Commissure Height Research Articles

Understanding clinical meaningfulness when targeting the depressor anguli oris muscle (DAO) with neuromodulators: a clinical prospective interventional study.

Neuromodulator injections in the US increased by 24% from 2021 to 2022. This rise is attributed to new products and growing acceptance of minimally invasive aesthetic treatments. Recent studies emphasize the importance of facial anatomy for precision and, consequently, a higher efficacy of neuromodulator treatments. This study aims to evaluate the clinical efficacy of a novel previously proposed injection technique targeting the depressor anguli oris (DAO) muscle to improve oral commissure position. This clinical, prospective study included 34 volunteers from the Shinobu Clinic, São Paulo, Brazil. Patients received 3 units of onabotulinumtoxinA per side, injected mid-distance between the oral commissure and jawline, following the labiomandibular sulcus (LMS). Standardized photographs and assessments using the Oral Commissure Severity Scale (OCSS) and Global Aesthetic Improvement Scale (GAIS) were conducted before and 30days post-treatment. Statistical analyses included t-tests, Wilcoxon Signed Rank test, and generalized linear models. The average increase in commissural height was 5.22% (p < 0.001). OCSS ratings improved significantly from baseline (clinician: 1.21 to 0.72, p < 0.001; patient: 0.93 to 0.69, p < 0.001). However, GAIS scores indicated no significant change (patient: 0.32, observer: 0.38; p = 0.491). The proposed injection technique improves perioral aesthetics objectively and subjectively. However, the lack of significant change in GAIS scores suggests that perceived improvements may not be clinically meaningful to patients. Future studies should focus on patient-centered evaluation methods to better assess aesthetic outcomes.

Dual versus Single Innervation of Gracilis Free Functional Muscle Transfer in Facial Paralysis: Long-Term Resting and Dynamic Outcomes.

The purpose of this study was to compare long-term tone and excursion in single- versus dual-innervated free functional muscle transfer (FFMT) in patients with longstanding facial paralysis. Patients with longstanding facial palsy treated with an FFMT innervated either by a nerve-to-masseter graft (single-innervation group) or nerve-to-masseter and cross-facial-nerve grafts (dual-innervation group) were included. One-year minimum follow-up was required. Outcome measures, based on standardized photographs, included excursion, smile angle, teeth exposure, commissure height deviation, and upper lip height deviation in repose and in closed and open-teeth smile preoperatively and at 3 months, 1 year, and 3 years postoperatively. Emotrics software and ImageJ software were used to take measurements. Between-group and within-group longitudinal comparisons were analyzed. At 3 years (single, n = 24; dual, n = 13), significance was found between groups in commissure position (single, 26.42 mm versus dual, 31.51 mm; P < 0.0001) and excursion with open-mouth smile (single, 31.32 mm versus dual, 26.59 mm; P < 0.001). Single-innervation FFMT within-group analysis lacked significant improvement in commissure height deviation and upper lip height deviation at 3 years in repose, whereas the dual-innervation group revealed significant improvements (3.67 mm [ P < 0.001], 3.17 mm [ P < 0.001], respectively). Teeth exposure revealed an increase in the dual-innervation group (single, 35.753 mm 2 versus dual, 64.177 mm 2 ), but significance was not observed. Dual-innervated FFMT revealed improvements in resting tone and teeth exposure with minimal decrease in smile excursion compared with single-innervated FFMT. Therapeutic, III.

Clinical audit of an artificial intelligence (AI) empowered smile simulation system: a prospective clinical trial

