Douglas K. Henstrom

Free Gracilis Transfer for Smile in Children: The Massachusetts Eye and Ear Infirmary Experience in Excursion and Quality-of-Life Changes

BACKGROUND Free muscle transfer for facial reanimation has become the standard of care in recent decades and is now the cornerstone intervention for dynamic smile reanimation. We sought to quantify smile excursion and quality-of-life (QOL) changes in our pediatric free gracilis recipients following reanimation. METHODS We quantified gracilis muscle excursion in 17 pediatric patients undergoing 19 consecutive pediatric free gracilis transplantation operations, using our validated SMILE program, as an objective measure of functional outcome. These were compared against excursion measured the same way in a cohort of 17 adults with 19 free gracilis operations. In addition, we prospectively evaluated QOL outcomes in these children using the Facial Clinimetric Evaluation (FaCE) instrument. RESULTS The mean gracilis excursion in our pediatric free gracilis recipients was 8.8 mm ± 5.0 mm, which matched adult results, but with fewer complete failures of less than 2-mm excursion, with 2 (11%) and 4 (21%), respectively. Quality-of-life measures indicated statistically significant improvements following dynamic smile reanimation (P = .01). CONCLUSIONS Dynamic facial reanimation using free gracilis transfer in children has an acceptable success rate, yields improved commissure excursion, and improves QOL in the pediatric population. It should be considered first-line therapy for children with lack of a meaningful smile secondary to facial paralysis.

Assessing Outcomes in Facial Reanimation: Evaluation and Validation of the SMILE System for Measuring Lip Excursion During Smiling

T here is no current consensus for objectively evaluating postoperative smiling outcome. Several objective measurement systems have been proposed, but, owing to their complexity, cumbersome nature, or cost, no single system has been adopted. With such variation in the reporting of results, it is difficult to make comparisons and draw conclusions about the outcome of different surgical techniques. We propose a simple facial analysis system, the scaled measurement of improvement in lip excursion (SMILE), that obviates the need for expensive equipment, facial marking, or prolonged patient cooperation. The system uses the iris diameter (corneal white-to-white diameter) as a scale reference for all facial dimensions on the same photograph. Rüfer et al measured the corneal white-to-white diameter in 390 healthy subjects aged 10 to 80 years with the Orbscan II system (Bausch & Lomb, Rochester, New York). They found the mean(SD)cornealdiameterwas11.77(0.42)mm.Withsuch small variation inhuman irisdiameter, thisbuilt-in scale— inthesameplaneas theoralcommissure—allows“real-life” millimetricmeasurementsofhorizontal toverticalcommissureexcursion tobeextrapolated fromfrontalphotographs using readily available photoediting software.

Surgical Treatment of the Periocular Complex and Improvement of Quality of Life in Patients With Facial Paralysis

OBJECTIVE A devastating sequela of facial paralysis is the inability to close the eye. The resulting loss of corneal protection can potentially lead to severe consequences. Eyelid weight placement, lower eyelid suspension, and brow ptosis correction are frequently performed to protect the eye. We sought to measure and report the change in quality of life (QOL) after surgical treatment of the periocular complex, using the validated Facial Clinimetric Evaluation (FaCE) QOL instrument. METHODS From March 2009 to May 2010, 49 patients presenting to the Facial Nerve Center with paralytic lagophthalmos requiring intervention were treated with static periocular reanimation. Thirty-seven of the patients completed preoperative and postoperative FaCE surveys. RESULTS Overall QOL, measured by the FaCE instrument, significantly improved following static periocular treatment. Mean FaCE scores increased from 44.1 to 52.7 (P < .001). Patients also reported a significant decrease in the amount of time their eye felt dry, irritated, or scratchy (P < .001). The amount of artificial tears and/or ointment also significantly decreased (P = .03). There were 2 cases of localized cellulitis with 1 eyelid weight extrusion. CONCLUSIONS We report the first series of postoperative QOL changes following static periocular treatment for paralytic lagophthalmos. Patients report a notable improvement in periocular comfort and overall QOL.

Good correlation between original and modified House Brackmann facial grading systems.

Subjective scales of facial function were plagued with reporting variations until the House‐Brackmann scale was described in 1985. Despite its utility, weaknesses were identified, including noninclusion of synkinesis phenomena and insensitivity to segmental weakness. Therefore, the scale was recently revised to address these weaknesses. The objective of this investigation was to determine agreement between the original and the updated House‐Brackmann scales.

Color Doppler ultrasound: effective monitoring of the buried free flap in facial reanimation.

Objective. The gracilis muscle free flap has become a reliable means for smile reanimation for patients with facial paralysis. Because it is a buried flap, it presents a postoperative monitoring challenge. We sought to evaluate our experience with color Doppler ultrasound in the monitoring of gracilis free flap viability in the immediate postoperative setting. Study Design. Case series with planned data collection. Setting. Tertiary medical center. Methods. Patients with facial paralysis treated with gracilis muscle free flap for smile reanimation performed between March 2009 and November 2010 were evaluated by color Doppler ultrasound and included in the study. Our experience with the use of the color Doppler ultrasound to monitor the gracilis muscle flap is presented. Results. Forty-six patients were identified. In all cases, color Doppler ultrasound was used postoperatively to assess flow through the vascular pedicle. Outcomes included an early flap survival rate of 100%, with no instances of equivocal or absent flow on either the arterial or venous side. Color Doppler ultrasound provided important objective information regarding muscle perfusion postoperatively in several instances of equivocal postoperative perfusion of the flap. Conclusion. Color Doppler ultrasound is a safe, noninvasive method that can be performed serially to evaluate a buried free flap. We have had success in verifying normal arterial and venous flow through the pedicle using this method of monitoring of the gracilis muscle free flap during facial reanimation, and in 3 instances, it eliminated the need for wound exploration to verify appropriate muscle perfusion.

