Chronic Facial Palsy Research Articles

Neuromuscular Retraining versus BTX-A Injection in Subjects with Chronic Facial Nerve Palsy, A Clinical Trial.

Introduction:Chronic facial nerve palsy has long been known to negatively affect the quality of life in patients. The present study aimed to investigate the efficacy of Botulinum Toxin A (BTX-A) and neuromuscular retraining therapy (NMRT) in the symmetry of chronic facial palsy. Materials and Methods:Two groups, namely experimental and control, were considered each consisting of 13 patients. The study population included a total of 15 female subjects. The BTX-A was injected into the synkinetic muscle in the experimental group; nevertheless, the patients in the second group participated in special neuromuscular retraining. The rate of reducing synkinesis and symmetrical improvement was evaluated using the Facial Grading System (FGS) after 4 months of treatment. The independent t-test was performed to compare the two groups. Results:According to the Sunnybrook FGS, the mean changes in Sunnybrook scores in the experimental and neuromuscular retraining groups were 3% and 24%, respectively. The comparison of the mean scores of the two groups was statistically significant after the interventions (P=0.033). A variable ratio of statistically significant improvement was observed in synkinesis in both groups following the treatment (P=0.041). In addition, by comparing the synkinesis scores between the two groups, the reduction of synkinesis was observed to be greater in the neuromuscular retraining group (P=0.041) after the treatment. Conclusions:The findings of the current study indicated that special neuromuscular retraining leads to significant improvement in the FGS score, compared to botulinum toxin therapy alone. Moreover, it was observed that facial symmetry can be treated with special neuromuscular retraining and the patient can overcome synkinesis.

Evaluating Functional Outcomes in Reanimation Surgery for Chronic Facial Paralysis: A Systematic Review.

Background:Chronic facial paralysis can lead to significant functional and psychosocial impairment. Treatment often involves free muscle flap-based facial reanimation surgery. Although surgical techniques have advanced considerably over the years, consensus has yet to be reached for postoperative outcome evaluation. To facilitate outcome comparison between the various techniques for free muscle-flap-based reanimation, a standardized, widely accepted functional outcomes assessment tool must be adopted.Methods:In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review of the PubMed, Cochrane, and Embase databases to identify the reported functional outcome measurement tools used in the free muscle flap-based reanimation literature.Results:The search yielded 219 articles, 43 of which met our inclusion and exclusion criteria. We noted an increase in publications reporting the utilization of objective measures over time, particularly software-based tools, as well as increased utilization of patient reported outcomes measures.Conclusions:Based on the trends identified in the literature, we suggest standardization of outcome measures following facial reanimation surgery with free muscle-flap using a combination of the Facial Assessment by Computer Evaluation (FACEgram) software and the Facial Clinimetric Evaluation (FaCE) Scale.

Facial Reanimation of the Eye Using Neurovascularised Flap of Platysma

Background: Dynamic reanimation is usually required to restore blink function in patients with chronic facial paralysis. In which case, platysma myocutaneous flap (PMF) is a good choice compared to gracilis flap. Platysma is a thin, pliable flap with matching skin colour to the eyelids. Despite this, it is underused.
 Aim: To investigate the neurovasculature of platysma in order to find a common “window” containing nerves and blood vessels supply which is present in every individual. This will aid the plastic surgeons to reconstruct the neurovasculature of the flap for grafting onto the eyelids.
 Methods: 3 fresh cadaver necks were dissected from 1 males and 2 females, aged 75-88 years old; (n=6 platysmas). 43 squared specimens (measuring 1.5cm x 1.5cm) surrounding any potential neurovascular structures were cut out, processed and analysed under high power microscope to confirm the presence of nerves and blood vessels. We also reviewed literature dated from 1999 to 2011.
 Results: From the literature reviewed, the authors concluded that PMF provided excellent functional and aesthetic outcome. In this study, we discovered a “window” flap (ranging from "2.5cm x 3cm‟ to "8cm x 10cm‟) bilaterally on each cadaver. This window is supplied by submental branch of facial artery, drained by facial vein, anterior and external jugular veins, and extensively innervated by cervical branch of facial nerve.
 Conclusion: We strongly advocate the use of PMF “window” by plastic surgeons in dynamic eyelids reanimation.

