Research & Current Literature
List compiled by Robin Lindsay, M.D.
Schaverien, M., G. Moran, et al. (2011). "Activation of the Masseter muscle during normal smile production and the implications for dynamic reanimation surgery for facial paralysis." J Plast Reconstr Aesthet Surg.
INTRODUCTION: In cases of unilateral facial paralysis, free muscle transfer with coaptation to the motor nerve of the Masseter is gaining popularity as a primary alternative to cross-facial nerve grafting. Despite initial expectations, a majority of these subjects can achieve a spontaneous smile. The mechanism behind this spontaneity is unclear. Plasticity of the cerebral cortex as well as the relative proximity of the motor centres of the mimetic and Masseter muscles has been used in explanation. This study demonstrates the involvement of the Masseter muscle during normal smile production, suggesting a more direct explanation for the spontaneous smile seen following reanimation procedures innervated by the Masseter nerve. METHODS: Twenty healthy volunteers were subjected to electromyography of the Masseter muscle bilaterally to demonstrate whether contraction of the Masseter muscle occurred during voluntary and involuntary smile production. RESULTS: Patient age ranged from 20 to 61 years (mean 41.6 years) with an equal male to female ratio. Activation of the Masseter occurred in 40 percent of individual muscles during smile production, occurring bilaterally in six participants, and unilaterally in four. There was no correlation between muscle activation and patient age or gender. CONCLUSIONS: Natural contraction of the Masseter muscle during normal smile production helps to explain the high rate of spontaneous smile development in subjects with facial paralysis who have undergone a free muscle reanimation procedure powered by the nerve to the Masseter muscle.
Chan, J. Y. and P. J. Byrne (2011). "Management of facial paralysis in the 21st century." Facial Plast Surg 27(4): 346-357.
Facial paralysis is a clinical entity associated with significant morbidity, which has a treatment paradigm that is continually evolving. Surgical management of the paralyzed face poses significant challenges to achieve the goal of returning patients to their premorbid states. Here we attempt to review the advances in facial reanimation, in particular with regards to chronic facial paralysis. These include recent developments in static and dynamic rehabilitation including advances like artificial muscles for eyelid reconstruction, dynamic muscle transfer for the eye, and orthodromic temporalis tendon transfer.
Amer, T. A., H. M. El-Minawi, et al. (2011). "Low-level versus high-level placement of gold plates in the upper eyelid in patients with facial palsy." Clin Ophthalmol 5: 891-895.
BACKGROUND: Lagophthalmos is a condition that results from facial paralysis causing functional as well as esthetic problems. This condition can be treated by a range of techniques, including tarsorrhaphy, facial slings, and canthopexies. Gold plates provide a solution for temporary or permanent lagophthalmos resulting from facial paralysis. This study discusses the use of gold plates in the treatment of lagophthalmos but with the introduction of gold plates in two different positions in the upper lids. METHODS: Group 1 (38 eyes) had a low level of placement (2 mm from the lid margin) of gold plates, while Group 2 (23 eyes) had a high level of placement (5 mm from the lid margin). RESULTS: Noticeable bulge was seen in 18.4% of Group 1 eyes compared with 13% in Group 2, and migration of the plate occurred in 2.6% and 0% of eyes in Group 1 and Group 2, respectively, as well as ptosis (7.8% and 4.3%) and conjunctival perforation (0% and 4.3%). The degree of improvement of eyelid closure, keratopathy, and visual acuity were the same for both techniques. CONCLUSION: Placement of gold plates at a higher level could avoid some of the drawbacks of lower level placement of these plates, such as upper eyelid bulge and ptosis, especially given the thinning of the eyelids and orbicularis muscles that occurs in facial palsy.
Ferguson, L. D., T. Paterson, et al. (2011). "Applied anatomy of the latissimus dorsi free flap for refinement in one-stage facial reanimation." J Plast Reconstr Aesthet Surg.
