Jonathan I. Leckenby

Is there an ideal outcome scoring system for facial reanimation surgery? A review of current methods and suggestions for future publications

Facial reanimation is the surgical process of attempting to restore dynamic, spontaneous symmetry to the paralysed face. We undertook to review the most frequently used scoring systems and discuss a universal set of assessments which every facial palsy surgeon can use to standardize the outcome of surgical intervention and allow a comparison to be drawn when comparing different operative techniques. A literature review was performed using PubMed and Cochrane databases to identify scoring systems for facial palsy, facial nerve regeneration and facial reanimation. The scoring systems were broken down into the following broad categories: observational, mathematical and computer-graphical measurements. More than 20 scoring systems were identified and included in the study. The scoring systems were analysed and assessed for reproducibility and inter-observer reliability. The current trend in the literature is to use the House-Brackmann Score due to its historical longevity, brevity and ease of understanding. However, this was never designed to assess outcomes of facial reanimation and there are clear limitations. Other more appropriate methods such as 3-D facial analysis are prohibitively expensive to widely implement. The quest continues to develop an ideal system. From this review it is clear that a quick, simple to use system should be used which incorporates the patients own views. Therefore a combination of pre- and post-operative photographs of the patient should be assessed by an independent panel as well as the patient. We propose a universal set of photographs that can be used to standardize the outcome of surgical intervention when publishing results in the literature. This will allow a comparison to be drawn when comparing different operative techniques and help surgeons work collectively towards the same goal while improving patient outcomes.

Static support in the facial palsy patient: A case series of 51 patients using tensor fascia lata slings as the sole treatment for correcting the position of the mouth

Although free functional muscle transfer (FFMT) remains the gold standard treatment of facial paralysis to produce a spontaneous, symmetrical smile in response to emotion, there are occasions when this option may not be available. Many patient factors and co-morbidities may result in a poor outcome, with flap and even patient survival being put at risk. The use of tensor facia lata (TFL) slings has been well described and provides a surgeon with a static option which yields acceptable results. We present the results of two surgeons experience using TFL sling as the sole treatment of facial paralysis and include complications, revision rates and outcomes. The results confirm that the use of a TFL sling equips the facial palsy surgeon with an excellent option for the cases where free functional muscle transfer is unavailable.

Poly Implant Prothèse™ (PIP) experience in the United Kingdom: A prospective cohort study into the accuracy of diagnostic imaging findings in comparison to operative findings of 1029 implants.

The Poly Implant Prosthèse™ (PIP) implants were withdrawn from market use in the United Kingdom on 31st March 2010 following Government issued advice. In June 2012 a final Government report was issued and during this period the majority of patients elected to have their prostheses removed. This study presents the operative findings of three surgeons. 517 patients were identified retrospectively from the implant database as having received PIP implants with a total of 1029 implants. 62 patients (124 implants) declined explantation after consultation and imaging. The data was recorded prospectively for all patients and included the clinical, imaging and operative findings. A total of 905 implants were removed of which 129 were ruptured at the time of explantation (14.25%). 27 implants were intact but the presence of liquid surrounding the prosthesis was noted. 93 implants were reported as being ruptured after diagnostic imaging but were intact operatively resulting in a test sensitivity of 0.82 and a specificity of 0.92 yielding a positive predictive value of 0.59 and a negative predictive value of 0.97 overall. Capsule formation was noted in 27 breasts (3%). Our study showed that the prevalence of PIP ruptures is comparable to other manufacturers. The prevalence of implant rupture predictably increased over time and the prevalence of abnormal capsule formation was similar to other manufacturers.

The use of a free vascularised fibula to reconstruct the radius following the resection of an osteosarcoma in a paediatric patient

Osteosarcoma is the most common high grade bone malignancy in children and the surgical treatment traditionally involves amputation. In our case, a 6-year-old girl was diagnosed with an osteosarcoma of the left distal radius after presenting with forearm pain. After initially being offered an amputation, a second opinion was sought and a limb salvage procedure was offered using a free vascularised fibula bone flap. This resulted in limb preserving surgery which allowed the potential for growth with the maximal preservation of function.

