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PubMed2000

The effect of muscle transplantation after unilateral partial facial paralysis on craniofacial growth and development: relationship between muscle and nerve histomorphometric findings.

Muscle transplantation has become an indispensable tool to restore the smile in patients with long-standing or congenital facial paralysis. However, little is known of the effect of this surgical intervention on craniofacial growth and development or of the adaptation of the transplant to its recipient site under circumstances of growth. The present study investigates these phenomena in the rabbit model. Twelve-day-old New Zealand White rabbits were randomly assigned to three experimental groups. The control group was used to study normal craniofacial growth and development (n = 15). In the nerve ablation group, unilateral paralysis of the buccal branches of the facial nerve was surgically induced (n = 15). In the transplant group, the surgically induced unilateral paralysis of the buccal branches was immediately followed by a neuromuscular graft (n = 12). All animals were operated on at the age of 12 days, and follow-up evaluations were performed at the ages of 2 months and 6 months. Computerized dorsoventral roentgencephalometric and computed tomography investigations were performed at both ages. Nerve and muscle histomorphometric measurements were performed at the age of 6 months to relate the quality of nerve and muscle regeneration to the growth parameters. The roentgencephalometric measurements revealed that analogous disturbed parameters were present in the nerve ablation and the transplant groups. However, in the transplant group, an additional significant effect of time between 2 and 6 months was seen for some parameters. This resulted in significant differences between the nerve ablation and transplant groups at 6 months for these parameters. Computed tomography measurements showed no significant differences in maxillary or mandibular volume in the transplant group compared with the control or nerve ablation groups. However, a significantly diminished increase in bone volume existed in the transplant group for the time period between 2 and 6 months in comparison with the control and nerve ablation groups. Muscle histomorphometric findings revealed a significant change in muscle fiber composition in the graft compared with the normal latissimus dorsi muscle; this was due to a major decrease in type IIB fibers, with an increase in type I and type IIA fibers. Compared with the normal zygomaticoauricular muscle, the amount of type I fibers was significantly increased. No fiber atrophy was found. Macroscopically, the transplanted muscle failed to increase its length during growth. Nerve histomorphometric findings demonstrated a normal amount of nerve fibers; however, they had significantly decreased diameters and reduced myelin areas. The nerve histomorphometric parameters were related to the muscle histomorphometric findings, which in turn were related to craniofacial growth disturbances. These findings suggested that the main growth differences between the transplant group and the control group may have been due to altered nerve function influencing muscle function. Scar tissue formation and the development of more intense muscle activity later are suggested as the causes of the additional effect of time between 2 and 6 months for the several parameters in the transplant group. Reasons for the failure of complete conversion of the graft to a fast muscle and the failure of the transplant to elongate during growth are discussed.

Animals↗
PubMed2000

Facial animation in children with Möbius syndrome after segmental gracilis muscle transplant.

Möbius syndrome is a complex congenital anomaly involving multiple cranial nerves, including the abducens (VI) and facial (II) nerves, and often associated with limb anomalies. Muscle transplantation has been used to address the lack of facial animation, lack of lower lip support, and speech difficulties these patients experience. The purpose of this study was to investigate the results of bilateral, segmental gracilis muscle transplantation to the face using the facial vessels for revascularization and the motor nerve to the masseter for reinnervation. The outcome of the two-stage procedure was assessed in 10 consecutive children with Möbius syndrome by direct interview, speech assessment, and oral commissure movement. Preoperative data were collected from direct questioning, viewing of preoperative videotapes, notes from prior medical evaluations, and rehabilitation medicine and speech pathology assessments. All of the patients developed reinnervation and muscle movement. The children who described self-esteem to be an issue preoperatively reported a significant posttransplant improvement. The muscle transplants produced a smile with an average commissure excursion of 1.37 cm. The frequency and severity of drooling and drinking difficulties decreased postoperatively in the seven symptomatic children. Speech difficulties improved in all children. Specifically, of the six children with bilabial incompetence, three received complete correction and three had significant improvement. Despite the length and complexity of these procedures, complications were minimal. Muscle transplantation had positive effects in all problematic areas, with a high degree of patient satisfaction and improvement in drooling, drinking, speech, and facial animation. The surgical technique is described in detail and the advantages over regional muscle transfers are outlined. Segmental gracilis muscle transplantation innervated by the motor nerve to the masseter is an effective method of treating patients with Möbius syndrome.

