Charles Nduka

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.

Age- and gravity-related changes in facial morphology: 3-dimensional analysis of facial morphology in mother-daughter pairs.

PURPOSE There is increasing focus on the effects of gravity and age on facial appearance. Understanding these effects on facial morphology requires an accurate means of measuring surface topography. We present a preliminary study on the changes in facial topographic landmarks in a cohort of mothers and their daughters. MATERIALS AND METHODS The faces of mother-daughter pairs (N = 15, aged 13 to 61 years) were imaged by stereophotogrammetry in the upright and supine positions. Twenty anthropometric surface landmarks were placed, and the corresponding x, y, and z coordinates were generated with custom software. The relative excursion of each landmark from the upright to the supine position was calculated. RESULTS Movement of up to 7.3 mm occurred in the horizontal (x) plane, 5.7 mm in the vertical (y) plane, and 7.6 mm in the dorsoventral (z) plane. Significant movement (P < .05) in the vertical plane occurred in the upper lip, lateral canthi, labial commissures, and gonia. There was no significant movement in the dorsoventral plane. Maximal movement occurred in the lower third of the face in both groups but was more marked in the mothers. CONCLUSIONS Age- and gravity-related effects on the face can be accurately measured and documented with 3-dimensional imaging. This technique will allow comparison of rejuvenation techniques and a better understanding of the mechanisms of facial aging.

Objective assessment of keloid scars with three-dimensional imaging: quantifying response to intralesional steroid therapy.

Background: Treatment of keloid scars poses a significant challenge. Assessment of treatment response and research in this area depend on the availability of objective, accurate, and reproducible outcome measures. At present, scars are assessed using subjective grading systems, or with cumbersome investigations such as direct casting. The authors assessed the feasibility of objectively monitoring response to intralesional steroid treatment in routine clinical practice with quantitative three-dimensional imaging. Methods: Scar volume was quantified using a validated three-dimensional speckle-pattern stereophotogrammetry before and for a minimum of 8 weeks after intralesional steroid therapy in 12 patients with keloid scars. Results: Mean scar volume at the start of treatment was 0.73 ± 0.701 cc (range, 0.12 to 2.15 cc); this was reduced to 0.14 ± 0.302 cc (range, 0.007 to 1.08 cc) after monthly intralesional injections of triamcinolone acetate (p < 0.001; analysis of variance). The majority of patients achieved a greater than 50 percent response within 8 weeks of the start of therapy, but poor treatment response was noted and quantified in a minority of patients. Conclusions: Three-dimensional stereophotogrammetry is a rapid and noninvasive method of scar volume assessment that could allow accurate and objective monitoring of treatment response to be incorporated into clinical practice. Therefore, it can be of considerable value in assessing treatment efficacy and evaluating new therapeutic strategies.

Visual Estimation of Finger Angles: Do we Need Goniometers?:

Seventy-one plastic surgeons and therapists, of varying levels of seniority and experience, were asked to examine a resin cast of an adult male hand and use estimation to measure the angles of the metacarpophalangeal and interphalangeal joints of each digit. Visual estimation by all subjects was inaccurate by a mean of approximately 25% (median percentage error 22, range 1–100). Consultants were the most accurate, whilst physiotherapists were the least. Regular goniometer users were no more accurate. However, hand surgery experience correlated with accuracy, as did a stated interest in hand surgery. Although visual accuracy improves with experience, it is still an inaccurate technique. We, therefore, recommend that goniometers should be used for measuring angles in hand surgery patients.

Assessment of the reproducibility of facial expressions with 3-D stereophotogrammetry.

OBJECTIVE: There is little research into analyzing whether facial expression changes are secondary to actual treatment or normal day-to-day variation. This study aims to ascertain whether nine-facial expressions were reproducible. SUBJECTS AND METHODS: Thirty-nine white subjects performed nine-facial expressions, captured by three-dimensional stereophotogrammetry in three sessions. After initial capture (session 1), each expression was repeated after 15 minutes (session 2) and then 4 weeks (session 3) after the initial session. Statistical analysis was performed on the mean variability of facial landmarks between session 1 and 2 and session 1 and 3. RESULTS: Repose was the most reproducible expression. The least reproducible was “blow-out-the-cheeks.” Analysis between session 1 and 2 showed no significant differences in expression reproducibility. Analysis between session 1 and 3 showed significant differences for the “smile-with-lips-open” and “blow-out-the-cheeks” expressions. CONCLUSION: Facial expressions are reproducible in a 15-minute period. There are significant differences in the ability to reproduce facial expressions 4 weeks apart for “smile-with-lips-open” and “blow-out-the-cheeks.”

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.