Smile aesthetics is an important factor to consider during orthodontic treatment planning. The aim of the present study is to assess the predictability of Invisalign SmileView for digital AI smile simulation in comparison to actual smile treatment outcomes, using various smile assessment parameters. A total of 24 adult subjects (12 females and 12 males; mean age 22 ± 5.2 years) who chose to be treated using Invisalign were prospectively recruited to have their pretreatment smiles captured using the Invisalign SmileView to simulate their new smiles before treatment was started. Patients were then treated using upper and lower Invisalign aligners with average treatment time of 18 ± 6 months. Full post-treatment records were obtained and full smile frame images of simulated smile and actual final smile of each subject were evaluated by an independent examiner using an objective assessment sheet. Ten smile variants were used to assess the characteristics of the full smile images. Significance level was set at P < 0.05. The ICC for the quantitative parameters showed that there was an overall excellent & good internal consistency (alpha value > 0.7 & > 0.9). The Independent t test was performed amongst the quantitative variables. The P value was not significant for all except maxillary inter canine width (P = 0.05), stating that for the five variables namely; philtrum height, commissure height, smile width, buccal corridor and smile index, actual mean values were similar to the simulation mean values. For the qualitative variables, the Kappa value ranged between 0.66 and − 0.75 which showed a substantial level of agreement between the examiners. Additionally, the Chi square test for the qualitative variables, revealed that the P value was found to be significant in all except lip line. This implies that only the lip line values are comparable. More optimal lip lines, straighter smile arcs and more ideal tooth display were achieved in actual post treatment results in comparison to the initially predicted smiles. Five quantitative smile assessment parameters i.e., philtrum height, commissure height, smile width, buccal corridor, and smile index, could be used as reliable predictors of smile simulation. Maxillary inter canine width cannot be considered to be a reliable parameter for smile simulation prediction. A single qualitative parameter, namely the lip line, can be used as a reliable predictor for smile simulation. Three qualitative parameters i.e., most posterior tooth display, smile arc, and amount of lower incisor exposure cannot be considered as reliable parameters for smile prediction.Trial Registration number and date: NCT06123585, (09/11/2023)

Development of a Simple Analytical Model to Facilitate Preoperative Surgical Planning in Valve-Sparing Aortic Root Replacement.

Valve-sparing root replacement (VSRR) is attractive for aortic root dilation as it preserves the native aortic valve (AoV). Low effective height (eH) after reconstruction is a risk factor for repair failure and reoperation. We developed and validated a quantitative AoV repair strategy to reliably restore normal valve proportions to promote long-term function. Normal AoV proportions were used to derive geometric relationships for sinotubular junction diameter (DSTJ), free edge length (FEL), free edge angle, and commissure height. These relationships informed two models for predicting eH following VSRR: (1) assuming valve symmetry and (2) accounting for valve asymmetry. Porcine heart (n = 6) ex vivo validation was performed under 4 VSRR scenarios: "Ideal" (tube graft size targeting FEL/DSTJ = 1.28), "Oversized" (one graft size larger than Ideal), "Undersized" (two sizes smaller), and "Undersized + Plicated" (FEL/DSTJ = 1.28 restored with leaflet plication). Our analytical models predicted eH using preoperative measurements and estimated reconstructed dimensions. The Oversized graft exhibited similar eH to Ideal but higher regurgitation in the ex vivo model, whereas the Undersized graft demonstrated lower eH and regurgitation. Plication in the Undersized graft restored valve function (regurgitation & eH) similar to Ideal in the ex vivo model and above Ideal in the analytical models. Both analytical models predicted ex vivo eH well except in the Oversized and Undersized + Plicated conditions. Utilizing measurements from preoperative imaging and simple mathematical models, patient-specific operative plans for VSRR can be created by estimating valve dimensions necessary to achieve favorable valve features post-repair. Clinical application of this approach promises to improve consistency in achieving optimal long-term dimensions and durability.

Virtual Reality Computed Tomography Evaluation - Anatomy and Clinical Implications for Valve-Sparing Aortic Root Replacement.

Three-dimensional aortic root evaluation using virtual reality (VR) techniques for valve-sparing aortic root replacement (VSARR) preparation has not yet been implemented, so we demonstrated VR computed tomography (VR-CT) and assessed its utility for VSARR.Methods and Results: We enrolled 72 patients who underwent multidetector CT before elective VSARR for annuloaortic ectasia with tricuspid aortic valve. The geometries of their aortic roots were measured with a VR-CT workstation. The mean values of geometric height (GH), free margin length (FML), and commissural height (CH) were 17.2±2.4 mm, 36.0±5.2 mm, and 24.0±4.3 mm, respectively. The right coronary/noncoronary CH was significantly greater than the left coronary/right coronary and left coronary/noncoronary CH. The left coronary cusp had the shortest FML, intercommissural distances (ICD), and smallest central angle. Although the right coronary cusp had the largest values for FML, ICD, and central angle, the right coronary cusp had the lowest GH and EH. The VR-CT measurements strongly correlated with intraoperative alternatives, especially with mean GH (R2=0.75) and left coronary/noncoronary CH (R2=0.79). Furthermore, mean GH was observed to be significantly different among the selected graft size groups; therefore, the preoperative mean GH could play a significant role in graft sizing. VR-CT evaluation allows a thorough understanding of aortic root anatomy, which could facilitate VSAAR.

