Sympathicotomy for isolated facial blushing: long-term follow-up of a randomized trial.

OBJECTIVES: Thoracoscopic sympathicotomy may be an effective treatment for disabling facial blushing in selected patients. Short- and mid-term results are good but very long-term results are scarce in the medical literature and there is no knowledge which extent of sympathicotomy is better long-term for isolated facial blushing. METHODS: We previously randomized 100 patients between a rib-oriented R2 or R2-R3 sympathicotomy for isolated facial blushing, and reported local effects, side effects and quality of life after 12 months. In the present study, we sent identical questionnaires to all patients after a median of 16 years (interquartile range 15-17 years). RESULTS: The response rate was 66%. Overall, 82% reported excellent or satisfactory results on facial blushing, with significant better local effect after R2 sympathicotomy compared with R2-R3 sympathicotomy. Patients who underwent R2 sympathicotomy were also significantly more satisfied with the operation. We found no significant difference between R2 and R2-R3 sympathicotomy in quality of life or rates of compensatory sweating (77%) and recurrence of blushing (41%) which was milder than preoperatively in most patients. CONCLUSIONS: R2 sympathicotomy should be the preferred approach for isolated facial blushing because of better local effect and higher satisfaction rates. Although this was a very long-term follow-up of the only randomized trial of its kind the response rate was limited leaving a risk of undetected bias.

Staged single-port thoracoscopic R2 sympathicotomy as a reproducible, safe and effective treatment option for debilitating severe facial blushing.

OBJECTIVES: Our goal was to investigate the safety, feasibility, success rate, complication rate and side effects of staged single-port thoracoscopic R2 sympathicotomy in the treatment of severe facial blushing. Facial blushing is considered a benign condition; however, severe facial blushing can have a major impact on quality of life. When nonsurgical options such as medication and psychological treatments offer no or insufficient relief, surgical treatment with thoracoscopic sympathicotomy should be considered. METHODS: All patients who underwent a staged thoracoscopic sympathicotomy at level R2 for severe facial blushing between January 2016 and September 2021 were included. Clinical and surgical data were prospectively collected and analysed. RESULTS: A total of 16 patients with low operative risk (American Society of Anesthesiologists class 1) were treated. No major perioperative complications were encountered. One patient experienced postoperative unilateral Horner's syndrome that resolved completely after 1 week. Two patients experienced compensatory hyperhidrosis. The success rate was 100%. One patient experienced a slight recurrence of blushing symptoms after 3 years that did not interfere with their quality of life. All patients were satisfied with the results and had no regrets of having undergone the procedure. CONCLUSIONS: Staged single-port thoracoscopic R2 sympathicotomy is a reproducible, safe and highly effective surgical treatment option with low compensatory hyperhidrosis rates and the potential to significantly improve quality of life in carefully selected patients suffering from severe facial blushing. We would like to increase awareness among healthcare professionals for debilitating facial blushing and suggest timely referral for surgical treatment.

Do your troubles today seem further away than yesterday? On sleep's role in mitigating the blushing response to a reactivated embarrassing episode.

The "sleep to forget and sleep to remember hypothesis" proposes that sleep weakens the emotional tone of an experience while preserving or even enhancing its content. Prior experimental research however shows contradictory findings on how emotional reactivity changes after a period of sleep, likely explained by methodological variations. By addressing these inconsistencies, we investigated the mitigating effect of overnight sleep on emotional reactivity triggered by memory reactivation. Using a karaoke paradigm, we recorded participants' singing of two songs, followed by exposing them to one of the recordings (rec1) to induce an embarrassing episode. After a 12-hr period of either day-time wakefulness (N = 20) or including nighttime sleep (N = 20), we assessed emotional reactivity to the previously exposed recording (rec1) and the newly exposed recording (rec2). Emotional reactivity was assessed with a physiological measure of facial blushing as the main outcome and subjective ratings of embarrassment and valence. Sleep and wake were monitored with diaries and actigraphy. The embarrassing episode was successfully induced as indicated by objective and subjective measures. After controlling for an order effect in stimulus presentation, we found a reduction in blushing response to the reactivated recording (rec1) from pre- to post-sleep compared to wakefulness. However, emotional reactivity to the reactivated recording (rec1) and the new recording (rec2) did not differ after sleep and wakefulness. This study shows that facial blushing was reduced following overnight sleep, while subjective ratings were unaffected. Whether the beneficial effect of sleep is due to changes in memory representation or rather emotion regulation remains elusive.

TIMI flow and myocardial blushing after rescue PCI and cardiac magnetic resonance: Results from the Myocardial Salvage After Rescue Angioplasty: Evaluation by Magnetic Resonance (SAVE-ME) study.