Activity limitations and participation restrictions in patients with peripheral facial palsy: a cross-sectional study over a six-year period.

Peripheral facial palsy is a pathological condition caused by a wide range of etiologies. A damage of VII cranial nerve produces facial disfigurement and limitations in daily life activities, such as drinking, eating and speaking. As a consequence, patients may experience psychological distress and social isolation. To counsel and design a patient-tailored rehabilitation for patients affected by peripheral facial palsy, physical and social limitations should be considered. Moreover, the knowledge of factors associated with disability plays a key role in the early identification and adequate care of patients with higher risk to develop psychological distress and participation restrictions. To evaluate activity limitations, psychological distress and participation restrictions of patients affected by peripheral facial palsy seeking for rehabilitation and to identify individual and disease-specific factors associated to disability. Cross-sectional study. Consultation hour dedicated to facial palsy patients in the outpatient clinic of a Rehabilitation Unit. One hundred eighty-six outpatients with recent or chronic peripheral facial palsy at the first assessment at our Rehabilitation Unit. Using multiple linear regression models, we evaluated the association between the two subscales of Facial Disability Index (FDI) and the composite score of Sunnybrook Facial Grading System, as well as the association between the two FDI subscales and other clinical and demographic variables. Activity limitations correlate with the severity of palsy, while psychological distress and participation restrictions do not correlate with the neurological impairment. The correlation between the severity of palsy and both activity limitations and participation restrictions is influenced by palsy etiology. Activity limitations decrease with time from palsy onset, while psychological distress and participation restrictions are more severe in women. Beyond severity, also etiology, time from onset and gender influence disability after facial palsy. These factors should be considered in counselling and planning a patient-tailored multidisciplinary rehabilitative treatment. Our study highlights the individual and pathology-associated factors related to activity limitations and participation restrictions in patients with peripheral facial palsy. These elements should be considered in the definition of a patient-tailored rehabilitative plan and in the organization of a multidisciplinary care.

Classification of facial movements in chronic facial palsy based on intramuscular EMG signals recorded from the paretic side.

Patients suffering from chronic facial palsy are frequently impaired by severe life-long dysfunctions. Thus, the loss of the ability to close eyes rapidly and completely bears the risk of corneal damages. Moreover, the loss of smile and an altered facial expression imply psychological stress and impede a healthy social life. Since surgical and conservative treatments frequently do not solve many problems sufficiently, closed-loop neural prosthesis are considered as feasible approach. For it, amongst others a reliable detection of the currently executed facial movement is necessary. In our proof of concept study, we propose a data-driven feature extraction for classifying eye closures and smile based on intramuscular EMGs from orbicularis oculi and zygomaticus muscles of the patient's palsy side. The data-adaptive nature of the approach enables a flexible applicability to different muscles and subjects without patient-or muscle-specific adaptations.

