reanimation surgery have been developed. Most of these tools utilize artificial intelligence to analyze emotional expression and symmetry of facial landmarks. Other tools have provided automated approaches to existing clinician-guided scales. Conclusions: Newly developed computer-based tools using artificial intelligence have been developed to both improve existing clinician-graded scales and provide new approaches to facial symmetry and emotional expressivity analysis.
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Affiliation(s)
- Jordan Fuzi
- Department of Otolaryngology/Head and Neck Surgery, Prince of Wales Hospital, Randwick, Australia
- Faculty of Medicine, University of Sydney, Camperdown, Australia
| | - Catherine Meller
- Department of Otolaryngology/Head and Neck Surgery, Prince of Wales Hospital, Randwick, Australia
| | - Sydney Ch'ng
- Faculty of Medicine, University of Sydney, Camperdown, Australia
- Department of Plastic and Reconstructive Surgery, Chris O'Brien Lifehouse, Camperdown, Australia
| | - Joseph Dusseldorp
- Faculty of Medicine, University of Sydney, Camperdown, Australia
- Department of Plastic and Reconstructive Surgery, Chris O'Brien Lifehouse, Camperdown, Australia
- Department of Plastic and Reconstructive Surgery, Concord Repatriation General Hospital, Concord, Australia
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Kimura KS, Kfoury P, Pepper JP. Evidence-Based Medicine: Facial Reanimation. Facial Plast Surg 2023; 39:266-272. [PMID: 36720255 DOI: 10.1055/a-2023-9051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
This article provides a brief historical overview of the assessment instruments that have been developed to categorize the severity of disease in patients with facial palsy. Important advances in the quality of these instruments are discussed. The modern-day instruments that are commonly required for evidence-based patient assessment are then presented, with emphasis on the level of evidence of the studies that describe these instruments.
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Affiliation(s)
- Kyle S Kimura
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Peter Kfoury
- American University of Beirut Medical School, American University of Beirut, Beirut, Lebanon
| | - Jon-Paul Pepper
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
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Pan DR, Clark NW, Chiang H, Kahmke RR, Phillips BT, Barrett DM. The evolution of facial reanimation techniques. Am J Otolaryngol 2023; 44:103822. [PMID: 36934594 DOI: 10.1016/j.amjoto.2023.103822] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 02/19/2023] [Indexed: 03/05/2023]
Abstract
This review article provides an updated discussion on evidence-based practices related to the evaluation and management of facial paralysis. Ultimately, the goals of facial reanimation include obtaining facial symmetry at rest, providing corneal protection, restoring smile symmetry and facial movement for functional and aesthetic purposes. The treatment of facial nerve injury is highly individualized, especially given the wide heterogeneity regarding the degree of initial neuronal insult and eventual functional outcome. Recent advancements in facial reanimation techniques have better equipped clinicians to approach challenging patient scenarios with reliable, effective strategies. We discuss how technology such as machine learning software has revolutionized pre- and post-intervention assessments and provide an overview of current controversies including timing of intervention, choice of donor nerve, and management of nonflaccid facial palsy with synkinesis. We highlight novel considerations to mainstay conservative management strategies and examine innovations in modern surgical techniques with a focus on gracilis free muscle transfer. Innervation sources, procedural staging, coaptation patterns, and multi-vector and multi-muscle paddle design are modifications that have significantly evolved over the past decade.
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Affiliation(s)
- Debbie R Pan
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, NC, United States of America
| | - Nicholas W Clark
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, NC, United States of America
| | - Harry Chiang
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, NC, United States of America
| | - Russel R Kahmke
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, NC, United States of America
| | - Brett T Phillips
- Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University, Durham, NC, United States of America
| | - Dane M Barrett
- Department of Head and Neck Surgery & Communication Sciences, Duke University, Durham, NC, United States of America.
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The Facial Graft: A Graft of Emotions? (About the Reanimation of the Facial Allotransplantation). Atlas Oral Maxillofac Surg Clin North Am 2023; 31:57-64. [PMID: 36754507 DOI: 10.1016/j.cxom.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Although there have been numerous scientific papers reporting on composite allotransplantation of the face, few have been about assessment and evolution of the functional benefit for patients in terms of soft tissue mobility, movement coordination, and face expressions, even fewer on the choice of the surgical procedures to restore motricity. On some videos and interviews, it is possible to analyze significative motricity. Of course that has been voluntary motricity, not emotional motricity. The data confirmed that the result on the complexity of the expression of the face is not great, providing opportunity to reflect on the question of nerve regeneration.
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Fuzi J, Meller C, Ch'ng S, Hadlock TM, Dusseldorp J. Voluntary and Spontaneous Smile Quantification in Facial Palsy Patients: Validation of a Novel Mobile Application. Facial Plast Surg Aesthet Med 2022. [DOI: 10.1089/fpsam.2022.0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Jordan Fuzi
- Prince of Wales Hospital, Randwick, Australia
- University of Sydney, Camperdown, Australia
| | | | - Sydney Ch'ng
- University of Sydney, Camperdown, Australia
- Chris O'Brien Lifehouse, Camperdown, Australia
| | | | - Joseph Dusseldorp
- University of Sydney, Camperdown, Australia
- Chris O'Brien Lifehouse, Camperdown, Australia
- Concord Repatriation General Hospital, Concord, Australia
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