INTRODUCTION: Thrombolysis is currently reserved for ST-elevation myocardial infarction (STEMI) patients who cannot access timely percutaneous coronary intervention (PCI). In case of failed thrombolysis, rescue PCI is a viable option. Substantial data concerning the outcomes in terms of infarct size and myocardial function after rescue PCI are lacking. METHODS: Forty patients treated with rescue PCI underwent serial contrast-enhanced cardiac magnetic resonance imaging (CMR) at 1 week, 3 months and 6 months from the index STEMI. Angiographic images were reviewed to assess Thrombolysis in Myocardial Infarction (TIMI) blood flow and TIMI Myocardial Blush Grade (TMBG) in the infarct related artery after PCI. RESULTS: Patients with lower TMBG at the end of procedure, but not patients with worse TIMI flow, had lower left ventricular ejection fraction (LVEF) and higher volume of late gadolinium enhancement (LGE) on baseline CMR (44 ± 13% vs 52 ± 9%, p = 0.026, and 41 ± 21 ml vs 26 ± 12, p = 0.030, respectively). Patients with lower TMBG remained with significantly lower LVEF at 6 months follow up (48 ± 16% vs 59 ± 14, p = 0.049). CONCLUSION: TMBG after rescue PCI is associated with reduced LVEF and increased LGE burden. As TMBG is a known marker of microvascular damage after STEMI, novel strategies aimed at improving microvascular function in the setting of rescue PCI are needed to improve the outcomes in this patient population.

Surgical treatment of facial blushing: Patient selection and operative technique (retrospective observational study).

Surgeons are often reluctant to offer further intervention to patients with medically intractable facial blushing. This is mainly because of the relatively high failure rate of blushing resolution and a high incidence of compensatory hyperhidrosis. In this study, we sought to identify the type of blushing that would benefit from surgery and minimize compensatory hyperhidrosis by applying diffuse sympathicotomy (DS). This study was a retrospective review of 62 patients who underwent R2 endoscopic thoracic sympathicotomy (ETS) and preemptive DS for facial blushing. Facial blushing was classified as autonomic-mediated blushing (thermoregulatory, emotional) and vasodilator-mediated blushing (constant) based on the history and precipitating factors for blushing. DS was performed at lower-thoracic levels in the form of limited DS (right R5/7/9/11, left R5/6/8/10) or extended DS (bilateral R5-11). Resolution of blushing (described as "almost disappeared") was achieved in 48% of patients with a median follow-up of 19.6 months. There was a significant difference in resolution among 3 types of blushing (emotional: 55%, thermoregulatory: 28%, constant: 15%, P = .03). Multivariate analysis confirmed thermoregulatory and constant type blushing as a potential independent predictor of blushing resolution. Even though there was no difference between the DS procedures with respect to compensatory hyperhidrosis, intolerable compensatory hyperhidrosis (Hyperhidrosis Disease Severity Scale = 4) occurred in only 11% of patients. DS redistributed sweating area, being predominantly on the chest and mid-back (89%), also seen on the abdomen-waist-groin-buttocks-thighs (63%). Overall, 77% of patients experienced satisfactory results. Emotional blushing proved to be an established indication of ETS where good long-term results can be expected. Expansion of surgical indication to thermoregulatory or constant type blushing needs to be validated in future studies. Additionally, compensatory hyperhidrosis, another hurdle for ETS, can be minimized by preemptive DS, resulting in redistribution and decrease of sweating.

Treatment Options for Fear of Blushing.

PURPOSE OF REVIEW: To review mechanisms of blushing and fear of blushing from physiological, neuropharmacological and psychological viewpoints, and to evaluate current forms of treatment for blushing-related fear. RECENT FINDINGS: Blushing appears to be driven primarily by sympathetic adrenomedullary and neural vasodilator discharge, possibly in association with secondary neurovascular inflammation. Psychological risk factors for fear of blushing include social anxiety, coupled with heightened self-focused attention and inflated beliefs about the likelihood and social costs of blushing. In addition, schemas of emotional inhibition, social isolation and alienation may underlie blushing-related fears. Established psychological treatments for fear of blushing include task concentration training, exposure, cognitive therapy, social skills training, psychoeducation and applied relaxation. More novel approaches include mindfulness and mindful self-compassion, video feedback and imagery rescripting. There are no established pharmacological treatments specifically for fear of blushing. However, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are effective treatments for social anxiety disorder and may thus help some patients manage their fear of blushing. A reactive sympathetic nervous system may interact with psychological predispositions to intensify fear of blushing. These physiological and psychological risk factors could be promising targets for treatment.

