The purpose of this paper is to describe the outcome of facial neuromuscular retraining for brow to oral and ocular to oral synkinesis in individuals with facial nerve disorders. Fourteen patients with unilateral facial nerve disorders and oral synkinesis who were enrolled in physical therapy for retraining were studied. Synkinesis was measured with quantitative video facial position analysis prior to the initiation of physical therapy and at regular intervals during retraining. Retraining included surface electromyographic biofeedback-assisted specific strategies for facial muscle reeducation and a home exercise program of specific facial movements. Twelve of 13 patients with brow to oral synkinesis and 12 of 14 patients with ocular to oral synkinesis reduced their synkinesis with retraining. Patients with a 1-year on greater duration of a facial neuromuscular disorder (excluding patients with unusually marked changes) demonstrated a significant decrease in brow to oral synkinesis and in ocular to oral synkinesis; there was a mean percentage decline in abnormal movement of 60.5 percent (SD = 26.48) and 30.1 percent (SD = 62.57), respectively. We conclude that brow to oral and ocular to oral synkineses associated with partial recovery from facial paralysis were reduced with facial neuromuscular retraining for individuals with facial nerve disorders.

Numerous studies have shown that the final stage in breast reconstruction, creation of the nipple-areolar complex, correlates highly with patient satisfaction and acceptance of body image. There are many different techniques, including nipple sharing, free-composite grafts, and local "pull-out" flaps, all of which are vulnerable to an unpredictable degree of loss of projection and possible need for reoperation. This leads to problems with symmetry and overbuilding the initial reconstruction with wider-based, larger flaps, which may cause breast-contour changes. We have used calcium hydroxylapatite (Radiesse, Bioform Inc., Franksville, WI) following nipple-areolar reconstruction to maintain or restore projection in selected breast-reconstruction patients. Approximately 0.4-1 mL of calcium hydroxylapatite was injected subdermally using a 27-gauge needle in 6 selected patients. All patients tolerated the office procedure well without the need for local anesthesia. We report initial short-term success, with 100% patient satisfaction, minimal loss of projection, and no complications. Semipermanent injectable soft-tissue fillers such as calcium hydroxylapatite may be useful in selected patients as a simple solution to the difficult problem of the lack of nipple projection following reconstruction.

Mastectomy rates at this institution have not shown the recent sharp increase observed by some authors. The association of age, race, family history, and parity with CPM has been corroborated in multiple studies. However, there is disagreement between statistically significant findings among investigators evaluating factors associated with CPM, and there is limited data in the literature characterizing BCS-eligible patients who chose CM. Larger prospective studies are necessary to further evaluate CM and CPM rates.

Reinnervation of the paralyzed hemiface with a cross-facial nerve graft (CFNG) required division of facial nerve branches on the normal hemiface to serve as axon donors. There is therefore concern about whether any impairment of normal hemiface motion occurs in the postoperative period. To minimize the likelihood of donor-side impairment, donor branches are chosen from the bucco-zygomatic region which was extensive cross branching, as opposed to be the single temporal or marginal mandibular branches. This study chose to determine quantitatively if this practice does, in fact, adversely affect the normal side hemiface motion governed by these branches, viz., eye closure, pucker, and smile. Since surgical procedures near the facial nerve (such as superficial parotidectomy) may leave the patient with transient facial weakness, even in the absence of nerve transection, the hypothesis was that hemiface motion would be impaired on the donor side during the early postoperative period (first month) secondary to edema and/or neuropraxia. However, based on the clinical observation that donor-side facial motion is not demonstrably impaired late after surgery, a further hypothesis was that any early facial motion is not demonstrably impaired late after surgery, a further hypothesis was that any early facial motion impairment would return to normal by 3 months postoperatively. Seven patients underwent sural CFNG as a primary or secondary component of their facial animation procedure. Their facial motion was quantified preoperatively and in serial postoperative examinations using the Maximal Static Response Assay (MSRA) of facial motion. Careful selection of redundant bucco-zygomatic branches of the facial nerve on the normal side for CFNG did not ultimately ( > or = 3 months postoperative) impair the important motions of eye closure, smile, or pucker. Early postoperative ( < or = 1 month) weakness of the smile was seen on both X and Y axes, indicating that both the risorius and zygomatic muscles were transiently weakened. The ability to elevate the lower eyelid was unaffected at any postoperative time point. Movement of the normal hemiface did not appear to be permanently affected by CFNG when a careful choice of redundant bucco-zygomatic donor branches was made.

Background. Breast conservation surgery (BCS) followed by radiation is as effective as mastectomy for long-term survival and is considered standard of care for early-stage breast cancer. An increasing number of patients are opting for cancer-side mastectomies (CM) and often contralateral prophylactic mastectomies (CPM). Our study investigates if there are increasing trends in our patient population toward CM and CPM and identifies common factors associated with those electing to have more extensive surgery. Methods. A retrospective analysis was performed on 812 breast cancer surgeries between January 2001 and December 2009 at The George Washington University Breast Care Center. BCS-eligible patients who elected to have BCS were compared with those who chose CM. Patients who underwent CM were compared with patients undergoing CM and CPM. Results. A personal or family history of breast cancer and larger tumor size were positively associated with choosing CM in BCS-eligible patients. A nonstatistically significant trend toward CM was seen in younger patients. Age, family history, fewer children, Caucasian race, and reconstructive surgery were positively associated with choosing CPM. Conclusion. Mastectomy rates at this institution have not shown the recent sharp increase observed by some authors. The association of age, race, family history, and parity with CPM has been corroborated in multiple studies. However, there is disagreement between statistically significant findings among investigators evaluating factors associated with CPM, and there is limited data in the literature characterizing BCS-eligible patients who chose CM. Larger prospective studies are necessary to further evaluate CM and CPM rates.In 1991, The National Institutes of Health issued a consensus statement advocating breast conservation surgery (BCS) as the preferred surgical treatment for earlystage breast cancer.1 Despite this long-standing recommendation, not all eligible patients receive this treatment. Furthermore, some institutions have noted an increasing trend in cancer-side mastectomy (CM) rates. In a 13-year institutional analysis of 5865 patients, McGuire and colleagues noted a rise in CM rates from 31% in 1997 to almost 60% in 2007. The authors cited possible reasons for this trend such as increased detection of additional foci, genetic testing, improved reconstruction techniques, and increased patient demand. Contralateral prophylactic mastectomy (CPM) reduces the risk of breast cancer by 91-96%.3,4 Although a significant improvement in survival has not been identified in most studies, a more recent study has demonstrated a modest survival benefit for women under 50. 5,6 Prophylactic mastectomy is usually reserved for patients who are at high risk for developing a contralateral breast cancer. The Society of Surgical Oncology's Position Statement on prophylactic mastectomy reports that CPM is potentially indicated in women at higher risk, such as those with BRCA1-2 gene mutations, atypical ductal hyperplasia, atypical lobular ...