Staged upper and lower lip reanimation following facial palsy: Peer-reviewed, patient-rated and objective outcomes.

BACKGROUND: One approach to reanimating both upper and lower lips following facial palsy is through staged surgery: cross-face nerve grafting at stage I, free gracilis muscle transfer to levators at stage II and pedicled anterior belly of digastric muscle transfer (ABDMT) to depressors at stage III. The results of this approach were hitherto unquantified. METHODS: This study retrospectively assessed peer-reviewed, patient-rated and objective outcomes following staged reanimation in adults between 2010 and 2020. Demographics, palsy characteristics and surgery details were recorded. Pre- and postoperative videos were rated by independent assessors using Terzis' aesthetic and symmetry scale. Photographs were analysed using Emotrics and patients completed the Glasgow Benefit Inventory (GBI) patient-rated outcome measure. RESULTS: Ten patients [mean age = 34 (SD = 12.48)] were eligible. All regained lip elevation and depression. All markers of symmetry improved after gracilis transfer. All markers were also improved after ABDMT except for lower lip height when smiling with teeth showing (p > 0.05). Five patients (50%) responded to the GBI (mean score = +39.44). No patients reported detriment from the reanimations. Mean Terzis' scores preoperatively and after stages II and III were 1.5, 2.26 and 2.39, respectively (p < 0.05). Nine patients underwent aesthetic refinements [lipofilling to lower lip notches (n = 5), debulking of gracilis bulk (n = 6), repositioning of muscle insertion (n = 5) and facelifts (n = 2)]. CONCLUSION: The outcomes were positive objectively and as judged by peers and patients themselves. Aesthetic refinements may also be required to enhance these results.

Lower lip depressor reanimation using anterior belly of digastric muscle transfer improves psychological wellbeing in facial palsy patients.

The authors previously published positive peer-reviewed (21 raters using the Terzis scale) and photogrammetric (Emotrics) outcomes in patients who had undergone two-stage lower lip reanimations up to 2018. Other series have published surgeon and peer-rated results, but we know of only two (n=12) that have assessed patients' views using patient satisfaction surveys. This paper presents patient-rated outcomes (PROMS) in an 11-year series of both single and two-stage anterior belly of digastric muscle (ABDM) lower lip reanimations. Demographics, paralysis characteristics, operative details, and complications were recorded. Patients were telephoned and requested to complete the Glasgow Benefit Inventory (GBI) to assess patient-rated outcomes. Thirty-two patients were eligible (mean age 36.4 years). Twenty-one (63.6%) completed the GBI (mean score +33.3). More patients reported benefit than detriment (95.2% vs 4.8%). Complications were infrequent and included three cases of superficial infections and one of dermatitis. Four patients (12.5%) underwent minor revisions, mostly lipofilling of lip notches. The median (range) duration of follow up was 2.8 (0.3 - 8.5) years. ABDM transfer for lower lip reanimation is a safe, low morbidity procedure that enhances the psychological wellbeing of patients with facial palsy.

Long-term outcomes of dual innervation in functional muscle transfers for facial palsy.

BACKGROUND: This study describes a different approach with a 2-stage facial reanimation in patients with long-standing unilateral facial paralysis using free gracilis muscle transfer, innervated by both cross-facial nerve graft and masseteric nerve. The authors present their rationale, surgical technique, and long-term outcomes. METHODS: Between August 2012 and March 2016, 11 patients (6 female and 5 male patients) underwent a 2-staged dually innervated gracilis muscle transfer. Patients were evaluated with physical examination and needle electromyography. A standardized assessment of preoperative and postoperative photographs and videos was performed using Terzis' smile functional grading system at 48 months following surgery and the Emotrics software to assess improvement in symmetry over a 36-month postoperative period. RESULTS: Voluntary contraction of the gracilis muscle was observed in all patients at a mean of 4 months and 4 days following muscle transfer. A spontaneous smile produced without teeth clenching was developed in all patients by 18 months postoperatively. Six patients achieved excellent and 5 good results. The difference between the averaged pre- and postoperative scores was statistically significant. With Emotrics, there were significant improvements in the smile angle, upper lip elevation, commissural excursion, and commissural height, with continuous improvement over 36 months. The postoperative electromyography (EMG) confirmed dual innervation of the gracilis muscle by the facial and masseteric donor motor neural sources. We present our results at minimum 48 months postoperatively. CONCLUSIONS: Dual innervated two-stage gracilis transfer is an effective method for reanimation in long-standing unilateral facial paralysis, providing both rapid reinnervation of the transferred muscle, together with a powerful, synchronous smile.

Lower Lip Reanimation: Experience Using the Anterior Belly of Digastric Muscle in 2-stage Procedure.