Adolescent↗
PubMed2001

Automated tracking of facial features in patients with facial neuromuscular dysfunction.

Facial neuromuscular dysfunction severely impacts adaptive and expressive behavior and emotional health. Appropriate treatment is aided by quantitative and efficient assessment of facial motion impairment. We validated a newly developed method of quantifying facial motion, automated face analysis (AFA), by comparing it with an established manual marking method, the Maximal Static Response Assay (MSRA). In the AFA, motion of facial features is tracked automatically by computer vision without the need for placement of physical markers or restrictions of rigid head motion. Nine patients (seven women and two men) with a mean age of 39.3 years and various facial nerve disorders (five with Bell's palsy, three with trauma, and one with tumor resection) participated. The patients were videotaped while performing voluntary facial action tasks (brow raise, eye closure, and smile). For comparison with MSRA, physical markers were placed on facial landmarks. Image sequences were digitized into 640 x 480 x 24-bit pixel arrays at 30 frames per second (1 pixel congruent with0.3 mm). As defined for the MSRA, the coordinates of the center of each marker were manually recorded in the initial and final digitized frames, which correspond to repose and maximal response. For the AFA, these points were tracked automatically in the image sequence. Pearson correlation coefficients were used to evaluate consistency of measurement between manual (the MSRA) and automated (the AFA) tracking methods, and paired t tests were used to assess the mean difference between methods for feature tracking. Feature measures were highly consistent between methods, Pearson's r = 0.96 or higher, p < 0.001 for each of the action tasks. The mean differences between the methods were small; the mean error between methods was comparable to the error within the manual method (less than 1 pixel). The AFA demonstrated strong concurrent validity with the MSRA for pixel-wise displacement. Tracking was fully automated and provided motion vectors, which may be useful in guiding surgical and rehabilitative approaches to restoring facial function in patients with facial neuromuscular disorders.

Adult↗
PubMed2002

Lip augmentation with superficial musculoaponeurotic system grafts: report of 103 cases.

Many patients suitable for a lip augmentation are of face lift age, and could benefit from a simultaneous lip enhancement during the rhytidectomy procedure. The healthy, live superficial musculoaponeurotic system (SMAS) tissue obtained from the face lift can be recycled and grafted with minimal additional operating time. From April of 1995 to January of 2000, 103 patients (99 women and four men) underwent a lip augmentation procedure by the senior author (N.L.) using SMAS grafts harvested from a simultaneous rhytidectomy. Indications for surgery were purely aesthetic in all 103 cases. The surgical technique used for the SMAS graft lip augmentation is as follows: Using a narrow tenotomy scissors, an intramuscular tunnel was created with blunt and sharp dissection across the lip. The graft, obtained from the posterior edge of the SMAS dissection, is left as long as possible, and is pulled through the tunnel with a tendon forceps. The lips are then stretched manually from the central point upward and downward, respectively. It is important to avoid suturing the ends of the graft into the closure; the grafts should be allowed to move freely, to avoid postoperative tethering on smiling or mouth opening. Most patients expressed some initial concern with their early appearances caused mainly by the swelling. By 2 weeks, most patients were extremely pleased with the size and shape, and their main concern was that the lip fullness would shrink even more. By 3 to 4 weeks, shrinkage largely ceased and the correction remained for varying periods, some as long as 5 years. A sampling of the results was obtained by means of a questionnaire mailed to all patients having undergone the SMAS graft lip augmentation. Fifty-four patients (52 percent) returned the questionnaire with their responses. Of those who responded to the survey, 42 patients (78 percent) reported fuller lips than before their operation. Significantly, 11 of 14 patients (79 percent) followed up after 24 months postoperatively reported fuller lips and excellent or good results. Complications and unsatisfactory results were very rare, occurring generally at the beginning of the learning curve of the series.SMAS grafts are useful for long-lasting lip augmentation, producing a youthful appearance by adding natural, soft roundness and fullness to lips without the artificial look and feel of synthetic material.

