Lin, Jason

Background: The perceptual response to aging changes in the periorbital region and the effects of surgical rejuvenation on that response have not been elucidated. The authors examined the reflexive visual response to periorbital aging before and after brow lift and upper blepharoplasty surgery and investigated how observers’ character attributions of the images were affected by the rejuvenative intervention. Methods: Preoperative and postoperative photographs were obtained of patients with brow ptosis and dermatochalasis who underwent brow lift and blepharoplasty. Forty observers examined each image while an infrared eye-tracking camera continuously recorded their eye movements. The observers rated the images with respect to character attributes (attractiveness, trustworthiness, sociability, healthiness, and capability) on a scale of one to seven. Results: Fourteen patients who underwent brow lift and blepharoplasty were identified and studied. The surgical intervention was found to increase observers’ attention to the eye and brow region, while decreasing relative attention to the forehead and lower eyelid areas; increase the two-dimensional surface area of the forehead and eye and brow zones in a manner directly associated with the measured changes in visual attention; and significantly increase the ratings for all five positively valanced character attributes compared with preoperative controls. Conclusions: The authors provide an important combination of explicit and implicit data illustrating how surgical rejuvenation unveils the periorbital region to the observer. This change in pattern of inspection was associated with an improvement in the perception of character.

Background: Obesity is a risk factor for complications in breast reconstruction. Thus, implant-based immediate breast reconstruction in obese women may be controversial. The authors analyzed obese patients who underwent skin-sparing mastectomy using Wise-pattern incisions (Goldilocks procedure) and compared outcomes between two groups: Goldilocks with immediate breast reconstruction and Goldilocks only. Methods: A retrospective review was performed of patients with a body mass index of 30 kg/m2 or higher who underwent the Goldilocks procedure at the Mayo Clinic Health System from 2012 to 2019. Data were extracted from electronic medical records. Minor complications (partial-thickness wound dehiscence or flap necrosis, or tissue expander/implant malposition) and major complications (full-thickness wound dehiscence or flap necrosis, capsular contracture, tissue expander/implant explantation, or unplanned reoperation or readmission) were compared between groups. Patient-reported outcomes using BREAST-Q questionnaires were also assessed. Results: One hundred five patients (181 breasts) were included. Mean ± SEM age and body mass index were 57.1 ± 10.4 years and 37.9 ± 5.8 kg/m2 for the Goldilocks-only group and 51.5 ± 1.1 years and 35.5 ± 0.4 kg/m2 for the Goldilocks with immediate breast reconstruction group, respectively. Median follow-up time was 15.1 months (interquartile range, 10.0 to 28.6 months). Overall, 96 breasts underwent the Goldilocks-only procedure and 85 Goldilocks with immediate breast reconstruction. Multivariable analyses revealed a higher rate of minor complications (adjusted hazard ratio, 2.83; 95 percent CI, 1.22 to 7.02) and major complications (adjusted hazard ratio, 2.26; 95 percent CI, 1.25 to 4.24) in the Goldilocks with immediate breast reconstruction group compared with the Goldilocks-only group, at any given time. Patient satisfaction was not statistically different between groups. Conclusions: The Goldilocks procedure is a feasible breast reconstructive option in obese patients; however, when it is performed with immediate breast reconstruction, it is associated with higher rates of complications. For patients with a body mass index of 40 kg/m2 or greater, the authors recommend the Goldilocks-only procedure or delayed reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Purpose: Examining the outcomes and progression of face transplants has expanded to include the recent advancements in artificial intelligence. This novel methodology has allowed for the objective exploration of emotional expression. To our knowledge, this examined emotional expression has yet to be correlated to the hypothesized functioning of the allograft. We have combined the result of the AI software with a software analyzing smile excursion; demonstrating the progression of the allograft in our face transplant patient. This study helps illuminate the software possibilities for objective measures in transplant progression. Methods: Images were analyzed from our face transplant patient post-operatively at approximately 6-month intervals for four years. The still images for each time interval include both a neutral facial expression and a full-face smile with teeth. The images were taken from video clips of the patient and then analyzed using the FACEgram software (Hadlock & Urban, 2012). The measurements of the smile excursion were standardized based off of the pupil diameter and excursion was measured relative to the neutral expression of each time period. The emotional expression data was acquired using FaceReader AI software from Noldus Information Technology (Wageningen, The Netherlands). The emotional analysis was done on 2 second clips from clinical videos of the patient, the same videos used for the still images. This data was correlated with the smile excursion measurements. Results: The post-operative smile excursion analysis from 6 to 49 months demonstrated a near double in smile excursion from 3.58mm to 6.04mm. The smile excursion data has a squared correlation of 0.705; a strong upward linear trend of excursion. From 6 to 35 months, the happy emotion increased gradually from 0% to 15.8% (49-month data unavailable). Performed correlative analysis showed a positive correlation coefficient of 0.63. This moderate to strong correlation demonstrates the intuitive relationship of happy emotion and lip excursion during full face smiling. The findings also substantiate the AI software’s detection of increasing activity in the lip corner puller action unit from zero to 3/5 intensity over the same period. Conclusion: This study demonstrates the correlation of smile excursion to happy emotional expression in our face transplant patient. The correlation square of the lip excursion shows a trend of increased functioning of the allograft over time; substantiating the AI’s finding. This data provides evidence for the use of artificial intelligence as a measure of transplant strength progression. The conjoined analysis of patient images and videos has supported proof for the ability to analyze transplant healing progression and efficacy in an objective form. Hadlock, T. A., & Urban, L. S. (2012). Toward a Universal, Automated Facial Measurement Tool in Facial Reanimation. Archives of Facial Plastic Surgery,14(4). doi:10.1001/archfacial.2012.111