Lower lip depression was historically regarded a neglected area of facial paralysis, but, with refinement of techniques, has gained increasing attention. We present the first detailed description and evaluation of a 2-stage technique, using first cross facial nerve graft and then the anterior belly of digastric muscle (ABDM), innervated by the cross facial nerve graft, to restore dynamic and spontaneous lower lip depression. METHODS: Retrospective analysis of 2-stage lower lip reanimations between 2010 and 2018 was performed. Demographics, etiology, and operative details were recorded. Videos were graded pre/postoperatively using a 5-point Likert scale by 21 independent observers. Objective changes of symmetry were analyzed using Photogrammetry (Emotrics). RESULTS: Twenty-seven patients were identified (median age 34.9 years, range 6-64). The mean duration between the 2 stages was 15.1 months. Follow-up ranged from 18-72 months. There were minor complications in 4 patients, and 1 case was abandoned due to insufficient length of anterior belly of digastric muscle. Average peer-reviewed scores improved from 2.1 to 3.2 (P < 0.05). Emotrics did not show improvement in static symmetry (P > 0.05). However, during open-lip smiling, lower lip height improved significantly (P < 0.05) whilst dental show improvements approached significance (P < 0.08). Lower lip symmetry was also improved during lower lip depression, as shown by improvements in lower lip height (P < 0.05), smile angle, and dental show (both P < 0.05). CONCLUSIONS: These results show the safety and efficacy of 2-stage lower lip reanimation using anterior belly of digastric muscle transposition. This procedure is our choice for longstanding lower lip paralysis and provides coordinated spontaneous lower lip depression, thus enhancing the overall perioral animation and smile.

Outcomes of major head and neck reconstruction during the COVID-19 pandemic: The St. Andrew's centre experience.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic has generated enormous pressure on healthcare establishments, prompting the restructuring of services to rationalise resources. Complex head and neck reconstructive surgery in this setting may carry substantial risk to patients and staff. This paper outlines the management strategy and outcomes of major head and neck oncological cases at a single regional tertiary referral centre. METHODS: A database review was undertaken of consecutive patients undergoing major head and neck surgery and reconstruction during the COVID-19 pandemic at St Andrew's Centre for Plastic Surgery & Burns, Chelmsford UK. Patient demographics, tumour and reconstruction characteristics as well as peri­operative information were determined. Patients were prospectively contacted with regard to COVID-related symptoms and investigations. RESULTS: Twenty-two patients (15 males and 7 females) with a mean age of 67 years (range: 36-92 years) were included between March 1 and June 13, 2020. Patients underwent pre-operative throat swabs at 72 h and 24 h as well as chest CT scanning as part of a robust protocol. Twelve free flaps, four loco-regional flaps, four parotidectomies and 23 cervical lymphadenectomies were performed. Two patients required a return to theatre. No post-operative deaths occurred and flap survival rate was 100%. A single patient tested positive for COVID-19 pre-operatively and no post-operative COVID-19 infections occurred. CONCLUSION: Although head and neck surgery represents a high-risk procedure to patients and healthcare professionals, our institutional experience suggests that in the presence of a robust peri­operative protocol and judicious patient selection, major head and neck surgery, including free tissue transfer reconstruction, may be performed safely.

Primary cutaneous osteosarcoma of the scalp.

Primary cutaneous extraskeletal osteosarcoma (PCEO) is a rare malignant neoplasm with less than 20 cases reported in the literature to date. Presenting as a nodule or mass on the skin, commonly at sites of previous trauma or radiation, these lesions are differentiated from other neoplasms through their characteristic microscopic appearance. This report highlights a case of PCEO in a 75-year-old man with a history of squamous cell carcinoma (SCC) of the scalp. Histological examination of a scalp nodule in the region of a previously excised SCC revealed proliferation of osteoid surrounded by malignant osteocytes. An overview of this condition and differential diagnoses are presented in this report.

Bell's palsy: a summary of current evidence and referral algorithm.

Spontaneous idiopathic facial nerve (Bell's) palsy leaves residual hemifacial weakness in 29% which is severe and disfiguring in over half of these cases. Acute medical management remains the best way to improve outcomes. Reconstructive surgery can improve long term disfigurement. However, acute and surgical options are time-dependent. As family practitioners see, on average, one case every 2 years, a summary of this condition based on common clinical questions may improve acute management and guide referral for those who need specialist input. We formulated a series of clinical questions likely to be of use to family practitioners on encountering this condition and sought evidence from the literature to answer them. The lifetime risk is 1 in 60, and is more common in pregnancy and diabetes mellitus. Patients often present with facial pain or paraesthesia, altered taste and intolerance to loud noise in addition to facial droop. It is probably caused by ischaemic compression of the facial nerve within the meatal segment of the facial canal probably as a result of viral inflammation. When given early, high dose corticosteroids can improve outcomes. Neither antiviral therapy nor other adjuvant therapies are supported by evidence. As the facial muscles remain viable re-innervation targets for up to 2 years, late referrals require more complex reconstructions. Early recognition, steroid therapy and early referral for facial reanimation (when the diagnosis is secure) are important features of good management when encountering these complex cases.