Powering the Gracilis for Facial Reanimation

Free gracilis transfer for dynamic reanimation in chronic facial paralysis is the gold standard, but there remains a need to better understand outcomes with respect to the donor nerve. To characterize outcomes in adults undergoing primary gracilis transfer for facial paralysis stratified by donor nerve used for neurotization. Search strategies were used in Ovid MEDLINE (1946-2019), Embase (1947-2019), Scopus (1823-2019), Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov (1997-2019). Inclusion and exclusion criteria were designed to capture studies in adults with unilateral chronic facial paralysis undergoing single-paddle free gracilis transfer. All study types were included except case reports. Abstracts and full texts were reviewed in duplicate. Of 130 unique citations, 10 studies including 295 patients were included after applying inclusion and exclusion criteria. Data were analyzed between November 2018 and December 2019. PRISMA guidelines were followed. The Newcastle-Ottawa scale was used to assess study quality, and the Cochrane Risk of Bias tool was used to assess risk of bias. Independent extraction by 2 authors (P.M.V. and J.J.C.) was performed. Data were pooled using a random-effects model. Owing to heterogeneity in reporting of facial reanimation outcomes, we first performed a systematic review, and then compiled available outcomes for meta-analysis. Outcomes studied for meta-analysis were oral commissure excursion and facial symmetry. Meta-analysis of masseteric nerve (MN) (n = 56) vs cross-facial nerve graft (CFNG) (n = 52) in 3 retrospective studies showed no statistical heterogeneity between these studies (I2 = 0%), and the standardized mean difference (SMD) was greater for MN (0.55; 95% CI, 0.17 to 0.94). Meta-analysis of angles of symmetry in 2 retrospective studies comparing MN (n = 51) to CFNG (n = 47) both at rest (-0.22; 95% CI, -0.63 to 0.18) and with smiling (-0.14; 95% CI, -0.73 to 0.46) were better with MN, though the difference was not statistically significant. Owing to heterogeneity in reported outcomes from facial reanimation, we were unable to make definitive conclusions regarding the optimal donor nerve. Establishing a reporting standard at peer-reviewed journals to improve results reporting is one method to allow for improved collaboration in the future. Standardizing follow-up times, assessing spontaneity in an objective and reproducible fashion, and use of consistent outcome measures would allow for future meta-analyses and better understanding of options for facial reanimation.

Α modified temporalis transfer technique for facial paralysis in elderly patients

IntroductionIn patients with chronic facial palsy where the treatment by conservative means or only nerve grafting is no longer an option, reconstruction by dynamic procedures such as pedicled and/or free muscle transfer is required. Patients and methodsFive patients with chronic facial palsy were treaded by temporalis muscle transfer to the eye and mouth simultaneously. In four of them, the combined Gillies-McLaughlin technique was used, but for the fifth one, a modified technique was applied. ResultsIn all patients, immediate and late postoperative clinical outcomes were satisfactory and improved their everyday quality of life. DiscussionDepending on the duration of the disease, there are different techniques that can be used. For the chronic facial palsy in elderly patients, the muscle transfer has better results, and a self-developed algorithm give us the opportunity to choose the best possible treatment for each one of our patients. The modified technique was found to be better with less surgical time, and recovery period for the patients. ConclusionAll the patients were satisfied with the results. For the fifth patient that the modified technique applied, the healing process was faster, and the aesthetic and functional reanimation achieved easiest, with no donor-site morbidity, comparatively with the rest patients where the standard Gillies-McLaughlin technique was used.

Immediate compared with late repair of extracranial branches of the facial nerve: a comparative study.

The best outcomes after injury to the facial nerve are seen after immediate direct coaptation, but in practice, this happens infrequently. We ask whether late repair (between 3 weeks and 18 months) is comparable to immediate repair. In this prospective observational study over a two-year period (2016-18), we identified 18 patients (11 male and 7 female, mean (range) age 58 (23-94) years), who had sustained extracranial injuries to the facial nerve. Eight were identified in the acute phase (within 72hours of injury) and repaired (immediate repair group). Ten presented in the late phase beyond six months (late repair group), and had direct coaptation, neurolysis, nerve transfer, or non-vascularised or vascularised nerve grafts. Patients were followed up clinically with photographic or video analysis every three months using the Sunnybrook facial grading scale and Terzis scores as quantitative tools. In the immediate repair group six patients had direct nerve coaptations, one had a free vascularised nerve graft, and one a fascicular nerve flap. In the late repair group six patients had coaptations, two had nerve transfers, one had neurolysis, and one nerve transfer and a free vascularised nerve graft. The null hypothesis that there was no difference between immediate and late repair of the facial nerve in terms of clinical improvement was accepted. The overall facial grading scale between the two groups showed no significant difference (mean 97 compared with 87; 95% CI: -25.61 to 5.32; p=0.18). However, the individual volitional facial grading score for the affected division showed that immediate repair fared significantly better than late repair (mean 4.55 compared with 3.14; 95% CI: -2.5 to -0.3; p=0.027). Supermicrosurgical techniques, together with advanced systems for nerve identification allow for coaptation of the maximum number of injured nerve branches. These factors accounted for a 97% mean return of function after immediate repair and an 87% recovery in the late repair group. While quantitatively, immediate repair is best, the re-establishment of nerve-muscle continuity before degeneration of the motor endplate confers the best possible physiological outcome, and is far superior to any of the techniques used to treat chronic facial paralysis.