Background In advanced pharyngoesophageal cancer patients, a critical event is represented by the failure of primary reconstruction with exposure of the carotid artery and partial or total defect of the cervical esophagus. For these high-risk patients, a partitioned pectoralis major musculocutaneous (PMMC) flap can prevent carotid blowout and provide skin for simultaneous esophageal reconstruction. Methods Twenty-six patients needing pharyngoesophageal reconstruction together with coverage of carotid artery exposure were included in this retrospective case series. The patients were treated with a partitioned PMMC flap, based on the branching pattern of the pectoral branch of the thoracoacromial artery and the perforators of the pectoralis major muscle, to simultaneously reconstruct the defect and provide coverage for the carotid artery. Results In 25 patients, the partitioned PMMC flap reconstructions resulted in complete wound healing without occurrence of carotid blowout syndrome or fistula formation. Minor complications as partial flap necrosis (7.7%) and strictures formation (7.7%) were recorded but did not compromise reconstruction. Twenty-two patients were able to adopt a semisolid diet, and 4 had recurrence of cancer. Conclusions The partitioned PMMC flap reconstruction represents a useful salvage solution to simultaneously restore the continuity of the alimentary tract and provide reliable coverage for the exposed carotid artery.

Summary: Social interactions are largely dependent on the interpretation of information conveyed through facial expressions. Although facial reanimation seeks restoration of the facial expression of emotion, outcome measures have not addressed this directly. This study evaluates the use of a machine learning technology to directly measure facial expression before and after facial reanimation surgery. Fifteen study subjects with facial palsy were evaluated both before and after undergoing cross-facial nerve grafting and free gracilis muscle transfer. Eight healthy volunteers were assessed for control comparison. Video footage of subjects with their face in repose and with a posed, closed-lip smile was obtained. The video data were then analyzed using the Noldus FaceReader software application to measure the relative proportions of seven cardinal facial expressions detected within each clip. The facial expression recognition application detected a far greater happy signal in postoperative (42 percent) versus preoperative (13 percent) smile videos (p < 0.0001), compared to 53 percent in videos of control faces smiling. This increase in postoperative happy signal was achieved in exchange for a reduction in the sad signal (15 percent to 9 percent; p = 0.092) and the neutral signal (57 percent to 37 percent; p = 0.0012). For video clips of patients in repose, no significant difference in happy emotion was detected between preoperative (3.1 percent) and postoperative (1.4 percent) states (p = 0.5). This study provides the first proof of concept for the use of a machine learning software application to objectively quantify facial expression before and after surgical reanimation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Abstract Central giant cell granuloma (CGCG) is a relatively uncommon benign bony lesion accounting for approximately 7% of all non-neoplastic lesions of the jaw. The clinical behavior of CGCG can vary from a slow-growing, painless lesion to fast-growing and locally destructive. When such a lesion involves the mandible, this can be quite debilitating for the patient, inhibiting oral intake and requiring an extensive resection and bone graft reconstruction. The authors present a case of effectively decreasing the surgical morbidity associated with a large and rapidly growing CGCG of the mandible in a pediatric patient. Neoadjuvant immunotherapy with denosumab (human monoclonal antibody) facilitated treatment of the tumor without the need for a large resection which would have otherwise necessitated a vascularized bony mandibular reconstruction. Consideration of neoadjuvant medical management of CGCG as the primary treatment is advocated.

AbstractBackgroundShear wave elastography (SWE) shows promise in peripheral neuropathy evaluation but has potential limitations due to tissue size and heterogeneity. We tested SWE sensitivity to elasticity change and the effect of probe position in a median nerve cadaver model.MethodsTen specimens were used to measure median nerve elasticity under increasing loads using SWE and indentation. Measurements were compared using repeated‐measures analysis of variance.ResultsIndentation and SWE‐based longitudinal nerve elasticity increased with tensile loading (P< .01), showing a similar relationship. Acquisition in a transverse plane showed lower values compared with longitudinal measurements, mostly under higher loads (P= .03), as did postdissection elasticity (P= .02). Elasticity did not change when measured proximal to the carpal tunnel.ConclusionsLongitudinal SWE is sensitive to changes in median nerve elasticity. Measuring elasticity of peripheral nerves noninvasively could elucidate intra‐neural pathology related to compression neuropathies, and proof to be of added value as a diagnostic or prognostic tool.

Abstract Cranio-orbital trauma is an uncommon yet devastating injury, especially one in the setting of a high-energy gunshot wound. Such injuries were historically reported in the setting of military conflict, and are associated with vision-threatening complications, often resulting in anophthalmos. The authors report a case of a self-inflicted gunshot wound to the eye, which requires orbital enucleation with exposed frontal lobe dura. To address the exposed dura, the extraocular muscles were utilized from the enucleation procedure to cover the defect in the acute setting prior to final staged reconstruction.