Dual-Innervated Gracilis Free Functional Muscle Transfers in Facial Palsy Patients: Comparing Long-Term Outcomes between One- versus Two-Stage Procedures.

In facial reanimation, dual-innervated gracilis free functional muscle transfers (FFMTs) may have amalgamated increases in tone, excursion, synchroneity, and potentially spontaneity when compared with single innervation. The ideal staging of dual-innervated gracilis FFMTs has not been investigated. We aim to compare objective long-term outcomes following one- and two-stage dual-innervated gracilis FFMTs. Included were adult patients with facial paralysis who underwent either one- (one-stage group) or two-stage (two-stage group) dual-innervated gracilis FFMT with ≥1 year of postoperative follow-up. Facial measurements were obtained from standardized photographs of patients in repose, closed-mouth smile, and open-mouth smile taken preoperatively, 1 year postoperatively, and 3 years postoperatively. Symmetry was calculated from the absolute difference between the paralyzed and healthy hemiface; a lower value indicates greater symmetry. Of 553 facial paralysis patients, 14 were included. Five and nine patients were in the one- and two-stage groups, with mean follow-up time, respectively, being 2.5 and 2.6 years. Within-group analysis of both groups, most paralyzed-side and symmetry measurements significantly improved over time with maintained significance at 3 years postoperatively in closed and open-mouth smile (all p ≤ 0.05). However, only the two-stage group had maintained significance in improvements at 3 years postoperatively in paralyzed-side and symmetry measurements in repose with commissure position (median change [interquartile range, IQR], 7.62 [6.00-10.56] mm), commissure angle (median change [IQR], 8.92 [6.18-13.69] degrees), commissure position symmetry (median change [IQR], -5.18 [-10.48 to -1.80] mm), commissure angle symmetry (median change [IQR], -9.78 [-11.73 to -7.32] degrees), and commissure height deviation (median change [IQR], -5.70 [-7.19 to -1.64] mm; all p ≤ 0.05). In the between-group analysis, all measurements were comparable in repose, closed-mouth smile, and open-mouth smile (all p > 0.05). Long-term outcomes demonstrate that both one- and two-stage dual-innervated gracilis FFMTs significantly improve excursion, but only two-stage reconstruction significantly improves resting tone.

Age-related outcomes of facial reanimation surgery using gracilis free functional muscle transfer innervated by the masseteric nerve: A retrospective cohort study

The free functional muscle gracilis transfer is an established approach in facial reanimation surgery; however, the significance of its neurotization and the patient's age is still inconclusive. Several donor nerves are available for facial reanimation using the free functional gracilis muscle transfer. This retrospective cohort study investigates whether the masseteric nerve is an equally reliable donor nerve in both older and younger patients. We included 46 patients (13-71 years, male and female) who underwent nerve-to-masseter (NTM)-driven free functional muscle transfer (FFMT) between January 2008 and December 2019. Patients were distributed into three cohorts according to their age at surgery. We assessed the facial symmetry before and after surgery using the pupillo-modiolar angle. Commissure height and excursion deviation were measured with the Emotrics software. Patient-reported outcome measurements were taken using the Facial Clinimetric Examination (FaCE) scale. All patients had successful flap innervation, except for one patient in the middle-aged cohort (31-51 years). The postoperative facial symmetry at rest, smiling, and laughing was analyzed with the pupillo-modiolar angle and the Emotrics software and showed similar results between all cohorts. The FaCE scale showed similar scores for the middle-aged (31-51 years) cohort and the senior cohort (52-71 years). The social function score in the senior cohort was higher than in the middle-aged cohort, without statistical significance. One patient in the middle-aged (31-51 years) cohort and the senior cohort (52-71 years), respectively, underwent emergency revision due to impaired flap perfusion and could be salvaged. NTM-driven FFMT for facial reanimation is a safe and reliable procedure across all age groups of patients.