Cosmetic Techniques↗
PubMedDate not supplied

Social support effects on cardiovascular reactivity: is a stranger as effective as a friend?

OBJECTIVE: We investigated whether the effects on cardiovascular reactivity of social support from an audience member depend only on the behavior of that person or also depend on the relationship between the audience and the actor. That is, is there any added reduction in physiological response if the person who is nodding and smiling supportively is also a friend? METHOD: Ninety subjects gave a speech to an observer. In two of the conditions, this observer was a confederate of the experimenter and a stranger to the subject. This confederate acted in either a supportive or neutral manner during the speech. In the final condition, this observer was a friend, brought by the subject, who was then trained to show support in the same manner as the supportive confederate. The comparison of the two confederate conditions tested the effect of support, holding the relationship constant. The comparison of friend and confederate supportive conditions tested the effect of the relationship, holding the supportive behaviors constant. All participants were female. RESULTS: Both supportive conditions produced significantly smaller cardiovascular increases than the confederate-neutral condition, and the friend-supportive condition produced significantly smaller systolic blood pressure increases than the confederate-supportive (friend-supportive: 7.9 mm Hg: confederate-supportive: 14.9 mm Hg; confederate-neutral: 22.9 mm Hg). Differences for diastolic pressure and heart rate were not significant, although the data followed the same pattern. CONCLUSIONS: Social support from a friend attenuated cardiovascular reactivity in a laboratory setting to a greater degree than support from a stranger. The subjects' construal of the supportive behaviors can have an effect on reactivity, over and above the effects of the actual behaviors themselves.

Adolescent↗
PubMed2004

Treatment of spastic diplegia in patients with cerebral palsy.

Appropriate treatment, which includes orthopaedic surgery, physical and occupational therapy, recreational therapy, orthotics, and utilization of assistive devices, will improve the functional outcomes of children with cerebral palsy. Medical modalities such as intramuscular injections of botulinum toxin, and constant intrathecal administration of Baclofen via an implanted pump may also be of benefit. There is a defined set of orthopaedic surgical procedures that can enhance function, and the challenge for the surgeon is to identify which combination of procedures is appropriate for each individual patient and at what point during development to implement them. Some surgeons prefer to wait until patients are older (8-10 years) and perform all of their surgical interventions in one sitting. We, however, favor a different approach wherein surgical procedures are done as indicated during childhood development to enhance function and allow further improvement of motor skills. We refer to this approach as 'Staged Multilevel Interventions in the Lower Extremity' or 'SMILE'. This paper will discuss the rationale for this approach and our recommendations regarding the indications and timing of surgical interventions, as well as techniques and outcomes as reported in the literature.

Cerebral Palsy↗
PubMed2005

Camouflaging changes in the appearance of a patient with ectodermal dysplasia.

This clinical report describes an innovative method to ease the transition of a patient from old implant-retained prostheses to enhanced prostheses that altered the vertical dimension, esthetics, smile, and overall facial appearance. This procedure was accomplished by a customized labial bow, such as the one commonly used for a removable Hawley-type retainer, adjusted to follow the contour of teeth waxed into a denture. This option was adopted because it is reversible, nondamaging to the denture teeth, yet still camouflages the appearance of the maxillary denture and changes in facial contour during the early transition stage from the old to the new prostheses.

Adult↗
PubMed2005

Facial paralysis and surgical rehabilitation: a quality of life analysis in a cohort of 1,595 patients after acoustic neuroma surgery.