Mixed Methods Investigation of Chronic Facial Paralysis in Individuals With Synkinesis

Mixed Methods Investigation of Chronic Facial Paralysis in Individuals With Synkinesis

Exploring intrinsic triggers for functional facial electrostimulation based on intramuscular electromyography recordings.

Based on univariate intramuscular electromyography (EMG) recordings of facial muscles of patients suffering from chronic idiopathic facial palsy we propose a data-driven feature selection process for the discrimination of different mimic maneuvers. Following fundamental ideas of automatic EMG decompositions based on templates defined by motor unit action potentials, the proposed approach relies on a multiple template matching. Yet, the novel methodology utilizes templates derived from the intramuscular EMG signal itself without any supervisor interaction or a priori information by identifying abundant short signal sections (motifs). Focusing on motifs as individual, characteristical graphoelements of an EMG recording implies a high level of flexibility. In connection with facial palsy such a flexibility is necessary, since unique individual, also pathological, EMG patterns can be expected due to the high spatial variability of intramuscular recordings combined with random patterns of aberrant reinnervation. The proposed methodology is applied to EMG data of frontalis, zygomaticus, and orbicularis oculi muscle without patient- or muscle-specific adaptations.

Combined delivery of VEGF and IGF-1 promotes functional innervation in mice and improves muscle transplantation in rabbits

Microvascular muscle transfer is the gold standard for reanimation following chronic facial nerve paralysis, however, despite the regenerative capacity of peripheral motor axons, poor reinnervation often results in sub-optimal function. We hypothesized that injection of alginate hydrogels releasing growth factors directly into donor tissue would promote reinnervation, muscle regeneration, and function. A murine model of sciatic nerve ligation and neurorrhaphy was first used to assess the ability of gel delivery of vascular endothelial growth factor (VEGF) and insulin-like growth factor-1 (IGF-1) to promote functional reinnervation. VEGF + IGF-1 gel delivery to aged mice resulted in prolonged ability to control toe movement, increased toe spreading, and improved static sciatic index score, indicative of improved sciatic nerve and neuromuscular junction function. Further, a 26% increase in muscle fiber area, and 2.8 and 3.0-fold increases in muscle contraction force and velocity, respectively, were found compared to blank alginate in the murine model. This strategy was subsequently tested in a rabbit model of craniofacial gracilis muscle transplantation. Electromyography demonstrated a 71% increase in compound muscle action potential 9 weeks after transplantation following treatment with VEGF + IGF-1 alginate, compared to blank alginate in the rabbit model. Improving functional innervation in transplanted muscle via a hydrogel source of growth factors may enhance the therapeutic outcomes of facial palsy treatments and, more broadly, muscle transplantations.

Facial Rehabilitation as Noninvasive Treatment for Chronic Facial Nerve Paralysis.

This study aims to evaluate the effectiveness of facial rehabilitation (FR) in patients with chronic facial nerve paralysis (FNP) and describe factors that predict improved facial nerve function after FR in this patient population. Retrospective case review. Tertiary referral center. Around 241 patients were referred to a university hospital facial rehabilitation (FR) program for FNP between 1995 and 2016. Seventy-six patients met criteria, defined as diagnosis of FNP ≥12 months prior to initiation of FR. Each received at least two sessions of directed FR by a single therapist. Techniques employed: neuromuscular retraining, stretching/massage, and active exercise. Variables affecting outcomes were analyzed to determine association with success of FR as measured by improvement in Facial Grading System (FGS) scale. Onset of FNP to initiation of FR ranged 12 to 384 months (mean latency = 64.7 months). All patients, age 20 to 89, showed improvement in FGS after FR (mean, 16.54 points, SD 9.35). Positive predictors of FGS improvement after therapy (p-values < 0.05): increased the number of therapy sessions, right side of face being treated for FNP, lower starting FGS score. When controlling for these important variables, time from diagnosis to initiation of therapy was not significantly associated with improvement in FGS score. Facial rehabilitation was associated with improved FGS score regardless of patient age, gender, or latency to facial rehabilitation. As a noninvasive treatment option with positive outcomes, it should be offered to patients with facial nerve paralysis regardless of chronicity.

