Reanimation of the Smile with Neuro-Vascular Anastomosed Gracilis Muscle: A Case Series.

BACKGROUND: The aim of our manuscript was to evaluate the time course of clinical and electromyographical (EMG) reinnervation after the reanimation of the smile using a gracilis muscle transplant which is reinnervated with the masseteric nerve. METHODS: We present a case series of five patients with a longstanding peripheral facial palsy, who underwent a reanimation of the lower face using a gracilis muscle transplant with masseteric nerve reinnervation from June 2019 to October 2020. Trial-specific follow-up examinations were carried out every three months using clinical assessment and EMG, up to 12 months after the surgery. The grading was carried out using the House-Brackmann scale (HB), the Stennert Index, and a self-designed Likert-like scale for graft reinnervation and smile excursion. RESULTS: The surgery was feasible in all of the patients. The reanimation was performed under general anesthesia in an inpatient setting. Postoperative complications which resulted in prolonged hospitalization occurred in two of the five patients. All of the patients showed a preoperative flaccid facial palsy. The first single reinnervation potentials were detected 3.1 ± 0.1 months after surgery. After 5.6 (±1.4) months, in three (3/5) patients, clear reinnervation patterns were present. Clinically, the patients obtained symmetry of the face at rest after 5.6 (±1.4) months, and could spontaneously smile without the co-activation of the jaw after an average time of 10.8 (±1.8) months. All of the patients were able to express a spontaneous emotion-stimulated smile after one year. CONCLUSION: Micro-neurovascular gracilis muscle transfer reinnervated with a masseteric nerve is a sufficient and reliable rehabilitation technique for the lower face, and is performed as a single-stage surgery. The nerve supply via the masseteric nerve allows the very rapid and strong reinnervation of the graft, and results in a spontaneous smile within 10 months.

Long-term therapy with botulinum toxin in facial synkinesis: Retrospective data analysis of data from 1998 to 2018.

OBJECTIVES: Treatment with botulinum toxin A (BoNT) is the therapy of choice for many patients with facial synkinesis. Repeated injections relieve hypertonicity and hyperkinesis of reinnervated mimic muscles. Aim of the study was to prove if the injection regime and dosage of BoNT change during long-time therapy. DESIGN: Retrospective analysis of patients´ data, who were treated for synkinesis with BoNT from 1998 to 2018. SETTING: Tertiary referral facial nerve centre. PARTICIPANTS: Injection pattern of BoNT was based on clinical symptoms, observations of the specialist and on previous treatment pattern. Onabotulinumtoxin (OnaBoNT), Incobotulinumtoxin (IncoBoNT) and Abobotulinumtoxin (AboBoNT) were available for treatment. Patients consulted our department for following treatment as soon as the symptoms re-occurred. MAIN OUTCOME MEASURES: Change in dosage and injection pattern, the time intervals between treatments over the entire therapy period. RESULTS: Seventy-three patients were repeatedly injected. The median number of treatments was 18, the median treatment interval was 3.0 months. During the initial treatment, orbicularis oculi and the mentalis muscles were the most frequently injected muscles (94%). During repeated treatment, the number of injected muscles increased significantly (P < .0001), whereas the dose per muscle remained stable. The initial dose was 24 U (95%-CI 22-27 U) for OnaBoNT and IncoBoNT; 69 U for AboBoNT(95%-CI 44-94 U). We observed a significant increase in dosage for OnaBoNT and IncoBoNT (P < .0001) during the long-term therapy. The time intervals between treatments were stable for all three BoNT preparations (P > .05). CONCLUSIONS: We observed significant change in treatment dose and injection pattern of BoNT in patients with facial synkinesis. These results provide an orientation in dose finding and injection regimen of BoNT in the long-term course of therapy.

[Planning and design of European prospective randomized trial on the value of drain in parotidectomy]. / Vorstellung einer europaweiten prospektiven Studie zur Wertigkeit einer Drainage bei Parotidektomie.