OBJECTIVES: On the basis of survey results of the Acoustic Neuroma Association, we report patient ratings of facial dysfunction and outcomes for various facial rehabilitative therapies after surgical treatment of acoustic neuroma (AN). We assessed patients' perceived quality of life (QOL) and reviewed the literature regarding facial dysfunction and its management associated with AN. STUDY DESIGN: The Acoustic Neuroma Association mailed a detailed questionnaire to 2,372 members to identify preoperative and postoperative symptoms, complications, and long-term effects on physical and psychosocial function. A cohort of 1,595 (82.2%) respondents who underwent surgical treatment of ANs reported their experiences with facial dysfunction. PATIENTS: Of all 1,940 survey respondents, 1,682 of 1,875 that had ANs underwent surgical treatment. The study included 1,595 patients with ANs (82.2% of all respondents) who underwent surgical treatment by way of the translabyrinthine, suboccipital, or middle fossa approaches and excluded 87 respondents who did not report the type of surgical approach. METHODS: Respondents answered questions intended to qualify and quantify the degree that facial dysfunction impacted QOL parameters. Responses were analyzed for tumor size, surgical approach, patient age, and sex. Statistical analysis was performed using SPSS software. RESULTS: In our analysis, 11% of all respondents experienced some degree of preoperative facial weakness or eye problems. Of all respondents, 45.5% (725 patients) experienced worsened facial weakness caused by surgery, and of these, 72% reported that it was permanent. The most commonly used successful therapy for facial reanimation for 271 (19.6%) patients was placement of a gold weight. The factor most often associated with poor outcome was a large tumor. Of all respondents, 28% felt significantly affected by facial weakness, 63% felt their smile was symmetric, and 70% were content "quite a bit" or "very much" with their QOL. CONCLUSIONS: In this large cohort study of AN patients, facial dysfunction was a significant morbidity. Physicians should be aware of the risk factors identified, specifically large tumor size and the impact facial dysfunction has on QOL, when counseling patients regarding optimal management of AN.

Adolescent↗
PubMed2004

Current concepts in lip reconstruction.

PURPOSE OF REVIEW: Approximately 25% of all oral cavity carcinomas involve the lips, and the primary management of these lesions is complete surgical resection. The management of the resulting lip defect remains a significant reconstructive challenge, requiring meticulous preoperative planning and surgical technique to optimize the functional and cosmetic outcome. Reviewed here are the accepted techniques of lip reconstruction, as well newer techniques that have been reported. RECENT FINDINGS: There have been no major advances in lip reconstruction; rather, continued improvement on accepted techniques. The main goals of reconstruction remain the restoration of oral competence, maintenance of oral opening, and the restoration of normal anatomic relations such that both the active (smile) and passive (form) cosmetic outcome is acceptable. The reconstruction should be tailored to the individual needs of the patient and should take into account the patient's condition, local tissue characteristics, previous treatment(s), and functional needs (eg, denture use), in addition to the size and location of the defect. SUMMARY: The lips play a key role in facial expression, speech, and eating. This requires meticulous attention to preoperative planning and surgical technique to maximize the functional and cosmetic outcome. It is important to assess local tissue characteristics (skin laxity) and previous treatment (surgery and/or irradiation) before the surgical plan is made final. Local tissue should be used whenever possible to provide the least donor site morbidity and the best overall tissue color and texture match. Whenever possible, dynamic reconstruction should be attempted. Careful preoperative assessment and planning will allow the surgeon to reach an acceptable balance between form and function with the reconstruction.

Carcinoma↗
PubMed2005

Sensitivity of screening tests for detecting vision in preschoolers-targeted vision disorders when specificity is 94%.

PURPOSE: To compare the sensitivity of 11 preschool vision screening tests administered by licensed eye care professionals for the detection of the 4 Vision in Preschoolers (VIP)-targeted vision disorders when specificity is 94%. METHODS: This study consisted of a sample (n = 2588) of 3- to 5-year-old children enrolled in Head Start programs, 57% of whom had failed an initial Head Start vision screening. Screening results from 11 tests were compared with results from a standardized comprehensive eye examination that was used to classify children with respect to the four VIP-targeted vision disorders: amblyopia, strabismus, significant refractive error, and unexplained reduced visual acuity (VA). With overall specificity set to 94%, we calculated the sensitivity for the detection of each targeted vision disorder. RESULTS: With the overall specificity set to 94%, the most accurate tests for detection of amblyopia were noncycloplegic retinoscopy (NCR) (88% sensitivity), the SureSight Vision Screener (80%), and the Retinomax Autorefractor (78%). For detection of strabismus, the most accurate tests were the MTI Photoscreener (65%), the cover-uncover test (60%), the Stereo Smile II stereoacuity test (58%), the SureSight Vision Screener (54%), and the Retinomax Autorefractor (54% in year 1, 53% in year 2). The most accurate tests for detection of significant refractive error were NCR (74%), the Retinomax Autorefractor (66%), the SureSight Vision Screener (63%), and the Lea Symbols VA test (58%). For detection of reduced VA, the most accurate tests were the Lea Symbols Distance VA test (48%), the Retinomax Autorefractor (39%), and NCR (38%). CONCLUSIONS: Similar to the previously reported results at 90% specificity, the screening tests vary widely in sensitivity with specificity set at 94%. The rankings of the sensitivities for detection of the 4 VIP-targeted vision disorders are similar to those with specificity set to 90%.