The axillary approach to raising the latissimus dorsi free flap for facial re-animation: a descriptive surgical technique.

The latissimus dorsi flap is popular due to the versatile nature of its applications. When used as a pedicled flap it provides a robust solution when soft tissue coverage is required following breast, thoracic and head and neck surgery. Its utilization as a free flap is extensive due to the muscles size, constant anatomy, large caliber of the pedicle and the fact it can be used for functional muscle transfers. In facial palsy it provides the surgeon with a long neurovascular pedicle that is invaluable in situations where commonly used facial vessels are not available, in congenital cases or where previous free functional muscle transfers have been attempted, or patients where a one-stage procedure is indicated and a long nerve is required to reach the contra-lateral side. Although some facial palsy surgeons use the trans-axillary approach, an operative guide of raising the flap by this method has not been provided. A clear guide of raising the flap with the patient in the supine position is described in detail and offers the benefits of reducing the risk of potential brachial plexus injury and allows two surgical teams to work synchronously to reduce operative time.

Reanimation of the brow and eye in facial paralysis: Review of the literature and personal algorithmic approach

Facial palsy patients suffer an array of problems ranging from functional to psychological issues. With regard to the eye, lacrimation, lagophthalmos and the inability to spontaneously blink are the main symptoms and if left untreated can compromise the cornea and vision. There are a multitude of treatment modalities available and the surgeon has the challenging prospect of choosing the correct intervention to yield the best outcome for a patient. The accurate assessment of the eye in facial paralysis is described and by approaching the brow and the eye separately the treatment options and indications are discussed having been broken down into static and dynamic modalities. Based on our units experience of more than 35 years and 1000 cases of facial palsy, we have developed a detailed approach to help manage these patients optimally. The aim of this article is to provide the reader with a systematic algorithm that can be used when consulting a patient with eye problems associated with facial palsy.

Local injections of tacrolimus-loaded hydrogel reduce systemic immunosuppression-related toxicity in vascularized composite allotransplantation.

Background Routine application of vascularized composite allotransplantation is hampered by immunosuppression-related health comorbidities. To mitigate these, we developed an inflammation-responsive hydrogel for local immunosuppression. Here, we report on its long-term effect on graft survival, immunological, and toxicological impact. Methods Brown Norway-to-Lewis rat hindlimb transplantations were treated either systemically with daily injections of 1 mg/kg tacrolimus (TAC) or with subcutaneous intragraft injections of hydrogel containing 7 mg TAC, every 70 days. Animals were monitored for rejection or other pathology for 280 days. Systemic and graft TAC levels, regulatory T cells, and donor cell chimerism were measured periodically. At endpoint, markers for kidney, liver, and metabolic state were compared to naive age-matched rats. Results Both daily systemic TAC and subcutaneous intragraft TAC hydrogel at 70-day intervals were able to sustain graft survival longer than 280 days in 5 of 6 recipients. In the hydrogel group, 1 graft progressed to grade 3 rejection at postoperative day 149. In systemic TAC group, 1 animal was euthanized due to lymphoma on postoperative day 275. Hydrogel treatment provided stable graft and reduced systemic TAC levels, and a 4 times smaller total TAC dose compared with systemic immunosuppression. Hydrogel-treated animals showed preserved kidney function, absence of malignancies or opportunistic infections and increased hematopoietic chimerism compared with systemic immunosuppression. Conclusions Our findings demonstrate that localized immunosuppression with TAC hydrogel is a long-term safe and reliable treatment. It may reduce the burden of systemic immunosuppression in vascularized composite allotransplantation, potentially boosting the clinical application of this surgical intervention.

Complex Reconstruction After Sarcoma Resection and the Role of the Plastic Surgeon: A Case Series of 298 Patients Treated at a Single Center.

