Citations

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.

Abstract Objectives/Background Treatment of migraine in the setting of either renal or hepatic disease can be daunting for clinicians. Not only does the method of metabolism have to be considered, but also the method of elimination/excretion of the parent drug and any active or toxic metabolites. Furthermore, it is difficult to think about liver or kidney disease in isolation, as liver disease can sometimes contribute to impaired renal function and renal disease can sometimes impair hepatic metabolism, through the cytochrome P450 system. Methods A detailed search for terms related to liver disease, renal disease, and migraine management was performed in PubMed, Ovid Medline, Embase, and the Cochrane Library.For each medication, product labels were retrieved and reviewed using the US FDA website, with additional review of IBM Micromedex, LiverTox, and the Renal Drug Handbook. Results This manuscript provides an overview of migraine drug metabolism and how it can be affected by liver and renal impairment. It reviews the standard terminology recommended by the US Food and Drug Administration for the different stages of hepatic and renal failure. The available evidence regarding the use of abortive and preventative medicines in the setting of organ failure is discussed in detail, including more recent therapies such as lasmiditan, gepants, and calcitonin gene‐related peptide antibodies. Conclusions For acute therapy, the use of NSAIDS should be limited, as these carry risk for both severe hepatic and renal disease. Triptans can be selectively used, often with dose guideline adjustments. Ubrogepant may be used in severe hepatic disease with dose adjustment and lasmiditan can be used in end stage renal disease. Though non‐medicine strategies may be the most reasonable initial approach, many preventative medications can be used in the setting of hepatic and renal disease, often with dose adjustment. This review provides tables of guidelines, including reduced dosing recommendations, for the use of abortive and preventative migraine medications in hepatic and renal failure.