Alison K. Snyder-Warwick

Facial nerve grading instruments: systematic review of the literature and suggestion for uniformity.

Background: A variety of facial nerve grading scales have been developed over the years with the intended goals of objectively documenting facial nerve function, tracking recovery, and facilitating communication between practitioners. Numerous scales have been proposed; however, all are subject to limitation because of varying degrees of subjectivity, reliability, or longitudinal applicability. At present, such scales remain the only widely accessible modalities for facial functional assessment. The authors’ objective was to ascertain which scales(s) best accomplish the goals of objective assessment. Methods: A systematic review of the English language literature was performed to identify facial nerve grading instruments. Each system was evaluated against the following criteria: convenience of clinical use, regional scoring, static and dynamic measures, features secondary to facial palsy (e.g., synkinesis), reproducibility with low interobserver and intraobserver variability, and sensitivity to changes over time and/or following interventions. Results: From 666 articles, 19 facial nerve grading scales were identified. Only the Sunnybrook Facial Grading Scale satisfied all criteria. The Facial Nerve Grading Scale 2.0 (or revised House-Brackmann Scale) fulfilled all criteria except intraobserver reliability, which has not been assessed. Conclusions: Facial nerve grading scales intend to provide objectivity and uniformity of reporting to otherwise subjective analysis. The Facial Nerve Grading Scale 2.0 requires further evaluation for intraobserver reliability. The Sunnybrook Facial Grading Scale has been robustly evaluated with respect to the criteria prescribed in this article. Although sophisticated technology-based methodologies are being developed for potential clinical application, the authors recommend widespread adoption of the Sunnybrook Facial Grading Scale as the current standard in reporting outcomes of facial nerve disorders.

The degree of facial movement following microvascular muscle transfer in pediatric facial reanimation depends on donor motor nerve axonal density.

Background: Free functional muscle transfer to the face is a standard of facial animation. The contralateral facial nerve, via a cross-face nerve graft, provides spontaneous innervation for the transferred muscle, but is not universally available and has additional shortcomings. The motor nerve to the masseter provides an alternative innervation source. In this study, the authors compared donor nerve histomorphometry and clinical outcomes in a single patient population undergoing free muscle transfer to the face. Methods: Pediatric patients undergoing dynamic facial (re-)animation with intraoperative nerve biopsies and gracilis transfer to the face powered by either the contralateral facial nerve via a cross-face nerve graft or the motor nerve to the masseter were reviewed over a 7-year period. Myelinated nerve counts were assessed histomorphometrically, and functional outcomes were evaluated with the Scaled Measurement of Improvement in Lip Excursion software. Results: From 2004 to 2011, 91 facial (re-)animation procedures satisfied study inclusion criteria. Average myelinated fiber counts were 6757 per mm2 in the donor facial nerve branch, 1647 per mm2 in the downstream cross-face nerve graft at the second stage, and 5289 per mm2 in the masseteric nerve. Reconstructions with either innervation source resulted in improvements in oral commissure excursion and smile symmetry, with the greatest amounts of oral commissure excursion noted in the masseteric nerve group. Conclusions: Facial (re-)animation procedures with use of the cross-face nerve graft or masseteric nerve are effective and result in symmetric smiles. The masseteric nerve provides a more robust innervation source and results in greater commissure excursion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Survey of methods of facial palsy documentation in use by members of the Sir Charles Bell Society

Facial palsy manifests a broad array of deficits affecting function, form, and psychological well‐being. Assessment scales were introduced to standardize and document the features of facial palsy and to facilitate the exchange of information and comparison of outcomes. The aim of this study was to determine which assessment methodologies are currently employed by those involved in the care of patients with facial palsy as a first step toward the development of consensus on the appropriate assessments for this patient population.

Single-stage autologous ear reconstruction for microtia.