Descriptive study and functional results of smile reanimation surgery in patients with facial palsy with gracilis flap in a tertiary hospital

Surgery in facial palsy aims to restore the face's symmetry in rest as well as reanimation of the smile. Gracilis flap is a therapeutic option for patients with long-term facial palsy. Our objective is to describe evolution and functional results of patients treated surgically through gracilis transposition. 27 patients with chronic (> 12 months) unilateral facial palsy were treated with gracilis transposition to reanimate smile. Demographic information such as age, gender and personal history was gathered, as well as onset of facial palsy, affected side, etiology, date and kind of surgery, complications and initiation of movement. Functional results were evaluated with the Facial Disability Index and the smile item on the Sunnybrook Scale. Mean age was 50 years old and a slight prevalence of women over men and right-sided palsy over left was observed. Most prevalent etiology was iatrogenic after acoustic neuroma surgery (33.3%). Fifty-nine percent of palsies were less than 5 years old in evolution. Donor nerve most frequently used was the masseter (48%), followed by the cross-face sural nerve graft with masseter babysitter (33.4%) and lastly, cross-face nerve graft (18.6%). Four patients required a second reanimation surgery. Most common complication was scar retraction at the angle of the mouth. Majority of patients initiated smile around 2–4 months after surgery, being a complete or almost complete movement in 66.6% of patients. Facial Disability Index Global Score was less than 100/200 in 20% of patients and more than 150/200 in 44% of them. Functional results were good in more than half the patients, with mild-moderate facial disability. There is a tendency to associate the use of masseter donor with better smile movements and facial disability indexes, even though results are not statistically significant was scar retraction at the angle of the mouth.

Hyaluronic acid gel implants for correction of pathological conditions of the orbit and eyelids

To evaluate the effectiveness of injectable implants made of hyaluronic acid gel (HAG) in ophthalmoplastics. The study included 57 patients (37 patients with lagophthalmos related to acute or chronic facial nerve palsy, endocrine ophthalmopathy; 20 patients with enophthalmos, anophthalmic syndrome). Depending on filler particle size, the patients received either intrapalpebral or intraorbital HAG injection. The biometric measures of palpebral fissure, the position of the eye/implant, and the condition of the cornea were evaluated during the follow-up period (12 months for eyelid and 18 for orbital injection). In the course of the follow-up, all patients showed reliable reduction of lagophthalmos; additionally, improvement of the condition of the cornea was observed in patients after intrapalpebral injection; patients after intraorbital injection exhibited reduction in enophthalmos, upper orbital palpebral fold retraction and upper eyelid excursion. No serious complications have occurred after the injection. As minimally invasive method of treating various pathologies of the orbit and eyelids, HAG fillers showed good clinical effectiveness and safety.

Reconstructive subperiosteal midface lift: A three nonvisible incision approach

ABSTRACTThis article describes our surgical technique for subperiosteal midface elevation in patients with paralytic lower eyelid malposition or cicatricial inferior eyelid retraction. Nineteen patients with paralytic lower eyelid malposition and 15 patients with cicatricial inferior eyelid retraction underwent a subperiosteal midface lift (n = 34). The procedure was performed under local anesthesia through three nonvisible incisions. A transconjunctival incision allows preseptal dissection to the orbital rim, followed by a subperiosteal dissection of the midface. An oral incision is useful to achieve complete subperiosteal dissection and to perform the distal periostomy, which allows complete release of the midface soft tissues. A temporal incision provides access to the temporal fascia for fixation of the elevated tissues and gives the surgeon the possibility of removing redundant skin from the scalp instead of the lower eyelid. Additional posterior lamellar grafting was performed in 24 patients. There was a statistically significant reduction in the distance from the pupil centre to the lower eyelid (margin reflex distance, MRD2) 1 month after surgery (preoperative MRD2 9.62 ± 4.52 mm, postoperative MRD2 5.28 ± 2.62 mm). The ectropion and lower eyelid retraction was resolved in all patients, except for one recurrence. Midfacial elevation is a safe and effective surgical technique in the treatment of static lower eyelid malposition after chronic facial nerve palsy or posttraumatic or iatrogenic lower eyelid retraction.

