Using High-Resolution Ultrasound to Assess Post-Facial Paralysis Synkinesis—Machine Settings and Technical Aspects for Facial Surgeons

Background: Synkinesis of the facial musculature is a detrimental sequalae in post-paralytic facial palsy (PPFP) patients. Detailed knowledge on the technical requirements and device properties in a high-resolution ultrasound (HRUS) examination is mandatory for a reliable facial muscle assessment in PPFP patients. We therefore aimed to outline the key steps in a HRUS examination and extract an optimized workflow schema. Methods: From December 2020 to April 2021, 20 patients with unilateral synkinesis underwent HRUS. All HRUS examinations were performed by the first author using US devices with linear multifrequency transducers of 4–18 MHz, including a LOGIQ E9 and a LOGIQ S7 XDclear (GE Healthcare; Milwaukee, WI, USA), as well as Philips Affinity 50G (Philips Health Systems; Eindhoven, the Netherlands). Results: Higher-frequency and multifrequency linear probes ≥15 MHz provided superior imaging qualities. The selection of the preset program Small Parts, Breast or Thyroid was linked with a more detailed contrast of the imaging morphology of facial tissue layers. Frequency (Frq) = 15 MHz, Gain (Gn) = 25–35 db, Depth (D) = 1–1.5 cm, and Focus (F) = 0.5 cm enhanced the image quality and assessability. Conclusions: An optimized HRUS examination protocol for quantitative and qualitative facial muscle assessments was proposed

Histomorphometry of the Sural Nerve for Use as a CFNG in Facial Reanimation Procedures

Facial palsy (FP) is a debilitating nerve pathology. Cross Face Nerve Grafting (CFNG) describes a surgical technique that uses nerve grafts to reanimate the paralyzed face. The sural nerve has been shown to be a reliable nerve graft with little donor side morbidity. Therefore, we aimed to investigate the microanatomy of the sural nerve. Biopsies were obtained from 15 FP patients who underwent CFNG using sural nerve grafts. Histological cross-sections were fixated, stained with PPD, and digitized. Histomorphometry and a validated software-based axon quantification were conducted. The median age of the operated patients was 37 years (5–62 years). There was a significant difference in axonal capacity decrease towards the periphery when comparing proximal vs. distal biopsies (p = 0.047), while the side of nerve harvest showed no significant differences in nerve caliber (proximal p = 0.253, distal p = 0.506) and axonal capacity for proximal and distal biopsies (proximal p = 0.414, distal p = 0.922). Age did not correlate with axonal capacity (proximal: R = −0.201, p = 0.603; distal: R = 0.317, p = 0.292). These novel insights into the microanatomy of the sural nerve may help refine CFNG techniques and individualize FP patient treatment plans, ultimately improving overall patient outcomes

Verzicht auf Drainagen bei der Abdominoplastik – eine randomisiert-kontrollierte Studie

Introduction There is insufficient scientific evidence from randomised controlled trials to support the routine use of closed-suction drains in body contouring procedures. The aim of this study was to evaluate cumulative seroma volume, length of hospital stay and complication rates in abdominoplasty patients without drains in direct comparison with a cohort receiving drains. Material and Methods Abdominoplasty patients were prospectively randomised in two study groups with (MD) and without (OD) placement of closed-suction drains. Patients with a BMI = 3. Cumulative seroma volume over a four-week follow-up period was assessed as the primary outcome measure. Secondary outcome measures were complications requiring surgical revision and length of hospital stay. Results This trial did not identify a statistically significant difference in cumulative seroma volume between the MD (30/53) and OD (23/53) cohorts in 53 patients (M(MD)493 +/- SD 407 ml; M(OD)459 +/- SD 624 ml; p = 0.812). However, a significantly shorter average length of hospital stay was observed in the OD population (M(MD)5.1 +/- SD 1.4 d; M(OD)4.2 +/- SD 1.5 d; p = 0.023). Complication rates were equal in both study groups (n(MD) = 1; n(OD) = 1). Conclusion The results of this trial do not justify routine placement of closed-suction drains in abdominoplasty procedures (horizontal or combined horizontal/vertical incision) in the pre-obese patient cohort (BMI <= 30 kg/m(2)). Drain placement should be evaluated on an individual patient-specific basis

Standard doses of Triamcinolone do not affect fibroblast cell migration of abdominoplasty patients in-vitro1