Essays on the facial nerve: Part I. Microanatomy.

BACKGROUND: Facial nerve explorations and microstimulation of distal nerve branches during facial reanimation procedures by the senior author (J.K.T.) have yielded various observations. This prompted the authors to quantify the surgical findings with an anatomical study and a subsequent analysis of the electrophysiologic intraoperative data. The present report details the microanatomical observations. METHODS: Ten fresh cadaveric hemiface dissections (five specimens) were performed. The facial nerve branches were traced distally under the operating microscope and mapped with India ink. A number of nerve branches exited the parotid at approximately 9 +/- 0.85 cm from the facial nerve trunk division, and their distribution was noted. Photographic documentation was obtained. RESULTS: The mean number of nerve branches was 7.70 +/- 1.05 at the anterior parotid border and 13.80 +/- 1.81 distally. Differences in the number and configuration of nerve branches existed even between the two sides of the face. The frontal branch had a mean nerve number of 2.80 +/- 0.63; the zygomatic branch, 4.40 +/- 1.34, the buccal branch, 3.20 +/- 0.78; and the marginal mandibular branch, 2.30 +/- 0.48. In 70 percent of specimens, the buccal branches originated from both upper and lower nerve divisions and interconnected with the marginal mandibular branch in 50 percent of specimens. Distally, connectivity was found between buccal branches and the infraorbital nerve, the marginal mandibular branches, and the mental nerve. A constant lower zygomatic or zygomaticobuccal branch reached the procerus and corrugator supercilii muscles. A twig from the frontal branch reached the corrugator muscle in 60 percent of cases. CONCLUSIONS: Diversity of facial nerve anatomy is recognized and documented. Specific anatomical relationships are clarified and demonstrated as a guiding map.

Necrotizing fasciitis following drainage of Streptococcus milleri empyema.

Streptococcus milleri (SM) is a heterogeneous group of Streptococci, which is a recognized cause of purulent infections of the mediastinal and pleural spaces. These infections are notoriously resistant and require aggressive surgical management. We present our experience with a 60-year-old patient, who developed necrotizing fasciitis of the chest wall after initial bedside drainage of a SM empyema. He required extensive debridement with significant soft tissue loss and subsequent latissimus dorsi flap reconstruction to cover the defect.

Outcomes of mini-hypoglossal nerve transfer and direct muscle neurotization for restoration of lower lip function in facial palsy.

BACKGROUND: Most reconstructions for lower lip palsy focus on paralyzing the contralateral normal lip or providing static support on the affected side. The authors' unit has reported dynamic strategies for lower lip reanimation and use of 40 percent of the hypoglossal nerve (mini-hypoglossal) in facial reanimation. They report their experience with mini-hypoglossal nerve transfer for lower lip palsy. METHODS: Between 1987 and 2005, 29 patients with unilateral facial palsy had lower lip reanimation with the mini-hypoglossal as the motor donor. Twenty patients had transfer of the mini-hypoglossal to the cervicofacial branch of the facial nerve and nine had direct depressor muscle neurotization. Five patients had a mean denervation time of 14.60 +/- 4.50 months (<2 years), and the rest had a mean denervation time of 10.63 +/- 9.23 years. In late cases, the facial nerve was in-continuity, and preoperative needle electromyographs of depressors showed at least fibrillations. Standardized videos taken preoperatively and at 2 years postoperatively were available for 27 patients and assessed by three independent reviewers. Needle electromyographic results were analyzed. RESULTS: Thirteen patients (48.15 percent) achieved excellent and good results, nine (33.33 percent) had moderate results, and five (18.52 percent) obtained fair results. The difference between the averaged preoperative and postoperative scores was statistically significant, as was the difference in electromyographic outcomes (p < 0.0001, Wilcoxon signed rank test). The nerve transfer and direct neurotization groups had no statistically significant difference in clinical and electromyographic outcomes. Four patients required muscle transfer for further outcome upgrading. CONCLUSION: Use of the mini-hypoglossal either for nerve transfer or for direct muscle neurotization of lower lip depressors can provide reinnervation and satisfactory clinical function, even for muscles with prolonged partial denervation.

"Babysitter" procedure with concomitant muscle transfer in facial paralysis.