Estimation of Breast Burn Size

It is the authors’ opinion that the size of chest burns on large-breasted women can be significantly underestimated, especially if the methods of calculation rely on burn charts, such as the Lund and Browder burns chart. This latter chart is based on data derived from only three women and eight men. The surface area of the torsos of 60 volunteers (20 men, 20 small-breasted women, and 20 large-breasted women) was measured using two well-established techniques. The torso surface area was divided into two parts: the anterior trunk and the posterior trunk (i.e., torso surface area = posterior trunk + anterior trunk). The anterior trunk was subdivided and the area above the costal margins defined as the pectoral region. These areas were measured separately for each individual. The volunteers’ total body surface area was calculated using normograms, based on their weight and height. The area of each torso section was recorded as a percentage of the total body surface area and torso surface area. Whereas the torso surface area/total body surface area ratio did not vary significantly between the groups, the proportion of anterior to posterior trunk size did depend on the sex and on breast size. There was a direct correlation between the woman’s bra cup size and the ratio of anterior-to-posterior trunk surface area. A simple chart was therefore derived that estimates the relative size of a woman’s torso surface area once her bra cup size is known. Such a chart can be used to improve accuracy in adult female chest burn estimation, when used in conjunction with a burns chart. Breast burns in larger breasted women are underestimated when calculated using current burn charts. We recommend that a correction be made when estimating chest burns in women to account for the increased surface area of the breasts. A chart, such as the one we have developed, could be used in conjunction with a burn chart (e.g., Lund and Browder) to make this correction.

Refinements in smile reanimation: 10-Year experience with the lengthening Temporalis Myoplasty

The lengthening Temporalis Myoplasty (LTM) is an innovative dynamic facial reanimation procedure that has been used to great effect following its conception during the early 1990s by the senior author. Since its first description in the literature the technique has been refined and it has become clear from correspondence that certain technical aspects of the procedure require particular attention to detail. We discuss from experience of more than a hundred cases and highlight not only the important technical aspects of the procedure but also the importance of pre-operative assessment and the avoidance of complications.

Implications of rationing and the European Working Time Directive on aesthetic breast surgery: A study of trainee exposure in 2005 and 2011

BACKGROUND There are concerns that current trainees may be lacking operative experience in aesthetic and functional breast surgeries. Reduced exposure to such cases during training may stem from rationing, EWTD compliance, and an increasingly consultant-led service. These issues are examined in a single NHS hospital, with analysis of trends over time, and are contrasted with the changes that have occurred in a related private hospital. METHODS A single NHS hospital trusts database was retrospectively analysed for all aesthetic breast surgeries from 2005 to 2011, noting the total number of cases and the grade of the principal surgeon. The analysis was repeated in a related private sector hospital in the same catchment area. RESULTS A statistically significant drop of 55% of NHS aesthetic breast surgeries performed in 2011 compared to 2005 was demonstrated with an increasing trend for consultant led procedures. The NHS caseload decline was matched by a corresponding increase of 57% within the private sector. CONCLUSIONS Current trainees in plastic surgery face a significant reduction in operative exposure to aesthetic breast surgeries compared to their predecessors due to the EWTD working hours, surgical rationing policies, and an increasingly consultant led service. Approaches to maintaining training standards are discussed.

Occurrence and severity of upper eyelid skin contracture in facial nerve palsy

PurposeTo describe the occurrence and severity of upper eyelid skin contracture in facial nerve palsy (FNP).MethodsWe enroled consecutive patients with unilateral FNP into this study. Patients with previous upper eyelid surgery for either side were excluded. We developed a standardised technique to measure the distance between the upper eyelid margin and the lower border of brow (LMBD). FNP was graded using the Sunnybrook grading scale. Its aetiology, duration, and treatment were noted. Upper and lower marginal reflex distance and lagophthalmos were also noted.ResultsSixty-six patients (mean age 51 years) were included. FNP was owing to a variety of aetiologies. LMBD on the paralytic side was shorter than the normal contralateral side in 47 (71%), equal in 15 (23%), and larger in four (6%) patients. The mean contracture was 3.4 mm (median: 3, range: 1–12) with 11 (17%) patients showing 5 mm or more of skin contracture. The mean LMBD on the paralytic side in all patients was significantly smaller than the contralateral side; 30±3.7 (median: 30; 95% CI 29–31) compared with 32±3.7 (median: 32; 95% CI 32–33), respectively, P<0.0001, two-tailed paired t-test.ConclusionTo our knowledge, this is the first study that quantitatively demonstrates contraction of the upper eyelid skin in FNP. This finding is valuable in directing optimal early management to minimise skin contracture and to caution surgeons against unnecessary upper eyelid skin excision.