BACKGROUND:Recent studies have demonstrated that local application of corticosteroids reduces wound exudation following abdominoplasty and other reconstructive surgical procedures. On the other hand, corticosteroids might provoke wound healing disturbances due to their immunosuppressive effects. OBJECTIVE:The main objective of this study was to gain further information about the impact of the corticosteroid triamcinolone on cell migration in abdominoplasty patients. METHODS:An in-vitro scratch assay wound healing model was applied to observe cell migration of fibroblasts cultured with nutrient medium containing human seroma aspirate±triamcinolone. RESULTS:There were no significant differences regarding cell migration when fibroblasts were incubated with triamcinolone + seroma containing culture medium compared to seroma containing culture medium without triamcinolone. CONCLUSIONS:The performed in-vitro study suggests that triamcinolone does not decelerate fibroblast cell migration which is considered as a surrogate of wound healing

The Influence of Pulsed Electromagnetic Field Therapy on Lymphatic Flow During Supermicrosurgery

Background: The influence of pulsed electromagnetic field therapy (PEMFT) on medium-sized vessels as well as capillary microcirculation is well known. Effects on lymphatic vessels, however, are difficult to visualize and have not been investigated to date. One of the operative treatment options in primary and secondary lymphedemas is lymphovenous anastomoses using supermicrosurgery. To prove patency of the anastomosis, the lymphatic flow is visualized by fluorescence using indocyanine green. The aim of this study was to investigate the influence of PEMFT on the lymphatic microcirculation, and compare it with conventional manual lymphatic drainage (MLD) during supermicrosurgery. Methods and Results: Ten patients with lymphedema were included. Indocyanine green was injected before the operation for intraoperative visualization of the lymphatic vessels using a microscope equipped with an integrated near-infrared illumination system (Zeiss). The PEMFT system (Bio-Electro-Magnetic-Energy Regulation [BEMER]) was used as our standard device during a single 2-minute application period (AP) followed by MLD or vice versa. The mean light intensity in the calibration period (CP) was 46.53 +/- 24.3 and 33.41 +/- 12.92 for PEMFT and MLD, respectively. During the AP, the mean light intensity changed to 45.61 +/- 24.40 for PEMFT and 57.05 +/- 18.80 during MLD. This change between CP and AP did not differ significantly for the PEMFT application (p = 0.26), but showed an increase in light intensity during MLD (p < 0.001). Conclusion: We found a light intensity enhancement equivalent to a flow increase during MLD of 78.7% +/- 45.7% (range 20%-144%) and no significant difference during the PEMFT application. A single period application of PEMFT did not affect the lymphatic flow

Clinical Impact of DIEP Flap Perforator Characteristics – A Prospective Indocyanine Green Fluorescence Imaging Study

Background: The question to what extent perfusion in deep inferior epigastric perforator (DIEP) flaps depends on specific perforator characteristics has been raised. Anatomical studies and previous clinical trials focussing on DIEP flap perfusion resulted in discrepancies. This prospective study investigates how perforator row, number and diameter affect DIEP flap microperfusion via Indocyanine Green (ICG) fluorescence angiography. Methods: The fractional weight of insufficiently perfused flap tissue in Zone 4 related to the total DIEP flap weight was measured based on ICG fluorescence angiography and defined as Zone 4 %. As a surrogate for overall DIEP flap perfusion, Zone 4 % was assessed according to the row, number and diameter of perforators included in the flap. Results: In 42 unilateral DIEP flap breast reconstructions, neither medial (33.6 +/- 14.2 %)/lateral perforator row (29.9 +/- 7.5 %, p = 0.683) nor the parameter perforator number (single perforator 31.5 +/- 14.4 %, two perforators 30.2 +/- 10.2 %, p = 0.727) had a statistically significant effect on flap tissue availability as measured via Zone 4 %. A negative correlative trend between perforator diameter and Zone 4 % (r = -0.096, p = 0.588) was observed. Conclusion: Zone 4 % provides a novel method for an objective assessment of DIEP flap perfusion. Medial/lateral row selection and other perforator properties (number, diameter) within the standard ranges, did not affect Zone 4 % as indicated by ICG fluorescence angiography. (C) 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved

Significance of the Marginal Mandibular Branch in Relation to Facial Palsy Reconstruction