A comparison of facial nerve grading systems.

Purpose This study aimed to compare a computerized tool to standard objective clinical scales for global and zone-specific assessment of facial nerve function. Methods This was a retrospective review of 77 patients with facial paralysis who underwent facial videography. Videos were independently scored by 3 facial nerve specialists using the House-Brackmann Scales (HBI and HBII). Digital scoring was performed with Facogram software. Scores were recorded and compared using intraclass and Pearson (r) correlations. Results Interobserver correlation was high with HBII, with overall scores in excellent agreement (intraclass correlation range, 0.78–0.95; P ⩽ 0.0001). There were strong correlations between Facogram and HBII (r ≥ 0.67, P ⩽ 0.0001) and strong intraobserver correlations between HBI and HBII (r ≥ 0.71, P ⩽ 0.0001). The HBII required more clinician time [mean (SD), 72 (21) seconds per case], compared with Facogram, which did not require any clinician time. Conclusions An automated, zone-specific facial analysis tool can eliminate clinician subjectivity and allow standardized assessment of facial paralysis.

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.

Surgical site infections after gracilis free flap reconstruction for facial paralysis.

Compared with other free tissue transfer procedures, the gracilis free muscle transfer (GFMT) for facial reanimation is unique in that the recipient site is typically uninvolved by malignancy or infection. In this study, the authors examined the incidence, bacteriology, and outcomes of surgical site infection (SSI) after gracilis free muscle transfer for facial reanimation. From 2003 to 2011, 105 patients underwent 107 GFMT operations, with 6 SSIs. All cases of infection occurred in patients receiving clindamycin, levofloxacin, and/or cefazolin perioperatively. None of the patients who received ampicillin-sulbactam developed an SSI. Surgical site cultures grew oral flora, including α-hemolytic streptococci, Haemophilus parainfluenzae, Fusobacterium and Neisseria species, and coagulase-negative staphylococci. Notably, there were no methicillin-resistant Staphylococcus aureus (MRSA) infections. These data may have implications for the optimal perioperative antibiotic choice in facial reanimation cases. Further study is needed to determine the ideal antibiotic regimen for this category of free flap surgeries.

The “Power” Brow Lift: Efficient Correction of the Paralyzed Brow

Purpose. To describe a novel approach to brow ptosis correction and evaluate its long-term efficacy in patients with facial-paralysis-associated brow ptosis. Methods. Twenty-two patients aged from 50 to 90 years underwent “power” brow lifting, involving 3 intrabrow stab incisions and suture suspension of the brow to the frontal calvarium via titanium miniplate. Long-term results of the operation were assessed retrospectively. Pre- and postoperative photographs were measured with FACE-gram software to evaluate efficacy of the procedure. Results. Seventeen patients who underwent “power” brow lift were available for postoperative evaluation. Among them, follow-up length ranged from 12 to 448 days. The average post-operative change in brow height was 5.7 mm, which was statistically significant (). There were no complications. Conclusions. The “power” brow procedure can help to restore upper facial symmetry and visual fields and improve periocular hygiene. The operation is easily performed in an office setting, under local anesthesia, and appears to provide reliable long-term results. The time required to perform the procedure is far less than that required for a standard direct brow lift; there is no risk of postoperative forehead hypesthesia, and there is no superciliary scar.

Infections after Gracilis Free Flap Reconstruction

Objective: Investigate the incidence, bacteriology, and clinical outcomes of surgical site infection (SSI) after gracilis transfer for facial reanimation, with a focus on determining the optimal perioperative antibiotics in these clean-contaminated cases. Method: A retrospective chart review was performed for facial paralysis patients who underwent gracilis free flap reconstruction from 2003 to 2010. Microbiology, medication allergies, type and duration of perioperative prophylactic antibiotics, surgery length, and ASA status were reviewed. Functional smile outcomes were compared between those who developed infections and those who were infection-free. Results: Since 2003, 110 patients have undergone 116 gracilis free flap operations for facial reanimation, with 6 SSIs. All of the infections occurred in patients receiving clindamycin, levofloxacin, and/or cefazolin perioperative antibiotics. None of the patients who received ampicillin/sulbactam developed a SSI. Surgical site cultures from infected patients grew alpha-hemolytic streptococci, Haemophilus parainfluenzae, Fusobacterium, coagulase-negative staphylococci, and Neisseria. Notably, there were no methicillin-resistant Staphylococcus aureus (MRSA) infections. In the patients with SSIs, the mean oral commissure excursion improved by 7.49 ± 3.83 mm, which was not significantly different from noninfected patients with subjective excellent outcomes of 11.4 ± 7.1 mm. Conclusion: In gracilis flap infections, the organisms identified were consistent with oral flora. Infections occurred in patients receiving prophylactic clindamycin, levaquin, and/or cefazolin, but not in those receiving prophylactic ampicillin/sulbactam. Infections were not associated with decreased functional outcome. These data may have implications for the optimal choice of prophylactic antibiotics.