The unique contribution of blushing to the development of social anxiety disorder symptoms: results from a longitudinal study.

BACKGROUND: Self-conscious emotional reactivity and its physiological marker - blushing has been proposed to be an etiological mechanism of social anxiety disorder (SAD), but so far, untested in longitudinal designs. This study tested, for the first time, whether self-conscious emotional reactivity (indexed as physiological blushing) contributes to the development of SAD symptoms over and above social behavioral inhibition (BI), which has been identified as the strongest predictor of SAD development in early childhood. METHODS: One hundred fifteen children (45% boys) and their mothers and fathers participated at ages 2.5, 4.5, and 7.5 years. Social BI was observed at all time points in a stranger approach task, and physiological blushing (blood volume, blood pulse amplitude, and temperature increases) was measured during a public performance (singing) and watching back the performance at ages 4.5 and 7.5. Child early social anxiety was reported by both parents at 4.5 years, and SAD symptoms were diagnosed by clinicians and reported by both parents at 7.5 years. RESULTS: Higher social BI at 2.5 and 4.5 years predicted greater social anxiety at 4.5 years, which, in turn, predicted SAD symptoms at 7.5 years. Blushing (temperature increase) at 4.5 years predicted SAD symptoms at 7.5 years over and above the influence of social BI and early social anxiety. CONCLUSIONS: That blushing uniquely contributes to the development of SAD symptoms over and above social BI suggests two pathways to childhood SAD: one that entails early high social BI and an early onset of social anxiety symptoms, and the other that consists of heightened self-conscious emotional reactivity (i.e. blushing) in early childhood.

Facial blushing influences perceived embarrassment and related social functional evaluations.

Facial blushing involves a reddening of the face elicited in situations involving unwanted social attention. Such situations include being caught committing a social transgression, which is typically considered embarrassing. While recent research has demonstrated that facial redness can influence social evaluations, including emotional states such as perceived anger, the influence of blushing on social perceptions related to embarrassment or social transgression has yet to be investigated. Across three experiments, we manipulated the redness of neutral faces (Exp. 1) and faces displaying different emotional expressions (Exps. 2 and 3), and had participants evaluate perceived embarrassment, apology sincerity, and likeliness to forgive a transgression for each set of stimuli. Results indicated that redder (relative to baseline) faces influenced perceived embarrassment, apology sincerity, and likeliness to forgive a transgression. We discuss the implications in the context of a social functional account of facial colour in emotion expression and perception.

Niacin biological challenge: A paradigm to evaluate social concerns.

BACKGROUND AND OBJECTIVES: Anxiety sensitivity (AS) social concerns, the fear of observable anxiety symptoms is posited as a risk factor for social anxiety by increasing fear reactivity in social situations when observable anxiety symptoms are present. Experimental evaluation of AS social concerns is limited. The current study utilized several manipulations designed to be relevant to AS social concerns or fear of negative evaluation (FNE), a distinct social anxiety risk factor. The effects of these manipulations on fear reactivity to a speech were examined. METHODS: Participants (N = 124 students; M age = 19.44, SD = 2.45; 64.5% female) were randomized to one of four conditions in a 2 (100 mg niacin vs 100 mg sugar pill) X 2 (instructional set) design. For the instructional set manipulation, participants were told their speech performance would be evaluated by a judge based on their performance (i.e., FNE-relevant) or their observable anxiety symptoms (i.e., AS social concerns-relevant). RESULTS: There was a main effect for vitamin condition with participants in the niacin condition reporting higher panic symptoms post-speech relative to those in the placebo condition. There was no main effect for speech instructions. As hypothesized, these effects were qualified by an interaction indicating that AS social concerns significantly predicted panic symptoms for those receiving niacin. LIMITATIONS: Limitations include the reliance on self-reports of outcome variables and the use of an undergraduate student sample. CONCLUSIONS: These findings highlight a distinct role of AS social concerns in fear responding to socially evaluative situations in the context of physically observable arousal.

Are Socially Anxious Children Poor or Advanced Mindreaders?

Why are some children more socially anxious than others? One theory holds that socially anxious children are poor mindreaders, which hampers their social interactions; another that socially anxious children are advanced mindreaders leading to heightened self-consciousness in social situations. To test these theories simultaneously, this study (N = 105, ages 8-12) assessed children's mindreading (accuracy in detecting mental states from the eye region), self-consciousness (indexed as physiological blushing during public performance), and social anxiety levels. Results support both theories, showing a quadratic relation between mindreading and social anxiety. Low mindreading was related to clinical levels of social anxiety. High mindreading was related to subclinical levels of social anxiety through blushing. Our findings suggest two social-cognitive pathways to heightened social anxiety.