50. Perceptual Smile Asymmetry is Impacted by Five Smile Parameters

PURPOSE: Facial expressions are integral to nonverbal communication. Dynamic smile reconstruction is a goal of care, and the aim of surgery is to create symmetry. This project evaluates how much asymmetry is tolerated in smile perception and quantifies that asymmetry. METHODS: Fifty-six facial photographs were categorized based on increasing smile asymmetry. Emotrics software was used to compute asymmetry in five mouth metrics. A Qualtrics survey consisting of 56 cropped photographs was disseminated using Amazon’s Mechanical Turk (MTurk). Three questions accompanied each photograph: 1) Is the person smiling? 2) What emotion is being expressed? 3) How symmetric is the facial expression? ANOVA, chi-squared, and multivariable linear modeling were performed. RESULTS: A total of 618 survey responses were analyzed. Smile recognition was 100%, 78%, and 33% in the symmetric, mild-moderately asymmetric, and asymmetric categories (p<0.001). Happy was identified in 89% of symmetric smiles, compared to 15% of asymmetric smiles (p<0.001). Disgust was conveyed in 26% of asymmetric smiles (p<0.001). If a smile was recognized, then 65% were happy; if not recognized, then disgust was chosen most frequently (p<0.001). Multivariable linear models using asymmetry in five mouth metrics predicted: smile recognition, happy emotion identification, and symmetry score (p<0.001). A 1% increase in asymmetry of lower lip height and commissure position decreased symmetry score by 32- and 18-points, respectively. CONCLUSIONS: Survey respondents are unable to recognize severely asymmetric smiles as smiles. Severely asymmetric smiles convey disgust rather than positivity. Mild differences in lower lip and commissure positions contribute to asymmetry perception, and models incorporating five smile parameters—nasolabial fold angle, interlabial distance, commissure height, commissure position, and lower lip height—were able to predict smile asymmetry.

Quantitative analysis of facial symmetry and animation following intraoral orthodromic temporalis transfer in facial paralysis

This study aimed to quantitatively analyze the degree and vector of commissure excursion following intraoral orthodromic temporalis transfer. Patients with unilateral facial paralysis who underwent intraoral temporalis transfer were included. Intra-oral coronoidectomy was followed by submucosa tunneling through two vertical intraoral incisions to fixate the temporalis tendon to the perioral location. Oral commissure excursion, upper lip and commissure height differences, and smile angle were measured.Postoperatively, the symmetry of commissure excursion improved in repose (affected side: 114.6 ± 7.0 mm, non-affected side: 115.2 ± 4.9 mm, p = 0.134), while asymmetry arose in smiling (affected side: 30.7 ± 3.4 mm, non-affected side: 34.5 ± 4.4 mm, p = 0.001). Furthermore, the postoperative smile angle demonstrated insufficient vertical movement on the affected side during smiling (affected side: 115.6 ± 5.8°, non-affected side: 118.4 ± 4.9°, p = 0.002) but no significant difference in repose (p = 0.134). Within the limitations of the study it seems that intraoral orthodromic temporalis transfer yields excellent resting symmetry, but smile asymmetry may occur owing to insufficient oral commissure excursion. Nevertheless, as a minimally invasive surgery, this technique can obviate visible scars and benefit patients wishing for the same and can have excellent resting symmetry.

Optimizing the results of facial animation surgery: Botulinum toxin injection into free functional gracilis flap transfer

Although neuromuscular gracilis transplantation is the best choice for facial reanimation in patients with congenital or inveterate palsy, the results are not completely satisfactory. Ancillary procedures developed to achieve better symmetry of the smile and reduce the hypercontractility of the transplanted muscle have been reported. However, the intramuscular injection of botulinum toxin has not been described for this purpose. Patients undergoing gracilis injections of botulinum toxin after facial reanimation surgery between September 1, 2020, and June 1, 2022, were retrospectively enrolled in this study. We collected photographs taken before and 20-30 days after injection and compared the symmetry of the face using software. Nine patients with a mean age of 23.56 years (range, 7-56 years) were enrolled. Reinnervation of the muscle was provided by the contralateral healthy facial nerve via a sural cross-graft (four patients), by the ipsilateral masseteric nerve (three cases), and by the contralateral masseteric and facial nerve (two). Using Emotrics software, we identified differences in the commissure excursion discrepancy of 3.82mm, the smile angle discrepancy of 0.084°, and the dental show discrepancy of 1.49mm; the average difference in the commissure height deviation was 2.26mm (P=0.02), and those in the upper- and lower-lip height deviation were 1.05mm and 1.49mm, respectively. Gracilis injection of botulinum toxin after gracilis transplantation is a safe and feasible procedure that could be applicable to all patients with asymmetric smiles related to excessive transplant contraction. It yields good esthetic results with little to no related morbidity.