BACKGROUND: The "babysitter" procedure combines cross-facial nerve grafting with segmental transfer of the hypoglossal to the affected facial nerve. Introduced by Terzis in 1984, the technique can produce satisfactory to excellent results. In long-lasting paralysis, nonetheless, the babysitter procedure may need to be combined with a muscle(s) flap(s) for outcome upgrading, which was the focus of the present study. METHODS: Thirty-eight patients had the babysitter procedure over a 20-year period (1984 to 2003). Twenty patients had only the babysitter procedure, whereas 18 needed an additional muscle flap(s) (up to three) to enhance function and cosmesis. These muscles included nine free (gracilis, pectoralis minor) and 20 regional (frontalis, minitemporalis, platysma, digastric) muscles for distinct target needs: eye closure, smile restoration, and lower lip depression. The need for a muscle flap was determined at the initial consultation. All free muscles were transferred at the second-stage of the babysitter procedure, whereas regional muscles were also transposed later. Three independent observers graded the results at two time intervals, preoperatively and 2 years after all operations were completed. RESULTS: The average postoperative grading scores were significantly higher compared with preoperative scores for eye closure, smile, lower lip depression, and overall aesthetic outcome (p < 0.0001, Wilcoxon signed ranks test). All patients had upgrading of overall aesthetics and smile, whereas four maintained similar scoring for eye closure and one maintained similar scoring for lip depression. All but two had secondary procedures to further enhance facial symmetry. CONCLUSION: The babysitter procedure in conjunction with muscle transfers in selected patients with late presentation can provide highly satisfactory results when seeking uncompromising outcome.

Prostaglandin EP2 and EP4 receptor agonists in bone formation and bone healing: In vivo and in vitro evidence.

BACKGROUND: Using agonists that selectively stimulate PGE2 receptors, the adverse effects that have limited the clinical utility of PGE2 can be avoided and there may be potential for their use as therapeutic agents in the treatment of bone loss in humans. OBJECTIVE: A comprehensive review of the recent literature on the effect of prostaglandins and their agonists on bone mineral density and fracture healing. METHODS: In vitro and in vivo evidence was collected using medical search engines MEDLINE (1950 to March 2008) and EMBASE (1980 to March 2008) databases. RESULTS/CONCLUSION: EP4 receptors have been identified in human osteoblast cell lines and have also been shown to activate osteoblast directly and osteoclast indirectly via osteoblastic activation. Although there are strong in vitro and in vivo collective data indicating that EP2 receptors may have a role in mediating the anabolic effects of PGE2 on bone, to date no functional EP2 receptors have been identified on human osteoblasts or osteoclasts. This suggests that PGE2 effect on bone formation and resorption in humans may be governed by activation of the EP4 receptor on osteoblasts. Selective EP4 receptor agonists may therefore provide therapeutic potential for systemic use in the treatment of osteoporosis and fracture healing. Further studies need to be carried out in order fully elicit the role of EP2 receptor agonists in fracture healing and bone formation in humans.

The "babysitter" procedure: minihypoglossal to facial nerve transfer and cross-facial nerve grafting.

BACKGROUND: In 1984, Terzis introduced the "babysitter" procedure, a new concept in facial reanimation. It involves two stages, with coaptation of ipsilateral 40 percent hypoglossal to facial nerve on the affected side, performed concomitantly with cross-facial nerve grafting and secondary microcoaptations 8 to 15 months later. This article presents the senior author's (J.K.T.) experience with the original procedure. METHODS: Of 75 patients who had minihypoglossal nerve transfer, 20 fulfilled the selection criteria for the original babysitter procedure. All patients' records, photographs, videotapes, and needle electromyography studies were reviewed. The clinical results were scored using Terzis' Grading Scale. Eye closure, smile, and lower lip depression were each assessed separately. Functional and aesthetic outcomes and preoperative and postoperative electromyography results were analyzed. RESULTS: Seventy-five percent of patients achieved excellent and good results, 15 percent had moderate results, and 10 percent had fair results. The difference between preoperative and postoperative eye closure was statistically significant (t test, p < 0.001). Symmetrical smile and full contraction (excellent result) was achieved in two patients (10 percent), 13 patients (65 percent) had nearly symmetrical smile (good result), and five patients (25 percent) had a moderate result. Two patients (10 percent) had full lower lip depression (excellent result) and 15 (75 percent) had good results. In three patients (15 percent), subsequent digastric or platysma muscle transfer was performed because of inadequate depression and symmetry (moderate result). A statistically significant difference was observed between preoperative and postoperative electromyography results, in eye closure, smile, and lower lip depression. CONCLUSIONS: The original babysitter procedure offers significant improvement in selected patients with facial paralysis. Symmetry and coordinated movements can be restored, with satisfying aesthetic and functional outcomes.