INTRODUCTION: There are no valid clinical studies on the value of wound drains in parotid surgery. The aim of the current trial is to analyze the influence of the closed wound drain (redon) on the incidence of postoperative complications such as bleeding, wound healing problems, infection, as well as salivary cyst and fistula after superficial or partial parotidectomy. METHODS: A European-wide multicenter prospective randomized study was planned. The study protocol was prepared by the leading study center (ENT University Hospital Cologne) in cooperation with the ENT University Hospitals Jena and Göttingen. The calculation of the number of cases was carried out with G*Power. The study includes test persons with an indication for parotidectomy for a benign tumor without known coagulation disorder or ongoing anticoagulation. Preoperative randomization and data management is software-supported (REDCap 9.1.24, Vanderbilt University). RESULTS: The study has been approved by the leading ethics committee in 10/2019 and is open since 04/2019. Currently, nine (9) ENT hospitals are participating in the study, 6 of them in Germany and 3 in Austria. Enrollment of patients is ongoing in 7 centers. With a calculated follow-up-to-treat population of 800 test persons, the planned duration of the study is 4 years. CONCLUSIONS: The Redon-study is the first prospective randomized study worldwide to investigate the effect of a drain in parotidectomy. In order to achieve the recruitment goal within the planned time frame, the participation of further specialized study centers is needed. We also encourage all ENT physicians to make their patients aware of the Redon study, inform them about the possibility of participating in the study and refer them to one of the participating centers.

Analyse und Management von postoperativen Schmerzen nach Sialendoskopie.

OBJECTIVE: Sialendocopy is a minimal-invasive technique used for the diagnosis and treatment of salivary gland diseases. The minimal-invasive character of sialendoscopy can be modified by using different surgical techniques. This is why both general and local anaesthesia are applied to perform this procedure and can be of great influence regarding the postoperative pain of those patients. The following study was performed to investigate the level of postoperative pain after sialendoscopy and its pain management. MATERIAL AND METHODS: 103 patients who were treated with a sialendoscopy of the parotid gland or submandibular gland in local anaesthesia between 2013-2015 were included in the study. The postoperative pain level was evaluated at rest and during periods of stress on the day of surgery and the first and second day after surgery. The pain level was analysed according to the numeric rating scale (NRS 0-10), which is used in the QUIPS project (Quality improvement of postoperative pain). RESULTS: The pain level on the day of surgery was 0,9 ± 1,9 at rest and 0,7 ± 1,4 during periods of stress. On the first postoperative day, pain levels of 1,2 ± 1,8 at rest and 0,9 ± 1,9 during stress were evaluated. On the second day after surgery there was a decrease of pain with a level of 0,75 ± 1,6 at rest and 0,73 ± 1,5 during stress. The analgesic therapy that was mostly used was Metamizol and Ibuprofen. 37,9 % of all patients received analgesic therapy on the day of surgery whereas on the first day after surgery only 26,2 % of all patients and on the second day after surgery only 12,6 % received pain medication. CONCLUSION: Sialendoscopy of the parotid gland and the submandibular gland is associated with moderate postoperative pain, which can be managed by using non-opioid analgesic therapy.

Impact of extent of parotidectomy on early and long-term complications: A prospective multicenter cohort trial.

BACKGROUND: In this prospective nonrandomized multicenter trial, we analyze the incidence of early and late complications after parotidectomy in correlation to the extent of dissection. METHODS: A total of 148 patients underwent a parotidectomy for a benign lesion in the superficial lobe. The number of intraoperatively dissected main facial nerve branches was photo-documented and defined the extent of tissue dissection. Early postoperative complications including sialocele were evaluated until 4 weeks after surgery. Late complications as facial nerve palsy, Frey's syndrome (FS) and the outcome of the scar and substance loss were furthermore assessed after 6 and 12 months. RESULTS: Early complications occurred in 22 patients (14%) and did not depend on the extent of facial nerve dissection (all P > .05). However, patients with higher number of intraoperatively dissected facial nerve branches showed significantly higher palsy scores on the first postoperative day (P = .026). FS occurred with incidence of 69% and correlated significantly to the extent of dissection (P = .003). Appearance of the scar and substance loss improved significantly during the follow-up (P < .001 and P < ,005, respectively) without significant correlation to the extent of dissection (P > .05 for both variables after 12 months). CONCLUSIONS: Less extensive tissue dissection resulted in better postoperative facial nerve function on the first postoperative day and in lower incidence of FS after 12 months. However, incidence of early complications did not depend on the extent of surgery. The study was registered in the German Clinical Trials Register prior to conducting the research. DRKS-ID: DRKS00008967, URL:http://apps.who.int/trialsearch/.