Quantitative analysis of the morphology of the lips according to different anteroposterior and vertical skeletal patterns

Objectives: The aim of this study was to compare the differences in the morphology of the lips according to anteroposte-rior dentoskeletal patterns and facial divergence.Materials and Methods: The samples were composed of the frontal facial photographs of 117 adult patients who satisfied all the cephalometric measurements for six groups (Class I or II or III and normodivergent or hyperdivergent). The morphol-ogy of the lips was evaluated on the frontal facial photographs and the measurements were compared between the groups.Results: In the normodivergent groups, the height-to-width ratio of the lip vermilion was significantly greater in the Class II group than in the Class I group, and the labrale superius angle and upper lip convexity of the Class II group was smaller than that of the Class I group. In the hyperdivergent groups, the stomion inferius angle of the Class III group was smaller than that of the Class II group. Lower facial height and the interlabial gap in the hyperdivergent groups tended to be larger than those in the normodivergent groups. The height-to-width ratio of the lip vermilion and the commissure height were larger in the hyperdivergent groups than in the normodivergent groups. However, the upper lip height and philtrum height did not differ between the hyperdivergent and normodivergent groups.Conclusion: The morphological characteristics of the lip vermilions on the frontal view differed according to the sagittal dentoskeletal relationship and facial divergence.

Biomechanical evaluation of aortic regurgitation from cusp prolapse using an ex vivo 3D-printed commissure geometric alignment device.

Aortic regurgitation (AR) is one of the most common cardiac valvular diseases, and it is frequently caused by cusp prolapse. However, the precise relationship of commissure position and aortic cusp prolapse with AR is not fully understood. In this study, we developed a 3D-printed commissure geometric alignment device to investigate the effect of commissure height and inter-commissure angle on AR and aortic cusp prolapse. Three porcine aortic valves were explanted from hearts obtained from a meat abattoir and were mounted in the commissure geometric alignment device. Nine commissure configurations were tested for each specimen, exploring independent and concurrent effects of commissure height and inter-commissure angle change on AR and aortic cusp prolapse. Each commissure configuration was tested in our 3D printed ex vivo left heart simulator. Hemodynamics data, echocardiography, and high-speed videography were obtained. AR due to aortic cusp prolapse was successfully generated using our commissure geometric alignment device. Mean aortic regurgitation fraction measured for the baseline, high commissure, low commissure, high commissure and wide inter-commissure angle, high commissure and narrow inter-commissure angle, low commissure and wide inter-commissure angle, low commissure and narrow inter-commissure angle, wide commissure, and narrow commissure configurations from all samples were 4.6 ± 1.4%, 9.7 ± 3.7%, 4.2 ± 0.5%, 11.7 ± 5.8%, 13.0 ± 8.5%, 4.8 ± 0.9%, 7.3 ± 1.7%, 5.1 ± 1.2%, and 7.1 ± 3.1%, respectively. AR was most prominent when commissure heights were changed from their native levels with concomitant reduced inter-commissure angle. Findings from this study provide important evidence demonstrating the relationship between commissure position and aortic cusp prolapse and may have a significant impact on patient outcomes after surgical repair of aortic valves.

Characteristics and Dynamics of Smile in Patients With Skeletal Class II Malocclusion Versus Class I Malocclusion Using Still Digital Video Captures: A Three-Group, Cross-Sectional, Comparative Study.