Background The marginal mandibular branch (MMB) of the facial nerve provides lower lip symmetry apparent during human smile or crying and is mandatory for vocal phonation. In treating facial palsy patients, so far, little attention is directed at the MMB in facial reanimation surgery. However, isolated paralysis may occur congenital, in Bell's palsy or iatrogenic during surgery, prone to its anatomical course. A variety of therapies address symmetry with either weakening of the functional side or reconstruction of the paralyzed side. To further clarify the histoanatomic basis of facial reanimation procedures using nerve transfers, we conducted a human cadaver study examining macroanatomical and microanatomical features of the MMB including its axonal capacity. Methods Nerve biopsies of the MMB were available from 96 facial halves. Histological processing, digitalization, nerve morphometry investigation, and semiautomated axonal quantification were performed. Statistical analysis was conducted with P < 0.05 as level of significance. Results The main branch of 96 specimens contained an average of 3.72 fascicles 1 to 12, and the axonal capacity was 1603 +/- 849 (398-5110, n = 85). Differences were found for sex (P = 0.018), not for facial sides (P = 0.687). Diameters were measured with 1130 +/- 327 mu m (643-2139, n = 79). A significant difference was noted between sexes (P = 0.029), not for facial sides (P = 0.512.) One millimeter in diameter corresponded to 1480 +/- 630 axons (n = 71). A number of 900 axons was correlated with 0.97 mm (specificity, 90%; sensitivity, 72%). Conclusions Our morphometric results for the MMB provide basic information for further investigations, among dealing with functional reconstructive procedures such as nerve transfers, nerve grafting for direct neurotization or babysitter procedures, and neurectomies to provide ideal power and authenticity

Anatomical study of the zygomatic and buccal branches of the facial nerve: Application to facial reanimation procedures

The facial nerve is responsible for any facial expression channeling human emotions. Facial paralysis causes asymmetry, lagophthalmus, oral incontinence, and social limitations. Facial dynamics may be re-established with cross-face-nerve-grafts (CFNG). Our aim was to reappraise the zygomaticobuccal branch system relevant for facial reanimation surgery with respect to anastomoses and crossings. Dissection was performed on 106 facial halves of 53 fresh frozen cadavers. Study endpoints were quantity and relative thickness of branches, correlation to "Zuker's point", interconnection patterns and crossings. Level I and level II branches were classified as relevant for CFNG. Anastomoses and fusion patterns were assessed in both levels. The zygomatic branch showed 2.98 +/- 0.86 (range 2-5) twigs at level II and the buccal branch 3.45 +/- 0.96 (range 2-5), respectively. In the zygomatic system a single dominant branch was present in 50%, two co-dominant branches in 9% and three in 1%. In 66% of cases a single dominant buccal twig, two co-dominant in 12.6%, and three in 1% of cases were detected. The most inferior zygomatic branch was the most dominant branch (P = 0.003). Using Zuker's point, a facial nerve branch was found within 5 mm in all facial halves. Fusions were detected in 80% of specimens. Two different types of fusion patterns could be identified. Undercrossing of branches was found in 24% at levels I and II. Our study describes facial nerve branch systems relevant for facial reanimation surgery in a three-dimensional relationship of branches to each other. Clin. Anat. 32:480-488, 2019. (c) 2019 Wiley Periodicals, Inc

“A-PePSI LIGhT” Assessment Score to Predict Pressure Sore Impaired Healing Late Recurrence, Immobility, Greater Surface, Inhibited Thrombocytes

Background: Complication rates of up to 46 percent are reported following pressure sore surgery. Pressure sore patients often exhibit ineffective postoperative wound healing despite tension-free flap coverage, necessitating surgical revision and prolonged hospitalization. Rather than pressure sore recurrence, such impaired healing reflects a failed progress through the physiologic stages of the normal wound-healing cascade. The principal objective of the study reported here was to elucidate potentially modifiable inherent variables that predict predisposition to impaired healing and to provide a tool for identifying cases at risk for complicated early postoperative recovery following pressure sore reconstruction. Methods: A retrospective chart review of late-stage (stage 3 or higher) sacral and ischial pressure sore patients who underwent flap reconstruction from 2014 to 2019 was performed. A multivariable logistic regression model was used to identify key patient and operative factors predictive of impaired healing. Furthermore, the Assessment Score to Predict Pressure Sore Impaired Healing (A-PePSI) was established based on the identified risk factors. Results: In a cohort of 121 patients, 36 percent exhibited impaired healing. Of these, 34 patients suffered from dehiscences, necessitating surgical revision. Statistically significant risk factors comprising late recurrence (OR, 3.8), immobility (OR, 12.4), greater surface (>5 cm diameter; OR, 7.3), and inhibited thrombocytes (aspirin monotherapy; OR, 5.7) were combined to formulate a prognostic scoring system (A-PePSI LIGhT). Conclusions: The A-PePSI LIGhT score serves as a prognostic instrument for assessing individual risk for impaired healing in pressure sore patients. Preoperative risk stratification supports rational decision-making regarding operative candidacy, allows evidence-based patient counseling, and supports the implementation of individualized treatment protocols