Effectiveness of electrical stimulation for rehabilitation of facial nerve paralysis

Background: Despite no significant advantage being demonstrated for its use and no standardization of treatment guidelines, electrical stimulation is still applied by therapists to treat facial paralysis. The aim of this investigation was to determine whether electrical stimulation therapy for patients with acute or chronic facial nerve paralysis improves time to, and rates of full recovery and facial function compared with no intervention. Method: A systematic review of randomized and quasi-randomized controlled trials through Scopus, Medline, PEDro, Embase, CINAHL, Pubmed, and Cochrane Library search engines for studies published up until August 2016. Reference lists were reviewed for further studies. Review Manager was used to extract data and review quality of the studies. Studies were assessed for randomization of participants, allocation concealment, blinding of participants, assessors and physiotherapists, presence and reporting of outcome data. Results: Five studies were included for analysis – four during acute recovery and one in chronic facial nerve paralysis. In acute facial nerve paralysis, two studies found no benefit of electrical stimulation and two studies found improvement. A meta-analysis on changes in the House–Brackmann Score after treatment, rates of full recovery and time to full recovery showed no statistically significant difference between intervention and control groups. In chronic facial nerve paralysis, one study found improvements after extensive electrical stimulation on the Facial Paralysis Recovery Profile. Conclusions: There is no evidence to support the use of electrical stimulation during the acute phase of recovery after Bell’s palsy and there is low-level evidence for patients with chronic symptoms. Furthermore, there is no evidence available on the use of electrical stimulation for other causes of facial nerve paralysis.

Thread lifting: aminimally invasive surgical technique for long-standing facial paralysis.

Chronic facial paralysis induces degenerative facial muscle changes on the involved side, thus, making the individual seem as older than their actual age. Furthermore, contralateral facial hypertrophy aggravates facial asymmetry. Athread-lifting procedure has been used widely for correction of a drooping or wrinkled face due to the aging process. In addition, botulinum toxin injection can be used to reduce facial hypertrophy. The aim of study was to evaluate the effectiveness of thread lifting with botulinum toxin injection for chronic facial paralysis. Atotal 34 of patients with chronic facial paralysis were enrolled from March to October 2014. Thread lifting for elevating loose facial muscles on the ipsilateral side and botulinum toxinA for controlling the facial muscle hypertrophy on the contralateral side were conducted. Facial function was evaluated using the Sunnybrook grading system and dynamic facial asymmetry ratios 1year after treatment. All 34patients displayed improved facial symmetry and showed improvement in Sunnybrook scores (37.4 vs. 83.3) and dynamic facial asymmetry ratios (0.58 vs 0.92). Of the 34patients, 28 (82.4%) reported being satisfied with treatment. The application of subdermal suspension with a reabsorbable thread in conjunction with botulinum toxinA to optimize facial rejuvenation of the contralateral side constitutes an effective and safe procedure for face lifting and rejuvenation of adrooping face as aresult of long-lasting facial paralysis.

Video Instruction for Synchronous Video Recording of Mimic Movement of Patients with Facial Palsy