Background More than 1000 new patients present to the London Sarcoma Unit each year and between 5% and 10% require plastic surgery intervention. Advancements in radiotherapy and chemotherapy protocols combined with higher expectations for limb preservation has led to increased reconstructive challenges. Frequently, primary closure is achievable; however, larger tumors often require specialist reconstruction. Study Design A retrospective chart review of all referred patients from the London Sarcoma Unit requiring reconstruction between February 2006 and January 2015 was performed. Patients who underwent primary amputation were excluded. Results The total number of operations performed was 298 and the mean follow-up was 16 months (12–46 months). 51% of patients had major comorbidities. Patients could be separated into early (0–1 week postoperatively, n = 167) and late reconstructions (>1 week postoperatively, n = 131). 32 patients were reconstructed with skin grafts, 137 patients were managed with regional flaps and 129 patients were treated with free flaps. Conclusions A patient with 3 or more major comorbidities resulted in a significantly increased risk of reconstructive failure (P < 0.05). Our experience has lead us to adhere to the following guidelines: (1) All patients should be reviewed in a multidisciplinary team meeting. (2) After primary excision, patients should be managed with a vacuum dressing until margins are clear. (3) Definitive reconstruction should be performed by a specialist reconstructive surgeon.

The incidence of facial vessel agenesis in patients with syndromic congenital facial palsy.

Background: Congenital facial palsy can result in significant disfigurement. A potential treatment option is free functional muscle transfer to reanimate the face. For this to be possible, a suitable recipient artery and vein must be present in the affected hemiface. In this study, the authors aim to identify whether patients with syndromic congenital facial palsy have a higher rate of facial vessel agenesis than those with isolated congenital facial palsy. Methods: Patients were identified between November of 2006 and October of 2013. Patients were stratified into two groups: those with syndromic congenital facial palsy and those with isolated congenital facial palsy. The presence or absence of facial vessels was determined intraoperatively. Results: Forty-seven eligible patients were included in the study. Those with syndromic congenital facial palsy were significantly more likely to have an absent facial vein than patients with isolated congenital facial palsy (p = 0.015). There was a strong trend toward those with syndromic facial palsy lacking a facial artery (p = 0.08). Subgroup analysis of patients with Möbius syndrome revealed that these patients were significantly more likely to have facial artery agenesis than those with isolated congenital facial palsy (p = 0.03). Conclusions: Facial vessel agenesis is significantly more common in patients with syndromic congenital facial palsy compared with those with isolated congenital facial palsy. This must be considered in the preoperative planning for facial reanimation with free functional muscle transfer. The operating surgeon should consider vascular studies of the affected hemiface before undertaking the procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

An Algorithm to Guide Recipient Vessel Selection in Cases of Free Functional Muscle Transfer for Facial Reanimation

Background The aim of this study was to review the recipient vessels used in our cases of facial reanimation with free functional muscle transfer and to identify patient variables that may predict when the facial vessels are absent. From this we present a protocol for vessel selection in cases when the facial artery and/or vein are absent. Methods Patients were identified from November 2006 to October 2013. Data was collected on patient demographics, facial palsy aetiology, history of previous facial surgery/trauma and flap/recipient vessels used. A standard operative approach was adopted and performed by a single surgeon. Results Eighty-seven eligible patients were identified for inclusion amongst which 98 hemifaces were operated upon. The facial artery and vein were the most commonly used recipient vessels (90% and 83% of patients, respectively). Commonly used alternative vessels were the transverse facial vein and superficial temporal artery. Those with congenital facial palsy were significantly more likely to lack a suitable facial vein (P=0.03) and those with a history of previous facial surgery or trauma were significantly more likely to have an absent facial artery and vein (P<0.05). Conclusions Our algorithm can help to guide vessel selection cases of facial reanimation with free functional muscle transfer. Amongst patients with congenital facial palsy or in those with a previous history of facial surgery or trauma, the facial vessels are more likely to be absent and so the surgeon should then look towards the transverse facial vein and superficial temporal artery as alternative recipient structures.