BACKGROUND: The face can be reanimated after long-term paralysis by free microneurovascular tissue transfer. Flaps from gracilis and pectoralis minor usually require a two-stage procedure with a cross-face nerve graft. Latissimus dorsi has a much longer muscular nerve, the thoracodorsal nerve, which could avoid the need for a second cross-face nerve graft. Our hypothesis is that the neurovascular pedicles of small segments of latissimus dorsi would be long enough to reach the opposite side of the face and to provide a reliable blood and nerve supply to the flaps. METHOD: To test this hypothesis the thoracodorsal pedicle and its primary branches were dissected in eleven embalmed cadavers. The segmental vessels and nerves were then traced in a series of simulated flaps approximately 8-10 cm x 2-3 cm by micro-dissection, tissue clearing and histology. RESULTS: The thoracodorsal pedicle is 10-14 cm long to where it enters the muscle, and with intra-muscular dissection small chimeric muscle segments 8-10 cm x 2-3 cm can be raised with a clearly defined neurovascular supply. Using micro-dissection the neurovascular pedicle can be lengthened to reach across the face. Segmental arteries and nerves extended to the distal end of all the flaps examined. Artery, vein and nerve run together and are of substantial diameter. CONCLUSION: Small muscle segments of latissimus dorsi can be raised on long neurovascular pedicles. The vessels and nerves are substantial and the likelihood of surgical complications such as flap necrosis and functional disuse on transplantation appear low. Although in our opinion the use of cross-face nerve grafts and transfer of smaller muscle flaps remains the gold standard in facial reanimation in straightforward cases, the micro-dissected latissimus dorsi flap is a useful option in complex cases of facial reanimation. CLINICAL APPLICATION: Facial reanimation using micro-dissected segments of latissimus dorsi has been performed in four complex cases of facial paralysis.
Starritt, N. E., S. A. Kettle, et al. (2011). "Sutureless repair of the facial nerve using biodegradable glass fabric." Laryngoscope 121(8): 1614-1619.
OBJECTIVES/HYPOTHESIS: To compare a sutureless method of facial nerve repair using a biodegradable glass fabric with the standard method of microsurgical suture. STUDY DESIGN: The facial nerve was transected in groups of six sheep and repaired by either entubulation with a biodegradable glass fabric or standard microsurgical epineurial suture repair. METHODS: Both methods of repair were compared with each other and with a normal control group using electrophysiological and morphometric analysis. RESULTS: Maximum conduction velocity, axon and fiber diameter, and myelin-sheath thickness were all reduced in the repaired nerves when compared with the normal nerves. There was no significant difference among any of the outcome variables between the repair groups. CONCLUSIONS: Repair of nerve injuries by entubulation has several theoretical advantages over standard suture repair: less trauma to nerve ends, no need for microsurgical skills, and delivery of neurotrophic growth factors. It is concluded that repair of the facial nerve by glass-wrap entubulation offers an alternative to standard suture repair without the demands of microsurgery on both time and surgical expertise.
Coulson, S., G. R. Croxson, et al. (2011). "Prognostic factors in herpes zoster oticus (ramsay hunt syndrome)." Otol Neurotol 32(6): 1025-1030.
OBJECTIVES: : To determine if an accurate prognosis can be made in patients with Herpes zoster oticus (HZO), facial nerve outcomes were assessed at 1-year after onset and compared with symptoms and signs at presentation. STUDY DESIGN: : Individual retrospective cohort study of 101 records in a case series (level of evidence: Level 2b). METHODS: : Symptoms, signs, audiology, and treatment records were analyzed to determine their association with facial nerve outcome at 1 year. RESULTS: : Mean improvement at 1 year for the 101 patients was 3 House-Brackmann (HB) grade units. Initially, severity ranged from HB III to HB VI. Mean recovery was significantly greater for those patients who were initially more affected, although at 1 year, they had still not recovered to the same grade as those initially less affected. Having both incomplete eye closure and a dry eye was associated with less recovery at 1 year. The use of prednisone combined with an antiviral agent, and begun at or after Day 5 of the illness, was related to a better facial nerve outcome. No other symptom, sign, or audiologic feature was of prognostic value. CONCLUSION: : All patients with HZO improved facial function to some degree, with the mean gain at 1 year after onset being 3 HB grade units. Improvement was less for patients who initially had both incomplete eye closure and dry eye. The group who received a combination of an antiviral medication with steroids given after 5 days had the best facial nerve outcome.
Henstrom, D. K., J. S. Malo, et al. (2011). "Platysmectomy: an effective intervention for facial synkinesis and hypertonicity." Arch Facial Plast Surg 13(4): 239-243.
Objectives To describe a procedure to permanently address platysmal synkinesis and hypertonicity and to report changes in quality of life associated with platysmectomy using the Facial Clinimetric Evaluation instrument. Methods Chemodenervation significantly relieves platysmal synkinesis in almost all patients with significant face and neck synkinesis associated with dynamic facial expressions. We recently began to offer platysmectomy as part of a permanent solution to chronic superficial torticollis-like neck symptoms. For a 10-month period, 24 patients underwent the procedure, and preoperative and postoperative Facial Clinimetric Evaluation data were obtained from 21 patients (88%). Results In 19 patients, platysmectomy was performed using local anesthesia without sedation. In the remaining 5 patients, platysmectomy was performed using general anesthesia concurrent with free gracilis transfer for smile reanimation. No intraoperative or postoperative complications occurred. Overall, the patients' quality of life significantly improved after platysmectomy (P = .02). Conclusion Platysmectomy is straightforward and seems effective in treating neck synkinesis associated with chronic hypertonic platysmal activity.