Background Photografy and video are necessary to record the severity of a facial palsy or to allow offline grading with a grading system. There is no international standard for the video recording urgently needed to allow a standardized comparison of different patient cohorts. Methods A video instruction was developed. The instruction was shown to the patient and presents several mimic movements. At the same time the patient is recorded while repeating the presented movement using commercial hardware. Facial movements were selected in such a way that it was afterwards possible to evaluate the recordings with standard grading systems (House-Brackmann, Sunnybrook, Stennert, Yanagihara) or even with (semi)automatic software. For quality control, the patients evaluated the instruction using a questionnaire. Results The video instruction takes 11 min and 05 and is divided in 3 parts: 1) Explanation of the procedure; 2) Foreplay and recreating of the facial movements; 3) Repeating of sentences to analyze the communication skills. So far 13 healthy subjects and 10 patients with acute or chronic facial palsy were recorded. All recordings could be assessed by the above mentioned grading systems. The instruction was rated as well explaining and easy to follow by healthy persons and patients. Discussion There is now a video instruction available for standardized recording of facial movement. This instruction is recommended for use in clinical routine and in clinical trials. This will allow a standardized comparison of patients within Germany and international patient cohorts.

An Anatomical study for localisation of Zygomatic branch of Facial nerve and Masseteric nerve - An aid to nerve coaptation for facial reanimation surgery: A cadaver based study in Eastern India.

Context:In cases of chronic facial palsy, where direct neurotisation is possible, ipsilateral masseteric nerve is a very suitable motor donor. We have tried to specifically locate the masseteric nerve for this purpose.Aims:Describing an approach of localisation and exposure of both the zygomatic branch of Facial nerve and the nerve to masseter, with respect to a soft tissue reference point over face.Settings and Design:Observational cross sectional study, conducted on 12 fresh cadavers.Subjects and Methods:A curved incision was given, passing about 0.5cms in front of the tragal cartilage. A reference point “R” was pointed out. The zygomatic branch of facial nerve and masseteric nerve were dissected out and their specific locations were recorded from fixed reference points with help of copper wire and slide callipers.Statistical Analysis Used:Central Tendency measurements and Unpaired “t” test.Results:Zygomatic branch of the Facial nerve was located within a small circular area of radius 1 cm, the centre of which lies at a distance of 1.1 cms (±0.4cm) in males and 0.2cm (±0.1cm) in females from the point, ‘R’, in a vertical (coronal) plane. The nerve to masseter was noted to lie within a circular area of 1 cm radius, the centre of which was at a distance of 2.5cms (±0.4cm) and 1.7cms (±0.2cm) from R, in male and female cadavers, respectively. Finally, Masseteric nerve's depth, from the masseteric surface was found to be 1cm (±0.1cm; male) and 0.8cm (±0.1cm; female).Conclusions:This novel approach can reduce the post operative cosmetic morbidity and per-operative complications of facial reanimation surgery.

Lower Eyelid Retraction Surgery Without Internal Spacer Graft

Internal eyelid spacer graft is routinely placed during lower eyelid retraction surgery, which may be unnecessary. To evaluate the efficacy of lower eyelid retraction surgery without internal graft in select cases. Retrospective analysis of patients undergoing reconstructive lower eyelid retraction surgery without internal graft, by one surgeon from 2013 to 2015. Surgical technique included transconjunctival lower eyelid retractor lysis, canthoplasty, and temporary tarsorrhaphy, with or without subperiosteal midface-sub oribularis oculi fat (SOOF) lifting and scar lysis. Eyelids with true lower eyelid middle-lamella shortage were excluded. Analysis included 17 surgeries (11 patients). Eight of 11 patients had undergone at least one previous lower eyelid surgery with resultant lower eyelid retraction and sclera show. Preoperative and postoperative photographs at longest follow-up visit were analyzed with standardized measurements. Patient satisfaction was recorded using questionnaire. Etiologies of lower eyelid retraction included prior lower blepharoplasty, thyroid eye disease, and chronic facial palsy. All 11 patients (17 procedures) demonstrated improvement of lower eyelid position. The mean improvement of marginal reflex distance was 2.2 mm (range, 1.6-2.8 mm). There was one case of mild overcorrection. The average follow-up was 7 months (range, 6 months-2 years). Midface lift was performed for 14 of 17 eyelids. This study demonstrates improvement of lower lid position after lower eyelid retraction surgery without internal eyelid spacer graft in select patients. Most patients in our study had undergone previous lower eyelid blepharoplasty and required midface-SOOF lifting. The author proposes that "routine" placement of lower eyelid internal spacer/graft may not be necessary during lower eyelid retraction surgery.