Background: The authors have been using the Nagata technique since 2002. In this review of 100 consecutive ear reconstructions, the authors present technique modifications that have evolved over this period that have contributed to improved auricular contour and that now allow for auricular reconstruction in a single stage. Methods: This study is a retrospective review of a prospectively acquired database. The series is restricted to primary reconstructions performed for congenital microtia. Photographs of 10 consecutive patients are presented to demonstrate the results of the technique. Surgical complication rates are discussed. Results: One hundred ear reconstructions were performed in 96 patients. There were 75 primary cases of congenital microtia. Twenty-four ears underwent a two-stage reconstruction, and 51 ears were reconstructed with a Nagata stage I procedure or a single-stage reconstruction. There was a gradual shift in technique, with a trend to perform fewer Nagata stage II outsetting procedures and more single-stage reconstructions. In patients who underwent an ear reconstruction in two stages, the surgical complication rate was 22 percent. In the last 40 consecutive ear reconstructions since abandoning the two-stage approach, the surgical complication rate is now 15 percent. Conclusions: A modification of Nagata’s technique of autologous ear reconstruction for microtia is described. Modifications of the three-dimensional framework address the contour of the inferior crus and control tragal projection and position. Inclusion of a projection block and recruitment of retroauricular skin allow for symmetric projection of the ear in a single stage. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Worldwide Testing of the eFACE Facial Nerve Clinician-Graded Scale

Background: The electronic, clinician-graded facial function scale (eFACE) is a potentially useful tool for assessing facial function. Beneficial features include its digital nature, use of visual analogue scales, and provision of graphic outputs and scores. The authors introduced the instrument to experienced facial nerve clinicians for feedback, and examined the effect of viewing a video tutorial on score agreement. Methods: Videos of 30 patients with facial palsy were embedded in an Apple eFACE application. Facial nerve clinicians were invited to perform eFACE video rating and tutorial observation. Participants downloaded the application, viewed the clips, and applied the scoring. They then viewed the tutorial and rescored the clips. Analysis of mean, standard deviation, and confidence interval were performed. Values were compared before and after tutorial viewing, and against scores obtained by an experienced eFACE user. Results: eFACE feedback was positive; participants reported eagerness to apply the instrument in clinical practice. Standard deviation decreased significantly in only two of the 16 categories after tutorial viewing. Subscores for static, dynamic, and synkinesis all demonstrated stable standard deviations, suggesting that the instrument is intuitive. Participants achieved posttutorial scores closer to the experienced eFACE user in 14 of 16 scores, although only a single score, nasolabial fold orientation with smiling, achieved statistically significant improvement. Conclusions: The eFACE may be a suitable, cross-platform, digital instrument for facial function assessment, and was well received by facial nerve experts. Tutorial viewing does not appear to be necessary to achieve agreement, although it does mildly improve agreement between occasional and frequent eFACE users.

Photographic Standards for Patients With Facial Palsy and Recommendations by Members of the Sir Charles Bell Society

