Thursday, June 9, 2011

Advances in Surgical Treatment of Facial Nerve Paralysis in Children – an article review

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

I read the second article below first.  I was struck by the opening paragraphs of Daniel Alam, MD’s commentary which note the importance of smiling in human communication and how it is often taken for granted EXCEPT by those who have lost the ability to smile.
This is far from the case for patients who have lost the ability to smile. Patients who have endured facial paralyses (even in the transient cases that occur in certain idiopathic facial nerve palsies, ie, Bell palsy) understand the true psychological effects of this disability. …...
I can attest to this on a personal level having had Bell’s palsy in 2002.  I have a quilt I’d like to make, a personal portrait ala Picasso, that would reflect the way it affected me.  I can’t seem to get it worked out yet, but will.
Back to these articles.  Alam commends Hadlock and colleagues (the first article below) for not just relying on emotional checks from the patients who often feel any improvement is a great result (bold emphasis is mine):
… Although this report is another well-designed clinical series of a well-established surgical technique, the true significance of this work extends far beyond the patients presented. ….This group, more than any other in facial plastic surgery, has made a concerted effort to quantify (to measure and validate) the outcomes they report. …
With that recommendation went looking for the Hadlock’s article.  
Hadlock and colleagues begin with background information which notes “free muscle transfer for facial reanimation has become the standard of care in recent decades and is now the cornerstone intervention for dynamic smile reanimation.”
While myriad muscles have been transferred into the face to restore the smile, most large series describe the use of the gracilis muscle, the latissimus dorsi muscle, or the pectorals minor.  Of these, the gracilis muscle is the most widely used, based on predictable pedicle anatomy, an acceptable donor deficit and scar, and favorable muscle microarchitectural features resulting in fast and robust excursion when activated.
Hadlock and colleagues used their SMILE program to objectively measure the functional outcome of 17 pediatric patients who had undergone 19 consecutive pediatric free gracilis transplantation operations.  The procedures were done over a 5-year period from October 2004 through September 2009.  The mean age of the patients was 11.5 years (range, 4-18 years).
All patients were prospectively administered the Facial Clinimetric Evaluation (FaCE) instrument which is a validated, standardized QOL instrument for patients with facial movement disorders.   Hadlock’s article referenced the Laryngoscope (3rd reference below) article for FaCE.
Hadlock and colleagues results
The mean commissure excursion improvement was 8.8 mm ± 5 mm (Figure 4), commensurate with the findings in other facial reanimation series.   When subdivided into those driven by a cross-face nerve graft vs those driven by the masseteric branch of the trigeminal nerve, the latter provided more excursion on average, as expected.
There was only one muscle failure in the series.  It resulted from an arterial thrombosis.
In conclusion:
In conclusion, free gracilis transfer for smile reanimation in children carries an acceptable failure rate, significantly improves smiling, and seems to improve QOL with respect to facial function. It should be a cornerstone intervention in the appropriately counseled patient and family. Because it carries a lower failure rate than a similar cohort of adult patients, there is no need to wait until patients reach adulthood to offer dynamic reanimation. Early facial reanimation provides the advantage of permitting children to express themselves nonverbally through smiling and may in fact lead to fewer negative social consequences as they interact with peers.

1.  Free Gracilis Transfer for Smile in Children:  The Massachusetts Eye and Ear Infirmary Experience in Excursion and Quality-of-Life Changes; Hadlock TA, Malo JS, Cheney ML, Henstrom DK; Arch Facial Plast Surg. 2011;13(3):190–194; doi: 10.1001/archfacial.2011.29
2.  Advances in Surgical Treatment in Facial Nerve Paralysis in Children (commentary); Daniel Alam, MD; AMA. 2011;305(20):2106-2107;  doi: 10.1001/jama.2011.689
3.  Validation of a patient-graded instrument for facial nerve paralysis: the FaCE scale; Kahn JB, Gliklich RE, Boyev KP, Stewart MG, Metson RB, McKenna MJ; Laryngoscope. 2001;111(3):387–398.

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