Amblyopia↗
PubMed2002

Neurovascular musculus obliquus internus abdominis flap free transfer for facial reanimation in a single stage.

A study of the anatomy and transplantation of the musculus obliquus internus abdominis with a neurovascular pedicle transfer for facial reanimation in one stage is presented. Eleven adult cadavers (22 face sides) were dissected to observe the shape, thickness, innervation, and blood supply of the musculus obliquus internus abdominis. The blood supply of this muscle primarily comes from the musculus obliquus internus abdominis branch of the deep circumflex iliac artery (diameter, 1.3 +/- 0.2 mm), but it can also come from the eleventh intercostal artery (diameter, 1.14 +/- 0.3 mm) and the infracostal artery (diameter, 1.5 +/- 0.2 mm). The branch of the deep circumflex iliac artery and its vena comitans, or the infracostal artery and its vena comitans, could be anastomosed for muscle transplantation. The innervation of the musculus obliquus internus abdominis comes from the tenth and eleventh intercostal nerves (length, 12.7 +/- 1.5 cm) and the infracostal nerve (length, 12.9 +/- 1.3 cm). The eleventh intercostal nerve and the infracostal nerve were selected for anastomosis of muscle transplantation. From November of 1995 to November of 1999, 14 patients with long established facial paralysis were treated with transplantation of a musculus obliquus internus abdominis flap in one stage and were followed for 10 months to 6 years. In 13 patients, the dynamic functions of the transplanted muscles were restored, the obliqueness of the mouth and philtrum while static was corrected, and the facial muscle activities while smiling were harmonized. The eyelids of the paralyzed side could be closed postoperatively, indicating that the function of the orbicularis oculi of the paralyzed side was restored. The single-stage transplantation of a free musculus obliquus internus abdominis flap with one vascular, multi-nerve pedicle is a new method for facial reanimation in the treatment of long established facial paralysis. Because of the simplicity of the procedure and the completeness of the functional reanimation of the paralyzed facial muscles, compared with the results of other free muscle flap transfers, it is an ideal procedure for facial reanimation.

Abdominal Muscles↗
PubMed2003

Dynamic restoration in Möbius and Möbius-like patients.

Möbius syndrome is classically characterized by bilateral facial nerve and abducens nerve paralysis in combination with limb defects. In the past 110 years, physicians diagnosed children as having the syndrome on the basis of heterogeneity of symptoms and used the term "Möbius syndrome" or "Möbius-like syndrome" for patients with multiple cranial nerve involvement. The cause and the exact pathogenesis of the syndrome still elude understanding. Genetic work-ups, radiological findings, and data from autopsies differ in their approaches and their findings of the basic causes of Möbius syndrome. In the international literature, about 301 case reports are found scattered through the past century. The appearance of the facial deformity is easy to recognize, because the Möbius patient is impaired in his or her ability to communicate nonverbally. Despite ophthalmologic problems, it is the search for a smile that brings these patients to the reconstructive surgeon. Over the past 100 years, surgical efforts attempted to improve the mask-like appearance by static and dynamic procedures, usually local muscle transpositions. Today, combinations of microsurgical procedures and aesthetic techniques are being used to restore some movement to the expressionless face of these patients by nerve and muscle transplantation. This article discusses the heterogeneity of Möbius syndrome, advocates a new classification system, presents the clinical findings of 42 patients who were seen and examined in consultation, and discusses the surgical management of 20 patients who underwent dynamic restorative microsurgery. Exemplary cases illustrating the preoperative work-up regimen and possible outcomes are reported.