Importance There is no widely accepted assessment tool or common language used by clinicians caring for patients with facial palsy, making exchange of information challenging. Standardized photography may represent such a language and is imperative for precise exchange of information and comparison of outcomes in this special patient population. Objectives To review the literature to evaluate the use of facial photography in the management of patients with facial palsy and to examine the use of photography in documenting facial nerve function among members of the Sir Charles Bell Society—a group of medical professionals dedicated to care of patients with facial palsy. Design, Setting, and Participants A literature search was performed to review photographic standards in patients with facial palsy. In addition, a cross-sectional survey of members of the Sir Charles Bell Society was conducted to examine use of medical photography in documenting facial nerve function. The literature search and analysis was performed in August and September 2015, and the survey was conducted in August and September 2013. Main Outcomes and Measures The literature review searched EMBASE, CINAHL, and MEDLINE databases from inception of each database through September 2015. Additional studies were identified by scanning references from relevant studies. Only English-language articles were eligible for inclusion. Articles that discussed patients with facial palsy and outlined photographic guidelines for this patient population were included in the study. The survey was disseminated to the Sir Charles Bell Society members in electronic form. It consisted of 10 questions related to facial grading scales, patient-reported outcome measures, other psychological assessment tools, and photographic and videographic recordings. Results In total, 393 articles were identified in the literature search, 7 of which fit the inclusion criteria. Six of the 7 articles discussed or proposed views specific to patients with facial palsy. However, none of the articles specifically focused on photographic standards for the population with facial palsy. Eighty-three of 151 members (55%) of the Sir Charles Bell Society responded to the survey. All survey respondents used photographic documentation, but there was variability in which facial expressions were used. Eighty-two percent (68 of 83) used some form of videography. From these data, we propose a set of minimum photographic standards for patients with facial palsy, including the following 10 static views: at rest or repose, small closed-mouth smile, large smile showing teeth, elevation of eyebrows, closure of eyes gently, closure of eyes tightly, puckering of lips, showing bottom teeth, snarling or wrinkling of the nose, and nasal base view. Conclusions and Relevance There is no consensus on photographic standardization to report outcomes for patients with facial palsy. Minimum photographic standards for facial paralysis publications are proposed. Videography of the dynamic movements of these views should also be recorded. Level of Evidence NA.

Surgical Treatment of Neuromas Improves Patient-reported Pain, Depression, and Quality of Life.

Background: Surgical management of neuromas is difficult, with no consensus on the most effective surgical procedure to improve pain and quality of life. This study evaluated the surgical treatment of neuromas by neurectomy, crush, and proximal transposition on improvement in pain, depression, and quality of life. Methods: Patients who underwent neuroma excision and proximal transposition were evaluated. Preoperative and postoperative visual analogue scale scores for pain (worst and average), depression, and quality of life were assessed using linear regression, and means were compared using paired t tests. The Disabilities of the Arm, Shoulder, and Hand questionnaire score was calculated preoperatively and postoperatively for upper extremity neuroma patients. Patients with long-term follow-up were analyzed using repeated measures analysis of variance comparing preoperative, postoperative, and long-term visual analogue scale scores. Results: Seventy patients (37 with upper extremity neuromas and 33 with lower extremity neuromas) met inclusion criteria. Statistically significant improvements in visual analogue scale scores were demonstrated for all four patient-rated qualities (p < 0.01) independent of duration of initial clinical follow-up. The change in preoperative to postoperative visual analogue scale scores was related inversely to the severity of preoperative scores for pain and depression. Neuroma excision and proximal transposition were equally effective in treating lower and upper extremity neuromas. Upper extremity neuroma patients had a statistically significant improvement in Disabilities of the Arm, Shoulder, and Hand questionnaire scores after surgical treatment (p < 0.02). Conclusions: Surgical neurectomy, crush, and proximal nerve transposition significantly improved self-reported pain, depression, and quality-of-life scores. Surgical intervention is a viable treatment of neuroma pain and should be considered in patients with symptomatic neuromas refractory to nonoperative management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Mandible Fracture Complications and Infection: The Influence of Demographics and Modifiable Factors.