Background Smiling is one of the effective ways for people to express their feelings. It is an integral part of the diagnosis and planning and a key point of the treatment objectivesin orthodontic care. Many factors are associated with a pleasant smile, such as correct anatomy, gingival health, and teeth proportion. Therefore, different malocclusion classes can affect the characteristics of smile esthetics. This study aimed to evaluate the effect of skeletal class II malocclusion on the characteristics and dynamics of the smile in the sagittal and frontal planes. Methodology The study sample included 60patients comprising three groups of malocclusion classes, namely, Class I, Class II division 1, and Class II division 2. A video recording was taken for 5-10 seconds for each patient using a specific camera mounted at a fixed distance from the imaged face. Two facial expressions were captured for each patient, one representing the lips at restand the second representing the unrestricted natural smile. The facial still images were derived from the streaming video recording, and two images were chosen for each plane (the frontal plane and the sagittal plane) for each patient. In total, 12 variables were assessed on these captured images. One-way analysis of variance (ANOVA) was used to detect significant differences between the three groups. Results There were statistically significant differences in some of the measured variables. The mean values of thickness of the upper lip, commissure height, gum width, maxillary incisor display, and interlabial gap were greater in the Class II division 1 group than in the other two groups. The proclined incisors were evident in the Class II division1 group, while the retroclined incisors were evident in the Class II division 2 group. Conclusions The skeletal Class II malocclusion influences the characteristics of the smile, either assessed on the anterior or lateral imaging angles, in addition to its influence on the resting position of the lips. Orthodontists should always analyze patients' facial expressions, including those related to the upper and lower lips at rest and when patients smile naturally. Depending on the results of this analysis, treatment planning could be built to improve the characteristics of the natural smile in patients with Class I and Class II malocclusions.

Morphology Optimization of Leaflet for Surgical Reconstruction of the Aortic Valve: In Vitro Test and Simulation-Based DOE Study.

This study was to evaluate the impact of leaflet trimming strategy on the hemodynamic behaviors of the aortic valve after reconstructive surgery, and give recommendations based on design of experiment (DOE) and in vitro studies. An in vitro hemodynamic test was performed on the simulated surgical model to quantify the efficacy of conventional reconstructive surgery. The very same computational model was built and verified, on which the full factorial DOE was carried out to summarize the correlations between leaflet trimming parameters and valve hemodynamic characteristics. Hemodynamic characteristics of the valve substitute were significantly associated with leaflet trimming parameters. The total regurgitant and transvalvular regurgitant of the valve substitute were reduced by 27.44% and 13.61% after optimization of the leaflet design. Synthetic use of in vitro tests and DOE study based on computational models helped improve outcomes of the reconstruction of aortic valve by reducing free edge length and increasing commissure height and leaflet height.

Age-related outcome of facial reanimation surgery using cross face nerve graft and gracilis free functional muscle transfer-A retrospective cohort study.

Free functional muscle transfer has become the criterion standard for the treatment of long-standing flaccid facial paralysis. Clinical experience suggests that a two-stage approach using a cross-face nerve graft (CFNG) as a donor nerve for free functional muscle transfers (FFMT) is less successful in older patients when compared to the pediatric population. However, clear data and scientific evidence are still rare. This study examines the age-related outcome of CFNG-driven FFMT. Twenty-eight patients with a mean age of 20.73 years (ranging 5-51 years) who received two-stage facial reanimation with CFNG-driven gracilis FFMT at our institution from 1998 to 2019 were included. The ipsilateral sural nerve was used as CFNG. After 12 months, the ipsilateral gracilis muscle was used as FFMT. Patients were distributed equally into three cohorts according to their age. We assessed facial symmetry before and after facial reanimation measuring the angle between the interpupillary and the intermodiolar line (pupillo-modiolar angle). Additionally, the commissure height was measured using the Emotrics software. The mean follow-up of the pediatric, young adults and the middle-aged cohort was 29.5± 7.3, 24.9± 6.3, and 25.5± 12.4months, respectively. One patient suffered flap loss due to flap ischemia. Four patients suffered insufficient innervation of the FFMT. Otherwise no major complication occurred. The likelihood of successful innervation of the FFMT was significantly higher in patients younger than 31 years (100% vs. 50%; p= .003). Smiling facial symmetry (pupillo-modiolar angle) significantly improved in the pediatric cohort (5-16 years; 8.68° ± 0.69° to 1.48° ± 0.67°; p< .001) and the young adults' cohort (17-30 years; 11.55° ± 1.95° to 4.62° ± 1.08°; p= .005), but improved only slightly in the middle-aged cohort (31-51 years; 11.77° ± 1.16° to 9.4° ± 1.8° p= .27). The postoperative smiling symmetry showed a significant correlation with increasing age (r= .62, p< .001). The smiling commissure height deviation significantly improved in the pediatric cohort (5-16 years; 6.5-2.3 mm; p= .006) and the postoperative result was significantly better than the middle-aged group (31-51 years; 2.3 vs. 7.5 mm; p= .02). The outcome of CFNG-driven gracilis FFMT is age-related. Static as well as dynamic facial symmetry after two-stage facial reanimation was best in the pediatric and young adult population. For older patients, other approaches like the nerve-to-masseter-driven FFMT should be considered.