Adult↗
PubMed2003

Upper labial deficiency in Mobius syndrome: a previously unreported feature and its correction.

Bilateral facial palsy in Möbius syndrome remains one of the greatest challenges in reconstructive plastic surgery. Facial reanimation is an invaluable aid to such patients because it allows for greater social interaction by means of the ability to smile. In performing facial reanimation surgery on patients with Möbius syndrome, it is the observation of the senior author (Harrison) that upper labial deficiency is a consistent and previously unreported feature of the syndrome. It has been the practice of the senior author to perform upper labial augmentation on Möbius syndrome patients by insertion of a lipodermal autograft, in addition to facial reanimation. Nine patients with Möbius syndrome who presented to the Department of Plastic Surgery during an 8-year period were reviewed. All nine possessed bilateral facial palsy and upper labial deficiency in addition to other abnormalities consistent with Möbius syndrome. Six patients underwent bilateral facial reanimation and upper labial augmentation alone. One patient refused facial reanimation surgery but consented to upper labial augmentation. One patient, with concomitant micrognathia, underwent bilateral facial reanimation, upper labial augmentation, and insertion of a Silastic chin implant. In one patient, a child who also exhibited micrognathia, bilateral facial reanimation alone was carried out, with further procedures for upper labial and chin cosmesis being postponed until adulthood. The indication for performing upper labial augmentation was cosmetic. The procedure improved upper labial appearance and restored balance to the mouth. Patients also expressed higher satisfaction with eating and drinking, which they related to the improved fullness of the upper lip. This was before the facial reanimation had become functional. Upper labial deficiency warrants addition to the list of facial features of Möbius syndrome and is something that must be assessed in the context of facial reanimation surgery.

Adolescent↗
PubMed2004

Neurovascular free-muscle transfer for the treatment of established facial paralysis following ablative surgery in the parotid region.

Neurovascular free-muscle transfer for facial reanimation was performed as a secondary reconstructive procedure for 45 patients with facial paralysis resulting from ablative surgery in the parotid region. This intervention differs from neurovascular free-muscle transfer for treatment of established facial paralysis resulting from conditions such as congenital dysfunction, unresolved Bell palsy, Hunt syndrome, or intracranial morbidity, with difficulties including selection of recipient vessels and nerves, and requirements for soft-tissue augmentation. This article describes the authors' operative procedure for neurovascular free-muscle transfer after ablative surgery in the parotid region. Gracilis muscle (n = 24) or latissimus dorsi muscle (n = 21) was used for transfer. With gracilis transfer, recipient vessels comprised the superficial temporal vessels in 12 patients and the facial vessels in 12. For latissimus dorsi transfer, recipient vessels comprised the facial vessels in 16 patients and the superior thyroid artery and superior thyroid or internal jugular vein in four. Facial vessels on the contralateral side were used with interpositional graft of radial vessels in the remaining patient with latissimus dorsi transfer. Cross-face nerve grafting was performed before muscle transfer in 22 patients undergoing gracilis transfer. In the remaining two gracilis patients, the ipsilateral facial nerve stump was used as the primary recipient nerve. Dermal fat flap overlying the gracilis muscle was used for cheek augmentation in one patient. In the other 23 patients, only the gracilis muscle was used. With latissimus dorsi transfer, the ipsilateral facial nerve stump was used as the recipient nerve in three patients, and a cross-face nerve graft was selected as the recipient nerve in six. The contralateral facial nerve was selected as the recipient nerve in 12 patients, and a thoracodorsal nerve from the latissimus dorsi muscle segment was crossed through the upper lip to the primary recipient branches. A soft-tissue flap was transferred simultaneously with the latissimus muscle segment in three patients. Contraction of grafted muscle was not observed in two patients with gracilis transfer and in three patients with latissimus dorsi transfer. In one patient with gracilis transfer and one patient with latissimus dorsi transfer, acquired muscle contraction was excessive, resulting in unnatural smile animation. The recipient nerves for both of these patients were the ipsilateral facial nerve stumps, which were dissected by opening the facial nerve canal in the mastoid process. From the standpoint of operative technique, the one-stage transfer for latissimus dorsi muscle appears superior. Namely, a combined soft-tissue flap can provide sufficient augmentation for depression of the parotid region following wide resection. A long vascular stalk of thoracodorsal vessels is also useful for anastomosis, with recipient vessels available after extensive ablation and neck dissection.