Background: Mandible fractures account for 36 to 70 percent of all facial fractures. Despite their high prevalence, the literature lacks a comprehensive review of demographics, fracture patterns, timing of management, antibiotic selection, and outcomes, particularly when evaluating pediatric versus adult patients. The authors aim to determine the complication and infection rates after surgical treatment of mandibular fractures and the bacterial isolates and antibiotic sensitivities from mandible infections after open reduction and internal fixation at their institution. Methods: Data were collected retrospectively for all mandible fractures treated at the authors’ institution between 2003 and 2013. Patients were divided into pediatric (younger than 16 years) and adult (16 years or older) subgroups. Demographics, fracture location, fracture cause, comorbidities, antibiotic choice, and subsequent complications and infections were analyzed. Data were evaluated using appropriate statistical tests for each variable. Results: Three hundred ninety-five patients were evaluated. Demographics and fracture cause were similar to those reported in current literature. Of the 56 pediatric patients, complications occurred in 5.6 percent. Time from injury to operative intervention did not affect outcome. The complication rate was 17.5 percent and the infection rate was 9.4 percent in the adult subgroup. Time from injury to operative intervention, sex, and edentulism were not significant predictors of complication or infection. Tobacco use, number of fractures, number of fractures fixated, and surgical approach were predictors of complication and infection. Perioperative ampicillin-sulbactam had a significantly lower risk of infection. Conclusions: Certain demographic and operative factors lead to significantly higher risks of complications after surgical management of mandibular fractures. Ampicillin-sulbactam provides effective antibiotic prophylaxis. Risk factor modification may improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Robust Axonal Regeneration in a Mouse Vascularized Composite Allotransplant Model Undergoing Delayed Tissue Rejection.

Background: Nerve regeneration in vascularized composite allotransplantation (VCA) is not well understood. Allogeneic transplant models experience complete loss of nerve tissue and axonal regeneration without immunosuppressive therapy. The purpose of this study was to determine the impact of incomplete immunosuppression on nerve regeneration. Methods: In this study, transgenic mice (4 groups in total) with endogenous fluorescent protein expression in axons (Thy1-YFP) and Schwann cells (S100-GFP) were used to evaluate axonal regeneration and Schwann cell (SC) migration in orthotopic-limb VCA models with incomplete immunosuppression using Tacrolimus (FK506). Survival and complication rates were assessed to determine the extent of tissue rejection. Nerve regeneration was assessed using serial imaging of axonal progression and SC migration and viability. Histomorphometry quantified the extent of axonal regeneration. Results: Incomplete immunosuppression with FK506 resulted in delayed rejection of skin, muscle, tendon, and bone in the transplanted limb. In contrast, the nerve demonstrated robust axonal regeneration and SC viability based on strong fluorescent protein expression by SCs and axons in transgenic donors and recipients. Total myelinated axon numbers measured at 8 weeks were comparable in all VCA groups and not statistically different from the syngeneic donor control group. Conclusions: Our data suggest that nerve and SCs are much weaker antigens compared with skin, muscle, tendon, and bone in VCA. To our knowledge, this study is the first to prove the weak antigenicity of nerve tissue in the orthotopic VCA mouse model.

Maxillomandibular Fixation by Plastic Surgeons: Cost Analysis and Utilization of Resources.

PurposeMaxillomandibular fixation (MMF) can be performed using various techniques. Two common approaches used are arch bars and bone screws. Arch bars are the gold standard and inexpensive, but often require increased procedure time. Bone screws with wire fixation is a popular alternative, but more expensive than arch bars. The differences in costs of care, complications, and operative times between these 2 techniques are analyzed. MethodsA chart review was conducted on patients treated over the last 12 years at our institution. Forty-four patients with CPT code 21453 (closed reduction of mandible fracture with interdental fixation) with an isolated mandible fracture were used in our data collection. The operating room (OR) costs, procedure duration, and complications for these patients were analyzed. ResultsOperative times were significantly shorter for patients treated with bone screws (P < 0.002). The costs for one trip to the OR for either method of fixation did not show any significant differences (P < 0.840). More patients with arch bar fixation (62%) required a second trip to the OR for removal in comparison to those with screw fixation (31%) (P < 0.068). This additional trip to the OR added significant cost. There were no differences in patient complications between these 2 fixation techniques. ConclusionsThe MMF with bone screws represents an attractive alternative to fixation with arch bars in appropriate scenarios. Screw fixation offers reduced costs, fewer trips to the OR, and decreased operative duration without a difference in complications. Cost savings were noted most significantly in a decreased need for secondary procedures in patients who were treated with MMF screws. Screw fixation offers potential for reducing the costs of care in treating patients with minimally displaced or favorable mandible fractures.