Functional Outcome Comparison of Free Gracilis Muscle Anchoring Methods in Patients with Facial Paralysis: Upper Lip Red Line Incision versus Facelift Incision Approach.

The greatest challenge of a free-muscle transfer in facial reanimation surgery is anchoring muscle to perioral soft tissue. An additional incision provides a better way to anchor the transferred muscle but leaves a visible scar. Herein, we compared the functional and aesthetic outcomes in a conventional facelift incision approach with and without the addition of a red line incision. This study included patients experiencing unilateral facial paralysis who underwent free gracilis transfer between December 2016 and December 2018. Anchoring through facelift incision with extended neck incision was performed in the control group, while a red line incision was added in the red line group by avoiding extended neck incision. Oral commissure excursion, upper lip and commissure height differences, and symmetry were measured. A total of 24 patients met the criteria and were included in this study. Of these, 10 patients were assigned to the red line group and 14 to the control group. The red line and control groups demonstrated a similar symmetry index in both resting (0.96 ± 0.18 and 0.92 ± 0.10, respectively; p = 0.435) and smiling (0.94 ± 0.12 and 0.91 ± 0.10, respectively; p = 0.314). However, the upper lip height difference demonstrated greater postoperative improvement (resting: 2.12 ± 1.13 vs. 3.92 ± 1.41 mm, p = 0.002, and smiling: 1.68 ± 0.88 vs. 3.41 ± 1.69 mm, p = 0.004, respectively). A scar could be easily concealed on the mucocutaneous line of the lip. This novel method for muscle anchoring in facial reanimation surgery allows surgeons to approach perioral muscle more directly. This leads to improved surgical results by securely anchoring the transferred muscles using a fixation point that is more medially located than in other approaches. Our method is effective and offers an improved surgical outcome for the free functional gracilis muscle transfer.

Impact of Variation in Interleaflet Triangle Height Between Fused Leaflets in the Functionally Bicuspid Aortic Valve on Hemodynamics and Tissue Biomechanics

AbstractThere is fusion between two leaflets in functionally bicuspid (bileaflet) aortic valves with trisinuate aortic root. The degree of fusion inversely correlates with variation in the interleaflet triangle height (“commissural height”). We aimed to determine the hemodynamics and biomechanical response in the thoracic aorta due to variations in the commissural height between fused leaflets in a bicuspid aortic valve with raphe. A three-dimensional (3D) aortic valve model was reconstructed using cardiac magnetic resonance (CMR) imaging from a patient with a normal trileaflet aortic valve. Fluid–structure interaction (FSI) simulations were used to investigate the effect of variation in commissural height between the coronary leaflets with leaflet fusion, and this was contrasted to a case with a normal trileaflet valve. Phase-contrast CMR was used for validation of the simulated hemodynamics. The aorta and leaflet tissues were treated as hyperelastic materials. In the normal trileaflet aortic valve, two counter-rotating vortex cores develop within the root at peak systole and interact with the walls of the ascending aorta. However, in the bicuspid aortic valve with fusion between the coronary leaflets, the vortex system becomes more asymmetric. This correlates with more recirculation of flow toward the fusion side of the aortic root. The peak velocity, pressure gradient, wall shear stress, and strain levels increase approximately linear with decreasing commissural height and increasing leaflet fusion. Decreasing interleaflet triangle height between the fused leaflets in bicuspid aortic valves with raphe results in linear elevation of wall shear stress at the sinutubular junction and proximal ascending aorta.