Adolescent↗
PubMed2004

Dynamic reconstruction of eye closure by muscle transposition or functional muscle transplantation in facial palsy.

For patients with facial palsy, lagophthalmus is often a more serious problem than the inability to smile. Dynamic reconstruction of eye closure by muscle transposition or by free functional muscle transplantation offers a good solution for regaining near-normal eye protection without the need for implants. This is the first quantitative study of three-dimensional preoperative and postoperative lid movements in patients treated for facial paralysis. Between February of 1998 and April of 2002, 44 patients were treated for facial palsy, including reconstruction of eye closure. Temporalis muscle transposition to the eye was used in 34 cases, and a regionally differentiated part of a free gracilis muscle transplant after double cross-face nerve grafting was used in 10 cases. Patients' facial movements were documented by a three-dimensional video analysis system preoperatively and 6, 12, 18, and 24 months postoperatively. For this comparative study, only the data of patients with preoperative and 12-month postoperative measurements were included. In the 27 patients with a final result after temporalis muscle transposition for eye closure, the distance between the upper and lower eyelid points during eye closing (as for sleep) was reduced from 10.33 +/- 2.43 mm (mean +/- SD) preoperatively to 5.84 +/- 4.34 mm postoperatively on the paralyzed side, compared with 0.0 +/- 0.0 mm preoperatively and postoperatively on the contralateral healthy side. In the resting position, preoperative values for the paralyzed side changed from 15.11 +/- 1.92 mm preoperatively to 13.46 +/- 1.94 mm postoperatively, compared with 12.17 +/- 2.02 mm preoperatively and 12.05 +/- 1.95 mm postoperatively on the healthy side. In the nine patients with a final result after surgery using a part of the free gracilis muscle transplant reinnervated by a zygomatic branch of the contralateral healthy side through a cross-face nerve graft, eyelid closure changed from 10.21 +/- 2.72 mm to 1.68 +/- 1.35 mm, compared with 13.70 +/- 1.56 mm to 6.63 +/- 1.51 mm preoperatively. The average closure for the healthy side was from 11.20 +/- 3.11 mm to 0.0 +/- 0.0 mm preoperatively and from 12.70 +/- 1.95 mm to 0.0 +/- 0.0 mm postoperatively. In three cases, the resting tonus of the part of the gracilis muscle transplant around the eye had increased to an extent that muscle weakening became necessary. Temporalis muscle transposition and free functional muscle transplantation for reanimation of the eye and mouth at the same time are reliable methods for reconstructing eye closure, with clinically adequate results. Detailed analysis of the resulting facial movements led to an important improvement of the authors' operative techniques within the last few years. Thus, the number of secondary operative corrections could be significantly reduced. These qualitative and quantitative studies of the reconstructed lid movements by three-dimensional video analysis support the authors' clinical concept of temporalis muscle transposition being the first-choice method in adult patients with facial palsy. In children, free muscle transplantation is preferred for eye closure, so as not to interfere with the growth of the face by transposition of a masticatory muscle. In addition, a higher degree of central plasticity in children might be expected.

Adolescent↗
PubMed2005

The phenomenon of the late recovered Bell's palsy: treatment options to improve facial symmetry.

