Asaad, Malke

Background: Dynamic facial reanimation is the gold standard treatment for a paralyzed face. The use of the cross-face nerve graft (CFNG) in combination with the masseteric nerve to innervate the free gracilis muscle has been reported to provide both spontaneity and strong neural input. We report a case series of dual innervation, using a novel method where the branch to masseter is coapted to the side of the CFNG. Methods: Eight patients received free gracilis muscle transfer using the new dual innervation method between September 2014 and December 2017. The CFNG, which was performed nine months prior, was sutured in an end-to-end fashion to the obturator nerve. A nerve graft was coapted to the ipsilateral masseteric nerve and then sutured in an end-to-side fashion to the CFNG proximal to its coaptation to the obturator nerve. Results: All patients recovered smile function with and without teeth clenching around the same time period. Smiles without teeth clenching appeared later in two of eight patients and earlier in one of eight patients, being noted at an average of 8.25 months of follow-up versus 7.6 months. The estimate of true attainment is limited by the spacing of follow-up dates. Average follow-up time was 36.07 months (range: 10–71.5). FACE-Gram software smile analysis with and without biting demonstrated similar excursion on average (7.64 mm versus 8.6 mm respectively, P = 0.93), both of which are significantly improved from preoperation. Conclusion: This novel method of a dual-innervated free gracilis muscle transfer offers a viable technique that achieves a symmetric, strong, and emotional smile.

Background: The goal of this study was to characterize the references provided as supporting evidence of the Plastic Surgery In-service Training Examination (PSITE) syllabi, including those on the novel “core surgical principles” section. Methods: We analyzed the references from five consecutive PSITE Examination syllabi (2016–2020). We collected the following information from each question: question section, total number of references, and source of publication of each reference. Results: We analyzed 1250 questions and 3436 references. Plastic and Reconstruction Surgery was overall the most frequently referenced journal followed by Journal of Hand Surgery (American Volume) and Annals of Plastic Surgery. The most commonly referenced textbooks were Plastic Surgery (by Neligan), Green’s Operative Hand Surgery, and Grabb and Smith’s Plastic Surgery. Regarding the “core surgical principles” section, Plastic and Reconstruction Surgery remained the most frequently cited journal, followed by the Journal of the American Medical Association, New England Journal of Medicine, Annals, and Aesthetic Surgery Journal. “Core surgical principles” contained the largest number of unique journals (n = 209) among all test sections. Within the “core” section, Statistics in Medicine was the most frequently referenced textbook followed by Grabb and Smith’s Plastic Surgery. Conclusions: The main plastic surgery texts and literature were used to support approximately half of the answers within the “core surgical principles” section. The references within this section originated from the largest number of different journals, thus highlighting the breadth and variety of this content and the challenges in preparing for this section.

Abstract Facial paralysis can impair one'™s ability to form facial expressions that are congruent with internal emotion. This hinders communication and the cognitive processing of emotional experience. Facial reanimation surgery, which aims to restore full facial expressivity is a relatively recent undertaking which is still evolving. Due in large part to published techniques, refinements, and clinical outcomes in the scientific literature, consensus on best practice is gradually emerging, whereas controversies still exist. Taking stock of how the discipline reached its current state can help delineate areas of agreement and debate, and more clearly reveal a path forward. To do this, the authors have analyzed the 50 seminal publications pertaining to facial reanimation surgery. In longstanding cases, the free gracilis transfer emerges as a clear muscle of choice but the nerve selection remains controversial with prevailing philosophies advocating cross facial nerve grafts (with or without the support of an ipsilateral motor donor) or an ipsilateral motor donor only, of which the hypoglossal and nerve to masseter predominate. The alternative orthodoxy has refined the approach popularized by Gillies in 1934 and does not require the deployment of microsurgical principles. Although this citation analysis does not tell the whole story, surgeons with an interest in facial reanimation will find that this is a good place to start.

Background: Cleft lip and cleft palate (CLP) are among the world’s most common congenital malformation and has a higher prevalence in developing nations due to environmental and genetic factors. Global efforts have been developed in order to prevent and treat the malformation. Telemedicine has been implemented in various humanitarian global missions with success and is currently the primary means of care due to COVID-19. Objective: To assess the benefits and barriers of telehealth in the care of patients with CLP through a global approach. Methods: Systematic review of the PubMed and Cochrane Review databases with relevant terms related to telemedicine in cleft lip and palate surgery. Results: Eight articles fit the inclusion criteria and suggested benefits with the use of telemedicine in regard to education, preoperative, and postoperative care as well as increased access to underserved populations. Barriers included connectivity and accessibility concerns. Conclusion: Telehealth is a beneficial way to evaluate patients with CLP in developing countries with proper care and follow-up to reduce complications and to improve health outcomes.

Summary: The novel coronavirus disease 2019 has had a major impact on human life and livelihood. The unprecedented challenges have expanded beyond just social and work life, and have grown to impact resident education. In this article, we review the structure of plastic surgery education before the pandemic, the different online learning opportunities for self-directed learning. A summary of the range of platforms and approaches of online remote access delivery of conferences and education that emerged or expanded as a result of the crisis has been reported. This article highlighted the rapid initiatives and efforts of programs and national and international societies to support continuing medical education in conjunction with the guidelines to “shelter at home” and maintain social distancing, and possible future for expanding the reach of online academic initiatives, in addition to the role of developing virtual technologies. The coronavirus disease 2019 crisis has created an opportunity to analyze and advance online learning options to overcome the associated challenges and continue as a reliable platform even following the resolution of the social distancing requirements.

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.