Advances and future directions in the care of patients with facial paralysis

Advances and future directions in the care of patients with facial paralysis

Relationship Between Leaflets and Root in Normal Aortic Valve Based on Computed Tomography Imaging: Implication for Aortic Valve Repair.

Objective: By assessing the normal dimensions and the relationship between the aortic root and leaflets in Chinese population, the objective of this three-dimensional computed tomography (3DCT)-based study was to establish a matching reference for leaflets and aortic root for aortic valve (AV) repair.Method: Electrocardiogram-gated multi-detector CT was performed on 168 Chinese participants with a normal aortic valve. Measurements of the aortic annuli and leaflets were obtained. The correlations between and the ratios of the specific root and leaflet measurements were analyzed. The references for the leaflet and root dimensions were suggested based on geometric height (gH) using a linear regression equation. The utility of the ratios was tested with CT images of 15 patients who underwent aortic valve repair.Result: The mean annulus diameter (AD), sino-tubular junction (STJ) diameter, geometric height (gH), effective height (eH), free margin length (FML), commissural height (ComH), inter-commissural distance (ICD), and coaptation height (CH) were 22.4 ± 1.7 mm, 27.3 ± 2, 0.4 mm, 15.5 ± 1.7 mm, 8.9 ± 1.2 mm, 32.0 ± 3.4 mm, 17.9 ± 1.9 mm, 23.1 ± 2.3 mm, and 3.1 ± 0.6 mm, respectively. The gH/AD, FML/ICD, and eH/ComH ratios were 0.69 ± 0.07, 1.38 ± 0.08, and 0.50 ± 0.07, respectively. The gH correlated with all other leaflet and root measurements (P < 0.01), whereas the FML demonstrated a better correlation with ICD compared with gH (R2 = 0.75, and R2 = 0.37, respectively). The FML/ICD and eH/ComH ratios might be used to assess leaflet-root mismatch and post-repair leaflet billowing.Conclusion: The normal aortic valve measurements based on 3DCT revealed a specific relationship between the root and leaflets; and this will guide the development of an objective method of aortic valve repair.

Abstract 11610: Characteristics and Predictors of Effective Height of the Aortic Valve Assessed by Electrocardiography-Gated Cardiac Computed Tomography

Introduction: Effective height of the aortic valve has been used as an index for durable aortic valve repair. This study aimed to analyze the relationship between effective height and the other morphological parameters of aortic valve complex when aortic valve is closed. Methods: We retrospectively analyzed 100 patients (70.7±10.2 years) without diseased aortic valve, root or ascending aorta, who had electrocardiography-gated cardiac computed tomography as a screening test of coronary artery, from August 2014 to December 2018. Parameters of the configuration of aortic valve complex (effective height ; geometric height ; aortic annular diameter ; sinus of Valsalva diameter ; sinotubular junction diameter ; commissure height) in diastole were measured using the software Ziostation2 (Ziosoft, Tokyo, Japan). Pearson correlation was used to evaluate the association between effective height and the other parameters. In addition, multiple regression analysis was performed to determine which variables predict effective height. Results: Significant correlations were shown between effective height and geometric height (r = 0.704 ; P &lt; 0.001), sinus of Valsalva diameter (r = 0.433 ; P &lt; 0.001), sinotubular junction diameter (r = 0.547 ; P &lt; 0.001) and commissure height (r = 0.396 ; P &lt; 0.001). There was no significant correlation between effective height and aortic annular diameter (r = 0.111 ; P = 0.27). Multivariable analysis showed that geometric height (regression coefficients β = 0.853 ; 95% confidence intervals, CI, 0.647 to 0.923 ; P &lt; 0.001), aortic annular diameter (β = -0.574 ; 95% CI, -0.467 to -0.284 ; P &lt; 0.001) and sinotubular junction diameter (β = 0.327 ; 95% CI, 0.085 to 0.211 ; p &lt; 0.001) were significant predictors of effective height. The overall model fit was R 2 = 0.716. Conclusions: This study demonstrated that effective height was strongly correlated with geometric height, and predicted by geometric height, aortic annular diameter and sinotubular junction diameter. These findings may help heart surgeon to decide an appropriate effective height for individual aortic valve complex during aortic valve repair surgery.