BACKGROUND: Bell's palsy is an idiopathic neuropathy of cranial nerve VII, and the incidence ranges from 15 to 40 per 100,000. The majority of patients recover, but up to 16 percent of patients have significant sequelae. The phenomenon of the "late recovered" Bell's palsy has the following specific features and has not formerly been described: (1) tightening of the facial muscles, with a deepening nasolabial fold and reduced palpebral fissure; (2) blepharospasm; and (3) incomplete recovery of peripheral VIIth nerve branches, with ipsilateral forehead paralysis, reduced depressor anguli oris function, and poor excursion of the angle of the mouth on smiling. METHODS: Nonsurgical treatment involved four monthly botulinum toxin injections. Patients had injections to paralyze the ipsilateral orbicularis oculi, contralateral forehead rhytides, and depressor anguli oris and to treat blepharospasm and muscle tightness. The effectiveness of the botulinum toxin injections on facial symmetry and patient appreciation of this were assessed by measuring brow height and teeth exposure before and 3 weeks after injection. RESULTS: Twenty-three patients were followed up for a mean period of 37 months. The difference in brow height and teeth exposure after injection was less than preinjection measurements, but this did not reach statistical significance. Patient self-assessments showed improvements in their appreciation of the facial symmetry, ability to go out in public, and feelings of self-worth (visual analogue scale). Surgical treatment options include ipsilateral brow lift, division of the contralateral frontal branch, contralateral tarsorrhaphy to equalize the palpebral fissures, and bilateral upper blepharoplasty. CONCLUSIONS: The true benefit of botulinum toxin injections was more apparent during facial animation and not when the face was static. The patients greatly appreciated the improvement in facial symmetry. Various treatment options are available to improve the quality of life for patients with late recovered Bell's palsy.

Adult↗
PubMed2005

Botulinum toxin for aberrant facial nerve regeneration: double-blind, placebo-controlled trial using subjective endpoints.

BACKGROUND: Aberrant facial nerve regeneration syndrome is systematically studied by constructing a subjective questionnaire organized into pertinent domains (impairment of quality of life, social interactions, perception of self-appearance, visual function, and perception of problem severity) and by physical assessment of degree of involuntary palpebral fissure closure during routine facial movements using videotaping and a physicians' grading scale. METHODS: The videotape measurements of corneal light reflex to upper lid margin distance and vertical palpebral distance were made during adynamic and active facial expression. Thirty-six patients were studied (six in an open-label pilot study design and 30 in a multicenter, double-blind, placebo-controlled trial). Botulinum toxin type A injections consistently suppressed the degree of involuntary eyelid movement associated with smiling, chewing, and puckering by each measurement and in both study designs. RESULTS: In all subjective morbidity domains, improvement was demonstrated in the double-blind study design (quality of life, p < 0.05; social interaction, p < 0.001; personal appearance, p < 0.001; peripheral visual impairment, p < 0.01; and perception of severity, p < 0.05). Correlation between degrees of physical impairment was significant but low comparing degree of subjective impairment to direct videotaped measurements. Correlation was more significant comparing subjective scores to the physicians' grading scale assessment of degree of physical impairment. CONCLUSIONS: Impairment in quality of life, social interactions, and self-assessment of appearance closely reflected the nature of the morbidity associated with palpebral fissure asymmetry associated with aberrant facial nerve regeneration. The physicians' grading scale best reflected subjective morbidity over direct videotaped measurements.

Adult↗
PubMed2005

Serratus anterior in vivo contractile force study.

BACKGROUND: A major limitation of functional muscle transfer for facial and intrinsic hand reanimation is the inability to predict the force that will be generated by the transplanted muscle. METHODS: The authors studied the contractile force of the slips of the serratus anterior in situ in 10 patients and tested the gracilis muscle in four subjects as a control. RESULTS: Mean contractile force generated by each serratus slip was 0.178 pound (range, 0.019 to 0.797 pound). This compares favorably with the maximum force generated by smiling (0.307 pound). Muscle strength correlated strongly with age (r = -0.805, p = 0.005). The lowest slip generated less force than those above it (0.133 pound versus 0.191 pound); this difference did not reach statistical significance. When the strength of the lowest slip is compared with the more superior slips as a percentage of total force generated by the slips (to compensate for the effect of age on muscle strength), the lowest slip was significantly weaker (18.6 percent of total force versus 25.5 percent of total force, p = 0.013). Mean contractile force generated by the gracilis was 0.963 pound, significantly different from that generated by a serratus anterior slip (p = 0.009). CONCLUSIONS: Each serratus slip could potentially be used to generate a separate force vector for facial reanimation. Further separation of the flap along preexisting fascial planes may allow generation of up to 10 independent force vectors, making the serratus anterior muscle flap an attractive option for facial reanimation and possibly intrinsic hand muscle reconstruction.

Adolescent↗